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Neuroplasticity and DevelopmentRewiring the Brain for Functional Changes in Learning, Behavior, Motor, and Cognitive Challenges

Presented by Debra Johnson, MS, OTR/L

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Neuroplasticity and DevelopmentRewiring the Brain for Functional Changes in Learning, Behavior, Motor, and Cognitive Challenges

Debra Johnson

ѩ 1. Evaluate the three neurological processes that define brain plasticity.

ѩ 2. Examine the differences and relevance of various forms of plasticity as related to functional changes in behavior and skills.

ѩ 3. Identify the impact of neuroplasticity on normal development vs atypical development.

ѩ 4. Classify the ten characteristics of effective interventions based on theories of neuroplasticity.

ѩ 5. Implement at least 6 effective treatment techniques that can influence brain function and brain-body connection to support learning, emotional regulation, and/or motor skills.

ѩ 6. Distinguish the positive and negative effects of technology on the pediatric brain.

ѩ 7. Utilize resources and knowledge to educate others on technology use for children.

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Debra Johnson

Workshop Notes

Neuroplasticityand Development

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

Challenges

Presented byDebra Johnson, MS, OTR/L

1

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

• Identify the impact of neuroplasticity in typical and atypicaldevelopment

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

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

• Use sound evidence based reasoning to determine validity ofneurologically based interventions

• Feel confident in explaining rationale for using neurologicallybased treatment interventions

• Advocate for and guide families in choosing appropriateinterventions 2

Defining Neuroplasticity

Neuroplasticity:the ability of the brain to form and reorganizesynaptic connections, especially in response tolearning and experience or following injury

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

3

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

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

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

Cajal outlined his cerebral gymnastics hypothesis, suggestingthat the capacity of the brain could be augmented byincreasing the number of connections

4

• Polish neuroscientist Jerzy Konorski postulated thatmorphological changes in neural connections couldbe the substrate of learning (1948)

• Canadian Psychologist Donald Olding Hebbarticulated a theory regarding the possible neuralmechanisms of learning and memory (1949)

• In the 1960s, research began linking neuroplasticityto behavioral responses in the context of behavioralpsychology; findings indicated that short termplasticity was important in responses to sensorystimuli, behavior modification, learning andmemory

5

• Research in the 1970s and 1980s expandedunderstanding of brain chemicals, as well assynaptic and structural changes in response toexternal factors such as exposure or deprivation;early research and treatment for brain injury

• 1990 1999: “The Decade of The Brain” as declaredby President Bush; focused on educating the publicabout brain research, advancing research efforts,and funding programs for early childhoodeducation as the result of increased awareness ofcrucial periods of brain development

• 2000 – today: Tremendous advances inneuroscience research with new technologies

6

9

Current Research and Knowledge

• Neurogensis: critical in prenatal period, oncethought to be impossible in adults is nowconsidered to occur in certain areas of the brainsuch as the hippocampus even in old age

• Effects of medications, toxins, and environmentalexposure to sensory input or chemicals on braindevelopment and function is now widelyaccepted

7

• Sleep, nutrition, exercise, and social interactionhave been found to have positive impacts onneuroplasticity and brain health

• Trauma, especially in young children, has beenidentified as having a significant negative impacton brain development and functional behaviors

• Differences in brain structure and function havebeen identified for individuals withneurodevelopmental disorders

8

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

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

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

That there is a distinct process in brain developmentthat includes neuroplasticity, making interventionpossible to support positive outcomes in learning andbehaviors.

9

What don’t we know?

How structural changes in the brain actually influencefunction, 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 functionaldifferences that vary from “typical”

10

10

BRAIN ANATOMY 101

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11

BRAIN DEVELOPMENT

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12

Brain Systems and Functions• Brainstem:

• Consists of the medulla oblongata, pons, midbrain

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

• Controls reflexes and automatic functions of the body

• Medulla oblongata controls breathing, blood pressure, heartrhythms, and swallowing

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

• Reticular Activating System: responsible for sleep cycles andalertness, located in medulla, pons, midbrain, and thalamus 13

Brain Systems and Functions• Cerebellum:

• Develops out of the hind brain

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

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

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

• New findings suggest involvement in reward learning andsocial/emotional behaviors

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

• Has tremendous capacity for plasticity with possibleneurogenesis 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 lobesdespite distinct functions

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

• Communication to the rest of the body is contralateral due todecussation of nerves where the medulla meets the spinalcord

• Has a great capacity for functional neuroplasticity, bothdevelopmentally and in response to injury 15

