Fun, Practical, Client-Centered Activities to Encourage Social Emotional Development in Pediatric Practice

Introduction

Nicole: Thanks to everyone for taking the time to be here. Today I want to demystify some of the fear around social-emotional learning. Many therapists I encounter tell me they are not sure what to do, and I was in that same boat. It is pretty fun once you start to do it and get a little more comfortable.

I want to bring this picture in Figure 1 to your attention. This is from one of the kids that I work with now. This is a picture that she took on the beach. She wrote the word stress and had the waves take it out. She made a video of it as well. This was a creative way for her to feel like she had control over her anxiety. During the process, she found that she really liked photography. She now has this picture framed on her wall. 

Figure 1. Stress-reducing activity example.

What is Social-Emotional Learning?

This is a process that children and adults use to gain critical skills for life effectiveness. Research shows it helps people to be successful in life. This includes positive relationships, ethical behavior, and the ability to handle challenging situations effectively. Many families have a lot of challenging situations on their plates. This becomes armor or a resiliency piece that is important. Strategies within social-emotional learning include recognizing and managing emotions and thinking about feelings and how one should act. It is understanding how your emotional responses influence your behavior and then regulating that behavior based upon thoughtful decision making. 

Definition

• Social-Emotional Learning (SEL)
  • A process through which children and adults:
    • Gain critical skills for life effectiveness
    • Behaving ethically
    • Handling challenging situations effectively
  • Strategies include:
    • Recognize and manage emotions
    • Think about feelings and how he/she should act
    • Regulate behavior based upon thoughtful decision making

Retrieved from: http://www.casel.org

Much of this information comes from the Collaborative for Academic, Social, and Emotional Learning, or CASEL (http://www.casel.org). They have many resources on social and emotional learning. This is where AOTA created its document as well (www.aota.org/-/media/corporate/files/practice/children/schoolmhtoolkit/social-and-emotional-learning-info-sheet.pdf).

Overview of Core Competencies

1. Self Awareness
2. Self Management
3. Social Awareness
4. Relationship Skills
5. Responsible Decision Making

(A PDF on these 5 core competencies can be downloaded from CASEL and this page: https://casel.org/what-is-sel/)

The first one is self-awareness. We have to have this before we can move forward. We then need self-management and social awareness in order to build relationship skills. The final component is responsible decision making. These go in a developmental pattern or sequence. Here is some interesting information that comes out of social-emotional learning and why it matters.

• 29%: Students who feel like their school provides a supportive, encouraging environment
• 83%: Students who make an academic gain when participating in an SEL program with academic components
• 11%: Average gained on standardized tests by participating in an SEL program
• SEL programs improve behavior & attitudes toward school and prevent substance abuse
• 11%: Average increase in GPA for participants in one SEL program​

Many times social-emotional learning sounds flowery to people. In a school context, everything is very academically focused. When I have to sell these approaches to people, I try to link it to academic success. The above infographic shows that only 29% of students feel that their school provides a supportive encouraging environment--this is when social-emotional learning is not involved. This is three out of every ten kids. This is a significant concern right off the bat. Eighty-three percent of students will make academic gains when they participate in some kind of social-emotional program, that has an academic component. This is what we do at the private school on campus where I work. We embed these social-emotional programs within their academic environment. You can see the corresponding academic gains that result. Eleven percent is the average increase in GPA for participants. This stat is a well-known research indicator of social-emotional programming. Sharing this information is a great way to get the administration on board.

Social-emotional programs also improve behaviors and attitudes towards school. There is a lot of research that shows that kids go from not liking school to liking school. They are also able to resist unhealthy behaviors such as substance abuse and peer pressure. Again, all of this information is from CASEL.

Figure 2 shows Maslow's Hierarchy of Needs.

Figure 2. Maslow's Hierarchy of Needs. (J. Finkelstein / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/)

• Participant Activity:
  • Pick 2 clients and place them on this hierarchy
  • Why did you place each on this particular level?
  • What is holding him/her back from the next level?

I use this model when working with kids and families. I think most are familiar with this model. It is from 1943. In this model, we start with getting our physiological needs met first. The bottom layer is physiological needs such as sleep, food, and water. These are obviously crucial for life. Once those are met, you move to safety needs. 

The safety needs level represents not only shelter from the weather or people, but you also need to have a perception of safety. As an example, children who do not feel safe, due to bullying or an unsafe home environment, will not have their safety needs met, even though they have shelter.

The third layer is the love and belonging needs. The child needs to feel loved, a sense of belonging, and needs to love and understand themself. This is a big part of self-awareness and the first part of the social-emotional learning process. Many times parents will say, "He really doesn't feel like he's loved or belongs. He knows we love him." The family members know that they love the child, but maybe the child does not feel that. Sometimes we think that they know it, but that does not mean that they do. It is a very strong perceptual piece.

The fourth level is self-esteem. The building blocks of esteem are having confidence, managing emotions effectively, and handling situations. Problem-solving is a big part of one's ability to feel confident. We also have to understand and manage our emotions, be able to reason, and analyze as well.

The top pinnacle is a self-actualization piece. This is what we all want; to really understand ourselves. With self-actualization, they can achieve their goals in life and handle anything that comes their way. They can behave ethically, soundly, and have confidence that they are able to do that. Often my kids struggle in safety and love and belonging levels. When they are at these levels, it is hard to move forward towards confidence. We need to address those bottom levels first. 

