Praxis and Play and Trauma - Attach 2017 - Handout Version · 10/16/2017 1 Teresa A. May-Benson,...

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Teresa A. May-Benson, ScD, OTR/L, FAOTA

� Teresa A. May-Benson, ScD, OTR/L, FAOTA

� [email protected]

� Executive Director, Spiral Foundation

� Senior Therapist, OTA the Koomar Center

� Tufts University, Part-time Lecturer

� www.thespiralfoundation.org

� www.otawatertown.com

© T May-Benson, 2017

� Jane Koomar, PhD, OTR/L, FAOTA, friend, mentor and colleague whose work in trauma and sensory integration I endeavor to continue.

� To the children and adults and their families we have learned so much from and for allowing us to share their stories.

© T May-Benson, 2017 © T May-Benson, 2017


�Occupational therapists with sensory integration training are treating increasing numbers of children who also have trauma and attachment disorders.


�Psychotherapists are treating children and adults with trauma who have sensory sensitivities secondary to trauma and can benefit from knowing how sensory strategies can help with:� regulation

� body awareness

� motor skills

� planning and organization.

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� Post-institutionalized children from orphanages

� Children who have received foster care

� Premature infants/medically fragile

� Individuals with autism

� Inner city/ lower income

� ADHD, Learning Disorders and Developmental Coordination Disorders

� Anxiety Disorders (including Obsessive-Compulsive Disorder, Panic)

� PTSD/Attachment Disorders

� Mood disorders (Major Depressive Disorder, Bipolar Disorder)

� Oppositional Defiant/Conduct Disorder

(c) Koomar, 2010


�Environmental:� Man-made

� Natural disasters

�Societal:� Terrorism

� Community/school violence

� Military Combat


� Physical: � Accidents

� Disease

� Medical procedures

� Birth trauma

� Relational: � Loss of a loved one

� Domestic violence

� Neglect

� Physical abuse

� Sexual abuse

� Regulation of arousal a primary concern in trauma interventions

� Arousal regulation may be affected by

� Sensory stimuli

� Task demands

� Motor skills

� Emotional/social demands

� Not all dysregulation of arousal is due to sensory may be due to praxis-related issues

� Motor performance problems and developmental delays are recognized in children who demonstrate trauma and attachment concerns

� Praxis allows one to adaptively interact with the world of people and things around them

� Traumatic experiences interfere with the ability to adaptively interact with the world

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© T May-Benson, 2017 ©2014 Spiral Foundation

The ability to make an adaptive response

to an environmental demand.


� Issues that disrupt development of praxis interfere with adaptive behavior like play

�However, the motor implications of trauma is a little discussed area of functioning

� Play depends on good praxis in typical development and is a mechanism by which children develop more complex praxis skills

� Play is part of development of and regulation of social behaviors…when children cannot play they cannot interact well with others

� Play with caregivers can promote bonding and attachment

� Traumatic experiences are known to interfere with development of social aspects of play

� Literature focuses on play therapies and child’s recreation or processing of traumatic event with little to no attention paid to other aspects of play from a developmental perspective

� Understand the relationship between praxis, play, adaptive behavior and arousal regulation

� Understand what is known about the relationship between praxis, play, adaptive behavior and trauma and attachment concerns

� Recognize ways to begin to address praxis, play and adaptive behavior in traumatized children.


�Dysregulates physical functioning

� Interferes with relationships

�Disrupts beliefs about oneself, others and the world

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� Trauma results in difficulties regulating emotions and behavior

� Results in decreased attention and increased anxiety

� Trauma interferes with the formation of neuronal models –needed for development of praxis

� Attachment experiences are an important part of the development of basic motor skills such as holding, eye contact, reaching

� Attachment experiences provide opportunities to engage in sensory exploration

� Early parent-infant play is an important part of attachment bonding


�Populations that frequently experience trauma are known to have delayed motor skills� Van Der Kolk

