the “sensory-friendly” classroom: facilitating children’s
TRANSCRIPT
May 2-3, 2019
1
SAFE PLACE:
A Collaborative Sensory Integration-
Based Trauma Program
Teresa A. May-Benson, ScD, OTR/L, FAOTAExecutive Director, Spiral Foundation
Sarah Sawyer, MA, OTR/LPresident/Clinical Director, OTA The Koomar Center
May 2, 2019
Acknowledgements
◼ Jane Koomar, PhD, OTR/L, FAOTA,
❑ Co-founder of SAFE PLACE
❑ She was a visionary in the world of SI-OT
❑ In her honor, we carry SAFE PLACE forward, dedicated to continuing to
serve traumatized children and their families by supporting their
experience of true joy and hope.
◼ Daniel Hughes, PhD
❑ Co-founder of SAFE PLACE
❑ His pioneering work in attachment theory and clinical practice serves as
the enduring inspiration for and heart of SAFE PLACE.
◼ Contributors to the SAFE PLACE Model
❑ Margaret (Peg) Ingolia, OTD, OTR/L
❑ Marsha Raredon, MS, OTR/L
❑ Deborah Rozelle, PsyD.
©2019 OTA The Koomar Center 2
Copyright
◼ This material is the copyrighted property of
OTA the Koomar Center and may not be
reproduced, except for personal use, without
permission.
◼ All rights are reserved.
©2019 OTA The Koomar Center 3
May 2-3, 2019
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Introduction to
SAFE PLACE
©2019 OTA The Koomar Center 4
SAFE PLACE IS:
◼ A theoretical model explicating the relationship
between sensory processing, disrupted attachment and
complex developmental trauma concerns in children.
◼ A specific 12-week collaborative, interdisciplinary,
sensory integration-based trauma-informed
intervention program among occupational therapists,
mental health clinicians and parents for children with
sensory processing disorder (SPD) and complex trauma
and attachment concerns.
©2019 OTA The Koomar Center 5
SAFE PLACE Model
◼ Provides a therapeutic framework for service providers and
parents
◼ Emphasizes development of body-based regulatory and
adaptive functions with co-regulation and intersubjective
experiences
◼ Supports a deepening of attachment bonds and security
◼ Facilitates the processing and healing of traumatic
experiences
◼ Occurs within the context of a sensory integration
intervention process
©2019 OTA The Koomar Center 6
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SAFE PLACE Model
◼ Encompasses the concepts and philosophies
of three core knowledge areas
❑ sensory integration theory
❑ attachment theory
❑ complex developmental trauma models
©2019 OTA The Koomar Center 7
Foundational Characteristics of the
SAFE PLACE Model
©2019 OTA The Koomar Center 8
“SAFE”
◼ Reflects the sensory component
of the theory
◼ Means Sensory Attunement-
Focused Environment
◼ Represents use of safe,
supportive, developmentally
appropriate, sensorimotor
activities and environments
◼ Promote engagement through
play and fun in children’s physical
and emotional development
©2019 OTA The Koomar Center 9
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“PLACE”
◼ Reflects the attachment
component of the theory
◼ Means Playfulness, Love,
Acceptance, Curiosity and
Empathy,
◼ Qualities of mindful
engagement utilized by
collaborating therapists to
facilitate secure attachment
and healing in the child and
family.
©2019 OTA The Koomar Center 10
“SAFE” and
“PLACE” as
“safe place”
◼ Represents the trauma
component of the theory
◼ Highlights the process of
establishing and maintaining
an environment and
experience of safety and
stability for the child
◼ Allows processing of
traumatic experiences
©2019 OTA The Koomar Center 11
SAFE PLACE Program: Criteria for
Participation
◼ Children 4 – 15 years of age
◼ Sensory integration problems
◼ Trauma background resulting in current attachment concerns
◼ Child is unable to make adequate progress in sensory
integration intervention because of trauma/attachment-
related problems
or
◼ Child is unable to make adequate progress with trauma
processing, etc. because of sensory integration and/or praxis
problems
©2019 OTA The Koomar Center 12
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SAFE PLACE Program
◼ Program consists of 3 processes
❑ Pre-SAFE PLACE Screening – Identifies initial
potential need for the program
❑ Assessment - Multi-disciplinary comprehensive
assessment to fully identify SI & MH needs and
determine eligibility for intervention
❑ Intervention – Multi-faceted and multi-stage
progression to addressing client and family needs
©2019 OTA The Koomar Center 13
SAFE PLACE Program: Participants
◼ Child
◼ Parents/Caregivers
◼ Mental Health Professional
◼ Occupational Therapists
©2019 OTA The Koomar Center 14
SAFE PLACE Program: Intervention
Structure
◼ 12-week program consisting of:
❑ Twice weekly child therapy with parent, occupational
therapist, and mental health professional for 1-hour
each session, conducted in a sensory integration clinic
environment.
