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Neuroplasticity and Development

Rewiring the Brain for Functional Changesin Learning, Behavior, Motor and Cognitive

Challenges

Presented by Debra Johnson, MS, OTR/L

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Goals for Today• Understand the neurological processes that define brain plasticity• Classify the different forms of plasticity as related to functional changes in skills and behaviors

• Identify the impact of neuroplasticity in typical and atypical development

• Examine the 10 principles of neuroplasticity and how they can be used in developmental therapy

• Learn how to add effective treatment techniques and activities to capitalize on neuroplasticity for improved functional outcomes

• Use sound evidence based reasoning to determine validity of neurologically based interventions

• Feel confident in explaining rationale for using neurologically based treatment interventions

• Advocate for and guide families in choosing appropriate interventions 2

Defining Neuroplasticity

Neuroplasticity: the ability of the brain to form and reorganize synaptic connections, especially in response to learning and experience or following injury

Developmental Neuroplasticity:changes in neural connections, brain structure, and function as influenced by biological processes and learning throughout the lifespan

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A Brief History• “Plasticity” was first used by William James, physician and psychologist, in 1890 publication of The Principles of Psychology

James had studied under Skinner; interested in emotion, habits, will, and how people may or may not change their responses to situations or stimuli

• Spanish neuroanatomist Santiago Ramon y Cajaldefined the neuron as the anatomical, physiological, genetic, and metabolic unit of the nervous system in his Neuron Doctrine (1899)

Cajal outlined his cerebral gymnastics hypothesis, suggesting that the capacity of the brain could be augmented by increasing the number of connections

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• Polish neuroscientist Jerzy Konorski postulated that morphological changes in neural connections could be the substrate of learning (1948)

• Canadian Psychologist Donald Olding Hebb articulated a theory regarding the possible neural mechanisms of learning and memory (1949)

• In the 1960s, research began linking neuroplasticity to behavioral responses in the context of behavioral psychology; findings indicated that short term plasticity was important in responses to sensory stimuli, behavior modification, learning and memory

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• Research in the 1970s and 1980s expanded understanding of brain chemicals, as well as synaptic and structural changes in response to external factors such as exposure or deprivation; early research and treatment for brain injury

• 1990‐1999: “The Decade of The Brain” as declared by President Bush; focused on educating the public about brain research, advancing research efforts, and funding programs for early childhood education as the result of increased awareness of crucial periods of brain development

• 2000 – today: Tremendous advances in neuroscience research with new technologies

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Current Research and Knowledge

• Neurogensis: critical in prenatal period, once thought to be impossible in adults is now considered to occur in certain areas of the brain such as the hippocampus even in old age

• Effects of medications, toxins, and environmental exposure to sensory input or chemicals on brain development and function is now widely accepted

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• Sleep, nutrition, exercise, and social interaction have been found to have positive impacts on neuroplasticity and brain health

• Trauma, especially in young children, has been identified as having a significant negative impact on brain development and functional behaviors

• Differences in brain structure and function have been identified for individuals with neurodevelopmental disorders

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But what do we really know?That the brain is perhaps more complex than ever imagined.

That a complex array of factors impact brain development and brain health, including genetics, physiology, environmental exposure, and experience.

That the brain is a dynamic organ, capable of change than can be either positive or negative.

That there is a distinct process in brain development that includes neuroplasticity, making intervention possible to support positive outcomes in learning and behaviors.

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What don’t we know?

How structural changes in the brain actually influence function, learning, or behavior

Causation versus correlation

How the brain processes and creates perceptions, emotions, and memories

How to “fix” a brain that has structural and functional differences that vary from “typical”

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BRAIN ANATOMY 101

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BRAIN DEVELOPMENT

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Brain Systems and Functions• Brainstem:

• Consists of the medulla oblongata, pons, midbrain

• Serves as a relay system coordinating messages from the body to the cerebral cortex

• Controls reflexes and automatic functions of the body

• Medulla oblongata controls breathing, blood pressure, heart rhythms, and swallowing

• Pons communicates with the cerebellum; controls eye and facial movements, equilibrium, facial sensations, and hearing as well as sleep, respiration, swallowing, and bladder control

• Reticular Activating System: responsible for sleep cycles and alertness, located in medulla, pons, midbrain, and thalamus

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Brain Systems and Functions• Cerebellum:

• Develops out of the hind brain

• Controls muscle tone and position of limbs, contributing to posture, balance, and equilibrium

• Fine tunes movements for accuracy and timing, allowing for rapid and coordinated movements

• Communicates with vestibular and visual systems as well as the prefrontal cortex.

• New findings suggest involvement in reward learning and social/emotional behaviors

• Does not cross midline: damage to one side of the cerebellum affects the same side of the body

• Has tremendous capacity for plasticity with possible neurogenesis 14

Brain Systems and Functions• Cerebrum:

• Largest part of the brain

• 4 lobes, 2 hemispheres

• Distinct functions between lobes and within lobes

• Complex connections that communicate between all lobes despite distinct functions

• Neural pathways travel to, from, and through the cerebrum to other parts of the brain

• Communication to the rest of the body is contralateral due to decussation of nerves where the medulla meets the spinal cord

• Has a great capacity for functional neuroplasticity, both developmentally and in response to injury

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Brain Systems and Functions

• Hypothalamus:• Acts as a relay to the pituitary gland

• Processes information coming from the autonomic nervous system

• Helps control eating, sexual behavior, and sleeping

• Regulates body temperature, emotions, secretion of hormones and movement

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• Thalamus: • Multiple functions, complex organ

• Major relay for sensory and motor pathways to the cerebral cortex

• Modulates input from the cerebral cortex with two way communication (cortex to thalamus to cortex)

• Believed to play a crucial role in consciousness, controls wake/sleep cycles

• Has connections to the cortex, cerebellum, and basal ganglia which appear to play a role in motor control

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• Limbic system:• Includes 4 structures in the midbrain

• hypothalamus, thalamus, amygdala, and hippocampus• Amygdala: memory, decision making, emotional responses

• Hippocampus: memory and learning; spatial skills• One of many parts of the brain that regulates visceral autonomic responses

• Influences the endocrine system• Plays critical role in emotional responses and behaviors• Supports memory, learning, and motivation• Has dopaminergic projections linked with rewards and addictive behaviors

• Connections to basal ganglia, influencing movement• Connections to prefrontal cortex, influencing motivation

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Neuroplasticity Processes in Brain Development

Proliferation

Pruning

Consolidation

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Proliferation • Is the third phase of CNS development in fetal development

• Begins at 2 to 4 months gestation with production of neuroblasts and glioblasts; Most rapid period of neurogenesis is from 5 to 12 months old

• Will result in one hundred billion nerve cells for brain development; 40‐50% more than needed for a mature brain

• Once thought to be completed in infancy, new research suggests that the hippocampus might be capable of neurogenesis into adulthood

• Also refers to the creation of new synapses during the lifespan20

Pruning

• The elimination or reduction of synaptic connections not used or relevant to behavior

• Occurs as a result of the brains over‐production of neurons, axons, and synaptic connections

• Begins at birth and continues into the mid‐20s

• Enhances efficiency of brain function

• Supports brain organization and consolidation

• Recent research suggests that pruning is abnormal in autistic brains, resulting in too many connections 21

Consolidation

• Refers to the organization of neural tracts and connections that supports memory and learning

• Occurs as a result of the brain processing and analyzing input, creating perceptions, and “testing” responses; requires increased frequency and duration of input to affect changes

• Allows the brain to create anticipatory response patterns that increase speed and efficiency

• Crucial for generalization of responses and mastery of skills

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Types of Neuroplasticity

Structural

Defined as the physical changes in the brain that result from experiences, learning, and memory.