� Bruce Perry

� Research on specific populations but not general trauma populations

� Post-institutionalized children – adoptees� Deprivation

� Decreased SIPT scores – PPr, OPr, PrVC, SPr

� Decreased balance and bilateral coordination (cerebellar/vestibular)

� Foster children who experienced trauma or neglect� 84% of children had problems with planning and ideas

on SPM

� Males had more “Some problems”; girls had more “definite problems”

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� Premature infants and medically fragile

� Delayed motor skills

� High incidence of SI problems

� Delayed somatosensory processing

� Physically abused children

� Atypical motor patterns

� Lack of movement/passivity

� Delayed motor skills

� Juvenile delinquents

� Fine motor problems

� Decreased praxis on SIPT

� Vestibular-related tests on SIPT

� Mental health disorders

� Anxiety related to poor vestibular functioning

� Decreased balance

� Martin Teichert, et al

� Limbic irritability

� temporal lobe epilepsy, increased EEG (brain wave) abnormalities.

� Deficient development

and differentiation of the

left hemisphere

� throughout cerebral cortex and the hippocampus (memory retrieval)

� Deficient left-right

hemisphere integration

� shifts in hemispheric activity during memory recall

� underdevelopment of middle portion corpus callosum

� Abnormal activity in the

cerebellar vermis

� plays role in emotional and attentional balance and regulates electrical activity in the limbic system


� Ideation

� Motor Organization

� Feedback

� Feedforward

� Sequencing/Organization

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� Definition:� The process of conceptualizing intentional and

purposeful actions, identifying a goal for the action, accessing internal schemas of the action, and motor preparation of the act.

� Is dependent on the knowledge

of action and object affordances


� Organizing actions for use

� Motor Planning

� Bilateral Coordination

� Projected Action Sequences


� Definition:

� The ability to plan, order and sequence a series of intentional motor actions

� Related to and depends on the ability to sequence

� Depends primarily on somatosensory inputs


� Definition:

� Involves organization and coordination of various parts of the body

� Depends primarily on vestibular inputs

� Develops from primitive postural reflexes


� Definition:

� Involves planning and organizing actions that require timing and movement through space

� Usually performed automatically and planning is largely unconscious

� Depends primarily on vestibular, proprioceptive, and visual inputs

� Demonstration of constructs of play

� characteristics that make something play

� Types of play

� Function and nature of play behavior

� Developmental levels

� Stages and progression of play skills,

� Social stages of play

� Ways that children play in relation to others

� Playfulness

� Approach that one takes toward an activity to make it play.

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� Clumsy child

� Problems with sports, dressing, eating, handwriting

� Disorganized

� Longer than average to learn new tasks

� Frustrated

� Does not know what to do

� Maybe socially awkward in a physical sense

� Poor body awareness

� Poor impulse control


� Major problem areas

� Motor coordination

� Behavior

� Social-emotional difficulties

� Performance daily life skills

� Play

� Difficulty with novel experiences

� Refusals or avoidance of new physical tasks

� Low frustration tolerance for learning

� Decreased exploration or exploratory play

� May be bossy or controlling to the extent of bullying

� Decreased ability to plan, organize or complete occupations

� Decreased pride and confidence in abilities

� Decreased perceptions of mastery of environment

� Difficulties planning body movements

� Closely monitors others doing tasks

� Avoidance of or asks assistance for challenging tasks

� Repetition of unworkable plans

� Problems following directions

� Difficulty with multi-step activities

� Difficulty anticipating upcoming events

� Motor problems can manifest differently in different clients depending on type of trauma and other factors


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� Ayres Sensory Integration approach–developed in a clinic setting with abundant therapeutic materials that can provide sensory experiences in a manner that are predominant in the earliest sensory experiences from the womb and during the first years of life (Ayres, 1972, Ayres, 2005)

(c) Koomar, 2010

Arousal

Regulation

Sensory

Opportunities

&

Adaptive Responses

Ensures

Physical Safety

Postural Ocular,

Oral Bilateral

Coordination Praxis and

Organization of

Behavior

Therapeutic

Alliance

Context of

Play

Tailor the

Just Right

Challenge

Ensures

Success

Collaborate on

Activity Choices

The Core Sensory Opportunities Are Body Based:

Proprioceptive, Tactile, and Vestibular.

