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BRICK BY BRICK: The Framework for Social &

Leisure Groups

Friday, October 7, 2016Amy Fuhrman, CTRS

Mary Louise Kennedy, OTR/LWendy Lorince, MS, OTR/LJulie Marchal, MOT, OTR/L

Objectives• To identify treatment ideas for variety of patients in

both inpatient and outpatient settings

• To gain knowledge regarding the benefits of therapeutic groups.

• To identify a basic guideline for implementation of a variety of pediatric group treatments.

• To provide information regarding need for appropriate outcome measures when running a group.

• To share our projected plans for continuity of groups/care across all settings and CCCHR locations.

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"Play is often talked about as if it were a relief from serious learning. But for children play

is serious learning. Play is really the work of childhood."

-Fred Rogers

The Foundation

• Core tenet of both Recreation Therapy and Occupational Therapy is a focus on mental health, positive mental health, and social interaction.

• Both disciplines use group intervention to achieve goals to improve client’s general health and well being.

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EVERY MOMENT COUNTS

Blue Print for…

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Project Goals

• Build capacity of OTs, school personnel and families to promote mental health and contribute to prevention and intervention

• Develop, implement and evaluate model programs and embedded strategies focusing on mental health promotion

• Disseminate materials using website, Pinterest, and Facebook

Guiding Framework

Public Health Approach to Mental Health

• To address the mental health

need of all children

• The call is for a dual focus:

- Promotion of mental health

and flourishing in ALL

- Early detection &

intervention for those with

mental health concerns.

(Davis, 2002)

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Every Moment Counts

Project Emphasizes

• Mental health promotion- in students with and without disabilities and mental health challenges

• Inclusion of students with disabilities and/or mental health challenges with non-disabled peers

• Integrating related services in natural school and community contexts- academic and non-academic

• Collaboration among all school personnel, community providers and families.

Mental health promotion initiative

• Based on a solid understanding

of positive mental health

- What it is?

- How to promote it?

- Who should be involved

• Research: positive

psychology, mental health

literacy, positive youth

development, mental health promotion

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Being mentally healthy is a positive state of functioning

• Positive affect or emotional state. Feeling good emotionally- happy, content, positive about life, etc.- Observe children’s affect; note significant changes

• Positive psychological and social function- enjoy fulfilling relationships?

• Doing well functionally- engaging in productive activities- Academically, socially, physically

• Tune into children’s schoolwork, friendships, interaction during lunch and recess

• Coping with life stressors and challenges- Observe how does the child cope with a poor test grade, losing a

game, not making the team, being teased, etc

How to promote mental health?

• Participation in enjoyable activities (Fredrickson, 2001); experiences that induce positive emotions (Seligman, 2002)- joy pleasure, contentment- Repeated thought-action tendencies have the potential to broaden habitual modes of thinking and acting- Experiencing positive emotions can build enduring personal resources that can foster resilience in the face of challenges

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How to promote mental health?

• Use of individual character strengths (creativity, humor, kindness, curiosity, persistence)

• Helping others; acts of kindness (Lyubmirsky et al., 2005)

• Expressing gratitude (Heller et al., 2004)

• Positive institutions- environments that foster positive emotions and character strengths (Seligman, 2002)

How else to promote mental health?

Meaningful Leisure Participation

• Positive Youth Development: Leisure is a context for positive youth development (Larson, 2000)

• Key features:

- Regular participation schedules

- Direction by one or more adults

- Rule-guided interaction

- Emphasis on skill development

- Performance requires sustained active attention over time and the provision of feedback

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BENEFITS of Leisure Participation

• Personal Development

- Identity work (assess talents, interests, values)

- Development of initiative- involves intrinsic motivation, concerted engagement, and commitment over time (Larson, 2000)

- Development of cognitive physical and emotional skills

• Interpersonal development- new peer friendships, social skills, close connections to adults with social capital (Mahoney et al., 2005)

BENEFITS of Leisure Participation

Promotes positive mental health & builds resilience

• Participation in enjoyable activities brings about positive emotions- joy, pleasure, contentment, creativity…

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How we did it…

• 5 CCCHR OT’s participated in Phase 1 of EMC

• 2 OT’s participated in Phase 2 of EMC

• These OT’s brought information to different satellite offices via inservices, mental health awareness day activities, case discussions.