❑ Once weekly parent education/consultation session for
1 hour each week with the occupational therapist and
mental health professional.
❑ Once weekly professional collaboration for 1 hour
each week between the occupational therapist and
mental health professional.
©2019 OTA The Koomar Center 15
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SAFE PLACE Program: Guiding
Tenets
©2019 OTA The Koomar Center 16
Building Safety and
Co-Regulation of Arousal
Building Attachment
Bonds
Facilitating Engagement and Mastery
Providing Opportunities for Trauma Processing
Theoretical Foundations
of SAFE PLACE Model
©2019 OTA The Koomar Center 17
Core Concepts and Practices.- originated from disciplines of OT &
Psychotherapy
• Ayres (1972, 1979)
• Koomar (2002, 2009) Sensory Integration
• Bolby (1958), Ainsworth (1969, 1991)
• Hughes (2007)Attachment Theory
• Van der Kolk (2003)
• Rozelle (2009)Trauma Theory
• Briere (2012, 2013)Mindfulness Orientated Practices
©2019 OTA The Koomar Center 18
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Sensory Integration and Attachment
◼ Attunement
◼ Intersubjective experience
◼ Relational Treatment
Models
◼ Safety
◼ Co-regulation
©2019 OTA The Koomar Center 19
Sensory Integration and Attachment
Continued
◼ Attachment bond helps the typically
developing child
❑ Cope with distress;
❑ Protects and mitigates ill effects of
stressful or traumatic experiences
◼ Physiologically sensitive children
with SPD are often more vulnerable
to adverse affects from traumatic
experiences that impact attachment.
©2019 OTA The Koomar Center 20
https://blogs.extension.org/militaryfamilies/files/2
013/10/woman-comforting-upset-boy.jpg
Sensory Integration and Trauma
◼ Safety – physical and emotional
◼ Regulation
◼ Processing and integrating (Trauma & SI)
◼ Competency
“Children who have experienced trauma must build a sense of
competency and mastery in order to gain physiological control over
their arousal state” Van der Kolk (2003)
©2019 OTA The Koomar Center 21
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Trauma and Attachment
◼ Research indicates up to
80% of children who have
experienced complex trauma
experience attachment
challenges (Ogle 2015)
◼ Early caregiving attachment
relationships, especially
those of mother and infant
are often compromised in
complex trauma
©2019 OTA The Koomar Center 22
This Photo by Unknown Author is
licensed under CC BY-ND
SAFE PLACE
Program:
Assessment
&
Intervention
Components
©2019 OTA The Koomar Center 23
Pre-SAFE PLACE Screening
◼ Purpose: to identify initial potential need
for the SAFE PLACE Program
◼ May be completed by OTs, mental health
professionals
◼ Initially screens for SI and trauma/attachment
challenges
◼ Outcome: referral for a comprehensive multi-
disciplinary SAFE PLACE evaluation
©2019 OTA The Koomar Center 24
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SAFE PLACE Assessment
◼ 3 phase
◼ Phase 1: Referral for SAFE PLACE Program and Initial
Program Screening
❑ Determines initial eligibility for program and initial assessment needs
◼ Phase 2: Multi-Disciplinary SAFE PLACE Assessment
❑ Comprehensive assessment of sensory integration and mental health
concerns identifies need areas and final eligibility for intervention
◼ Phase 3: Evaluator Meeting, Goal Setting and Identifying
Outcomes
❑ Evaluator meeting with parents to convey assessment results and
recommendations, set goals if intervention is recommended and
identify anticipated treatment outcomes
©2019 OTA The Koomar Center 25
SAFE PLACE Intervention
Components
◼ Structural Components
❑ Sensory-Rich
Treatment Space
❑ Collaborative Team
❑ Parent Involvement
◼ Process Components
❑ Contextual Factors
❑ Interpersonal Factors
◼ Expected Outcomes
❑ Establishment of
Safety and Regulation
❑ Building Attachment
❑ Engagement and
Mastery
❑ Trauma Processing
©2019 OTA The Koomar Center 26
Intervention: Structural Components
Sensory-Rich Treatment Space
◼ Intervention happens within a sensory-rich treatment space
designed and set-up for comfort, safety, and to facilitate
participation of all
◼ The SAFE PLACE environment should be at a minimum a
room 12’ X 12’in size which is equipped with a variety of
suspended and non-suspended equipment that can provide
tactile, proprioceptive and vestibular sensory inputs;
postural challenges; and praxis activities.
