OTS 51: FAB Strategies For Complex Behaviors Feat. Dr. John Pagano
- Jayson Davies
- Jun 14, 2020
- 32 min read
Updated: Jun 24
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Welcome to the show notes for Episode 51 of the OT Schoolhouse Podcast.
In this episode, Jayson and Dr. John Pagano talk about the assessment and treatment of children and adolescents displaying complex behaviors. Dr. Pagano shares resources that he has developed over the years that you can access for free at FABStrategies.org.
This podcast does not qualify as a Professional Development Podcast. You can learn more about how to earn professional development credits through the OTSH Podcast for your OT/COTA renewal certification here!
Links to Show References:
Visit Dr. Pagano's website FABStrategies.org to get the freebies that he mentioned in the episode
Get the FAB Strategies book at Amazon
Be sure to subscribe to the OT School House email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs.
Have any questions or comments about the podcast? Email Jayson at Jayson@otschoolhouse.com
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Episode Transcript
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Amazing Narrator
Hello and welcome to the OT school house podcast, your source for school based occupational therapy tips, interviews and professional development. Now to get the conversation started, here is your host. Jayson Davies class is officially in session.
Jayson Davies
Hey everyone. And welcome to episode 51 of the OT school house podcast. As always, my name is Jayson Davies, your host for the show, and today, we are going to be talking about complex behavioral difficulties and some strategies that we can use to go ahead and potentially to support these students who might have these behavioral issues. That's a good way to put it, I think, and to do that, we have a very special guest on by the name of Dr John Pagano. I'll give him a little introduction here in a moment, but first I want to share a little bit of an announcement. I actually, as I was sitting down to record this introduction, I saw an email that the OT school housed A to Z school based ot course has actually been board approved by the state of Florida as a continuing education course for eight hours of continuing education. That is awesome news for me. That's awesome news for everyone that's in the course, and I hope it's also awesome news for anyone who may be interested in taking the course. So yeah, as we finish up and or as we finish up this week, it's Friday, as I'm recording this, and I am kind of putting the end to this week. This was actually the first week of the current A to Z school based ot core cohort, and it was just a great week. We have about 100 occupational therapists meeting together, and we're going over the entire process of school based ot from the very beginning with 504 plans and SSTs, all the way through the RTI process and through evaluations, through the IEP, and even eventually to when students are ready to graduate, and how we can facilitate that process in an ethical manner. So that's kind of what I'm going through right now with those or with that cohort, and it's just been awesome. It's a big, small group, if you know what I mean, like, it's not too big to be overwhelming, but it's big enough that we all feel like we can collaborate a little bit together, and the conversations that we've been having have just been awesome. All right, so I want to go ahead and jump into today's content with our special guest, Dr John Pagano, so I'm going to go ahead and introduce him right now. So Dr John Pagano, he actually presents on what he has coined the term fab strategies. And we'll get into what fab strategy stands for in a second. He presents about these strategies internationally for therapists as well as speech therapists, physical therapists, mental health therapists all over the world on improving self regulation in children, adolescents and adults with complex behavioral, developmental and sensory processing challenges. He's been a therapist for over 30 years, and has worked in just about well, not every setting, but many settings, including the NICU Birth to Three sensory integration clinics, preschool schools, group homes and a psychiatric hospital setting. He's known for his humorous style, as you'll get to see in this episode, and he is he has a lot of his extensive background, I guess I could say in working with young adults with autism spectrum and other complex behavioral and developmental challenges. Dr pagano holds a Bachelor's of Science degree in occupational therapy, a master's in special education and a PhD in Human Development and Family Therapy, and I really think that that is key. You'll hear me talk about a little bit later, how important I think it is that for those therapists who who were able to get a bachelor's in occupational therapy and become licensed and registered because it allowed them to go on and get masters in other diverse areas, and I think that is so beneficial to our field. And I'll talk a little bit about that as we go, as we get into the interview, you'll hear that later. But more about Dr Pagano. He is certified in pivotal response treatment, neurodevelopmental treatment for children and infants, early childhood mental health, QST, sensory massage for autism. And he is also an instructor for positive behavioral support and movement based learning. All right, so that is just a lot he has done. He has done many things. I didn't even mention that he's actually the vice president of the Connecticut Occupational Therapy Association, and has several published papers with, actually, people that have been on this podcast before, and he is very involved in OT community up there in Connecticut, in the surrounding areas. So please, please, please help me. Welcome to the show. Dr John Pagano, Good morning, John. Welcome to the OT school house podcast. How are you doing this morning?
John Pagano
Great. I've listened to your podcast before, so it's really cool to be on. It, yeah, and actually,
Jayson Davies
you reached out to me in an email, and it sounded like you were familiar with one of our previous guests on the show, and tell us about that.