• As a result, 2 other OT’s joined EMC for Phase 3, which included development of 3 groups.

GAME BREAK

Blue Print for…

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Game Break!

OT Leisure Coaching in Outpatient ClinicJenny Negrey, MOT, OTR/L & Julie Marchal, MOT, OTR/L

Game Break!

• Goal: To foster independent/family leisure skills that will be carried over at home and with peers

• Target demographics: Youth with –- limited extracurricular leisure interests;

- limited friends at school; some had struggled with bullying

- co-existing mental health diagnoses and/or limited parental investment and involvement in child’s leisure pursuits

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Game Break!

Group components:• Began with a short ice breaker/intro activity (5 min.)

• Played 1 game each week: Charades/Pictionary, Outburst Jr., Puzzles, Trivial Pursuit Kids, Uno/Dominoes

• Group reflection and ‘homework’ at end: How did you like the game? Would you play it again at home? What did you learn?

Families received an information sheet each week about how to play and/or modify the game at home

Game Break!

At the end of the 5 week session: • Each child picked a game to take home• Families received a packet on how to implement a family

game night at home and an extensive list of appropriate games

Reactions of children & families: Very positive! • Children learned how to play games, take turns and interact

socially in positive ways; developed friendships• Parents were very pleased to see their children learning how

to play games, make new friends, and be happy.

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“It’s easier than you think”

• ‘It’s easier than you think’ to organize and implement groups promoting leisure participation in a large outpatient setting

• Obtain ‘buy in’ and support from administration: Have an implementation plan with purpose, goals, & benefits of the group including supporting research

• Demonstrate feasibility in terms of time, staffing, and needed materials.

Game Break! Video

http://www.everymomentcounts.org/view.php?nav_id=178

(http://www.everymomentcounts.org/view.php?nav_id=178)

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COMMUNITY BASED GROUP

Blue Print for…

Community-Based GroupJenny Negrey, MOT, OTR/L & Julie Marchal, MOT, OTR/L

• Pilot program with plans for future development

• Focus on IADL skills in real context

- Shopping

- Laundry

- Dining

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Community-Based Group

• Pre and post survey used to determine current frequency of community outings, patient confidence and performance in “community skills”

• Weekly group plan used, and given for home programming which included: - Skills Addressed

- Carry-over to home setting

- Preparation for next group outing

Sample: Target Skills Addressed • Reading/following a list

• Reading labels and department signs

• Physically navigating building

• Reaching for and/or carrying items

• Visual scanning

• Money management/estimation

• Estimating size for clothing items

• Social interaction – cashier, others in store, requesting assistance

• Transporting merchandise from store to car

• Using coupons (if applicable)

• Navigating dressing room (if applicable)

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Sample: Community “Home Program”

Grocery Store Potential Tasks 

Increasing Challenge  Decreasing Challenge 

Creating Grocery List  

Patient creates list (handwritten) Patient creates list (talk to text on smart

phone or typing on device) Patient selects items for list based on recipe

(simple or complex)

Caregiver creates visual list with actual pictures of product to match

Caregiver provides written list with exact name and brand

Gathering Items 

Patient is responsible for selection of route (with or without aisle numbers next to items)

Mixed item list vs. categorized list (listing all vegetables in one section of list or scattering list and allowing patient to organize) – will increase challenge of searching for items.

Have patient write approximate amount of item next to list (ex: $3.99 = 4.00)

Write aisle number next to item (this requires pre planning, however during next grocery trip, write numbers down and have idea for future reference)

Direct patient to correct aisle, instruct to walk down one side, then the other in search for item

Bring patient to correct area of aisle and direct to scan from top to bottom, left to right for item that matches picture

Checking out  

Patient estimates amount to pay within $10 Patient determines dollar bill amount to pay

cashier Patient reviews receipt and change received. Patient swipes card (if appropriate) and

follows commands on screen (read or point to prompts as needed)

Pt signs screen (if own card)

Give patient designated amount of money to purchase, have patient hand to cashier.

