Anxiety Archives • Page 2 of 2 • kyu̇r-ē-ˈä-s(ə-)tē

August 4, 2020May 1, 2021

Self-Regulation: Cognitive and Occupation-Based Interventions

Self-regulation is a crucial element of providing holistic sensory integration and sensory based therapy. But what exactly does it entail? I like the four components of self-regulation that Leah Kyupers, author of the Zones of Regulation, highlights:

Part of the thought process behind implementing sensory integration and sensory-based therapy is that as a child’s sensory processing abilities improve, so too will their self-regulation. I think this definitely is a possibility, but we must be mindful that oftentimes the children we work with need to be directly taught regulation skills. As their sensory-processing improves, children may be more calm more of the time. This in turn may facilitate them learning self-regulation strategies for the next time they are becoming dysregulated. However, the need for direct modeling and practice of tools to regulate remains.

Journal American Journal of Occupational Therapy (SNIP score 1.121)

Article Title Effectiveness of Cognitive and Occupation-Based Interventions for Children with Challenges in Sensory Processing and Integration: A Systematic Review

1A Systematic review of homogenous RCTs
1B Well-designed individual RCT
2A Systematic review of cohort studies
2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
3A Systematic Review of case control studies
3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
4 Case series (and low quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
* This was a systematic review which included a wide array of evidence from RCT to Level IV single-case experimental design. As this type of systematic review doesn’t fall into either 2A nor 3A, I chose to categorize it into a level 2B study. The evidence reviewed was higher than case studies but lower than cohort studies.

Methods

The authors of this systematic review included peer reviewed studies that concentrated on interventions in the scope of OT for children and adolescents who had sensory processing and integration challenges. Authors of this review ensured this in that studies they included demonstrated the use of an assessment that specifically confirmed the participants had sensory processing or sensory integration challenges. The authors selected studies that also included outcome measures that specifically evaluated sensory processing and integration (Pfeiffer, Clark, & Arbesman, 2017, p. 3).

The authors of this review specifically reviewed interventions defined as either cognitive or occupation-based. I appreciate that the authors were specific by excluding studies that did not explicitly indicate subjects as having sensory processing or integration disorders (Pfeiffer, Clark, & Arbesman, 2017, p. 4) While it is sometimes frustrating to have less articles, it is better to have consistent and accurate definitions so that we can feel confident of what is being reported!

Findings

Two studies included evaluated cognitive interventions that targeted outcome measures of self-regulation and executive functions of inhibitory control, social cognition, behavioral and emotional regulation and externalizing behavior problems (Pfeiffer, Clark, & Arbesman, 2017, p. 5).

Alert Program for Self-Regulation

A level I study assessed the effectiveness of 12 individual 1 hour sessions of the Alert Program for Self-Regulation for children with Fetal Alcohol Syndrome. Authors grouped children into an immediate and delayed treatment group. The delayed treatment group served as the control. Both groups received treatment, with the group receiving treatment first demonstrating significant increases in their inhibitory control and social cognition. These gains were maintained at a 6 month follow-up. Also noteworthy is that parents of children in this group indicated their children’s behavior and emotional regulation improved. These parents also noted a reduction in externalizing behavior problems in their children (Pfeiffer, Clark, & Arbesman, 2017, p. 5).

Components of the Alert Program

A level IV study included an intervention of Social Stories for 9 weeks in a self-contained pre-school classroom. This intervention with 3 male pre-schoolers entailed reading and then talking about a Social Story concentrated on the children’s goals (Pfeiffer, Clark, & Arbesman, 2017, p. 5). Children also practiced their strategies as part of the intervention. The interventionists used Social Stories that met Carol Gray’s criteria for social stories.

All three children in this study showed increased frequency of their desired behaviors. The baseline, intervention and maintenance phase percentages of frequency of desired behaviors are shown.