John Pagano
Well, I got contacted by a ot a and joined this thing we call school mental health working group, it's a bunch of us that meet together by zoom and like, write papers together, but like, have never met sometimes and Susan, two Susans have been helpful, Susan basic and Susan Cahill. I wrote a paper with Susan Cahill because it was bothering me that when I had a kid in a psychiatric hospital, I was sending him back to the public school, the principal would say, you can't give him ot in our school because he has no handwriting problems. And I was like, we do more than that. Susan Cahill is this big professor, and so her and me wrote a paper, and it's saying that the A, ot A says we can do more than handwriting. We can work on kids social skills, on helping them not punch the teacher. There's a lot of other things we couldn't do. So this way, people now have the blessing of the A ot A, that our scope of practice includes mental health, social skills, handwriting and lots of other things. That's fantastic.
Jayson Davies
So is that an Asia ot article, or is that like an A ot a paper?
John Pagano
It's an A ot a paper, but I'll send it to you, because there's so many resources at the OT a that you almost have to be a tech expert to dig out what you want in under five minutes. That
Jayson Davies
is true, that is, they have a lot of resources on their page, and you can kind of get lost if you don't know how to use their page a little bit. I completely agree. But they did read they recently redid the page, and it looks beautiful, so I got to give them credit for that. Yes, cool. And so for everyone listening out there, he's going to send me that PDF so or the link to it. So be sure to check out ot schoolhouse.com, forward slash episode 51 to get all the resources from today's episode. All right, so you talked a little bit about that. Why don't you go ahead and give us a little bit of background into yourself as an occupational therapist.
John Pagano
Well, I'm gonna give you guys a trip in history. I'm 62 years old, and I had a sister who had Down syndrome and died of pneumonia, and when I was 14, I saw someone, and their tongues looked different. I'd never seen him before, and I felt kind of scared by him, and that really upset me. So I went into down the street was a facility where they house children with developmental disabilities, and I said, I want to be a volunteer and just like, jump into it. And this lady was trying to feed one kid, another kid was crying, so she took this little girl who had cerebral palsy and threw her in my arms, and immediately she just conformed to my arms and stopped crying. And I said, this is my thing, like, this is what I was supposed to do. So I volunteered. When I was 16, they hired me as a recreation therapist, and then when I was 18, I started ot school and got my Bachelor's in OT that's what it was in those days, and a license, and worked in pediatrics and developmental disabilities, mostly school system. And then I got a job in a clinic, and I was doing Birth to Three. I was doing clinic sensory integration. I was doing everything, and they sent me out to do our school mental health contract. We had some locked psychiatric hospitals that had adolescents in them, and the because their kids, they had to go to school, and if they had handwriting on their IEP, then they needed an OT so I went there, and they realized they wanted to cut seclusion, where they lock kids in rooms, and they wanted to cut out restraint, where they jump on kids. And everyone wanted to stop that. All the aides wanted to stop that, the superintendent wanted to stop that, and they felt that I had a role in it, so they hired me full time. I left the clinic, and I've been there for 11 years now. Let me add a second. OT, Oh, nice. So it's. Is a hospital, the only locked hospital for adolescents in Connecticut, and then I also work next door in the prt f it's like a step down unit, a psychiatric residential treatment facility for adolescent girls. And now there's two OTs. There's a new school OT, and it's a big part. They basically bought me anything I want. So I've weighted blankets, I have weeded vests, I have steamroller Deluxes, I have a punching bag, anything I want, they order for me. So, yeah.
Jayson Davies
And so you said it's for teenagers, it sounds like but it's a hospital. They still have to get their education right.
John Pagano
Right, so I also help out in the school, but I'm not technically the school therapist anymore. They contracted someone else to do
Jayson Davies
that, but that school is housed within the hospital. Yeah, within the hospital, that's a very interesting setting.
John Pagano
Then it's been a real they didn't have OT, and then they had school OT, and now they have two OTs, and their other school has OT. We got Yale adolescent hospital, to add ot once they see what we can do, they added in. In the old days, when I graduated in 81 psychiatry was a major part of occupational therapy, we started to drift away. And I think it's a shame, because we felt that if someone chopped off their hand in a meat cleaver, or someone suddenly had a spinal cord injury, it wasn't going to just be physical, it was going to have psych implications, and if you didn't know how to handle that, you weren't going to get anywhere. And I think that's still true, yeah.
Jayson Davies
Yeah. I agree. And you know what, there is a big push. I mean, in California, we have, it's called ot Occupational Therapy Association of California, and there's a few people that are really grabbing the reins on mental health and really pushing for it, and they're really trying to get people interested again in mental health, and that's, it's just great, yeah, I just really like what they're doing.
