The Role of Occupational Therapy within 2011 Inpatient Psychiatry

Report
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The Integration of Sensory Modulation into
Acute Behavioral Health Care
New Jersey OT Conference
October 2, 2011
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A Collaborative Effort: Workshop Presenters

Names and Schools
 Doris
Obler, MSW, OTR/L – LIU - Brooklyn
 Renee Ortega, MS COTA/L, R-DMT – LIU - Brooklyn
 Emily Raphael-Greenfield, EdD, OTR/L – Columbia
University
 Suzanne White, MA, OTR/L – SUNY Downstate

Organized effort to bring back OT services to Inpatient Psychiatry

Our plan: Start with one hospital and expand!
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Workshop Objectives
 Identify
research to support use of sensory modulation in
acute settings
 Examine
the administration and interpretation of the
Adolescent/Adult Sensory Profile
 Incorporate
sensory techniques and interventions
 Experiential
Component of Workshop
 Discuss
potential collaboration with Behavioral Health
Centers that do not have occupational therapy services.
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Experiencing Sensory Modulation:
Self Monitor – Take Your Sensory Temperature
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Governmental Regulation Supports Sensory
Modulation Approach
The President’s New Freedom Commission on Mental
Health
 Consumer-driven services
 Evidenced-based
 Innovative methods of
CARE
SAFETY
RESPONSIBILITY
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1999 Problem Statement
National Association of State Mental Health Directors

Overutilization of seclusion and restraint - symptom of the
general culture in the clinical environment

Misapplication of the techniques for S&R creates safety issues
The rate of work-related injuries was higher in mental
health settings than in construction
 More staff injuries occur during the implementation of
S&R than occur from unexpected assaults


Chemical Restraint
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Trauma-Informed Care
 Understanding
profound influence and high prevalence of trauma
 Understanding
the potential environment as source of trauma or
reminder of trauma
 Trauma
Symptoms & Behaviors
 Trauma-informed
Assessment
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OT Experts on Sensory Experiences
 The
experience of being human is embedded in the sensory events of
everyday life. Dunn
 Sensation
are nourishment to the nervous system. Ayres
 3 Goals of a practitioner using sensory integration therapy;
 Assist in reaching a state of calm alertness.
 Enhance the organization of sensation into information.
 Acquire concepts that underlie learning. King
 The
only avenue for intervention is through the sensory system. Allen
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OTPF and Sensory Information
 Where
is Sensory Information in the Occupational Therapy
Practice Framework?
 Performance Skills and Sensory–Perceptual Skills
 Client Factors and Body Functions
 Categories
Sensory Functions and Pain

Bodily Functions

Client Factors
 Body Structures
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What is Sensory Processing?
 The
way the nervous system receives, organizes and
makes sense of sensory information.
 The
ability to regulate and organize reactions to
sensory input in a graded and adaptive manner.
 The
balancing of excitatory and inhibitory inputs
and adapting to environmental changes.
 Sensory
information received from within the body
and from the surrounding environment.
Ayres, 1960’s
Theory of Sensory Processing- Simplified
Figure 11-8 Sensory Integration Theory and Practice, 2nd ed.
Anita Bundy, Shelley Lane, Elizabeth Murray
Sensory Processing
Miller, 2001
Sensory Detection
 The
awareness of present
sensation.

It may be the conscious
realization or the
unconscious awareness of
any sensation.
Sensory Modulation

The capacity to regulate
and organize the degree,
intensity, and nature of
responses to sensory input
in a graded and adaptive
manner. This allows the
individual to achieve and
maintain an optimal range
of performance and to
adapt to challenges in daily
life. (Miller & Lane, 2000)
Sensory Discrimination

The ability to discern the
qualities, similarities, and
differences among sensory
stimuli, including
differentiation of the
temporal or spatial qualities
of sensory input. (Miller and
Lane, 2000)
Sensory Integration

The neurological
process that organizes
sensation from one’s
own body and from the
environment and makes
it possible to use the
body effectively within
the environment.
(Ayres, 1979)
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Sensory Processing Dysregulation:
Who is at risk ?