Brain Systems and Functions

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

• Processes information coming from the autonomicnervous system

• Helps control eating, sexual behavior, and sleeping

• Regulates body temperature, emotions, secretion ofhormones and movement

16


• Thalamus:• Multiple functions, complex organ

• Major relay for sensory and motor pathways to thecerebral cortex

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

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

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

17


• Limbic system:• Includes 4 structures in the midbrain

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

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

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

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

18

13

Neuroplasticity Processes in BrainDevelopment

Proliferation

Pruning

Consolidation

19

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

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

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

• Once thought to be completed in infancy, new research suggeststhat the hippocampus might be capable of neurogenesis intoadulthood

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

Pruning

• The elimination or reduction of synaptic connections not used orrelevant 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 autisticbrains, resulting in too many connections 21

Consolidation

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

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

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

• Crucial for generalization of responses and mastery of skills22

Types of Neuroplasticity

Structural

Defined as the physical changes in the brainthat result from experiences, learning, andmemory.

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

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

23

Types of NeuroplasticityFunctional

Refers to the brain’s ability to have cells arounddamaged tissue take on the function of thedamaged cells.

Allows for re learning of skills lost after brain injuryor stroke

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

24

14

Development = Structural ChangeInjury = Functional Change

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

CP occur during the prenatal period, infancy throughearly childhood, and adolescence

CP are characterized by rapid changes in the structureand function of the brain, either throughdevelopmental processes or as a result of sensitivity toexternal factors

Despite the presence of CP, research indicates thatbrain changes can occur any time in the lifespan whenstimuli are strong enough and conditions are conduciveto learning or recovery 25

Functional Implications For Practice

Experience dependent neuroplasticity leads to structuralchanges in the brain with either positive or negativeconsequences that are dependent on the nature of theexperiences.

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

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

26

Functional Implications For Practice

Neuroplasticity related to learning is impacted bydevelopmental disorders and brain changes that may or maynot be malleable

Best practice involves consideration of current research andclinical experience to choose the appropriate interventionbased on theories of neuroplasticity that consider theindividual child

27

Developmental Implications:Neuroplasticity through the Lifespan

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

Current research focuses on actual physical changes tothe brain in terms of structure and connectivity in thebrain. Advancements in imaging and neurosciencemethods have contributed to a surge in the study ofbrain plasticity in neurotypical individuals and how itprogresses through the lifespan.

28

Prenatal Period

Brain development is rapid and goes throughpredictable stages of proliferation

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

• 2nd Trimester: Brain stem is fully formed and bodilyfunctions being regulated, including sleep cycles andswallowing; Rapid proliferation of cells and connectionswith beginning organization of function through theprocess of migration

29

Prenatal Period

• 3rd Trimester: Continued proliferation andmigration of cells to lay down the functionalareas of the brain, increasing neuralorganization results in ability to process sensoryinput such as hearing, movement, and touch;Rapid growth period for the cerebral cortex,laying the groundwork for the brain’s ability torespond to experiences after birth

30

15

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

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

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

• Using fMRI studies at 37 39 weeks gestations, researchersidentified that the brain organization and connectivity offetuses was adversely affected by maternal stress, with thecerebellum particularly affected

(Cognitive Neuroscience Society, 2018)31

Prenatal Period

• A recent study revealed that fetal growth restrictionin sheep altered cerebellar development. “Weconfirm that cerebellar injuries develop antenatallyin FGR, and therefore, interventions to preventlong term motor and coordination deficits shouldbe implemented either antenatally or perinatally,thereby targeting neuroinflammatory and oxidativestress pathways.”

(Yawno T,. Et al, 2019)

32

Infancy Toddlerhood

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

• While previous researchers theorized that brainchanges would only occur in responses to largeintensity events, new studies reveal significant changesin brain structure as a result of small and eveninnocuous events

• Primary factors for plasticity at this age are sensorymotor experiences and social connection; poorlydeveloped frontal lobes with significant proliferation ofconnections and organization occurring in the brain 33

Infancy Toddlerhood

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

(Kolb & Gibb, 2011)

• Study of preterm infants’ responses to touch indicatechanges in brain response. “We showed that, whencontrolling for prematurity and analgesics, supportiveexperiences (e.g., breastfeeding, skin to skin care) areassociated with stronger brain responses, whereas painfulexperiences (e.g., skin punctures, tube insertions) areassociated with reduced brain responses to the same touchstimuli. Our results shed crucial insights into themechanisms through which common early perinatalexperiences may shape the somatosensory scaffolding oflater perceptual, cognitive, and social development.