May be an increased number of connections and growth in the size of a brain structure

May result in reduced connections and/or lack of growth in specific brain structure

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Types of NeuroplasticityFunctional

Refers to the brain’s ability to have cells around damaged tissue take on the function of the damaged cells.

Allows for re‐learning of skills lost after brain injury or stroke

Is present in brains of people born blind or deaf, where those areas of the brain take on additional functions of processing other sensory input (eg: occipital lobes process tactile input) and after hemispherectomies in children

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Development = Structural ChangeInjury = Functional Change

Neuroplasticity occurs throughout the lifespan with “critical periods” (CP) of development indicated by research

CP occur during the prenatal period, infancy through early childhood, and adolescence

CP are characterized by rapid changes in the structure and function of the brain, either through developmental processes or as a result of sensitivity to external factors

Despite the presence of CP, research indicates that brain changes can occur any time in the lifespan when stimuli are strong enough and conditions are conducive to learning or recovery 25

Functional Implications For Practice

Experience dependent neuroplasticity leads to structural changes in the brain with either positive or negative consequences that are dependent on the nature of the experiences.

Exposure to external stimuli such as toxins or stress can result in either suppressing or enhancing neuroplasticity.

Developmentally, the brain has a tremendous capacity to overcome structural disorders to enhance function.

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Functional Implications For Practice

Neuroplasticity related to learning is impacted by developmental disorders and brain changes that may or may not be malleable

Best practice involves consideration of current research and clinical experience to choose the appropriate intervention based on theories of neuroplasticity that consider the individual child

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Developmental Implications: Neuroplasticity through the Lifespan

Initially, the study of neuroplasticity was focused on behavior and learning as a way to measure changes in brain function. The assumption was that if behavior changed, the brain must have changed.

Current research focuses on actual physical changes to the brain in terms of structure and connectivity in the brain. Advancements in imaging and neuroscience methods have contributed to a surge in the study of brain plasticity in neurotypical individuals and how it progresses through the lifespan.

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Prenatal Period

Brain development is rapid and goes through predictable stages of proliferation

• 1st Trimester: Brain and spinal cord develop, first synapse impulses can be detected, unorganized firing

• 2nd Trimester: Brain stem is fully formed and bodily functions being regulated, including sleep cycles and swallowing; Rapid proliferation of cells and connections with beginning organization of function through the process of migration

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Prenatal Period

• 3rd Trimester: Continued proliferation and migration of cells to lay down the functional areas of the brain, increasing neural organization results in ability to process sensory input such as hearing, movement, and touch; Rapid growth period for the cerebral cortex, laying the groundwork for the brain’s ability to respond to experiences after birth

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Prenatal Period• Factors that influence brain health include genetics, maternal health, exposure to chemicals/toxins

• Functional deficits can often be predicted by the period in which injury or disruption occurs

• One study found structural changes in the brains of preterm infants that correlated with maternal report of high stress levels during pregnancy. (King’s College London, 2019)

• Using fMRI studies at 37‐39 weeks gestations, researchers identified that the brain organization and connectivity of fetuses was adversely affected by maternal stress, with the cerebellum particularly affected

(Cognitive Neuroscience Society, 2018)31

Prenatal Period

• A recent study revealed that fetal growth restriction in sheep altered cerebellar development. “We confirm that cerebellar injuries develop antenatally in FGR, and therefore, interventions to prevent long‐term motor and coordination deficits should be implemented either antenatally or perinatally, thereby targeting neuroinflammatory and oxidative stress pathways.”

(Yawno T,. Et al, 2019)

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Infancy ‐ Toddlerhood

• Critical Period of neural connections, organization, establishing pathways for responses, and pruning of unused synapses

• While previous researchers theorized that brain changes would only occur in responses to large intensity events, new studies reveal significant changes in brain structure as a result of small and even innocuous events

• Primary factors for plasticity at this age are sensory‐motor experiences and social connection; poorly developed frontal lobes with significant proliferation of connections and organization occurring in the brain 33

Infancy ‐ Toddlerhood

• Laboratory studies on infant rats have shown significant changes in brain structure in response to deprivation, enrichment, and complexity of the sensory environment.

(Kolb & Gibb, 2011)

• Study of preterm infants’ responses to touch indicate changes in brain response. “We showed that, when controlling for prematurity and analgesics, supportive experiences (e.g., breastfeeding, skin‐to‐skin care) are associated with stronger brain responses, whereas painful experiences (e.g., skin punctures, tube insertions) are associated with reduced brain responses to the same touch stimuli. Our results shed crucial insights into the mechanisms through which common early perinatal experiences may shape the somatosensory scaffolding of later perceptual, cognitive, and social development.

(Maitre, et al,2017)

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Early Childhood• Learning continues through sensory motor experiences, social interactions, and opportunity for unstructured, self‐directed play

• Rapid period of pruning and organization in the brain; continued development of frontal lobes and connections that support problem solving, self‐regulation, and learning

• Children learn through a variety of methods including non‐associative learning (CNS functions), associative learning (conditioned responses), imitation, and reasoning

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Early Childhood• Many studies are now showing the significant impact that exposure to language has on the developing brain throughout childhood. The American Academy of Pediatrics emphasizes the importance of language exposure, reading out loud, and engaging with children of all ages as key to developing later literacy success.

(American Academy of Pediatrics, 2014)

• Children’s neural connectivity is directly linked to language exposure and research shows that children have a strong preference for conversational language, benefitting from adult‐child conversations. (Romeo, et al; 2018)

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Early Childhood• Research has long supported the need for repetition in experiences and exposure for neurological and learning changes to occur in young children. (LoBue, 2019)

• Relationships, environment, stress, diet, hormones and medication are some of the external factors that influence neuroplasticity and synaptic connectivity throughout childhood (Kolb & Gibb, 2011)

• Self‐regulation exhibits rapid changes during childhood with recent research showing that improved cognitive control results in improved emotional regulation suggesting relevance for improved executive function skills.

(Hendricks & Buchanan, 2016) 37

Adolescence

• Continued rapid development of frontal lobes and connectivity for reasoning, judgement, and decision making.

• Critical period of pruning occurs during adolescence with increased organization of the brain connections evident in imaging studies.

• Myelination rate increases during adolescence, resulting in more efficient and stable connections throughout the brain.