Anxiety Disorders

ADHD

Dissociative Disorders

Autism spectrum disorders

Schizophrenia

Affective disorders

Substance use disorders

Dementia

Axis II Personality Disorders
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Introduction of Sensory Modulation in
Behavioral Health
 To
 To
decrease seclusion and restraint
manage sensory modulation on their own post
discharge
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Emerging Best OT Practice: Sensory Modulation
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Using Sensory Modulation Approaches and
Tools on an Inpatient Psychiatric Service
 Incorporating




sensory techniques
increases the range of therapeutic options for patients
provides an opportunity for patients to have greater
input into treatment plans
helps patients learn self regulation skills
continues efforts toward use of alternatives to seclusion
and restraint, while increasing overall safety and
promoting staff knowledge of therapeutic alternatives.
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Sensory Interventions for Acute Units
 Develop
a Crisis Prevention Plan for early
warning signs/triggers
 Modify
 Create
or enhance the physical environment
a Comfort (Sensory) Room
 Develop
individual Sensory Diets
Crisis Prevention Plan
Advanced Directive/Trauma History
University Hospital Nursing Station 52
Comfort/Sensory Rooms
 Demand-free
 Patients
can explore different modalities without
expectations of accomplishment or understanding
 Individuals
determine whether sound, aroma, taste,
tactile, proprioceptive or visual stimulation is most
effective
 Choice
allows individuals to control and learn
alternative methods of self regulation
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What is a Sensory
Diet?
Regular, scheduled sensory
stimulation for healthy,
adaptive functioning
Start the day
Calm
Safe
Comfortable
Heavy work &
Vibration
Regular heart healthy
meals
End the Day
Sleep work
Calm
Massage
To bed
Soothing music
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Sensory Diet
Sensory Modulation Interventions: Uniquely
Effective
 Communication
is the corner-stone of psychiatric
intervention BUT when patients are highly
stressed, thinking and problem solving
capacities are diminished; patients are less able
to use cognitive-based therapies.
 Sensory modulation




Does not introduce a potentially traumatic event
Provides immediate calming sensory environment
Creates self regulation experiences
Enhances therapeutic relationships.
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Group and Individual Sensory
Interventions
Sensory Modulation Groups


Group teaches patients sensorybased self-assessment tools
Identify simple methods for altering
or improving their feeling states
through sensory modulation both
on the unit and after discharge

Individual Sensory Modulation
Interventions
Improve ability to self-regulate

Patients too ill or in a crisis to manage
group work.

Poor or slow responsiveness to
psychopharmacological interventions
and/or difficult to manage behaviors

Behavioral observation followed by regular
use of sensory equipment incorporated
into individualized treatment plan
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How do the Sensory Processing Groups
Help?
 Opportunities
 Planning
for clients to control their environment
for discharge
 Preparation
for independent living
 Strategies
for life challenges in the everyday world.
 Decrease
Seclusion & Restraint while hospitalized
 Maximize
staff involvement in discharge planning
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Recommendations for Increased Use of
Sensory Modulation Equipment

Evaluate sensory preferences of all new admissions

Place sensory preferences in patient charts

Occupational therapy consultants and students provide training for all
staff on unit

Establish a sign-out sheet for sensory modulation equipment that is
monitored by mental health aides

Incorporate sensory modulation equipment and a sensory modulation
experience within all unit groups

Encourage use of available objects in patient bedrooms to promote
sensory regulation (blankets, glass of water, shower, etc.)
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Assessment in Behavioral Health:
Adolescent/Adult Sensory Profile
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Experiential Workshop: Take the A/ASP!
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History and Purpose of the Sensory Profile
 Winnie
Dunn and the Sensory Profile
 Catana
Brown’s dissertation
 Reliability and Validity tests
 Tested with individuals beyond childhood diagnosed with
schizophrenia, bipolar disorder, and no mental illness
 Provides
information about an individual’s sensory
processing
 Allows
for treatment planning and intervention based on
sensory considerations.
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Benefits of A/ASP
 Theory
based
 Can
cover the life span when taken together with the Sensory
Profile and the Infant/Toddler Sensory Profile
 Non-intrusive
 Items
and easy to administer
focus on everyday life
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Theoretical Framework of A/ASP
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Sensory Profile’s 4 Quadrants

Low Registration: is the combination of high neurological threshold and passive self
regulation strategy.

Sensation Seeking: is the combination of high neurological thresholds and an active self
regulation strategy.

Sensory Sensitivity: is the combination of low neurological thresholds and a passive self
regulation strategy.