(Maitre, et al,2017)

34

Early Childhood• Learning continues through sensory motorexperiences, social interactions, and opportunityfor unstructured, self directed play

• Rapid period of pruning and organization in thebrain; continued development of frontal lobes andconnections that support problem solving, selfregulation, and learning

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

35

Early Childhood• Many studies are now showing the significant impact thatexposure to language has on the developing brainthroughout childhood. The American Academy of Pediatricsemphasizes the importance of language exposure, readingout loud, and engaging with children of all ages as key todeveloping later literacy success.

(American Academy of Pediatrics, 2014)

• Children’s neural connectivity is directly linked to languageexposure and research shows that children have a strongpreference for conversational language, benefitting fromadult child conversations. (Romeo, et al; 2018)

36

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

• Relationships, environment, stress, diet, hormones andmedication are some of the external factors that influenceneuroplasticity and synaptic connectivity throughoutchildhood (Kolb & Gibb, 2011)

• Self regulation exhibits rapid changes during childhood withrecent research showing that improved cognitive controlresults in improved emotional regulation suggestingrelevance for improved executive function skills.

(Hendricks & Buchanan, 2016) 37

Adolescence

• Continued rapid development of frontal lobes andconnectivity for reasoning, judgement, and decisionmaking.

• Critical period of pruning occurs duringadolescence with increased organization of thebrain connections evident in imaging studies.

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

38

Adolescence

• “Adolescent brain transformations include both progressiveand regressive changes that are regionally specific and serveto refine brain functional connectivity. Along with stillmaturing inhibitory control systems that can be overcomeunder emotional circumstances, the adolescent brain isassociated with sometimes elevated activation of rewardrelevant brain regions, whereas sensitivity to aversive stimulimay be attenuated. At this time, the developmental shiftfrom greater brain plasticity early in life to the relativestability of the mature brain is still tilted more towardsplasticity than seen in adulthood, perhaps providing anopportunity for some experience influenced sculpting of theadolescent brain.”

(Spear, 2013)39

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

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

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

40

Adulthood

• Adults have the capacity to make conscious choices that alter brainconnections and structure through forming new habits whileeliminating old ones.

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

• Daily exercise appears to contribute to the growth of thehippocampus even in elderly adults, supporting memory andlearning 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 ofthe brain that results in dysfunction in the child’s behaviorrelated to emotion, learning, self control, memory, and/ormotor control.

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

42

17

Types of neurodevelopmental disorders

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

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

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

43

Brain Differences in Atypical Populations

• fMRI studies revealed significant differences inconnectivity between the brains of children withdysgraphia or dyslexia and a control group.

(Richards, et al; 2015)

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

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

44


• Imaging revealed significant differences in brain structuresof children with HFA/Asperger Syndrome, and nonverballearning disorders. Especially affected were thehippocampus, amygdala, and anterior cingulate cortex, all ofwhich play a part in emotional regulation, impulse control,and decision making.

(Semrud Clikeman, et al; 2013)

• Children with nonverbal learning disorder presented with asmaller splenium of the corpus callosum, which carriesfibers connecting the temporal and parietal lobes as well asthose linking primary and secondary visual areas.

(Fine, et al; 2014)

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Imaging study on ADHDOver 3200 participants; International study; participants ranged from4 years old to 63 years oldThe study found that overall brain volume and five of the regionalvolumes were smaller in people with ADHD the caudate nucleus,putamen, nucleus accumbens, amygdala and hippocampus. Inaddition, these differences were notable in children but less so inadults. The differences were not correlated with prior medication use."The results from our study confirm that people with ADHD havedifferences in their brain structure and therefore suggest that ADHD isa disorder of the brain," added Dr Hoogman. "We hope that this willhelp to reduce stigma that ADHD is 'just a label' for difficult childrenor 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 lifewhen synaptic development and maturation are occurring at a rapidrate, and one of the most consistent morphological findings thatemerged from the structural neuroimaging studies in ASD is earlybrain overgrowth. Such atypical brain enlargement appears to bemost pronounced between 2 and 5 years of age, and itpreferentially affects the frontal and temporal cortices.Furthermore, recent evidence indicates that atypical corticaldevelopment in ASD subjects persists beyond toddlerhood. Inparticular, evidence of cortical thinning has been observed amongadolescents and young adults. These observations led to thehypothesis that ASD is associated with a significant disruption of thetypical synaptic maturation and plasticity. (Desarkar, et al; 2015)

47


Autism Studies• fMRI studies show aberrant connectivity in children withautism as well as adults. Research is not clear onwhether ASD might involve hypo connectivity or hyperconnectivity as studies exist with both outcomesevident.

