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MANELA 2013 1 Miriam Manela OTR/L Pediatric Occupational Therapist.

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Presentation on theme: "MANELA 2013 1 Miriam Manela OTR/L Pediatric Occupational Therapist."— Presentation transcript:

1 MANELA 2013 1 Miriam Manela OTR/L Pediatric Occupational Therapist

2 IS IT BEHAVIORAL? MANELA 2013 2

3 THE QUESTION: IS THE BEHAVIOR WILLFUL? MANELA 2013 3

4 Occupational Therapy in Mental Health Participation in Meaningful Roles and Activities Satisfaction and a Sense of purpose and Success A way to Develop Self-Control A Positive Self-Image Enhance Emotional Well-Being Promotion of Social Competence Healthy Parent-Child & Teacher-Student Relationship Social Competence Having the social, emotional, and cognitive skills to be able to participate in all the different relationships in a person’s everyday life. LANNIGAN & MANELA 2013 4

5 WHY ADDRESS CHILDHOOD MENTAL, EMOTIONAL AND BEHAVIORAL PROBLEMS? Affect the way young people think, feel and behave Interferes with success in daily life Stressful for the child and family Unhappy, angry, or fearful children struggle to meet the expectations of their roles and activities Diminished confidence. LANNIGAN & MANELA 2013 5

6 WHY ADDRESS CHILDHOOD MENTAL, EMOTIONAL AND BEHAVIORAL PROBLEMS? (CONT.) Limited or Maladaptive Social Participation Lack of Motivation in the Classroom and in other Occupations Inability to Develop a Healthy Sense of Self Stressful Family Dynamics Mental Health Problems (Substance Abuse and Mental Health Services Administration (SAMHSA), 2003a) LANNIGAN & MANELA 2013 6

7 ROLE OF OT IN TREATMENT OF CHILDHOOD MENTAL HEALTH DISORDERS Identify factors that result in poor ability Analyze and break down tasks Provide the child with a sense of mastery Enable the child to develop a healthy identity, despite his or her emotional disorder LANNIGAN & MANELA 2013 7

8 WHEN CHILDREN MISBEHAVE, WHAT FEELINGS DOES IT CONJURE UP IN US AS THERAPISTS, TEACHERS AND PARENTS? MANELA 2013 8

9 WHEN WE TREAT BEHAVIOR CHALLENGES WE ARE TREATING COGNITION, EMOTION AND SENSATION. MANELA 2013 9 Cognition Sensation Emotion

10 ATTACHMENT THEORY MANELA 2013 10

11 WHAT IS ATTACHMENT CONNECTION? MANELA 2013 11 A pattern of interaction in a specific relationship. Develops during primary connection with caregiver-grows the brain.

12 ATTACHMENT IS ABOUT DANGER AND SURVIVAL MANELA 2013 12 Behavioral patterns are survival strategies used by the child to get needs met Life and Death Safety

13 GENETICS AND EXPERIENCE MANELA 2013 13 Our genetic inheritance directs the overall brain organization, while experience influences how and when genes become expressed.

14 ATTACHMENT STYLE FORMS WITHIN THE FIRST 12 MONTHS. HOWEVER, IT CAN BE "UPDATED" WITH NEW EXPERIENCES. MANELA 2013 14

15 The brain is dependent on experience. Early experience shapes the architecture of the child’s developing brain. MANELA 2013 15

16 RIGHT ORBITO-FRONTAL CORTEX MANELA 2013 16 Social intelligence, impulse control, attention and short-term memory OFC chooses information to focus on “Brakes of the Brain”

17 GLEAMING AND BEAMING MANELA 2013 17

18 ATTACHMENT PATTERNS MANELA 2013 18 Type A: Avoidant of negative affect and predictable (Avoidant Attachment). Type B: Secure and Balanced Type C: Preoccupied with negative affect and unpredictable (Anxious Attachment).

