Consultant in Adult Developmental. Lead Occupational Therapist Cornwall Partnership NHS Foundation Trust

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1 Developing and Evidencing SI Clinics Dr Rohit Shankar Consultant in Adult Developmental Neuropsychiatry Mrs Carolyn Wilkins Lead Occupational Therapist Cornwall Partnership NHS Foundation Trust

2 One mm3

3 Neuronal Thinking 100 Billion Neurons Once the structure of the brain changes, the functions of the human being begin to change. Therefore, brain structure determines the level of human function. The Brain Can Think For Itself!!! Faulty Wiring

4 Sensory Integration Ability to organise Sensory Information interact effectively with the world and others around us perform functions of dil daily livingi adapt to changes/challenges g within the environment remain calm and alert tdespite challenges hll

5 Hogwarts staircase Neuronal Plasticity!!

6 SI concept Physical movements & different sensory experiences more than daily normal leads to new neural pathways Helps integrate and make sense of the sensory experiences in a more organised way Sensory Processing hinges on positive experiences of physical and sensory challenges Their active participation leads to neuronal plasticity adaptive response reduces their arousal levels and helps calm and alert improve their quality of life

7 Sensory Processing Care Pathway Referral received Indicator screening tool Complete minimum two observations/activities in at least two different Environments, if possible Sensory Processin g issues identified Choose from toolbox of SP Ax Yes Need for more detailed d Sensory processing Ax identified No Signpost onto other services Complete other OT Ax as per OT care pathway Yes (continue to next page) No

8 Sensory Integration Clinic

9 What is examined? Risk Assessments and Health and Safety reports are already completed Sensory problems including arousal & anxiety Vestibular problems Propioceptive p problems Supported by Neurology Assessments Relevant MDT involvement

10 Clinic Assessment Tools Assessment used for testing of proprioceptive and vestibular processing Clinical Observations, Research Version , 2009, Blanche Imperatore, Reinsoso, Kiefer Blanche Assessments used for screening/assessment of Sensory Disorder Adolescent/Adult Sensory Profile Catana Brown, PhD, OTR, FAOTA, Winnie Dunn, PhD, OTR, FAOTA, The Psychological Association, 2002 Sensory Integration Inventory Revised for individuals with developmental disabilities Judith E Reisman, PhD, OTR, FAOTA, Bonnie Hanschu, OTR PDP Press, 1992 Session Records scoring developed from: Sensory Stimulation, Sensory Integration and the Adaptive Response Gretchen Dahl Reeves, PhD, OT FAOTA Neurology Neurological examination Cambridge soft neurological signsinventoryinventory scale

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14 Interpretation of results/formulation of hypothesis Sensory Modulation Disorder SMD Sensory based Motor disorder SBMD Sensory discrimination Disorder SDD Written/visual representation of behaviours in relation to levels of arousal Complete a Shared Therapy Agreement Complete Assessment Summary Goal Setting/intervention planning Sensory Profile Sensory Diets Sensory boxes/ sensory spaces Feed into Person Centred Plan Information leaflets Training/ workshops Monitor/review against goals set Summary of intervention/ Discharge summary Goals Achieved Goals not met/achieved Discharge

15 Outcome Measures A Multi source feedback system of Subjective and objective measures is used Subjective reports Carer and Family reports Professional satisfaction anddischargedischarge The volition Hierarchy Goal attainment Scale HONOS LD Reduction in Psychotropic medication Steady decrease in contact with health professionals Reduced self injury and reduced physical intervention

16 Review of attendance October 2010 Nigel Number of sessions Discharged Primary reason for referral * 3 SBMD Sam 11 SMD Nick 5 SMD Danny 7 SMD Gemma 9 SMD Nazim 0 SBMD Kathryn 1 SBMD Barry 1 SBMD Joanne 3 SMD Michael 2 SMD Gary 3 SMD Ben 4 SMD Chris 4 SMD Lena 0 SBMD/SDD Tracey 1 SMD Hannah 2 SBMD Thomas 1 SBMD Richard 1 SMD Those with 0 : DNA *Primary Reason for referral: SMD Sensory Modulation Disorder SBMD Sensory Based Motor Disorder SDD Sensory Discrimination Disorder