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

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

18


Autism StudiesRecent studies are exploring ways to definitively diagnose ASDearlier in order to provide supports for improved outcomes indevelopment.

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

49

Childhood Trauma

TerminologyChildhood Trauma

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

50

Childhood TraumaTerminology

Adverse Childhood Experiences (ACEs)is the term used to describe all types of abuse, neglect, andother potentially traumatic experiences that occur to peopleunder the age of 18.” – US Department of Health and HumanServices, 2019Includes: Abuse, Neglect, Household Dysfunction, MedicalTrauma, Discrimination, Community Violence, School Violenceand 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., childmaltreatment)

• 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 oxytocinproduction, excess cortisol production, and atypical hypothalamicpituitary adrenal function

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

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

(Ashcroft, Lynch, Tekell; 2019)53

How Can We Harness Brain Plasticityto 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

54

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Neurorehabilitation

“(Neurological) rehabilitation is a process of education ofthe disabled person with the ultimate aim of assisting thatindividual to cope with family, friends, work, and leisure asindependently as possible. It is a process that centrallyinvolves the disabled person in making plans and settinggoals that are important and relevant to their ownparticular circumstances. In other words, it is a process thatis not done to the disabled person but a process that isdone by the disabled person themselves, but with theguidance, support, and help of wide range of professionals.Rehabilitation has to go beyond the rather narrow confinesof physical disease and needs to deal with the psychologicalconsequences of disability as well as the social milieu inwhich the disabled person has to function.” (Barnes, 2004)

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How can we use this approach to supportindividuals with neurodevelopmental disorders?

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

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

In neurorehabilitation, we support the person in regaining skillsbased on principles of neuroplasticity. Since we now haveevidence of neurodevelopmental disorders being characterizedby neurological differences, it is a natural step to attempt toapply 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’taddress 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 brainchanges with functional changes in behavior

Don’t follow best practice guidelines for evidence basedpractice

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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 thatare relevant and meaningful to them

Recognize individual differences

Understand the research: neuroscience and interventions

Use evidence based practice to guide treatment plans and use ofinterventions 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 functionscan lead to functional degradation.

“Research shows that neural circuits not actively engaged intask performance for an extended period of time begin todegrade. This was shown first in the 1960s by Hubel andWiesel, whose experiments revealed degradation and reducednumber of neurons in the visual cortex of mice when one eyewas sewn shut.”

“Deprivation of one sensory modality may cause itscorresponding cortical area to be at least partially taken overby another modality. For example, fMRI studies of blindsubjects show activation of the visual cortex with tactilestimulation, whereas deaf subjects show auditory corticalactivation 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 behavioralexperience can enhance behavioral performance andoptimize restorative brain plasticity after brain damage. Ithas long been known that housing animals in complexenvironments pre and/or post injury can enhancefunctional recovery.”

“Motor skill training after unilateral cortical damage hasbeen found to both improve motor function and to driverestorative 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 mereuse, seem to be required to produces significant changes inpatterns of neural connectivity. For example, motor skillacquisition is associated with the changes in gene expression,dendritic growth, synapse addition, and neuronal activity in themotor cortex and cerebellum.”

“Learning induced brain changes in also show regionalspecificity. For example, unilateral training in reach and grasptasks in rats causes dendritic growth in the motor cortexcontralateral to the trained limb but has only subtle effects onthe ipsilateral motor cortex.” (Kleim & Jones, 2008) 62

Repetition Matters

Induction of plasticity requires sufficient repetition.“Repetition of a newly learned (or relearned) behavior may berequired to induce lasting neural changes. For example, ratstrained on a skilled reaching task do not show increased insynaptic strength, synapse number or map reorganization untilafter several days of training, despite making significantbehavioral gains.”

“We suggest that a sufficient level of rehabilitation is likely tobe required in order to get the subject “over the hump” – thatis, repetition may be needed to obtain a level of improvementand brain reorganization sufficient for the patient to continueto use the affected function outside of therapy and to maintainand 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 400reaches per day had increases in synapse number within themotor cortex, whereas animals trained to reach 60 times perday did not have such increases…Transcranial magneticstimulation experiments within human motor cortex haveshown that stimulation trains consisting of 1800 pulses, butnot 150 pulses, were sufficient to induce lasting increases inmotor evoked potential amplitudes.”

