+ the integration of sensory modulation into acute behavioral health care new jersey ot conference...

+ The Integration of Sensory Modulation into Acute Behavioral Health Care

New Jersey OT ConferenceOctober 2, 2011

+ A Collaborative Effort: Workshop Presenters

Names and Schools Doris Obler, MSW, OTR/L – LIU - Brooklyn Renee Ortega, MS COTA/L, R-DMT – LIU -

Brooklyn Emily Raphael-Greenfield, EdD, OTR/L –

Columbia University Suzanne White, MA, OTR/L – SUNY Downstate

Organized effort to bring back OT services to Inpatient Psychiatry

Our plan: Start with one hospital and expand!

+Workshop Objectives

Identify research to support use of sensory modulation in acute settings

Examine the administration and interpretation of the Adolescent/Adult Sensory Profile 

Incorporate sensory techniques and interventions

Experiential Component of Workshop

Discuss potential collaboration with Behavioral Health Centers that do not have occupational therapy services.

+ Experiencing Sensory Modulation:Self Monitor – Take Your Sensory

Temperature

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+Governmental Regulation Supports

Sensory Modulation Approach

The President’s New Freedom Commission on Mental Health Consumer-driven services Evidenced-based Innovative methods of

CARESAFETYRESPONSIBILITY

+ 1999 Problem Statement National Association of State Mental

Health Directors

Overutilization of seclusion and restraint - symptom of the general culture in the clinical environment

Misapplication of the techniques for S&R creates safety issues

The rate of work-related injuries was higher in mental health settings than in construction

More staff injuries occur during the implementation of S&R than occur from unexpected assaults

Chemical Restraint

+Trauma-Informed Care

Understanding profound influence and high prevalence of trauma

Understanding the potential environment as source of trauma or reminder of trauma

Trauma Symptoms & Behaviors

Trauma-informed Assessment

+

OT Experts on Sensory Experiences

The experience of being human is embedded in the sensory events of everyday life. Dunn

Sensation are nourishment to the nervous system. Ayres

3 Goals of a practitioner using sensory integration therapy; Assist in reaching a state of calm alertness. Enhance the organization of sensation into

information. Acquire concepts that underlie learning. King

The only avenue for intervention is through the sensory system. Allen

+OTPF and Sensory Information

Where is Sensory Information in the Occupational Therapy Practice Framework? Performance Skills and Sensory–Perceptual Skills Client Factors and Body Functions

Categories Sensory Functions and Pain

Bodily Functions Client Factors

Body Structures

+

What is Sensory Processing?

The way the nervous system receives, organizes and makes sense of sensory information.

The ability to regulate and organize reactions to sensory input in a graded and adaptive manner.

The balancing of excitatory and inhibitory inputs and adapting to environmental changes.

Sensory information received from within the body and from the surrounding environment.

Ayres, 1960’s

Figure 11-8 Sensory Integration Theory and Practice, 2nd ed.Anita Bundy, Shelley Lane, Elizabeth Murray

Theory of Sensory Processing- Simplified

Sensory Processing

Miller, 2001

Sensory Detection

The awareness of present sensation.

It may be the conscious realization or the unconscious awareness of any sensation.

Sensory Modulation

The capacity to regulate and organize the degree, intensity, and nature of responses to sensory input in a graded and adaptive manner. This allows the individual to achieve and maintain an optimal range of performance and to adapt to challenges in daily life. (Miller & Lane, 2000)

Sensory Discrimination

The ability to discern the qualities, similarities, and differences among sensory stimuli, including differentiation of the temporal or spatial qualities of sensory input. (Miller and Lane, 2000)

Sensory Integration

The neurological process that organizes sensation from one’s own body and from the environment and makes it possible to use the body effectively within the environment.

(Ayres, 1979)

+Sensory Processing Dysregulation:

Who is at risk ?

