Sensory Connection to Trauma and Treatment in Youth

Trauma Informed Symposium of Wisconsin

April 12th, 2017 Oshkosh, WI

Karen M. Moore, OTR/L & Angela Balzarini-Leonhart, OTR/L

Karen M. Moore, OTR/L 476 Timber Lane, Franconia NH 03580 E-mail: [email protected] Website: www.sensoryconnectionprogram.com

Karen Moore is an occupational therapist, a graduate of Worcester State College, who worked in mental health at Worcester State Hospital and on the Acute Adult Psychiatric Unit at UMASS Medical Center. Her career long commitment to the study and use of sensory modalities for treatment in psychiatric care culminated in the writing of her book The Sensory Connection Program: Activities for Mental Health Treatment (2005). She developed a sensory-based treatment group which is a popular group for patients with cognitive and language difficulties which continues to run daily at UMASS. She led a clinical research project on the efficacy of using the Wilbarger Protocol, an intensive sensory treatment program, with patients with psychiatric diagnoses along with sensory defensiveness, PTSD, and self-injurious behaviors (Moore & Henry, 2002). Over the years Karen has presented on sensory related treatment to hospitals, behavioral units, community programs, college programs, nursing homes, and numerous occupational therapy conferences including MAOT, NHOTA, OTAC and SSOT/SK. She lectures on the use of sensory related treatment strategies throughout the country and provides consultation on the development of sensory rooms and program groups. Karen newest book is entitled The Sensory Connection Program: Curriculum for Self-regulation: Group Treatment for Emotional Regulation, Crisis Intervention & Stress Management.

Angela Balzarini-Leonhart, OTR/L 52 Oliver Ave S. Minneapolis, MH 55405 Email: [email protected]

Angela Balzarini-Leonhart is an Occupational Therapist who specializes in the use of Sensory Intervention and Self-Regulation strategies. Angie is a graduate of St. Catherine’s University OT program. She received her BS in Psychology at Northern Michigan University. Angie currently works as an OT Lead and Sensory Intervention Consultant for the MH Department of Regions Hospital in St. Paul MN. Angie was an integral part in the development of the sensory program at Regions. She is the first OT in the state of Minnesota to have the title MH Sensory Intervention Consultant. She has assisted in writing grants and has shared her sensory knowledge for the inpatient mental health sensory program setup and logistics. Angie has trained interdisciplinary staff and implemented sensory programs throughout the hospital and the organization. Angie is active in MOTA SIG presenting for both the Chronic Pain, Mental Health specialty groups and the 2015 Annual Conference. She is also active with NAMI and OTAMMHS, which advocate and support OT’s work in mental health settings in the state of Minnesota. In the past 2 years, Angie has had the honor of presenting with Karen Moore, from the Sensory Connection Program. She has had the pleasure of sharing her wealth of clinical experience utilizing sensory approaches at trainings in Minnesota, Wisconsin and recently in Denver, Colorado.

Participants in this training have permission to make copies of the pages of this handout to use for educational and clinical purposes within their program or facility.

More resources, free games and activities, and a comprehensive and updated list of references are available on the Sensory Connection Program Website.

http://www.sensoryconnectionprogram.com/index.php

Make Your Own Tool Box

As the SCP workshops progress, use this form to keep track of ideas that will make sense to use in your clinical setting so that you can develop your own personalized tool box.

Mouth Tools Hearing Tools Smell Tools

Eye Tools

Body Tools Hand Tools Doing Ideas

Learning About Calming and Alerting

This worksheet is to help you identify when calming or alerting sensory input is needed and also the general characteristics that make sensory input calming or alerting for most people. Remember that reactions to sensory input are very personal. What one person finds calming another person might find alerting. It is important to experiment and see what works for you.

Calming is needed when you are: Alerting is needed when you are:

Upset Unable to focus Anxious Feeling “out of it” Angry Having negative thoughts Overwhelmed Dissociating Tense Having flashbacks Feeling stressed Feel sleepy or sluggish In need of relaxing In need of pepping up

Calming Input is usually: Alerting input is usually:

Mild/soft Strong/pronounced Slow Fast paced Rhythmic Non-rhythmic Simple Complex Familiar Novel Expected/predictable Surprising/unpredictable Soothing Irritating Undemanding Demanding Containing positive associations Containing negative associations

Symptoms of Distress

Stop!!!! These are signs that a person is having difficulty tolerating the activity

Acting out Anxiety Excuses Confusion Irritability

Resistance to activity Defensive behaviors Lightheadedness Increased perspiration Flushing or pallor Shortness of breath Over arousal Paranoia Fearful expression

DEEP BREATHING EXERCISES

Deep breathing, also called diaphragmatic breathing; it is the most basic relaxation exercise. By breathing slowly and deeply from the abdomen a person can enter a deep state of relaxation anywhere, anytime, with no special equipment or training. It works best if it is practiced on a daily basis. Even a few breaths can help the body to calm down. Ideally you should work up to ten and then twenty minutes of deep breathing each day. Make yourself comfortable. You can lie down on your back with the head supported by a pillow and possibly another pillow under the knees. One drawback to this position is that people fall asleep. This can be used to your advantage at night, but it is not a full deep breathing experience unless you remain focused on the breathing. You can also sit in the lotus position with the legs crossed in front or in a semi lotus position with one leg extended. Sitting on a pillow makes this position more comfortable for some people. You can also sit in a chair. It is important to be comfortable. * * * * * * * * * * * * * * * *

 Close your eyes and put your hands gently on the stomach in order to feel the breaths. Inhale deeply through the nose feeling the abdomen expand as you breathe in. Pause, and then slowly exhale with your mouth and lips puckered as if blowing bubbles. That helps to slow down the breathing. Exhale until the lungs feel empty.

 Continue to breathe in and out slowly and deeply—in through the nose and out through pursed lips. Make sure the stomach expands and contracts with the breaths; if the shoulders rise and fall instead, your breathing is still shallow and only expanding the chest area.

 One way to make the breaths more rhythmic is to count to four slowly as you inhale, pause, and them exhale slowly to the count of four.

 Focus on your breathing. When your thoughts wander, just bring them back to focus on the breathing. If worries come into your mind, just set them aside and refocus. This becomes easier with practice.

 Each time you breathe out, try to relax the body a little bit more. If a particular area is tense, focus on relaxing it as you exhale.

 Continue to breathe for just a few minutes or as long as twenty minutes. When ready to stop, open your eyes slowly and continue a few more breaths and remain still for a few minutes before returning to other activities.

 The more you practice, the more helpful the breathing exercises will become. It is easier to utilize them in times of stress if you have practiced regularly.

How to Give a Hand Massage

You can give a patient or family member the gift of relaxation, calming and pain relief with a 10 minute hand massage! Sit down so that you can comfortably hold the other person’s hand in front of you. Put a small amount of lotion or oil on your palms and rub them to warm up. Start with effleurage - firm stroking motions using the palms of the hands, moving from fingers to wrist on both sides of the hand. This can be repeated at intervals throughout the massage to keep the skin warm. Now, work through the following moves:

 Supporting the hand with one of your palms, make small, firm circular motions of your other thumb in their palm, concentrating on the muscles near the thumb and little finger, and the base of each finger.

