ENHANCING ATTENTION AND COOPERATION WITH YOUR PEDIATRIC PATIENTS

Justine Faghihifar, M.S., OTR, CFLEJfaghihifar@gmail.com

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INTRODUCTION AND BACKGROUND My story Professional experience (range of children) Advanced study topics

Family Communication Emotional comprehension, expression, and

control in children Bullying Child nutrition and obesity Sexuality in teens with intellectual disabilities Community integration

Providing insight, knowledge and teaching to professionals and parents

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OBJECTIVES FOR THIS CLASS Obtain foundational knowledge on how Mirror Motor

Neurons impact humans Understand how social and emotional intelligence set the

stage for attention and cooperation in our treatment sessions

Learn treatment techniques to facilitate/increase attention in pediatric patients

Gain strategies to help children recognize emotions, in self and others

View techniques to shape negative behaviors and release power struggles

Learn how to praise children in meaningful ways that increase cooperative behaviors

Learn “super” strategies for use during problem situations or to increase positive interactions

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5 VITAL ELEMENTS These are the 8 takeaways from this

presentation that will be knowledge that can be used immediately Build rapport initially (DO NOT PUSH THE GOALS) Stimulate the Mirror Neuron System Teach/model emotional identification and expression Use effective praise Shape and teach during negative behaviors (but not

always, sometimes it’s better to wait) Negotiate (it’s ok) Everyday is a new day so do not hold grudges as

kids know Be prepared to be upbeat, silly, and a clown

EVERYDAY

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WHAT IS ATTENTION? Attention can be defined as one’s ability to

concentrate on an object or thought for more than seconds (2 types)

Focused attention is when something in the environment stimulates our attention briefly (seconds), phone ringing, doorbell, someone yelling etc.

Sustained attention is the ability to focus on something for longer periods of time (minutes) Expectations for children: 1 minute per year old

plus one minute

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THINGS THAT DECREASE ATTENTION Rapidly moving images (things that facilitate

focused attention) such as those on TV, video games, computers, etcetera

Dynamic environments, especially those that are auditorally over stimulating

Fatigue/illness Lack of understanding of emotions, actions,

or words (think of young children and elderly) Lack of interaction with nature, known as,

“Nature Deficit Disorder” (Louv, 2008)

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MIRROR NEURON’ SYSTEM The Mirror Neuron System (MNS) is a three part system that

includes motor, visual, and auditory neurons in the brain The MNS is responsible for imitation and the learning of

language as well as social cognition (Le Bel et. al, 2009; Oberman & Ramachandran, 2007; Oberman, Pineda, and Ramachandran, 2007) Social cognition includes: understanding of emotions,

actions, or words Researchers postulate that humans learn best when all

three areas are stimulated simultaneously (Le Bel et al, 2009; Oberman & Ramachandran, 2007) OT’s do this!

The link between observation of an action and development of social skills (infant imitation) that include another’s intentions, thoughts, feelings and forecasting of the next action/s (Oberman, Pineda, & Ramachandran, 2007) VIDEO

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SOCIAL AND EMOTIONAL LEARNING Buzz words of social and emotional learning,

social intelligence, and social awareness, social recognition and social interaction

Marc Brackett director of the Center for Emotional Intelligence at Yale and Maurice Ellas is director of the Social and Emotional Learning Lab at Rutgers University (NPR Interview, 2013)

Defined as a skill set to get along with others (while they engage in their occupations of: family life, school, and play) We interact with many more people in many more ways

No direct instruction for this except in a few pilot programs in schools

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SOCIAL AND EMOTIONAL LEARNING “Deficient” feeling vocabulary Using/teaching research based strategies to

help children regulate their emotions and use self-calming for anger, sadness, despair, frustration, excitement and elation (I would add sensory….we OT’s know this!)

http://www.casel.org/social-and-emotional-learning and http://sciencefriday.com/segment/08/09/2013/reading-writing-rithmetic-and-respect.html)

