Using the Science of Sensory Process to Survive The Holidays

Introduction

I am really excited to talk with everyone today about what I think is a critical topic. Today is not about giving a whole lot of knowledge. What we are going to work on today is to take a lot of what you already know and apply it. Think of it as a toolkit of self-care. We will talk about sensory strategies, occupational therapy, and occupational disruption and pull those together to show how one can be resilient in the face of life's inevitable stressors. Many inevitable stressors are found during holidays. I hope by the end of this talk you will think differently about how to use what you have been studying for many years, what you have learned from others, and what you have learned in your own family to create successful holidays for yourself and your clients.

Our learning outcomes today are focused on applying the knowledge that you have. I will talk a little bit about some prevalent diagnoses, but today is not really about going in-depth about each of the diagnoses. What they all have in common is that individuals have difficulty regulating their arousal levels. Those of us who are parents of these children may also have difficulty regulating our arousal level in response to the dysregulation. I will touch on that very briefly, but I will trust that you have a lot of information on the actual diagnosis. Today will also be about using what we know to increase our family's quality of life during the holidays, applying our knowledge about occupation and performance patterns.

The Occupational Therapy Practice Framework (OTPF) is currently coming out with version four. However, I am going to be using version three today. Version four is still under review. It should probably be out in the spring (2021). One of my favorite areas of the OTPF is performance patterns. These are the habits, routines, roles, and rituals. How do we use these areas to increase engagement during the holidays?

The final objective that we want to meet today is to apply the knowledge that we have in our toolkits and use that to support families via adaptive responses during stressful family celebrations. Around this time of year, I get many calls, as does AOTA, about managing holiday stress. As therapists, we can help families think carefully about the sorts of activities they are bringing into the family. And, during the pandemic this year, I think many people were thinking more about that. Occupational therapy has a depth of knowledge to help families sort through this.

Outline

1. Why Holidays become a Holidaze
   1. Stress of holidays (anatomy of an upset)
   2. Disruption 
   3. Exacerbation of developmental delays
2. Using Performance Patterns for Resilience
   1. Habits
   2. Routines
   3. Roles 
   4. Rituals
3. Activities to Promote Resilience during times of disruption (like the holidays)

I am going to organize our talk today with this outline. First, why are holidays so crazy? I want to introduce this concept called the anatomy of an upset. I am going to talk a little bit about what an upset is and the causes. How can we get prepared for that? We have had some opportunity to think quite a bit about occupational disruptions this past year. Still, I think it applies very directly to what happens during the holidays, so I want to take some time and talk about that. And then finally, what is the exacerbation of developmental delays in the areas of disruption and stress. I think all of this adds up to these what could be a stressful holiday. We all are entitled to restful and satisfying holidays.

Next, I want to spend some time unpacking performance patterns: habits, routines, roles, and rituals. I want to look at how to use those to build resilience in our lives.

We will then finish up talking about some activities that promote resilience during times of disruption. Again, we are talking about the holidays, but I hope that some of what we chat about together today becomes some ideas that you can apply across the year and not during the holidays.

Holiday Stress: Holidaze

I want to start by showing you a photograph. This is a photograph of my family taken years ago in Figure 1.

Figure 1. Author's family.

The little squiggly one in the front is now 17. I love this picture because this shows the craziness that went into our holiday photo where the little one was sitting very nicely in big brother's lap and looking like all was well. However, before that, you can see he was kicking up a storm and screaming. There can be holiday stress with something as simple as taking pictures for the holiday card. This can be so disruptive and throw the whole day off. You have to say to yourself, "How important is it to get this perfect photograph?" When we actually did get a shot, I instructed the older sibling, Zachary, to give Alex a big bear hug. So in the final rendition, you see the older son giving this adorable and loving hug to the younger one. It took a little bit of sensory integration to help us get that shot, and then we were done for the day. I knew that I had one shot at it. The picture reminds me every year that holiday stress really can exacerbate any underlying disruptive behaviors with families. I think it is a good reminder for all of us that we ask many of our children during the holidays.

Appropriately Ambitious

• Being appropriately ambitious
  • “Occupational therapy practitioners apply theory, evidence, knowledge, and skills regarding the therapeutic use of occupations to affect the client’s health positively, well-being, and life satisfaction.”

AOTA (2017)

One of the things we can explore is if we are appropriately ambitious. As occupational therapy professionals, we apply our theory, evidence, and knowledge to positively affect the client's health, wellbeing, and life satisfaction. We look at all the areas of occupation that get disrupted by life and provide interventions in our toolkit on behalf of people, groups, and populations to achieve ultimate health, wellbeing, and life satisfaction. It is definitely an ambitious goal, but how can we be appropriately ambitious?  I hope today's talk will encourage you to start thinking in that direction. Let's just start by introducing a little bit of language. 

Habits, Routines, and Rituals

• Habits, routines, and rituals help us feel organized and calm and normalize our daily experiences. 
• The more internal disorganization we experience, the more we rely on external structure and organization to feel calm and peaceful. 