Do this as firmly as they want.  Do a similar movement using the knuckles of one hand.  Turn their hand over, and use your index finger to make small circles down the gaps between the tendons on the back of the hand, finishing by gently pinching the web of skin between the fingers.  Starting at the knuckle of each finger and thumb, make small circles down to the fingertip with your thumb, and then gently pull on the finger as you let go.  Hold the whole hand by the sides with both hands, so your thumbs are next to each other on the back of the hand (this is hard to describe in words). Gently pull your hands apart and down over the back of their hand, as if trying to separate it out. Repeat a couple of times.  Turn the hand back round. With their fingers facing towards you and your hands facing palms up, interlace your ring and little fingers of each hand with the gaps between their fingers and thumb, and then use your thumbs to firmly massage their palm and wrist.  Releasing the grip used above, make small circles up their fingers from the underside of the knuckle to the tip, again pulling off at the ends.  Finally, finish off by doing more effleurage followed by pressing their hand between your palms and pulling towards and then off from their fingertips.

Weighted Eye Masks

Help improve your sleep by; blocking out light, providing weight to relax the muscles of the eyes, and inviting in the relaxing smell of lavender (optional).

Supplies needed

1 piece pattern material- precut and sewn (image to the right)

1 piece cream material- precut and sewn

Needle & Thread

Measuring cup

Pellets

Lavender (optional)

Directions

1. Choose material. Consider personal preference of texture and pattern. 2. Fill with pellets, ranging from 1 cup to 2 cups, depending on how heavy you would like the mask.

3. *Optional add up to 1/4 cup of lavender. Use less if you prefer more subtle aroma. 4. Hand stitch open end of eye mask. Fold in edges around complete circle. Loop stitch around end of material back in (about 1/8 inch)

5. Place bag inside choosen material. Enjoy rest and relaxation!

My Body Feelings Chart

What emotion are you feeling? Anger Fear Anxiety Agitation Other:______

Tune into your body. Put a big dot on the body below to show where you are “feeling that emotion.”

Use the boxes to help explain what you are feeling.

Head

Throat Pain Dizziness Dry Hoarse Burning Heart

Fast Beat

Neck and Shoulders Pounding Tightness Pain Tight

Stomach

Lungs Fluttery Sick Panting Growling Short of Breath

Fast Breathing

Skin Legs Sweaty Shaking Cold Weak Itchy

Difficult Emotions

What is a difficult emotion for you to handle?

Is it anger or fear or frustration or feeling out of control or feeling humiliated or something else?

Write your emotion in the box.

Where you feel this emotion? Emotion Scale Cause of this emotion:

Show where on the character below. Rate your emotion.

______10 = strongest 1= weakest ______

______

______10 Describe how you feel?

9 ______

______8 ______7 ______

______6 ______

5 What can you do?

______4 ______3 ______

Tool Time Protocol

T-T is a quick way to signal that it is time to use a tool for calming or alerting.

Appropriate tools must be identified ahead of time for common problematic situations. Education and practice must be provided so that a connection is made between a behavior and a good tool choice. Tools must be available in the classroom Tool Kit or in a personalized tool kit or fanny pack.

Step 1: Problematic Situations

Brainstorm common problematic situations with the individual and or classroom teachers and care providers. Prioritize several problems needing calming or alerting sensory input. Choose one problem or lump together several problems that might respond to the same activities.

Step 2: Sensory Exploration

Provide opportunities to try a wide variety of sensory tools. This can happen in one session or several or throughout several days. Allow individual to identify what is helpful. Note what they identify and what others have noticed as helpful.

Tools can include activities such as a “Doing Break” or “Quiet Time Break.” See suggestions for the tool box including mouth tools, hearing tools, hand tools, eye tools and doing tools.

Step 3: Create Toolbox

The toolbox can be an individual box or possibly a sensory toolbox in the classroom. It might be best to put tools in an individual box to start. Person can have additional tools in their own sensory Fanny Pack. Tools must be easily accessible. Consideration needs to be given to tools that can be a distraction to other students. Make large cards with words or pictures to designate “Doing Tools.” These might include doing some chair pushups or kneel standing on the chair to do work.

Step 4: Making Connections

Help individuals make the connection between a problematic behavior and the need for a tool. Keep language simple and age appropriate. Use non-verbal communication whenever possible (it will be less disruptive and embarrassing in the classroom). Practice using tools. Provide support as needed initially and work towards independence.

Tool Box Items for Tool Time

Mouth Tools Body Tools

Sweet hard candies Pressure belt (sports stores) Sour candies Lycra Hug - (handouts) Gum Weighted animal Lollipops Weighted vest Fire/Hot Ball Weighted lap pad Crunchy snack Weighted blanket Veggie sticks or raisins Snug Tube (Lycra Tube)

Coffee stirrers Vibrating bug or disk Refrigerator tubing (hardware stores) Massager tools Water bottle with straw Cozy Comforter (Shoulder pad - handouts)

Hearing Tools Eye Tools

MP3 Player or IPod (special music/sounds) Oggz (internet) Metronome Strobe ball or wand Humming (make card) Picture book Sound machine Photo of someone special or pet Rain stick Sunglasses (shut off distracting input) Small fan (white noise) Glitter wand Ear plugs Sand timer Clackers ball (internet) Liquid motion toys

Doing Tools Hand Tools (Make large cards to represent these tools) 4 deep breaths Fidget widgets & tangles Sit on hands or legs Koosh balls Kneel-stand (kneel on chair, foot on floor) Stress balls Chair push-ups Finger mazes (catalogs) Doodle Beanbag Hum, whistle or sing Hand cream Massage hands Fabric square Go to a quiet place Smooth stone or shell Rock or swing Silly putty or Theraputty Take a walk Squigglets (Fuzzy bracelets) Self-Hug Small wrist weights Drum, tap or snap fingers Worry bead bracelet Push against the wall Fiddle rings Joint compression (stand, hang hands on Silicone bracelets or rings head, bounce on heels gently) Snap bracelets Sit on therapy ball Slinky Jumping jacks Rub gently on clothes - really feel it!

Sensory Kit for Clinical Outreach in the Community

This kit is designed for mental health providers to take with them into the community to help when they meet clients for assessment or treatment. It has a selection of tools for calming, alerting organizing and grounding.

Oral Motor Items

These can help in many ways for calming and organizing and helping with attention.

Gum, lollipops, hard candies, small bag of pretzels or nuts, coffee stirrers or straws to chew on

Fidget Widgets

These help clients relax during the appointment and may improve their ability to communicate. Fidgets can actually be used during the interview. Selection of four or more choices is recommended.

Stress ball, squiggle or worm ball, tangle, smooth stone, rubber band bracelet

Focused Activity

These can be used while the person is waiting for the appointment or used as a motivator when the appointment is over.