©2019 OTA The Koomar Center 27
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Space and Environment and
Equipment
©2019 OTA The Koomar Center 28
Space and Environment and
Equipment
©2019 OTA The Koomar Center 29
Space and Environment and
Equipment
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Space and Environment and
Equipment
©2019 OTA The Koomar Center 31
Space and Environment and
Equipment
©2019 OTA The Koomar Center 32
Space and Environment and
Equipment
©2019 OTA The Koomar Center 33
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Intervention: Structural Components
Collaborative Team
◼ Members
❑ Occupational Therapist
❑ Mental Health Professional
❑ Child
❑ Parent/caregiver
◼ Occupational Therapist - sensory environment that is: Safe
and supportive & facilitates regulation and skill, promotes
interaction with caregiver and child to support trauma
processing
◼ Mental Health Practitioner - Guides and facilitates trauma
processing within sensory environment and promotes
attachment healing with child and parent/caregiver
©2019 OTA The Koomar Center 34
Intervention: Structural Components
Collaborative Team
◼ Child – Supported to develop competency in:
❑ Sensory processing
❑ Co-regulation leading to Self-regulation
❑ Skill development and mastery
❑ Reclaim the innate capacity for fun and play
❑ Engage in trauma healing
◼ Parent - Supported to co-regulate with their child
❑ Engage in attachment healing with the child through play
❑ Supports child in progression of mastery and competency
❑ Collaborates with therapists during sessions and meetings
❑ Recognizes and addresses their own sensory and trauma
patterns
©2019 OTA The Koomar Center 35
Intervention: Structural Components
Parent Involvement
❑ provide emotionally and physically
safe spaces for interactions with
their child
❑ Understanding their own sensory
profiles
❑ Understanding any trauma and
attachment history and associated
response patterns of their own
❑ Understanding how their own
background impacts how they deal
with relational and behavioral
challenges when working with their
child
Parents are integrated
part of therapy sessions
in sensory space and
collaborative meetings.
©2019 OTA The Koomar Center 36
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Intervention: Process Factors
©2019 OTA The Koomar Center 37
Intervention: Contextual Factors
◼ Include implementation of key principles of
Ayres Sensory Integration based on ASIFM
❑ Insures physical and emotional safety,
❑ Presents rich sensory opportunities for the body
senses
❑ Available activities allow child to calm as well as
move into a joyous state, provision of activities
that allow the child to use postural muscles and
balance over time
©2019 OTA The Koomar Center 38
Intervention: Contextual Factors
Continued
❑ Provision of materials child can create with,
creation and tailoring of play activities to just the
right challenge
❑ Insures that play activities are successful
❑ Monitors the child’s arousal level and adjusts
accordingly
©2019 OTA The Koomar Center 39
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Intervention: Interpersonal Factors
◼ Intersects with contextual factors in provision of
physical and emotional safety of the child.
◼ Includes establishment of a partnership with the
child through therapist-parent-child
collaboration on activity choice and
development of a therapeutic alliance
◼ Key are PLACE concepts of playfulness, love,
acceptance, curiosity, and empathy.
©2019 OTA The Koomar Center 40
Intervention Process: Phases
◼ Intervention sessions promote a phase-oriented
process which emphasizes aspects of sensory
processing, attachment and trauma processing
at varying times.
◼ Phases are flexible and child may move among
phases within a session and over time.
