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Erin Bilben Occupational Therapist

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1 Erin Bilben Occupational Therapist

2 My OT Background  Providing OT services to school based population.  Service provider with Renfrew Educational Services to the CBE (Bridges program, Children’s Village School, and William Roper Hull School).  Provided OT services to Independent School Board in Partnership with Psychology team  Currently working in hardest role, with longest work hours…

3 Overview What is an OT? Mental Health OT Breaking down Aggression & Defiance Lesson Plans A little game to keep your attention – in the slides there are song titles in quotation marks, name the artist.

4 What is Occupational Therapy? “Working 9 to 5” Occupational Therapy is a health care profession that is concerned with a person’s ability to perform the daily occupations they are expected to, need to do or want to do. Daily occupations include self-care, productivity, and leisure activities. An OT strives to increase productivity and function within the person’s current environment.

5 Mental Health OT Occupational Therapists offer: Direct therapy services to student’s who struggle with emotional and behavioural concerns Activity based psycho-educational groups An exploration of behaviour from a sensory perspective Collaboration and consultation with teachers and the mental health team to ensure students receive the appropriate therapy service

6 Activity Analysis of Behaviour “ABC” Ask the questions: Why are they acting out? Working on the principle of Antecedent, Behaviour, Consequence (ABC) we look at A Where does this behaviour frequently occur? When is it happening most? With Who? How do they react? Despite what you may believe BEHAVIOUR IS PREDICTABLE

7 Common Antecedents Removing access to preferred item or activity Requiring compliance Requesting completion of non preferred tasks Participation in a group Marcia L Braden, PhD PC

8 Hidden Antecedents Physical Ill Anxious, panicked, headaches, gastro intestinal issues Curricular Tasks that are too difficult Environmental Transitions Crowds Loud and unpredictable sounds Marcia L Braden, PhD PC

9 Social Antecedents Introductions, eye contact, hand shaking Perceived or real conflict/confrontation Embarrassment, compliments, criticism, attention Verbal interaction, phone calls, conversational exchange, direct questioning Marcia L Braden, PhD PC

10 ALL BEHAVIOUR SERVES A PURPOSE Maintain Avoid Escape Attention Marcia L Braden, PhD PC


12 Working Model of Aggression 1. Frustration Moves a Child to Attack Aggression is the outcome of frustration Attacks can be verbal or nonverbal and can be primitive or learned 2. Frustration first moves the child to effect change. Frustration is the experience of something not working; therefore the first logical impulse would be to change the frustrating circumstances 3. Failing that, feelings of frustration should turn into feelings of futility. The feeling that no matter how much they cry, scream, hit or yell it is not going to change the outcome, essentially the child gives up.

13 Aggression Model

14 Working Model of Aggression…cont’d 4. Failing that, the impulses to attack should be tempered with conflicting elements. When impulses to attack emerge into the awareness of the child, the mind scans for anything in consciousness that would conflict with the expression of those impulses (consequences, rules, empathy, desire to be good, etc.) 5. Failing that, Frustration seeks expression in aggression.

15 Six Helpful Ways of Viewing Aggression 1. as an EMOTIONAL problem instead of a behaviour problem. 2. as a FRUSTRATION problem instead of an anger problem. 3. as an IMMATURITY problem instead of a learning problem 4. as a VULNERABILITY problem instead of an exposure problem 5. an ADAPTATION problem instead of a trauma problem 6. an ATTACHMENT problem instead of a social problem

16 Why conventional discipline is ineffective with aggression  Punishments and consequences are chosen to be deliberately frustrating.  “since you have such a difficult time handling frustration in a civilized manner, let me give you even more frustration to handle”  If a child is able to come to terms with futility giving consequences would work.  However, children with aggression problems cannot come to terms with futility and will actually be pushed to aggression with this technique because it breeds frustration.