17 Subjective Patient and Carer quotes from recent clinics: "I feel calm when I have been to the session" Her personal care routine is easier now and she does not hurt herself so much She is exploring her environment more

18 The Volition Hierarchy ACHIEVEMENT Autonomy Seeks challenges Seeks additional responsibility Invests additional energy/emotion/attention Pursues activity to completion/accomplishment COMPETENCY Facing new challenges Ti Tries to correct mistakes Tries to solve problems Shows pride Stays engaged Indicates goals EXPLORATION Emerging self-efficacy Shows an activity is special or significant Shows preferences Tries new things Initiates actions/tasks Shows curiosity Ref: adapted from A Model of Human Occupation, Theory and Application, Kielhofner, G. (2002) and Remotivation Process: Progressive Intervention for Individuals with Severe Volitional Challenges, de Las Heras, C. G. and Kielhofner, G. (2003)

19 GOAL ATTAINMENT SCALE Overall Goal: to be engaged in self occupation Specific goal: for Miss ** to sit quietly while mother prepares a meal Self injury is so severe mother unable to leave he. She provides her with deep pressure from cuddling, and vestibular input from slow rhythmic rocking Mother responds to Miss ** s self injury regularly (at least every 5 minutes) whilst doing simple kitchen tasks, (wiping table, washing up). Mother able to prepare a drink with her sitting without self injury, but becoming increasingly anxious. Miss ** uses weighted blanket and deep pressure from being seated in heavy bean bag Mother able to prepare snack meal giving verbal reassurance and physical contact before and after. Miss ** uses calming strategies from Sensory Diet, holding vibration massager and deep ppressure from cushions on sofa Mother able to prepare evening meal without giving her any contact. She happily engaged in exploring items in her Sensory Box

20 GOAL ATTAINMENT SCALE Overall Goal: to participate willingly in personal care tasks Specific goal: to have toe nails cut with no self injury Refuses to have nails cut, self injury too severe, including hitting head, pulling her hair Largest nails (2 on each foot) cut with some resistance and banging arms into sides despite use of self calming strategies (vibration) Needs to be held firmly while all toe nails cut, but with some resistance, though no self injury. Wears weighted vest and vibrating massager to reduce arousal levels Sits with no self injury whilst all nails are cut. Body tense but uses self calming strategies from sensory diet and a weighted lap blanket Sits quietly while all nails are cut. Smiles and enjoys the engagement and physical contact

21 OUTCOMES for the person A highly specialised service that provides an age appropriate opportunity for enabling sensory integration to occur The expertise of a Consultant in Developmental Neuro psychiatry and others in a multi disciplinary approach to enhance knowledge for paid and non paid carers Potential reduction in medication, i (already (l demonstrated dwith ihsome individuals) Reduced support needs, especially with physical intervention because the carers have an increased knowledge in how to reduce arousal levels using an individually designed Sensory Profile Safe environment Greater independence in personal skills Increased mobility lesser falls Increased engagement in occupation and social activities Increased dignity by providing age appropriate activities in an appropriate space Space to allow expression

22 OUTCOMES for the staff Learning from each other, supporting and developing skills in working with highly complex individuals that can frequently challenge services Safe environment to practice Increased motivation, enthusiasm and direct clinical supervision

23 OUTCOMES for Cornwall Foundation Trust Rd Reduced dwaiting times, especially ill secondary waits for therapy services Increased productivity we can see more people A high quality service unique in Cornwall, and available in very few places in the UK Prevention and de escalation of behaviours that could provide a challenge to services Decreased travel costs Better recording with more detailed observations and analysis of clinical information Possible reduction in inpatient admissions?