Sensation Avoiding: is the combination of low neurological thresholds and an active
self regulation strategy.
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Features of Sensation Seeking
 Tend
to create additional stimuli or look for highly
stimulating environments
 Tendency
 Regard
 Tend
 May
to explore their environments
sensory experiences as pleasurable
to get bored easily
find low-stimulating environment intolerable.
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Features of Sensation Avoiding

May be bothered by input more than others

May be rule bound, ritual driven

May come across as uncooperative

May engage in various behaviors to limit the sensory input they face.

Gifted at creating low-stimulus environments.

Enjoy being alone.

We hypothesize that they limit sensory opportunities because unfamiliar
sensory input is difficult to understand and organize and rituals provide a high
rate of familiar sensory input, while simultaneously limiting the possibility of
unfamiliar input.
Dunn (1997)
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Features of Sensory Sensitivity

Respond readily to sensory stimuli.

Distractible and upset by intense stimuli.

Notice stimuli as they occur.

High level of awareness of the environment.

Ability to be discriminative, and to attend to detail.
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Features of Low Registration

Miss or take longer to respond to stimuli such as lack of awareness of
name being called

May be the last to “get” a joke.

Can focus easily in distracting environments.

Has ability to be comfortable in a wide range of environments.

Doesn’t cry when seriously hurt or injured and poor awareness of being
touched

Preference for sedentary activities

Slow to respond to directions or complete assignments
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Experiential Workshop:
Case Study Application

Divide into small groups

Read 1 of 4 Case Scenarios in each group

In your group try to identify the sensory profile pattern and why for
your selected case

Be ready to share your results
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Research to Support the Sensory Modulation
Model
 Using
2002)
Adolescent & Adult Sensory Profile (Brown & Dunn,
 When
compared to normal control, subjects with
schizophrenia had higher scores on low registration and
lower scores on sensation seeking (Brown et al. (2002)
Schizophrenia Research).
 Compared
to general population, adults with OCD
scored higher on low registration and lower on sensation
seeking (Rieke & Anderson (2009) American Journal of
Occupational Therapy).
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Traditional Intervention
Sensory Intervention in a Sensory Room
Alone time or quiet time
Aromas
Increased supervision
Candy (sweet or sour tastes)
1 to 1 staff time (most common choice)
Colored eyeglasses
Pacing
Kaleidoscopes
Space Restriction ( self release lap belts)
Lava Lamps
Removed form Stimulation
Music recordings
Room Schedules
Scented Candles
As needed medication
Sound recordings (e.g. waves, rain)
Tactile stimulation (e.g. Squeeze balls, sand table, tactile
surfaces)
Wall images
Weighted Blankets
(Knight, et al., 2010)
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Research: Benefits of Sensory Modulation
 Decrease
in PRN medication
 Help
individuals on inpatient psychiatric units
manage psychiatric symptoms
 Increase in individual choice
 Can
offer common solutions for those learning to
cope with complex symptoms and illness
 Can redirect attention from intellectually based
activities to one of the senses (Knight, et al., 2010)
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Multi-University Collaborative Efforts:
Assessment

Using the Adolescent/Adult Sensory Profile at Bellevue
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Pilot Study (Spring 2011) using the Adolescent/Adult Sensory Profile. A total of 19
profiles (6 female and 13 male) were reviewed
Age range was 30-77.
Preliminary results: only 1 scored within the normal range.
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Most significant area noted was Sensation Avoiding.
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More than half scored “much more than most people”.
•
•

Pooling A/ASP Assessments by students from different university OT
Programs
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Collaborative Efforts with Groups: FW I
Long Island University-Brooklyn
Staff was very interested in learning
about Sensory Processing and
implementing the techniques with
patients
Students were excited about bringing
OT to Bellevue psychiatry and
administered 19 assessments,
compiled the data and wrote
individual results for each patient.
Patients were interested and willing
to participate in the A/ASP
assessment and to engage in
groups which they found nonthreatening and fun
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Collaborative Efforts:
LIU Groups at Bellevue
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Activity Rooms were converted into
Sensory rooms during groups.
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The clients participated either
standing or sitting in movement
activities including a parachute, balls
and ROM exercise providing
proprioceptive and vestibular
stimulation.
•
The clients were offered sensory
experiences including olfactory
scents, tastes, nature tapes, and
calming visual imagery.
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Collaborative Efforts: SUNY-Downstate
Groups at Bellevue
What are your 5 SENSES?
Why is learning about your senses
important?
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Collaborative Efforts: Downstate Groups
Used The Sensory Survey
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Collaborative Efforts: Downstate Groups
Make Senses Work for Recovery:
Start a Sensory Tool Kit

Make sensory thermometer

Identify one place where you
feel calm, safe, and
comfortable.
 Picture that place in your
mind.
 Do you feel any different
after thinking about your
comforting place?
 Use the thermometer to
notice the change.