◼ Specific steps and goals occur during each
phase as well as varying roles of individuals
involved, intervention activities and support
activities.
©2019 OTA The Koomar Center 41
Intervention: Expected Outcomes
◼ Traditional outcomes of OT-SI such as
integration of sensory information to
build body scheme, praxis and self-
regulation
◼ Facilitation of co-regulation between
child and caregiver
◼ Security of attachments between child
and caregiver
◼ Healthy adaptive child development
across all domains
◼ Healing of child’s reactions to traumatic
experiences
©2019 OTA The Koomar Center 42
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SAFE PLACE
Intervention
©2019 OTA The Koomar Center 43
SAFE PLACE Intervention
◼ What is needed to implement the program
❑ Manualization of the program
❑ Staff considerations
❑ Stages of Intervention
©2019 OTA The Koomar Center 44
SAFE PLACE Intervention Manual
◼ SAFE PLACE Program
has been manualized.
.
©2019 OTA The Koomar Center 45
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SAFE PLACE Intervention Manual
◼ Describes core components of the theory and
model;
◼ Describes assessment process in detail
◼ Description of the program structure
◼ Describes staffing requirements and space
◼ Core components of the intervention along with
descriptions of the clinical reasoning process
and activities needed to implement the
intervention
◼ Allows for replicable implementation
©2019 OTA The Koomar Center 46
Staff Considerations
◼ Required staff characteristics for those who
implement SAFE PLACE
❑ Qualifications
❑ Self Awareness
©2019 OTA The Koomar Center 47
Qualifications of Staff: OT
Sensory
Integration
• Must have expertise in SI theory and intervention
• Be SIPT certified
• Have 5 years experience in sensory integration
• 50 hours of mentoring in sensory integration
Attachment • Understanding of and ability to use PACE
• Good understanding of attachment theory
• Have taken Dan Hughes’ one day course on attachment
and trauma
Trauma • Good understanding of trauma theory
• Ability to recognize signs and symptoms of trauma
reactions
• Have available ongoing consultation/mentoring from a
mental health professional
• Have taken at least one course (6 hours) on trauma
informed care©2019 OTA The Koomar Center 48
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Qualifications of Staff: Mental
Health Professional
©2019 OTA The Koomar Center 49
Sensory
Integration
• Must have good understanding of SI theory and
intervention
• Recognize impact of sensory inputs on arousal
• Understand what inputs are provided by specific pieces
of equipment
Attachment • Expertise in area of attachment theory and intervention
• Have taken Dan Hughes’ Level 1 course on attachment
and trauma
Trauma • Expertise in trauma theory and intervention
• Have 5 years experience in counseling/psychotherapy in
the area of trauma and attachment
• Have at least 12 hours coursework or continuing
education in trauma and 12 hours in attachment
• Have 50 hours of mentoring in trauma and attachment
counseling/psychotherapy
Intervention: Considerations for
Service Providers
◼ SAFE PLACE assumes providers understand
their own sensory preferences and profiles
and are sufficiently adaptive in their overall
social, emotional, and behavioral functioning
to assist the child as co-regulators in the
SAFE PLACE treatment process.
©2019 OTA The Koomar Center 50
Activity: Sensory Preferences
Questionnaire
◼ Complete questionnaire on
yourself
◼ Complete questionnaire on
your child or partner
◼ How are your sensory
preferences similar or different
than your child or partner?
◼ What kind of mismatches might
occur when there are
differences?
©2019 OTA The Koomar Center 51
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Intervention: Implementation
◼ The SAFE PLACE intervention process is
based on the13 core contextual and
interpersonal intervention principles
presented earlier.
◼ Implemented over four phases of intervention
that reflect the desired outcomes of SAFE
PLACE.
◼ Each phase consists of multiple steps.
