School mental health interventions

A child with an anxiety disorder may present with excessive worry, poor information processing, low motivation, poor attention span, poor sleep hygiene, social isolation, and low self-esteem at home, school, and in the community. Occupational therapy practitioners provide multiple levels of intervention, including promotion and prevention.

This section includes considerations that you can use when working with students who have symptoms of, and/or are at-risk for anxiety.

• Advocate for school-wide efforts to reduce stress and sensory overload throughout the day for:
  • social-emotional learning approaches,
  • school-wide bullying prevention,
  • after-school leisure activities, and
  • stress-management activities.
• Teach school personnel how to create supportive relationships with children for
  • healthy discipline
  • positive behavioral supports, and
  • effective emotion management.
• Promote environments that support regulation (e.g., brain breaks throughout the day, attending to sensory qualities of the classroom).
• Help teachers incorporate relaxation techniques (e.g., stretching, balance postures, breathing exercises) into existing course structures and routines.
• Foster supportive environments that develop personal passions and promote the play and leisure interests of children.
• Plan inclusive recess experiences (e.g., activity zones, organized group sports) to support social participation, attention, perseverance, cooperation, and conflict resolution.
• Educate school staff and parents on the use of student-specific relaxation kits (e.g., comfort items, fidgets).
• Model emotional regulation strategies and coping skills to children.
• Promote occupation- and activity-based teaching methods for positive relational skills and problem-solving during existing school and after-school programs (e.g., group sports, recess games, classroom jobs).
• Establish predictable routines and habits with children and school staff that promote mental well-being (e.g., classroom routines, organizational skills).

Students

• Use Cognitive Behavioral Therapy (CBT) and Social and Emotional Learning (SEL) to help students recognize and manage their emotions, thoughts, and behaviors.
  • Use self-awareness techniques to teach children emotional regulation strategies.
  • Teach children mindfulness strategies to reduce stress and cope with overwhelming emotions.
• Allow children to gain control by offering choice within activities and contexts.
• Help children build self-esteem by providing frequent praise and positive reinforcement as well as frequent direct instruction and modeling.
• Engage children in activities that promote optimal levels of arousal and relaxation (e.g., stretching, balanced postures, breathing exercises).
• Collaborate with families to address sleep hygiene and sleep routines.
• Use social stories to help children know what to do in stressful situations.
• Offer occupation- and activity-based social skills programs (e.g., play, leisure, life skills) for children at-risk for social isolation (e.g., computer and video games).
• Provide opportunities for creative expression (e.g., art, creative writing, music).
• Check-in on students through self-report measures (e.g., those that address well-being, self-efficacy, or self-regulation skills).
• Promote friendships and positive peer interactions.

School team (including teachers, administrators, related services providers, student, and family)

• Collaborate with the teacher to provide modifications on assignments to
  • break them down into smaller steps,
  • allow flexible deadlines for harder assignments, and
  • reduce homework load.
• Create opportunities for stress reduction in the classroom in collaboration with the teacher to
  • allow breaks for symptom management,
  • develop cues or signals between child and teacher for when a child wants to speak during class, and
  • ask the teacher for the child to be partnered with a friend during more challenging learning activities.
• Educate teachers, caregivers, and children on arousal states (e.g., alertness levels and how to regulate them, the progression of emotion, emotional connection to thoughts and behaviors).

AOTA resources

• Occupational therapy practice guidelines for children and youth ages 5-21 years
• Addressing mental health needs of elementary school children through university-community collaboration
• Group discussions: helping kids plan their transition to middle school

Additional resources

• Mental-health benefits of a mindfulness-based prevention program on elementary school children
• Effectiveness of a mindfulness-based social-emotional learning program
• Research review: the effects of mindfulness-based interventions on cognition and mental health in children and adolescents
• Intervention strategies for anxiety in children
• Mental health

Mei-Ling, L., Nasser, A., Molina, C., Smith, E., & Millar, K. (2020). Mental-health benefits of a mindfulness-based prevention program on elementary schoolchildren. American Journal of Occupational Therapy, 74, 7411515385. https://doi.org/10.5014/ajot.2020.74S1-PO4128