Five Core Competencies of Social Learning

The information I am reviewing in this section is from AOTA's Social and Emotional Learning Info Sheet (https://www.aota.org/~/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Social-and-Emotional-Learning-Info-Sheet.pdf).

#1: Self-Awareness

• Identifying one's emotions, thoughts, interests, and values
• Assessing strengths and limitations
• Maintaining self-confidence

Self-awareness is a foundational piece that builds toward love and belonging and other areas. You have to understand your own thoughts, emotions, interests, and values before you can move forward. You also have to understand your strengths and limitations. This is the bottom level of self-confidence, and esteem is much higher. We have to have this basic self-confidence before we can move toward esteem.

#2: Self-Management

• Regulating one's emotions, thoughts, and behaviors
• Controlling impulses
• Setting personal goals

Self-management is being able to regulate your emotions, thoughts, and behaviors. They cannot do that until they know what they are. They also need to be able to control their impulses. Impulse control and inhibition are important pieces of the puzzle, as you move through social-emotional learning development. It is also hard for them to set goals if they do not have any awareness of themself.

#3: Social Awareness

• Understanding social and cultural norms
• Respecting others
• Emphasizing with others

This is understanding social and cultural norms. That sounds very simple, but it is actually quite complicated. Kids need opportunities to navigate these norms. The ability to respect others comes from respecting yourself. These first two competencies build toward being able to respect and empathize with others. Many adults say kids are disrespectful.  I have to remind them that kids cannot be respectful if they do not have respect for themselves. They are not there yet. Once I open their eyes to that, they give them a little more slack. They are behind developmentally. They are not little adults, they are developing.

#4: Relationship Skills

• Establishing and maintaining relationships with others
• Resisting social pressures
• Effectively preventing and resolving conflicts
• Recognizing when to seek help

I often see therapists really frustrated because they are working on social skills with kids, and it is not working. The kids are not able to generalize. We have to have these other building blocks before we start to work on relationships. Establishing and maintaining relationships with others would be considered part of this. Resisting social pressures is another. You can see where this is a big part of that love and belonging, and then moving into the esteem aspect of Maslow's Hierarchy of Needs. Effectively preventing and resolving conflicts is another area to address. Many kids that I work with either avoid conflict completely or they tend to have a lot of conflicts. Sometimes they are misidentifying conflict. I like to teach them that conflict is an opportunity, and help them to identify when to seek help. They also need to know who they can rely on in that process.

#5: Responsible Decision Making

• Identifying and evaluating problems
• Making a decision based on ethical and social norms
• Contributing to the well-being of self and others

They have to have social awareness and understand the social norms before they can make decisions according to expectations and norms. This contributes to the well-being of self and others. Again, the CASEL website has many resources including assessments.

Active Learning

Research shows that embedding social-emotional learning strategies within the school curriculum promotes improved behavior, academic performance, and social skills. If you want to develop a program, this is your selling piece. Social-emotional learning competency improves participation within school and outside of school. This has been highlighted in multiple studies.

Different people and situations require a different skill set. As OT's and OTA's, we are always looking at the person, environment, context, and occupation. Things are different at home than they are at school. We need to make sure that these kids get different opportunities. I have some suggestions, that I will discuss later, on how to work with families and other extracurricular professionals, like coaches. Context challenges are great opportunities for kids to problem solve and work on some of these things. You want to use those as opportunities and take advantage of them. 

Bronfenbrenner's Model of Child Development

•  Bronfenbrenner (1979)
• Child at center
• Influences at a variety of levels impact the child's development
• Therefore, the focus is on the child, not a disorder

Figure 3. Bronfenbrenner's model of child development. (Hchokr at English Wikipedia / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

The child is the center of this huge concentric, contextual puzzle. The nuclear family is right around them in the first ring, and then teachers and peers are also really close. Moving outward, you start getting into the school environment, the preschool environment, and home. Some of the outer rings look at more macro-level contextual things, like local, community, and government types of things. The outer bands are culture, ideology, and social values. We have to think about all these different layers when dealing with children. We have to be mindful of helping them process through some of the unique circumstances they encounter. The key is we focus on the child, not the disorder. The context affects their development. It is not just the diagnosis that is influencing them, but it is everything around them.

Child Factors

• Self-confidence/self-worth
• Communication
• Social skills
• Social-emotional
• Sensory
• Motor
• View of self/world
• Temperament

Child factors are things you want to consider with social-emotional learning and development. We need to look at their self-confidence and self-worth, communication abilities, and strengths and limits. We want to assess the social skills that they already have. What is their social-emotional standing at this point? What is their sensory processing like? This is a very important piece of the puzzle. What are their motor abilities? Kids will base a lot of their self worth on how they do motorically as compared to peers. They do a lot of comparisons with peers at this age. What is their view of his or her self within the world? 

Parent Factors

• Responsivity
• Discipline style
• Communication
• Home routine
• Demands on child

Parent factors are also important. How responsive is the parent? What type of discipline style do they follow? Are they consistent? How are their communication abilities? The home routine is very important. Performance patterns, habits and routines, and demands on the child are all areas to address. What are the expectations?