Habits, routines, and rituals help us feel organized and calm, and they help normalize our daily experience. The more internally disorganized we are, the more we rely on external structure and organization to feel calm and peaceful. That is a tenet that we use not only for ourselves but also for our clients, especially children, across the lifespan when we are having moments of disruption. This could be due to an injury, a disability, or something happening in the environment. This is one of those pieces in our practice that we hear so much about that we forget to think about what it really means.

For example, I have a habit of making a cup of coffee every morning. I go down the stairs, and I make a cup of coffee for myself in the morning. It is a habit that I have done so many times that it has become a routine. Another true thing is my alertness in the morning is not as high as I would like it to be. I tend to drop things or be kind of "fumbly." One of the things that I have learned to do to combat this is to set up my coffee cup at the Keurig before I go to bed. Then, when I wake up in the morning, I have set myself up to be successful instead of rooting around to find a coffee cup and potentially dropping it. I also have some favorite coffee cups. I also make sure that the coffee cup that I like the most is washed and ready to go. This habit supports my morning routine. Another ritual of mine is that I set out cheese and crackers every day at five o'clock and have a glass of wine. This is my family's happy hour. My in-laws have had this particular ritual for at least 30 years, and it was well-established when I met them. It signified there was an ending of the workday and the beginning of family and friend time. When my mother-in-law passed away, that ritual got disrupted, and we had to find a way to replace that for my father-in-law.

We use these external organizing strategies to help us feel more organized when we cannot find that organization inside. This applies to our children as well. Some children have more difficulty getting themselves organized than others. The little squiggly guy had a lot more difficulty getting himself organized for a picture than the older son. We had to bring in an external strategy to help him organize himself to sit long enough for a picture to be snapped. Thus, the more internal disorganization we experience, the more we will rely on the external structure and organization to feel calm and at peace.

Many of us have routines or rituals like setting the table in a certain way. This helps us feel organized. You may have a special centerpiece from your mom or your grandma's china. It can really help you. However, it can also be disruptive. What might bring us a feeling of calm and order might be disruptive for someone else. We have to be almost like a detective to see if we can figure out the stressors. 

Disruptions to Routines

• Holidays are stressful because they bring change, disrupt routine, and demand new responses to the changing environment.  
• They are novel, so we are in a constant state of stress (out of our routine). 

Holidays are stressful specifically because they bring a lot of change. They disrupt our routine. They demand new responses to a changing environment. For instance, we move the furniture around in my house to put up a tree. When we move things, we now may not walk through the house in our normal fashion. We might stub our toe on something that is typically not in our path. Holidays become stressful because we are changing a lot and disrupting our routines. We are demanding new responses throughout the day like wearing festive clothes (i.e., an itchy tie), standing in front of the room and singing, and letting people stand up close to you. There are also different smells in the environment. These are all novel experiences causing a constant state of stress.

When we are out of our routine, we know one way to activate the nervous system is to present something novel. And if we cannot find a way to normalize our response and adapt to that, then we can be in a state of high alert. Holidays are stressful in large part because they are in and of themselves disruptive.

• The contexts change, our homes are filled with new artifacts (indoor trees, fragile dishes, new smells, and seasonal foods). 
• Some children, especially those who struggle to feel organized internally due to delays in their sensory-motor system, can feel stressed and upset with the family’s attempts to enjoy the holiday experience. 

The context may change as well. As I said, we are bringing in new artifacts from the outside. We bring trees inside. Some children may think that because of this, they can bring in other items. My son wanted to bring in a jawbone that he found in the creek. We had to have this long discussion about things that can come in and things that cannot come in. Additionally, there are new smells with seasonal foods and dishes. At the same time, some dishes are important to us. The things that are important to us are not necessarily important to anyone else.

Exacerbations of Developmental Delays

Children who struggle to feel organized due to delays in their sensory-motor system or cognition may feel stressed and upset. This can upset a family's attempts to enjoy the holiday experience. We may have a meltdown when we say something like, "Tonight, instead of having dinner, we're going to have breakfast. Isn't that fun?" Parents may try to make it a lovely experience, but children may consider it a threat. 

Reflection

• Reflect for a minute how you feel when you are forced into an unfamiliar environment. There are many new and unfamiliar smells, sounds, and sights.  

I am going to ask you to take just a moment to reflect. Think about how you feel when you are forced into an unfamiliar environment. There are a lot of new and unfamiliar smells, sounds, and sights. I have been noticing this in my own nervous system recently when I have to go to the grocery store, and I have to wear a mask. I have to think about where to stand. There are arrows on the floor, and I have to go up and down certain aisles in the correct pattern. Sometimes I miss it, and sometimes other people miss it. Then I get a little stressed about it or watch the other person get stressed about it. We have had many experiences like this with unfamiliar environments, new rules, and unfamiliar smells and sounds, and sights. As we are stepping into the holidays with high expectations, we may be setting ourselves up for even more stress.

Again, unfamiliar environments can often be overstimulating for many of us, but more so in children, as they have immature nervous systems. When you have a disrupted internal state, a feeling of equilibrium can get expressed by overstimulation. We may see disruptive behavior. I see that in myself. After I go to the grocery store, I come home exhausted. I get overstimulated and need a moment to pull myself back together. Exposing our child gradually to these anticipated changes in routines is a key strategy. Preparing a child for a successful transition to an upcoming special event, like a holiday or new environment, is one of the primary strategies we use. For example, when we say we will put a tree up, we can have a countdown or a way to anticipate changes that are coming. This helps to gradually expose the child or others in the family to get ready to adapt. It also helps us understand and think about what the child will need to be successful at this change that is coming. Do you need more sleep to prepare?