Moreno-Gómez, A.-J., & Cejudo, J. (2019). Effectiveness of a mindfulness-based social–emotional learning program on psychosocial adjustment and neuropsychological maturity in kindergarten children. Mindfulness, 10, 111–121. https://doi.org/10.1007/s12671-018-0956-6

Dunning. D., Griffiths, K., Kuyken, W., Crane, C., Foulkes, L., Parker, J., & Dalgleish, T. (2019). Research review: The effects of mindfulness-based interventions on cognition and mental health in children and adolescents—a meta-analysis of randomized controlled trials. Journal of Child Psychology and Psychiatry, 60, 244–258. https://doi.org/10.1111/jcpp.12980

Contributing author

Rebekah Highlander, MSOT
Saint Louis University

Occupational therapy practitioners work as part of an interprofessional team to structure environments, teach cognitive strategies, and support children’s social and emotional skill development to promote self-regulation, and feelings of competence, well-being, and resilience through participation in everyday activities and occupations. This decision guide includes considerations that occupational therapy practitioners can use when working with children who have or may have experienced trauma.

• Raise awareness about the occurrence and impact of childhood trauma.
• Create a culture of nonviolence through promoting positive behaviors.
• Foster children’s interests in healthy and safe play and leisure occupations.
• Teach children positive coping skills, relational skills, and problem-solving skills.
• Model and teach staff and adults who serve survivors of trauma principles of emotional regu­lation and co-regulation.
• Model and teach children emotional regulation skills.

• Recognize signs and symptoms of trauma.
• Collaborate with clients to identify goals and interventions designed to empower them.
• Use self-awareness techniques to teach children emotional regulation strategies.
• Teach children mindfulness strategies to reduce stress and to cope with overwhelming emo­tions.
• Provide interventions focused on self-regulation and sensory modulation, as well as self-efficacy.
• Educate parents and teachers about healthy discipline including the use of positive behavioral supports and ways to effectively deal with crises.
• Create predictable routines.
• Allow children to gain control by offering choice within activities and contexts.
• Provide frequent praise and positive reinforcement.
• Provide frequent direct instruction and modeling to create opportunities for ongoing competence and success.

AOTA resources

• Web Article –Understanding Children who have Experienced Early Adversity: Implications for Practitioners Practicing Sensory Integration
• Book — Trauma, Occupation, and Participation: Foundations and Population Considerations in Occupational Therapy
• Podcast episode – Trauma, Occupation, and Participation: Foundations and Population Considerations in Occupational Therapy

Additional resources

• The National Child Traumatic Stress Network
• The Adverse Childhood Experience Study
• What is Child Abuse and Neglect? Recognizing Signs and Symptoms

In the United States, foster care provides temporary out-of-home (OOH) care for children who cannot live with their families. Of these placements, 16% are due to abuse, and 84% as a result of neglect, parental/child substance abuse, disability, child behavior problems, parent death or incarceration, caretaker inability to cope, and relinquishment or inadequate housing (Casey Family Programs, 2019).

Children in foster care may present with needs in all areas of occupation. Occupational therapy practitioners provide multiple levels of intervention at individual, system, and policy levels. This section provides considerations that occupational therapy practitioners can use when working with clients at the individual level who are currently or have previously been placed in foster care.

These services may occur within various environments, including the foster home, home environment, pre- and post-reunification, daycare, school, welfare agency, or other natural environments for the individual. Practices may vary widely from state to state and type of OOH placement.

Occupational therapy can assist former foster youth in improved occupation, participation, and health in adulthood by fulfilling gaps in current programming and providing individualized performance-based assessment (Armstrong-Heimsoth et al, 2020). Former system youth express the need for person-centered services that include social skill development, increased participation in meaningful activities, decision-making opportunities, and peer group programming (Armstrong-Heimsoth et al, 2020).

Foundational principles for occupational therapy practitioners include SAMHSA (2014) principles of Trauma-Informed practice. These include safety, trustworthiness, peer support, collaboration, empowerment (voice and choice), cultural, historical, gender, and disability (co-existing condition).

These principles serve as a guide for occupational practitioners to apply occupation-based practice through a trauma lens. Regardless of the setting, SAMHSA principles provide the lens through which OT practice is applied, including the overlay of any additional Trauma-Informed Models of Practice.