Occupational Factors

• Choice, motivating preferred play activities (grade with non-play, then non-preferred)
• Self-awareness embedded
• Management embedded
• Relationship embedded
• Challenge: Responsivity to others

This is where we come in to play. Preferred play activities need to be involved in therapy. We need to grade these activities with non-play, and then non-preferred. We start embedding these aspects into preferred play. Then to challenge them contextually, we can add into non-play activities, but still preferred. The final step would be a non-preferred task. Often I see therapists starting with a non-preferred activity, and that can be the nail in the coffin. We want to build those competencies around things that are meaningful. Occupations are meaningful and purposeful activities. We also want self-awareness embedded into the occupational piece. They need to start to manage their emotions. Sometimes you have to poke and prod these kids to give them opportunities to practice that emotional management. If you have a good relationship, it is a safe space for them to practice those skills. The more they practice, the more they will be able to handle other contextual demands. We need to also have them work on relationships within the occupation. The challenge is responsivity to others. This is trying to get them to be responsive to others within your session. Dr. Susan Bazyk does a lot of mental health work with children and schools. Dr. Bazyk refers to this as a positive development. Let's now talk about one of those child factors, temperament. 

Temperament

• Activity level
• The regularity of biological function
• Sensory thresholds
• Quality of moods
• The intensity of mood expression
• Distractibility
• Persistence
• Adaptability to change
• Approach/withdrawal tendencies for new situations
• Attention span

Temperament is evident in the first few days of life. You can see someone's temperament right away. Components are activity level and the regularity of his or her biological function. Sensory thresholds are part of temperament, as are the quality of moods and the intensity of the mood expression. Persistence and distractibility also make up one's temperament. Adaptability to change is another and many kids struggle with that. Temperament also looks at approach and withdrawal tendencies for new situations, persistence, and attention span. Temperament affects social-emotional learning.

Spirited, Bold, and Feisty

The first is spirited, bold, and feisty temperament (Figure 4).

Figure 4. Spirited, bold, and feisty temperament.

There is a variable aspect to their biological rhythmicity, activity level, and sensory thresholds. There are also extremes in mood, attention span, persistence, and distractibility. I can imagine a lot of you are thinking right now, "I know this kid".

Shy, Cautious, Fearful

Then, there is the shy, cautious, fearful temperament (see Figure 5).

Figure 5. Shy, cautious, fearful temperament.

Their rhythmicity, mood, attention, persistence, and distractibility are slow or varied. Sometimes they are slow to warm up. Their sensory threshold and activity level tend to be low to moderate. This very typical of this type of temperament.

Flexible

Finally, you have a flexible child or flexible temperament (see Figure 6).

Figure 6. Flexible temperament.

They tend to have a very middle of the road activity level, regular rhythmicity, a moderate sensory threshold, and they easily adapt to situations. Their mood is pleasant. They are right down the middle and do not have extremes in their mood. They do however have a varied attention span, distractibility, and persistence. This kid is usually the one that was labeled an "easy baby."

Self-regulatory behaviors are affected by temperament. Temperament determines how you are going to display those self-regulatory behaviors. Then the final step of what we are looking for is called effortful control. Some of you might call this impulse control, inhibition, or response inhibition. Basically, it is inhibiting an impulse in favor of displaying another response that is socially acceptable. Children start to learn those pretty quickly.

Temperament in Children

• Reactive
• Self-regulatory
• Effortful control: Inhibiting an impulse in favor of displaying another response that is socially acceptable

(Olson, L. J. (2010). A frame of reference to enhance social participation. In Kramer and Hinojosa (eds.), Frames of reference for pediatric occupational therapy. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.)

When you look at child number one, he looks like he is having some difficulty with self-regulation. His face is not very animated. His mood is indicative of being tired or weary. His eyes are not very alert. There is also a redness to his face that we associate with being stressed. He has a stressed demeanor that shows he might be stuck in a reactive mode. This is going to affect how the caregivers respond to him. It can be very challenging to work with a child who is hard to regulate. When you look at number two, this child has a very different mood. He looks engaging and alert. You can see the difference between picture one and two in terms of self-regulation and reactivity. Again, the response and approach from the caregiver are obviously going to be very different.

Child Development

The first three years of life are when kids develop some of these foundational skills.

Parenting

• Responsive care
• Nurturing and affection
• Conflict resolution
• Maslow: Safety, love
• Cultural appreciation
• Network of love
• Appreciate differences

We want to think about nurturing and affection in terms of responsive care. How do their parents resolve conflict because that is modeled for us? Are Maslow's safety and love areas being met? Hopefully, the physiological piece is being met as well.

Cultural appreciation has been shown to affect social-emotional learning. They call it the network of love surrounding the child. Are the parents accepting of differences in others? Is that something that is in the environment?

ZERO to THREE (www.zerotothree.org) is a great website that has a lot of social-emotional development tools. This can be very helpful for those of you that work with the younger population and in early intervention. 

Self Control

The development of self-control starts with self-regulation (see Figure 7).

Figure 7. Self-control.

