ICD Weighted Items final

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1 TBRI Practice Brief September 2015, No. 1 Weighted Items Tools for Helping Children Learn to Regulate Weighted Items Are Calming Weighted items provide safe, calming, deep pres- sure for persons experiencing anxiety, distress, restless- ness, and difficulties with attention and executive con- trol. These items include blankets, vests, dolls, and other soft items that are filled with heavy beads or pellets to add extra weight to them. We have successfully used weighted blankets, weighted vests, weighted dolls, and weighted teddy bears in our work for over fifteen years, as a way to help children and teens learn to self-manage their emotions and behavior. Children can hold a weighted item, place it on their lap, wrap it around their shoulders, or use it as a sleep aid. The amount of weight that is helpful for specific children can vary, and the weight that is most comfortable for the individual child should be used. HOW a weighted item is used, and WHETHER to use a weighted item, are AL- WAYS controlled by the child or teen that is using it. Toddler holding a weighted — Dr. Karyn B. Purvis doll. Weighted Items significant: There was a 23% reduc- indicate that weighted blankets are tion in off-task behavior, an 82% re- safe, while data obtained on effec- Weighted items such as weighted duction in out-of-seat behavior, and a tiveness revealed a 33% decrease vests and weighted blankets have 52% reduction in fidgeting (Lin et al., in electrodermal activity (an indi- been shown to have a number of ben- 2014). Fertel-Daly et al. (2001), Ol- cator of emotional arousal) and a efits for children, teens, and adults. son and Moulton (2004), and Van- 63% decrease in self-reported anxi- For example, Buckle et al. (2011) denBerg (2001) have published addi- ety after use, while 78% of the par- found, using an experimental ma- tional evidence regarding the use and ticipants preferred the blanket as a nipulation, that weighted vests im- effectiveness of weighted vests. calming modality. The authors con- proved the in-seat behavior and clude that weighted blankets can attention-to-task of school-aged chil- There is not as much evidence have a safe, calming influence for dren diagnosed with ADHD. Simi- for the impact of weighted blan- at least some non-hospitalized adults larly, Lin et al. (2014) found, again kets as there is for weighted vests, (Mullen et al., 2008). using an experimental manipula- but the data are beginning to ac- tion, that weighted vests improved cumulate. Mullen et al. (2008) in- In an in-home study, Lindstedt three different attentional measures vestigated the safety and efficacy and Oie Umb-Carlsson (2013) found and three different on-task behav- of weighted blankets in college-age that adults diagnosed with ADHD iors among school-aged children di- adults using an experimental design rated weighted blankets as “most agnosed with ADHD. The impact on with multiple physiological and self- helpful” among a suite of cogni- classroom behavior in this study was report measures. Vital sign metrics tive assisted technologies designed to Weighted Items: Tools for Helping Children Learn to Regulate m child.tcu.edu T (817) 257-7415 B [email protected] Page 1

2 TBRI Practice Brief September 2015, No. 1 support daily activities and promote weighted blanket in the sensory room camp (Purvis and Cross, 2006; Purvis life satisfaction. In an evaluation of reported significantly greater reduc- et al., 2007, see also the figure on this a sensory room in a hospital (psy- tions in distress and clinician-rated page). In the next section of this TBRI chiatric) setting, Novak et al. (2012) anxiety than those who did not use Practice Brief, we take a look at Sen- found that use of a sensory room a blanket. Positive research findings sory Rooms , which commonly em- was associated with significant reduc- are consistent with the growing use ploy weighted items as part of a sen- tions in distress and improvements in of weighted blankets in clinical set- sory menu. a range of disturbed behaviors, and tings (Mullen et al., 2008), as well that those individuals who used a as in our own therapeutic summer A Hope Connection camper with a weighted blanket. Sensory Rooms tient distress, as rated by the patient ning framework for mental health agencies that specifies comfort and (48% reduction), and by the clini- Sensory rooms are designed to sensory rooms as seclusion/restraint