19 TYPE C (ANXIOUS) STRATEGIES MANELA 2013 19 Lack confidence in caregiver reliability Related to anxiety and behavior disorders

20 TYPE C (ANXIOUS) STRATEGIES MANELA 2013 20 Clingy, needy, insecure Keeps caregiver engaged

21 TYPE C (ANXIOUS) STRATEGIES MANELA 2013 21 Over-feelers Anxious Preoccupied with negative emotions Unpredictable in their behavior

22 EXAGGERATED NEGATIVE AFFECT PREOCCUPIED WITH NEGATIVE AFFECT MANELA 2013 22

23 DEVELOPMENT OF C STRATEGY MANELA 2013 23 Unpredictable Consequences Inconsistent Care Giving Caregivers’ Responses Fluctuate Child Preoccupied with Caregivers’ State of Mind.

24 Attachment Anxiety/Type C - Have self regulatory deficits that develop in the prefrontal cortex (Schore, 2001). Therefore, self soothing skills need to be taught. MANELA 2013 24 For those high in anxiety attachment (Type C), relationships are associated with emotional dysregulation. (Lopez & Gormley, 2002)

25 TYPE A (AVOIDANT) STRATEGIES: AVOIDANT OF NEGATIVE AFFECT MANELA 2013 25 Rely heavily on cognition. Predictability. Minimize negative feelings. Do what is expected; avoid punishment. Disorders of inhibition and compulsion.

26 TYPE A (AVOIDANT) STRATEGIES (CONT.): MANELA 2013 26 Avoid disorganizing stimulation from mom. Constant parasympathetic state. Gaze aversion and passive avoidance. Limited capacity to experience intense emotion. “Over-regulation disturbances.” Too much inhibition.

27 TYPE A (AVOIDANT) STRATEGIES (CONT.): MANELA 2013 27 Over-thinkers. Avoidant of negative emotions and very predictable. False positive affect. Don’t trust their feelings.

28 DEVELOPMENT OF “A” STRATEGIES: MANELA 2013 28 Dismissive caregivers Competitive caregivers Learns to repress negative emotion

29 DEVELOPMENT OF “A” STRATEGIES (CONT.): MANELA 2013 29 Child remains distressed. Caregiver minimizes intimate interactions. Emphasis upon over-activation of child’s exploration and competence.

30 All sensory experiences are emotional experiences. Amygdale is the sensory center and emotions center. MANELA 2013 30

31 CHALLENGES WITH REGULATION MAY RESULT IN: In-Attention to task Poor Impulse Control Limited Frustration Tolerance Poor Balance of Emotions Sleep Disturbances Poor Self-Calming Intolerance of Change Anxiety Feeding Problems Mood Regulation Problems MANELA 2013 31

32 Secure Attachment correlates to lower levels of pain severity, depression, pain catastrophizing and anxiety (Tremblay & Sullivan, 2009). Insecure Attachment- predicts lower pain threshold, lower perceptions for both pain control and ability to lessen pain, greater stress, depression, catastrophizing, substance abuse disorders, eating disorders and impulsivity. MANELA 2013 32

33 TECHNIQUES FOR REGULATION AND SECURE ATTACHMENT MANELA 2013 33

34 TWO MODES OF REGULATION MANELA 2013 34 Co-Regulation: Use of relationships. Auto-Regulation: Ability to self-regulate independently.

35 REGULATING STATE CHANGES MANELA 2013 35 Where are the child and I in the window? What are the indicators? How do I use this information to adjust my contact to be regulating?

