An OT and SLP Team Approach to Educational Success

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An OT and SLP Team Approach to Educational Success

• 2014 Georgia Organization of School-based
  Speech-Language Pathologists
• March 6th, 2014
• Presented by Cindy Terry, Coordinator of
  Therapeutic Services Gwinnett County Public
  Schools and
• Doris Osborne, Supervisor of Related Services
• Cobb County School District

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What is a Related Service?

• Under part B of IDEA, OT PT are related
  services for eligible students, who, because of
  their disabilities, need special education and
  related services. Related services are support
  services that help the student to benefit from
  special education. (AOTA)

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??Eligible??

• A child does not become eligible for OT or PT.
  He or she becomes eligible for special education.
  The results of an OT or PT assessment or
  evaluation presented to the IEP committee for
  consideration drive the need for school- based
  therapy support.

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What is educationally relevant OT or PT?

• A student with a disability has a need for
  improvement in his functional skills as related
  to his performance in the educational
  environment. The student may have an educational
  need as well as a medical or clinical need.
  However, some motor difficulties may not directly
  impact educational progress and may not
  constitute educational need. (CA DOE)
• School- based OT and PT services are performed in
  the educational environment with educational
  staff.

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What is the GA Consideration Tool?

• Guidance tool for determining the need for
  educationally relevant therapy and time required
  to support the IEP goals/objectives
• Summary of educational considerations based on a
  review of
• student records, evaluations, observations,
  progress notes, parent/teacher information, and
  other data
• Visual aid to display the clinical reasoning
  process as noted by AOTA APTA Best Practices
  for school-based therapists.

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SLP and OT Co-Treatment

• Research in this area is limited.
• Studies reported most collaboration between
  school-based SLPs and OTs are with students with
  ASD.
• 1999 AJOT study reported SLP and OT with a 98
  collaboration during the evaluation 100 during
  intervention for students with ASD
• 2011 Study by Laura Czernik LEND Fellow found
  advantages with the most common being increased
  participation by the child

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Overview of ASD

• Leo Kanner- 1943
• Coined the term autism
• biological impairment like physical and
  intellectual handicaps Noted perceptual
  difficulties and overreaction to loud noises and
  moving objects.
• 50s and 60s- viewed as an emotionally based
  disorder resulting from cold refrigerator
  mother
• 70s- back to recognition as neurological
  impairment
• Literature focused on social, communication,
  behavior and cognitive issues. Attention to
  perceptual and sensory processing difficulties
  (abnormal response to visual, vestibular and
  auditory stimuli disorder of sensorimotor
  integration problems with modulation of sensory
  input and motor output)

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Occupational Therapy

• 1970s- Jean Ayers- behavioral problems
  associated with inadequate sensory integration.
• 1980s Knickerbocker- behaviors exhibited by
  individuals with autism may be related to hyper-
  or hypo- reactions to sensory input. Planned
  sensory input provided through specific
  activities could help normalize reactions to
  sensory input and improve behavior.
• Autopsy studies of individuals with autism have
  found developmental abnormalities in the
  cerebellum and limbic regions of the brain.
  Significant roles within sensory integrative
  process including modulation of sensory input.
• Adults with autism have written personal accounts
  of sensory experiences- Temple Grandin, Donna
  Williams, Zosia Zaks, Judy Endow, Sean Barron,
  Stephen Shore, John Elder Robison, Larry
  Bisonnette Tracy Thresher.

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Examples of functional skills needed for school

• Hand function
• Visual skills/ visual perceptual skills
• Handwriting
• Attention span
• Organizational skills
• Sensory awareness
• Sensory processing
• Self care skills
• Positioning
• Social Skills
• Motor planning

• Functional Mobility (walking or WC skills)
• Stair climbing
• Balance
• Coordination
• Oral motor skills
• Gross motor skills
• Fine motor skills
• Assistive technology
• Pre-vocational tasks
• Leisure skills

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All learning has its basis in sensory
development.From Sensory Secrets.
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Sensory Processing

• The organization of sensory input for adaptive
  responses learning, motor skills, perceptual
  skills, behavior, social skills.