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EMOTIONS What I have seen clinically about emotions

Do not lump all emotions into happy, sad, and mad Increase emotional vocabulary as children age

and use a variety of emotions to describe your own emotions when talking with children

Use visual supports, pictures of emotions If a child is upset and cannot express their

emotions, you can state it, if you are wrong they will be quick to correct you

Empathy starts with the ability to recognize and attend to another’s emotional state and cooperation occurs when another person’s point of view is understood

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FRIENDLY AND UNFRIENDLY Children learn to be social from a young age

and they have an innate desire to have friends

They know that certain behaviors are associated with having friends (friendliness) and certain behaviors prevent or impede friendships (unfriendliness)

These words remove focus from the person and places them squarely on the behavior

Can be used to describe or give examples for witnessed behavior to facilitate discussions with children [example in the clinic] (Michelle G Winner, Pamela Crooke, & Kelly Knopp, 2010)

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AM I OFF TASK? RAMBLING? So why have we talked about Mirror Motor

Neurons and emotion understanding and/or recognition? How does this relate to our treatment sessions and facilitating attention and cooperation with our kiddos?

Adults typically come with all of these skills relatively intact and we don’t have to them build up

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FACILITATING A CHILD’S SOCIAL AND EMOTIONAL AWARENESS Number one is “modeling” (stimulation of the Mirror Neuron

System) Give the child your attention, including eye-contact, turning your

body towards them, open body posture, bending down or sitting so you are eye-to eye, express emotion, verbally comment, and validate the child (not judgment or minimizing ) of feelings (Dinkmeyer et. al, 1997, Faber & Mazlish, 2012)

Verbally request child’s eye contact Lift their arms to shoulder height as that brings eyes upward Gently touch hands, arms, or face

Tell how you’re feeling and match your facial expression to your emotion (over expression is needed with young children or when you first begin tx)

Ask child to label how you’re feeling, correct if they do not recognize

Ask child to repeat what you just expressed, or ask if they understand

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HOW DO WE INCREASE ATTENTION IN OUR PEDIATRIC PATIENTS? Slow down Give the child your undivided attention, model, use

an open posture Move to a less distracting environment Bring child’s hands to my face, near my eyes or at

my throat as I hum or draw out a syllable to use vibration to stimulate an alternate sensory pathway with vibration

Hold desired items up to my eye level to obtain an eye-flick or to increase eye contact.

Tap into several sensory pathways while stimulating the Mirror Neuron System

Have the child do 2-3 repetitions more once they demonstrate loss of interest in the task or activity

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COOPERATION Defined as working together for the common

good or assisting, not resisting [praise example] sometimes this is all we get in early sessions

There is no magic for obtaining cooperation it’s the way a professional sets up or manages situations over time, but it can be shaped, and this is where that initial rapport building you did in early sessions pays off

Discuss cooperation as teamwork to a child while incorporating the terms of friendly and unfriendly

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COOPERATION Cooperation facts:

Children desire to please and when praised for a positive action or behavior they will repeat it (Flaskerud, 2011; Kersey & Masterson, 2011; Kurcinka, 2000; Lantieri, 2008). Video PWC 1

Children cooperate more frequently when they are encouraged (McKay, 1976)

Acknowledging a child’s feelings helps develop trust and attachment which facilitates cooperation (Champagne, 2011)

The child who has learned self-control/regulation cooperates more frequently (Champagne, 2011) and this is what Brackett and Ellas (2013) have also seen in their work

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NEGOTIATE AND SHAPE There is no win/lose in relating to a child, a child is not the

enemy [story, some parents never give in] (Vital Element) Challenging moments are teachable moments and it is

appropriate to use a therapeutic use of self with your own social and emotion knowledge to build up an “intentional relationship” (Taylor, 2008).