17 Conventional discipline…cont’d  Using “time-out” with children with aggression problems will also back fire because you are showing them that you can only be around me when you are good.  It appears to be effective in the short term because it evokes a desperate pursuit of proximity. However the root problem of frustration is never addressed.  Unfortunately there is a need for discipline for social reasons, and a commitment to the community.  However if we find ourselves having to impose discipline for social reasons, we should try as much as possible to depersonalize the discipline process and personalize the relationship.

18 Food for thought… ”Don’t Stop Believing” You may not be able to validate the behaviour but you can ALWAYS validate the frustration. In our efforts of trying not to upset children, we now have to deal with children who are upsetting others through aggression. Praise with an aggressive child may back fire because accepting your praise my mean that they won’t measure up next time.

19 Food for thought…cont’d When you lose the will to connect that is the time that you need to step back and take a minute because anything you say at that moment will hurt/harm the connection. Wait until that will to connect returns. We meet a child at the level they are at for toileting, language, etc. and help to develop the skills they need…why wouldn’t we do that with aggression? It is far more important to nurture a child than to reward them.


21 Defiance occurs in many diagnoses ADD & ADHD Tourette’s Disorder Anxiety Disorders Mood Disorders Autism Spectrum Disorder / Fragile X Social/Emotional Issues Learning/ Developmental Concerns

22 Oppositional Defiant Disorder (ODD) “The Right Kind of Wrong”  Always looking for option B  Focused on when others break rules however no personal insight.  Very black and white  Kids tend to get a sense enjoyment out of manipulating situations to their benefit.

23 What does it mean to have this Diagnostic Label? Family functioning difficulties Academic failure Social failure – lack of social opportunities Being labeled as a “bad kid” Teachers, parents or other adults being very reluctant to have the child in their environments

24 Problems with the Diagnosis It can encourage adults not to take responsibility for their role in the behaviour and in the solution (i.e.: parenting styles). It labels the child as a behaviour problem – they can never get away from it, therefore what is the motivation to be good. It does not explain why the behaviour is occurring – these children crave a greater level of control. Decide what is appropriate for them to control?

25 DEALING WITH OPPOSITIONAL BEHAVIOURS Dr. Greene – author of The Explosive Child and Lost at School. describes oppositional children as inflexible-explosive. Defiant behaviours for children with an ODD diagnosis are not typically due to the following: lack of motivation, need to seek attention, lack of appreciation for authority, inept parenting. How we perceive these children is directly related to how we respond to their behaviours.

26 Collaborative Problem Solving Dr. Ross Greene Behind every challenging behaviour is a lagging skill and a demand for that skill (i.e.: an unsolved problem) Kids do well if they CAN…if they can’t we adults need to figure out what is getting in the way so we can help. Assessment of Lagging Skills & Unsolved Problems (ALSUP): tool used to enhance discussion about where children are having difficulty in development. Form is available for free on under paperwork.

27 __ Poor sense of time __ Difficulty maintaining focus __ Difficulty considering the likely outcomes or consequences of actions (impulsive) __ Difficulty considering a range of solutions to a problem __ Difficulty expressing concerns, needs, or thoughts in words __ Difficulty understanding what is being said __ Difficulty managing emotional response to frustration so as to think rationally __ Difficulty deviating from rules, routine __ Difficulty handling unpredictability, ambiguity, uncertainty, novelty __ Difficulty shifting from original idea, plan, or solution Examples of Lagging Skills from ALSUP

28 Interesting Research “Response Perseveration and Sensitivity to reward and Punishment in Boys with ODD.” Mattys, W., van Goozen, S.H., Snoek, H & van Engeland, H. (2004). European Child and Adolescent Psychiatry, 13, 362-364. Assessed using a computerized door-opening task. The boys decide whether to open the next door or stop playing the game. When the boys open a door, if there is a happy face they get a dime, if there is a sad face they must give back a dime. There is a steadily increasing ratio of sad faces (punishment) to happy faces (reward). The boys are told that they can stop playing at any time. The boys with ODD opened significantly more doors than the boys without ODD. Following punishment the boys with ODD more quickly opened the next door than did the boys without ODD. Thus, in this study, the boys with ODD showed low sensitivity to punishment.