Use smart phone or calculator to estimate amount to be paid (assist by giving patient approximate prices, or use list with prices)

Patient swipes card when appropriate, parent completes transaction with commands on screen if unable.

Packing car, unloading car  

Pt organizes fragile items in car safely (eggs, bread)

Pt uses affected extremity only to pick up and place bags (R hand task)- loading and unloading

Pt responsible for safely navigating parking lot to return cart to store or cart return

Patient removes bags from cart and places in car with assistance to organize fragile items

Walk with patient to return cart for safety if needed Patient carries only items that are not fragile Uses unaffected extremity to complete task

To be continued…

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YOUNG ARTISTS

Blue Print for…

Young ArtistsJenny Negrey, MOT, OTR/L & Julie Marchal, MOT, OTR/L

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Young Artists

• 8 week group

• Each session with a focus on particular artist and artwork

• Promotion of

- Positive mental health

- Exploration of leisure pursuits

- Social skills and peer engagement

Young Artists • Utilized Devereux Student Strengths Assessment (DESSA) as

well as a specifically designed pre/post survey of interests and experiences with art.

• Hosted Art Show with family and community involvement at end of group

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Young Artists

Parent Support Group

Sample items from agenda:

• Benefits of Healthy Socialization in an Adolescent’s Social/Emotional Development

• Where to find programs, events and activities in community that promote healthy socialization

• Summer camps: planning, funding, and resources

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MODEL ME SOCIAL SKILLS GROUP

Blue Print for…

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Model Me Social Skills Group

• 12 weeks

• Can be used with a wide range of ages

• Uses video modeling

• Social Thinking Curriculum (Incredible Flexible You)

• Focus: explicit instruction on specific social skills

• 21 lessons to choose from

• Using the Home and Community Social Behavioral Scales for outcomes measurement

• Video Modeling is a visual teaching method that occurs by watching a video of someone modeling a targeted behavior or skill and then imitating the behavior/skill watched.

• Video Modeling is a simple and effective teaching tool that motivates children to learn through a fun and enticing visual medium

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Example of Video Modeling Segment

http://www.modelmekids.com/aspergers-syndrome-videos.htm

https://www.youtube.com/watch?v=0DLSf3lMkhs

(https://www.youtube.com/watch?v=0DLSf3IMkhs)

Sample Topics Covered in Model Me

• Talk on Topic

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Sample Topics Covered in Model Me

• Voice Volume Modulation

Sample Topics Covered in Model Me

• Good Listening

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Sample Topics Covered in Model Me

• Problem Solving

Sample Topics Covered in Model Me

• Self Calming

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Sample Topics Cvered in Model Me

Sample Topics Covered in Model Me

Parent Testimonials

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DRIVER’S ED

Blue Print for…

Driver’s Ed: An Anger Management Group for Kids

• 10 sessions

• Based on the book: What to do When my Temper Flares: A Kid’s Guide to Overcoming Problems with Anger, by Dawn Hubner, Ph. D.

• Best used with upper elementary aged kids

• Children learn to recognize triggers and employ 4 anger dousing strategies during hands-on lessons

• Using the HCSBS for outcomes measurement

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Pictures from Driver’s Ed

Pictures from Driver’s Ed

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POSITIVE PURSUITS

Blue Print for…

Positive Pursuits• 6-8 weeks

• Can be adapted for any age group

• Based off of Sue Bazyk’s research with Every Moment Counts and her HOPE manual for groups

• Kid Play Profile used to identify interests and areas for peer interaction

• Purpose:

- Explore and expand meaningful leisure pursuits

- Promote positive mental health

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Kid Play Profile

Kid Play Profile

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Kid Play Profile

Kid Play Profile

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Sample Leisure Pursuits Explored

CookingCCOOKING cCRAFTSBOARD GAMES

CSPORTS

CHIKING

CVIDEO GAMES

IN‐PATIENT GROUPS

Blue Print for…

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In-Patient Teams

• Peds

• Rehab

• Pain

• Day Treatment Program

• Dialysis

“Construction” Crew

• Case Manager

• Medicine-hospitalist/attending, Nurse Practitioner

• Music Therapy (MT)

• Nursing

• Nutrition

• Occupational Therapy (OT)

• Physical Therapy (PT)

