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

January 7, 2021January 7, 2021

Mindfulness Training & Its Impact on Self-Regulation

Mindfulness has been a buzz word for I would say the past four years or so in education. Maybe in society at large also, but it seems it’s really made itself known in how it might help the young minds we help to educate. Kids have always needed adults to model and teach how to process the sometimes overwhelming world. However, in today’s society where technology is king, one has to be more and more intentional to be truly connected to what is going on in your life.

I really loved this article because I think it highlights the importance and connection of mindfulness on self-regulation. As an OT I often approach self-regulation by addressing sensory processing deficits with sensory input or modifications to the environment. However, I also love bringing children’s awareness to situations, triggers and reactions and teaching them tools they can use to help in those situations.

Also…I’m really interested in one of the assessment measures they used. It’s called the Head-Toes-Knees-Shoulders and is used to assess controlling and directing actions, inhibitory control, paying attention and remembering instructions! If I were working right now, especially in the schools, I would definitely be looking into this.

Journal Journal of Child and Family Studies (SNIP 1.061)

Article Title Effects of a Mindfulness-Based Program on Young Children’s Self-Regulation, Prosocial Behavior and Hyperactivity

1A Systematic review of homogeneous 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) [This study was a cross-sectional study]
5 Expert opinion without explicit critical appraisal

Methods Investigators assigned 127 children aged 4-6 in eight kindergarten classrooms from Toronto public schools to either a control or intervention group. The primary researcher implemented the training program for all classrooms as she was trained in the specific program used in this study. It is the Mindful Schools program.

Intervention

Children in the intervention group participated three times a week in twenty minute lessons for a period of six weeks. Some components of this particular mindfulness program included children practicing external and internal mindful awareness practices and lessons in “heartfulness”(Viglas, M. & Perlman, M. p. 1153, 2018). To conclude the session, children wrote or drew about the new practice they learned in their “Mindfulness Journal.” In addition, investigators encouraged children to practice these skills and teach them to their family. Children were invited to share about those experiences at the start of the subsequent session.

Measures To measure controlling and directing actions, inhibitory control, paying attention and remembering instructions, researchers assessed children with the Head-Toes-Knees-Shoulders (HTKS).

Teachers filled out the Strengths and Difficulties Questionnaire as a means to assess children’s prosocial and hyperactive behaviors. The five subscales are Prosocial Behavior, Hyperactivity, Conduct Problems, Emotional Symptoms and Peer Problems.

These items were measured before the intervention began and once the six week program had finished.

Findings

After the intervention was complete, students who participated in the Mindful Schools program showed better self-regulation skills than those in the control group per results of the HTKS.

Children in the mindfulness group also demonstrated significantly better scores in the Prosocial and Hyperactivity subcales on the Strengths and Difficulties Questionnaire when compared to peers in the control group. Researchers detected no significant difference between groups for the subscales for Conduct Problems, Emotional Symptoms and Peer Problems.

When researchers compared children’s scores from the first to second assessment using the HTKS, they found those who had lower self-regulation at the start had significantly more gains and benefited to a higher degree from the mindfulness interventions than those with higher scores on the HTKS during the first data collection.

Similarly, change in scores from before to after intervention of the teacher completed questionnaire indicated that those with higher scores for hyperactivity and lower scores for prosocial subscales before treatment benefited significantly more from mindfulness training than peers with opposite scores (higher prosocial and lower hyperactivity) before the program began.

Things to Consider

When I select articles, I make an effort to look into interventions that are relevant to OT practice. A limitation as an OT in applying this research is that this study assessed a specific program. In order to be truly confident of generalizing the findings here, you would have to use this same program.

Also, the program is structured in a way that seems to provide treatment on a group level. In this study, the same interventionist visited classrooms three times a week. I know that isn’t possible for you and your school caseload.

However, I’m taking this information as evidence that a structured program/curriculum on mindfulness can demonstrate significant and positive results for self-regulation. I’ll continue to research into mindfulness programs and will definitely share if I find one geared more toward a one on one approach to increase its generalizability to OT sessions.

Reference

Viglas, M. & Perlman, M. (2018). Effects of a Mindfulness-Based Program on Young Children’s Self-Regulation, Prosocial Behavior and Hyperactivity. Journal of Child and Family Studies (27) 1150–1161. https://doi.org/10.1007/s10826-017-0971-6

November 11, 2020November 11, 2020

Sensory Techniques for Children with Difficulties in Sensory Integration

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 mostly RCT’s and Level II studies. As this type of systematic review doesn’t fall into either 1A nor 2B, I chose to categorize it into a level 2A study. The evidence reviewed was higher than case studies but lower than cohort studies.