29 Strategies for Dealing with Defiance  Focus on proactive rather than reactive – identify triggers  Identify situations in advance that will cause explosions  Read warning signals and take quick action, rather than waiting  Be aware as an adult how you are responding to the child  Maintain the relationship at all costs  Act don’t react, Act don’t “yak”  Begin instructions with student’s name  2 word instructions  Learn what is motivating the student  Use incentive program

30 Language is KEY!!! “When You Say Nothing At All” “What is your job right now?” “Your job is ___, my job is ___?” “You get what you NEED, not what you want.” “You get what you get, don’t get upset” “It’s OK to be mad, it’s not OK to be mean.” “I don’t appreciate your behaviour right now, make a choice.” “I am expecting to see frustration with _____, so what is our plan to deal with that?” “What is not working for you right now?” “What can we change?” “I am sure you are feeling frustrated, you must need to get the feelings out.” Don’t start with “Don’t” – “Hit this not that”, “Punch this…”, “gentle hands”, “calm feet” 30

31 Social Skills We have identified that kids with aggression and defiance problems are delayed developmentally in their ability to express their emotions. For kids this usually manifests itself into problems with social skills and peer relations. Number one referral request when working in behavioural classrooms. Teachers feel equipped to modify curriculum but how do we teach social skills.

32 Emotional Bingo Excellent activity to teach understanding of emotions Extension Activities: use faces to act out feelings verbally & non- verbally have kids tell a story of a time they felt each feeling

33 Classroom Quest Activity adapted from: Teaching Friendship Skills – Intermediate Version, by Pat Huggins, Ernie Hergenroeder and Larry Moen (Dec 1993) pg 511 Materials: Classroom Quest Interview form Classroom Quest Bingo sheet Bingo Dabbers

34 Classmate Quest – Interview Form 1. Where were you born? 2. Where is your favorite place to go? 3. Do you like to spend time by yourself? 4. Do you have a pet? 5. Do you have a brother or sister? 6. Can you speak another language? 7. What is your favorite color? 8. What is your favorite food? 9. What is your favorite TV show? 10. What is your favorite story? 11. What is your favorite sport? 12. If you could be someone else for a day, who would you be and why?

35 Eats supper with their family Is an only child Has a petWatches TV at supper time Is wearing sandals Has their own email address Likes to readRides the bus to school Is on a sports team Can count to ten in another language Was born in Calgary Has/had braces Makes their own lunch Doesn’t like chocolate Likes to spend time by themself Favorite color is red Lives in a blue house Doesn’t have a pet Is wearing socks other than white Was born outside of Alberta Has hair long enough for a pony tail Has been on an airplane Favorite food is pizza Has curly hair Has brown eyes

36 Personal Space Space Invaders Activity Purpose: To introduce strategies for students to create their own personal space and respect others personal space.

37 Space Invaders Discussion: What is personal space? Why is personal space important? How do you feel when your personal space has been invaded? Uncomfortable, mad, annoyed, nervous, scared When do you feel this way? Talking to someone that you don’t know, someone is mad at you, being bullied, sitting at the carpet, touching, talking too loudly.

38 Space Invaders What can you do if someone is invading your personal space? Increase personal space yourself – move, take a step back, sit in a different spot, use furniture to create space Measure an arm length when someone is approaching you Tell the person – “I feel more comfortable right here”, “I would feel more comfortable if you were right here” – show them arms length Walk away if the other person is ignoring your strategies

39 Discussion: Are you a space invader ? How do you think other’s feel when you invade their space? When have you been a space invader, what were you doing? Assemblies, during free time, playground, lunch time, standing in line What are the consequences of being a space invader? Kids don’t want to play with you, kids may be scared of you, etc. How do you know if you are being a space invader? Facial expressions of other person, is the other person moving away, ask before you reach out and touch someone or their stuff, check your arms length

40 Space Invaders Freeze game Using lively music have students move around the room, and when the music stops have them use their arms length check to see if they are being space invaders. If students struggle maintaining personal space independently it may be useful to use hoola hoops to give students a physical measure of personal space distance. Measuring comfort with personal space Place a piece of masking tape on the floor approximately 2 meters long Have one student stand at the end of the tape Each student takes turns walking along the tape until they feel comfortable with the distance between themselves and the other person

41 Space Invaders Please note: for students who need lots of distance between them and other people this activity may make them feel uncomfortable. Use this as a discussion among the class so they learn what each of their classmates needs for personal space. Tip: After a social skills lesson I always end with a coloring activity to transition back to seat work and allow kids time to debrief after lesson.