Babies soothe themselves. You can start to teach them what they can and cannot do during their first three years. It is impossible to spoil a baby. They need to be spoiled. This is how they get the foundation for moving forward with everything. With toddlers, you start to teach them to stop the behavior. At this stage, they also start to learn how to label their emotions. We start to offer them an appropriate emotional outlet, and they start to problem solve. Parents and caregivers are at the top of the funnel. Occupation is an opportunity for learning. The temperament and the environment applied to the occupation creates self-control. For example, if we consider the child's temperament and make the environment supportive, then they can have opportunities for learning through occupation in conjunction with parental influence. With all of these components, they can start to form self-control, even the kids that struggle with it.

Development: Emotional Self-Regulation

• Year 1: Infants try to reduce negative arousal by physical strategies
• Year 2: Capable of actively utilizing emotional regulation strategies
• Preschool age: Able to calm self and start to learn basic feelings, emotions, and management
• Ages 6-10: Understand and apply social rules regarding emotions
• Adolescence: Able to employ more complicated emotional regulation strategies to promote socialization

In year one, infants try to reduce negative arousal through physical strategies, like sucking or kicking. They put their hands and feet in their mouth or will make a fuss to get the parents to respond. Most of you have probably seen the still face experiments where mom is unresponsive, and the kid becomes very distressed. The nice thing about kids is they recover quickly. We want parents to be consistent and responsive as this is a really important part of their routine. By year two, we want them to start to actively use emotional regulation strategies. They can start to calm themselves, sometimes using things like a blanket or a teddy bear. However, they are not quite there yet. They need a little help, but they are starting to utilize those strategies. At preschool age, they are able to start calming themselves consistently. They start to learn basic feelings, emotions, and management. Elementary age kids understand and apply social rules regarding emotions. Finally, adolescents are able to employ more complicated emotional regulation strategies. As peers become very important at this stage, they are highly motivated to employ these complicated strategies for increased socialization.

Coping 

Coping Model

The Coping Model, found in this source (shop.lww.com/Frames-of-Reference-for-Pediatric-Occupational-Therapy/p/9780781768269) is a different way of looking at things beyond behavior management. It is a process of making adaptations to meet the child's needs and responding to the demands of the environment or context.

• Process of making adaptations to meet personal needs and respond to demands of the environment
  • Transactional
  • Coping strategies are LEARNED
  • The coping process generated by STRESS
  • KEY: developmentally appropriate level of stress, different for each child, facilitates
    • motivation
    • learning
    • mastery

You have to teach them the coping model. There are coping strategies that they need to learn to deal with stress. Something in the environment is stressful, and the child has to learn how to deal with it. We want to figure out what is the motivation, the learning, and the mastery for this child that is developmentally appropriate. When I say developmentally, I mean not only typical development, but this particular child's development. The Coping Model can also be found in this source: 

(Williamson, G. G. & Szczepanski, M. (1999). Coping Model. In Kramer, P., & Hinojosa, J. (Eds.).Frames of reference for pediatric occupational therapy. Philadelphia: Williams & Wilkins.)

The child has his or her own internal events. These represent things like temperament. How do they respond to sensory input, what are their biological rhythms, what are their moods, etc? Then you have the interface of the external environment. External events happen to the child. They are filtered through those emerging beliefs and values, or the cultural piece, as well as their identity.

The first step is determining the meaning of an event. In this example, this is a child who is aggressive toward his parents. Why does he hit his parents during these situations? What is the meaning? The first step is analysis. The second step is developing an action plan. What is my plan to address this event and help this child to cope? What is the coping strategy, and the effort that the child is going to have to use to get a different response? In step three, we want to see the outcome using emotional management, self-regulation, or effortful control. Finally, we want to evaluate the process. Did it work?

This is not different from behavioral analysis. However, it is not only using a behavioral approach but also using something outside of that. If it is a sensory situation, behavior plans will not work. I have to use something else, either social-emotional or sensory-related. Usually, I combine the two, which we will talk about in a second.

Think about it from the process of the child. They have their own coping style, that goes along with temperament. They have beliefs and values. They have physical and affective states. They have developmental skills as well. Externally, they have family and human support, adults, and peers. They have material and environmental support. These two processes (internal and external) affect their pragmatic reasoning and how they are going to develop an action plan. Think about parents who always swoop in to save their child. We are going to have to figure out how to address that in the action plan. This is why parents and teachers have to be involved. It needs to be communicated, and they need to be on board, or it is not going to work. When the coping effort is implemented, they may need to be coached to hang back and let the child do it themselves. We help them practice in a safe environment, then start to hang back. I like to give them a role as parents need to feel like they are doing something. Telling parents to hold back does not work most of the time. They want to be helpful. Often I ask them to time something so they feel like they are part of the treatment.  

PAL Strategy

The PAL Strategy is a plan.

• P: Plan
  • Assess, observe behavioral STORY and SEL competence
• A: Access
  • Opportunities for safe (no judgment) embedded SEL (exploration)
• L: Learning
  • Practice and refine (generalize) abilities through occupation

(Quint, 2014)

We need to observe their behavioral story and social-emotional learning competence. Then we want to provide opportunities, the access piece, for safe (without judgment) exploration. When we go back to Maslow's hierarchy of needs, safety is also about judgment. Often we do not feel safe. For example on social media, we do not put out our opinion about something because we do not want to be attacked. We may withdraw. Children are not going to practice if they feel judged or attacked. This is true for the parents and the professionals we work with as well. This is why we work to make this environment safe. I utilize the idea of a mulligan--that is one of my favorite things that I use. I say that we are going to try things. I have them then tell me if it worked or it did not work. They may have a hard time verbalizing as they are so emotionally involved, but they can use a thumbs up or down, or they can make a face. This is still working on the emotional piece. We also celebrate mistakes and do not fear failure. I will do something wrong to let them point out that I messed up. Role modeling is really important. Overall, this is embedding SEL in your safe environment. The final piece of the puzzle is the learning piece. This is practicing, refining, and learning to generalize these abilities through occupation. I want to emphasize this is through preferred play activities. We want to make it as fun as possible and motivating for them to work on it.