Of course, this year, due to the COVID-19 pandemic, we are not doing those big family gatherings, but you get my point that planning is crucial. We can use these countdown strategies at other times to prepare children. "In an hour, we're going to put our shoes on." "In 30 minutes, we're going to put our coat on and go for a walk outside." This is using an external strategy to help them anticipate the changes that are coming. If we are going to go into a particularly challenging situation, deep pressure and slow rocking input are great for the proprioceptive system. Those are our three big bangs for the buck. If we put those into the system, then we are creating opportunities for that system to be more resilient in facing challenges that will be coming up in the environment.

Individual Stress Responses

• It is also important to help families recognize individuals' stressors.
  • Sensory Over Responsive
  • Sensory Under Responsive
  • Sensory Craving-Seeking

When we think about what we know from the research, there are different ways individuals respond to their environment. Ayres describes sensory craving or sensory seeking as those children that like to touch things. They are trying their best to organize their system, but they are doing so by being active instead of being passive. I think it is important to help families recognize each stressor, including those of adults. We, as adults, are just big kids. We all were on the spectrum, and I am certainly still on this spectrum. I am a sensory over-responsive kid. My mother bought special popcorn for me as it was a big deal. And, when I come home from a grocery store trip, you can bet that I will have a temper tantrum if there is something sticky on the counter. I hate it. 

I look just like a little girl with a pink hat in Figure 2.

Figure 2. Example of a sensory over-responsive child.

My older son is sensory under-responsive, as in the image in Figure 3.

Figure 3. Example of a sensory under-responsive child.

When things get overwhelming, he just goes to the couch. It is like somebody takes his batteries out. And then, because the cosmic joker is real, my younger child is a sensory craver like the child in Figure 4.

Figure 4. Example of a sensory craver.

As he gets more dysregulated, he wants to touch everything. We joke that he is the official breaker of the family. As we have these different kinds of nervous systems operating within my family, I have to think about what I can do to help us all. We know from theory that our biggest bang for the buck is to provide proprioceptive input via deep pressure and slow rocking to prepare for the stressors and keep us regulated to have a better experience.

Choosing Wisely

• Don’t provide sensory-based interventions to individual children or youth without documented assessment results of difficulties in processing or integrating sensory information.
• Challenges with sensory integration and process are complex and have unique presentations. Careful evaluation is necessary to produce safe and optimal outcomes. Recommendations for using sensory-based interventions/strategies such as weighted vests/compression garments or sensory diets are not consistent with best practice.

AOTA has provided a clear decision tree to assist clinical reasoning.  [in reference list]

We need to choose interventions wisely. As a disclaimer, we are going to talk today about the use of sensory strategies. I want to distinguish what I mean by that and what I don't mean by that. We will use what we understand about the sensory nervous system to help us all feel more regulated, less stressed, more adaptive, and more resilient. This is in comparison to providing sensory-based interventions to individuals or children without documenting assessment results. This talk is not about going into a classroom and saying that everyone gets a sensory strategy. If we have not done the upfront assessment of individuals and know-how to specifically choose those sensory strategies for that individual's nervous system, we are not using Ayres' sensory integrative theory as an intervention.

What I am really talking about today is to use what we understand about the sensory nervous system. We know that because of how the nervous system is wired, we can all do things to help ourselves feel better. For example, I know that if I go for a brisk walk, I will be a little more resilient when I come home and have to put the groceries away. I know that if my son carries the groceries into the house, he will be a little more resilient when he finds out that the store was once again out of mandarin oranges. This is just using what we understand about the central nervous system. Choosing wisely is being mindful in a therapeutic situation to ensure that we have conducted proper assessments before we provide therapeutic intervention. It is a little different, and I wanted to make sure we were clear. 

Theory Review

Some people are not interested in theory, but I created a cheat sheet for you in Figure 5.

Figure 5. Theory review.

One of the greatest things that Freud gave us was his talk about the use of defense mechanisms. We say to people, "Don't be defensive." This is a shortcut of "Don't use a defense mechanism." Defense mechanisms are there to protect us from falling apart. Sometimes we may think that a parent is defensive when they say things like, "My child is perfect. He is fine." Or, "He doesn't have anything wrong with him." Using that as a defense mechanism is important to protect the psyche. Once we have a strategy, we can give up our defense mechanism, but this is initial protection. I wanted to give a little nod to Freud as he did leave us with something that I think is meaningful and helpful.

Erickson came along with neo-Freudian ideas. He looked at development across the lifespan. He is one of my favorite theorists, and I use it quite a lot. He gave us moments of crisis across the lifespan that we have to succeed in to move on to the next developmental level. What is great about his theory about being adaptive during the holidays is to embrace the challenge of each stage so that we can grow. Like teenagers, they put on a different hat every day and have different friends all the time. One day, they wear crazy clothes, and the next day they wear formal clothes. This is all part of them figuring out their identity, which is one of Erikson's stages. As we get older, we move into generativity, which is about thinking of others before ourselves and how we can give back, and so on.