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Adolescence

• “Adolescent brain transformations include both progressive and regressive changes that are regionally specific and serve to refine brain functional connectivity. Along with still maturing inhibitory control systems that can be overcome under emotional circumstances, the adolescent brain is associated with sometimes elevated activation of reward‐relevant brain regions, whereas sensitivity to aversive stimuli may be attenuated. At this time, the developmental shift from greater brain plasticity early in life to the relative stability of the mature brain is still tilted more towards plasticity than seen in adulthood, perhaps providing an opportunity for some experience‐influenced sculpting of the adolescent brain.”

(Spear, 2013)39

Adulthood• Once believed to be a period of declining brain health, current research supports theories of lifelong neuroplasticity.

• New learning appears to enhance neural connections well into the later years of adult life and the capacity to learn new information/skills continues throughout the lifespan, in the absence of illness or injury.

• There is evidence of sleep, nutrition, exercise and social activity level impacting brain health regardless of age.

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Adulthood

• Adults have the capacity to make conscious choices that alter brain connections and structure through forming new habits while eliminating old ones.

• Fully mature frontal lobes allow adults to exercise insight and self‐awareness, with increased cognitive control over self‐regulation. However, research suggests the prefrontal cortex continues development well into the 4th and 5th decades of life.

• Daily exercise appears to contribute to the growth of the hippocampus even in elderly adults, supporting memory and learning as we age. (Varma, et al; 2015) 41

Neurodevelopmental Disorders: Implications for Neuroplasticity

What is a neurodevelopmental disorder?• Genetic or acquired biological disability in the functioning of the brain that results in dysfunction in the child’s behavior related to emotion, learning, self‐control, memory, and/or motor control.

What factors contribute to neurodevelopmental disorders?• Genetics and DNA expression, injury, metabolic or immune disorders, exposure to toxins, social deprivation, and nutrition

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Types of neurodevelopmental disorders

• Intellectual disability• Specific Learning Disorders• Autism Spectrum Disorders• Motor Disorders (including DCD, dyspraxia, stereotyped movements)

• Tic Disorders• TBI (congenital injuries or CP; acquired trauma)• Communication, speech & language disorders• Genetic disorders (Fragile X, Down Syndrome, ADHD, mental health disorders, physical disorders)

• Disorders due to exposure to neurotoxins (Fetal AlchoholSyndrome, heavy metal exposure, drug exposure)

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Brain Differences in Atypical Populations

• fMRI studies revealed significant differences in connectivity between the brains of children with dysgraphia or dyslexia and a control group.

(Richards, et al; 2015)

• Structural brain differences are identified in children with reading disorders and are present prior to instruction and development of reading/writing skills.

(Eckert, et al; 2017 and Vanderauwera, et al; 2017)

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• Imaging revealed significant differences in brain structures of children with HFA/Asperger Syndrome, and nonverbal learning disorders. Especially affected were the hippocampus, amygdala, and anterior cingulate cortex, all of which play a part in emotional regulation, impulse control, and decision making.

(Semrud‐Clikeman, et al; 2013)

• Children with nonverbal learning disorder presented with a smaller splenium of the corpus callosum, which carries fibers connecting the temporal and parietal lobes as well as those linking primary and secondary visual areas.

(Fine, et al; 2014)

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Imaging study on ADHDOver 3200 participants; International study; participants ranged from 4 years old to 63 years oldThe study found that overall brain volume and five of the regional volumes were smaller in people with ADHD ‐‐ the caudate nucleus, putamen, nucleus accumbens, amygdala and hippocampus. In addition, these differences were notable in children but less so in adults. The differences were not correlated with prior medication use."The results from our study confirm that people with ADHD have differences in their brain structure and therefore suggest that ADHD is a disorder of the brain," added Dr Hoogman. "We hope that this will help to reduce stigma that ADHD is 'just a label' for difficult children or caused by poor parenting.”

Radboud University Nijmegen Medical Centre (2017)46


Autism StudiesMost of the symptoms of ASD develop in the first few years of life when synaptic development and maturation are occurring at a rapid rate, and one of the most consistent morphological findings that emerged from the structural neuroimaging studies in ASD is early brain overgrowth. Such atypical brain enlargement appears to be most pronounced between 2 and 5 years of age, and it preferentially affects the frontal and temporal cortices. Furthermore, recent evidence indicates that atypical cortical development in ASD subjects persists beyond toddlerhood. In particular, evidence of cortical thinning has been observed among adolescents and young adults. These observations led to the hypothesis that ASD is associated with a significant disruption of the typical synaptic maturation and plasticity. (Desarkar, et al; 2015)

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Autism Studies• fMRI studies show aberrant connectivity in children with autism as well as adults. Research is not clear on whether ASD might involve hypo‐connectivity or hyper‐connectivity as studies exist with both outcomes evident.

• “ASD is likely a 'neural systems' condition that is mediated by abnormalities in regionally distributed cortical networks rather than separated brain regions. Therefore, ASD has also been referred to as a 'developmental disconnection syndrome’.”

(Ha, Sohn, et.al; 2015) 48


Autism StudiesRecent studies are exploring ways to definitively diagnose ASD earlier in order to provide supports for improved outcomes in development.

A study conducted by researchers at Dartmouth College identified a specific marker in binocular rivalry deficits that was 87% accurate in diagnosing autism and predicting severity of symptoms in children. The marker shows that individuals with autism are slower to dampen neural activity in response to visual signals in the brain, which correlates with prior research showing reduced effects of the neurotransmitter GABA to filter and regulate sensory signals in the autistic brain. (Spiegel, et al; 2019)

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Childhood Trauma

TerminologyChildhood TraumaA psychologically distressing event involving “exposure to actual or threatened death, serious injury, or sexual violence…” (American Psychiatric Association, 2013, p. 261). Involves a sense of fear, helplessness, and horror. Childhood trauma occurs whenever both internal and external resources are inadequate to cope with an external threat (van der Kolk, 1989).

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Childhood TraumaTerminology

Adverse Childhood Experiences (ACEs)is the term used to describe all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18.” – US Department of Health and Human Services, 2019 Includes: Abuse, Neglect, Household Dysfunction, Medical Trauma, Discrimination, Community Violence, School Violence and other problems, Disasters, and Poverty

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/aboutace.html 51

Childhood Trauma

Terminology

Complex Developmental Trauma

• Results from chronic interpersonal trauma (i.e., child maltreatment)

• Results in higher levels of dysregulation (affective, physiological, attentional, behavioral, and relational), functional impairments, and psychiatric hospitalizations

(Kisiel et al., 2014)52

Childhood Trauma

Neurological Effects of TraumaChemical: Changes in dopaminergic system, lower oxytocin production, excess cortisol production, and atypical hypothalamic‐pituitary adrenal function

Cellular: Changes include and compound due to hormonal changes; Excess glucocorticoid increases cell death in hippocampus. Brain circuitry is disrupted, parasympathetic nervous system states remain elevated which increases fear based responses.