ADL

• Focus on bathing, personal hygiene, culturally appropriate hygiene for transracial foster families.
• Teach healthy body boundaries (safe touch vs. unsafe touch).
• Establish a healthy feeding routine.
• Address coping stress with maladaptive behaviors around mealtime or food.

Rest/Sleep

• Develop regulation and co-regulation skills.
• Establish a healthy sleep routine to avoid lack of participation due to frequent sleeping as an avoidance behavior due to stress, falling asleep or night terrors could impact rest and sleep.

Education

• Consider accommodations needed in school to promote occupation and avoid re-traumatization.
• Help children transition to new schools and establish relationships with new teachers and peers.

Play

• Foster developmental skills for play (social, physical, cognitive).
• Promote awareness of possible inconsistent school experience and unidentified learning challenges.
• Facilitate play with caregivers and those who directly interact with the child (i.e., foster family, biological and/or first family, educators, support staff, etc.).
• Strengthen awareness of caregiver’s play skills when interactions with infants and toddlers.

Health management

• Teach basic safety knowledge, such as
  • emergency contact,
  • identifying safe adults,
  • voicing needs,
  • regulation (physical and emotional), and
  • OOH placement awareness of and minimization of trauma triggers.

Social participation

• Promote the development of play and social skills, social-emotional learning.
• Promote awareness of self, self-management, social awareness, responsible decision making, relationship skills.

Client factors to consider

• Foster developmental milestones including:
  • mental function,
  • higher-level cognition,
  • attention,
  • sequencing complex movement physical development,
  • attachment,
  • sensory processing and interoception needs,
  • medical needs,
  • values (consider how first family values and beliefs are carried over in OOH care), and
  • self-identity and knowing “my story” (life book, scrapbooks, etc.)

** Please note that children with experiences of early adversity will frequently demonstrate needs expected to be mastered at a younger age, i.e., their biological age may not match their maturational and developmental age. While occupational considerations are organized generically by age expectation, the provider team understands that benchmarks are mastered in a developmental sequence. For example, a child who is 17 may lack necessary skills such as judgment, problem-solving, impulse control, and perspective-taking needed for healthy social relationships.**

ADL

• Strengthen increased independence with self-care routines including,
  • planning (including weather and context-appropriate clothing),
  • sequencing ADLs, and
  • helping the child explore and create appropriate sexual boundaries for self and others.

IADL

• Explore age-appropriate chores.
• Develop a sense of self through agency over personal spaces, pet care, community mobility, financial management (saving vs. spending), and simple meal preparation.

Rest/Sleep

• Develop sleep hygiene, regulation, and co-regulation skills necessary for the preparation of rest and sleep.

Education

• Consider social and academic accommodation needs and education regarding puberty and body changes.
• Consider social-emotional learning (awareness of self, self-management, social awareness, responsible decision making, relationship skills).
• Assist in school community efforts to promote mental health— bullying prevention, substance use prevention.

Health management

• Promote social-emotional health management.
• Assist with communicating safety needs and symptom/condition management at a developmentally appropriate level.

Play

• Address the foundation of play skills that may have been missed earlier in development.
• Support skills to build team and cooperative play.

Leisure

• Introduce healthy leisure activities or clubs with an emphasis on identifying areas of preferred leisure, internet, and phone safety during leisure such as gaming, sports, theater, band, and extra-curricular activities.

Social participation

• Promote peer group participation and social skills including social media and safety.
• Promote opportunities for team and group activities and community activities.

Client factor considerations

• Consider physical and mental health needs and development.
• Consider cognitive development including,
  • executive functioning,
  • sensory processing and interoception needs,
  • spirituality, values (considering first family values/beliefs as well as supporting child developed values),
  • body image, self-concept, and
  • self-esteem.

** Please note that children with experiences of early adversity will frequently demonstrate needs expected to be mastered at a younger age, i.e., their biological age may not match their maturational and developmental age. While occupational considerations are organized generically by age expectation, the provider team understands that benchmarks are mastered in a developmental sequence. For example, a child who is 17 may lack necessary skills such as judgment, problem-solving, impulse control, and perspective-taking needed for healthy social relationships.**

ADL

• Sequence and take ownership of morning ADL routines.
• Create safe sex practices and education regarding sexually transmitted diseases and sexual identity needs.