Behavior is shaped through rewards. This comes from Watson and Skinner. 

For cognitive, Piaget said how we think influences how we interact. I love Piaget's theories specifically related to this conversation we are having today because the way we think influences how we interact with each other and that children think differently than we do. Piaget reminded us of that, and the importance of the sensory-motor system is as a foundation for development. In fact, there is quite a bit of overlap with Piaget's theory when we are talking about the use of sensory strategies and sensation as a way of helping us all feel more regulated.

Attachment theory is probably best captured by the theorist Bowlby. You rely on a trusted adult to support your sense of wellbeing. When a child starts to feel overwhelmed, they turn to a trusted adult. Perhaps, they are clingy or fussy, but according to Bowlby's theory, they are letting you know that they trust you to help them. "I am out of sorts and need some help."

Social learning theory is one of the predominant ones by Bandura. Adults can model adaptive responses. And then, there is the sociocultural theory by Vygotsky whereby children learn by hands-on experiences. These last two theories have risen to be the best evidenced when supporting our interventions. The adults in the family have to figure out how to be responsive in an adaptive way. If I am a crazy redhead, my family is going to model after me. If I am cool and easy-going, then everyone will follow suit. To have an adaptive response to stressors in the family, the adult/parent is the key to success during occupational disruption, especially during the holidays. Vygotsky is looking at the right level of learning. Thus, we do not want to give a child who is developmentally five the task of opening gifts for 30 minutes, waiting patiently, and taking turns. It is just not the just-right challenge for that child.

I do not want to beat anyone over the head with theory, but I think there is a lot here that will help us with the rest of our conversation today. 

Developmental Disability Statistics

• Developmental disabilities affect approximately 10 million children in the United States alone, or about 15% of the school-aged population, a 17% increase over the last decade or approximately 1.8 million more children than the previous 12 years. 
• About 16% of children in early elementary years present with symptoms of sensory over-responsivity, a form of sensory modulation disorder (Ben-Sasson, 2009).
• 80% to 90% of children with ASD have sensory modulation disorders  (Rogers & Ozonoff, 2005; Tomchek & Dunn, 2007). 
• 5% to 15% of children within the general population show signs of sensory modulation difficulties. (Ahn, Miller, Milberger, & McIntosh, 2004)     

Developmental disabilities affect about 10 million children in America. That is about 15% of school-age kids, a 17% increase over the last decade. If you have 10 children around you, one of them will have a developmental disability of some kind. About 16% of children in early elementary years have some sensory over or under responsivity symptoms, which is a form of sensory modulation disorder. About 16% of kids that you meet are going to have difficulty regulating their states of arousal. Between 80 to 90% of kids with autism spectrum disorder have a sensory modulation disorder. And, five to 15% of children within the general population show signs of sensory modulation difficulty. The research is still ongoing about ADHD and sensory processing, but I think it is safe to say that children with ADHD have difficulty modulating their sensations. There are some indicators that we are looking specifically at sensory under responsivity, either passive (on the couch example) or actively trying to get the kind of sensation they need to feel in that "just right" zone of arousal. For me, these statistics are beneficial.

I live in a community that is packed with eight wild boys. There are no girl children in my immediate neighborhood, but there are eight very wild Tom Sawyers in my neighborhood. Those are my very favorite kids. They come over, and their arms and feet are flailing and going in different directions. I just love them. Often, I have some kind of organizing thing in my front yard. Since COVID, you can often find me doing different activities that can be completed while social distancing but still allowing the boys to blow off steam. One example is shooting off rockets. One boy walked by the other day when we were setting up for Thanksgiving outside in the cold to distance with neighbors socially. He said, "I really like your house." And I replied, "Oh, thank you." He asked, "What are you doing with your table?" After I told him that we were having Thanksgiving outdoors, he kind of slumped and said, "Ah, we're having a boring Thanksgiving inside with just the three of us." I thought that it was interesting that he perceived that eating outdoors in 40-degree weather was ideal. I made a mental note about that for the future. While many things happened this year that were bad, some consequences like outdoor dining and socializing are accidentally brilliant. We can put these ideas in our toolkit moving forward. Many children are trying their best to regulate. The bottom line is that if we recognize occupational performance patterns, habits, routines, roles, and rituals, how can we use them to promote what we really care about, which is engagement with one another?

As Carl Sandburg said, "Time is the coin of your life. It's the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you." When you have these external pressures telling you how to have Thanksgiving or other holidays, you can really push up against invisible pressures that, at the end of the day, are not going to give you what you want, which is occupational engagement.