John Pagano
Since I started back in to being in that working group with the two Susan other people, I really realized that, you know, it's a lot of money I pay, like $150 a year, but they really advocate for US legally. And then I added to my bucket list that I wanted to be a part of the state association. So I called them up, and they said, Great, your vice president. Oh, wow, probably a mistake. I would suggest people start with like doing media. Did it for four years, and I met some really cool.
Jayson Davies
Oh, that's fantastic, man. Well, thank you so much for advocating for the profession. We all appreciate that. All right, so one thing that I I find really, I don't know I I just really appreciate when ot used to be a bachelor's, and I'm going to tell you why. It's because, when you meet people that are slightly older or experienced and they have their Bachelor's in OT, they always have additional credentials versus newer therapists. We had go through so much school just to get our masters or OT D, it almost limits our ability to then go out and get a masters or a doctorate in something else. So when I was looking at your information, yeah, right. And so when I was looking at your information, I saw that you have a few extra masters degrees and even a doctorate. So I wanted to ask you about those. Why did you get them? And what are they?
John Pagano
I was working as an OT in pediatrics, and I felt like I didn't know enough like about language and stuff, so I went to the local college at night and in summers, because I was a school OT and did my internship in the summers, and got my masters in early childhood special ed, they made Me take courses in speech pathology in regular ed teacher courses, and it was really, really helpful. And then they said, suddenly, they said, now you're supposed to also be able to rehabilitate the parents. I have parents who are coke addicts. I had who were intellectually disabled, I didn't know how to work with parents, so I went to UConn and got my doctorate in the marriage and family therapy program, like going three days a week, and it was really a helpful experience. I didn't become a teacher. And I didn't become a marriage family therapist. I just stayed licensed in OT but I'm really glad I did it.
Jayson Davies
Awesome. That's great. That's it. I just find it so awesome when OTs just have degrees and other things. I just think that's amazing, because I'm sure that you introduce many people in those fields to occupational therapy, and not because you were purposefully trying to, but just because you ventured out of your realm and got some education in another area. And so I just think that's really cool.
John Pagano
I really well, I don't want to get you in political trouble. I feel strongly that they shouldn't up the credentials for CODAs to make them be bachelors. That's why we got so many men and people in color who don't have much money. Because when I graduated in 81 It was outrageous. I had to go to a private college. It was $5,000 a year with room and board. My students say they play pay that for books. Now you end up with this crazy, crazy debt that I'm afraid only elite people are gonna be OTs and CODIS someday, and I don't want that. Yeah, people want people who look like them, you know?
Jayson Davies
Yeah. And I think, I think that a lot of people out there that do agree or have similar feelings that you have about that. So, yeah, I agree. I don't want to get too much into it yet, but I think that might be a great podcast for another day. But today we are actually here to talk about children, adolescents who display complex behavioral concerns. And so we're actually going to go through a little bit of assessments about how you assess. We're going to talk a little bit about the research, and then we're also going to talk a little bit about the treatment and how you go about helping these students and adolescents that you work with. So you know what? Let's start off with first, let's give a definition to complex or challenging behaviors. What are you talking about when you use that term?
John Pagano
I especially enjoy working with kids with complex behavioral challenges, not the kids who are tiny bit naughty, kids who punch, kids who spit, kids who are sexually inappropriate, because I feel it's an important part of OT functionally. If somebody can't write really, really well, they can still make it in life, but people don't want to live with someone who's violent. They don't want to have them in the workplace. It's very, very problematic functionally, if you have inappropriate behavior, and that's something that I feel we OTs are good at helping with within like two weeks, my ot students at the psychiatric hospital are as effective in treating as I am. And one time, they kind of conned me, because I have a lot of friends who are in the colleges. So they said, I said, I really think I can only handle one ot students. They said, All right, but we're gonna send four and get rid of three and pick one. And they sent four fantastic students. I said, I'm really kind of like them all. And they said, Okay, well, how about you take them all? So I did. I took four. There was just me, and what they noticed was we have this big shot doctor who works for Yale, and he did a study and found that there was more incidences of violence on the weekends when there were no OTs than during the week when my students were there, wow. And I think it's simply because we're taught to value the person. There's this ot president who said, OTs ask what matters to you, not what's the matter with you. And and I love that, because I think that's how we were taught. You know that everybody's a person. They may have a disease or they may have a mental illness, lots of people do but their person, and if you could get to what is meaningful to them, then you're going to be able to motivate them to get better.
Jayson Davies
Exactly. No, you're absolutely correct on that. So, yeah, I love that quote. I am trying to think of who I've heard it too, and I'm trying to remember which President it was, but I will look that up, and I would get that out there, someone out there screaming at me, like it is this name. I'm sure of it. Yeah. Yeah, all right, so for the purpose of today, then you talked a little bit about complex behaviors there. What? What is that ideal student that as we're talking today, or that ideal adolescent? Can you give us a picture of who we're talking about today?