Here's an example in Figure 8.

Figure 8. Examples of PAL strategy.

In the above example, this child has anxiety and an over-responsive sensory system. He tends to ask for help via hitting and head butting his mother. He also does a lot of random yelling and vocalizations. He is verbal, but makes a lot of noises and is very loud. It is attention-seeking with a history of meltdowns. He also has a lot of difficulty with transitions. He panics and is oppositional. Oppositional is often what people will call it. I am not a fan of that term. There is also a lot of disrupted sleep and refusal to go to bed. Many "I hate myself" quotes come out of him. He is also gifted and successful in school.

On Maslow's Hierarchy of Needs, I placed him at the bottom level of physiological, which is sleep. His sleep was really disrupted. When you are not getting enough of your REM sleep, you are going to be very crabby. He also did not feel safe in large and different environments because of the sensory piece. He had such intense sensory responses that were looked at as a problem. He had this kind of abnormal threat analysis going on. Then, definitely love and understanding was a problem. He would tell me that his family loved him, but he did not understand why. He did not love himself. He felt his family loved him because they had to. "That's the rule."

For the access piece, we looked at some cognitive-behavioral strategies for calming down. We learned his strengths and had him name his meltdowns. He had two types of meltdowns. One was called "Farty McNarty", and the other one was the "Creeper." (He is an 8-year-old boy). I also had his mom videotape him in a meltdown so he could watch it later and start to see what was going on and talk me through it. That is a hard thing for kids to do, but it is part of the process. It is part of self-awareness and learning that it is not shameful. Shame is a very powerful emotion. We want to start to chip away at the shame.

We worked on sleep hygiene. That worked very well. He also got a sensory Body Sox. He had a sleeping bag that he started to sleep in. We made a calming jar, which is just a jar with glitter in it. I have them shake it, the glitter goes around, and that buys you some time to calm down. He also used a cognitive-behavioral strategy. He created a superhero, and his name was Shazam. He had a shirt, we made a cape, and he had a symbol. We identified Shazam's superhero powers (the child's strengths). As you know, every superhero also has a weakness (Kryptonite). This is a way for the child to work on strengths and weaknesses in a non-threatening way. One of Shazam's superhero strengths was that he was really good at eating donuts. I just thought that was always so cute. I worked with mom on positive parenting and really working on her language and positive feedback. We made a Creeper book. This was a meltdown book. We worked on mindfulness and a worry shell. These strategies really worked for him.

The learning piece of the PAL model was just practicing all these strategies in the clinic, with a home program for mom. We did a collaborative problem-solving approach. Mom was educated and present for all of it. She was able to express what worked and what did not work. He was also supposed to tell me when things working or not. We worked on confidence building through problem identification, problem-solving, and then accountability. I worked with him for about a year. He had some motor and sensory integration issues that we worked on as well. He is most likely now at love and belonging to Maslow's hierarchy of needs. I see him occasionally for a reevaluation, and some consulting with school stuff, but he is doing well and working toward esteem. For his social emotional learning, he is working on social awareness and relationships. He has a friend now that we are starting to practice some things by coaching mom. He has not had a meltdown in six months. Mom is very happy about that. 

Positive Parenting

When we are teaching these children, both professionals and parents, I cannot stress enough that we have to avoid the word no.

• Reflection:
  • How does "no" affect learning?
  • How does "no" affect the emotional state?
  • How does "no" affect motivation?
  • How would you address excessive usage of now with professional or parent?

When someone is learning, no is not feedback. It is an answer to a yes or no question. "Can I go to the store?" "No, you may not." "Can we play this game?" "No, not right now." It can also be used for safety. "No, you need to stop." This is fine. However, when a child is learning something, and they are struggling, we should not give them the feedback of "No." We need to be mindful of how we use the word "no" and start to eliminate it from feedback. We want to learn how to give feedback that is meaningful to the child and not add to their emotional frustration.

When I have fieldwork students or mentoring therapists, the first thing I do is count how many times they say "no" as feedback during a session. The average is about 30 times. I then have them try something difficult and will say "no" however many times they said "no" during their session. They tell me how frustrating it was. We need to realize that "no" is a motivation killer.

Meltdowns

I want you to appreciate that meltdowns are not tantrums or behavioral communication. They are often sensory related, and a fight or flight reaction. They are autonomic responses that the child does not have control over. They are also confidence killers. These kids really need support and not punishment. This is where the Coping Model can be very helpful.

• Flight or flight signs include:
  • Redness or ears/skin
  • Fisting
  • Change in tone (increase or decrease)
  • Breathing changes
  • A spontaneous decrease in function

These children start to identify sensory input as a threat. Over time our systems are so wonderful and efficient that the fight or flight response and activation of the limbic system become more effective. The problem is the child will start to have meltdowns over misidentified stimuli or over things that are seemingly benign. It is really confusing for people.