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• The brain locates, sorts and orders sensations
  somewhat as a traffic officer directs moving
  cars. When sensations flow in a well organized
  or integrated manner, the brain can use those
  sensations to form perceptions, behaviors and
  learning. When the flow of sensations is
  disorganized, life can be like a rush hour
  traffic jam.
• -Jean Ayers, 1979

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The brain acts much like a computer!

• Input goes in through the sensory systems
• Which is processed in the brain
• Resulting in an adaptive response
• Which provides feedback/sensory input
• Which is processed in the brain
• Resulting in an adaptive response
• The process is cyclical.

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Components of SP

• Sensory Registration
• Be aware of a sensory stimulus
• Orientation
• Pay attention to new information being received
• Determine what sensory input needs attention and
  what can be ignored
• Utilize functions of inhibition and facilitation
  modulation
• Interpretation
• Interpret and describe sensory input
• Allows for fight, fright, and flight responses
  (protective system)
• Organization of a response
• Determine if a response to a sensory stimuli is
  needed, and how
• cognitive, emotional, physical
• Execution of a response
• Execution of the cognitive, emotional, or
  physical response

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Sensory Modulation

• The ability of the nervous system to
• Regulate, prioritize, and organize incoming
  sensory information.
• Adapt to changes in the environment.
• Maintain arousal level appropriate to the task.
• Results in
• Registration, arousal, self-regulation,
  attention, focus, and behavior or emotional
  responses

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Sensory Processing Disorders

• Over-reactive to sensory stimulation
• Under-reactive to sensory stimulation
• Modulation disorders
• Integration disorders
• Difficulties with arousal levels-that just
  right state for learning
• Use sensory assessments to analyze.

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The 2 Functions of the Nervous System

1. Protection fright, flight, fight
2. Discrimination for learning, communication,
   behavior

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Central Nervous SystemSensory Processing Sets
Foundation for

• Cognitive
• academic learning,
• daily living skills, behavior
• Perceptual-Motor
• auditory language skills, visual-spatial
  perception,
• attention center functions, eye-hand
  coordination,
• ocular-motor control, postural adjustment
• Sensory-Motor
• body scheme, reflex maturity, ability to screen
  input,
• postural security, awareness of the two sides of
  the body, motor planning
• Sensory
• olfactory, Visual, auditory, gustatory, tactile,
  vestibular, proprioception

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Sensory Systems

• From eyes vision
• From ears hearing
• From skin touch
• From nose smell
• From mouth taste
• From semi circular canals vestibular
• From muscles/joints - proprioception

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THE TACTILE SYSTEM

• Provides us with our sense of touch
• First sensory system to operate in uterus
• Rooting reflex, calming to neutral warmth
• Receptors in the skin provide information about
  light touch, pressure, vibration, temperature,
  pain
• Feedback- development of body awareness, motor
  planning
• Needed for ADLs including schoolwork, job tasks

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Tactile cont.

• Protective tactile system- more primitive
• Initially dominant
• Informs us when dangerous contact is made
• May be gently alerted or activate fright, flight
  or fight response
• Discriminative tactile system- allows us to feel
  the quality of the item we are touching
• Higher level- necessary for learning and brain
  development

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Tactile Dysfunction

• Hyper- or hypo- sensitive to touch
• Problems with tactile discrimination
• Sensory modulation- unable to screen out
  sensations overwhelmed to point of not
  responding to other sensory systems
• Tactile defensiveness- (hyper-)regarded as
  threatening. Can tolerate touch but not receive
  touch
• Behaviorally- anxious, aggressive, controlling,
  inflexible, unwilling to participate in
  activities
• Hypo-low arousal levels require intense input
• Body awareness, motor planning problems due to
  impaired feedback
• Delayed reaction to touch- may not realize injury
• Seeking tactile input- constantly touching-
  social implications

