Many children with movement difficulties also have behavior, emotion regulation and attention difficulties which impact on their function and participation at home and at school. These children often have a diagnosis of sensory processing disorder (SPD) and receive sensory integration therapy (SIT).
SPD and SIT are based on the ideas developed by Jean Ayres in the 1970's. The basis for therapy is providing the brain with a variety of sensory experiences to "normalise" brain function. Treatment specifically avoids goal oriented training of skills.
However, the last 30 years our understanding of brain function has increased enormously and recent research makes it possible, not only to understand why and how some children fail to develop the attention, emotion self-regulation and cognitive skills needed for learning, but also provide vital information about how children can be helped to acquire these skills.
Bottom up and top down behavior regulation strategies
When a child engages in a task, his/her motivation, persistence, willingness to tolerate errors, as well capacity for sustained attention is determined by the interaction between two brain networks, the salience network that integrates information from all brain regions and the body and sets the emotional tone and the frontal network that is driven by the goals and plans and responds in a more controlled, thoughtful manner.
Salience network: bottom up control: reactive, automatic and fast, responds to feelings and emotional content, and is highly sensitive to threat and errors, influences alerness and readiness for action.
Top down network dorsolateral prefrontal cortex network: provides a more controlled mode is reflective, endogenous, strategic, logical, and effortful (Hendersen 201%).
Effective therapy moderates bottom up reactivity and train top down attention and executive functions.
A multi pronged approach to training appears to be the best way forwards (Diamond 2016) and should include:
- Strategies to modulate an overactive salience network ( also known as the emotional brain) - including fitness and mindfulness training
- Strategies to train top down modulation of emotional behaviors linked to an over reactive salience network - based on principles of cognitive behavioral therapy (CBT)
- Goal directed task based training that incorporates and trains attention and the executive functions of inhibitory control, working memory, and cognitive flexibility
Behaviors that indicate poor attention, emotion and cognitive (executive function) regulation and skills
High levels of negative arousal in new and unfamiliar situations
Dysregulated fear behavior - excessive fearful behavior and distress when confronted with new situations
Meltdowns and tantrums when overwhelmed
Hyper vigilance in new situations: appears on edge, notices little changes in the environment, visually scanss the room, very watchful and easily distracted by slight noises or deviations in the environment.
Hesitant or fearful in new situations - slow to warm up
Approaches new situations or activities very hesitantly
Gets upset at being left in new situations for the first time (e.g., kindergarten, preschool, childcare)
Is very quiet around new (adult) guests to the preschool, kindergarten, or child care centre
Takes many days to adjust to new situations (e.g., kindergarten, preschool, childcare)
Is shy when first meeting new children, does not approach a group of unfamiliar children to ask to join in
Tends to watch other children, rather than join in their games
Strong negative responses to sensory inputs
Dislikes busy noisy places: malls, supermarkets.
Dislike unexpected noises
Reacts strongly to new or unfamiliar foods
Becomes quite uncomfortable when cold and/or
Is quite upset by a little cut or bruise.
Is likely to cry when even a little bit hurt.
Strong negative responses to uncertainty
Dislikes of transitions and changes
Fear of injury and avoids physical challenges
Fear of heights and falling, fear of the dark.
Lacks confidence in activities that involve physical challenge (e.g., climbing, jumping from heights)
Is hesitant to explore new play equipment
Avoidance of tasks that are difficult or new.
Strong negative response to failure, does not like make errors
Does not recognize own successes, has negative opinion of own work, focuses on failures
Soothability and settling down
Has difficulty going to sleep
Has a hard time settling down after an exciting activity.
When angry about something, s/he tends to stay upset for ten minutes or longer.
Is very difficult to soothe when s/he has become upset.
Impulsivity and inhibitory control
Usually rushes into an activity without thinking about it.
Often rushes into new situations.
Tends to say the first thing that comes to mind, without stopping to think about it.
Has trouble sitting still when s/he is told to (at movies, church, etc.).Is good at following instructions.
Has difficulty stopping an activity when s/he is told "no."
I am worried about my child's dysregulated emotional behavior. What should I do?
Children who exhibit dysregulated behaviors that markedly interfere with home and school function and participation should examined by the family doctor to rule out any physical causes for the behavior difficulties. These may be linked to food intolerances, allergies such as allergic rhinitis, sleep apnea, chronic ear infections and other medical conditions. Your child should also be assessed by an educational psychologist or a developmental pediatrician to identify specific learning disorders, assessed for autism, ADHD/ADD or childhood anxiety and conduct disorders.
There are evidence based approaches to helping children with established learning and behavioral conditions and generally early intervention provides the best hope for helping children overcome learning and behavioral challenges. A specific diagnosis is also helpful in getting added support at school.
Once I have a diagnosis, what next?
Depending on your child's difficulties and behavioral condition you may be referred for one or more services
- A case manager - in an ideal world to - ensure effective coordination between the different therapists.
- Parent training: parents play a major role in helping children to learn better self-regulation
- Some form of behavioral intervention, very often cognitive behavior therapy - usually implemented by a child psychologist individually or in groups
- Speech therapy if there are speech and language learning disorders
- School based occupational therapy to assist with managing the interface between the child's abilities and school demands
- Physical therapy for fitness and coordination training if this is needed.
How OT's help children with behavior difficulties in a school setting
Extract from American Occupational Therapy Association Fact Sheet
"Occupational therapy is a health profession in which therapists and therapy assistants help individuals to do and engage in the specific activities that make up daily life. For children and youth in schools, occupational therapy works to ensure that a student can participate in the full breadth of school activities—from paying attention in class; concentrating on the task at hand; holding a pencil, musical instrument, or book in the easiest way; or just behaving appropriately in class.
Occupational therapists and occupational therapy assistants help students perform particular tasks necessary for participation or learning. “The whole purpose of school-based occupational therapy is to help kids succeed,” says pediatric occupational therapist Leslie Jackson. Occupational therapy practitioners don’t just focus on the specific problem that a child’s disability may present; rather, they look at the whole child and tackle individual tasks, helping students find ways to do the things they need and want to do.
Usually, occupational therapy is provided to students with disabilities. But occupational therapy can be made available to other children who are having specific problems in school. Occupational therapy practitioners also work to provide consultation to teachers about how classroom design affects attention, why particular children behave inappropriately at certain times, and where best to seat a child based on his or her learning style or other needs. Occupational therapy may be recommended for an individual student for reasons that might be affecting his or learning or behavior, such as motor skills, cognitive processing, visual or perceptual problems, mental health concerns, difficulties staying on task, disorganization, or inappropriate sensory responses.
A common manifestation of difficulties in school involves handwriting, in many cases because this is a key “occupation” that students must master to succeed in school. A teacher might notice that a student cannot write legibly or has serious problems in other motor tasks. The occupational therapy practitioner can work with the teacher to evaluate the child to identify the underlying problems that may be contributing to handwriting difficulty. The occupational therapy practitioner looks at the child’s skills and other problems (including behavior), in addition to his or her visual, sensory, and physical capabilities. They also take into account the school, home, and classroom environments to find ways to improve the handwriting or to identify ways the child can compensate, such as using a computer."
Skills for Action Movement and Mindfulness Physiotherapy (MM-PT) recognizes that many children with movement conditions also have co-occurring emotional and cognitive self-regulation difficulties that interfere, not only with learning of new motor skills but also impact on function and participation at home and at school. In order to address the many different facets of a child's abilities, MM physiotherapy combines fitness and coordination training with mindfulness and attention training. Read more