An OT and SLP Team Approach to Educational Success

1. 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

2. 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)

3. ??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.

4. 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.

5. 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.

6. 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

7. 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. 50’s and 60’s- viewed as an emotionally based disorder resulting from cold “refrigerator mother” 70’s- 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)

8. Occupational Therapy • 1970’s- Jean Ayers- behavioral problems associated with inadequate sensory integration. • 1980’s 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.

9. 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

10. “All learning has it’s basis in sensory development.”From Sensory Secrets.

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

12. 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

13. 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.

14. 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

15. 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

16. 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.

18. The 2 Functions of the Nervous System: • Protection: fright, flight, fight • Discrimination: for learning, communication, behavior

19. Central Nervous System:Sensory 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

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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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)

27. 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

28. Autism Sensory Processing

29. 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.

30. Since looking at someone’s 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.”

31. 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

32. 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).

33. …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).

34. BRAIN ACTIVITY

35. Be aware of your sensory needs….Be aware of the sensory needs of your students! Everyone has them!

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

39. 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

40. Problem Behavior: • Student does not conduct himself properly for the environment or situation. • Student’s 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: Who’s problem is it?

41. Prioritize need for Behavioral Change/Hierarchy: • Behaviors that harm self. • Behaviors that harm others. • Behaviors that harm property. • Behaviors that are disruptive. • Behaviors that are distracting.

42. 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

43. 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)

44. SESNORY BASED LEARNERSHandout

45. TASK AVOIDANCE Handout

46. Some common misconceptions about negative behavior and sensory concerns: • Sensory strategies will reinforce negative behavior. • “He enjoys it, there’s a smile on his/her face the whole time.” • “She can do it, she did it before…she just doesn’t want to.” • “He’s just being manipulative.”

47. 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)

48. Antecedent Control:Set 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.

49. Environmental Factors that Impact Behavior • 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 • 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

50. 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.