cian (47% reduction). Similar find- provide a self-managed sensory diet reduction tools (Huckshorn, 2005). ings have been reported by Smith and for children, teens, and adults who Tonarelli (2007) provides some guid- Jones (2014). In our own work with are experiencing difficulties self- ance for setting up sensory rooms residential treatment centers (RTCs) regulating their emotional and be- serving youth, we have seen a virtual in residential facilities, but Chalmers havioral states (Champagne and et al. (2012) discuss how environ- elimination of restraints and seclu- Stromberg, 2004; Webber, 2007). mental changes are insufficient on sions once the RTCs implement a vol- Sometimes, sensory rooms are re- their own, and must be accompanied untary sensory room, stocked with ferred to as “multi-sensory rooms” by deliberate cultural change efforts weighted blankets, among other sen- or “comfort rooms.” Very often, sen- within residential settings, with buy- sory items (see also Champagne and sory rooms include weighted items, in from both staff and clients. Stromberg, 2004). as in the study by Novak et al. (2012), mentioned in the previous Based on studies such as these, as section. You will recall that the over- well as a growing foundation of clin- Deep Pressure all sensory room experience was ther- ical experience, there is considerable Weighted items such as blan- apeutic, as was the self-managed interest in sensory rooms as a thera- use of weighted blankets (Novak peutic modality in residential settings kets, vests, dolls, and stuffed ani- mals provide a particular form of et al., 2012). In a separate study of (Champagne and Stromberg, 2004; sensory stimulation, namely, what sensory-based approaches deployed Webber, 2007). As part of this move- Mullen et al. (2008) and others re- within an inpatient psychiatric set- ment, the National Association of Deep Pressure Stimulation fer to as ting (Chalmers et al., 2012), there State Mental Health Program Direc- (DPS). Grandin (1992) observed that were significant reductions in pa- tors (NASMHPD) has issued a plan- Weighted Items: Tools for Helping Children Learn to Regulate m child.tcu.edu T (817) 257-7415 B [email protected] Page 2

3 TBRI Practice Brief September 2015, No. 1 DPS can help calm austistic children, of touch and massage for adult social 2009). The sensory processing sup- calm children diagnosed with ADHD, interaction and personal well-being. ports that have been discussed in this Field et al. (2010) argue that the neu- and calm other large mammals be- newsletter, including weighted items rophysiological mechanism for mas- sides humans. She further specu- and sensory rooms, are elements of lated that the neurological mecha- vagal system, sage (DPS) involves the a large menu of sensory strategies which develops into an autonomic nisms responsible for the calming ef- that are available to those who wish platform for the child’s engagement fect of DPS may involve the cere- to help youth “who come from hard bellum, a topic to which we will with with his or her environment. places.” return later in this Practice Brief (see Sensory Processing , below). “ More recently, Reynolds et al. (2015) The diverse benefits of found that DPS, applied with a “Vayu massage therapy observed therapeuticsystems.com Vest” ( ), re- across a wide range of con- duced sympathetic arousal (distress), ditions may stem from a increased parasympathetic arousal common underlying mech- (calming), and enhanced cognitive findings Recent anism. performance in a sample of normal suggest that this mech- adults. anism may involve in- creased vagal activity from the stimulation of pressure receptors under the skin. Teen with a weighted blanket. (p. 381) ” – Field et al. (2010) Relational Trauma Children adopted from Easter Eu- ropean orphanages may experience serious sensory processing challenges Sensory Processing (Cermak and Danhauer, 1997; Cer- mak and Groza, 1998), and that the The vagal system works with the Youth with a weighted animal. extent of their sensory processing autonomic systems of the brain and challenges increases with the length DPS can take many forms, in- body (sympathetic and parasympa- of their institutionalization (Lin et al., cluding weighted items, hugs, and thetic) to regulate arousal as we hu- 2005). These children may also expe- massage. There is considerable neu- mans engage with the physical and rience self-regulation challenges, ap- ropsychological research on the