Miriam Manela OTR/L Pediatric Occupational Therapist

1. Miriam Manela OTR/L Pediatric Occupational Therapist Manela 2013

2. Is It Behavioral? Manela 2013

3. The Question: Is the behavior willful? Manela 2013

4. Occupational Therapy in Mental Health • Participation in Meaningful Roles and Activities • Satisfaction and a Sense of purpose and Success • Away to Develop Self-Control • A Positive Self-Image • Enhance Emotional Well-Being • Promotion of Social Competence • Healthy Parent-Child & Teacher-Student Relationship Social Competence • Having the social, emotional, and cognitive skills to be able to participate in all the different relationships in a person’s everyday life. Lannigan & Manela 2013

5. Why addresschildhood mental, emotional and behavioral problems? • Affect the way young people think, feel and behave • Interferes with success in daily life • Stressful for the child and family • Unhappy, angry, or fearful children struggle to meet the expectations of their roles and activities • Diminished confidence. Lannigan & Manela 2013

6. Why address Childhood mental, emotional and behavioral problems? (cont.) • Limited or Maladaptive Social Participation • Lack of Motivation in the Classroom and in other Occupations • Inability to Develop a Healthy Sense of Self • Stressful Family Dynamics • Mental Health Problems (Substance Abuse and Mental Health Services Administration (SAMHSA), 2003a) Lannigan & Manela 2013

7. Role of OT in Treatment of Childhood Mental Health Disorders • Identify factors that result in poor ability • Analyze and break down tasks • Provide the child with a sense of mastery • Enable the child to develop a healthy identity, despite his or her emotional disorder Lannigan & Manela 2013

8. When children misbehave, what feelings does it conjure up in us as therapists, teachers and parents? Manela 2013

9. When we treat behavior challenges we are treating cognition, emotion and sensation. Manela 2013

10. Attachment Theory Manela 2013

11. What is Attachment Connection? • A pattern of interaction in a specific relationship. • Develops during primary connection with caregiver-grows the brain. Manela 2013

12. Attachment is about Danger and Survival • Behavioral patterns are survival strategies used by the child to get needs met • Life and Death • Safety Manela 2013

13. Genetics and Experience Our genetic inheritance directs the overall brain organization, while experience influences how and when genes become expressed. Manela 2013

14. Attachment style forms within the first 12 months.  However, it can be "updated" with new experiences. Manela 2013

15. The brain is dependent on experience. • Early experience shapes the architecture of the child’s developing brain. Manela 2013

16. Right Orbito-Frontal Cortex • Social intelligence, impulse control, attention and short-term memory • OFC chooses information to focus on • “Brakes of the Brain” Manela 2013

17. Gleaming and Beaming Manela 2013

18. Attachment Patterns • Type A: Avoidant of negative affect and predictable (Avoidant Attachment). • Type B: Secure and Balanced • Type C: Preoccupied with negative affect and unpredictable (Anxious Attachment). Manela 2013

19. Type C (Anxious) Strategies • Lack confidence in caregiver reliability • Related to anxiety and behavior disorders Manela 2013

20. Type C (Anxious) Strategies • Clingy, needy, insecure • Keeps caregiver engaged Manela 2013

21. Type C (Anxious) Strategies • Over-feelers • Anxious • Preoccupied with negative emotions • Unpredictable in their behavior Manela 2013

22. Exaggerated Negative AffectPreoccupied with Negative Affect Manela 2013

23. Development of C Strategy • Unpredictable Consequences • Inconsistent Care Giving • Caregivers’ Responses Fluctuate • Child Preoccupied with Caregivers’ State of Mind. Manela 2013

24. For those high in anxiety attachment (Type C), relationships are associated with emotional dysregulation. (Lopez & Gormley, 2002) • Attachment Anxiety/Type C -Have self regulatory deficits that develop in the prefrontal cortex (Schore, 2001). Therefore, • self soothing • skills need to • be taught. Manela 2013

25. Type A (Avoidant) Strategies:Avoidant of Negative Affect • Rely heavily on cognition. • Predictability. • Minimize negative feelings. • Do what is expected; avoid punishment. • Disorders of inhibition and compulsion. Manela 2013

26. Type A (Avoidant) Strategies (cont.): • Avoid disorganizing stimulation from mom. • Constant parasympathetic state. • Gaze aversion and passive avoidance. • Limited capacity to experience intense emotion. • “Over-regulation disturbances.” • Too much inhibition. Manela 2013

27. Type A (Avoidant) Strategies (cont.): • Over-thinkers. • Avoidant of negative emotions and very predictable. False positive affect. • Don’t trust their feelings. Manela 2013