Occupation-Based Interventions

Horseback Riding to Promote Self-Regulation Skills

A level I RCT investigated the effectiveness of horseback riding on children’s social functioning. Subjects were children 4-10 years old with ASD. These children participated in 1 hour per week of horseback riding lessons for 12 weeks. This was done at an equestrian center with trained instructors. Children who participated in the horseback riding intervention demonstrated statistically significant changes in their overall Sensory Profile Score, as completed by their parents (Pfeiffer, Clark, & Arbesman, 2017, p. 6). Specifically, the following subscales were impacted: Sensory Seeking, Sensory Sensitivity, Inattention/Distractibility and Sedentary Behaviors. These children also demonstrated significant changes in social motivation.

A level III study used lessons that a school group coordinator designed about: sensory orientation to the environment, mounting a horse and riding (Pfeiffer, Clark, & Arbesman, 2017, p. 6). Subjects were children in kindergarten through fifth grade with ASD. Children who participated in horseback riding demonstrating significant improvements in their social interaction, sensory processing as well as reduced severity of symptoms associated with ASD. It is noteworthy that in this study, subjects had built in breaks and during breaks, the gains were not consistently maintained (Pfeiffer, Clark, & Arbesman, 2017, p. 6).

Yoga as a Means to Promote Self-Regulation

A level III study assessed the use of yoga for subjects 12-18 years old who were in partial hospitalization or an inpatient mental health unit (Pfeiffer, Clark, & Arbesman, 2017, p. 6). These subjects took part in at least two 50 minute yoga sessions over 5 months. A Yoga Alliance-registered teacher taught the classes. Participants in the yoga intervention demonstrated significant improvements in their pulse rate and self-reported distress ratings.

What’s the Best Way to Promote Self-Regulation?

As OT’s we know that there are many factors that contribute to our clients meeting goals and living fulfilling and enjoyable lives. I liked that this study highlighted both the need for cognitive strategies and occupations. Teaching children to become more aware of their body’s state of regulation helps empower them to self-regulate . I am excited to see that children can participate in occupations that are enjoyable that can also help develop self-regulation skills! What are your favorite programs and tools to teach children self-regulation?

References

Pfeiffer, B., Frolek Clark, G., & Arbesman, M. (2017). Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: A systematic review. American Journal of Occupational Therapy, 72, 7201190020. https://doi.org/10.5014/ajot.2018.028233.

July 28, 2020July 29, 2020

Childhood Anxiety-What’s an OT to do?

Last week I reviewed an article that investigated the relationship between preschoolers with sensory over-responsivity and school-age anxiety disorders. The authors found a significant correlation between the two factors. Now we know that sensory over-responsivity may contribute to clients who present with anxiety. The next question is, “What is my role in treating childhood anxiety as an occupational therapist?”

It intrigues me that despite OT’s mental health origins, I don’t want to overstep and treat a child with anxiety. Using the Zones of Regulation curriculum has equipped me to help a child who presents with generalized anxiety and self-regulation troubles.

When It’s More Than Anxiety

I personally feel that when I sense a bigger family dynamic, it’s time to refer to a family counselor. Also, I see that many professions are supporting trauma informed care. I believe [read: my opinion] to work with children with more complex psychological involvement, we have an obligation to pursue continuing education in that realm and/or know when it’s time to refer out.

OT’s Role in Treating Childhood Anxiety from AOTA’s Perspective

Let’s see what AOTA has to say. In its Anxiety Disorders fact sheet, AOTA mentions that anxiety impacts children’s participation because the fears they may have of failing, interacting with others, or more intense factors like panic attacks may cause children to limit the activities they are willing to participate in.

They next point to the cycle of how not being able to participate in these activities can lead to low self-esteem and impact their habits and routines. This is totally the stuff of OT! Also very interesting to me is children not knowing what activities to do to relax. This seems especially important in the age of technology when it’s way too easy to do everything online. We as OT’s know that occupations we do with our hands promote mental health!

Alright, now that we know where OT can help children in managing their anxiety, what action steps we can take?

Action Steps for OT’s to Address Anxiety

At home OT’s help the child and family in establishing routines, educating family members on how anxiety presents and how it impacts a child’s engagement in activities. An OT can also help a family to find activities they can enjoy together to promote balance and relaxation.