Hand held Simon Game, glitter wand, small note pad and pencil for doodling, Thinking Putty

Strong Sensory Input

Lycra Hug for calming can be effective for someone who is upset to use during the interview.

Exercise band can be used to set up a one or two man “rowing motion” that is very compelling and organizing and might be particularly helpful for adolescents.

A Koosh Ball can be used to toss back and forth in a rhythmic pattern which can be engaging and calming.

Bean bag for tapping firmly on the hands, arms, shoulders, legs and feet (never on the head or stomach area).

Grounding Items

These provide very strong sensory input that can help to break up a dissociative episode, trouble with flashbacks or breaks in reality orientation.

Hot “fire” balls, Altoids, smell canister

Fanny Packer

Teacher & Parent Handout

Fanny packs or sensory kits provide a way to have appropriate sensory tools available as needed for calming and alerting. These suggestions feature “quiet” tools that can be brought to school. Individualize choices. Practice identifying situations and possible tools.

Calming Tools can be helpful when you are: losing control, feeling anxious or overwhelmed, being over stimulated, feeling angry, facing a difficult appointment or time of the day, feeling upset or just needing to relax.

Helpful calming tools include: gum, stress ball, fidget widget, smooth stone to feel, sweet hard candy, water bottle with straw, coffee stirrer to chew on, soft square of cloth to feel, finger maze, silly putty, beanbag, “bendables,” shaped silicone wrist bands, rubber novelty bracelet, giant fiber noodle, fragrant hand cream, worry bead bracelet, picture of loved one, sun glasses

Alerting Tools can be helpful when you are: unable to focus, having difficulty paying attention, needing to work but feeling drowsy, needing to be more aware of the environment, needing to be energized.

Helpful alerting tools include: gum, sour candies, small Koosh balls, fidget widgets, film canister with cotton ball with strong smell, mini bag of pretzels, crunchy snacks, pencil with something silly on top to stroke the face, coffee stirrers to chew, piece of “refrigerator tubing” to chew or tangle

Identify typical situations needing calming:

Calming suggestions for Fanny Pack:

Identify typical situations needing alerting:

Alerting suggestions for Fanny Pack:

These suggestions are specially identified for:

______Name

What Helps? Activity

This activity is designed to help people identify helpful strategies for different emotional situations. Two situations are chosen. Pictures from the attached sheets are cut out to represent various helpful strategies. They are glued under the chosen situations. When completed this poster should be made available to staff, family members or care providers so that they can help the person choose helpful coping strategies when they are in an emotional crisis.

This activity can be printed out in color from the Sensory Connection Program website on the Free Activities page. http://www.sensoryconnectionprogram.com/free_activities.php

What Helps? Situations include: When I’m Angry, When I’m Overwhelmed, When I’m Upset, & When I’m Scared. Choose two situations and using the What Helps? Activity printout; list 5 possible activities under each situation for your case scenario.

What Helps? What Helps?

When I’m ______When I’m ______

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

Learning About Mantras

According to the Merriam Webster Dictionary a mantra is a sound, word, or phrase that is repeated by someone who is praying or meditating or a word or phrase that is repeated often or that expresses someone's basic beliefs.

A mantra can be sung or recited or repeated silently in the mind. It is used as an object of concentration that has a spiritual connection.

Activity 1: the OM Mantra

The OM is an ancient chant consisting of three sounds a and u and m. It is believed that the sound OM brings us in resonance with the universe. OM vibrates at 432 Hertz which is considered the natural musical pitch of the universe.

Try sitting in a comfortable position in a chair or in a yoga posture and hum the OM mantra drawing out the sounds for as long as you can. Feel the vibration. Focus on the connection to the universe – to all beings. Repeat the chant over and over for approximately five minutes.

Activity 2: Discover your own Mantra.

A Mantra can also be a word or phrase that is meaningful and powerful to you. Sit quietly for a few minutes and think about some words that come from your “core being.” These words should help you to be a better person or to help you appreciate the person that you are or help connect you to others. Form your thoughts into a short powerful statement.

A few examples: “I know I can, I know I can, I know I can.” “Trust the quiet within.” “It all comes down to love.” “And all will be well, and all will be well, and all will be well.” “I am strong, I will get through this.” “I love God and God loves me.”

Write down your mantra on the line below. Repeat your mantra several times a day whenever you feel the need to revitalize or to refocus.

My personal Mantra

______

From the Sensory Connection Program Curriculum for Self-Regulation 16

Idea Cards for Non-Tool Based Sensory Activities

Cut up the Idea Cards along the solid lines. They can be laminated if they are going to be used frequently. They can also be used to give to people as reminders of activities that might be useful or passed out and used as a group game.

Chair Pushups (Work up to 5) Foot-Flexes (Try 5)

Grip the sides of a straight chair and use arms to Point toes and then flex feet and hold for a few lift the upper body slightly off the seat of the seconds to give a little stretch to the lower leg, chair. relax.

Trunk Turns (Try 5) Sun Breaths (Try 6)

Place hands on top of head and turn slowly to While seated straighten to feel the “tall” spine; one side and then the other, stop in center place hands on thighs palms down; as you inhale position. lift hands a few inches; as you exhale bring palms back to thighs

Full Body Joint Compression (1 slowly) Upper Body Joint Compression (1)

In a standing position place hands on top of Place hands on table or wall and lift heels of head, “bounce” 10 times by lifting heels and palms up and down, gently “bouncing” 10 times. then gently bouncing them down on the floor.

Slap and Clap (10 times - change pattern) Walk and Slap (10 – 20)

While seated slap thighs and then clap hands Walk forward while lifting leg high and slapping with a rhythmic beat; try various patterns such it, step down and lift opposite leg and slap it - try as slapping once, clapping twice… slapping on the same side and then cross over and slap on opposite thigh.

Hand Press (5 times) Glider/Slider (2 times)

Press palms of hands together firmly (prayer Extend arms, cross just above wrist, clasp hands; position) hold to the count of five and release slide hands slowly down legs towards floor, relax and relax . Repeat and let natural stretch happen; slowly return to seated position

Suggestions for Sensory Approaches to Treatment in Adolescent Residential Treatment

Upon admission, work with adolescents to develop a personal sensory kit so that helpful sensory input items are available when needed. Making the kit provides a learning opportunity to send a message that it is the youth’s responsibility to learn good self control but staff will be there to help and support them in this process.

Provide ongoing education on sensory approaches.

Give staff as well as adolescents opportunities to try sensory activities and identify sensory preferences.

Encourage staff to role model the use of sensory strategies.

Bring sensory items to meetings and groups and have them readily available when needed.

Offer daily opportunities for exercise and sports activities.

Use games to reinforce the “social engagement system” and teach social skills.

Offer groups that teach self-regulation skills that include the use of sensory input. Help students pair levels of anxiety or anger with internal sensations. Make groups interactive and fun.

Teach and practice relaxation techniques such as deep breathing and mindfulness so that youths experience a sense of internal control.

Offer sensory rich groups such as pet therapy, Yoga classes, art therapy and sensori-motor groups.