28. Development of “A” Strategies: • Dismissive caregivers • Competitive caregivers • Learns to repress negative emotion Manela 2013

29. Development of “A” Strategies (cont.): • Child remains distressed. • Caregiver minimizes intimate interactions. • Emphasis upon over-activation of child’s exploration and competence. Manela 2013

30. All sensory experiences are emotional experiences. Amygdale is the sensory center and emotions center. Manela 2013

31. Challenges with Regulation may Result in: • In-Attention to task • Poor Impulse Control • Limited Frustration Tolerance • Poor Balance of Emotions • Sleep Disturbances • Poor Self-Calming • Intolerance of Change • Anxiety • Feeding Problems • Mood Regulation Problems Manela 2013

32. Secure Attachment correlates to lower • levels of pain severity, depression, pain catastrophizing and anxiety (Tremblay & Sullivan, 2009).  • Insecure Attachment- predicts lower pain threshold, lower perceptions for both pain control and ability to lessen pain, greater stress, depression, catastrophizing, substance abuse disorders, eating disorders and impulsivity. Manela 2013

33. Techniques for Regulation and Secure Attachment Manela 2013

34. Two Modes of Regulation • Co-Regulation: Use of relationships. • Auto-Regulation: Ability to self-regulate independently. Manela 2013

35. Regulating State Changes • Where are the child and I in the window? • What are the indicators? • How do I use this information to adjust my contact to be regulating? Manela 2013

36. Co-Regulating Child’s State of Arousal • Matching vitality of affect • Match tone • Match intensity • Match prosody • Don’t match the emotion Manela 2013

37. Reading the Mind in the Eyes The eyes hold the information of affect. Manela 2013

38. Magic of Connection Manela 2013

39. Don’t Take Behavior Personally Manela 2013

40. Regulate ourselves in the presence of chaos “Stay in place” Manela 2013

41. Developing mindfulness • Staying present • Attunement • Self-Regulation • Compassion • Implicit Memory and Explicit Memory • Choosing our Words • Sensing into the Body Manela 2013

42. The clinician’s mindfulness and its effects on the child's dramatic involvement with emotions. Manela 2013

43. Environments that Support Attachment The overarching term “environment” refers to the life experiences, family patterns and relationships that support healthy functioning. Manela 2013

44. Activities for Therapists to Enhance the Development of Consistent Responses • Psycho-education • Modeling • Homework • Teaching reinforcement • Small steps • Successive approximations • Track progress • Teacher training • Practice, role play • Teacher coaching • Start small, start easy • Address needs, not wants • Experiment • Predict pitfalls Manela 2013

45. Activities to Enhance the Development of Routines • A Strategy • Encourage material choices. • Encourage progressively more interactive play time, encourage choices. • Develop ‘verbal blueprint’ of transition expectations. • C Strategy • Offer limited material choices. • Structure play time, limit choices, alternate active games with self-regulation activities (blanket wrapping, play dough.) Manela 2013

46. Activities to Enhance Mastery of Developmental Tasks • A • Teach social skills. • Consider settings that allow the child to play alone, then in pairs, then progressively with larger groups. • Progress from structured instructional time to more free play. • Encourage the development of skills: music, sports, art, etc. Start with quiet settings and move toward more interactive social settings. • C • Model social skills. Set limits. • Keep over stimulating environments to a minimum. Begin with opportunities for parallel play. Progressively move to settings with more children. • Progress from free play to more instructional time. • Encourage the development of skills by observing what the child does well and then systematically increase their time spent on those tasks in order to master them. Manela 2013

47. Activities to Enhance Child Self Development/Identity • C • Ask child’s opinion, but limit options, ‘would you like to do your report now or after recess?’ • Explain why things are done in short sentences. Cover one issue at a time. Answer questions when they are asked. Always reduce anxiety before attempting to explain anything. • Use concrete markers: height measures, life books. • A • Encourage exploration and making choices, e.g. involve child in planning play time. • Ask child’s opinion in decision making, ‘what would you like to put on your project?’ • Explain why things are done the way they are done. Encourage questions. Manela 2013

48. Strategies • Use Connection • Work on Relationship, not Incident • “Draw out the Tears” • Draw out the tempering element Manela 2013

49. Strategies (cont.) • Scripting desired behavior • Change environment • Draw connections Manela 2013

50. Strategies to Teach Parents and Caregivers • Teach that the paradigm can change • Awareness of intrinsic worth • Role play • Model appropriate attachment-related behavior • Use of self-made movie clips and stories Manela 2013