An OT at school may similarly provide information to staff on how anxiety may impact a child’s participation. OT’s also can present ideas for how to structure a child’s day and strategies to assist with regulation. An OT may also promote presenting activities in a modified way to reduce anxiety.

The AOTA fact sheet recommends that an OT can help on the community level by offering education and ideas of how to cope with anxiety symptoms to organizations that involve parents and work with youth.

What’s Your Next Move?

Knowing that AOTA recommends the above in treating children with anxiety, what will you do differently the next time you join a child and family on their journey with anxiety?

References

Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Anxiety Disorders. Retrieved July 20, 2020, from https://www.aota.org/~/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Anxiety

July 21, 2020July 21, 2020

Is it Sensory Over-Responsivity or Anxiety?

We’re all overly familiar with the phrase, “sensory or behavior,” but I think we may leave important factors out when we pit the two as an “or” situation as well as the connotation of what “behavior” means to us. Behavior, while simplified by an Antecedent, Behavior, Consequence model can seem straightforward, is often just the opposite.

What impacts a child’s behavior? So. many. things. We know that physiological factors like blood sugar and being tired impact it. We also know that emotional processing and patterns shaped by dynamics at home and with caregivers impacts it. Communication skills, especially an impairment of, guide behavior.

Today’s review explores a study that investigated the relationship between sensory processing and anxiety. A CuriosOT follower on Facebook requested that I explore this topic, and I was happy to do so as this is a topic I’ve wondered about myself in recent years.

In our busy society, I think we can see that more adults and children alike are presenting with mental health concerns. As an OT I know that I have seen kids who may have sensory issues, but definitely have anxiety. Other times I’ve seen children who seem to me that they obviously have anxiety, and I’m not sure if sensory processing is contributing to their challenges in occupational performance.

So, are sensory processing and anxiety related? Either way, what is OT’s role in treatment when we receive a child who has one or both of these diagnoses? Today’s post will cover the relationship between sensory processing and anxiety, and my next post will cover what is OT’s role.

Journal Journal of Abnormal Child Psychology (SNIP score 1.759)

Article Title Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children

Level of Evidence

1A Systematic review of homogenous RCTs
1 B Well-designed individual RCT
2A Systematic review of cohort studies
2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
3A Systematic review of case control studies
3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal

Methods

The study authors obtained their baseline sample from the larger sample of the Duke Preschool Anxiety Study. That study had three parts: screening, in-home assessment and a laboratory phase (Carpenter et al., 2018, p. 4). The sample from the Duke Anxiety studied was obtained by screening children between 2-5 years old during visits to their primary care clinics. The sample was found to be representative of the general population.

Authors of the Duke Anxiety study invited the children who met criteria for generalized anxiety disorder (GAD), separation anxiety disorder (SAD) and/or social phobia to participate in the Phase 3 laboratory assessment (Carpenter et al., 2018, p. 4). Authors of the current study recruited children from this phase 3 to participate in the Learning About the Developing Brain (LABD) study. This was a five year study in which researchers followed a group of 191 children to assess relationships between sensory processing during preschool years and anxiety during school-age years.

Assessments

Study authors used the Preschool Age Psychiatric Assessment to assess anxiety and sensory over responsivity characteristics. Parents completed interviews to assess for symptoms of a variety of psychiatric disorders for children of preschool age. Parents of 191 children completed this assessment when their child was in preschool and age at school-age.

Anxiety

Researchers classified children as either meeting impairment and symptom criteria for the included anxiety disorders (GAD, SAD and/or social phobia) or not meeting those criteria. Children were identified as positive on the anxiety screening if their parent included at least 4 of 10 items on the screening tool.

Sensory Over-Responsivity

Researchers used the PAPA at baseline and follow-up to assess sensory over-responsivity. Responses to the following sensory experiences were accounted for: 1. physical contact with other people 2. Contact with fabrics, clothes tags, etc. 3. Contact with food textures 3. Visual experiences 5. Auditory experiences, including loud or high-pitched noises 7. Olfactory experiences 7. Tastes 8. Sensations of motion 9. Any other sensory experiences.