©2019 OTA The Koomar Center 52
Intervention: Phases
©2019 OTA The Koomar Center 53
•Integration
•Child directed play
•Resiliency and engagement with others
•Stabilization, grounding, centering
•Processing emotions
•Reconnection
•Orientation to the present
•Attunement
•Intersubjectivity in here and now
•Co-regulation & co-creation of meaning
•Intersubjectivity in sharing past experiences
•Development in sense of self
•Establish safe physical environment
•Establish safe emotional environment
•Provide sensory activities for regulation of arousal
•Develop competency in motor skills
Establishing Safety and
Regulation of Arousal
Promoting Opportunity for Building Attachment
Facilitating Engagement and Mastery
Providing Opportunities for Trauma Processing
Intervention Phase One: Establish
Safety and Regulation of Arousal
©2019 OTA The Koomar Center 54
◼ Step 1: Establish Safe Physical Environment
❑ Child can freely engage in child-directed activities
◼ Step 2: Establish Safe Emotional Environment
❑ Child can trust others and take risks
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Intervention Phase One: Establishing
Safety and Regulation of Arousal
◼ Step 3: Provide Sensory Activities for
Regulation of Arousal
❑ Child can self-regulate to maintain functional arousal
❑ Child can stay with an activity to completion
◼ Step 4: Develop Competency In Motor Skills
❑ Child can initiate and complete motor skills
©2019 OTA The Koomar Center 55
Intervention Phase Two: Promote
Opportunities for Building Attachment
©2019 OTA The Koomar Center 56
◼ Step 1: Attunement
❑ Child and Parent are able to engage together in
parallel activity
◼ Step 2: Inter-Subjectivity in Here and Now
❑ Child and Parent are able to engage in positive
reciprocal interactions in the here and now
Intervention Phase Two: Promote
Opportunities for Building Attachment
◼ Step 3: Co-Regulation & Co-Creation of
Meaning
❑ Child and parent are able to engage in clinician-
initiated positive interactions
◼ Step 4: Inter-Subjectivity in Processing
Past Experiences
❑ Child and parent are able to engage in child
initiated positive interactions around past
experiences that build trust and predictability
©2019 OTA The Koomar Center 57
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Intervention Phase Two: Promote
Opportunities for Building Attachment
◼ Step 5: Development of Sense of Self
❑ Child will develop trust and a working alliance with
parent
❑ Child and parent are able to engage in parent-
initiated positive interactions which allow the child
to take direction
©2019 OTA The Koomar Center 58
Intervention Phase Three: Provide
Opportunities for Trauma Processing
◼ Step 1: Stabilization/ Grounding/ Centering
❑ Child will develop an awareness of his/her
body and internal sensations in response to
emotional events
◼ Step 2: Processing Emotions
❑ Child will develop ability to recognize and
modulate emotions and memories
❑ Child will develop a coherent, mindful
orientation to living
©2019 OTA The Koomar Center 59
Intervention Phase Three: Provide
Opportunities for Trauma Processing
◼ Step 3: Reconnection
❑ Child will create and enhance meaningful
involvement in interpersonal pursuits
❑ Child will be able to handle healthy aggression
and return to equilibrium
◼ Step 4: Orientation to Present
❑ Child will attend to their current state and
demonstrate agency and empowerment in
managing emotional situations
©2019 OTA The Koomar Center 60
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Intervention Phase Four: Facilitate
Engagement and Mastery
◼ Step 1: Integration
❑ Child will be able to engage in and assist in planning
of activities
❑ Child will be able to self-regulate during and following
disrupting events with support of parent or therapists
◼ Step 2: Child-Directed Play
❑ Child will be able to plan and engage in child-directed
activities with parent and therapists
❑ Child will be able to process disrupting events and
continue or return to the original activity
©2019 OTA The Koomar Center 61
Intervention Phase Four: Facilitate
Engagement and Mastery
◼ Step 3: Resiliency and Engagement with
Others
❑ Child will be able to plan and engage in child-directed
activities with peers
❑ Child will be able to recover from disrupting events
and continue activity with minimal support from parent
or therapists
©2019 OTA The Koomar Center 62
Parent Education and Support
◼ Step 1: Identification of Future Interventions
❑ Identify need for continued individual SI-OT and/or
mental health services
❑ Parent support services
◼ Step 2: Identification and Provision of On-
going Family Supports
❑ Sensory diet programs
❑ Consultation to family or school
©2019 OTA The Koomar Center 63
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Parent Education and Support
Resources
◼ Family Sensory Preferences Profile
❑ (Koomar & Hughes, 2007)
◼ Tool is designed to increase understanding and
respect for individual differences. Also used to
help identify activities that are mutually
enjoyable and where participation between
parent and child can help to lay a foundation for
establishing or enhancing attachment.