John Pagano
Well, one of the reasons I went back and got my doctorate was I was taught what to do if someone has autism spectrum disorder. I was taught what to do if someone has post traumatic stress disorder, but what I get very frequently, and what I think OT is uniquely suited for, is a kid who has, say, Autism Spectrum Disorder, Oppositional Defiant Disorder, has been abused, has been in 15 different homes, and also has a lot of difficulty following directions because they have a sensory processing disorder. So they've got all four, and school didn't tell me what to do with all four, but I think it kind of gave us the foundation to figure that out. And so I think OTs are very good at that, and a traditional psychologist may not have training in developmental disabilities. When someone has a mental illness and developmental disabilities, it's a little bit of a different ball game, and that's what I think we're good at.
Jayson Davies
Yeah, no, I think you're right, and I really appreciate how OTs just look at the whole picture. And this kind of leads me to my next question is, I don't know, have you ever had the chance to work with BCBAs and behavioral therapists?
John Pagano
Yeah, a lot of times, and it's been interesting. I prefer something that's very research proven, but they're terrible marketers. It's called pivotal response training. And what happened was this ABA expert who studied with love, loss and all that was smart enough to marry a speech therapist and she became a doctor with him. They're called the kogels, and Dr and Dr Kogel developed pivotal response training, it is ABA, uses ABA, but in order to developmentally Progress people's motivation, social emotional skills and their generalizability, and I use it a lot for kids who aren't autistic but need more motivation, better social skills and better generalizability. So I don't see ABA as evil or anything, but I like better this pivotal response training brand of it, because I find that it's important to work on those An example would be, let's take motivation. If a child gives you a good answer, he tried really hard, but he didn't get it right. You reward him anyway, because you want him to become more motivated. An example of generalization and social skills is you embed a human being in the reinforcer. And it's usually what I would consider an OT activity. A kid says, jump and I jump on a bed with him so he can jump higher because I'm jumping with him and I weigh more than or he says, swing. So I push him on a swing, rather than he says, swing, and I shove an Eminem in his mouth. It's much more practical. It's the adult is embedded in the reinforcer. And you're going to, if he gives you a cruddy try, you're not going to reinforce them. But if he gives you a good approximation of saying swing and he tried his damnedest, you're going to push him anyway. Yeah, then you're going to ask for a little more. And they're very respectful to OT, obviously, to speech because the wife is a speech pathologist, and I just like that brand a little better.
Jayson Davies
Okay, and yeah, again, I'll have to put that information up on the pod or up on the research page, so that people can find more about that. One thing about about ABA is that, I think that there's so many things like you're talking about, we can do a lot of those strategies that ABA does. In fact, we already do many of those ABA strategies. What I do find, at least in the schools, is, in my opinion, I see ABA therapists often, and they're coming in now. I don't. Know how it is in Connecticut, in the schools, but in California, there are a lot of ABA therapists now coming into the schools. And in my opinion, it's often because, like you said earlier, we are seen as a, the handwriting specialist and B, because our caseload is so high that we often kind of almost push away from maybe taking on those cases that we're going to talk about today, those behavioral type of cases. But yeah, that's just kind of my two cents in it. So I want to move on to behave or sorry assessments, assessments of behavior. And so when you get a new patient, a new client, a new student, what type of assessments are you using?
John Pagano
The first thing I do is a trigger and coping strategies form, and I'll put that on your website. I adapted it from the Massachusetts safety tool, and although it's copyrighted, I give it out. I give everyone permission to use it. So it's a bunch of pictures on the first page, and you pick the three pictures that most appeal to you. So first are environmental triggers. It's something that happens, and when it happens, after it happens, you do what gets you in trouble? You cut yourself, you punch somebody, you swear at somebody. So an environmental trigger is a bunch of pictures of like I'm held to restrain. I'm told, No, which is the biggest one in the research. I'm told I can't do something. I'm told, you know, I can't do what I want. I'm tired, I'm hungry, and they circle the three pictures that are their biggest environmental triggers. The next page is their body triggers. What do they do before they punch? I make a fist before I yell at somebody. So that's my environmental trigger. Some people cry, get a red hot face, act silly, swear, so that they are identifying their warning situations and their warning body movements. A lot of times we have to figure this out for them, but you're starting to ask them about that. Then the next five pages, they have to pick three coping strategies that they're already using, and they work. And then we're going to try to expand on those. So that's a pretty much an eval I do with everybody. And the reason is, a lot of times when I get kids, their behavior is so challenging, and they've already had ot they know I can't help them, so they're not going to cooperate. So this gives you a way to trick them into showing them that you got something to offer that so things they don't know, like Thera band. I'll teach them Thera band hitting a punching bag. I'll teach them a scooter board. I'll give them a ride on a scooter board. So whenever they see coping strategies, they don't know even tense and relaxed muscles. You teach it to them as we're going along. So it gets them. I give it first. It gets them to do the assessment. Yeah, yeah. And then I give the sensory profile. Often, I'll have the short form filled out by a teacher or a parent ahead of time, because it often has things, especially if I see a kid once a month that I can eat, I can't fill it out good. So I'd rather get other people to fill it out, but they have to fill out every question. That's what you tell make your best guess. Otherwise, I can't score Exactly.