“One potential negative side effect of training intensity afterbrain damage is that it is possible to over use impairedextremities 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 ofas a process rather than as a single measurable event. Indeed, itis a complex cascade of molecular, cellular, structural, andphysiological events. Certain forms of plasticity appear toprecede and even depend upon others. Thus, the nature of theplasticity observed and its behavioral relevance may depend onwhen one looks at the brain.”

“If therapy promotes neural restructuring, then it should workanytime, but there may be time windows in which it isparticularly effective in directing the lesion induced reactiveplasticity.” (Kleim & Jones, 2008) 65

Salience MattersThe training experience must be sufficiently salient to

induce plasticity.“Research using auditory tones as classical conditioningstimuli has…demonstrated that plasticity within theauditory cortex is dependent upon the salience of theexperience. In this paradigm, animals are trained torecognize a tone of a specific frequency in order to receivea reward. Thus, one tone becomes more salient than theothers. Animals trained in such a manner show anincrease in the representation of the salient tone withinthe auditory cortex. Simply playing the tone without thereward does not alter the topography of the auditorymaps.” (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 theaging brain. Normal aging is associated with widespreadneuronal and synaptic atrophy and physiologicaldegradation. ..and some have argued that plasticity is themechanism by which the brain compensates for aging.Nevertheless, the aging brain is also clearly responsive toexperience, even though the brain changes may be lessprofound and/or slower to occur than those observed inyounger brains. There is evidence in both humans andanimal models that the effects of aging vary with lifespanexperiences and are generally better in inidividuals withgreater 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 oneset of neural circuits to promotes concurrent orsubsequent plasticity. It has long been known that ratshouse in complex environments have better functionaloutcomes…compared with rats housed in standardlaboratory environments.”“Although learning may be needed to promote theformation of functionally appropriate synaptic connectionsafter brain damage, exercise may be more appropriate forpromoting a fertile environment to support thesechanges.” (Kleim & Jones, 2008) 68

Interference

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

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

“It is possible for behavioral experiences to drive plasticitywithin residual brain areas in a direction that will impedeoptimal behavioral recovery. Brain damage survivors maydevelop compensatory strategies that easier to perform (“badhabits”) than more difficult but ultimately more effectivestrategies acquired through rehabilitation.”

“When maladaptive, these self taught compensatorystrategies may induce plasticity that will have to be overcomewith subsequent rehabilitation and other treatmentapproaches.” (Kleim & Jones, 2008) 69

Good Foundations For Brain Health

Science has identified FIVE key components forhealthy 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 medicallycomplex which limits or negatively impacts nutrition.

May have sleep disorders or struggle with goodsleeping hygiene

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

May have social impairments which limit socialinteractions or cause social isolation

May be subject to increased stress and trauma whichnegatively 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 evidencebased practice

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

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…are guided by:

Individual differences and response totreatment

Parent/caregiver goals, resources, andinvestment

FUNCTIONAL and MEANINGFUL OUTCOMES74

Evidence Based Practice:An Overview to Guide Decision Making

Evidence based practice (EBP) is based on integratingcritically appraised research results with the

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

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Evidence based practice (EBP) is the conscientious andjudicious use of current best evidence in conjunction withclinical expertise and patient values to guide health caredecisions. Best evidence includes empirical evidence fromrandomized controlled trials; evidence from other scientificmethods such as descriptive and qualitative research; as wellas use of information from case reports, scientific principles,and expert opinion. When enough research evidence isavailable, the practice should be guided by research evidencein conjunction with clinical expertise and patient values. Insome cases, however, a sufficient research base may not beavailable, and health care decision making is derived principallyfrom non research evidence sources such as expert opinionand scientific principles. As more research is done in a specificarea, 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 CaliforniaState University, Chico (2010). Can be applied to researchstudies, 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 andmeets 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 tobe effective if:

They address foundations of brain health

They have been proven to be effective with soundresearch

They are clinically appropriate for the individual

They are easy to implement and consistent with 10Principles 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 foreveryone”

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

Implementation is not sustainable or consistent with 10Principles of Neuroplasticity

Child is passive in process

Parent/caregiver is not supportive of the intervention84

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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 importanceof parent child relationships and the impact thateither positive or negative relationships have on achild’s development.

If a strong, trustworthy, and stable relationship iscrucial for child development, we must focus ourefforts on establishing and supporting theserelationships for all children.