Behavioral Challenges

This study highlighted sleep problems, GI problems, food selectivity and irritability as related behavioral challenges.

Findings

Sensory Over-responsivity is not Uncommon for Preschool Children

Twenty percent of parents reported at least one sensory domain as over-responsive from the pre-school sample (Carpenter et al., 2018, p. 8). The most commonly rated areas were tactile (18%) and auditory (4%). Children with sensory over-responsivity at preschool who remained rated as such by school-age was 56%. Sixteen percent of children whose parents did not rate them as sensory over-responsive in preschool were rated as having sensory over-responsivity by school-age.

The proportion of females who parents described as sensory over-responsive was higher than the proportion of males who parents ranked as so (Carpenter et al., 2018, p. 8). Parents of children whose children were categorized as below the federal poverty line also were significantly ranked more often as sensory over-responsive.

Relationship Between Sensory Over-responsivity and Anxiety Disorders in the Preschool Sample

Researchers found a significant relationship between sensory over-responsivity and anxiety diagnoses in preschool, as 43% of children who were categorized as sensory over-responsive also demonstrated criteria of anxiety disorder. Researchers found that there was also a significant relationship between sensory over-responsivity and other disorders (i.e. ADHD) from the preschool sample (Carpenter et al., 2018, p. 9).

Did Sensory Over-responsivity in Preschool Predict Anxiety Symptoms by School-age?

The authors found that sensory over-responsivity in preschool significantly predicted anxiety symptoms by six years old. This stayed true when other potentially confounding variables (including sex, age, race, poverty status) were accounted for. This also remained true when the factors of a child having sensory over-responsivity by school age, anxiety symptoms when in preschool and a diagnosis of other disorders in preschool were accounted for. All this to say that potentially confounding factors assessed for in preschool did not otherwise explain the development of anxiety by school-age.

What Type of Anxiety Disorder Does Sensory Over-responsivity Predict?

The authors found sensory over-responsivity as a significant predictor only for generalized anxiety disorder, not separation anxiety disorder or social phobias.

Could Preschool Anxiety Cause School-age Sensory Over-responsivity?

A child having anxiety symptoms in preschool did not significantly predict a presence of sensory over-responsivity in school age children. When researchers assessed if preschool sensory over-responsivity predicted non-anxiety disorders for school age children, they found it did not. This indicates that preschool sensory over-responsivity is a significant predictor specifically of anxiety for school age children as opposed to a wide variety of non-anxiety disorders.

So What’s the Link Between Preschool Sensory Over-responsivity, School-age Anxiety and the Behavioral Challenges We See by School-age?

Researchers found a significant relationship between preschool children with higher levels of sensory over-responsivity showing higher levels of anxiety by school-age. They also noted that school-age children with higher levels of anxiety have higher incidences of irritability and sleep problems. Researchers did not find a significant relationship between the sensory and anxiety measures as they impacted GI symptoms or food selectivity by school age.

Things to Consider

The authors mention that they only collected data for two periods of time which is insufficient to completely achieve the ideal statistical criteria to state the impact sensory over-responsivity has on how anxiety and behavioral challenges manifest.

The authors also mentioned that to measure sensory over-responsivity they used an interview that was comprehensive and not specific to sensory over-responsivity. They feel it may be best to use a tool that specifically measures that.

Also of note is that the measures for anxiety and over-responsivity came exclusively from parent-report. It would be beneficial to have a second rater to corroborate these levels. They also mentioned that research has shown that sometimes a mother’s emotional symptoms impacts her rating of her child’s symptoms of mental health conditions.

The researchers would also like to assess how sensory under-responsivity and sensory seeking relate to anxiety.

What Do You Think?

How do you decide if a child presents with anxiety or sensory processing disorder? How would you use this information to guide your treatment?

References

Carpenter, K. L., Baranek, G. T., Copeland, W. E., Compton, S., Zucker, N., Dawson, G., & Egger, H. L. (2018). Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children. Journal of Abnormal Child Psychology, 47(6), 1075-1088. doi:10.1007/s10802-018-0502-y