• Psychiatry

• Psychology

• Recreation Therapy (RT)

• Registered Respiratory Therapy (RRT)

• Social Worker

• Speech & Language Therapy (SLT)

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Peds Team

- infants/toddlers-tracheostomy and ventilator dependent that are stable enough to leave NICU, or kids needing IV antibiotics or diabetes management- ages vary

• Play Group*

• Community Integration

• Story Time*

• Rehab Music Group

• Toddler Music Group *

• Low Stimulation Infant Music Group

• Stander Group with Music

Play Group

• Focuses on developmental play skills, social interaction, sensory stimulation, communication, gross/fine motor skills in a group setting

• 1 hour/day 1 day/week

• Lead by RTs; OT, PT, & SLT involved with planning and implementation as well- RRT will join as needed

• Older infants and toddlers (~9m-3yo)

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“Structure” to Play Group• Repetitious

- Sing hello and goodbye- Relaxation/Stretching/Positioning- Same theme for 3-4 consecutive weeks- Same time/day each week

• Modalities- Book and song for each theme- Art project- Sensory play- Movement Activity

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Story Time

- Newer Program

- Focuses on parent/family involvement in a less structured environment to help with bonding and interactions between parent and child

• siblings invited

- 1 hour/day 1 day/week

- Lead by RT

- Peds and Rehab units • infant-toddler age

Toddler Music Group

- Focuses on social interaction, following directions, turn taking, sharing and music exploration through singing, playing instruments and participating.

- Offered to Peds & Rehab Units• Peds unit- ~9m-3yo

• Rehab unit/Day hospital- 1-5yo

- Lead by MT, supported by RT

- OT, PT, and SLT join for co-tx during this group

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Music Group

Rehab Team• ages vary- TBI, SCI, stroke, cardiac, epilepsy

- tolerating 3 hours + a day

- Day Treatment Program- Kids within the Rehab program continue to attend an intense 3 hours +/day of therapy but go home or hotel/Ronald McDonald House for the night

• Rehab Group*

• Play Group

• Community Reintegration

• Evening RT

• Family RT

• Story Time

• Horticulture*

• Rehab Music Group

• Toddler Music Group

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Rehab Group

- Focuses on addressing social interaction, communication, executive function, fine/gross motor skills, and endurance in a group setting.

- 1 hour/day 3 days/week

- Plan & lead by RT, SLT, OT, Educator

• All therapies can co-treat during

- Any Child/Adolescent Kindergarten through 21 y/o participating in inpatient programs and recommended by a member of an inpatient team based on child's needs

Art Week: sun-catchers

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Movement Monday/Yoga

Fine Motor: Ring Art

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Who am I? Ice breakers, communication and social

interaction game

Horticulture Therapy

• Focuses on achieving therapeutic goals via gardening and wellness based activities

• 1-2x/month

• Lead by Horticulture Specialists

• Rehab, Pain, and Dialysis Units

• All therapies involved and co-treat

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Horticulture Therapy

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Pain Team• age range varies ~8-19yo – chronic pain, headaches, CRPS, POTS,

etc

• Intensive 2 week inpatient treatment and one week Day Treatment program

• Parents are encouraged to be very involved and there are programs specifically for them and as a family

• Back in the Game*

• Creative Arts Group

• Community Reintegration

• Aquatics Group

• Evening RT Group

• Leisure Education Group

• Family RT*

• Parent Wellness*

• Horticulture

Back in the Game

• Focuses on getting back to the game of life. Kids with chronic pain often withdraw from school, sports, friends, etc.

• 1x/week

• RT & Educator

• Variety of activities-- Wellness Wheel

- Role Playing

- Stress Activities

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Wellness Wheel

• There are several important elements to evaluating your overall wellness. The “Wellness Wheel: demonstrates how these elements interrelate to promote a general sense of well-being.

• Elements of the wellness wheel• Physical• Intellectual• Emotional• Social• Spiritual• Occupational

Parent Wellness

• 3 part program for parents to focus on their own wellness.