©2019 OTA The Koomar Center 64
Parent Education and Support
Resources
◼ Parenting Profile for Developing Attachment
❑ (Hughes, 2012)
◼ Examines the parenting style of the caregiver
to identify areas of personal growth that may
need to be addressed to allow the caregiver
to most effectively promote attachment
bonding in their child.
©2019 OTA The Koomar Center 65
Parent Education and Support
Resources
◼ Questions for Parental Self-Reflection
❑ (Hughes, 2012)
◼ A series of 10 question for parents and
caregivers to assist them in relating their
personal attachment histories to their child’s
experiences.
©2019 OTA The Koomar Center 66
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Parent Education and Support
Resources
◼ Sensory Regulation Activities for Parents and
Therapists (Video)
❑ Available through the Spiral Foundation at
www.thespiralfoundation.org.
❑ This video demonstrates a variety of treatment
activities for parents and therapists for over ten pieces
of primarily non-suspended and easy to use or make
equipment. It provides ideas for promoting self-
regulation and praxis in children, adolescents, and
adults with sensory processing disorders.
©2019 OTA The Koomar Center 67
Research Supporting
SAFE PLACE
©2019 OTA The Koomar Center 68
SAFE PLACE Research To Date
◼ Studies have been completed which
examine:
❑ Validation of the theoretical construct
◼ Qualitative video review
◼ Examination of intervention fidelity
❑ Feasibility of implementation and preliminary
outcomes of clinical implementation
◼ Case study of clinical outcomes
◼ Feasibility program review with one child
©2019 OTA The Koomar Center 69
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Construct Validity Through Video
Review
◼ Mixed methods study
◼ Used a grounded theory model
◼ Examined qualitative themes in transcriptions of video segments of sessions purporting to use SAFE PLACE tenets.
◼ 6 videos of sessions
◼ Included an occupational therapist, a mental health practitioner (usually a psychotherapist or psychologist) with knowledge of SAFE PLACE principles, a parent, and the child
◼ Coded by 4 OTs.
70©2019 OTA The Koomar Center
Construct Validity Through Video
Review: Results of Themes
◼ Four themes supported
SAFE PLACE theoretical
model
◼ Communication
❑ Across persons communications
involved verbal and non-verbal
communications that were
directed at each other and in
general.
❑ All persons communicated with
each other and the child.
©2019 OTA The Koomar Center 71
https://wearyourvoicemag.com/wp-
content/uploads/2016/02/3895377417_cbe655ddbb_z.jpg
Construct Validity Through Video
Review: Results of Themes
◼ Management and
Engagement of
Activities❑ All individuals participated in
activities in some way.
❑ OT and mental health
professional tended to manage
aspects of the activity such as
presenting activities, assisting
the child, changing activities,
and hanging up equipment.
❑ Child engaged in activities
and invited other to
participate.
❑ Adults participated in child
activities primarily at the
child’s invitation.
©2019 OTA The Koomar Center 72
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Construct Validity Through Video
Review: Results of Themes
◼ Expression of Emotion
and Affect
❑ All individuals expressed
emotions and varied affect during
the sessions.
❑ OT and mental health
professional
◼ Encouraged and praised the child
◼ Celebrated the child’s achievements
◼ Generally expressed positive
emotions through words and affect
such as smiles and laughter.
©2019 OTA The Koomar Center 73
http://www.parcofontario.com/
Construct Validity Through Video
Review: Results of Themes
❑ Parents
◼ Expressed emotions and affect, generally positive
◼ At times expressed refusals, upset, and distress.
❑ Child
◼ Expressed a wide range of emotions and affect
❑ From increased or avoidant eye contact
❑ To screams
❑ To smiles and laughter.
©2019 OTA The Koomar Center 74
Construct Validity Through Video
Review: Results of Themes
◼ Interpersonal
Interactions
❑ Individuals moved their
physical placement in
relation to others
❑ Reasons included:
◼ To allow one person to
have increased proximity
to the child or equipment
◼ To distance proximity
◼ Included interactions in
close proximity such as
touching the child.