Anxiety Disorders

ADHD

Dissociative Disorders

Autism spectrum disorders

Schizophrenia

Affective disorders

Substance use disorders

Dementia

Axis II Personality Disorders

+Introduction of Sensory

Modulation in Behavioral Health

To decrease seclusion and restraint

To manage sensory modulation on their own post discharge

+Emerging Best OT Practice: Sensory Emerging Best OT Practice: Sensory

Modulation Modulation

+Using Sensory Modulation Using Sensory Modulation

Approaches and Tools on an Approaches and Tools on an Inpatient Psychiatric ServiceInpatient Psychiatric Service

Incorporating sensory techniques increases the range of therapeutic options

for patients provides an opportunity for patients to

have greater input into treatment plans helps patients learn self regulation skills continues efforts toward use of

alternatives to seclusion and restraint, while increasing overall safety and promoting staff knowledge of therapeutic alternatives.

+Sensory Interventions for Acute

Units

Develop a Crisis Prevention Plan for early warning signs/triggers

Modify or enhance the physical environment

Create a Comfort (Sensory) Room

Develop individual Sensory Diets

Crisis Prevention PlanAdvanced Directive/Trauma History

University Hospital Nursing Station 52

Comfort/Sensory RoomsDemand-free

Patients can explore different modalities without expectations of accomplishment or understanding

Individuals determine whether sound, aroma, taste, tactile, proprioceptive or visual stimulation is most effective

Choice allows individuals to control and learn alternative methods of self regulation

+What is a Sensory Diet?

Regular, scheduled sensory stimulation for healthy, adaptive functioning

Start the dayCalm SafeComfortableHeavy work & VibrationRegular heart healthy meals

End the DaySleep work Calm MassageTo bed Soothing music

+Sensory Diet

Sensory Modulation Interventions: Uniquely Effective

Communication is the corner-stone of psychiatric intervention BUT when patients are highly stressed, thinking and problem solving capacities are diminished; patients are less able to use cognitive-based therapies.

Sensory modulation Does not introduce a potentially traumatic event Provides immediate calming sensory environment Creates self regulation experiences Enhances therapeutic relationships.

+Group and Individual Sensory

Interventions

Group teaches patients sensory-based self-assessment tools

Identify simple methods for altering

or improving their feeling states through sensory modulation both on the unit and after discharge

Improve ability to self-regulate

Patients too ill or in a crisis to manage group work.

Poor or slow responsiveness to psychopharmacological interventions and/or difficult to manage behaviors

Behavioral observation followed by regular use of sensory equipment incorporated into individualized treatment plan

Sensory Modulation Groups

Individual Sensory Modulation Interventions

+How do the Sensory Processing

Groups Help?

Opportunities for clients to control their environment

Planning for discharge

Preparation for independent living

Strategies for life challenges in the everyday world.

Decrease Seclusion & Restraint while hospitalized

Maximize staff involvement in discharge planning

+Recommendations for Increased

Use of Sensory Modulation Equipment

Evaluate sensory preferences of all new admissions

Place sensory preferences in patient charts

Occupational therapy consultants and students provide training for all staff on unit

Establish a sign-out sheet for sensory modulation equipment that is monitored by mental health aides

Incorporate sensory modulation equipment and a sensory modulation experience within all unit groups

Encourage use of available objects in patient bedrooms to promote sensory regulation (blankets, glass of water, shower, etc.)

+Assessment in Behavioral Health:Adolescent/Adult Sensory Profile

+Experiential Workshop: Take the

A/ASP!

+History and Purpose of the Sensory

Profile

Winnie Dunn and the Sensory Profile

Catana Brown’s dissertation Reliability and Validity tests Tested with individuals beyond childhood

diagnosed with schizophrenia, bipolar disorder, and no mental illness

Provides information about an individual’s sensory processing

Allows for treatment planning and intervention based on sensory considerations.

+Benefits of A/ASP

Theory based

Can cover the life span when taken together with the Sensory Profile and the Infant/Toddler Sensory Profile

Non-intrusive and easy to administer

Items focus on everyday life

+Theoretical Framework of A/ASP

+Sensory Profile’s 4 Quadrants

Low Registration: is the combination of high neurological threshold and passive self regulation strategy.

Sensation Seeking: is the combination of high neurological thresholds and an active self regulation strategy.

Sensory Sensitivity: is the combination of low neurological thresholds and a passive self regulation strategy.

Sensation Avoiding: is the combination of low neurological thresholds and an active self regulation strategy.

+Features of Sensation Seeking

Tend to create additional stimuli or look for highly stimulating environments

Tendency to explore their environments

Regard sensory experiences as pleasurable

Tend to get bored easily

May find low-stimulating environment intolerable.

