+ the integration of sensory modulation into acute behavioral health care new jersey ot conference...
TRANSCRIPT
+ 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 – [email protected]
Renee Ortega, MS COTA/L, R-DMT – [email protected]
Emily Raphael-Greenfield, EdD, OTR/L – [email protected]
Suzanne White, MA, OTR/L – [email protected]
Contact information for Tina Champagne, OTD, OTR/L, CCAP
www.ot-innovations.com