Jayson Davies
Yep. Okay, yeah. And one thing about the sensory profile, do do you use the school factors that that gives you?
John Pagano
I've been using just because I learn one thing I like, and I keep it I use the short sensory profile too. I like it for children, because it's fast and because it's reliable and valid, but also what it does now is, when he done, puts what's sensory like, I put my hands over my ears to protect my ears from sound, versus what's non sensory she doesn't like, if I call it behavior, but tantrums spitting at people, yeah, so that you have a bunch of things and you get a score of, Do they have sensory problems. Do they have behavior problems, or do they have both? Usually they have both, but it helps you to organize. Usually kids have both problems. But sometimes they don't. They just have a sensory problem. And those are the kids you get tons. Tons of them coming to your clinic in September because they hold it together in school and then beat the hell out of their brothers and sisters, it's true, so they can hold it together. Also, parents have complained that doctors give Rita Ritalin at school, but then none at home because they don't like parents. So I went to a pediatric psychiatrist. I said, Why do you do that? And he said, I do that because they won't sleep all night. It's actually a stimulant, so if I give it in school, It'll wear off by nine o'clock at night. So that's why they do it. But still, we, who are clinic therapists or even school therapists have to be sensitive that maybe we need to drop the demands at home and like, my son has five hours of homework. That's ridiculous. Yeah, I didn't get five hours of homework in the old days much.
Jayson Davies
Yeah, and I think our teachers are becoming more aware of that, and they really are telling the parents, you know, what, the demands are so high here at school. And the parents are saying the same thing, you know, he works very hard at school when he comes home, he needs a break, or he or she just needs a break when they come home.
John Pagano
And a behavioral tool that I found helpful, again, from pivotal response training is interspersed easy. So instead of giving them an hour of homework, you give them 10 minutes. And a lot of really smart teachers can give them 10 minutes of math that has all the concepts that the hour has, yeah, so they go through. And what I'll do for kids with low frustration tolerance is every other math problem will be one they already know they won't get as frustrated. So numbers 2468, 10 are new, but 1357, are things I know they're going to get right so you don't get them as frustrating.
Jayson Davies
Yeah, yeah. Completely agree with that. Okay, so you had listed a few other assessment tools that you it looks like you use, and they were behavioral, it seemed like or a little more on the behavioral side, I think the DECA, the D, E, C, A, what's that? One?
John Pagano
Is the DevRel early childhood assessment. It's a Do you have? Most of you probably do the PBIS curriculums.
Jayson Davies
Yeah, positive behavioral intervention strategies.
John Pagano
What that stuff really is about, they're different flavors, like different brands. It's scientific. But what it says is, If children have high attachment initiative and self control and low behavior concerns, they're going to do well, even if they have some neurological problems, even if they have some malnutrition, even if they have a very dangerous neighborhood they live In. So what PBIS tries to do is build up attachment, initiative in self control. So you get a score of how low is their attachment, initiative, self control. If it's two standard deviations below the mean, they're really low in Initiative, or in attachment or in self control. And it's very easy for an OT to build it up. If a kid's got poor initiative, you reinforce them for doing things for yourself. If a kid's got low self control, you have them do things like Simon Says, or red light, green light, where Simon says, Do this, do this. You want to do that. Touch your head. But if you do, you're out of the game. And when you think about behavior problems, punching somebody or swearing at somebody is a lack of motor inhibitory control, you should have kept your mouth shut. But you didn't. You said it. You should have kept your fists open, but you punched somebody with them. And so I think it's something we as OTs are very good at teaching. If attachment is something, then you have them do a special thing, just you and them. You work on your relationship, not Freudian attachment. It's attachment of using teachers and therapists the way you're supposed to use some of my kids. If, if they write two and two is five, the teacher marks it wrong, they'll slap the teacher. Well, the teachers marking it wrong because it's wrong, and you really need to learn how to accept that, that that correction.
Jayson Davies
Yeah, and that's one of the reasons that I'm trying to push more into the classrooms next year, is to help the teachers build that relationship a little bit. But I can see your mind turning in and I know sometimes in this. Podcast. We get a little bit off topic, but I want to bring that back a little bit to the decade. So is that what the DECA kind of looks at then? Is it a questionnaire, or what is it?