+Features of Sensation Avoiding

May be bothered by input more than others

May be rule bound, ritual driven

May come across as uncooperative

May engage in various behaviors to limit the sensory input they face.

Gifted at creating low-stimulus environments.

Enjoy being alone.

We hypothesize that they limit sensory opportunities because unfamiliar sensory input is difficult to understand and organize and rituals provide a high rate of familiar sensory input, while simultaneously limiting the possibility of unfamiliar input.

Dunn (1997)

+Features of Sensory Sensitivity

Respond readily to sensory stimuli.

Distractible and upset by intense stimuli.

Notice stimuli as they occur.

High level of awareness of the environment.

Ability to be discriminative, and to attend to detail.

+ Features of Low Registration

Miss or take longer to respond to stimuli such as lack of awareness of name being called

May be the last to “get” a joke.

Can focus easily in distracting environments.

Has ability to be comfortable in a wide range of environments. 

Doesn’t cry when seriously hurt or injured and poor awareness of being touched

Preference for sedentary activities

Slow to respond to directions or complete assignments  

+Experiential Workshop:Case Study Application

Divide into small groups

Read 1 of 4 Case Scenarios in each group

In your group try to identify the sensory profile pattern and why for your selected case

Be ready to share your results

+Research to Support the Sensory

Modulation Model

Using Adolescent & Adult Sensory Profile (Brown & Dunn, 2002)

When compared to normal control, subjects with schizophrenia had higher scores on low registration and lower scores on sensation seeking (Brown et al. (2002) Schizophrenia Research).

Compared to general population, adults with OCD scored higher on low registration and lower on sensation seeking (Rieke & Anderson (2009) American Journal of Occupational Therapy).

+

Traditional Intervention Sensory Intervention in a Sensory Room

Alone time or quiet time Aromas

Increased supervision Candy (sweet or sour tastes)

1 to 1 staff time (most common choice) Colored eyeglasses

Pacing Kaleidoscopes

Space Restriction ( self release lap belts) Lava Lamps

Removed form Stimulation Music recordings

Room Schedules Scented Candles

As needed medication Sound recordings (e.g. waves, rain)

Tactile stimulation (e.g. Squeeze balls, sand table, tactile surfaces)

Wall images

Weighted Blankets

(Knight, et al., 2010)

+Research: Benefits of Sensory

ModulationDecrease in PRN medication

Help individuals on inpatient psychiatric units manage psychiatric symptoms

Increase in individual choice

Can offer common solutions for those learning to cope with complex symptoms and illness

Can redirect attention from intellectually based activities to one of the senses (Knight, et al., 2010)

+Multi-University Collaborative

Efforts: Assessment

Using the Adolescent/Adult Sensory Profile at Bellevue• Pilot Study (Spring 2011) using the Adolescent/Adult Sensory

Profile. A total of 19 profiles (6 female and 13 male) were reviewed

• Age range was 30-77.• Preliminary results: only 1 scored within the normal range.• Most significant area noted was Sensation Avoiding. • More than half scored “much more than most people”.

Pooling A/ASP Assessments by students from different university OT Programs

+ 

Collaborative Efforts with Groups: FW I Long Island University-

Brooklyn Staff was very interested in learning about Sensory Processing and implementing the techniques with patients

Students were excited about bringing OT to Bellevue psychiatry and administered 19 assessments, compiled the data and wrote individual results for each patient.

Patients were interested and willing to participate in the A/ASP assessment and to engage in groups which they found non-threatening and fun

+Collaborative Efforts:

LIU Groups at Bellevue

• Activity Rooms were converted into Sensory rooms during groups.

• The clients participated either standing or sitting in movement activities including a parachute, balls and ROM exercise providing proprioceptive and vestibular stimulation.

• The clients were offered sensory experiences including olfactory scents, tastes, nature tapes, and calming visual imagery.

+Collaborative Efforts: SUNY-

Downstate Groups at Bellevue

What are your 5 SENSES? Why is learning about your senses important?

+Collaborative Efforts: Downstate Groups Used The Sensory Survey

+Collaborative Efforts: Downstate Groups Make Senses Work for

Recovery:Recovery: Start a Sensory Tool KitSensory Tool Kit Make sensory

thermometer

Identify one place where you feel calm, safe, and comfortable.