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THE VESTIBULAR SYSTEM

• Provides information about movement, gravity,
  changing head positions
• Tells us if we are moving, still, direction and
  speed of movement
• Develops relationship to earth- body position
  vertical or horizontal even with eyes shut
• Balance, postural security, self- regulation and
  modulation
• Receptors located within structures of ear(
  semi-circular canals, utricle, saccule)
• Influences development of eye movements-
  tracking, focusing, maintaining upright posture
• Influences muscle tone, readiness to perform
  work
• Protective- reflexes to prevent falling
• Discriminative- recognize going faster, slowing
  down, rotary movements, rhythmical

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VESTIBULAR DYSFUNCTION

• Hyper- fearful with changes in gravity and
  position- gravitationally insecure- do not like
  heights, feet off ground
• May feel discomfort, nausea, or dizziness with
  movement
• No exploration of environment, no motor memory
  poor motor planning
• Hypo- seekers, crave movement- climbing, jumping,
  excessive movement to stay alert and organized
• Problems with self-regulation- inconsistent
  responses to sensory input , emotional
  instability, inappropriate arousal levels,
  difficulty maintaining and shifting attention

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PROPRIOCEPTIVE SYSTEM

• Unconscious awareness of body position
• How much force necessary for muscles to exert so
  we can grade movements
• Receptors located in muscles, tendons, ligaments,
  joint capsules, connective tissue
• Respond to movement and gravity- helps us make
  sense of movement and touch experiences
• Position in space, body map- motor planning
• Regulate arousal levels (stretch, heavy work)

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Proprioceptive Dysfunction

• Poor body awareness
• poor grading of movements- break items, writing
  too hard or too light, may fatigue easily
• May use proprioceptive input to reduce
  hypersensitivity to other sensations- intense
  rocking, banging back and head against chair,
  jump on beds, squeeze between furniture, hide
  under heavy blankets

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Autism Sensory Processing
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Sensory Quota Systemaccording to Zosia Zaks

• Say my brain has only 100 Sensory Processing
  Units. If it takes 95 units to decipher the
  sounds of a conversation, decode the
  conversational signals that indicate turns and
  innuendo, pick up the contextual clues that
  impart social meaning, and modulate my voice, I
  have just five units remaining to use for other
  sensory sources.

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• Since looking at someones face, decoding facial
  expressions and coping with the pain of the
  fluorescent lights requires (hypothetically) at
  least 75 units, in this case I would not have
  enough Sensory Processing Units to look at the
  other person, or even open my eyes, while we
  conversed. This helps explain why most autistic
  people are unable to look at someone in the eyes
  while also talking, a characteristic behavior of
  autism spectrum disorders.

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• When SPUs are used up
• Sensory overwhelm or sensory meltdown
• Need to calm self ALONE
• Scrambling- difficulty sorting sensory input into
  meaningful chunks of information
• Sensory cross-firing (synaesthesia)- experiencing
  a sensation in one sensory system yet perceiving
  the sensation in another modality

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• Research continues to demonstrate that people
  with ASD tend to have more issues with sensory
  processing than the general population (Kientz
  Dunn, 1997 Watling, Dietz White, 2001).
• Those with ASD demonstrate sensory symptoms
  specifically indentified in taste, smell, tactile
  and auditory processing (Rogers, Hepburn
  Wehner, 2003).

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• people with ASD often over- or under-process
  sensory input from the environment (Ornitz, 1989
  Wainwright-Sharp and Bryson, 1993) or have
  trouble regulating sensory information (Lincoln
  et.al., 1993, 1995).

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• BRAIN ACTIVITY

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Be aware of your sensory needs.Be aware of
the sensory needs of your students!

• Everyone has them!

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Behavior

• Everything we do.
• Behavior may be learned, a nervous system
  response to an environmental stimuli, or both.
• Behaviors have specific functions.

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Functions of Behavior

• Escape avoidance of a person, task, situation,
  or environment
• Tangible desire for a specific item, activity
  or feeling
• Attention desire for positive or negative
  attention from peers or adults
• Sensory desire for a feeling, taste, sound, or
  environment to meet a sensory need or a fear or
  avoidance of sensory input
• Power/Control desire for clout, authority, the
  last word, influence over their environment

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Problem Behavior

• Student does not conduct himself properly for the
  environment or situation.
• Students behavior does not match what we expect
  from his peers.
• Student does not do what we want him to do, when
  we want him to do it, or how we want him to do
  it.
• Consider Whos problem is it?