I have an example here of a video that you can watch on your own time, of a young man having a meltdown. I want you to appreciate the five signs of fight or flight.

Ears and skin will become red. Fisting can happen. There is a change in tone, either rigid or noodle boy or noodle girl. They get floppy. They might have breathing changes. These are variable, but the last example is across the board. They will have a significant spontaneous decrease in function. They will be fine in their functioning, and then all of a sudden it falls apart. social-emotional learning can help with meltdowns. Here is a PAL strategy for a meltdown in Figure 9.

Figure 9. Meltdown PAL.

You can use the same strategies with tantrums or meltdowns. It just might not be so sensory specific. We have to talk about it (the incident). We want to start to eliminate the shame, the embarrassment, and the stigma that comes with it, as well as parental frustration. We want to provide some judgment-free opportunities and resources. I like to watch a video of the meltdown. I try to get the family to take a video of it. If that is not available, we might watch a video on YouTube of another child.

The child then gives the meltdown a name or a feeling. They make it something separate from themself. They can take a cognitive approach and move away from limbic involvement. Then what we use is the Coping Model to obtain a strategy. What do you want to do to calm down when you get upset? I teach the signs of the meltdown to mom or dad so that they can identify the signs, like fisting, floppiness, and/or red ears. They can then say, "Farty McNarty's coming, and we want Farty McNarty to go away."

Once we have a strategy, we practice. I typically educate the child and the parent that it is brain versus body. The body is taking over, but the child has a really smart brain, and the brain can start to take over using the coping strategy. I find out these kids' triggers so that, when we are doing activities, I can use these triggers to upset them and start limbic activation. The child then uses the strategy that we have chosen; telling it to go away, deep breathing, closing their eyes, counting, etc. I also give the parents a job, like timing and tracking the meltdowns. This way over time they can see that the meltdowns are decreasing and/or that they are shorter. Parents also have to learn that they cannot talk during a meltdown. Talking and trying to help them make it worse. 

Assessments

I am going to go through the assessments rather quickly. I am going to give them to you as a resource.

Emotional intelligence:

• knowing one's emotions
• managing emotions 
• motivating oneself
• recognizing emotions in others
• handling relationships 

This sounds very similar to SEL, and I tend to use this in the assessment process. It helps me with the sequence of things. Again, use the CASEL resource. The majority of the resources are free. Some are free, some are not free. Some are affordable, while others are a little bit more expensive. Some you might already use some of these. 

Coping/Adaptation/Environmental

• Vineland Adaptive Behavior Scales (VABS)
• Coping Inventory
• Short Child Occupational Profile (SCOPE)

Behavior

• Behavioral Emotional Screening System (BESS)
• Behavior Assessment System for Children (BASC)
• Child Behavior Checklist (CBC)
• Burk's Behavior Rating Scale

Strengths-Based

• Devereaux Tools (DECA, DESSA, mini DESSA)
• Child and Adolescent Needs and Strengths (CANS)
• Strengths and Difficulties Questionnaire (Free, SDQ) (http://www.sdqinfo.org)
• Behavioral and Emotional Rating Scale (BERS)

Self-Regulation

• Adolescent Self-Regulation Inventory (free, ASRI) (https://www.rand.org/education-and-labor/projects/assessments/tool/2007/adolescent-self-regulatory-inventory-adolescent.html)
• Multiple options (http://www.childtrends.org/wp-content/uploads/2010/10/Child_Trends-2010_10_05_RB_AssesSelfReg.pdf)
• Anxiety: Anxiety Control Questionnaire-Ch (free, ACQ-Ch) (https://www.researchgate.net/publication/317237333_Anxiety_Control_Questionnaire_for_Children)

I use the Strength and Difficulties Questionnaire, SDQ, a lot. This is a great way to find out what kids see as their strengths and weaknesses. I love self-assessments. If they are old enough to do them, we should let them. Sometimes having them do it will give you an idea if they are ready or not, and that is okay too. The Adolescent Self-Regulation Inventory, ASRI, is free. Another great resource is the Child Trends website. I think there are five or six free ones on there that are fantastic. One is the Anxiety Control Questionnaire. It is free and standardized. I often use anxiety NOS as a code for when I am working with kids that have meltdowns or have significant stress that requires coping. That way it can be part of the treatment process, and billing is not an issue.

Here are some more assessments. I always include a sensory measure of some kind as well as a motoric one. Often, kids that have motor difficulties have difficulties with their emotional management as well.

Social

• SSIS (Social Skills Improvement System)
• SSRS (Social Skills Rating System)
• Social Skills Questionnaires

Occupational

• School Function Assessment (SFA)
• Sensory Profile
• Sensory Processing Measure
• OT Psychosocial Assessment of Learning (OT PAL-MOHO)

Goal Writing

Here are some examples of goal writing specifically to social-emotional learning and some behaviors in Figure 10.

Figure 10. Goal writing example.

In this example, "S" will demonstrate the ability to self regulate her emotional behaviors, with minimal to no tantrums, aggression, or defiance by three strategies. This gives me a pattern of where I am going and the process. One goal is identifying four effective strategies that she can use to calm herself down. The next goal is demonstrating these identified strategies during role-playing scenarios, 80% without cueing. If I know they can do it 80% of the time, they should be able to handle it outside of the clinic. I then want her to generalize the strategies during functional activities when upset with minimal cueing. Additionally, if I can have her perform the strategies, with minimal cueing, we are good.