Picture that place in your mind.

Do you feel any different after thinking about your comforting place?

Use the thermometer to notice the change.

Make visual reminder of your comforting place

+Collaborative Efforts: Downstate

Groups Use Self Discovery of Senses

1. Use my sensory thermometer

2. Use your calm, safe, comforting place as needed (PRN)

3. Bring in one object from your home you use to calm yourself.

My Sensory Goal for this Week

+Collaborative Efforts: Columbia University FW I Group Protocols

Sensory Mod Squad Group

Frame of Reference: Sensory Integration

Purpose: develop sensory strategies for self-soothing/alerting

Group Goals and Rationale: Combined Sensory Modulation with Cognitive and Social Communication Skills to avoid re-traumatizing patients

Outcome criteria: pre and post test identifying soothing and alerting stimuli

Method: 5 modules that introduce 7 senses; use of Build a City activity; musical activity; cooking activity; movement activity (Foster and Gardner, 2011).

+Collaborative Efforts: Columbia University FW I Group Protocols

Processing My Senses GroupFrame of Reference: Sensory IntegrationPurpose: develop greater awareness of sensory input and bodily responses Group Goals and Rationale: Increase sensory awareness and develop strategies for greater sensory regulationOutcome criteria: achieve 2 out of 5 goalsMethod: Overview of sensory modulation by psychoeducation; collage activity; music and movement; flubber making; create Sensory Kits (Fernandez & Solan)

+Columbia University FW I and Case

Study

A/ASP results – High Sensation Seeking

DSM IV: Bi-polar D/O, Schizoaffective D/O, Polysubstance Abuse, Personality D/O; GAF 25.

Strengths: Independent ADLs; Cognitively intact

Impairments: Poor IADLs; Poor emotion regulation

Interventions: Exploration of Sensory Equipment; Role Play to practice impulse control; Use of weighted vest throughout day

+Experiential Workshop:Case Study Application

In your small groups with same case scenario, identify any interventions you would recommend and why. Be ready to share your results.

+Interventions for Sensation

Avoiding

High Scores: Strategies to reduce environmental stimuli

Eliminate background noise Establish comforting and supportive routines Give yourself permission to be alone

Low Scores: Take breaks during movement activities Try meditation or other relaxation strategies Guard against overexposure to heat and cold

+Interventions for Sensory

Sensitivity

High scores: Eliminate distractions Add supports to help maintain focus Use rocking chairs for calming effects Use deep pressure touch rather than light touch

Low scores: Not a major area to address, because the

individual is aware of stimuli, but not distracted by them.

Make a conscious effort to attend to sensory features of daily life

+Interventions for Low Registration

High scores in Low registration Need for enhanced contextual cues to spark

registration of stimuli. Slow down rate of stimuli so that the individual

has the time to process. Use weights or other forms of resistance Add texture to objects to help with detection.

Low scores in Low registration Note: does not mean that individual is sensitive:

does not miss stimuli, but does not respond to it strongly.

Provide consistency, repetition. Seek familiarity in settings, people, experiences

+Interventions for Sensation

Seeking

Interventions for High Scores in Sensation Seeking Chew gum or eat mints when feeling restless Incorporate movement in activities Engage in movement activity before cognitive task Use bright lighting

Interventions for Low Scores in Sensation Seeking Explore new foods Change the order of your morning routine Take a bath or shower and use a textured washcloth

+Wilbarger Protocol

+Treatment of Adult Psychiatric Patients Using the Wilbarger

Protocol This pilot study examined the effect of the Wilbarger brushing

and joint compression protocol and sensory diet on symptoms associated with Sensory Defensiveness among 3 women with histories of self-injurious behaviors.

Treatment lasted approximately 1 month. Symptoms and patterns of role engagement and self-injury were compared before and nine months after treatment.

At follow-up all participants were re-engaged in valued roles with no incidents of self-injury. This treatment approach appeared to have some positive influence on Sensory Defensive symptoms. Results suggest that it may be useful in treating women with a history of self-injurious behavior and they indicate the need for further investigation of this treatment approach (Moore &  Henry, 2002).