Many times people think of the OTPF as linear. On one end, there are the client factors or how people's bodies are made up. And then, on the other side, you have these things called context and performance patterns. That is not really how it works. The way it is supposed to work is as a three-dimensional model, if you will. It is kind of like Russian nesting dolls. The way we do things is stacked within a series of habits, roles, and a context. I have the occupational role of mother, daughter, home maintenance person, neighbor, etc. Within those roles, I have given myself these pictures of how I think I'm supposed to do things. I am supposed to have good habits of keeping my house orderly, making sure that my children have the gifts they want for Christmas, and so on. We have had some changes in our life this year. And because of this, I am using a lot of mental energy thinking about what I need to do to make sure that I create a holiday for my son that will meet his expectations. I am setting myself up for failure. I expect that I will figure everything out within my roles and do all the tasks/occupations correctly. However, there is only one thing that can come with that, being upset. Something is not going to turn out the way I expect it. We may break something important or spill something on the tablecloth. We are going to forget something. What would help me? What would help you? Or, what would help those that we care for? Whether it is our client or the people in our family and friends' circles, what really would help? What habits do we have? What routines, what rituals within those roles that we have, what would help promote occupation during the holidays? That is the coin of our life that we get to spend. That is the question of the day. 

Using Performance Patterns for Resilience

Habits, routines, roles, and rituals support or hinder occupational performance. Figure 6 is a picture of snow on a sand table.

Figure 6. Snow in a kid's sand table.

We were living in California at the time, and I took some fake snow and dumped ice water in it. It was freezing, but it was relatively warm outside, even for December. I set up this play station out on the front lawn for my then five-year-old to play with so that he could come in and meet the challenge of different people in our home for the holidays. They were family, but he did not see them very often. It is about creating tiny little moments of respite to give some input into the sensory nervous system to increase resilience.

Performance Patterns- Components/Definitions

• Develop over time, contextually influenced
  • Habits- 
    • automatic behaviors
    • Check to see how families are using habits; Useful or impoverished, dominating?
  • Routines – 
    • established occupations that provide structure
    • Are routines health-promoting or damaging? 
  • Roles – 
    • Behaviors with socially agreed upon function
    • Are occupations limited by stereotyping? Restrict patterns of engagement?
  • Rituals -
    • symbolic actions with spiritual, cultural, or social meaning that contribute to our identity
    • Are the rituals being used reinforcing values and beliefs

Habits are things we do automatically and do not think about. Routines are those established occupations that provide structure for us. We have a routine of how we drive. We have a routine of getting dressed in the morning. We have a routine and brushing and flossing. Those morning routines are beneficial. We also have our roles. These are behaviors that are socially agreed upon and have their functions nested in there. Lastly, we have rituals. These are those symbolic actions that have spiritual, cultural, or even social meaning and contribute to our identity. For example, I have a ritual of lighting a candle in my window and taking a picture, and sending it to friends that are having a moment of distress. I also have the ritual of baking sand tarts in my family. My older son is now living in Japan, and he wanted to make this traditional Christmas cookie. However, as part of the pandemic in Japan, they do not have access to butter right now. It is like our version of a lack of toilet paper. It is not on the shelves. He was really stressing about missing the ritual of making sand tarts. "It's not going to feel like the holidays." I had to remind him that he could make butter out of cream. I used to have my boys make butter out of cream as it is an excellent proprioceptive activity to do before sitting down to dinner.

We need to be appropriately ambitious with our families when assessing habits. How are you using your habits? Are they useful? Are they impoverished? I was just talking to a friend about how many Hallmark movies she is watching? Maybe this habit during the holidays is a little bit impoverished if you are watching too many. Are they dominating? Do you feel like you have to do it? Is it a habit that is in the way? We can help families to think about that. This is important for us to take stock of as well for ourselves and our family.

How do we look at the routines? Are they promoting or damaging health?  For roles, are the occupations limited by stereotyping? These are statements like, "Only the dad does that," or "Only the mom does that." "Grandpa's the only one that can carve the turkey." Sometimes, we can be stereotypical in the way that we think about the roles. We need to bring that out to reconsider it. Do they restrict our patterns of engagement?

Are rituals being used to reinforce our values and beliefs? I have a ritual of watching all the Christmas movies. You may have your own rituals and need to see if it is consistent or with your beliefs and values. I am going to pick on my older son for a minute. He is in Japan during the pandemic and feeling a little sad. I reminded him that one of the rituals we had when he was young was buying a couple of gifts with his allowance. We figured out the budget, and he donated those gifts to local firefighters collecting for charity. This ritual started one year when we saw a few firefighters in our community shopping for needy kids. He was just so excited. It was like running into Santa Claus for him. They were so gracious in receiving whatever it was Zachary had bought that year out of his allowance. Reminding him of that helped Zachary to one of his greatest values of being generous. As a result, he and his wife decided to look for ways in their community to be generous. That is what they are working on now. Instead of feeling stuck and sad that they could not travel to see family and friends, they returned to a ritual that reinforced values and beliefs.

Again, I think that performance patterns are vibrant with opportunities and invitations for us. I have given you blank bubbles in the handout. I would like you to take one minute of mindfulness and come up with one habit, one routine, one role, and one ritual in your personal life that you feel would be helpful to increase occupational engagement through the holidays. I hope you each came up with at least one thing.

Here is an anecdote that I would like to share. A friend of mine was telling me a story about her mother. Her mother has a disorder that affects her immune system, so she is immunocompromised. Her mother was unfortunate as she always baked over the Thanksgiving holiday and dropped off these baked goods to friends. This ritual has been a part of her life for many years. Every year, she does this, but this year she did not feel safe. She wanted to connect with people safely, and the routine of baking was essential to her. She decided to bake about 20 loaves of pumpkin bread, wrapped them nicely, and dropped them off at friends' houses. She would then call and text from her car to say, "I've left you something." Many of her friends responded. One of them, in particular, took a picture of the bread and said, "I'm happy now that I have my pumpkin bread." This filled my friend's mother's heart with joy. It allowed her to have that experience that she wanted. While it was different, I think we have all learned that different does not have to be bad this year. Helping people think about habits, routines, rules, and rituals can give us the outcomes of being occupationally engaged.