Develop Safety Plans that identify signs and triggers and helpful and harmful interventions. Ask youth to identify several coping strategies that he or she is willing to try in crisis. Make this information readily available.

Assess the environment and make sure it feels nurturing and safe.

Develop a Sensory Room and work with staff and clients to make sure it is well used.

Encourage adolescents to develop their own “safe space” where they can retreat when upset or anxious.

When interacting with a youth that is upset: make eye contact, modulate your voice and use reassuring body language, bring the person to a safe place, refocus on familiar things and sensations, engage in a simple activity (tossing a ball, having tea, playing a Kazoo, walking together). When the youth is calmer, help facilitate the use of identifies coping strategies.

ANGRY? UPSET?

FRUSTRATED? UNSAFE?

PAUSE

CONNECT

ENGAGE

From the Sensory Connection Program Curriculum for Self-Regulation 19

Crisis Intervention Steps: Pause! Connect! Engage!

Note: These are just suggestions. There is no “cook-book” answer. Make a connection. Assure safety. Be positive. Reward small progress. Give choices. Don’t rush. Person may need to calm down before accepting usual sensory strategies. Progress may not be linear. Be flexible.

Pause! (Think! Use gesture of pointing to head to signal thinking)

Connect!

Bring the person to a safe space Make a connection - Make eye contact - Lower voice - Show empathy - Hold hand or put hand on shoulder. Reflect back what you see (Wow, you really seem very upset about something.) Assure safety (You are safe. You have supports. You will get through this.) Identify feeling (angry, frustrated, hurt, worried, scared, unsafe, disappointed, shamed) How bad is it on scale of 1 - 10? Connect feeling with physical body sensation (Describe what the body is feeling: rapid heart, feeling flushed, stomach pains, chest tightness, rapid breathing.) Reflect back (That must be very terrible for you - feeling so hurt.) Assure safety

Bring to present - Focus on touching clothing - describe it.

Engage! Ask what might help Try a known or obvious strategy (Pace around together, toss a Koosh ball back and forth, do something rhythmic like “slap-clap,” use a smell box) Try 4 deep breaths together Assess progress. How bad is it now on scale of 1 - 10? Ask what usually works - check chart Offer two choices from things person identified (You want buy in.) (Should we try some pushups or a weighted blanket?) Person may not be ready - continue to pace around. Assess progress. How bad is it now? Give positive feedback. Suggest known strategies again. Give choices. If person is calm enough, invite to Sensory Room. (Would you like to hold the vibrating pillow or try Spandex hug?) Engage in activities with the person. Listen if person is ready. Reflect emotion (I can see that you are bothered by this). Not the time to solve the problem. Acknowledge self-control. Offer to address the problem at another time.

If needed repeat steps.

Grounding Strategies Worksheet

Grounding techniques are strategies that are useful when a person is experiencing dissociative episodes (loss of touch with the body, time, and the environment), psychotic thinking, Making a Perfume Canister for Grounding suicidal thinking, flashbacks, thoughts of self-harm, negative thinking, extreme anxiety, or panic attacks. Equipment: Small plastic film canister, cotton balls, strong perfume Grounding techniques use some type of compelling sensory input Directions: Several cotton balls are placed in the film canister. Several drops of a strong perfume are to bring a person back to reality and to the present moment. dropped onto the cotton and the cap is replaced They help reorient a person by bringing back an awareness of the making sure it is on tightly. body and the immediate surroundings. To Use: The canister can be kept in a pocket or pocketbook. When a person feels like a dissociative Grounding strategies should be started at the first sign of episode is coming on, he or she opens the canister and takes a whiff of the perfume. trouble. In order to determine the most effective strategies, preferences need to be explored.

This is a list of common strategies. Put a star beside the ones that you think might be helpful for you. Some strategies are more powerful than others. As you try them rate the strategy power or helpfulness on a scale from 1 - 5 with 1 being very low power and 5 being the highest power.

Strong Input Strategies Helpfulness Activity Strategies Helpfulness

Smell a perfume canister Doodle

Smell a scented handkerchief Fidget with something

Suck on hot balls/strong mints Hold someone’s hand

Chew a large wad of gum Write yourself a caring message

Suck on a popsicle Bounce a ball over and over

Chew crushed ice Toss a Koosh ball

Hold a bag of crushed ice Squeeze a stress ball

Stamp feet hard Write in a journal

Clap hands hard Sing along with a song

Do vigorous exercise Phone a friend

Pace or walk briskly Play Solitaire or Sudoku

Snap a rubber band on wrist Do a crossword or word search puzzle

Take a cool shower Do a coloring, art, or craft project

Do heavy work Do a detailed jigsaw puzzle

What Helps? – Core Crisis Intervention Strategies

Four Deep Breaths Walking or Pacing

Vigorous Exercise Weighted Blanket

Weighted Lap pad or Weighted Animal Gum or Pop or Oral Motor Tool

Smell Box or Strong Smell Hot “Fire” Balls (candy)

Hard Work Swinging or Rocking

Bouncing on a Therapy Ball Using a Stress ball or Koosh

Wrapping in Spandex Hug/Blanket Wrapping in a Warm Blanket

Focused Activity Holding Ice in a plastic Bag

Beanbag Tapping Writing in a Journal

Sucking on a Popsicle or Ice Chips Quiet Safe Space

Being with a Caring Person Playing an Instrument/Humming

Hugging a Vibrating Pillow Exercise Band Rowing

Developing a Crisis Intervention Plan

 Intervene early  Identify Signs and Triggers  Identify Helpful Strategies  Have a Plan  Contract for action “When I am upset I will………….…….”  Post the plan where children and care providers can see and use it!

Adolescents and Children

A crisis intervention plan should be developed over several sessions with the child or adolescent. Adolescents can have more input and for the plan to be effective they need to be invested in the plan. The pictorial “Safety Tool” developed by MASS Department of Mental Health might be the most helpful for brainstorming with younger children. An Adolescent tool developed by MASS Department of Mental Health can also be useful. The following SCP tools are designed to be used when there is additional time to brainstorm signs and triggers. In order to identify helpful strategies the child or adolescent should try various activities in the Sensory Room or those available in the classroom. The crisis intervention plan developed should be readily available as a reference. Ideally adolescents may learn to recognize possible signs and triggers and develop the habit of seeking help from teachers or staff in order to deal with difficult situations. Younger children should be encouraged to recognize signs of trouble but adults, teachers and care providers will need to be attuned to signs and ready to help the child identify and try helpful strategies.

SCP Crisis Intervention

What Are the Warning Signs?

Check things that are signs that you may lose control.

o Sweating o Being Rude o Crying o Signs of Anger o Loud Voice o Yelling o Bad Thoughts (self or others) o Uncooperativeness o Clenching Fists o Extreme Anxiety o Wringing Hands o Argumentative o Biting Arm or Body Part o Flashbacks o Banging Wall or Furniture o Self Injury o Throwing Things o Temper Tantrums o Withdrawal/Isolation o Withdrawal o Giddy/Laughing o Emotional Swings o Rocking o Dissociation o Suicidality o Disruptiveness o Agitation o Threats o Pacing o Other o Can’t Sit Still

Do you have warning signs that are not listed? Describe. ______

What are the most worrisome signs? ______

Ask a staff person, friend, or family member what signs they notice before a crisis: ______

SCP Crisis Intervention

What Are the Triggers?