John Pagano
And what quick questionnaire? And it runs from preschool all the way up to 18 years old. It's something that's commonly used in the schools to mark somebody social, emotionally maladjusted. The psychologists use it, but they they call it the instead of calling it the DECA, they call it something else, but it's the same questions norm for different age. Did you say? How much in the last month did the kid do something that made adults smile or show interest in him or her? If never, that's a low attachment score for that item. Gotcha. How often did they touch adults or children inappropriately? If they very frequently did, then that's going to be a problematic score for behavior concerns and self control.
Jayson Davies
Okay, so it kind of breaks down those areas that you just described to us. Yeah,
John Pagano
and I, I kind of will, in the body of my ot of Val, talk about the very extreme scores, and then just talk about, do they have a problem in attachment, initiative or self control?
Jayson Davies
Gotcha. Okay. Cool. Thank you for explaining that you had one other one, the ASQ se.
John Pagano
questions about behavior, function, Q, A, B, F, and this, I've gotten some criticism for OTs from OTs for using but I feel it's very, very important. It gives you the functional reason that kids are misbehaving. What the research shows is, if kids are misbehaving to escape work, and every time they punch somebody, I take them out of their work and give them sensory input. I'm going to make them worse. Now, if they're the function of their behavior is sensory input, which the behavior that's also call something else. They call it non social, but it's really sensory. That's the kid with autism who's rocking because he digs rocking, rocking gives him something. So if I give him a rocking chair to rock in instead, it's going to make him better, but if he's doing it not for sensory if he's doing it to escape work, then I've got to work with my speech pathologist and figure out a way that he can appropriately tell me he wants to stop working rather than punch me. So when a kid, even if they're on a behavior program and they're and you're doing it and they're getting worse, then you need to do the Q, A, B, F, okay, and that will quickly. It's a check sheet you can do, and you can even as the OT fill it out. It's very simple questions, not not real intimate questions like the sensory profile, and it tells you, why are they being bad? Are they? But you have to get a very specific behavior. It can't be like tantrum. It's got to be punches, people. It's got to be screams. You're answering the questions for one specific observable behavior. Okay, that's a different the worst one first, something I always say, something my mother could see she's not an OT but she can get what punching is. She doesn't get what tantrum is.
Jayson Davies
Gotcha. Yeah. I mean, tantrum is a very broad term for it. Can mean very different things between this kid and that kid and and the other kid. Tantrums can look very different. So all right, I want to get into a little bit of research. You've already thrown a little bit in here and there, but in the resources that you sent me the first area that you talked about, because, I mean, maybe you need to talk a little bit about your strategies, but primarily the three areas that you focus on with research is mindfulness, sensory and then also environmental impacts on behavior. And so I want to start a little bit with the mindfulness and behavior. What research has really, has really, just like motivated you, or what research have you found? Very helpful.
John Pagano
My kind of side job is I give workshops. I give workshops for teachers. I give two day workshops with the Ri for school therapists and for occupational physical speech. I. And so when I give these workshops, what I did was and for myself personally, I developed a form I call fab strategies. Form, put it on your website, and it's got four areas, environmental adaptations, sensory modulation, that's b, c is positive behavioral support, and D is physical self regulation. So I got those four areas, and when going in, I treat I check off what do those strategies work? Because sometimes in the schools, I'm 62 they have me going out four times a year. I can't remember a kid when I see him four times a year. So when I see him the first time, I write down what strategies worked well, and I have the teacher triumph. Then when I come back, I keep the ones that worked well, and I try to add a couple more so that I can remember, so I use it as a daily data sheet, whether I see the kid weekly or monthly. And then it makes it easy to make it into a home program for teachers for next year's ot for the new school. So it's got double value, and it can be done very quickly. My biggest frustration when I work in schools is I don't have enough time.
Jayson Davies
Yeah, yeah, and then you have to really rely on the carryover. So exactly. So I saw the fab Strategies Worksheet, and so I want to talk about that research a little bit. What is the mindfulness research that has helped you to develop that fab strategies.
John Pagano
There's a lot of what I do is environmental adaptation. There's a lot of research. People will say there's no research. I'm real lucky, because my work gives me an hour a day just to do research, because we're teaching hospital so and it takes an hour day. There's so much stuff coming down. So there's a lot of evidence in environmental adaptation that what helps students learn is to highlight the curriculum that stuff you want them to pay attention to. So if they're going four plus four equals zero, they're minus thing they should have been plusing. If you take a yellow highlighter over all the pluses, you can help him to pay attention that it's pluses, and that's been proven research, proven to help children. Another is to decrease the stuff you don't want them paying attention to. So we use, there's proof. We use study carrels to help kids pay attention to their paper. If we use heavy duty walls to separate the sound or noise canceling headphones to reduce the noise level. So you want to get rid of basically all the distractions, and you want to increase curriculum related things. I might have a child read a story, and as he's reading the story, listen to that same story, he's reading on headphones, so he has auditory and visual channels. I might have the teacher have a microphone called an AV system, and the kids got one in his ear. So what the teacher saying is what he's hearing loudest, and I might use noise canceling headphones to help him to not be distracted by the other kids, or if he doesn't like wearing them, what I do is give one to the teacher, and teacher whisper to him, there's going to be a fire drill. I got your headphones. So the fire drill goes off. He's expecting it. She hands him his headphones, and he doesn't make weird sounds during the fire drill.