©2019 OTA The Koomar Center 75
http://www.catalysttherapy.com/
May 2-3, 2019
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Construct Validity Through Video
Review: Results of Themes
❑ For child and parent additional interactions
involved:
◼ Non-engagement
◼ Rejection
◼ Ignoring
◼ Approaching
◼ Accepting suggestions
◼ Following
©2019 OTA The Koomar Center 76
http://www.specialneeds.com/
Construct Validity Through Video
Review: Role Differences
◼ Observations within each theme were examined
by participant roles.
◼ Differences among participants roles emerged
by themes.
◼ There was a distinct difference in adult roles and
the child roles as well as differences among
each adult role which varied by individual
themes as well as overall.
◼ Supported need for all participants in
intervention
©2019 OTA The Koomar Center 77
Fidelity to Intervention
◼ A SAFE PLACE Fidelity Measure reflecting
structural and process elements was
developed as part of manualization of
intervention process
◼ Two studies were completed
❑ Fidelity during qualitative video review
❑ Fidelity during program review
©2019 OTA The Koomar Center 78
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Fidelity to Intervention
◼ Fidelity during Qualitative Video Review
Study
❑ 6 videos (4 treatments, 1 consult, 1 assessment)
were rated by 4 therapists
❑ ICC for inter-rater reliability of ratings was .989 for
total score, .985 and .972 for Contextual and
Interpersonal factors
❑ Assessment case did not meet fidelity criteria of
85%
©2019 OTA The Koomar Center 79
Fidelity to Intervention
◼ Fidelity during Program Review
❑ Six fidelity checks were completed approximately
equally spaced across the study
❑ All sessions met fidelity to the intervention with
responses of 85% or greater on the fidelity
measure.
❑ Thus adherence to the intervention was
supported.
©2019 OTA The Koomar Center 80
Research on Implementation
of
SAFE PLACE in Practice
©2019 OTA The Koomar Center 81
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Case Study: Preliminary Outcomes
◼ M, 4.10 year old male, adopted from Russia,
◼ Received no previous occupational therapy
services
◼ Attended a preschool setting
◼ Both parents were professionals
◼ M was often watched by a nanny, who was a
family relation
◼ Mother primarily participated in the intervention
©2019 OTA The Koomar Center 82
Case Study: Outcome Measures
◼ Sensory & Motor
❑ Movement Assessment Battery
for Children – 2 (MABC): Motor
development.
❑ Sensory Integration Clinical
Observations (COs): Sensory
integration and sensory
processing difficulties.
❑ The Beery-Buktenica
Developmental Test of Visual
Motor Integration – 6th Ed.:
Visual motor problems.
❑ Sensory Processing Measure
Home Form (SPM): Sensory
processing.
◼ Behavior/Executive
Function/Social
❑ The Behavior Rating Inventory
of Executive Functioning
(BRIEF): Executive functioning
skills.
❑ Behavior Assessment System
for Children – Third Edition
(BASC-3): Adaptive behaviors
and emotions.
❑ The Social Skills Improvement
System Rating Scales (SSIS):
Social skills.
©2019 OTA The Koomar Center 83
Case Study: Outcome Measures
◼ Functional Performance
❑ Pediatric Evaluation of
Disability Inventory – Computer
Adaptive Test (PEDI-CAT):
Functional performance.
❑ The Roll Evaluation of
Activities of Life (REAL):
Activities of daily living.
❑ Goal Attainment Scaling (GAS)
Goals: Functional Performance
Measure.
◼ Parent Measure
❑ Parenting Profile for
Developing Attachment
(PPDA): Parent preferences for
sensory experiences.