Different Ranges of Energy

As we move through the OTPF to the temporal, one universal truth about human beings is that we have different energy ranges. Each day we spend it in different ways. Each of these expenses to the muscles of the neuromuscular system adds up to our daily allotment. I am making these numbers up, but some people may wake up with 10 units while others have 5. We have a limited amount per day. I used to say to my boys when they were little when they were asking to do things, "I can clean up your mess for you, but I only have 10 units of energy every day. And I think that's going to take two. I'm happy to use my two units of energy to clean that mess up for you. But if I do that, I won't have those two units of energy to read you a second bedtime story. I would like to read your second bedtime story, but it's up to you. You get to spend mom's energy any way you want." This type of language helped them to understand. The truth is we only have a certain amount of energy to go around. I think this is helpful to impart to families as it can be empowering for them. It is also empowering for our children.

Assessment: Activity Time Clock

• Take an average day in your life.  Think about how you spend each minute of your day.  For example, how much time do you spend on sleep? Eating? Preparing meals? Studying? Work? Child care? Self-care? etc. Write it all down.
• Using a 24-hour clock, determine the number of minutes you spend and shade the clock accordingly. Bring your clocks to class for discussion.

I pulled this example of time use on an average weekday for full-time university college students in Figure 7.

Figure 7. Time used on an average weekday for full-time college students (Source: https://www.bls.gov/tus/charts.htm).

Many college students are in finals right now, and it has been a brutal couple of semesters for most students. Now, they are coming home. It has been a time of disruption for these young adults. I thought this was a good chart to review time use. You can see that if someone is working more than almost two and a half hours a day, that will have to cut into something else, either leisure or usually sleep. Educational activities, eating and drinking, and grooming take up another big portion of the time. Of course, we see that many students take from the grooming time and put it into something else. Many of us during this pandemic have regained travel time. My son gets up in the morning and goes to school by rolling over in bed and turning on his Chromebook. That is the way he travels to school. When we have a change or a disruption in our time usage, I think it is imperative to take a peek and make sure are we using the coin of our life for the things we value most. 

Many learn about the Activity Time Clock in the first year of OT school. I think it is the most powerful and underutilized tool that we have in our toolkit. If you take an average day in your life and you think about how you spend each minute, like sleep, eat, so on, and you write it all down, and then you use a 24-hour time clock. You can put this on an Excel spreadsheet if you want. You determine the number of minutes that you spend, and you shade in the clock accordingly. You want to see if you are spending the coin of your life in the way that you want. 

Caring for Others

One of the things that happens during the holidays is that we tend to spend quite a bit of time caring for others. While we may choose to spend that time caring for others, they may not always value that. This an example of an anatomy of an upset. We expect that people will say, "Oh, thank you so much for bringing this over." However, this may not happen. "I didn't notice that you brought this over." Or, "Are these home-baked, or did you buy them?" You are now upset. We can go on and on. It is personal for everyone.

Mothers of children with autism, ADHD, and sensory processing disorder spend two and a half hours more per day just in the care of the children. Let's think about the time clock again. What would they give up? Would they give up an hour of sleep? Would they give up grooming? I have had parents tell me that they shower irregularly or got their hair cut short not to have to spend time on it. You also hear this about eating and drinking. "I have a shake in the morning and at night. That's all I have time for." Or, "My nutrition is horrible. I've put on 50 pounds." Parenting a child with a developmental disability is correlated with weight gain and a reduction in educational activities. Doing the things that they want to do or meeting their own aspirations often get robbed. Leisure is another area that gets robbed quite a bit.

I find this a handy graphic in Figure 8.

Figure 8. Average time parents spend on caretaking per day (Source: https://www.bls.gov/charts/american-time-use/activity-by-parent.htm).

This shows the average hours per day that parents spend caring for and helping household children in 2019. These are typical children. During the holidays, this time increases. We have to make sure they have their fancy clothes on, do not just eat candy canes all day, and so on. Obviously, demands have also increased in 2020. We need to stop and think if we are putting in what is giving us joy? If not, this is the anatomy of an upset, and we will have unfulfilled expectations. You think that you are putting in all this energy to bring happiness to you and the family, but you may be using your coin and not getting the right outcomes.

Today, I want to show some strategies that can help us develop the ambitious outcome of quality of life, wellbeing, and resilience for the family. And, I think the use of time is an area where we can develop some useful strategies. Again, we want to get that good movement and that nice proprioceptive input. We need to set aside time to go out for a walk, ride a bike, shovel snow, et cetera, as this builds the sensory nervous system to be more resilient. If everything is put into the care area, we might want to turn that around a little bit. Perhaps, we do not need a bath every day. I just think it is a really fertile place for us to look at to develop some strategies on how to use our time wisely.