Jayson Davies
Yeah. And so then, have you ever incorporated some sort of yoga or meditation or anything like that into the classroom?
John Pagano
Yeah, that's the sensory modulation part. So tense and relaxed muscles, and I'll send them like one of my PDFs of what a course might look like, but tense and relaxed muscles is proven to work, but it lasts an hour when the teachers do it and the kids just slap each other. So what I have them do is just tense their face, raise their shoulders up and tense and release their hands. It's got to be a two minute exercise that the teacher could do it fast, or you could do it at the beginning of every ot session, and then move on.
Jayson Davies
Gotcha All right. Cool. One thing that I saw in here. And you already kind of talked about it, is that sensory as a reinforcer versus sensory as an actual treatment, and you had some research about that, I think, yeah.
John Pagano
It's both. And again, I'll put it on your website, but we do have a lot of good research. In fact, the University of North Carolina just added ot as an evidence based practice sensory integration, I'm sorry, as an evidence based practice for autism, people have been working their butts off these smart researchers like Lucy Jay Miller and and Winnie done and stuff, and so they have finally done the quality of research, but it's not going to change. A lot of pediatricians and a lot of behaviorists believe sensory integration is garbage, and they're going to keep saying that, even with the evidence based practice that's finally come out. So we need to know the research too, and that's why I give it to OTs fast, because you don't get an hour day to do research, but I do so I can give it to you, and that's what I think those of us who do speaking, that's our job to get the research for you guys.
Jayson Davies
Yes, and we appreciate it. I try to get some myself, too. So the practical side of things, you talked about how you see kids a lot of times, and I don't know, is it more, if we call it a pull out setting, you're seeing kids individually or in a group. But what are some of your go to strategies? Then for a teacher, you talked about your fab strategies paper. I know you have strategies on there, and everyone can get that at the show notes. But what are some of your go to strategies to give to the teacher?
John Pagano
A couple of different things. One is to optimally stable seat kids who have cruddy balance, like how to make sure that their feet are touching the floor and stuff, and how to use disco sits for kids who have good balance but are just really fidgety and that type of thing to specifically target the problem that they're having. I also find that the forms are helpful, because a lot of times when I go into a classroom, all the other kids start bothering the teacher, so I can't talk to her. So having these sheets enable you and the teacher to have a really fast written backup to what strategies you're asking her to do, because we aren't always paid enough to communicate with each other. I mean, every principal wants us to, but it's not always practical when the teacher has your undivided attention.
Jayson Davies
Absolutely, yeah, and I always tell people, you know, you can't just go into a classroom and interrupt them and start talking to them. I mean, as much as you want to and you feel like you should be able to, you just destroy the whole aspect of the classroom when you do that, and so you have to be careful, and you have to actually plan to have a conversation. You can't just have it at 11 o'clock in the morning when they're in the middle of math time. So yeah, there's
John Pagano
been some really cool ideas out there too. One is like block time that I found helpful. So if I have three very disabled kids in a particular preschool classroom, what I'll do special ed is I'll put them back to back so they're three half hours, 839, nine and 939, 3010 and then I'll with their parents permission, use their time three ways. I'll pull them out 20 minutes. I'll work with all three of them as a group for an hour a week. And in addition, I'll go into the whole classroom and give say a lesson to the whole class. And I find that that's one easy way to do it. Some therapists are playing with they're hired for so many hours, and they handle all the PPT. I haven't got the okay for that, but I think that's the coolest way. And so that way you can really make a difference. And it's a challenge, though, because there are times that the class is so chaotic you have to pull out. But I've also gone into classrooms and worked with my kids right in the classroom. I consider it direct, because I'm only with my one kid, but I'm sitting next to him, yeah.
Jayson Davies
Yeah. No, I really, I really. Really like that, mixed methods that you kind of talked about, where you're working with one a kid, individually, then in a group, and then in the classroom, because that just really, in my opinion, that helps with the generalization back into the classroom. And, you know, I always tell people, what's the point of doing therapy if it's only going to help them when they're with us? We're always trying to get them to be able to be in the natural environment, right? We want them to succeed in the natural environment, not just for 30 minutes in therapy.
John Pagano
So keeps us honest too. Oh, yeah. Does it really work in the natural environment? And sometimes it keeps me honest. I've conned myself in one to one. Yeah, that's not really how much learning takes place.