For "N, I usually use age-appropriate goals, but I might put something a bit more concrete, like social awareness or something like that. I have N accurately identifying emotions in varied contexts 100%. I want to work on that first level of identifying emotions on self. Then, I have him incorporating self-calming strategies with minimal cueing during activity. First I want him to identify the emotions, and then start incorporating calming strategies in six months. This is a normal timeframe as N was seven or eight years old. I wanted him to identify self-regulation status 100% accuracy in three months, implement a strategy to promote regulation with cueing, 80%. Finally, I wanted him to identify the results of his actions on others. As you can see we are starting to move into understanding that that piece of social awareness and starting to get into the relationship piece. I also wanted him to alter behaviors for an improved response from others with cueing in 12 months. Can he start to handle these different challenges, as you move forward developmentally?

Case Example

Here is a case example in Figure 11.

Figure 11. Case example "J".

I think he was four years old. He was diagnosed with autism, specifically Asperger's, and very rigid with things. He had a lot of meltdowns regarding being late or changes in the routine. The Adaptive Behavior Index from the Coping Inventory showed he was situationally effective with coping. He could cope sometimes, but not others. He was able to demonstrate behaviors using personal resources to meet his goals. We had to work on having more resources for him as he tended to be a rigid kid. It was kind of hard for him to be flexible. I gave him opportunities to practice so that he could see that one strategy was not always going to work. He was consistent with both the self and the environment. The Coping Inventory looks at both internal and external coping. For him, these were similar. Rigidity was really the main issue. How could I help him get some coping strategies and be open to different ideas?

His goals were that he would demonstrate coping abilities across context. He was really afraid of failing. We wanted him to demonstrate two strategies to avoid aggression with his brother during play, as he used to beat his brother up a lot. He needed to demonstrate the ability to tolerate failure using a predetermined strategy with cueing assistance in three months. He met this goal.

Here are some examples. If he was writing and he made a mistake, typically he would wad it up and throw it away. He would never finish his work because if there was one little mistake, he threw it away. He started learning to make drawings or symbols out of the writing mistakes. We also used the term "mulligan" to ask for a redo, instead of quitting or getting upset. He called his meltdowns "Squishy" and asked it to go away with prompting or coaching. We also had goals for the home program. The goal was that his mother would demonstrate the application of behavior modification to prevent aggression during play with brother. She would also demonstrate the independent use of positive behavior support for use in the home. Mom was there to learn the strategies in situ, and then go home and practice them and tell me what worked and what did not.

Interventions: Self-Awareness

We are trying to build strengths and work on emotions for self-awareness. We want them to understand what is hard for them. Here are some links for some emotion computer games:

• http://pbskids.org/arthur/games/aboutface/aboutface.html
• http://www.do2learn.com/games/feelingsgame/
• http://pbskids.org/itsmylife/games/story_strips_flash.html

There are different activities that would work depending on their age and their interests and there are many resources on Pinterest (https://www.pinterest.com/search/pins/?q=Social emotional learning&rs=typed&term_meta[]=Social|typed&term_meta[]=emotional|typed&term_meta[]=learning|typed). Some examples including expressing emotion with pasta and circle time emotions.

And again, you can get some of the fine motor pieces and all that. A lot of these activities I do use a co-occupation or a collaborative approach. We are sharing some of the tasks, but you can also make it challenging to see if they get frustrated. Again, you want it to be a preferred activity.

Figure 12 shows the POWER! Battery System.

Figure 12. POWER! Battery System.

This is something that I created, but if you use the Alert Program® or Zones of Regulation, that is fine too. Many of my kids could not handle the five different areas of the Zones of Regulation, and could only handle three. However, they are very familiar with iPads and iPhones, so this is why I developed the POWER! Battery System. I use a battery symbol to indicate their self-regulation. The yellow indicates a dying battery or low power. The green one in the middle is the charged and "ready to learn". The red symbolizes power surge. One of my kids said, "If it was a Samsung, it would catch on fire." This means really active, and not ready to learn. I have them start to identify where they fall on this continuum.

For tweens and older kids, here are some sample activities (www.actforyouth.net/youth_development/professionals/sel/self-awareness.cfm).

They can interview others about what they like about them. What do you like about me? If they do not really have any friends, they can ask their parents or siblings. Journaling is really effective with this age group. They can start to tease out what they really like. Art activities are great for this population. I did this flower project with one of my tweens, and it was really fun because, on each petal, she had to indicate who she is. It was really hard for her. However, after we did a few, she started going online and looking up words. She now has this hanging up on her wall.

This is the Moods game (www.amazon.com/Hasbro-40028-Moods-Board-Game/dp/B00005BY52). It has different cards inside of it that you read. One card example is, "I can't believe I'm sitting next to you." They would have to do it in the emotion (sad, happy, excited, etc.) that they pulled. The rest of the group has to guess which emotion it was. They get to then see if they displayed the emotion correctly. The kids have a good time with it. There is also role-playing involved. Depending on how many participants you have, you can make it a lot of fun.