Cortical: Changes include deficits in frontostriatal region and deficits in somatosensory cortex and medial temporal lobe

(Ashcroft, Lynch, Tekell; 2019)53

How Can We Harness Brain Plasticity to Support Development?

Understand typical and atypical brain development

Appreciate the limits of neuroscience

Consider all the complexities of development

Focus on functional changes as outcomes

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Neurorehabilitation

“(Neurological) rehabilitation is a process of education of the disabled person with the ultimate aim of assisting that individual to cope with family, friends, work, and leisure as independently as possible. It is a process that centrally involves the disabled person in making plans and setting goals that are important and relevant to their own particular circumstances. In other words, it is a process that is not done to the disabled person but a process that is done by the disabled person themselves, but with the guidance, support, and help of wide range of professionals. Rehabilitation has to go beyond the rather narrow confines of physical disease and needs to deal with the psychological consequences of disability as well as the social milieu in which the disabled person has to function.” (Barnes, 2004)

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How can we use this approach to support individuals with neurodevelopmental disorders?

Habilitation: Services that help a person learn, keep, or improve skills and function for daily living activities.

Rehabilitation: Services that support restoration of skills, abilities, or knowledge that may have been lost or compromised as a result of illness, injury, or acquiring a disability.

In neurorehabilitation, we support the person in regaining skills based on principles of neuroplasticity. Since we now have evidence of neurodevelopmental disorders being characterized by neurological differences, it is a natural step to attempt to apply the these rehabilitation principles to this population.

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The problem is that we often…

Forget about the principles of rehabilitation and don’t address the psychological or social aspects of the disability

Focus on “fixing” the child so that they function in a “typical” manner

Provide treatment strategies in a “one size fits all” approach

Fail to recognize the limits of neuroscience; Equate brain changes with functional changes in behavior

Don’t follow best practice guidelines for evidence based practice

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We can be successful when we…

Focus our efforts on the whole child

Strive to support the child’s ability to learn and gain new skills that are relevant and meaningful to them

Recognize individual differences

Understand the research: neuroscience and interventions

Use evidence based practice to guide treatment plans and use of interventions for FUNCTIONAL OUTCOMES

Educate families and children on their disability or disorder

Advocate in the community 58

Principles of Neuroplasticity

Use Or Lose ItUse And Improve ItSpecificityRepetition MattersIntensity MattersTime MattersSalience MattersAge MattersTransferenceInterference (Kleim & Jones, 2008)

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Use It OR Lose ItFailure to drive specific brain functions can lead to functional degradation.

“Research shows that neural circuits not actively engaged in task performance for an extended period of time begin to degrade. This was shown first in the 1960s by Hubel and Wiesel, whose experiments revealed degradation and reduced number of neurons in the visual cortex of mice when one eye was sewn shut.”

“Deprivation of one sensory modality may cause its corresponding cortical area to be at least partially taken over by another modality. For example, fMRI studies of blind subjects show activation of the visual cortex with tactile stimulation, whereas deaf subjects show auditory cortical activation to visual stimuli.” (Kleim & Jones, 2008)

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Use It AND Improve ItTraining that drives a specific brain function can lead to an

enhancement of that function.

“A great deal of research indicates that behavioral experience can enhance behavioral performance and optimize restorative brain plasticity after brain damage. It has long been known that housing animals in complex environments pre‐ and/or post‐injury can enhance functional recovery.”

“Motor skill training after unilateral cortical damage has been found to both improve motor function and to drive restorative neural plasticity in remaining cortical regions.”

(Kleim & Jones, 2008) 61

SpecificityThe nature of the training experiences dictates the nature of

the plasticity.“In many studies, learning or skill acquisition, rather than mere use, seem to be required to produces significant changes in patterns of neural connectivity. For example, motor skill acquisition is associated with the changes in gene expression, dendritic growth, synapse addition, and neuronal activity in the motor cortex and cerebellum.”

“Learning‐induced brain changes in also show regional specificity. For example, unilateral training in reach‐and‐grasp tasks in rats causes dendritic growth in the motor cortex contralateral to the trained limb but has only subtle effects on the ipsilateral motor cortex.” (Kleim & Jones, 2008) 62

Repetition Matters

Induction of plasticity requires sufficient repetition.“Repetition of a newly learned (or relearned) behavior may be required to induce lasting neural changes. For example, rats trained on a skilled reaching task do not show increased in synaptic strength, synapse number or map reorganization until after several days of training, despite making significant behavioral gains.”

“We suggest that a sufficient level of rehabilitation is likely to be required in order to get the subject “over the hump” – that is, repetition may be needed to obtain a level of improvement and brain reorganization sufficient for the patient to continue to use the affected function outside of therapy and to maintain and make further functional gains.” (Kleim & Jones, 2008)

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Intensity MattersInduction of plasticity requires sufficient training intensity

“Animals trained on a skilled reaching task to perform 400 reaches per day had increases in synapse number within the motor cortex, whereas animals trained to reach 60 times per day did not have such increases…Transcranial magnetic stimulation experiments within human motor cortex have shown that stimulation trains consisting of 1800 pulses, but not 150 pulses, were sufficient to induce lasting increases in motor‐evoked potential amplitudes.”

“One potential negative side effect of training intensity after brain damage is that it is possible to over‐use impaired extremities in a manner that worsens function.”

(Kleim & Jones, 2008)64

Time MattersDifferent forms of plasticity occur at different times during

training“The neural plasticity underlying learning can be best thought of as a process rather than as a single measurable event. Indeed, it is a complex cascade of molecular, cellular, structural, and physiological events. Certain forms of plasticity appear to precede and even depend upon others. Thus, the nature of the plasticity observed and its behavioral relevance may depend on when one looks at the brain.”

“If therapy promotes neural restructuring, then it should work anytime, but there may be time windows in which it is particularly effective in directing the lesion‐induced reactive plasticity.” (Kleim & Jones, 2008) 65

Salience MattersThe training experience must be sufficiently salient to

induce plasticity.“Research using auditory tones as classical conditioning stimuli has…demonstrated that plasticity within the auditory cortex is dependent upon the salience of the experience. In this paradigm, animals are trained to recognize a tone of a specific frequency in order to receive a reward. Thus, one tone becomes more salient than the others. Animals trained in such a manner show an increase in the representation of the salient tone within the auditory cortex. Simply playing the tone without the reward does not alter the topography of the auditory maps.” (Kleim & Jones, 2008)

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Age MattersTraining‐induced plasticity occurs more readily in

younger brains“It is clear that neuroplastic responses are altered in the aging brain. Normal aging is associated with widespread neuronal and synaptic atrophy and physiological degradation. ..and some have argued that plasticity is the mechanism by which the brain compensates for aging. Nevertheless, the aging brain is also clearly responsive to experience, even though the brain changes may be less profound and/or slower to occur than those observed in younger brains. There is evidence in both humans and animal models that the effects of aging vary with lifespan experiences and are generally better in inidividuals with greater physical and mental activity.” (Kleim & Jones, 2008)67

TransferencePlasticity in response to one training experience can

enhance the acquisition of similar behaviors.“Transference refers to the ability of plasticity within one set of neural circuits to promotes concurrent or subsequent plasticity. It has long been known that rats house in complex environments have better functional outcomes…compared with rats housed in standard laboratory environments.” “Although learning may be needed to promote the formation of functionally appropriate synaptic connections after brain damage, exercise may be more appropriate for promoting a fertile environment to support these changes.” (Kleim & Jones, 2008) 68

Interference

Plasticity in response to one experience can interfere with the acquisition of other behaviors.