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

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

(Maitre, et al; 2007)

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

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

Interventions that Use andSupport Relationships

DIR/Floortime

STAR Institute Treatment Model; integrates DIR with SIintervention

Collaborative & Proactive Solutions Model for challengingbehaviors

Social Emotional learning programs

Trust Based Relational Intervention (TBRI); trauma informedcare

Early Intervention models: parent coaching88

“Outcome measures in developmental relationship basedinterventions examine the caregiver’s sensitivity andability to perceive and infer the child’s intent by observingthe child’s gestural and/or verbal cues; the caregiver’s skillin following, pacing and responding to the child’s intent;and the extent to which caregivers are effective inestablishing reciprocal social 6 exchanges, expanding onthe child’s idea, and supporting the child’s initiation andshared problem solving. The outcomes of these studies,using valid and reliable measures document that DRBIconsistently improve caregiver sensitivity, responsivity,and effectiveness leading to the improved socialrelationships and functional development includingimprovement in joint attention, initiation, language, playskills, social interactions and functional development.”

(Cullinane, et al; 2017) 89

Integrating Relationship Based Practicesinto Intervention

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

• View the child/caregiver relationship holistically througha wide contextual lens

• Speak from the child’s perspective to help fosterunderstanding from the caregiver

• Model appropriate interactions that support therapeuticgoals

• Empower caregivers and support belief of competency

• Refer for appropriate support services when necessary90

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Integrating Relationship Based Practicesinto Intervention

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

• Consider the child’s needs being expressed by behaviors

• View the situation from the child’s perspective, consideringfactors that may not be visible to you as impacting behaviors orresponse to treatment

• Use empathic communication

• Focus on strengths

• Develop your therapeutic use of self to support co regulationwith children 91

Making Connections

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Play Based

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

Play has been identified as building social skills,improving creativity and problem solving, enhancingself regulation, and supporting executive functionskills. Supporting children in play can have aprofound 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 recoverfrom trauma.

• Play helps families bond.

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

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Interventions that Use andSupport 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 therapy95

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

Play is not frivolous: it enhances brain structure and function and promotesexecutive 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’slife, toxic stress can disrupt the development of executive function and thelearning of prosocial behavior; in the presence of childhood adversity, playbecomes even more important. The mutual joy and shared communicationand attunement (harmonious serve and return interactions) that parentsand children can experience during play regulate the body’s stressresponse.

(American Academy of Pediatrics, 2018)96

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Integrating Play Based Practicesinto Intervention

Play is:Pleasurable: Children must enjoy theactivity or it is not play

Intrinsically Motivated: Children engage inplay simply for the satisfaction the behavioritself brings. It has no extrinsically motivatedfunction or goal.

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

Freely Chosen: It is spontaneous andvoluntary. If a child is pressured, they willlikely not think of the activity as play.

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Play is:Actively Engaged: Players must bephysically and/or mentally involved in theactivity.

Non literal: In involves make believe orsuspension 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 playexperience

Provide a variety of equipment/materials for exploration

Support caregiver participation in play activities102

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Making Connections

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Music & AuditoryInterventions

“Music can lift us out of depression or move us totears – it is a remedy, a tonic, orange juice for theear. But for many of my neurological patients, musicis even more – it can provide access, even when nomedication can, to movement, to speech, to life. Forthem, 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 limbicconnectively in the brain when people listened to musicthey preferred. (Wilkens et al, 2014)

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

• Changes in brain plasticity and behavioral outcomeswere evident when music therapy was added asprecursor to occupational and speech therapy forchildren with severe neurological disorders.

(Bringas, et al; 2015)

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What does the research say?

• Music training is correlated with improvements in literacyskills and children with reading disorders were found tohave correlating disorders in music processing. A metaanalysis of research found there is promise “ that musictraining may enhance literacy development via changes inbrain mechanisms that support both music and languagecognition.” (Gordon et al; 2015)

• A meta analysis of 46 studies on the effects of music is“suggestive of some beneficial effects” but cited poorresearch 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 altruisticbehavior and help the experimenter after having been bounced tomusic in synchrony with her, compared to infants who werebounced to music asynchronously with her. The results ofExperiment 2, using anti phase bouncing, suggest that this is due tothe contingency of the synchronous movements as opposed tomovement symmetry. These findings support the hypothesis thatinterpersonal motor synchrony might be one key component ofmusical engagement that encourages social bonds among groupmembers, and suggest that this motor synchrony to music maypromote 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

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Integrating Music & AuditoryBased Practices into Intervention

Use music as background for calming oralerting

Use the rhythm of the music for timingmovements

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

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Integrating Music & AuditoryBased Practices into Intervention

Create a dance or synchronized movementsto music

Sing with the child; integrate turn taking andreciprocal interactions into the singing

Support the child for participation incommunity based music programs

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Using Rhythm to Enhance Timingand Sequencing

Play based activities that use timing, coordinatedmovements and sequences

Drumming and musical instruments for rhythm

Interactive Metronome®

Astronaut Training®

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Vestibular Auditory Visual Triad

• Auditory and Visual pathways areneurologically connected through theVestibular pathways.

