Enhancing attention and cooperation with your pediatric patients

1. Enhancing attention and cooperation with your pediatric patients Justine Faghihifar, M.S., OTR, CFLE Jfaghihifar@gmail.com

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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)

10. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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”

19. 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

20. 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)

21. 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

22. 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)

23. 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

24. 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

25. 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