• Good for kids to see wellness as a life long issue

• Important for parents to take care of themselves

• 1x/week

• Wellness Wheel, Art Therapy Activity, Nutrition, and Relaxation

• Lead by: RT, Nutrition, Psychology

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Family RT

• Focuses on having fun as a family

• Allows and encourages getting to know and have fun with other families

• 1x/week

• Activities:• Team building

• Minute to Win It

• Art Projects

- Lead by: RT

Dialysis• 8 CCCHR hemodialysis patients at Judith M. Powers Unit ages 9-19 years old

with End Stage Renal Disease or Chronic Kidney Disease

- 3 days/week 4 hours/day for treatment

• Interdisciplinary team : Nephrologist, Nurse Practitioner, registered nurses, dietitian, psychologist, social worker, and Recreational Therapist.

• Group/individual treatments focused on-

- Facilitate interventions that teach patients life, social, and communication skills needed to obtain a kidney transplant. Through the various interventions our patients develop tools to improve appropriate social interactions, increase functional living skills, and create a sense of unity between the members in the dialysis unit. The ultimate goal of the program is to empower these teens to embrace their lives, not only as dialysis patients, but as maturing adults.

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“Construction” Tools

• GRST- General Recreation Screening Tool

• CAPE/PAC- Children’s Assessment of Participation & Enjoyment/Preference for Activities of Children

• Parent Surveys

• Developmental Milestone Guidelines

• Not a lot of EBP available for RT in pediatrics- future projects for RT Dept

ADDITIONAL LAYERS

Blue Print for…

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Construction Costs(Billing)

• RT does not bill to insurance, productivity minutes

- Billed under room charge/facility cost

• PT, OT, SLT bill group or individual treatment

• To bill group- must see at least 2 patients in the hour

• Minimal issues with reimbursement for in-patient and out-patient groups

• Different system to system

Mortar• Gap between in-patient and out-patient

groups

• Share information between locations on what groups are being offered.

• Get manuals together with framework, agendas, handouts, etc. for each group so that they can be implemented easily.

• Consult with school therapists, teachers, county board of developmental disabilities personnel, etc.

• Share successes and ideas for improvement.

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• EMC has increased national and international awareness of positive mental health and efforts to promote it.

• Additional funding is being explored to continue EMC initiative.

• EMC groups are being implemented through out the country.

• More facilities are doing research on positive mental health and use of groups.

Future Construction

References• Bazyk, S. (ed.). (2011). Mental health promotion, prevention, and intervention for

children and youth: A guiding framework for occupational therapy. Publisher: AOTA Press.

• Carolgraysocialstories.com. N.p., n.d. Web. 14 Sept. 2016.

• Davis, N.J. (2002). The promotion of mental health and the prevention of mental and behavioral disorders: Surely the time is right. International Journal of Emergency Mental Health,4(1), 3-29.

• Dunn Buron, Kari, Curtis, Mitzi. The Incredible 5-Point Scale. Shawnee Mission: Autism Asperger, 2004. Print

• Fredrickson, B.L. (2001). The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. American Psychologist, 56, 218-226.

• Hendrix, Ryan, Kari Zweber Palmer, Nancy Tarish, and Michele Garcia Winner. The Incredible Flexible You: A Social Thinking Curriculum for the Preschool and Early Elementary Years. Deluxe ed. Vol. 1. San Jose: Think Social, 2013. Print.

• Huebner, Dawn, Ph.D. What To Do When Your Temper Flares: A Kid's Guide to Overcoming Problems with Anger. Washington, DC: Magination, 2008. Print.

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References• Keyes, C.L. (2007). Promoting and protecting mental health as flourishing. A

complementary strategy for improving national mental health. American Psychologist, 62, 95-108.

• Larson, R. W. (2000). Toward a psychology of positive youth development. American Psychologist, 55, 170-183.

• Mahoney, J., Larson, R., & Eccles, J. (2005). (Eds.), Organized activities as contexts of development: Extracurricular activities, after-school and community programs. (pp. 3-23). Mahwah, New Jersey: Lawrence Erlbaum Associates.

• Modelmekids.com. N.p., n.d. Web. 14 Sept. 2016.

• Seligman, M.E.P. (2002). Authentic happiness. New York: Free Press.

• WHO (World Health Orgzanization). (2001). Mental health: new understating, new hope. The world health report. WHO, Geneva.