Jayson Davies
All right, so that was the that was some strategies for the teacher. Do you use the same strategies if you're giving any information to the parent, or do you provide different strategies? Or what do you think about communication, communicating with the parent and providing them some help?
John Pagano
Again, that's why, I mean, I really use this sheet constantly. On the bottom of the fab strategy sheet, it says Signature of parent guardian that they agree with and support this program, because that way you can send it home in their lunchbox if you have to, and get them to sign. So if you're doing any kind of touch, or you're giving a chewy or rifting chair, you get the parent to sign it. You shove it in a drawer, and if there's ever a problem, you have parental permission to do these things, because I've had friends who have gotten in trouble, even for giving a rifting chair to a girl with cerebral palsy was falling out of her chair and smashing her head because the parents didn't want her looking funny. So this way, you've quickly gotten the parent permission, and you're covered.
Jayson Davies
There you go, man. And it's interesting just to think about. I mean, I hadn't even thought about CHEWIES, but I don't know how what it's like in Connecticut, or what they're talking about schools coming back into session. But I know that CHEWIES are not the most sanitary things in the world, and with COVID 19 and everything going on, I can only imagine that schools might say, no CHEWIES.
John Pagano
I am. Appreciate that you're keeping me on track, and I love how you're doing it. I want to go out track one more time. I've been so impressed. I'm the vice president of our Connecticut ot Association, and they have this Community of Practice School system that goes on for an hour a week in meets, and the job they're doing, I'm just so impressed. I you know, they're using video, they're tracking down kids. They've lost. These OTs are just amazing to me, the people in the school. And I just wanted to thank your audience. I'm just really amazed that how they've coped with a situation that they didn't have much warning for.
Jayson Davies
Amazing to me. It's it's been crazy. I mean, in the in the snap of a finger. I mean, we went from seeing kids in the classroom to seeing kids on Zoom and, I mean no training, and teachers too. I mean, shout out to the teachers who are doing amazing work as well, and all the all the school employees, really, and the parents too, of course. But yeah, it it was a big shift in a very limited amount of time. And so.
John Pagano
Yeah, thought it was incredible. Yeah, OTs are adaptive.
Jayson Davies
I think everyone's had to adapt. Everyone's had to do it. I mean, it's crazy, but, yeah, no, I just want to follow up, though I really don't I can see schools. I mean, saying just, hey, sorry, we can't do chews anymore because of the saliva, like you kind of, I think you kind of mentioned was, you know, a kid takes out their chewy and saliva kind of flings across the room. I mean, that's not gonna be able to happen.
John Pagano
You could try to use it at home, you know, yeah, I think in school, I've become very much by necessity. So I didn't get frustrated seeing myself as a consultant. A consultant gives teachers and parents advice, and they're welcome to take it or leave it. What I do to up the ante is when I'm first giving a teacher or I'm first giving a parent a home strategy, I give them what I'm sure is gonna work. You know how, as we get old, as therapists, we kind of know what's working effectively. So I've tried this. This is gonna give them a lot of bang for their buck, and that's all I give first, and I make a copy, and if they lose it, I give them another copy. But then if they say, give me. More then those are the teachers I know I'm going to work a lot with, or those are the parents that I'm going to spend time with the HOME program, because they've got time to do it.
Jayson Davies
Yeah, no, and you know, I that's the other thing you got to tell people, is that some people will be receptive, others will not, and understand where to focus your time. Yes, you know you are going to have some kids in that classroom with the teacher that is not receptive, and you need to give those kids as much time as you can, as much energy as you can. But when it comes to finding a teacher that really wants to work with, you take it and run with it, because that's where you're going to see so much improvement in those kids, not just right now, but in the long term too. So absolutely. Well, John, I think it's about time to wrap up. I want to say a huge thank you, but I also want to give you the opportunity to share any last thoughts and also contact information for you, or where people can learn more about you and complex behaviors.
John Pagano
I'm going to put on your website, the fab strategies form. I also wrote a fab strategies book so that, if you don't know what I call something, you call it something else you can just look it up in the index. I call myself fab functionally alert behavior strategies. And I also have a Facebook, fab strategies site, so people are welcome to connect with me in any of those ways, or email me or whatever.
Jayson Davies
All right, sounds good. Thank you so much for coming on. Really appreciate it, and let's stay in touch and do this again.
John Pagano
Thanks. It's been a pleasure.
Jayson Davies
Take care. All right. Thank you so much again to Dr John pagano for coming on to the OT school house podcast and talking about complex behaviors. Hope you all gain some knowledge from that. Be sure to check out ot schoolhouse.com forward slash episode 51 for all of the show notes and links to John's pages such as fab strategies.com. All right, we will see you next time for episode 52 Take care, everyone. Bye, bye.
Amazing Narrator
Thank you for listening to the OT school house podcast for more ways to help you and your students succeed right now, head on over to otschoolhouse.com Until next time class is dismissed.
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