IADL

• Develop transition planning for life after foster care such as:
  • child-rearing,
  • driving and community mobility,
  • financial management (banking, budgeting, financial decision making),
  • meal preparation and planning, and
  • vehicle maintenance and responsibilities.
• Create a plan for decision-making opportunities and self-advocacy skills related to the legal system and life skills.

Rest

• Develop sleep hygiene, self-regulation skills, mindfulness, identifying meaningful restful activity.

Education

• Consider social as well as academic needs.
• Identify any specific training/education needed for post-high school planning.
• Promote high school completion.
• Assist in school community efforts to promote mental health—bullying prevention, substance use prevention.

Health management

• Advocate for physical and mental health needs, communication with the healthcare system, medication management.

Work

• Foster employment interests and pursuits.
• Encourage employment seeking and acquisition, job performance, and maintenance.
• Explore volunteer opportunities and participation.

Leisure

• Introduce leisure activities such as sports, theater and/or band, extracurricular, and volunteer activities.
• Cultivate time management for restoration activities.

Social participation

• Promote peer group participation and intimate partner relationships.
• Develop social and safety skills for social media and the internet.

Client factor considerations

• Consider physical and mental health needs and development.
• Consider cognitive development including,
  • executive functioning,
  • sensory processing and interoception needs,
  • spirituality, values (considering first family values/beliefs as well as supporting child developed values),
  • body image, self-concept, and
  • self-esteem.

** Please note that children with experiences of early adversity will frequently demonstrate needs expected to be mastered at a younger age, i.e., their biological age may not match their maturational and developmental age. While occupational considerations are organized generically by age expectation, the provider team understands that benchmarks are mastered in a developmental sequence. For example, a child who is 17 may lack necessary skills such as judgment, problem-solving, impulse control, and perspective-taking needed for healthy social relationships.**

AOTA resources

Ashcraft, R., Lynch, A., & Tekell, L. (2019). Chapter 31: Best Practices in Supporting Students who have Experienced Trauma; In G. Frolek Clark, B.E. Chandler, Rioux, J. (Eds.) Best Practices for Occupational Therapy in Schools. (2nd ed., pp. 243-252) American Occupational Therapy Association Press. ISBN 13: 9781569004111

Lynch, A., Ashcraft, R., & March Tekell, L. (2017). Understanding Children Who Have Experienced Early Adversity: Implications for Practitioners Practicing Sensory Integration. SIS Quarterly Practice Connections, 2(3), 5–7

Lynch, A., Ashcraft, R., Tekell, L. (Eds.). (in press). Trauma, occupation, and participation: Foundations and population considerations in occupational therapy. AOTA Press.

Additional resources

Adverse Childhood Experiences

Child Welfare Information Gateway

Collaborative for Academic, Social and Emotional Learning

Resources for Youth In Transition

Zero to Three

Armstong-Heimsoth, A., Hahn-Floyd, M., Williamson, H., Lockmiller, C. (2020). Toward a Defined Role for Occupational Therapy in Foster Care Transitioning Program. The Open Journal of Occupational Therapy, 8(4), 1-8. https://doi.org/10.15453/2168-6408.1726

Armstrong-Heimsoth, A. (2020). Former foster system youth: Perspectives on transitional supports and programs. Journal of Behavioral Health Services & Research, 1–18. https://doi.org/10.1007/s11414-020-09693-6

Casey Family Programs. (2019). National fact sheet: United States. https://www.casey.org/media/state-data-sheet-US.pdf

Lynch, A. K., Ashcraft, R., Mahler, K., Whiting, C. C., Schroeder, K., & Weber, M. (2020): Using a public health model as a foundation for trauma-informed care for occupational therapists in school settings. Journal of Occupational Therapy, Schools, & Early Intervention. https://doi.org/10.1080/19411243.2020.1732263

SAMHSA’s Trauma and Justice Strategic Initiative. (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

Whiting, C. C. (2018). Trauma and the role of the school-based occupational therapist. Journal of Occupational Therapy, Schools, & Early Intervention, 11(3), 291-301

Contributing authors:

Amy Armstrong-Heimsoth, OTD, OTR/L, Northern Arizona University
Rachel Ashcraft, MS, OTR/L, TBRI® Practitioner, Cicero Therapies; Foster the Future Alabama
Arezou Salamat, OTD, OTR/L, Loma Linda University
Lisa Tekell, OTD, OTR/L, Independent Practitioner

Methods used to physically manage a student's behavior or involuntarily confine their movement are dangerous and may cause trauma. Many schools have stopped using restraint and seclusion and have adopted crisis prevention and response methods to address the needs of students experiencing emotional and behavioral distress.