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Prioritize need for Behavioral Change/Hierarchy

1. Behaviors that harm self.
2. Behaviors that harm others.
3. Behaviors that harm property.
4. Behaviors that are disruptive.
5. Behaviors that are distracting.

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Behavioral Model

• Behavior is conditioned via external stimuli
• Based on the work of B.F. Skinner
• When external stimuli are identified, they can be
  manipulated and result in an increase, decrease
  or maintenance of the behavior (used in ABA, PBS,
  etc.)
• Positive and Negative Reinforcement
• Punishment and Extinction

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• Behavior Assumptions

• Sensory Assumptions

• Serves a function (obtain or escape)
• Function is valid for the individual
• Is learned and can be unlearned
• Problem behavior is often viewed as a form of
  communication.
• Problem behavior results from a lack of basic
  social skills.
• Problem behavior may be a source of internal
  pleasure.
• Problem behavior can be something a student does
  when he or she does not know what else to do.
• (Alberto Troutman, 2009)

• Problem behaviors may result from an underlying
  sensory processing disorder
• Sensory behaviors serve a function
• Sensory behaviors may be productive or
  nonproductive
• Productive- meet a regulatory need
• Nonproductive- may be a source of internal
  pleasure
• Sensory behaviors will be acceptable or
  unacceptable
• Sensory behaviors can be used for communication
  purposes.
• (Murray-Slutsky Paris, 2005)

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SESNORY BASED LEARNERSHandout
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TASK AVOIDANCE Handout
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Some common misconceptions about negative
behavior and sensory concerns

• Sensory strategies will reinforce negative
  behavior.
• He enjoys it, theres a smile on his/her face
  the whole time.
• She can do it, she did it beforeshe just
  doesnt want to.
• Hes just being manipulative.

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A-B-C Model

• A- Antecedent Events that occur before
  behaviors and that may cue or set the stage for
  certain behaviors. (Who, what, when, where?)
• B- Behavior of concern
• C- Consequence Events that follow a behavior
  that determine whether the behavior will be
  repeated or not.
• (Murray-Slutsky Paris, 2012)

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Antecedent ControlSet the stage for success!

• Environmental influences
• Scheduling considerations
• Activity considerations
• Can reduce the need for specific sensory diets
• or behavior plans as we manage behavior.

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Environmental Factors that Impact Behavior

• Behaviors are Less Likely to Occur
• Small rooms
• Structured tasks
• One to One child-adult ratio
• Engrossing, task
• Stimulating, interesting activities
• No waiting time
• Quiet environment
• Area free from distractions and clutter
• Repetition, routine
• Pre-planned transitions
• Familiar People
• Assistance Provided

• Behaviors are More likely to Occur
• Large Room
• Unstructured tasks or schedule
• Poorly planned transitions
• Low child-adult ratio
• Proximity of others
• Stress or frustration
• Environmental factors noise, clutter
• Change people, place, activities
• Bored, lack of Stimulation
• Excessive Waiting

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Environmental Influences

• Promote an environment which facilitates
  sensory modulation. Utilize calming and
  excitatory influences throughout the day,
  depending upon the specific task and
  requirements.
• Adjust lighting.
• Utilize music or white noise when appropriate.
• Utilize aroma therapy.
• Offer an array of seating and positioning
  options, including those that offer movement.
• Make weighted lap pads or snakes if possible.
• Offer water bottles, gum, chewy or crunchy snacks.

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Scheduling Considerations

• Intersperse all sitting and concentrating
  activities with movement or heavy work activities
• Use visuals to communicate schedules so students
  can prepare for changes and transitions
• Verbally prepare students in advance when
  non-typical activities will occur, i.e.- fire
  drill, outings, visitors

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Ways you can help..