“Interference refers to the ability of plasticity within a given neural circuitry to impede the induction of new, or expression of existing, plasticity within the same circuitry.”

“It is possible for behavioral experiences to drive plasticity within residual brain areas in a direction that will impede optimal behavioral recovery. Brain damage survivors may develop compensatory strategies that easier to perform (“bad habits”) than more difficult but ultimately more effective strategies acquired through rehabilitation.”

“When maladaptive, these self‐taught compensatory strategies may induce plasticity that will have to be overcome with subsequent rehabilitation and other treatment approaches.” (Kleim & Jones, 2008) 69

Good Foundations For Brain Health

Science has identified FIVE key components for healthy brain development throughout the lifespan.

Nutrition

Sleep

Exercise

Social Interaction

Reduced Stress

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Children with neurodevelopmental disorders…

May be picky eaters, problem feeders, or medically complex which limits or negatively impacts nutrition.

May have sleep disorders or struggle with good sleeping hygiene

May be limited in physical skills or capacities which limit exercise and activity level

May have social impairments which limit social interactions or cause social isolation

May be subject to increased stress and trauma which negatively impacts brain function

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Remember that effective interventions…

...start with good foundations:

Nutrition, Sleep, Exercise/Activity Level

Enhance relationships and social interactions

Reduce stress for child and family/caregivers

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…are selected through:

Sound clinical reasoning guided by evidence‐based practice

Collaboration with parent/caregiver for goals, resource allocation, and commitment

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…are guided by:

Individual differences and response to treatment

Parent/caregiver goals, resources, and investment

FUNCTIONAL and MEANINGFUL OUTCOMES74

Evidence‐Based Practice: An Overview to Guide Decision Making

Evidence‐based practice (EBP) is based on integrating critically appraised research results with the

practitioner’s clinical expertise, and the client’s preferences, beliefs, and values. (AOTA.org; 2019)

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Evidence‐based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decision making is derived principally from non‐research evidence sources such as expert opinion and scientific principles. As more research is done in a specific area, the research evidence must be incorporated into the EBP.

(Titler, 2008)76

Tools for Decision Making • The Research Pyramid• The CRAAP test• Think F.I.R.S.T.• Sources cited • Professional and Expert opinions• Claims made by the program’s marketing• Cost of intervention• Potential benefits• Potential harm

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From: Research Pyramid: A New Evidence-Based Practice Model for Occupational Therapy

Am J Occup Ther. 2011;65(2):189-196. doi:10.5014/ajot.2011.000828

Research Pyramid.Note. Meta- = meta-analyses.

Legend:

The American Journal of Occupational Therapy

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The CRAAP test

Guide for evaluating information developed by California State University, Chico (2010). Can be applied to research studies, articles, and websites.

Currency: The timeliness of the information.Relevance: The importance of the information for your needs.Authority: The source of the informationAccuracy: The reliability, truthfulness and correctness of the

content.Purpose: The reason the information exists.

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Think F.I.R.S.T.

• Funding: What is the source of funding for the study? What are the potential conflicts of interest?

• Investigation: Correlation or Causation? Cohort or case study? Randomized with control group?

• Result: How are the results presented? Definitive findings, hsuggestion of findings, consideration for limitations?

• Subjects: Animals or people? How many? Who?

• Time: How old is the study? How long did the study run? 80

Guidelines for ImplementationDo your research (see Tools for Decision Making)Discuss findings and optionsChoose an intervention that fits into EBP and meets the needs of the child/familyFollow the 10 Principles of NeuroplasticityRe‐assess on a regular basisModify approach in response to re‐assessmentEnd intervention appropriately

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One Size Does NOT Fit All

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Clinical interventions are likely to be effective if:

They address foundations of brain health

They have been proven to be effective with sound research

They are clinically appropriate for the individual

They are easy to implement and consistent with 10 Principles of Neuroplasticity

Child is actively engaged in the process

Parent/caregiver supports the intervention 83

Clinical interventions may be lesseffective if:

They are touted to “cure everything” and “work for everyone”

They have only been tested on healthy individuals or research does not pass EBP criteria

Implementation is not sustainable or consistent with 10 Principles of Neuroplasticity

Child is passive in process

Parent/caregiver is not supportive of the intervention84

Five Categories of Effective Interventions

1. Relationship Based

2. Play Based

3. Music and Auditory techniques

4. Movement and motor skills

5. Meditation and Mindfulness85

Relationship Based

There is an ever increasing focus on the importance of parent‐child relationships and the impact that either positive or negative relationships have on a child’s development.

If a strong, trustworthy, and stable relationship is crucial for child development, we must focus our efforts on establishing and supporting these relationships for all children.

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What does the research say? • Conversational language between adult & child improves language and cognition more than “exposure to words” (Romeo, et al; 2018)

• Touching, hugging your child is crucial for sensory development and supports brain development

(Maitre, et al; 2007)

• Social connection supports co‐regulation; co‐regulation is a critical step to support children in learning how to self‐regulate (Housman, et al; 2018)

• Unstable parent/child relationships lead to increased anxiety and difficulty with self‐regulation, behaviors, and social engagement (Golden, 2019) 87

Interventions that Use and Support Relationships

DIR/Floortime

STAR Institute Treatment Model; integrates DIR with SI intervention

Collaborative & Proactive Solutions Model for challenging behaviors

Social‐Emotional learning programs

Trust Based Relational Intervention (TBRI); trauma informed care

Early Intervention models: parent coaching88

“Outcome measures in developmental relationship‐based interventions examine the caregiver’s sensitivity and ability to perceive and infer the child’s intent by observing the child’s gestural and/or verbal cues; the caregiver’s skill in following, pacing and responding to the child’s intent; and the extent to which caregivers are effective in establishing reciprocal social 6 exchanges, expanding on the child’s idea, and supporting the child’s initiation and shared problem solving. The outcomes of these studies, using valid and reliable measures document that DRBI consistently improve caregiver sensitivity, responsivity, and effectiveness leading to the improved social relationships and functional development including improvement in joint attention, initiation, language, play skills, social interactions and functional development.”