Interventions: Self-Management

When we intervene with younger kids, we want to think about meltdown strategies, the battery strategies, and embedding practice of these different strategies into the activities you are doing. We also want to work on mindfulness. With older kids, I work a lot on anxiety management, expression activities, and the arts. We want to take them from the "I can't" to "I can".

Here's one for the little guys called the "Grouchies." It can be found here: http://www.grouchies.com/. There are an online book and a YouTube video as well. I typically have the kids make a grouchy on a popsicle stick. They can work on some of the fine motor pieces with this activity. I also give this to mom and dad to have with them. If you look at the book, there are the happy faces that tell the grouchies to go away. The first thing we play is musical grouchies. We sit in a circle and pass the grouchy during a song. When the music stops, the person who has the grouchy has to tell the grouchy to go away. It is a cognitive-behavioral and coping strategy. When they tell it to go away, we hand them the sun. We say, "We feel so much better, how do you feel?" I let all the people have a chance, and the kid is the last one to go. They have then had the opportunity to see everybody else do this, and have had time to cope. By the time it is their turn, hopefully, they are ready to do it. We can also blow it away, wave goodbye, or stomp on the grouchy. We also play the game, "Who has the grouchies?" It is the same thing. If they are feeling grouchy, I might purposely be grouchy with them, and then they have to tell me to make my grouchies go away and get my sun. Then of course just the "go away grouchies". This is when they can take it home, and it is a nice little tool for mom or dad to use.

Here is the POWER! Battery System again in Figure 13.

Figure 13. POWER! Battery System descriptions.

This is the backside of the batteries. This one has the emotions on it. This gives strategies on how to change their battery level. There are ideas for heavy work, postural things, eating a chewy snack, and pretzel push, which is making yourself into a pretzel and pushing yourself for proprioceptive input. The charged battery just tells you what to look for, like a calm body and mind. You are paying attention and making good choices. With a power surge, there are strategies of how to calm down. They tell themselves "be here now", heavy work, and chair melt, which is melting in the chair in a slumped posture. Other ideas are taking deep breaths, closing their eyes, and sitting on the bean bag. I have also put the corresponding emotions in there. The kid can start to correlate the emotions with the battery level.

These are examples of anxiety or feelings meters: www.pinterest.com/pamdyson/feelings-thermometers/

One of my kids liked Angry Birds. He says that when his battery is red, he is wild. When he is green, he feels like Batman, confident and ready. Finally, he is tired, frozen, and sad when yellow. Another example is putting a bead on a pipe cleaner. They can then indicate where they are on the thermometer. In my previous example, if he was feeling like he was surging, he could pick one of the strategies of the battery to see what worked. These are fun tools and I usually have them make one to take home. Kids love the emoticons and Disney related stuff too. The faces have metal pins that allow things to move, so you change the emotions. On the far right with the mood meters, the kids can use their own or their family's faces. 

Calming strategies are shown in Figure 14.

Figure 14. Examples of calming strategies.

I like my kids to name the behavior. My kid named it Creeper and made a book. He also learned the strategies. His strategy was to tell Creeper to go away and to chew gum. For example, he was traveling by plane and was very nervous that Creeper was going to come while he was on the plane. He tended to kick the seat in front of him and get in trouble, causing a meltdown. He developed a whole strategy that he was going to chew gum so his ears would not hurt, and it was going to organize him. He was going to tell Creeper to go away, and he was going to take his heavy lap pad for proprioception. Then if he had to, he was going to go to the bathroom and take a break. He also had music to help him stay calm. These strategies worked for him and flying was a success.

I like to make social stories with the kids on a PowerPoint. And they love it. They love picking out the pictures, figuring out how they feel, and identifying strategies. I also have some already have pre-made as well.

Some mindfulness-based strategies that I have used are calming jars, worry beads, a worry shell, feeling stones, comfort boxes. Many of these items can be handmade and many examples are on Pinterest. For feeling stones, they draw on the rocks and take the positive rock with them. They can shake up a calming jar (mason jar with liquid and confetti) to help them to calm down. One that I love is using empty matchboxes. They can decorate them and put a message on the inside. It might be a comforting message or have strategies written in there. It might also have a saying or a picture that makes them feel powerful. Worry beads can be made into a necklace, and it can help them feel calmer or be used as a fidget.  

A reframing thought poster can be used in groups as in Figure 15.

Figure 15. Example of a group activity.

This is one where they change their words to hopefully change their mindset. We gave an example of one thought they might have and how to make it a positive mindset. One example is,  "I don't understand." What else could they say instead? Other kids would then get points if they helped the kid reframe it. 

Interventions: Social Awareness, Relationship Skills

Ideas for social awareness include: good sportsmanship, taking turns and attending to others, body language games, charades, What is he/she thinking/feeling? and volunteering and helping others. They need to work on good sportsmanship and taking turns. Often, my kids not only struggle with losing, but they also struggle with good winning behaviors as well. What is a "Friend"? is a social story.

I-messages are great strategies to help kids to express emotions and address conflict. Examples are:

• I feel... (insert feeling word)
• when...(tell what caused the feeling).
• I would like...(tell what you want to happen instead).

They can use these to express their emotions and address conflicts. The All About Me book is another great resource. Edutopia has some great active listening activities (www.edutopia.org/blog/fostering-classroom-re