36 CO-REGULATING CHILD’S STATE OF AROUSAL MANELA 2013 36 Matching vitality of affect Match tone Match intensity Match prosody Don’t match the emotion

37 READING THE MIND IN THE EYES MANELA 2013 37 The eyes hold the information of affect.

38 MAGIC OF CONNECTION MANELA 2013 38

39 Don’t Take Behavior Personally MANELA 2013 39

40 Regulate ourselves in the presence of chaos “Stay in place” MANELA 2013 40

41 DEVELOPING MINDFULNESS Staying present Attunement Self-Regulation Compassion Implicit Memory and Explicit Memory Choosing our Words Sensing into the Body MANELA 2013 41

42 The clinician’s mindfulness and its effects on the child's dramatic involvement with emotions. MANELA 2013 42

43 ENVIRONMENTS THAT SUPPORT ATTACHMENT The overarching term “environment” refers to the life experiences, family patterns and relationships that support healthy functioning. MANELA 2013 43

44 Activities for Therapists to Enhance the Development of Consistent Responses Psycho-education Modeling Homework Teaching reinforcement Small steps Successive approximations Track progress Teacher training Practice, role play Teacher coaching Start small, start easy Address needs, not wants Experiment Predict pitfalls MANELA 2013 44

45 Activities to Enhance the Development of Routines A Strategy Encourage material choices. Encourage progressively more interactive play time, encourage choices. Develop ‘verbal blueprint’ of transition expectations. C Strategy Offer limited material choices. Structure play time, limit choices, alternate active games with self- regulation activities (blanket wrapping, play dough.) MANELA 2013 45

46 Activities to Enhance Mastery of Developmental Tasks A Teach social skills. Consider settings that allow the child to play alone, then in pairs, then progressively with larger groups. Progress from structured instructional time to more free play. Encourage the development of skills: music, sports, art, etc. Start with quiet settings and move toward more interactive social settings. C Model social skills. Set limits. Keep over stimulating environments to a minimum. Begin with opportunities for parallel play. Progressively move to settings with more children. Progress from free play to more instructional time. Encourage the development of skills by observing what the child does well and then systematically increase their time spent on those tasks in order to master them. MANELA 2013 46

47 Activities to Enhance Child Self Development/Identity A Encourage exploration and making choices, e.g. involve child in planning play time. Ask child’s opinion in decision making, ‘what would you like to put on your project?’ Explain why things are done the way they are done. Encourage questions. C Ask child’s opinion, but limit options, ‘would you like to do your report now or after recess?’ Explain why things are done in short sentences. Cover one issue at a time. Answer questions when they are asked. Always reduce anxiety before attempting to explain anything. Use concrete markers: height measures, life books. MANELA 2013 47

48 Strategies Use Connection Work on Relationship, not Incident “Draw out the Tears” Draw out the tempering element MANELA 2013 48

49 Strategies (cont.) Scripting desired behavior Change environment Draw connections MANELA 2013 49

50 STRATEGIES TO TEACH PARENTS AND CAREGIVERS Teach that the paradigm can change Awareness of intrinsic worth Role play Model appropriate attachment-related behavior Use of self-made movie clips and stories MANELA 2013 50

51 Adaptations for C’s in the Classroom Educators’ responsibilities to themselves. Offer appropriate choices to share control. Identify owner of problem. Set limits with “thinking words” or enforceable statements. MANELA 2013 51

52 Adaptations for C’s in the Classroom (cont.) Appropriate consequences Safe environment Punishment counterproductive MANELA 2013 52

53 Adaptations for C’s in the Classroom (cont.) Tightly structured and loving environment Slowly decrease structure Conditional and reverse positives MANELA 2013 53

54 Adaptations for C’s in the Classroom (cont.) Avoid Unconditional Negatives: “You never study!” Avoid Unconditional Positives: “You are so smart!” Avoid Conditional Negatives: “You did not study for the test!” Conditional “yes” more often than “no.” MANELA 2013 54

55 Adaptations for C’s in the Classroom (cont.) Acknowledge good behavior and decisions with specific language. Allow natural consequences Consequences without anger. MANELA 2013 55

56 Adaptations for C’s in the Classroom (cont.) Avoid lectures, sarcasm and comments such as, “I hope you learned your lesson.” Provide consequences the first time. Do not give the child a second chance. Avoid behavior modification strategies. Use one-liners as often as possible. MANELA 2013 56

57 THINK OF A PERSON THAT PUSHES YOUR BUTTONS What do they do that bothers you? What are your judgments about the behavior? What do you do in response to the behavior? MANELA 2013 57