+Benefits of Brushing Protocol

An improved ability to transition between various daily activities

An improvement in the ability to pay attention

A decreased fear and discomfort of being touched (tactile defensiveness)

An increase in the ability of the central nervous system to use information from the peripheral nervous system more effectively, resulting in enhanced movement coordination, functional communication, sensory modulation, and hence, self-regulation.

+Weighted Blankets

+Benefits of Weighted Blankets

A therapeutic modality: never to be used as a restraint:

To improve body awareness

To calm and improve attention and focus

To decrease self injury

+Experiential Workshop:Case Study Application

In your small groups with same case scenario, knowing his/her sensory patterns, identify any sensory interventions you would recommend and why( include proprioceptive, tactile, sensory kit, sensory diet, comfort room, etc.). Be ready to share your results.

+ Experiential Workshop:Consideration of Sensory Modulation

Across the Continuum of Care

Elicit different settings from audience

Elicit sensory interventions from audience

+ Experiencing Sensory Modulation:Self Monitor – Take Your Sensory

Temperature

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+Next Steps for Multi-University Collaboration

Fieldwork Level I Continued – Fieldwork Level II - Universities providing supervision

Re-employing OTs at psychiatric centers

Research A/ASP research continues Effect of sensory modulation interventions on patients

in inpatient units – new study

Keep mental health coursework/fieldwork in OT curriculum

Presentations at psychiatric grand rounds and conferences 

+References

AOTA Fact Sheets: Occupational Therapy’s Role in Mental Health Recovery & Occupational Therapy Using a Sensory Integration-Based Approach with Adult Populations.

Knight, M., Adkison, L., Kovach, J.S. (2010) A comparison of multisensory and traditional interventions on inpatient psychiatry and geriatric neuropsychiatry units. Journal of Psychosocial Nursing, 48, 24-31.

Brown C., & Dunn, W., (2002). Adolescent/Adult Sensory Profile. San Antonio, TX: The Psychological Corporation.

Bundy, A., Lane, S., Murray, E. (2002). Sensory Integration Theory and Practice, 2nd Ed. Philadelphia. F.A. Davis.

Champagne, T. (2008). Sensory modulation & environnent: Essential elements of occupation (3rd ed.). Southampton, MA: Champagne Conferences.

Champagne, T., Mullen, B. & Debra Dickson, D. (2007). Exploring the Safety & Effectiveness of the Use of Weighted Blankets with Adult Populations, American Occupational Therapy Association’s Annual Conference Presentation.

Dunn W. (1997). Implementing neuroscience principles to support habilitation and recovery. In: C. Christiansen & C. Baum, eds. Occupational Therapy: Enabling Function and Well-Being. 2nd ed. Thorofare, NJ: SLACK Incorporated; 186-232.

Miller, L. J. (2001) Sensory Integration Dysfunction in Individuals with Cognitive Disabilities. Unpublished Presentation for the Coleman Institute Workshop, Aspen, CO.

Miller, L. J., & Lane, S. J. (March 2000). Towards a consensus in terminology in sensory integration theory and practice: Part 1: Taxonomy of neurophysiological processes. Sensory Integration Special Interest Quarterly, 23, 1-4.

Moore, K., &  Henry, A. (2002). Treatment of adult psychiatric patients using the Wilbarger protocol. Occupational Therapy in Mental Health, 18(1), 43-63.

New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS pub no SMA-03–3832. Rockville Md, Department of Health and Human Services, 2003. Available atwww.mentalhealthcommission.gov/reports/finalreport/fullreport-02.htm

Rieke, E. F. & Anderson, D. (2009) Adolescent/adult sensory profile and obsessive compulsive disorder. American Journal of Occupational Therapy, 63,138-145.

Solomon, J. (2000). Pediatric Skills for Occupational Therapy Assistants. St. Louis, MO: Mosby.

+Presenters

Doris Obler, MSW, OTR/L – doris.obler@liu.edu

Renee Ortega, MS COTA/L, R-DMT – renee.ortega@liu.edu

Emily Raphael-Greenfield, EdD, OTR/L – eir12@columbia.edu

Suzanne White, MA, OTR/L – suzanne.white@downstate.edu

Contact information for Tina Champagne, OTD, OTR/L, CCAP

www.ot-innovations.com