Mailloux, Koomar, Roley, Blanche,Schaff, May-Benson, Schoen, Benevides, 2010

� Regulation of the nervous system to decrease hyperarousal.

� Grounding in one’s own body experiences to increase a sense of stability and power.

� Development of foundation skills for postural, motor, social/emotional and cognitive skills to increase resiliency.

� Neuropathways supporting differentiation and integration.

(c) Koomar, 2010

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�van der Kolk - Organism can heal when client feels safe and is in a state of joy

�Perry – Organism can heal if sense of safety is enhanced and repetition can occur to develop new neuronal models (Perry & Szalavitz, 2006)

�Ayres – With the optimum-for-growth situation, the child “turns on” with an obvious zest (1972)

(c) Koomar, 2010 © T May-Benson, 2017

�Allow the parent to have a greater role in the therapeutic process of OT with a sensory integration focus

� Sessions not only address the sensory processing needs of the child, but also allow the development of attachment to become a key component

Rozelle, Donnis, Koomar

© T May-Benson, 2017 ©2014 Spiral Foundation

� Establish physical and emotional safety

� Child direction

� Active participation in sensory

motor experiences

� The just right challenge

� Adaptive response


� Ball pit

� Jello Squishes

� Crawling and Rolling

� Climbing

� Tire Swing

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© T May-Benson, 2017 ©2014 Spiral Foundation © T May-Benson, 2017 ©2014 Spiral Foundation


� Trauma triggers

� Dissociation & safety

� Playing with fears

� Competition


�Superhero play

�Lovies, transitional objects, substitutes

�Storytelling


� Pulling Game

� Block Knock

� Ring Game

� Obstacle Courses

� Scooter Board Challenges

� Net, Tire and Glider Swings

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© T May-Benson, 2017 © T May-Benson, 2017 ©2014 Spiral Foundation



� Net Swings and Rings

� Scooter Boards and Targets

� Targeting Games

� Trapeze Games

� Bolster and Glider Swings

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� Delight in the child, allow the child to know how much you enjoy him or her

� Dance with the child

� Focus on parents and help them get a playful rhythm going with the child

� Match the vitality level of emotion

� Create clear verbal and nonverbal communication

� Talk for child and check on your accuracy

� Parent does all comforting and safety monitoring

� Any treats come from parent, not therapist© T May-Benson, 2017

� Repair is needed on several levels

� Individual professionals have limited knowledge & skill

� Trauma treatment requires multiple helpers with myriad skill sets

� Team offers “potential space” for physiological & attachment repair

Copyright © 2006 Rozelle, Donnis, Koomar All rights reserved

� Dan Hughes and Jane Koomar teamed up to combine the PACE Model with SI principles

� PLACE for parents –Playfulness, Love, Acceptance, Curiosity and Empathy with

� SAFE, sensory attunement focused environments based on SI theory.


Blending Dyadic Developmental Psychotherapy Blending Dyadic Developmental Psychotherapy

with Sensory Integration Principalswith Sensory Integration Principals

D. Hughes, J. Koomar, 2009

Empathy

Create New Personal Narratives or Stories

Co-regulate negative emotions

Acceptance

Establish a Partnership

Collaborate in Activity Choice

Ensure Activities are Successful

Creating a SAFE PLACE for the special children in our lives.