ben- (especially) the social environments parently as a function of extreme de- efits of massage, which may pro- (Porges, 2011; Porges and Furman, privation during their formative years vide insight about the neurophys- 2011). Research suggests that these (Gunnar, 2001; Gunnar et al., 2001). iological underpinnings of DPS ef- autonomic systems are what give A similar pattern of outcomes is as- fects in general. In a comprehensive children and youth the capacity for sociated with early relational trauma review of therapeutic massage re- resilience in the face of challenge (Atchison, 2007; Schore, 2001), even search, Field et al. (2005) conclude and stress (Doussard-Roosevelt et al., though these children typically have that therapeutic massage results in 2003; Porges, 2011). These lower- not experienced nearly the level a 31% decrease in cortisol, a 28% order neurophysiological systems are of deprivation that the orphanage- increase in serotonin, and a 31% the foundation for engagement it- reared children have experienced. increase in dopamine. All of these self, which involves a complex and changes are in the direction of im- But why are social and sensori- dynamic network of interacting sen- motor experiences so important to proved psychological functioning and sory, cognitive, and motor compo- the developing human? Esther The- well-being, and they are averaged nents (Angelaki and Cullen, 2008; len and Linda Smith provide some across studies investigating a wide Koziol et al., 2011; Owen et al., answers, for they argue that sensori- range of problems, including depres- 2013). Building on the pioneering motor experiences and processes are sion, chronic pain, autoimmune con- work of Ayres (1979) and Wilbarger essential components of a complex ditions, and stress reduction. Field (1984), occupational therapists have dynamic system that generates key (2010) reviews the effects of touch developed a wide range of sen- developmental outcomes (Smith and more generally, including the neces- sory processing supports for children Thelen, 2003; Thelen, 2000). In par- sity of healthy touch for the develop- (Kranowitz, 2006; Miller and Fuller, ticular, Smith and Breazeal (2007) ing child, and the beneficial impact 2007), and for teens (Dorman et al., Weighted Items: Tools for Helping Children Learn to Regulate m child.tcu.edu T (817) 257-7415 B [email protected] Page 3

4 TBRI Practice Brief September 2015, No. 1 identify three principles that, when social, and complex. In light of this, nings provided by sensorimotor ex- taken together, can explain develop- it is interesting (and important) that periences (Perry, 2006, 2009). Bath mental change: (a) coordination of we can see an emerging consensus (2008) has synthesized these ideas component processes during sensori- about interventions designed to help and proposed an approach that is motor activity; (b) coordination of those who have experienced rela- based on three “pillars” of trauma- external actions and internal states tional trauma. In the view of promi- informed care: with a (mindful) social partner; (c) nent developmental traumatologists, 1. Connection (Relationship) overlapping component processes en- successful interventions must include 2. Felt-Safety gaged in the solution of many inter- a focus on the body and sensorimo- 3. Self-Regulation related and developmentally ordered tor experiences. Bessel van der Kolk It is worth noting that providing tasks. These are likely to be the devel- (2014) provides a strong, evidence- weighted items not only helps chil- opmental mechanisms whereby the based argument for “body work” with (the ob- self-regulate dren and youth complex neurophysiological systems adults, and Warner et al. (2013) ex- vious effect), but also helps them feel described by Angelaki and Cullen tend this argument to youth living safe self-regulated feel (because they (2008) and Koziol et al. (2011) are in residential settings. Kaiser et al. and in control of their own feelings Sensory Process- constructed (see (2010) is one example of an empir- and actions) and (because connected , above). ing ical demonstration of these princi- they appreciate an adult seeing and According to Smith and Breazeal ples. Bruce Perry’s Neuro-Sequential meeting their needs). (2007), developmental change arises Model also recognizes the develop- on processes that are sensorimotor, mental and therapeutic underpin- References Annual Review Angelaki, D. E. and Cullen, K. E. (2008). Vestibular