• Our brain uses the vestibular system as anorganizing mechanism that supports posturalcontrol, balance, movement, and coordinationthrough integration of these three senses.

112

Vestibular Auditory Visual TriadSI based theory suggests that combiningthese sensory experiences into movementand 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, attentiondisorders, and behavioral conditions there has beenmuch interest in the health impacts of sedentarylifestyles, increased time with technology, and thepaucity of unstructured time for children to engagein movement.

Early learning is known to be based in sensory motorexperiences that begin in utero and are the primaryform of learning from birth through 8 years.

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• “Single bouts of moderate intensity exercise may be aneffective means for modulating neural activity associatedwith the efficient allocation of attentional resources coupledwith reductions in conflict monitoring. The current findingsfurther suggest that such a relationship may be enhanced toa greater extent among groups of children characterized bylower levels of cognitive control ability.” (Drollet et al; 2014)

• Strong evidence suggests physical activity improves selfperceptions and self esteem however few studies examinedthe 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 withstructural changes in the brain. (Adami et al; 2018)

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

(Firth et al; 2018)

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

• Research has begun to illuminate the complex role of thevestibular 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 thepositive outcomes of physical activities for all children.

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

• Many activities that are beneficial from the perspective ofgeneral health and wellness cannot be connected bycausation to improvement in cognition, learning, orbehaviors, although correlation may be evident in theresearch.

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Interventions that Use or SupportMovement 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 BasedPractices into Intervention

Provide opportunities for exploring movementthrough 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 bythe 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 intodevelopmentally 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 ofcontemporary, medically based mindfulness—over 30 yearsago he developed a therapeutic meditation practice known asMindful Based Stress Reduction (MBSR)—defines mindfulnesssimply as “paying attention in a particular way: on purpose, inthe present moment and non judgmentally.”

In the last few years mindfulness has emerged as a way oftreating children and adolescents with conditions rangingfrom ADHD to anxiety, autism spectrum disorders, depressionand 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 thehippocampus, which governs learning and memory, and incertain areas of the brain that play roles in emotionregulation and self referential processing. There werealso decreases in brain cell volume in the amygdala, which isresponsible for fear, anxiety, and stress – and these changesmatched the participants’ self reports of their stress levels,indicating that meditation not only changes the brain, but itchanges 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 adultswith autism showed a significant reduction indepression, anxiety and rumination in the interventiongroup, as opposed to the control group. Furthermore,positive affect increased in the intervention group, butnot in the control group. (Speck, et al; 2013)

• Numerous studies on adults with ADHD indicate thatmindfulness and/or yoga practice can be helpful inmanaging symptoms and improving focus. Research onchildren and randomized control studies remainlimited. (Aadil, et al; 2017)

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Even brief practice of meditation can improveattention in several different conditions as noted byneurological changes and performance on tests ofattention in meditation naïve individuals.However, increased neuroticism in subjects resultedin less substantial improvements in attention unlessthey were supported in continued and regularpractice of mindfulness, with brief periods ofpractice not benefitting these subjects with samepositive effects. (Norris et al; 2018)

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Interventions that Use and SupportMindfulness &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 BasedPractices into Intervention

Build meditation or quiet time into your sessionson a regular basis; adapt programs for individualdifferences

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

Teach relaxation poses and sensory strategies thatsupport meditation, calm, and mindfulness

129

Integrating Mindfulness BasedPractices into Intervention

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

Run group programs to support social skills inconjunction with mindfulness

Encourage and support outdoor time and naturebased play

Consider the impact of sensory challenges onability to practice mindfulness/meditation

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Making Connections

131

Technology & Screens

As of 2020, an entire generation has grown up with technologyincluding computers, cell phones, video games, the World WideWeb, and GPS.

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

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

Technology isn’t new, it’s just always changing. Our challenge is toadapt 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 researchon video games with a wide variety of questionsasked. VG use has an effect in a variety of brainfunctions and, ultimately, in behavioral changesand in cognitive performance.

• Improvements in bottom up and top downattention, optimization of attentional resources,integration between attentional and sensorimotorareas, and improvements in selective andperipheral visual attention have been featured in alarge 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 usecompared to typically developing adults. Highly restrictedinterests, preoccupations, and perseverative interests are keydiagnostic features of ASD and may contribute to this risk.Problematic game use may further exacerbate social isolationand impede participation in other activities.