• Routine
• Provides student with understanding- gives
  confidence and security
• Gives sense of predictability
• BUThave to help with what happens when changes
  occurprepare, prepare, prepare
• First/ Then routines
• Individual Schedules
• Use photos, icons, words
• Length of schedule
• Various ways to use them
• For the days events
• For specific routines in the room

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Activity Considerations

• Give choices when possible
• Mix non-preferred with preferred
• Make tasks short manageable, especially if
  frustrating
• Use reinforcers
• Make expectations and consequences/rewards clear
• Reduce the Anxiety
• SCHEDULE DOWN TIME- will melt down if have to
  earn
• Sensory Input- determine function, use tools-
  nubby seats, balls, tramps, velcro, pressure,
  sensory diet
• Fidgets
• Students with ADD/ADHD may exhibit improved focus
  by allowing them to hold fidget

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Principles for Using Sensory Strategies

1. Make sure strategies are not used to reinforce
   negative behaviors- be proactive, not reactive
2. Provide a sensory diet- schedule frequent breaks
   (movement/ stationary), heavy work throughout
   day, use strategies that can be used during
   learning tasks. When in doubt- use
   proprioception!
3. Utilize strategies to regulate arousal level,
   teach self-regulation mouth, hands, move,
   auditory, visual
4. Teach the student to communicate needs.

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Interventions

• Based on information gathered, the therapist
  collaborates with teachers and parents to design
  an intervention plan to address the child's
  sensory processing problems.
• The goal of a sensory based approach is to
  provide the just right amount of input in order
  to help the child regulate his sensory system and
  adapt to improve attention and focus for learning
  to occur.

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Sensory Diet

• Term coined by Patricia and Julia Wilbarger in
  1991.
• Individualized, planned and scheduled activity
  program developed to help a specific child meet
  his/her sensory needs.
• Combination of alerting, organizing, and calming
  activities.
• Dynamic- Adapts with the childs sensory changes
• Everyone has one.

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Sensory Diet

• Metaphor- nutritional diet. Sensory diet requires
  the right combination of sensory input to keep an
  optimal level of arousal throughout the day.
• Sensory snacks short term
• Sensory entrees last longer, very powerful
• Powerful behavioral tool!

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Sensory Diet ConsiderationsHandout
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Sensory Diet

• Over-responsive/ hypersensitive
• Schedule sensory activities throughout the
  childs day to modify arousal levels to fit the
  childs needs.
• Activities with intensity and long lasting
  effects
• Be proactive to keep child calm and organized.
• Deep proprioceptive activities are calming and
  organizing heavy work, wall push ups, weights,
  climbing, pushing, pulling
• Tactile deep touch pressure, massage
• Vestibular Proceed with caution beginning slowly
  with proprioceptive activities. Jumping on
  trampoline, swinging

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If your student is overly sensitive to or overly
stimulated by sensory input

• Touch Use firm pressure. Always approach from
  the front. Ask permission to touch. Allow to be
  in front or rear of lines.
• Noise Keep classroom noise to a minimum. Try
  using white noise. Try using earplugs,
  earphones, or cotton balls in ears when in noisy
  environments. Always prepare in advance of a fire
  drill. Muffle your classroom speakers. Position
  desk on outer periphery of classroom and away
  from doorways/hallways.
• Vision Keep classroom and walls uncluttered.
  Have student keep minimal items on his/her desk.
  Use simplified worksheets. Use a reading or
  writing window. Position desk in front of
  classroom and away from doorways. Try using a
  study carrel or an office. Use sunglasses
  outside if needed.

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• Sensory Diet Under-responsive/ hyposensitive
• Sensory activities to wake up the systems.
  Intense to increase registration, awareness,
  overall processing.
• Be proactive to keep child alert, awake,
  organized, engaged.
• Modify environment to alert bright colors and
  lights, animation
• Proprioceptive weights, pushing, pulling,
  carrying lifting heavy objects. Combine with
  vestibular jogging, climbing, monkey bars
• Tactile sucking, chewing, massage, vibration,
  sand table activities alternating sand, rice,
  beans putty
• Vestibular jumping on trampoline, swinging,
  bouncing on ball