Methods

The authors of this systematic review included studies that investigated the effect of interventions that are not Ayres Sensory Integration specifically. They included studies published between 2007 and May 2015. Authors included studies on sensory-based techniques as well as sensory environmental modifications. Interventions targeted clients between 2-21 years old with sensory integration difficulties. Authors ensured that articles investigated specific sensory techniques or sensory environmental modifications.

Findings

Qi-jong massage The authors concluded there is strong evidence for young children with ASD with Qi-jong massage (Bodison, S.C. & Parham, L.D. 2017, p. 5).

Three Level I and and 1 Level II studies demonstrated improvements in self-regulation, parenting stress, tactile differences and ASD symptoms. Children were 2-7 years old and had ASD. Their parents, after being trained by occupational therapists, provided 15 minute daily massage. The studies lasted 4 and 5 months.

Important to note is that the OT’s had at least 50 hours of training in Qi-jong before training parents on its implementation. This may make it a challenge intervention for most OT’s to implement.

Weighted Vests The authors concluded there is limited evidence for the use of weighted vests for children with ADHD (Bodison, S.C. & Parham, L.D. 2017, p. 5).

A level I study did show improved attention and in-seat behavior when a group of 6-9 year olds wore vests with 10% of their body weight. The authors mention that limitations in the design of the study impacted its internal validity. This in turn caused them to interpret these findings with caution.

Study authors also noted that the evidence they found for the use of weighted vests with children with ASD had low levels of evidence, so these studies were not formally included in the review. The authors conclude the evidence for the effectiveness of weighted vests for children with ASD is insufficient at this time.

Slow Linear Swinging The authors concluded there is insufficient evidence to support the use of slow linear swinging to improve attention for children with ASD.

A level I study investigated the impact of being on-task following slow, linear swinging in a group of children with ASD. The study demonstrated no significant difference between children who swung and those in the control group (Bodison, S.C. & Parham, L.D. 2017, p. 6).

Study authors did note a limitation of this study is that the arousal level of children was not assessed prior to their participation in swinging. They posited, therefore, that if a child was in a low arousal state prior to a calming activity, this may have demonstrated no positive impact on the child’s on-task behaviors.

Sensory Enrichment in Preschool The authors concluded there is insufficient evidence supporting sensory enrichment in a preschool classroom.

This level I study investigated the impact of embedding tactile, proprioceptive and vestibular activities for 12 weeks in a preschool classroom’s daily routine. All children in the classroom participated in these activities, but one group of children also received ASI through OT sessions.

Both groups improved in their play skills, but no difference was noted between them. Study authors of this review mention that design limitations, including a very small sample size of 8, limit the implications of the study findings.

Sensory Environmental Modifications The authors concluded there is moderate evidence supporting sensory adaptations of a dental environment to assist participation for children with ASD in their routine dental cleanings (Bodison, S.C. & Parham, L.D. 2017, p. 6).

Children reported improved measures of pain intensity and sensory discomfort as well as improved participation in dental cleaning for typically developing children and those with ASD. Children received deep pressure from a decorative wrap and the auditory and visual aspects of the the dental environment (Bodison, S.C. & Parham, L.D. 2017, p. 7).

Most interesting to me is that investigators measured children’s electrodermal responses as a means to quantify impact on stress and anxiety. They found a moderate to large effect size for children with ASD after they received the intervention!

So What Do You Think?

I appreciate when studies have high standards for the research they include in their reviews. However, due to the nature of the current evidence in OT, that sometimes means there is limited information on the interventions we use most.

I’m interested in the idea of Qi-jong massage, but I will say that the skeptic in me thinks, “Well, if anyone received a 15 minute massage to start their day, I would definitely expect them to show improvements in their behaviors.” I also am curious to see if the massage was compared to other interventions such as a tailored sensory diet. If families really followed up with those every day with good fidelity, I hypothesize that we would similarly see as good if not better results in the developmental gains for children.

Reference

Bodison, S.C., and Parham, L.D. (2017). Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth with Sensory Integration Difficulties: A Systematic Review. American Journal of Occupational Therapy 72 (1). https://doi.org/10.5014/ajot.2018.029413

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.