(Englehart et al; 2017)

• A recent study found that the video game Pico’s Adventurewas effective in enhancing initiation of social interaction,reducing repetitive movements and improved the child’sgestural expression after just 4 sessions of game play in asmall group of four to six year olds whether they played aloneor in pairs. Game play with parents was noted to be aseffective 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 ofscreen based media in the context of the AAP guidelines wasassociated with lower microstructural integrity of brain whitematter tracts that support language, executive functions, andemergent literacy skills, controlling for child age andhousehold income. Screen use was also associated with lowerscores on corresponding behavioral measures, controlling forage. Given that screen based media use is ubiquitous andincreasing in children in home, childcare, and school settings,these findings suggest the need for further study to identifythe implications for the developing brain, particularly duringstages 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 fromparent/caregiver surveys regarding screen use andpsychological well being of approximately 40,000children between the ages of 2 and 17 years old

• Results found correlation of poor self regulation inyounger children and higher rates of anxiety ordepression in adolescents who were “moderate tohigh users of screens.”

• There was no evidence of causation in this studyand call for further research to understand thecomplexities of “screen use” in children as relatedto 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 TDchildren.

That some children, especially those with ASD, canbecome overly focused and “addicted” to screens.Gaming, social media, and even the notifications onour phones appear to trigger the reward centers of ourbrain.

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But what do we really know?

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

That over use of screens results in less time for children to beengaged in active learning, social participation, conversationallanguage with others, and physical activity.

That exposure to blue light disrupts sleep patterns and affectseye development

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The long term effects of technology use on thebrains of young children

The correlation vs causation relationship betweendevelopmental concerns and screen use

Whether the potential benefits from gaming areconsistently transferable to real life skills

139


Whether changes in the brain translate tofunctional impairments in developmental skills

Whether obsessive gaming is truly an addiction ora symptom of other underlying conditions such asdepression or anxiety

Why some people are negatively affected bygaming 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 balancewith other activities and pursuits

Adapt the use to reduce negative consequencesand enhance positive outcomes

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Gamification:Enhancing Therapy and Education“Gamification” refers to the application of typicalelements of game playing (such as point scoring andcompetition) to other areas of activity. Initially appliedto marketing and consumer use, it is now a widely usedconcept in business and education.

Game based learning refers to the use of video gamesor platforms to learn specific skills. There is conflictingresearch about the effects of game based learning andgamification.

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“Brain Games”

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

• Research has shown that individuals only performbetter on the tasks in the game. There is littleevidence that playing games to improve cognitiveskills such as working memory translate togeneralized skills in daily activities.

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

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

• Adding components of game design to otherwisemundane tasks can enhance motivation forparticipation.

• Clinical reasoning should guide the use of alltechnology as interventions.

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Elements of Video Game Design that may beused 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 negativerepercussionsChances 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 motivatorsfor learning

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Potential Benefits

• Gamifiying therapy or education enhances motivation andparticipation for activities that might not otherwise be engagingor intrinsically rewarding

• “Smart game design” can be applied, wherein the game isautomatically adjusted to accommodate the participant andprovide for “the just right challenge” as learning progresses. Thisprevents the participant from becoming too frustrated withcomplex tasks, too bored with simple tasks. It can provide theright pacing that keeps participants engaged and interested sothat they focus on learning, and may lead to a state of deeplyabsorbed learning often referred to as “flow.”

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

Interactive Metronome: Game platforms forimproving timing and rhythm which may improvehigher level skills

Movement based games for various gamingsystems

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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 andhabit development

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Technology is a Tool

Research on technology use is divided in whether thereis benefit or harm for children. Questions remain as towhether there is causation or correlation regardingneurological changes.The focus needs to be on moderating use so that thereis a healthy benefit from engagement with technology,as opposed to limiting use out of fear andmisperceptions.For many children, use of technology opens doors forlearning, provides skills for future employment, andincreases 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 rawcomponents; create, cause to happen, or generate

What is possible when you know how to usetechnology 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 andmotivation

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 themabout 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 strengthensneural pathways in the brain and actually reducesthe amount of activity due to the automaticity ofthe habit.

• Researchers theorize that habits are neurologicallyencoded in the striatum and serve to reduce thedecision 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 thehabit 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 dayadds up

• Phases of Change: Sustainable changehappens 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

163 164

Summit Blog Page

https://blog.summit education.com/johnson 2/

• Includes:•Manual• PowerPoint• References•Additional supplements

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