Times where getting some cooperation is better than none When a task is overwhelming to the child When the child is tired/ill/recovering When there's been several upsets in a day When child is disappointed about something (tell why you’re

helping) (Olivia PWC 3) Take turns, let the child do the last one and praise, mention

teamwork or cooperation Request that the child do 2-3 more and then they can “be

done”

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PRAISING EFFECTIVELY Be proactive and praise desired behavior or

actions, instead of waiting till something goes wrong to correct or discipline (Kersey & Masterson, 2011)

Look for opportunities to praise, good words, good actions, or good behavior

Praise by specifically stating what the child did that was desired or appreciated in age appropriate terms (Kersey & Masterson, 2011)

Praise by stating how you feel/felt then the child helped and let them observe your facial expression, if they don’t look at you, request eye-contact so they can see your emotion/s

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KEEP IT POSITIVE Minimize raising your voice, children get

desensitized to it and then it has to be intensified to obtain attention and/or cooperation, and kids begin yelling in return (Wyckoff & Unell, 2002)

Treat kids with the respect you want, modeling once again (Kurcinka, 2000)

Do not put down the child; but, focus on the behavior (MacKenzie, 2001) Depersonalize [ears story]

Take a time out for yourself (this models that time outs are a strategy for emotional regulation rather than a punishment). This demonstrates positive self-control modeling (Kurcinka, 2000)

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BRIEF TUNE-UP ON MANAGING NEGATIVE BEHAVIORS Try to model calm behavior (think modeling for the

MNS) Use clear, calm language without drama, strong

emotion, or judging intonation (MacKenzie, 2001) Try not to use parents as a way to coax good

behavior or participation. I do use showing off a skill to a parent as motivation for cooperation

Do not bribe or reward. Use first-then so child understands he/she gets what they want when they have followed through with your request (Cline & Fay, 2006)

Negotiate with children it is better to get some of what you want then to have shut-down or melt-down with hard tasks

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TUNE-UP If you have to remove a favored item do not

threaten, state without drama and “always” follow through (MacKenzie, 2001) Let them earn it back

Limit the choices to two when times get tough (Dinkmeyer et, al, 1997)

Good or bad, tell child how their cooperation or lack of it makes you feel

Recap to child prior to the waiting room follow-up (maybe while shoes are being donned) or the chaos in the room will not allow the child to process the takeaway

Next session, you can restate what positive thing the child did so that they see/hear you still are happy/proud etc. (sometimes it’s better to wait)

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SUPER STRATEGIES Get the child’s visual attention Exaggerate your facial expressions, facilitate

empathy (Pineda, 2008) Use the language, “friendly and unfriendly” Do not over talk/explain (most explanations

can be done in 10 words or less) Do not console or hug too early [story] Change environment or let the child know

ahead of time that you are instituting new rules or a token system

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FINAL WRAP AND VITAL ELEMENTS The Mirror Neuron System requires stimulation for

social emotional cognition and skills learning Emotion and feeling recognition in self and others

is vital to attention and cooperation Vital Elements

Build rapport initially (DO NOT PUSH THE GOALS) Stimulate the Mirror Neuron System Teach/model emotional identification and expression Use effective praise Shape and teach during negative behaviors (but not

always, sometimes it’s better to wait) Negotiate (it’s ok) Everyday is a new day do not hold grudges, they know Be prepared to be upbeat, silly, and a clown EVERYDAY

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LEAVE YOU WITH MAGIC MOMENTS Article by Lucy Jane Miller and Britt Collins (Feb,

2013) in Autism and Asperger’s Digest The authors state by working on the “just right

emotional connection” the therapy process reinforces the interpersonal relationship between the therapist and child. Combining that connection with a treatment session that is fun and the child is more than willing to participate. The “process is key, not the completing of one more activity” (Miller & Collins, 2013)

Magic moments are: “quick beautiful connections” where a child achieves mastery and shares it with another individual. That is what OT’s work for and teach parents to facilitate