What are some of the things that make you upset, or scared, or cause you to go into crisis?

o Being touched o Being isolated o Loud environment o Having nothing to do o Yelling o Feeling overwhelmed o Evening time o Nightmares o Darkness o Not being able to sleep o Flashbacks o Being restrained o Certain time of day o Seclusion o Being humiliated o Build up of anxiety o Teasing o Panic attacks o Demands from others o Certain place (explain) o Being ignored

Changes in routine, staff, room (explain)______Not having control, choices or input (explain)______Being around men or women (which?)______Time of year (when? Anniversary of event?)______Reminders of bad experiences (explain)______Contact with person who is upsetting (explain)______Going outside – large open spaces (explain)______Closed doors – feeling claustrophobic______Auditory or Visual Hallucinations______Psychotic thinking or Mania (explain)______Paranoia – thinking someone is following you or talking about you (explain)______Symptoms of illness (explain)______Other (explain)______

Ask a friend, family member, or staff person if he/she has noticed anything that seems to set you off or precedes crisis. ______

SCP Crisis Intervention

What Helps?

Identify things that help you calm down and regain self-control. You may want to fill this worksheet in as you experiment with various sensory input and other strategies.

o Medication o Tossing or bouncing a ball o Being with a caring person o Bouncing/rocking on therapy ball o Grounding Strategies (see o Rocking in a chair or glider handout) o Swinging o Smell box o Exercise band rowing o Holding Ice o Pacing o Sucking on Hot balls, Altoids, o Walking or jogging Popsicle o Hot or cold shower o Aromatherapy o Warm bath o Chewing gum/sucking on candy o Yoga or a movement routine o Snacking o Time in the CCC (Sensory) o Warm or cold drink Room o Sucking thick liquid with a straw o Choosing something from the o Listening to Music Sensory cart/box o Relaxation tapes o Voluntary time in the quiet room o Sound machine o Talking with a friend o Deep breathing/mindfulness o Talking with a staff person exercise o Calling a family member o Looking at art or beautiful books o Keeping busy o Watching a funny or calming o Helper tasks (cleaning etc.) video o Hard work o Watching a lava lamp/bubble o Writing in a journal tube o Coloring or painting o Wrapping up in a blanket o Doing art work o Wrapping a Lycra fabric tube o Doing puzzles/word around body search/crosswords o Weighted blanket o Reading o Weighted animal o Stroking or playing with a pet o Weighted lap pad, vest, or hat o Other o Vibrating dog or pillow o Other o Using a beanbag chair and a o Other warm cover o Warmed lap or shoulder pad o Beanbag tapping/brushing o Squeezing a stress ball o Hugging a pillow o Fidget widgets, Koosh Balls

Crisis Intervention/Safety Plan Summary

Triggers that often cause problems leading to crisis

Signs or Symptoms of possible crisis

Who are the people that you can go to when you are experiencing difficulty?

What helps? Name at least four strategies that you are willing to try.

What doesn’t help?

Signature ______Date______

From the Sensory Connection Program Workbook for Self-Regulation

Wish List for Comfort Space and Sensory Solution Equipment

When others ask, “What can I do?” or “How can I help?” perhaps they could help you purchase one of these items. Items can be used for a personal sensory kit or comfort space or to make the home environment more comfortable. Having tools available helps to support self-regulation, self-soothing and stress reduction. Think about the things that you found helpful.

Mark or circle items that will be helpful. Put a star beside the ones that are a priority.

o Rocking chair, glider, or large beanbag chair o Weighted blanket, lap pad, or weighted animal o Exercise equipment (Bosu Ball, exercise bands, medicine ball, yoga mat, hand and leg weights) o Scented items: perfumes, lotions, pillow sprays, toiletries, soaps, candles o Squares of fleece fabric o I Pod or CD player o Relaxation CDs (Steven Halpern also offers CDs specifically designed to promote sleep and inner peace http://innerpeacemusic.com). o Mindfullness CDs (Dr. Kabat-Zinn (www.mindfulnesscds.com). o Visual tools (liquid motions toys, glitter wand, L.E.D. Spinner, lava lamp, fiber optic light) o Crossword puzzle, Word Search or Sudoku books o Adult Coloring Books (www.doverpublications.com) o Art supplies o Stress balls, Kooshes, fidget widgets, squiggle balls beanbags o Moonsand, Silly Putty, modeling clay, or Crazy Aaron’s Thinking Putty o Craft items (Wikki Sticks, Geoboard and elastics, Looper Loom and loops, stamping projects) o Jewelry and bead supplies o Sound machine or frame drum o Chinese hand exercise balls o Mini Simon Game o Mouth tools (gum, hard candy, pops, pretzels, licorice, plastic straws) o Vibrating massagers or massage seat cushion or vibrating pilow o Spandex hug made from 18” Spandex bathing suit material o Journal or small notebook o Grounding items (smell canister, cinnamon hot balls) o Picture books, travel books, art books, inspirational books o Games (cards, Jenga, Etch-a-Sketch, board games) o Fanny pack to keep items o Gift certificate for a massage o Membership to a gym o Lessons for cooking, art, crafts, photography

Note: Most of the items can be purchased at discount stores or through Amazon.

You

Name______

Need to Be in Control of your Own Emotions!

What Can You Do? How Can We Help?

Respect Yourself!

Respect Others!

Others Will Respect You!!!!

This packet uses with permission and gratitude two Safety Zone Tools developed by MA Department of Mental Health.

I TRIED IT!!!

Name______

As you try each activity, put a score in the box from 1 (no help) - 10 (extremely helpful).

Deep Abdominal Breathing Comfort/Sensory Room

Walking or Pacing Massaging Mat

Weighted Blanket Vibro-acoustic Mat

Heavy Therapy Animal Bouncing on Therapy Ball

Jumping on LoLo Ball

Spandex Hug

Fidget Widgets

Rocking Chair Smell Canister or Scents

Swing Yoga or Meditation

Listening to Music Cozy Comforter

Exercise Bands

Halo or Weighted Cap

Weighted Lap Mat Activities/Puzzles

Warm or Cool Bath or Shower Bosu Ball

Massachusetts DMH Safety Zone Tools Triggers Tool What makes you feel upset? (Circle all that make you feel sad, mad, scared or other feelings) Touch See

Being touched Too many people Darkness

Hear

Loud noises Yelling Thunderstorms

Other

Missing someone Being left alone Being surprised Having a fight with a friend

Not having visitors Being hungry Being tired Someone being mean

Being sick Certain time of year Certain time of day/night Having my bedroom door open

Anything else that makes you feel upset? ______

NOTE: The following are general triggers for people Being told what to do rather than asked; Being told no rather than being given choices.