system: The many facets of a multimodal sense. , 31:125–150. of Neuroscience Atchison, B. J. (2007). Sensory modulation disorders among children with a history of trauma: A frame of reference Language, Speech, and Hearing Services in Schools , 38:109–116. for speech-language pathologists. Sensory integration and the child . Western Psychological Services, Los Angeles. Ayres, A. J. (1979). Bath, H. (2008). The three pillars of trauma-informed care. Reclaiming Children and Youth , 17(3):17–21. Buckle, F., Franzsen, D., and Bester, J. (2011). The effect of the wearing of weighted vests on the sensory behaviour of learners diagnosed with attention deficit hyperactivity disorder within a school context. South African Journal of Occupational Therapy , 41(3):36–42. Cermak, S. A. and Danhauer, L. A. (1997). Sensory processing in the post-institutionalized child. Journal of Occupa- tional Therapy , 51:500–507. Cermak, S. A. and Groza, V. (1998). Sensory processing problems in post-institutionalized children: Implications for social work. Child and Adolescent Social Work Journal , 15:5–37. Weighted Items: Tools for Helping Children Learn to Regulate m child.tcu.edu T (817) 257-7415 B [email protected] Page 4

5 TBRI Practice Brief September 2015, No. 1 Chalmers, A., Harrison, S., Mollison, K., Molloy, N., and Gray, K. (2012). Establishing sensory-based approaches in mental health inpatient care: A multidisciplinary approach. Australasion Psychiatry , 20(1):35–39. Champagne, T. and Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings: Innovative alterna- Journal of Psychosocial Nursing tives to seclusion and restraint. , 42(9):1–8. Dorman, C., Lehsten, L. N., Woodin, M., Cohen, R. L., Schweitzer, J. A., and Tona, J. T. (2009). Using sensory tools for teens with behavioral and emotional problems. OT Practice , pages 16–21. Doussard-Roosevelt, J. A., Montgomery, L. A., and Porges, S. W. (2003). Short-term stability of physiological measures . in Kindergarten children: Respiratory sinus arrhythmia, heart period, and cortisol. Developmental Psychobiology Fertel-Daly, D., Bedell, G., and Hinojosa, J. (2001). Effects of a weighted vest on attention to task and self-stimulatory behaviors in preschoolers with pervasive developmental disorders. American Journal of Occupational Therapy , 55(6):629–640. Field, T., Diego, M., and Hernandez-Reif, M. (2010). Moderate pressure is essential for massage therapy. International Journal of Neuroscience , 120:381–385. Field, T., Hernandez-Reif, M., Diego, Miguel Schanberg, S., and Kuhn, C. (2005). Cortisol decreases and serotonin and dopamine increase following massage therapy. , 115(10):1397–1413. International Journal of Neuroscience Field, T. M. (2010). Touch for socioemotional and physical well-being: A review. Developmental Review , 30(4):367– 383. Grandin, T. (1992). Calming effects of deep touch pressure in patients with autistic disorder, college students, and animals. , 2(1):63–72. Journal of Child and Adolescent Psychopharmacology Gunnar, M. R. (2001). Effects of early deprivation: Findings from orphanage-reared infants and children. In Nel- son, C. A. and Luciana, M., editors, Handbook of developmental cognitive neuroscience , pages 617–629. MIT Press, Cambridge, MA. Gunnar, M. R., Morison, S. J., Chisholm, K., and Schuder, M. (2001). Salivary cortisol levels in children adopted from Romanian orphanages. Development and Psychopathology , 13(3):611–628. Huckshorn, K. A. (2005). Six core strategies to reduce the use of seclusion and restraint planning tool. National Technical Assistance Center & National Association of State Mental Health Program Directors. Kaiser, E. M., Gillette, C. S., and Spnazzola, J. (2010). A controlled pilot-outcome study of sensory integration in the treatment of complex adaptation to traumatic stress. , 19:699–720. Journal of Aggression, Maltreatment & Trauma Koziol, L. F., Budding, D. E., and Chidekel, D. (2011). Sensory integration, sensory processing, and sensory modula- tion disorders: Putative functional neuroanatomic underpinnings. Cerebellum , 10:770–792. The out-of-sync child: Recognizing and coping with sensory processing disorder Kranowitz, C. (2006). . Penguin Putnam, New York, revised edition. Lin, H.-Y., Lee, P., Chang, W.-D., and Hong, F.