Make visual reminder of your
comforting place
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Collaborative Efforts: Downstate Groups Use
Self Discovery of Senses
My Sensory Goal for this Week
1.
Use my sensory thermometer
2.
Use your calm, safe, comforting
place as needed (PRN)
3.
Bring in one object from your
home you use to calm yourself.
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Collaborative Efforts: Columbia University
FW I Group Protocols
Sensory Mod Squad Group

Frame of Reference: Sensory Integration

Purpose: develop sensory strategies for selfsoothing/alerting

Group Goals and Rationale: Combined
Sensory Modulation with Cognitive and
Social Communication Skills to avoid retraumatizing patients

Outcome criteria: pre and post test
identifying soothing and alerting stimuli

Method: 5 modules that introduce 7 senses;
use of Build a City activity; musical
activity; cooking activity; movement
activity (Foster and Gardner, 2011).
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Collaborative Efforts: Columbia University
FW I Group Protocols
Processing My Senses Group
Frame
of Reference: Sensory
Integration
Purpose: develop greater awareness
of sensory input and bodily responses
Group Goals and Rationale:
Increase sensory awareness and
develop strategies for greater sensory
regulation
Outcome criteria: achieve 2 out of 5
goals
Method: Overview of sensory
modulation by psychoeducation;
collage activity; music and movement;
flubber making; create Sensory Kits
(Fernandez & Solan)
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Columbia University FW I and Case Study

A/ASP results – High Sensation
Seeking

DSM IV: Bi-polar D/O,
Schizoaffective D/O,
Polysubstance Abuse, Personality
D/O; GAF 25.

Strengths: Independent ADLs;
Cognitively intact

Impairments: Poor IADLs; Poor
emotion regulation

Interventions: Exploration of
Sensory Equipment; Role Play to
practice impulse control; Use of
weighted vest throughout day
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Experiential Workshop:
Case Study Application
 In
your small groups with same case scenario,
identify any interventions you would recommend
and why. Be ready to share your results.
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Interventions for Sensation Avoiding
 High
Scores:
 Strategies to reduce environmental stimuli
 Eliminate background noise
 Establish comforting and supportive routines
 Give yourself permission to be alone
 Low
Scores:
 Take breaks during movement activities
 Try meditation or other relaxation strategies
 Guard against overexposure to heat and cold
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Interventions for Sensory Sensitivity
 High
scores:
 Eliminate distractions
 Add supports to help maintain focus
 Use rocking chairs for calming effects
 Use deep pressure touch rather than light touch
 Low
scores:
 Not a major area to address, because the individual is
aware of stimuli, but not distracted by them.
 Make a conscious effort to attend to sensory features of
daily life
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Interventions for Low Registration
 High
scores in Low registration
 Need for enhanced contextual cues to spark registration
of stimuli.
 Slow down rate of stimuli so that the individual has the
time to process.
 Use weights or other forms of resistance
 Add texture to objects to help with detection.
 Low
scores in Low registration
 Note: does not mean that individual is sensitive: does not
miss stimuli, but does not respond to it strongly.
 Provide consistency, repetition.
 Seek familiarity in settings, people, experiences
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Interventions for Sensation Seeking


Interventions for High Scores in Sensation Seeking

Chew gum or eat mints when feeling restless

Incorporate movement in activities

Engage in movement activity before cognitive task

Use bright lighting
Interventions for Low Scores in Sensation Seeking

Explore new foods

Change the order of your morning routine

Take a bath or shower and use a textured washcloth
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Wilbarger Protocol
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Treatment of Adult Psychiatric Patients
Using the Wilbarger Protocol

This pilot study examined the effect of the Wilbarger brushing and joint
compression protocol and sensory diet on symptoms associated with Sensory
Defensiveness among 3 women with histories of self-injurious behaviors.

Treatment lasted approximately 1 month. Symptoms and patterns of role
engagement and self-injury were compared before and nine months after
treatment.