58 OCCUPATIONAL THERAPY COLLABORATION OTs and OTAs collaborate with other professionals, as well as with the children and those who care for them, to provide mental health services: Children—to help develop performance skills in a variety of roles such as student, friend, team member, and family member. LANNIGAN & MANELA 2013 58

59 OCCUPATIONAL THERAPY COLLABORATION (CONT.) Parents or care providers- to provide education about the social, emotional, sensory, and cognitive difficulties that interfere with a child’s participation in play, activities of daily living, and social activities; and to help develop emotional supports, structure, and effective disciplinary systems Educators- to develop strategies for a child to successfully complete classroom, recess, and lunchroom activities, and to interact effectively with peers and adults. LANNIGAN & MANELA 2013 59

60 OCCUPATIONAL THERAPY COLLABORATION (CONT.) Counselors, social workers, and psychologists—to provide insights into the interpersonal, communication, sensory processing, and cognitive remediation methods that aid emotional and social development Pediatricians, family doctors, and psychiatrists—to support medical intervention for persistent mental illness and to provide a psychosocial and sensory component to supplement medical intervention LANNIGAN & MANELA 2013 60

61 OCCUPATIONAL THERAPY COLLABORATION (CONT.) Administrators- to develop programs that promote social competence and to train staff and families to help kids learn and maintain sensory self-regulation strategies Communities- to support participation in community leisure and sports programs; to encourage education, understanding, and early intervention for children with mental health problems; and to develop advocacy and community programs for promoting understanding of the mental health diagnosis and decreasing stigma LANNIGAN & MANELA 2013 61

62 AROUSAL STRATEGIES AND TREATMENT MANELA 2013 62 When it works, it’s treatment! When it doesn’t, it’s assessment!

63 DOWN-REGULATING TO A JUST RIGHT STATE MANELA 2013 63

64 UP-REGULATING TO A JUST RIGHT STATE MANELA 2013 64 In order to find the ‘just right state,’ some individuals need to seek and energize their bodies to sustain alertness and produce adaptive responses.

65 Rhythm provides structure for movement telling us how to move through time and space. Speed of the rhythm can help either up- regulate or down- regulate dependent upon what is needed MANELA 2013 65

66 TOUCH IN REGULATION WORK Calming and grounding. Creates a felt sense of safety. Can also be triggering, thus one must possess the understanding of potentially traumatic effects of touch for dysregulated people. Having caregivers present in the room helps increase comfort. ( Calming Touch) MANELA 2013 66

67 DEEP PRESSURE TOUCH MANELA 2013 67 When in doubt, use deep pressure! Deep Pressure Activities

68 Heavy Jobs MANELA 2013 68

69 ROUGH AND TUMBLE PLAY Soothing stimulation by caregivers and the self- stimulation rhythms of the infant are quickly replaced by peer play (rough and tumble play at the preschool age, and contact sports through grade school and high school). MANELA 2013 69

70 SCHOOL AGED TACTILE MANELA 2013 70

71 CONTACT SPORTS MANELA 2013 71

72 HOKKI MOVING STOOL MANELA 2013 72 LINEAR VESTIBULAR STIMULATION

73 ORAL STRATEGIES MANELA 2013 73

74 Color Therapy MANELA 2013 74

75 QUESTIONS? MANELA 2013 75

76 HAVE A WONDERFUL DAY THANK YOU! MANELA 2013 76

77 PHONE (917) 573-5540 FAX (973) 777-7411 EMAIL MIRIAM@OTTHRIVE.COM WEB WWW.OTTHRIVE.COMMIRIAM@OTTHRIVE.COMWWW.OTTHRIVE.COM MANELA 2013 77 Miriam Manela OTR/L Pediatric Occupational Therapist