Consistent crisis prevention and response interventions can be incorporated into multi-tiered systems of support (MTSS) at the school, classroom, small group, and individual levels. Occupational therapy practitioners collaborate with educators and other school personnel to provide multiple levels of intervention that address crisis response and prevention.

This section describes proactive evidence-based strategies within the scope of occupational therapy practice and can be used when working with students who are experiencing emotional and behavioral distress.

Multidisciplinary school team

• Train interdisciplinary staff on restraint reduction interventions, including how to identify, implement, and evaluate outcomes related to short- and long-term goals for restraint reduction.
• Educate families and school personnel on signs and symptoms of emotional and behavioral distress and who to notify.
• Use evidence-based and culturally responsive strategies to address emotional and behavioral health concerns and create a supportive school climate.
• Educate staff on trauma-informed care and trauma-responsive approaches to avoid retraumatization.
• Incorporate movement and mindfulness (e.g., breathing, quiet reflection) breaks throughout the school day.

Students

• Provide education to students and school personnel on effective, non-violent communication.
• Coach student leaders to identify, address, and report mistreatment (e.g., bullying, putdowns, exclusion) of other students.
• Teach students social skills, rules, expected behaviors, and self-regulation skills.
• Promote positive relationships among students in the classroom, cafeteria, and playground.
• Teach students to become aware of their early triggers and provide safe spaces for breaks and the use of effective calming strategies.

School team (including teachers, administrators, related services providers, student, and family)

• Consult with educators and other school personnel to integrate movement (e.g., yoga), mindfulness breaks, and trauma-informed strategies into daily routines.
• Consult with teachers, families, and other school personnel to develop an individualized plan to support the student and facilitate de-escalation and promote overall health and wellness.

Students

• Perform comprehensive assessments of the client’s strengths, facilitators, and barriers to occupational performance.
• Document assessment results for students with difficulties processing sensory information. Provide sensory equipment as needed.
• Modify and adapt classroom environments (e.g., reduce distractions and triggers) and other contextual features to support students’ emotional and behavioral wellness.
• Provide opportunities for students to engage in preferred creative arts activities (e.g., drumming, blogging) that allow for individual expression.
• Use play-based approaches to support behavior regulation and social-emotional development.
• Teach students to self-monitor and request breaks and coping strategies as needed.
• Teach students how to effectively communicate and build positive relationships with adults and peers.
• Encourage students with individualized education plans (IEPs) to attend and participate in their meetings.

AOTA resources

• Mental/Behavior Health and Well-being Decision Guide - pdf
• Choosing Wisely Guide to Sensory-specific and Related Assessments
• Occupational Therapy Practice Guidelines for Children and Youth 5-21
• Addressing Acute Stress and Trauma—Decision Guide for COVID-19
• Societal Statement on Stress, Trauma, and Post-Traumatic Stress Disorder

Additional resources

These websites provide information and resources for occupational therapy practitioners engaging in crisis prevention and response.

• PBIS World
• STAR Institute
• FAB Strategies
• National Alliance of Specialized Instructional Support Personnel (NASISP)
• The National Center for Pyramid Model Innovations

Fraser, K., MacKenzie, D., & Versnel, J. (2017). Complex trauma in children and youth: A scoping review of sensory-based interventions. Occupational Therapy in Mental Health, 33(3), 199–216

Grasley-Boy, N. M., Reichow, B., van Dijk, W., & Gage, N. A. (2020, May 4). Systematic review of Tier 1 PBIS implementation in alternative education settings. Behavioral Disorders. https://doi.org/0198742920915648

Pat-Horenczyk, R., & Yochman, A. (2020). Sensory modulation in children exposed to continuous traumatic stress. American Journal of Occupational Therapy, 74(4_Supplement_1), 7411505189p1. https://doi.org/7411505189p1

Authors

John Pagano, PhD, OTR/L
Faculty, Department of Occupational Therapy
Quinnipiac University

Susan Cahill, PhD, OTR/L, FAOTA
Director of Evidence Based Practice
AOTA