At follow-up all participants were re-engaged in valued roles with no incidents
of self-injury. This treatment approach appeared to have some positive influence
on Sensory Defensive symptoms. Results suggest that it may be useful in
treating women with a history of self-injurious behavior and they indicate the
need for further investigation of this treatment approach (Moore & Henry,
2002).
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Benefits of Brushing Protocol

An improved ability to transition between various daily activities

An improvement in the ability to pay attention

A decreased fear and discomfort of being touched (tactile
defensiveness)

An increase in the ability of the central nervous system to use
information from the peripheral nervous system more effectively,
resulting in enhanced movement coordination, functional
communication, sensory modulation, and hence, self-regulation.
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Weighted Blankets
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Benefits of Weighted Blankets
A therapeutic modality: never to be used as a restraint:

To improve body awareness

To calm and improve attention and focus
To
decrease self injury
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Experiential Workshop:
Case Study Application
 In
your small groups with same case scenario,
knowing his/her sensory patterns, identify any
sensory interventions you would recommend and
why( include proprioceptive, tactile, sensory kit,
sensory diet, comfort room, etc.). Be ready to share
your results.
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Experiential Workshop:
Consideration of Sensory Modulation Across the
Continuum of Care
 Elicit
different settings from audience
 Elicit
sensory interventions from audience
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Experiencing Sensory Modulation:
Self Monitor – Take Your Sensory Temperature
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Next Steps for Multi-University Collaboration

Fieldwork
 Level I Continued –
 Fieldwork Level II - Universities providing supervision
 Re-employing
OTs at psychiatric centers

Research
 A/ASP research continues
 Effect of sensory modulation interventions on patients in
inpatient units – new study

Keep mental health coursework/fieldwork in OT curriculum

Presentations at psychiatric grand rounds and conferences
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References
AOTA Fact Sheets: Occupational Therapy’s Role in Mental Health Recovery & Occupational Therapy Using a Sensory IntegrationBased Approach with Adult Populations.
Knight, M., Adkison, L., Kovach, J.S. (2010) A comparison of multisensory and traditional interventions on inpatient psychiatry and
geriatric neuropsychiatry units. Journal of Psychosocial Nursing, 48, 24-31.
Brown C., & Dunn, W., (2002). Adolescent/Adult Sensory Profile. San Antonio, TX: The Psychological Corporation.
Bundy, A., Lane, S., Murray, E. (2002). Sensory Integration Theory and Practice, 2nd Ed. Philadelphia. F.A. Davis.
Champagne, T. (2008). Sensory modulation & environnent: Essential elements of occupation (3rd ed.). Southampton, MA: Champagne
Conferences.
Champagne, T., Mullen, B. & Debra Dickson, D. (2007). Exploring the Safety & Effectiveness of the Use of Weighted Blankets with
Adult Populations, American Occupational Therapy Association’s Annual Conference Presentation.
Dunn W. (1997). Implementing neuroscience principles to support habilitation and recovery. In: C. Christiansen & C. Baum, eds.
Occupational Therapy: Enabling Function and Well-Being. 2nd ed. Thorofare, NJ: SLACK Incorporated; 186-232.
Miller, L. J. (2001) Sensory Integration Dysfunction in Individuals with Cognitive Disabilities. Unpublished Presentation for the
Coleman Institute Workshop, Aspen, CO.
Miller, L. J., & Lane, S. J. (March 2000). Towards a consensus in terminology in sensory integration theory and practice: Part 1:
Taxonomy of neurophysiological processes. Sensory Integration Special Interest Quarterly, 23, 1-4.
Moore, K., & Henry, A. (2002). Treatment of adult psychiatric patients using the Wilbarger protocol. Occupational Therapy in Mental
Health, 18(1), 43-63.
New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America. Final Report.
DHHS pub no SMA-03–3832. Rockville Md, Department of Health and Human Services, 2003. Available
atwww.mentalhealthcommission.gov/reports/finalreport/fullreport-02.htm
Rieke, E. F. & Anderson, D. (2009) Adolescent/adult sensory profile and obsessive compulsive disorder. American Journal of Occupational
Therapy, 63,138-145.
Solomon, J. (2000). Pediatric Skills for Occupational Therapy Assistants. St. Louis, MO: Mosby.
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Presenters

Doris Obler, MSW, OTR/L – [email protected]

Renee Ortega, MS COTA/L, R-DMT – [email protected]

Emily Raphael-Greenfield, EdD, OTR/L – [email protected]

Suzanne White, MA, OTR/L – [email protected]
Contact information for Tina Champagne, OTD, OTR/L, CCAP
www.ot-innovations.com

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