31 Massachusetts Department of Mental Health Safety Tool - August 2006 (adapted)

Warning Sign Tool Massachusetts DMH Safety Zone Tools

What happens to my body when I am angry, scared or upset? (Circle all that apply)

Cry Clench teeth Loud voice Red/hot face Laughing/giggling

Being mean or rude Swearing Racing heart Breathing hard Wringing hands

Clenched fists Upset stomach shaking or tapping Jumping up and down or stamping feet

Rocking Hyper Running or pacing

Massachusetts Department of Mental Health Safety Tool - August 2006 (adapted)

Safety Tool Massachusetts DMH Safety Zone Tools

What helps you feel better? (Circle all that help you) Touch

Writing Fidget tools Games Holding ice

Bath or Shower Stress ball or clay Weighted animal

Any other objects you touch or hold that help you feel better? ______

See

Reading Watching TV Looking at pictures Using a computer

Any other objects you like to look at that help you feel better? ______

Movement

Using a rocking chair Swinging Dancing Sports (kickball, basketball, soccer, etc)

Any other movements you like that help you feel better? ______

Massachusetts Department of Mental Health Safety Tool - August 2006 (adapted)

Hear

Talking on Listening Singing or Quiet place Counting the telephone to music humming to ten

Do you prefer music that is: Loud or Soft

What type of music do you prefer: ______

Any other sounds or noises that help you feel better? ______

Pressure touch

Massaging mat Sitting in a bean bag chair Using a weighted blanket Weighted cap or halo

Yoga or meditation Exercise Sitting on a therapy ball Getting a hug

Any other activities that help you feel better? ______(Examples: blowing bubbles, deep breathing, etc.)

Smell

Any smells that help you feel better? ______(Examples: peppermint, popcorn, cookies, flowers, etc.)

Taste

Any certain tastes that help you feel better? ______(Examples: chewy, crunchy, salty, sour, spicy, etc.)

Are there times that it is important or helpful for you to eat? ______

Massachusetts Department of Mental Health Safety Tool - August 2006 (adapted) 34

Comfort Space Plan

A Comfort Space is a personalized place to rest and relax and to calm down throughout the day and especially before and after work, school and stressful events. Ask others to respect your need for quiet time when you are using this space. Circle or check your answers below to help you design your space.

Where will it be located?______

What type of chair?

What tools for smell?

scented creams pillow spray smell canister room freshener scented soaps

What tools for taste and oral-motor?

gum pops/hard candy fruit pretzels/nuts hot fire balls

What tools for sound?

drum/instrument Kazoo iPod/ music sound machine Simon Game

What tools for vision?

Oggz Kaleidoscope Liquid motion toy Beautiful books Spinner

What tools for pressure touch?

Weighted blanket vibrating pillow Lycra “hug” beanbag weighted animal

What fidget widget tools?

Silly Putty/clay Koosh balls prayer beads stress ball Tangle

What doing activities?

cards puzzle book art/coloring books Needlework/crafts journal

When do you plan to use your comfort space?

10 minutes in morning, afternoon and evening to chill out. Before school or work. After school or work. Before doctor’s appointment or party or stressful event. After going to something stressful. Before bed to relax and unwind.

Name______Date______

Share this plan with family and care providers so that they can help you develop a Comfort Space. You may not be able to find these exact items but something similar should be available. This activity is to get you thinking.

From the Sensory Connection Program Curriculum for Self-Regulation 36

Sensory Sensitivities Discovery

Sometimes there are things in the environment or situations that really bother our senses but no one else seems to notice. Our reaction can be mild to severe. If we can identify these bothersome experiences there may be ways to eliminate them or at least minimize them. Read through the common irritants below and circle any that bother you. Beside the circle put an M for mild or an S for severe.

Vision Bright lights * dim lights * flashing lights * flickering lights * darkness * strobes * changing light * flat light * fast moving images * riding in a car (looking out windows) * other (______)

Hearing Loud noises * fluorescent lights * crowd noise * too many people talking * yelling * quiet *

fireworks * base drums * background noise * certain music (explain:______)

Smell Perfume * bathrooms * bad odors * food smells * scented candles * incense * pet food * other (______)

Taste/Oral Motor Lumpy food * strong tastes * messy food * mushy foods * chewing * cold drinks * hot food * sour tastes * other (______)

Touch Being touched * hugs * touching things * being too close to people * sticky/messy stuff * dressing* certain clothing * walking barefoot * showering * face washing * brushing teeth * sweating * messy stuff * bare skin * other (______)

Moving/balance Exercise * bumpy surfaces * stairs * spinning * riding in a car * heights * moving quickly * carnival rides * swinging * darkness

Spaces Small spaces * open spaces * crowds * high places * closed doors * lunchrooms * stores * being alone * other (______)

Name______Date______

Sensory Sensitivities – What Can We Do?

Tell someone – ask for help.

Eliminate it.

Avoid it.

Work around it.

Use a sensory tool.

Change the time.

Prepare yourself.

Relax afterwards.

Pause – Connect - Engage Worksheet

Pause! (for warning signs or triggers)

Describe a situation which should make you pause because you are overly angry, upset, frightened or approaching emotional crisis.

What triggers the situation and what are the signs that you are having trouble?

Connect! (seek/accept help)

Describe a healthy “connection” that would help you to calm down (helpful staff person, family member, teacher, clergy, pet). What can this person to do to help you?

Engage! (do something positive)

Describe three coping strategies that you could try to get yourself back in control.

From the Sensory Connection Program Curriculum for Self-Regulation 39

Circuit Breaker for Crisis Intervention

Name the feeling: (upset, mad, scared, angry)

I feel it in my (stomach, shoulders, lungs, head, heart, bowels)……

10 On a scale of 1 to 10 (1 = low, 10 = high) my emotional response level is at a………

I am going to reach out to ______for support.

I am going to try……

 Four Deep Breaths

 Humming a tune

 Saying a mantra All will be well. I am safe now. I can calm down.

 Pacing in a figure eight.

GOAL SETTING Integrating Sensory Approaches: What are your priorities? Where will you begin? What will work in your clinical setting?

 What components of the SCP make sense to you?