Routines Provide Structure

• Energy conservation and work simplification are two therapeutic processes that provide a systematic method of evaluating your daily tasks for energy output and apply strategies that help you be more mindful of those expenses.  
• A quick time and motion study allows you to mindfully consider your daily needs for energy and work to assure you do not overextend yourself to the point of exhaustion.  
• Much like your financial budget, your energy needs a budget, a savings plan, expenditures that align with your values, and ways to replenish or make regular deposits into the account. 

Now, let's take a little bit of time and talk about routines. Energy conservation and work simplification can be built into routines. More and more people are starting to talk about these therapeutic processes and not necessarily attributing them to our profession. OTs have been talking about this for a really long time. Like I said to my kids when they were little, "How do you want to spend my energy?" We have to conserve energy to do the things we need and want to do throughout the day.

Similarly, how do we simplify the work of the holidays? What do you need to do to conserve energy? It is important to do this for yourself and also help children identify ways to achieve this. The expression "If mom ain't happy, ain't nobody happy" is very true. A significant amount of research shows that the stress of the mother influences the stress of the family. Interestingly, the stress of the father does not influence the stress of the family. When we take a quick time/motion study, this allows us to think carefully and mindfully about the daily energy needs. This can help us, our families, and our clients so that we do not overextend ourselves to the point of exhaustion.

None of us are effective when we are exhausted. I understand that this is easier said than done, especially when many of us have a collapse of roles and role conflict. Right now, I am a mother, professor, home maintenance person, daughter, and so on. My father-in-law fell and broke his leg recently, and I had to think carefully about how I would be able to help. I had to take my computer with me because I have these meetings I have to do. I also had to be with him and to do so, I had to get COVID tested. I would have taken my teenager, but he could not go into the facility. This was a real role collapse for me. It was exhausting, but I had to think about setting all of this up without overextending myself, as that would not help anyone in the whole situation.

Many of us have aging parents. We are afraid for them and their safety, whether exposure to COVID or the mental health effects of loneliness. Meanwhile, many of us are working from home and helping our children navigate school in a whole new way. We need to realistic about our expectations, especially as we step into the holidays. What might we need to give up? It is like a financial budget. You have a hundred bucks to spend, and that is it. You can also view these as units of energy. You have to make a savings plan for expenditures to align with your values and ways to replenish yourself. One of the things that we did this year in early September was to move two chairs to our small front porch. As I said, we have a robust neighborhood with many little wiggy boys running around who are delightful. I love them. We have done a lot of porch sitting this year where people can stand six to 10 feet away and say hello when walking by. We did this, so we did not feel so isolated in our house. This was all about setting up an environment to help me replenish. While I could not necessarily be with people in the way that I used to be, I could do this one little thing to give me money in my energetic budget.

Many other things replenish us, like having a cup of tea. We can make a list of things that replenish us or ask our clients to do that. "What is one thing that you can do that would give you back a little bit of energy?" I do not know if you have heard of the Spoon Theory. A woman came up with this analogy. She said to a friend, "I have 12 spoons every day. I have to sort of think about leaving enough energy (a spoon) at the end to be able to get into bed at night. If I go out with friends, that might cost me a spoon's worth of energy. If I have to walk from my car and it is raining or really hot, that might take two spoons instead of one. Then, I have to really be careful about how long I stay out and interact with people." I love this analogy. We need to have the same kind of thinking about energy conservation and work simplification for ourselves and our children. Children with disabilities also have to be careful about how they spend their time and energy.

Habits Should Be Useful: Help Families Consider

• Resist the habit of perfectionism and the futile attempt to re-create the ‘perfect holiday.’ 
• What would be good enough this season?  How many toys does a child need?  How many cookies do you need to bake?  How clean do you really need your house to be before company arrives? How important is it that your children are wearing ‘festive’ clothes?  
• Would the holidays be more satisfying if a child has on their favorite soft shirt but happily getting in the car for the trip to grandma's?  

Habits should be useful. Resist the habit to create the "perfect holiday." What would be the perfect holiday? It is often remarkable when children state what their perfect holiday is. "I can have mashed potatoes and watch cartoons." Well, that is easy. What would be good enough this season? How many toys does a child really need? How many cookies do you need to bake? How clean do you really need to have your house before company arrives? Do children need to wear festive clothes? That was so important to me growing up. Both my boys said, "I'm not wearing festive clothes." To which I responded, "You have to." Do they really have to? Will the holidays be more satisfying if they have on their favorite soft shirt instead of fancy clothes, but they are happily getting in the car for a trip to grandma's house?

Rituals Should Reinforce and Express Your Values

• Spend one's energy wisely – 
• Take the opportunity to sit down as a family, set some priorities this season, spend your time on what you value, and save your energy. Eliminate steps of a task, so it takes you less time and energy. 
• Eliminate tasks and prioritize activities by asking yourself, “Will this give or take energy from my child and me?”  “What does this teach my child about our family’s values?”

A ritual should reinforce and express your values. You want to spend your energy wisely. Ask yourself, "Will this give or take energy away from my child and me. What does it teach my child about our family values?" One of the magical pieces of the holidays is to help our children and ourselves reconnect with our values and what brings us a feeling of worth. This gets into Erick Erikson's stage of development of generativity. What helps me feel like I am leaving a legacy and gives my life meaning? How do we teach that to others?