Curiosity

Just Right Challenge

Co-create personal narratives

Playfulness

Physical & Emotional Safety

Co-create positive emotions

Cognitive

Reflective Functioning

Emotional

Co-regulation

Physical

Body Regulation & Communication

Depth of Experience

Spiritual

MakingMeaning

Love

Physical Competence

Love

� Two 1-hour direct intervention sessions/ week for 12 weeks

� One 1-hour consultation session with parent/week

� One 1-hour collaboration treatment planning time for OT and MHP

� Personnel included OT, Psychiatrist, Mother, Child

� Additional sessions with Father and Auntie (nanny caregiver)

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� Initial screening for trauma & attachment concerns

� Initial assessment and GAS goal setting

� Baseline – no treatment period 10 weeks

� Post-baseline assessment

� SAFE PLACE Intervention – 12 weeks (actually took 15 due to illnesses, absenses, holidays, etc.)

� Post-intervention assessment

� Post-Intervention baseline– began separate SI-OT 1 time weekly and psychotherapy

� Post-baseline assessment

� Child: Liam

� 4 years old,

� adopted from Russia at age 14 months

� Several recent changes in nannies over past year and half

� Severe anxiety and “behavioral issues”

� Primary Concerns

� Aggression towards mother- hitting, kicking, spitting, etc.

� Biting other children at school

� Inability to calm self

� Inability to express feelings, would not accept hugs

� Problems with transitions, groups and fine motor skills

� Recover from a meltdown without physical restraint due to hitting, kicking, spitting, etc.

� When mom joins dinner after work, Liam will continue eating without mom needing to spoon feed him.

� Liam will be able to participate in a group activity like soccer without needing 1:1 adult attention

� Engage in an art/craft activity at home with adult supervision

� Mom will feel relaxed taking Liam to a busy environment like a playground by herself


�GAS

�Sensory

� SPM

�Motor� M-ABC

� Ayres Clinical Observations

�Behavior� BRIEF

� BASC

� GAS Goals

1) Meltdown Recovery – 1

� Some weeks no meltdowns, mom handles differently

2) Feeding self – 2

� 99% independent, wanting help with dressing

3) Participate in groups – 0

� Soccer still hard but able to do parties

4) Fine motor - -2

� Doing at school but not home

5) Mom feel relaxed in public - 0

� Comfortable 70% of time

� M-ABC

� Total score improved 4 points

� SPM

� Total score improved 6 points but 5/7 subscoresimproved 4 – 10 points

� BRIEF

� 9 subscores improved

� BASC

� 11/18 subscores improved

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� Therapists need to attend to motor and praxis problems in children who experience trauma

� Similarly, therapists working with traumatized children need to be aware of potential impact of trauma triggers

� Therapists need to look at all aspects of play with children including playfulness, etc.

� More research is needed on the motor and praxis concerns of trauma

� Available on OTA the Koomar Center Website

� www.otathekoomarcenter.com

� White paper

� Video review results

� Preliminary Program Review results

�Our intention is to be fully present to the child’s and family’s needs, fears and hopes. This is key to our intervention.

�Never underestimate the transformative power the belief in the joy and wholeness of the child can have in helping each child and family rewrite the stories of their lives.

Copyright © 2006 Rozelle, Donnis, Koomar All rights reserved

� Lin, S. H., Cermak, S., Coster, W. J., & Miller, L. (2005). The relation between length of institutionalization and sensory integration in children adopted from Eastern Europe. American Journal of Occupational Therapy, 59(2), 139-147.

� Cermak, S., & Groza, V. (1998). Sensory processing problems in post-institutionalized children: Implications for social work. Child and Adolescent Social Work

Journal, 15(1), 5-37.

� Van der Kolk, B. A. (2015). The body keeps the score:

Brain, mind, and body in the healing of trauma. Penguin Books.

� Gaskill, R. L., & Perry, B. (2014). The neurobiological power of play. Creative arts and play therapy for

attachment problems, 178-94

� Ryan, K., Lane, S. J., & Powers, D. (2017). A multidisciplinary model for treating complex trauma in early childhood. International Journal of Play

Therapy, 26(2), 111.

� Tomoda, A. (2015). Adverse Sensory Input of Childhood Maltreatment Modified by Early Experience Ascertaining the Neural Basis of Neurodevelopmental and Attachment Disorders. Seishin shinkeigaku zasshi= Psychiatria et

neurologia Japonica, 117(11), 928-935.