78 REFERENCES Ayres, A. J. (1973). Sensory integration and learning disorders. Torrance, CA: Western Psychological Services. Ayres, A. J. (2005). Sensory integration and the child: Twenty-fifth anniversary edition. Torrance, CA: Western Psychological Services. (Original work published 1979) Bradshaw, J. (2005). Healing the shame that binds you (Rev. ed.). Deerfield Beach, FL: Health Communications. Brown, B. (2010). The gifts of imperfection: Let go of who you think you're supposed to be and embrace who you are. Center City, MN: Hazelden. Carter, A. S., Ben-Sasson, A., & Briggs-Gowan, M. J. (2011). Sensory over-responsivity, psychopathology, and family impairment in school-aged children. Journal of the American Academy of Child and Adult Psychiatry, 50(12), 1210- 1219. Eisenberg, N., Thompson Gershoff, E., Fabes, R. A., Shepard, S. A., Cumberland, A. J., Losoya, S. H.,... Murphy, B. C. (2001). Mothers' emotional expressivity and children's behavior problems and social competence: Mediation through children's regulation. Developmental Psychology, 37(4), 475-490. Engel-Yeger, B., & Dunn, W. (2011). The relationship between sensory processing difficulties and anxiety level of healthy adults. British Journal of Occupational Therapy, 74(5), 210-216. Field, T. (2000). Touch therapy. London, UK: Churchill Livingstone. MANELA 2013 78

79 REFERENCES Field, T. (2003). Touch. Boston, MA: Bradford Books. Francis, D., Kaiser, D., & Deaver, S.P. (2003) Representations of attachment security in the bird’s nest drawings of clients with substance abuse disorders. Art Therapy, 20, 125-137. Goddard, S. (2005). Reflexes, learning and behavior: A window into the child's mind: A non-invasive approach to solving learning and behavior problems (2nd ed.). Eugene, OR: Fern Ridge. Greene, R. (2009). Lost at school: Why our kids with behavioral challenges are falling through the cracks and how we can help them. New York, NY: Scribner. Karp, H. (2003). The happiest baby on the block: The new way to calm crying and help your newborn baby sleep longer. Bantam Books. Kawar, M. J., & Frick, S. M. (2005). Astronaut training: A sound activated vestibular-visual protocol for moving, looking and listening. Madison, WI: Vital Links. Lopez, F.G., & Gormley, B. (2002). Stability and change in adult attachment style over the first-year college transition: relations to self-confidence, coping, and distress patterns. Journal of Counseling Psychology, 49, 355-364. Maurice, C. (1994). Let me hear your voice: A family's triumph over autism. New York, NY: Random House. MANELA 2013 79

80 REFERENCES Melillo, R. (2010). Disconnected kids: The groundbreaking brain balance program for children with autism, ADHD, dyslexia, and other neurological disorders (Reprint ed.). New York, NY: Perigee Trade. Meredith, P., Strong, J., Feeney, J.A. (2006). Adult attachment, anxiety, and pain-self efficacy as predictors of pain intensity and disability Pain, 123, 146-154. Perry, B., & Szalavitz, M. (2007). The boy who was raised as a dog and other stories from a child psychiatrist's notebook: What traumatized children can teach us about loss, love, and healing (Reprint ed.). New York, NY: Basic Books. Ramacciotti, A., Sorbello, M., Pazzagli, A., Vismara, L., Mancone, & Pallanti, S. (2001). Attachment processes in eating disorders. Eating and Weight Disorders, 6, 166-170. Schaaf, R. C., Miller, L. J., Seawell, D., & O'Keefe, S. (2003). Children with disturbances in sensory processing: A pilot study examining the role of the parasympathetic nervous system. The American Journal of Occupational Therapy, 57(4), 442-449. Schore, A.N. (2001). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 22, 7-66. Tremblay I., & Sullivan, M.J. (2009). Attachment and Pain Outcomes in Adolescents: The Mediating Role of Pain Catastrophizing and Anxiety. Journal of Pain 11, 160-171. Van Hulle, C. A., Schmidt, N. L., & Hill Goldsmith, H. (2012). Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis. Journal of Child Psychology and Psychiatry, 53(1), 64-72. MANELA 2013 80


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