(Cullinane, et al; 2017) 89

Integrating Relationship Based Practices into Intervention

• Supporting Child/Caregiver Relationships: • Establish relationship with the caregiver first

• View the child/caregiver relationship holistically through a wide contextual lens

• Speak from the child’s perspective to help foster understanding from the caregiver

• Model appropriate interactions that support therapeutic goals

• Empower caregivers and support belief of competency

• Refer for appropriate support services when necessary90

Integrating Relationship Based Practices into Intervention

• Provide care from an empathic viewpoint• Strive to establish a relationship based on trust and respect between you and the child

• Consider the child’s needs being expressed by behaviors

• View the situation from the child’s perspective, considering factors that may not be visible to you as impacting behaviors or response to treatment

• Use empathic communication

• Focus on strengths

• Develop your therapeutic use of self to support co‐regulation with children 91

Making Connections

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Play Based

After decades of increased academic expectations on young children in an effort to boost learning, researchers are now focusing on the importance of play as a foundation for learning.

Play has been identified as building social skills, improving creativity and problem solving, enhancing self‐regulation, and supporting executive function skills. Supporting children in play can have a profound impact on development.

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What does the research say? • Play is essential for healthy brain development.

• Play reduces obesity and associated diseases.

• Play helps children manage stress and even recover from trauma.

• Play helps families bond.

• Play contributes to academic skills.(American Academy of Pediatrics, 2018)

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Interventions that Use and Support Play

DIR/Floortime

The Play Project

Ayres SI® Treatment model

Integrated Play Group model

Denver and Early Start Denver Models

Play Therapy

OT, PT, and speech therapy 95

Research demonstrates that developmentally appropriate play with parents and peers is a singular opportunity to promote the social‐emotional, cognitive, language, and self‐regulation skills that build executive function and a prosocial brain. Furthermore, play supports the formation of the safe, stable, and nurturing relationships with all caregivers that children need to thrive.

Play is not frivolous: it enhances brain structure and function and promotes executive function (ie, the process of learning, rather than the content), which allow us to pursue goals and ignore distractions.When play and safe, stable, nurturing relationships are missing in a child’s life, toxic stress can disrupt the development of executive function and the learning of prosocial behavior; in the presence of childhood adversity, play becomes even more important. The mutual joy and shared communication and attunement (harmonious serve and return interactions) that parents and children can experience during play regulate the body’s stress response.

(American Academy of Pediatrics, 2018)96

Integrating Play Based Practices into Intervention

Play is: Pleasurable: Children must enjoy the activity or it is not play

Intrinsically Motivated: Children engage in play simply for the satisfaction the behavior itself brings. It has no extrinsically motivated function or goal.

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Play is: Process Oriented: when children play, the means are more important than the end.

Freely Chosen: It is spontaneous and voluntary. If a child is pressured, they will likely not think of the activity as play.

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Play is: Actively Engaged: Players must be physically and/or mentally involved in the activity.

Non‐literal: In involves make‐believe or suspension of reality

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Types of Play: Social Play

Physical or “Rough & Tumble” Play

Pretend Play

Outdoor Play

Media Play100


Role of the Adult: Onlooker

Stage Manager

Co‐Player

Play Leader

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Facilitating Play: Follow the child’s lead

“Strew opportunities” for exploration and discovery

Scaffold for skill development/support

Provide adequate time for the development of the play experience

Provide a variety of equipment/materials for exploration

Support caregiver participation in play activities102

Making Connections

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Music & Auditory Interventions

“Music can lift us out of depression or move us to tears – it is a remedy, a tonic, orange juice for the ear. But for many of my neurological patients, music is even more – it can provide access, even when no medication can, to movement, to speech, to life. For them, music is not a luxury, but a necessity.”

Oliver Sacks, neurologist

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What does the research say? • fMRI studies revealed stronger auditory‐limbic connectively in the brain when people listened to music they preferred. (Wilkens et al, 2014)

• Music training induces brain changes and skills enhancement. (Habibi, et al, 2018)

• Changes in brain plasticity and behavioral outcomes were evident when music therapy was added as precursor to occupational and speech therapy for children with severe neurological disorders.

(Bringas, et al; 2015)

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What does the research say?

• Music training is correlated with improvements in literacy skills and children with reading disorders were found to have correlating disorders in music processing. A meta‐analysis of research found there is promise “ that music training may enhance literacy development via changes in brain mechanisms that support both music and language cognition.” (Gordon et al; 2015)

• A meta‐analysis of 46 studies on the effects of music is “suggestive of some beneficial effects” but cited poor research designs and inconclusive results in many studies.

(Dumont, et al; 2017)

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What does the research say? The Case For Music and Movement with Children

14‐month‐old infants were more likely to engage in altruistic behavior and help the experimenter after having been bounced to music in synchrony with her, compared to infants who were bounced to music asynchronously with her. The results of Experiment 2, using anti‐phase bouncing, suggest that this is due to the contingency of the synchronous movements as opposed to movement symmetry. These findings support the hypothesis that interpersonal motor synchrony might be one key component of musical engagement that encourages social bonds among group members, and suggest that this motor synchrony to music may promote the very early development of altruistic behavior.

(Cirelli, et al; 2014)

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Music/Auditory InterventionsMusic Therapy

Berard Auditory Integration Training®(AIT)

Integrated Listening Systems ®(iLs)

Therapeutic Listening®

The Listening Program®

Fast Forword®

Interactive Metronome®108

Integrating Music & Auditory Based Practices into Intervention

Use music as background for calming or alerting

Use the rhythm of the music for timing movements

Change the words to a familiar song to fit the activity being done at the time

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Integrating Music & Auditory Based Practices into Intervention

Create a dance or synchronized movements to music

Sing with the child; integrate turn taking and reciprocal interactions into the singing

Support the child for participation in community based music programs

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Using Rhythm to Enhance Timing and Sequencing

Play based activities that use timing, coordinated movements and sequences

Drumming and musical instruments for rhythm

Interactive Metronome®

Astronaut Training®

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Vestibular‐Auditory‐Visual Triad

• Auditory and Visual pathways are neurologically connected through the Vestibular pathways.

• Our brain uses the vestibular system as an organizing mechanism that supports postural control, balance, movement, and coordination through integration of these three senses.

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Vestibular‐Auditory‐Visual TriadSI based theory suggests that combining these sensory experiences into movement and functional activities can greatly enhance

overall functional skills.

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Making Connections

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Movement Based

With a rise in childhood obesity, anxiety, attention disorders, and behavioral conditions there has been much interest in the health impacts of sedentary lifestyles, increased time with technology, and the paucity of unstructured time for children to engage in movement.

Early learning is known to be based in sensory‐motor experiences that begin in utero and are the primary form of learning from birth through 8 years.

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• “Single bouts of moderate intensity exercise may be an effective means for modulating neural activity associated with the efficient allocation of attentional resources coupled with reductions in conflict monitoring. The current findings further suggest that such a relationship may be enhanced to a greater extent among groups of children characterized by lower levels of cognitive control ability.” (Drollet et al; 2014)

• Strong evidence suggests physical activity improves self‐perceptions and self‐esteem however few studies examined the neurobiological and behavioral mechanisms

(Lubans et al; 2016)

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What does the research say? • In animal studies, weight bearing status was associated with structural changes in the brain. (Adami et al; 2018)

• Exercise increases hippocampal size and functional connectivity as well as enhances neurogenesis in elderly.