Suggestions for Promoting Quality of Life During the Holidays

Make a Plan and Be Mindful

• Help families create a plan together – Many children respond well to knowing the plan for the day. 
• Be mindful that each day includes a moment of rest and reflection (like, ‘read with mom for 10 minutes snuggling under the cozy blanket’), some heavy work (carry a bucket of water outside and give the plants a drink), and something that builds the spirit (take a walk and look a the lights in the neighborhood).  Sprinkling this throughout the list of more traditional chores helps build an internal sense of calm organization necessary to fend off seasonal stress.   

Let's talk a little bit about some suggestions for promoting quality of life during the holidays, making a plan, and being mindful. Perhaps, each day includes a moment of rest and reflection. "Today is Tuesday, and on Tuesdays, I read with mom for 10 minutes under a cozy blanket." Or, "I have some heavy work." I used to have a little note posted on my refrigerator that said that the boys had to each day do something that would strengthen their brain, strengthen their body, and support them in being a good friend. That is what they had to achieve every day. Every day I would say, "Have you done those three things?" What they chose to do with those three things was often remarkable to me. What they chose was often instructive for me, and it built habits and routines. If we think therapeutically about a child and give sensory input into the system to prepare their body to meet challenges, we also want to do that for the family unit to meet the challenge of the day. 

Prioritize

• Think about what the holiday really means and prioritize what the essential elements are, and give you the impetus to let go of any tradition that is not essential.  
  • Maybe you can let Grandma’s specially decorated cookies go.  
  • Maybe your child doesn’t need new ‘festive clothing.’

We want to think about what the holiday really means and then prioritize. A significant question during this pandemic is what is truly essential? Is it really essential that we drive 30 minutes for a faculty meeting? Is that really essential? Let's choose carefully. If it is essential, let's do it; however, let's not do that if it is not essential.

Break Down Tasks

• Make large tasks smaller.
• Smaller tasks are more manageable and less tiring. As children fatigue, their ability to handle stress and sensory information decreases. Grownups are not immune to this fatigue-induced stress, and we can start to act like a child (or want to!)  
  • Shopping for gifts for the family could be divided into smaller shopping tasks for one family member or one gift.  
  • Help your child think about gifts from their heart, like a book of coupons for mom promising to dust a room while a parent vacuums, put away dishes every Thursday.

We know that one way to help people with their time/motion activity is to make larger tasks smaller and break them down. For example, shopping for gifts can be divided into smaller tasks. Help your child think about gifts from the heart like books or coupons for helping with chores. Those are so much more meaningful and a way to contribute.

Restorative Time

• Encourage families to set aside restorative time – 
• Even fifteen minutes per day where the children have their special time can help decrease stress and provide security.  
• This time could be used to enjoy a book together, play a game, or work on a project. 
• Remember: when parents are stressed, children’s stress levels increase, so quality alone time for parents is also important. 

We want to co-create performance patterns for a stress-free time, like encouraging families to set aside time to restore our spirits and our bodies. "This is my time," or "It's five o'clock, and let's all take a moment." You can all take a walk together to get your bodies ready for the evening. During the pandemic, my son and I went through a Wendy's drive-through. This is a real treat for him. While he ate in the car, we rode around looking at Christmas lights. It was a big nothing, but we both just felt so full and happy at the end of those silly little 30 minutes. It was just so remarkable.

Set Reasonable Expectations

• Help families set reasonable (developmentally appropriate ) expectations – 
• Knowing your children’s stressors and needs will help structure your expectations during the holidays.  
• Example: 
• If noise is a stressor, shopping will be difficult. Consider earphones or use an app with mindfulness/calming scripts. 
• Making expectations clear can go a long way when we ask a child to ‘hold it together.’ You can offer a list to your child [review before going into the store] and have her be in charge of marking each item off – once the items are collected, it’s clear the challenge is over. Control can be a potent tool for modulating arousal. 

Using all of our developmental theories, we want to pay attention to developmentally appropriate expectations for children and adults during the season. Also, knowing a child's and parents' stressors will help structure some of the expectations during the holidays. We all have stressors like noise, touch, or whatever, and we need to structure activities around these stressors.

Let Kids Use Their Imagination

• Encourage families to let children use their imaginations
• Teach children about limits and limitless-ness
• Set budgets of money and time
• Focus on the meaning of your traditions, [the togetherness, the family time]. Re-value gestures that express values can be important life lessons.  
• Make a list of anyone you wish to recognize this season, and together think of how you might like to express that rather than a list of people you need a gift for.  

I encourage families to let children use their imagination and teach children about limits and limitlessness. Time is limited. Enjoying each other is limitless. It is important to start to use language that highlights this. One example would be to make a list of anyone you want to recognize this season or writing thank you notes. This is a big piece of a lot of family traditions during the holidays.

Thinking About Others

• Help families think about others. 
• This is the perfect time of year for children to go through their toy boxes to select things they don’t use anymore. Ask your child to choose one or two toys that are still in good condition to donate to a shelter or even buy a new toy for a toy drive. Parents can explain that they will soon be receiving new toys, and it feels good to share toys with children who might not have many