42 Things Kids Do That Bug ME Adapted from: Teaching Friendship Skills: Intermediate version. by Pat Huggins, Ernie Hergenroeder and Larry Moen (Dec 1993) Pg 69 Worksheet #1: Instructor reads list of items and asks students to check off what bugs them. Brainstorm and write on the board ideas of how these things make everyone feel (i.e.: angry, frustrated, etc.). Worksheet #2: Have the students pick one thing that bugs them (from worksheet #1) and how it makes them feel. Students will be able to copy directly from the brainstorming written on the board.

43 Worksheet #1 It Bugs Me When… __kids tell my secrets __kids break promises __ kids call me names __ kids tell lies __ kids try to be the center of attention __ people get mad over little things __ kids copy me __ kids poke, push or hit me __kids borrow my things don’t give them back __ kids want their own way __ kids interrupt me __ kids brag about themselves __ kids cheat in a game __ kids tell on me __ kids tease me __ kids act bossy

44 Worksheet #2 It Bugs Me When: _______________________________________________ _______________________________________________ _________________ When kids do this to me I feel: _____________________________________ signed __________________

45 Am I A Bug? Extension activity to be done after “Things Kids do that Bug Me” Have a discussion about being honest with your answers, it can be embarrassing but we need to learn from our mistakes. It is helpful if teacher answers honestly as well. Brainstorm feelings that others would feel when we treat them poorly. Tie this lesson back to the previous one and compare answers. If answers are the same discuss concept of treating others the way you want to be treated.

46 Worksheet #1 Sometimes I…. __ tell other peoples secrets __ break promises __ call people names __ tell lies __ try to be the center of attention __ get mad over little things __ copy people __ poke, push or hit people __ borrow things and not give them back __ want my own way __ interrupt people __ brag about myself __ cheat in a game __ tell on people __ tease people __ act bossy

47 Worksheet #2 A Little Promise to Myself… These things bug ME so much I sure won’t do them to anyone else! Signed ____________________________

48 Extra tidbits…. Using Break cards – kids can cash in a break card when they are feeling overwhelmed. Set number of cards and duration of break, as well as discussing what an appropriate break is. Reward cards – create a bunch of red and green squares, red indicates no reward and green indicates earning a reward. Discuss expectations for earning a reward, and then throughout lesson reward on task behviour with a green card going into a jar, and off task behaviour puts a red card into the jar. Tally cards up at the end and see if class earns a reward. Transitions – most common time for behavioural outbursts. Encourage students to use a transition object, carry a box, binder etc. with some weight for sensory input. Send student ahead of the class as an “investigator” gets them out of a line that may be overwhelming. Sensory breaks as transition tools – chair push ups, seated twists, etc.

49 Resources Dr. Gordon Neufeld – Hold On To Your Kids Dr. Ross Greene – The Explosive Child Marcia Braden Ph.D, P.C – School Specialty – Abilitations – Is It Sensory or Is It Behavior? - Author(s): Betty A. Paris, PT, M.Ed. Carolyn Murray-Slutsky, MS, OTR Teaching Friendship Skills (Beginner & Intermediate version) – Author(s): Pat Huggins, Donna Wood Manion, Larry Moen

50 Summary Behaviour is predictable! Try your absolute best to avoid taking a child’s expression of their behaviour personally. Always strive to find the cause of the behaviour; what is frustrating them and work to change that. Maintaining a relationship is the most important factor in behavioural change.

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