(Firth et al; 2018)

• Task specific training is more effective for DCD compared to process oriented training. (Kirby & Sugden, 2007)

• Research has begun to illuminate the complex role of the vestibular system, linking to spatial memory, cognition, sense of self, and body perceptions. (Besnard et al; 2015)

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• In general, there is substantial evidence that supports the positive outcomes of physical activities for all children.

• However, research on specific protocols for movement based interventions is often biased, poorly constructed, and/or inconclusive.

• Many activities that are beneficial from the perspective of general health and wellness cannot be connected by causation to improvement in cognition, learning, or behaviors, although correlation may be evident in the research.

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Interventions that Use or Support Movement and Motor Skills

Occupational and Physical therapyDance/Movement therapyAutism Movement Therapy®The Co‐Op ApproachAstronaut Training®Reflex Integration training programs (RMTi, MNRI®)Brain Gym®, Brain Balance ®, Bal‐A‐Vis‐X®, etc.Hippotherapy, aquatic therapySports participation & skills trainingPlay groups, play activities 119

Integrating Movement Based Practices into Intervention

Provide opportunities for exploring movement through active and playful participation

• Space• Equipment• Music and movement• Guided versus self‐directed play

Facilitate whole body movements: • Crossing midline• Upper and lower body; right and left sides of the body• Alternating, symmetrical, contralateral

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Scaffold activities for successful problem solving by the child to enhance learning

• Allow time for the child to problem solve• Allow mistakes• Facilitate insight/awareness

Build in repetition and spiraling skill development• Intrinsic motivation for repetition and mastery• “The Just Right Challenge”• Addition of novel components for interest

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Integrate therapeutic movement into developmentally appropriate leisure activities

• Community based programs• Peer interaction• Social engagement, imitation

Engage Motivation!• Interests and strengths• Gamification or game based activities• Child directed activities

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Making Connections

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Meditation/Mindfulness

Jon Kabat‐Zinn, the scientist and widely recognized father of contemporary, medically based mindfulness—over 30 years ago he developed a therapeutic meditation practice known as Mindful Based Stress Reduction (MBSR)—defines mindfulness simply as “paying attention in a particular way: on purpose, in the present moment and non‐judgmentally.”

In the last few years mindfulness has emerged as a way of treating children and adolescents with conditions ranging from ADHD to anxiety, autism spectrum disorders, depression and stress. And the benefits are proving to be tremendous.

(childmind.org; 2019)

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• “Eight weeks of Mindfulness‐Based Stress Reduction (MBSR) was found to increase cortical thickness in the hippocampus, which governs learning and memory, and in certain areas of the brain that play roles in emotion regulation and self‐referential processing. There were also decreases in brain cell volume in the amygdala, which is responsible for fear, anxiety, and stress – and these changes matched the participants’ self‐reports of their stress levels, indicating that meditation not only changes the brain, but it changes our subjective perception and feelings as well.”

(Forbes, 2015; citing Lazar et al; 2011)

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• A 9‐week modified MBT training program for adults with autism showed a significant reduction in depression, anxiety and rumination in the intervention group, as opposed to the control group. Furthermore, positive affect increased in the intervention group, but not in the control group. (Speck, et al; 2013)

• Numerous studies on adults with ADHD indicate that mindfulness and/or yoga practice can be helpful in managing symptoms and improving focus. Research on children and randomized control studies remain limited. (Aadil, et al; 2017)

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Even brief practice of meditation can improve attention in several different conditions as noted by neurological changes and performance on tests of attention in meditation naïve individuals. However, increased neuroticism in subjects resulted in less substantial improvements in attention unless they were supported in continued and regular practice of mindfulness, with brief periods of practice not benefitting these subjects with same positive effects. (Norris et al; 2018)

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Interventions that Use and Support Mindfulness & Meditation

Mindfulness‐Based Stress Reduction (MBSR)

Yoga

Cosmic Kids Yoga (Youtube.com)

GoZen.com (web based anxiety program)

Apps on iOS and android devices

Community based yoga and mindfulness classes

Mental health practice, counseling, groups 128

Integrating Mindfulness Based Practices into Intervention

Build meditation or quiet time into your sessions on a regular basis; adapt programs for individual differences

Use resources to develop home programs, educate parents, and promote daily practice; encourage parents to practice as well

Teach relaxation poses and sensory strategies that support meditation, calm, and mindfulness

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Integrating Mindfulness Based Practices into Intervention

Model mindfulness in your own behaviors; participate in practice with children

Run group programs to support social skills in conjunction with mindfulness

Encourage and support outdoor time and nature‐based play

Consider the impact of sensory challenges on ability to practice mindfulness/meditation

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Making Connections

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Technology & Screens

As of 2020, an entire generation has grown up with technology including computers, cell phones, video games, the World Wide Web, and GPS.

In the 1970s, an entire generation had grown up with television and electric gadgets, including microwave ovens.

In the 1920s, an entire generation had grown up with telephones and radios common in the home.

Technology isn’t new, it’s just always changing. Our challenge is to adapt to the change and use it to our advantage.

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What Does the Research Say?• There has been a tremendous amount of research on video games with a wide variety of questions asked. VG use has an effect in a variety of brain functions and, ultimately, in behavioral changes and in cognitive performance.

• Improvements in bottom‐up and top‐down attention, optimization of attentional resources, integration between attentional and sensorimotor areas, and improvements in selective and peripheral visual attention have been featured in a large number of studies. (Palaus et al; 2017)

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What Does the Research Say?• Adults with ASD are at higher risk for pathological game use compared to typically developing adults. Highly restricted interests, preoccupations, and perseverative interests are key diagnostic features of ASD and may contribute to this risk. Problematic game use may further exacerbate social isolation and impede participation in other activities.

(Englehart et al; 2017)

• A recent study found that the video game Pico’s Adventure was effective in enhancing initiation of social interaction, reducing repetitive movements and improved the child’s gestural expression after just 4 sessions of game play in a small group of four to six year olds whether they played alone or in pairs. Game play with parents was noted to be as effective as free‐play in promoting social initiation.

(Ángeles Mairena et al; 2019)134

What Does the Research Say?• “In this study of 47 preschool‐aged children, increased use of screen‐based media in the context of the AAP guidelines was associated with lower microstructural integrity of brain white matter tracts that support language, executive functions, and emergent literacy skills, controlling for child age and household income. Screen use was also associated with lower scores on corresponding behavioral measures, controlling for age. Given that screen‐based media use is ubiquitous and increasing in children in home, childcare, and school settings, these findings suggest the need for further study to identify the implications for the developing brain, particularly during stages of dynamic brain growth in early childhood.”

(Hutton et al; 2019)

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What Does the Research Say?• A large population based study reviewed data from parent/caregiver surveys regarding screen use and psychological well being of approximately 40,000 children between the ages of 2 and 17 years old

• Results found correlation of poor self‐regulation in younger children and higher rates of anxiety or depression in adolescents who were “moderate to high users of screens.”