©2019 OTA The Koomar Center 84
May 2-3, 2019
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Preliminary Intervention Outcomes:
Sensory & Motor
Assessment Pre-Post Changes
Movement ABC Total Score Improved 4 Points
Beery VMI Total Score Improved10 Points
Clinical Observations Total Score Improved 50 Points
SPM 5/7 Sub scores Improved 4 – 10
Points
2/7 Sub scores Got Worse 3 – 7
Points
Total Score Improved 6 Points
©2019 OTA The Koomar Center 85
Preliminary Intervention Outcomes:
Behavior/Executive Function/Social
Assessment Pre-Post Change
BRIEF 9 Sub scores Improved
2 Sub scores Decreased 2 Points
BASC 11/18 Sub scores Improved
3/18 Sub scores Got Worse
4/18 Sub scores No Change
SSIS* *All scores in Average or Above Average
range
©2019 OTA The Koomar Center 86
Preliminary Intervention Outcomes:
Functional Outcomes & Parenting
Assessment Pre-Post Change
REAL Total Score Got Worse 2.6 Points
PEDI-CAT 1/4 Sub scores Improved
1/4 Sub scores Got Worse
2/4 Sub scores No Change
GAS t-score = 53
Parenting Profile for
Developing
Attachment:
Perception of Self
5 Point Improvement
©2019 OTA The Koomar Center 87
May 2-3, 2019
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Preliminary Intervention Outcomes:
Qualitative Feedback from Parent
◼ “This has been a fantastic experience and had
a significant impact on my son and our
relationship.”
◼ “The program not only helped my son, but
helped me to be more aware of my reactions
and learning new methods and techniques for
dealing with his behaviors in a positive, loving
and effective manner.”
◼ “The ability to participate in this intervention
program was a blessing!”
©2019 OTA The Koomar Center 88
Preliminary Intervention Outcomes:
Conclusions
◼ Objective sensory and motor outcomes
demonstrated the most positive change
◼ Parent report outcomes of behavioral, social
and functional skills were variable
◼ Functional goals (GAS) demonstrated above
average change
◼ Qualitative changes experienced by family
were valued and identified as extremely
positive to changing parent-child relationship
©2019 OTA The Koomar Center 89
Program Review Feasibility Study
◼ Recruitment Capability
◼ Safety and Acceptability
◼ Resources and Management of Study
Implementation
❑ Staffing
❑ Space
❑ Scheduling
❑ Finances
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May 2-3, 2019
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Recruitment Capability
Safety and Acceptability
◼ Recruitment of clients for participation in the
project was no problem.
◼ There were no adverse events or safety
concerns during the program.
◼ The program was acceptable to family with
an average rating of 4.3 on a five-point scale.
◼ The family was very satisfied with the
intervention and its outcomes with a rating of
4.75
©2019 OTA The Koomar Center 91
Resources and Management of
Study Implementation
◼ Staffing
❑ Qualified OT were easy
❑ Challenge to recruit a MHP
❑ Need a regularly scheduled MHP on staff
◼ Space
❑ Coordinating space around regular clinic use was
a challenge to scheduling
❑ SI clinic space was vital for program
©2019 OTA The Koomar Center 92
Resources and Management of
Study Implementation
◼ Scheduling
❑ Scheduling for family a challenge
❑ Afterschool and weekend hours would be helpful
❑ Coordinating multiple schedules for makeups,
vacations, holidays, etc. extended program
duration
◼ Finances
❑ Only able to do partial insurance coverage
❑ Out of pocket costs may be prohibitive
©2019 OTA The Koomar Center 93
May 2-3, 2019
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Important Take Home Points -
Clinicians
◼ Assess how you are collaborating with child,
parent and other professionals
◼ Bring parents into sessions as participants
not observers and facilitate their interaction
with the child during in the moment activity
◼ Model how to have fun WITH the child
◼ Model for parents how to process and
facilitate child in times of frustration
©2019 OTA The Koomar Center 94
Important Take Home Points -
Clinicians
◼ Develop relationships with local mental health
professionals/ or and OT
◼ Create opportunities for regular case
consultation with other professionals
◼ Explore ways to implement sensory activities
in other settings and facilities across
professions
©2019 OTA The Koomar Center 95
Important Take Home Points -
Parents
◼ Respect child’s desires for activities and
conversational topics
◼ Be aware of impact of sensory differences
among parent/child/family members
◼ Be aware of your own needs, history and
support systems
◼ Support collaboration among OT and mental
health professionals involved with your child
©2019 OTA The Koomar Center 96
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Resources
◼ OTA The Koomar Center:
❑ Distance Mentorship Program
❑ Therapeutic Consultations
❑ Sensory Integration Facility Design Consults
◼ Spiral Foundation
❑ Educational Webinars, podcasts and courses
www.otathekoomarcenter.com
www.thespiralfoundation.org
97©2019 OTA The Koomar Center
Thank you!
Questions???
98©2019 OTA The Koomar Center