-Y. (2014). Effects of weighted vests on attention, impulse control, and on-task behavior in children with attention deficit hyperactivity disorder. American Journal of Occupational Therapy , 68:149–158. Lin, S. H., Cermak, S., Coster, W. J., and 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. Lindstedt, H. and Oie Umb-Carlsson, . (2013). Cognitive assistive technology and professional support in everyday life for adults with adhd. Disability and Rehabilitation: Assistive Technology , 8(5):402–408. Miller, L. J. and Fuller, D. A. (2007). Sensational kids: Hope and help for children with sensory processing disorder . Perigree Trade, New York. Mullen, B., Champagne, T., Krishnamurty, S., Dickson, D., and Gao, R. X. (2008). Exploring the safety and therapeutic effects of deep pressure stimulation using a weighted blanket. Occupational Therapy in Mental Health , 24(1):65–89. Weighted Items: Tools for Helping Children Learn to Regulate m child.tcu.edu T (817) 257-7415 B [email protected] Page 5

6 TBRI Practice Brief September 2015, No. 1 Novak, T., Scanlan, J., McCaul, D., MacDonald, N., and Clarke, T. (2012). Pilot study of a sensory room in an acute inpatient psychiatric unit. Australasion Psychiatry , 20(5):401–406. Olson, L. J. and Moulton, H. J. (2004). Occupational therapists’ reported experiences using weighted vests with Occupational Therapy International children with specific developmental disorders. , 11(1):52–66. Owen, J. P., Marco, E. J., Desai, S., Fourie, E., Harris, J., Hill, S. S., Arnett, A. B., and Mukherjee, P. (2013). Abnormal white matter microstructure in children with sensory processing disorders. Neuroimage: Clinical , 2:844–853. Perry, B. D. (2006). Applying principles of neurodevelopment to clinical work with maltreated and traumatized children: The neurosequential model of therapeutics. In Webb, N. B., editor, Working with traumatized youth in child welfare , pages 27–52. Guilford Press. Perry, B. D. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma , 14(4):240–255. Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation . Norton Series on Interpersonal Neurobiology. W. W. Norton, New York. Porges, S. W. and Furman, S. A. (2011). The early development of the autonomic nervous system provides a neural platform for social behaviour: A polyvagal perspective. , 20(1):106–118. Infant and Child Development Purvis, K. B. and Cross, D. R. (2006). Improvements in salivary cortisol, depression, and representations of fam- ily relationships in at-risk adopted children utilizing a short-term therapeutic intervention. Adoption Quarterly , 10(1):25–43. Purvis, K. B., Cross, D. R., Federici, D. R., Johnson, D., and McKenzie, L. B. (2007). The Hope Connection: A ther- Adoption & Fostering , apeutic summer camp for adopted and at-risk children with special socio-emotional needs. 31:38–48. Reynolds, S., Lane, S. J., and Mullen, B. (2015). Effect of deep pressure stimulation on physiological arousal. American Journal of Occupational Therapy , 69(3). Schore, A. N. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal , 22(1–2):201–269. Smith, L. B. and Breazeal, C. (2007). The dynamic lift of developmental process. Developmental Science , 10(1):61–68. TRENDS in Cognitive Sciences Smith, L. B. and Thelen, E. (2003). Development as a dynamic system. , 7(8):343–348. Smith, S. and Jones, J. (2014). Use of a sensory room on an intensive care unit. Journal of Psychosocial Nursing and Mental Health Services , 52(5):22–30. Infancy , 1(1):3–28. Thelen, E. (2000). Grounded in the world: Developmental origins of the embodied mind. Current Activities in Longterm Care , Tonarelli, L. (2007). Some starter tips on creating and using a sensory room. pages 47–49. van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma . Viking, New York. VandenBerg, N. L. (2001). The use of a weighted vest to increase on-task behavior in children with attention difficulties. American Journal of Occupational Therapy , 55(6):621–628. Warner, E., Koomar, J., Lary, B., and Cook, A. (2013). Can the body change the score? Application of sensory Journal of Family Violence , modulation principles in the treatment of traumatized adolescents in residential settings. 28:729–738. Webber, L. (2007). From seclusion to solutions. Office of the Senior Practitioner (Victoria, Australia): Positive solutions in practice , 2:1–4. Wilbarger, P. (1984). Planning an adequate “sensory diet:” application of sensory processing theory during the first years of life. Zero to Three , pages 7–12. Weighted Items: Tools for Helping Children Learn to Regulate m child.tcu.edu T (817) 257-7415 B [email protected] Page 6

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