• There was no evidence of causation in this study and call for further research to understand the complexities of “screen use” in children as related to psychological well being.

(Twenge & Campbell, 2018)136

But what do we really know?

That children with ASD and ADHD, especially boys, tend to prefer screens/video games more than TD children.

That some children, especially those with ASD, can become overly focused and “addicted” to screens. Gaming, social media, and even the notifications on our phones appear to trigger the reward centers of our brain.

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But what do we really know?

That heavy screen use is associated with structural and functional brain changes in many different areas of the brain.

That over use of screens results in less time for children to be engaged in active learning, social participation, conversational language with others, and physical activity.

That exposure to blue light disrupts sleep patterns and affects eye development

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The long term effects of technology use on the brains of young children

The correlation vs causation relationship between developmental concerns and screen use

Whether the potential benefits from gaming are consistently transferable to real life skills

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Whether changes in the brain translate to functional impairments in developmental skills

Whether obsessive gaming is truly an addiction or a symptom of other underlying conditions such as depression or anxiety

Why some people are negatively affected by gaming or screen use and others are not

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What can we do?

Embrace technology

Use technology in moderation and with intent

Observe behaviors related to technology use

Teach children how to use technology in balance with other activities and pursuits

Adapt the use to reduce negative consequences and enhance positive outcomes

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Gamification: Enhancing Therapy and Education “Gamification” refers to the application of typical elements of game playing (such as point scoring and competition) to other areas of activity. Initially applied to marketing and consumer use, it is now a widely used concept in business and education.

Game‐based learning refers to the use of video games or platforms to learn specific skills. There is conflicting research about the effects of game‐based learning and gamification.

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“Brain Games”

• In 2016 the creators of “Lumosity” were fined $2M by the US FTC for falsely claiming that use of the “brain games” improved cognitive impairments associated with health conditions.

• Research has shown that individuals only perform better on the tasks in the game. There is little evidence that playing games to improve cognitive skills such as working memory translate to generalized skills in daily activities.

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“Brain‐y Games”• Video games range from simple puzzle games to complex problem solving story themed games.

• There is opportunity for grading the gaming experience to meet the needs of the individual.

• Adding components of game design to otherwise mundane tasks can enhance motivation for participation.

• Clinical reasoning should guide the use of all technology as interventions.

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Elements of Video Game Design that may be used to motivate and facilitate learning include:

• Progress mechanics (points/badges/leaderboards, or PBL's)

• Narrative and characters• Player control• Immediate feedback• Opportunities for collaborative problem solving• Scaffolded learning with increasing challenges• Opportunities for mastery, and leveling up• Social connection

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Potential Benefits of Gamification

Giving individuals ownership of their learningFreedom to fail and try again without negative repercussionsChances to increase fun and joy in learningOpportunities for differentiated instructionMaking learning visible and measurableProviding a manageable set of subtasks and tasksInspiring students to discover intrinsic motivators for learning

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Potential Benefits

• Gamifiying therapy or education enhances motivation and participation for activities that might not otherwise be engaging or intrinsically rewarding

• “Smart game design” can be applied, wherein the game is automatically adjusted to accommodate the participant and provide for “the just right challenge” as learning progresses. This prevents the participant from becoming too frustrated with complex tasks, too bored with simple tasks. It can provide the right pacing that keeps participants engaged and interested so that they focus on learning, and may lead to a state of deeply absorbed learning often referred to as “flow.”

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Technology Based InterventionsThe Mightier: Video games paired with biofeedback for learning self regulation

Interactive Metronome: Game platforms for improving timing and rhythm which may improve higher level skills

Movement based games for various gaming systems

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Technology Based Interventions

Skill specific apps and games: Visual‐spatial, handwriting, problem solving, academic skills, etc

Minecraft and other community based games (MMOs)

Social media, web‐based support group

Web or app based programs for social skills, anxiety, meditation, executive function skills and habit development

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Technology is a Tool

Research on technology use is divided in whether there is benefit or harm for children. Questions remain as to whether there is causation or correlation regarding neurological changes.The focus needs to be on moderating use so that there is a healthy benefit from engagement with technology, as opposed to limiting use out of fear and misperceptions.For many children, use of technology opens doors for learning, provides skills for future employment, and increases socialization opportunities.

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Consume: to engross or obsess; to use upWhat most of us do with technology

Produce:make or manufacture from raw components; create, cause to happen, or generate

What is possible when you know how to use technology correctly

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What Our Kids Can Do With “Screens”

Connect• Build relationships with family & friends• Find communities of belonging• Establish connections that foster interest and motivation

Learn• Enhance learning

potential & opportunities• Develop skills that are

applicable to daily life• Gain knowledge that

can support independence

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What Our Kids Can Do With “Screens”

Create• Expressive arts: Videos, Photography, Writing, Drawing, Animation, Music

• STEM: Science, Engineering, Computer science, mathematics, design technology, architecture

Participate• Communication • Social interaction• Employment

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Guidelines for Parents (from the American Academy of Pediatrics)

• Create a Family Media Plan• Structure media use with limits and expectations• Set tech‐free zones and times• Encourage free play, including outdoor time• Make screen time a social experience• Don’t use screens as emotional pacifiers• Limit screen time by age of the child• Know what your child is doing online; educate them about online safety and interactions

• Be a good role model with your own tech use154

Practical Support for Parents

Empathize

• Cultural differences

• Daily demands

• Challenges for change

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Educate

• Science versus myths

• Positive vs harmful outcomes

• Using technology wisely

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Empower

• Competency

• Communication

• Practical strategies

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Habits and Routines: Neuroplasticity Everyday

• Research shows that developing habits strengthens neural pathways in the brain and actually reduces the amount of activity due to the automaticity of the habit.

• Researchers theorize that habits are neurologically encoded in the striatum and serve to reduce the decision making and streamline brain function.

• An animal study revealed that the brain “chunks” brain activity sequences that are “rewarded habits” within the striatum, which may make changing the habit more difficult. (Martiros, et al; 2018)

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Changing Habits

• Change is HARD

• Habits don’t change without intent to change

• The 1% Difference: Small change every day adds up

• Phases of Change: Sustainable change happens in increments

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Four Laws of Behavior ChangeJames Clear (Atomic Habits)

• Cue

• Craving

• Response

• Reward

• Make it Obvious/Invisible

• Make it Attractive/Unattractive

• Make it Easy/Difficult

• Make it Satisfying/Unsatisfying

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Making Connections

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Final Thoughts

• Be “Humble and Curious” • Be intentional about your interventions• Be supportive of simple solutions• Be wary of “cure all” solutions • Be focused on functional outcomes• Be responsive to client/caregiver needs• Be confident in supporting children and families

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Contact Me!

Debra Johnson, MS, OTR/L

STEPS for Kids, Inc1581 Sycamore Rd. Yorkville, IL 60560

P: 630-552-9890F: 630-552-9891

[email protected]

www.rightstepsforkids.com

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