SCP Components

Sensory Kit for Your Clinic

Personal Sensory Kits for Children

Teaching about  Identify one or two Long Term Goals for Integration of sensory Interoception – Body strategies into your clinical setting. Chart Handout

What Helps? Activity

Sensory Kit in the classroom or nurses station

Crisis Intervention Plan

 Identify several short term goals for integrating sensory strategies Pause, Connect, Plan into your clinical setting. approach

Planned Quiet Time and Sensory Input Breaks

Teaching Games for self-regulation

Sensory/Comfort Spaces or rooms

Sense-ability Group 41

Environmental Changes

References for Trauma Symposium of Wisconsin

Note: A full and updated set of references can be found on the Resources and References page of the Sensory Connection Program website. http://www.sensoryconnectionprogram.com/resources.php

Ayres, J. (1979). Sensory integration and the child. Los Angeles: Western Psychological Services. Babyak, M., Blumenthal, J. A., Herman, S., Khatri, P., Doraiswamy, M., Moore, K., Craighead, E., Barnes, K. Vogel, K. & Beck, A. (2011). Occupational therapy for children with severe emotional disturbance in alternative educational settings. In Bazyk, S., ed. Mental Health Promotion, Prevention, and intervention with children and youth. Bethesda, MD: AOTA Press, 207-229. Barnes, K., Vogel, K., Beck, A., Schoenfeld, H., & Owen, S. (2008). Self-Regulation strategies of children with emotional disturbance. Physical and Occupational Therapy in Pediatrics, 28(4), 367-385. Bazyk, S. Ed. (2011). Mental health promotion, prevention and intervention with children and Youth: A guiding framework for occupational therapy. Bethesda, MD: AOTA Press. Bright, T., Bittizh, K., & Fleenan, B. (1981). Reduction of self-injurious behavior using SI techniques. American Journal of Occupational Therapy, 35 (3): 167-172. Brown, C. & Dunn, W. (2002). Adolescent/ adult sensory profile. San Antonio, TX.: Psychological Corporation. Caldwell, B., Albert, C., Azeem, M.W., Beck, S., Cocoros, T., Montes, R., & Reddy, D. (2014 Successful seclusion and restraint prevention efforts in child and adolescent programs. Journal of Adolescent Nursing and Mental Health Services, 52(11), 30-38. Chalmers, A., Harrison, S., Mollison, K/, Molloy, N., & Gray. K. (January 2012). Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach. Australas Psychiatry, 20: 35- 39. https://www.rompa.com/media/free-resources/establishing_sensory- based_approaches_in_mental_health.pdf. Retrieved 8/22/2015. Champagne, T. (2005, March). Expanding the role of sensory approaches for acute inpatient psychiatry. Mental Health Special Interest Section Quarterly. Champagne, T. (2003). Creating nurturing environments and a culture of care. Advance for Occupational Therapy, 19 (19), 50. Craig, A.D. (2015). How do you feel? An interoceptive moment with your neurobiological self. Princeton, NJ: Princeton University Press Donnelly, J.E., Lambourne, K. (2011) Classroom-based physical activity, cognition, and academic achievement. Preventative Medicine 52, S36-S42 Dorman, C., Lehsten, L. N., Woodin, M., Cohen, R. L., Schweitzer, J. A., Tona, J. T. (2009) Using Sensory Tools: for Teens With Behavioral and Emotional Problems. OT Practice, Nov 23, 14 (21), 16-21. [http://www.ateachabout.com/pdf/OTP_Nov09_UsingSensoryTools_Teens.pdf]. Dunn, W. (2009) Living Sensationally: Understanding your senses. Philadelphia, PA: Jessica Kingsley Publishers. Edelson, S., Edelson, M., Kerr, D., & Grandin, T. (1999). Behavioral and physiological effects of deep pressure on children with autism: A pilot study evaluating the efficacy of Grandin's hug machine. American Journal of Occupational Therapy, 53, 145-152. Fertel-Daly, D., Bedell, G., & Hinojosa, J. (2001). The effects of the weighted vest on attention to task and self-stimulatory behaviors in preschool children with pervasive developmental disorders. American Journal of Occupational Therapy, 55, 629-640.

Field, T., Diego, M. & Sanders, C. (2001). Exercise positively affects adolescents’ relationships and academics. Adolescence, 36, 105-110. Frick, S.M. (2002) Listening with the whole body. Professional Development Press. Frick, S. & Lawton-Shirley, N. (1994) Auditory Integrative Training from a sensory integrative perspective. Sensory Integration Special Interest Section Newsletter, 17 (4), 1-3. Grandin, T. (1992). Calming effects of deep pressure in patients with autistic disorder, college students, and animals. Journal of child and adolescent psychopharmacology, 2, 63-72. Bazyk, S. Ed. (2011). Mental health promotion, prevention and intervention with children and Youth: A guiding framework for occupational therapy. Bethesda, MD: AOTA Press. Harlow, H. (1959). Love in infant monkeys. Scientific American, 200, 68-74 Henry, D., Wheeler, T. & Sava, D. (2004). Sensory integration tools for teens: Strategies to promote sensory processing. Youngtown, AZ: Henry OT Services Inc. Kellner, M., & Bry, B. (1999) The effects of anger management groups in a day school for emotionally disturbed adolescents. Adolescence, 34 (136), 645 Kinnealey, M. & Fuiek, M. (1999). The relationship between sensory defensiveness, anxiety, depression and perception of pain in adults. Occcupational Therapy International, 6 (3), 195-206. Kuypers, L. (2011). Zones of regulation: A curriculum designed to foster self-regulation and emotional control. Jan Jose, CA: Social Thinking Publishing. Maas, C., Mason, R., & Candler, C. (2008). “When I get mad…” OT Practice, 13 (19), 9-14. MacLachlan, J., & Stromberg, N. (2007) Safety Tools. In Massachusetts Department of mental Health (Ed.), Developing positive cultures of care: Resource guide, 1-21. Boston:Editor Mahler, K. (2016). Interoception: The eighth sensory system. Lenexa, KS: AAPC Publishing. Mahler, K. (2016). Interoception: The eighth sensory system: This often overlooked mechanism helps us calm and self-regulate. Advance for Occupational Therapy Practitioners, 32 (5), 16-18. Mason, W. & Berkson, G. (1975). Effects of maternal mobility on the development of rocking and other behaviors in Rhesus monkeys: A study with artificial mothers. Developmental Psychobiology, 8, 197-221. Moore, K. (2016). Following the evidence: Sensory approaches in mental health, a literature review http://www.sensoryconnectionprogram.com/sensory_treatment.php retrieved 1/21/2017. Moore, K. (2015). The sensory connection program: Curriculum for self-regulation: group treatment for emotional regulation, crisis intervention & stress management. Framingham, MA: Therapro, Inc. Moore, K. (2008). The sensory connection self-regulation workbook: Learning to use sensory activities to manage stress, anxiety and emotional crisis. Framingham, MA: Therapro. Moore, K. (2005) The sensory connection program: Activities form mental health treatment. Manual and Handbook. Framingham, MA: Therapro, Inc. Moyes, R. (2010). Building sensory friendly classrooms to support children with challenging behaviors. Arlingotn, TX: Sensory World. Mullen, B., Champagne, T. Krishnamurty, S., Dickson, D. & Gao, R. (2008, February). Exploring the safety and therapeutic effects of deep pressure stimulation using a weighted blanket. Occupational Therapy in Mental Health, 24, 65-89. Murray-Slutsky, C. & Paris, B. (2005). Is it sensory or is it behavior? Behavior problem identification, assessment and intervention. Austin, TX: Hammill Institute on Disabilities Myles, B., Hagiwara, T., Dunn, W., Rinner, L. Reese, M., Huggins, A., Becker, S. (2004). Sensory issues in children with asperger syndrome and autism. Education and Training in Mental Retardation and Developmental Disabilities, 39 (4). Oetter, P., Ritcher, E., & Frick, S. (1995). MORE: Integrating the mouth with sensory and postural functions. Hugo, MN: PDP Press, Inc.

Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York: W. W. Norton. Olson, L., & Moulton, H. (2004a). Occupational therapists' reported experiences using weighted vests with children with specific developmental disorders. Occupational Therapy International, 11, 52-66. Olson, L., & Moulton, H., (2004b). Use of weighted vests in pediatric occupational therapy practice. Physical and Occupational Therapy in Pediatrics, 24 (2/3), 45-60. Ostrove, B. & Hartman, R. (2013). Sound minds: Establishing a sensory modulation education group at a mental health hospital. OT Practice, 18(18), 14-18. Porges, S. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York, NY: Norton, W.W. & Company Porges SW. (2009). Reciprocal influences between body and brain in the perception and expression of affect: A polyvagal perspective. In D Fosha, D Siegel, and M Solomon, eds. The Healing Power of Emotion: Affective Neuroscience, Development, and Clinical Practice. New York: Norton, 27-54. Porges SW. (2008). Music therapy and trauma: Insights from the polyvagal theory. In K Stewart, ed. Symposium on Music Therapy & Trauma: Bridging Theory and Clinical Practice. New York: Satchnote Press. Porges S. (2004). Neuroception: A subconscious system for detecting threat and safety. Zero to Three: Bulletin of the National Center for Clinical Infant Programs,24:5,9-24. Porges, S. W., Macellaio, M., Stanfill, S. D., McCue, K., Lewis, G. F., Harden, E. R., Handelman, M., Denver, J., Bazhenova, O. V., & Heilman, K. J. (2013). Respiratory sinus arrhythmia and auditory processing in autism: Modifiable deficits of an integrated social engagement System? International Journal of Psychophysiology, 88, 261-270. Reynolds, S. & Lane, S. (2007, March). Diagnostic Validity of Sensory Over-responsivity: A review of the literature and case reports. Journal of Autism and Developmental Disorders, 38(3), 516-529. Ross, M. (1997). Intergative group therapy – mobilizing coping abilities with the five-stage group. Bethesda, MD: American Occupational Therapy Association. Ross, M. & Bachner, S. (Eds.) (1998). Adults with developmental disabilities: Current approaches in Occupational Therapy. Bethesda, MD: American Occupational Therapy Association. Sanders, C., Field, C., Diego, M., & Kaplan, M. (2001). Moderate involvement in sports is related to lower depression levels among adolescents. Adolescence, 35, 793-797. Schaaf, R. C., Benevides, T., Blanche, E. I., Brett-Green, B. A., Burke, J. P., Cohn, E. S., Koomar, J., Lane, S. J., Miller, L. J., May-Benson, T. A., Parham, D., & Schoen, S. A. (2010). Parasympathetic functions in children with sensory processing disorder. Frontiers of Integrative Neuroscience, 4 (4). Schaaf, R. C., Miller, L. J., Seawell, D., & Keefe, S. O., (2003) Children with disturbances in sensory processing: A pilot study examining the role of the parasympathetic nervous system. American Journal of Occupational Therapy, 57, 442-449. Schoen, S.A., Miller, L.J., Brett-Green, B.A. & Nielson, D.M. (2009). Physiological and behavioral differences in sensory processing: A comparison of children with autism spectrum disorder and sensory modulation disorder. Frontiers in Integrative Science, 3, 1-11. Shepard, J. (2007) Sensory-based treatment for adults with developmental disabilities. Advance for Occupational Therapy Practitioners, 23(18), 38-39. Sudders, M. (2004). Child and adolescent inpatient restraint reduction: A state initiative to promote strength based care. Journal of American Academy of Child and Adolescent Psychiatry, 43 (1), 37. Smith, S. A., Press, B., Koenig, K. P., & Kinnealey, M. (2005). Effects of sensory integration on self- stimulating and self-injurious behaviors. The American Journal of Occupational Therapy, 59:4, 418-425. Sutton, D., & Nicholson, E. (2011). Sensory modulation in acute mental health wards: A qualitative study of staff and service user perspectives. Auckland, New Zealand: Te Pou o Te Whakaaro Nui.

http://aut.researchgateway.ac.nz/bitstream/handle/10292/4312/Sutton%20sensory%20modulation%2 0in%20acute%20mental%20health%20wards.pdf?sequence=6 retrieved 9/1/2013 Tolle, E. (2008). Milton’s Secret. Charlottesville, VA: Hampton Roads Publishing Company, Inc. Trivedi, M., Greer, T., Grannemann, B., Chambliss, H., & Jordan, A.. (2006). Exercise as an augmentation strategy for treatment of major depression. Journal of Psychiatric Practice, 12(4), 205-13. Vandenberg, N., (2001). The use of a weighted vest to increase on-task behavior in children with attention difficulties. American Journal of Occupational Therapy, 55, 621-628. Van der Kolk, B. (2014). The body keeps score: brain, mind and body in the healing of trauma. NY: Viking. Van der Kolk, B. (2006). Clinical Implications of Neuroscience Research in PTSD. Annals of New York Academy of Sciences 1-17. Van der Kolk, B., (1994). The body keeps score. Harvard Review of Psychiatry, 1, 253-265. Van der Kolk , B. & Fisler, R. (1994). Childhood abuse and neglect and loss of self-regulation. Bulletin of the Menninger Clinic, 58 (2), 145-168. Wagner, M. K. (2001). Behavioral characteristics related to substance abuse and risk-taking, sensation- seeking, anxiety sensitivity, and self-reinforcement. Addictive Behaviors, 26, 115–120 Walker, D. & McCormack, K. (2002). The weighted blanket an essential nutrient in a sensory diet. Everett, MA: Village Therapy. Warner, E., Cook, A., Westcott, A., & Koomar, J. (2011). Sensory motor arousal regulation treatment (SMART). A manual for therapies for working with children and adolescents: A “bottom up” approach to treatment of complex trauma. Boston: Trauma Center at JRI. Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the Body Change the Score? Application of Sensory Modulation Principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28, 729-738. Warner, E., Spinazzola, J., Westcott, A., Gunn, C., & Hodgdon, H. (2014). The body can change the score: Empirical support for somatic regulation in the treatment of traumatized adolescents. Journal of Child and Adolescent Trauma, 7:237-246. Published online http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf Retrieved 8/22/2015. Wilbarger, P. (1995). The sensory diet: Activity programs based on sensory processing theory. Sensory Integration: Special Interest Section Newsletter, 18 (2), 110-113. Wilbarger, J. (1998). The emerging concept of sensory modulation disorders. Sensory Integration Special Interest Section Newsletter, 21 (3). Williams, M. & Shellenberger, S. (1996). “How does your engine run?”: A leaders guide to the Alert Program for self regulation. Albuquerque, NM: Therapy Works, Inc. Wylie, M. (2004). The Limits of Talk: Bessel van der Kolk wants to transform the treatment of trauma. Psychotherapy Networker. Jan/Feb http://www.traumacenter.org/products/pdf_files/Networker.pdf Retrieved 1/15/08