� Mubarak, A., Cyr, C., St-André, M., Paquette, D., Emond-Nakamura, M., Boisjoly, L., ... & Stikarovska, I. (2016). Child attachment and sensory regulation in psychiatric clinic-referred preschoolers. Clinical child psychology and

psychiatry, 1359104516667997.

� Perry, B. D. (2001). The neurodevelopmental impact of violence in childhood. Textbook of child and adolescent

forensic psychiatry, 221-238.

� Atchison, B. J. (2007). Sensory modulation disorders among children with a history of trauma: A frame of reference for speech-language pathologists. Language, speech, and

hearing services in schools, 38(2), 109-116.

� Van der Kolk, B. A. (2005). Developmental Trauma Disorder. Psychiatric annals, 35(5), 401.

� Jacob, R. G., Furman, J. M., Durrant, J. D., & Turner, S. M. (1996). Panic, agoraphobia, and vestibular dysfunction. American Journal of Psychiatry, 153(4), 503-512.

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� Purvis, K. B., McKenzie, L. B., Cross, D. R., & Razuri, E. B. (2013). A Spontaneous Emergence of Attachment Behavior in At-Risk Children and a Correlation With Sensory Deficits. Journal of Child and Adolescent Psychiatric

Nursing, 26(3), 165-172.

� Mitchell, A. W., Moore, E. M., Roberts, E. J., Hachtel, K. W., & Brown, M. S. (2015). Sensory processing disorder in children ages birth–3 years born prematurely: a systematic review. American Journal of Occupational Therapy, 69(1), 6901220030p1-6901220030p11.

� Roeber, B. J., Tober, C. L., Bolt, D. M., & Pollak, S. D. (2012). Gross motor development in children adopted from orphanage settings. Developmental Medicine & Child

Neurology, 54(6), 527-531.

� Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., Navalta, C. P., & Kim, D. M. (2003). The neurobiological consequences of early stress and childhood maltreatment. Neuroscience & Biobehavioral

Reviews, 27(1), 33-44.

� Teicher, M. H., Samson, J. A., Polcari, A., & McGreenery, C. E. (2006). Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment. American Journal of Psychiatry, 163(6), 993-1000.

� May-Benson, T.A. (2014). Praxis Disorders. In Autism

Interventions: Exploring the Spectrum of Autism. Carolyn Murray-Slutsky & Betty A. Paris (Ed.) Austin, TX: HammillInstitute on Disabilities.

� May-Benson, T. A. & Murray-Slutsky, C. (2014). Intervention for Praxis Deficits. In Autism Interventions: Exploring the Spectrum

of Autism. Carolyn Murray-Slutsky & Betty A. Paris (Ed.). Austin, TX: Hammill Institute on Disabilities.

� May-Benson, T. & Teasdale, A. (April 13, 2017). The SAFE PLACE Program: A Program Review – Interim Project Summary. Newton, MA: The Spiral Foundation.

� May-Benson, T. & Teasdale, A. (May 24, 2016). SAFE PLACE: Construct Validity Through Video Review – Project Summary. Newton, MA: The Spiral Foundation.

� May-Benson, T. (March 17, 2016). OTA The Koomar Center White Paper: A Sensory Integration-Based Perspective to Trauma-Informed Care for Children. Newton, MA: OTA the Koomar Center.

� Holland, C. & May-Benson, T.A. (2014). Rationale for Integrating

Attachment, Trauma, and Sensory Integration Theory: Spiral Foundation Self Study Series-Article. Newton, MA: Spiral Foundation.

Praxis and Play and Trauma - Attach 2017 - Handout Version · 10/16/2017 1 Teresa A. May-Benson,...

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Transcript of Praxis and Play and Trauma - Attach 2017 - Handout Version · 10/16/2017 1 Teresa A. May-Benson,...