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• Sensory Diet Sensory seekers
• Schedule sensory activities throughout the day to
  modify arousal levels. Assure availability of
  activities.
• Select 1 or 2 powerful activities to maintain
  optimal alert state.
• Intense, long lasting effects
• Be proactive to keep child calm and organized.
• Proprioceptive activities for calming,
  organizing. Heavy work, wall chair push ups,
  climbing, monkey bars, pushing, pulling, weights
• Tactile deep touch pressure, massage
• Vestibular Linear movement, bouncing on ball,
  jumping on trampoline, riding bike

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Sensory Strategies Used in Schools
Activity or Equipment Sensory System Purpose/criterion
Weighted vest P,T Calming, organizing, attending. Adhere to protocol
Weighted lap-pads or snakes P,T Calming, organizing, attending
Pressure vests P,T Calming, organizing, attending. Offers sustained input
Wiggle cushions V, T Facilitates attending. Allows movement while remaining in seat.
Quiet or safe area in classroom Designed to target 1or more systems Allows student to control need to re-group, chill-out, prepare for unscheduled event. Favorite calming act.

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Sensory Input Calming Alerting
General Characteristics Mild/Soft Slow/ Rhythmical Simple/ Familiar/ Expected Low Demand/ Assoc. Strong/ Pronounced Fast/ Jerky/ Non- rhythmical Complex/ Busy Unfamiliar/Unexpected High Demand/ - Assoc.
Movement Vestibular, Proprioception/ Kinesthetic Slow rocking, swinging Heavy work pushing, pulling Fast rocking, swinging Bouncing/ Jumping
Tactile Firm, steady pressure or weight Student prepared Warm neutral Soft/ Smooth Light or erratic touch Student unprepared Cold/ Stiff/ Scratchy
Auditory Soft/ Slow Classical, soft rock, some jazz Static/ White noise Loud/Fast/Non-rhythm Hard rock/ Rap
Visual Neutral or soothing colors Simple/ Soft lighting Bright or loud colors Busy/ Bright lighting
Smell Soft pleasant smells Strong or noxious odors
Taste Sucking/ Sweet/ Bland Crunchy/ Cold/ Bitter/ Spicy
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Sensory Supports

• Sensory stories
• The Alert Program
• Drive Thru Menus Exercise Programs
• Stickids
• Sensational Brain
• Equipment- tramps, pressure vests, weighted
  vests, blankets, fidgets, swings, dynamic
  seating, etc.

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Great Resources

• Youre Welcome 30 Innovative Ideas for the
  Inclusive Classroom
• Patrick Schwartz and Paula Kluth
• The Incredible 5-Point Scale
• Kari Dunn Buron and Mitzi Curtis
• Just Give Him the Whale!
• Paula Kluth and Patrick Schwarz
• Practical Solutions to Everyday Challenges for
  Children with Aspergers Syndrome
• Haley Morgan Myles

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• Building Bridges Through Sensory Integration
  Therapy of Children with Autism and Other
  Pervasive Developmental Disorders
• Ellen Yack, Paula Aquilla, Shirley Sutton

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Additional Resources

• Scool Moves for Learning Enhance Learning
  Through Self- Regulation Activities
• Wilson, Debra Em and Heiniger-White, Margot C.
• More Minute Moves Seven Weeks to Classroom
  Management Success
• Wilson, Debra Em
• www.schoolmoves.com
• Too Loud, Too Bright, Too Fast, Too Tight What
  to do if you are Sensory Defensive in an
  Overstimulating World
• Heller, Sharon
• Sensory Secrets How to Jump-start Learning in
  Children
• Schneider, Catherine Chemin
• Oh Behave! Sensory Processing and Behavioral
  Strategies A Practical Guide for Clinicians,
  Teachers and Parents
• Trott, Maryann Colby
• Self- Calming Cards
• Crary, Elizabeth and Katayama, Mits
• Sensory Challenges and Answers
• Grandin, Temple
• Building Bridges Through Sensory Integration
  Therapy of Children with Autism and Other
  Pervasive Developmental Disorders
• Ellen Yack, Paula Aquilla, Shirley Sutton
• Need assistance locating these or other
  resources, contact Cindy Terry _at_
  cindy_terry_at_gwinnett.k12.ga.us.