Name: Mario (pseudonym)
Age and Gender: Five-year-old boy
Program Delivered: SSP Core (Hours 1-5); SSP Connect (Hour 1)
Mario is a five-year-old autistic boy who experienced difficulty engaging with and trusting others, as well as participating in daily routines and tasks. It was common for him to experience rigidity in his routines and ideas, and experience large meltdowns. He would often flee situations without letting anyone know why and would become distressed if something was presented to him, such as a game or activity, that he did not choose or prefer. Because of Mario’s challenges, he experienced great difficulty starting kindergarten and participating in age-expected activities.
Mario lives with his mom, dad and older sister, who has a diagnosis of ADHD. From about the age of two or three, his parents noticed differences in Mario and realized he might benefit from some intervention. At about three years old, he was diagnosed with autism.
Mario was referred to occupational therapy (OT) to support feeding, regulation and play skills. His parents’ goals were to find ways to help reduce the time Mario spent in fight-or-flight, help his nervous system better deal with stress, and provide access to a relaxed state.
They hoped to increase his food repertoire and decrease the distress he experienced during mealtime. They wanted to better understand his sensory needs in an effort to support regulation and support feelings of safety in his environment to enable him to successfully play with family and peers with reduced rigidity and meltdowns.
Implementation of the Safe and Sound Protocol (SSP)
The Safe and Sound Protocol (SSP) was delivered remotely after a thorough in-person teaching session was completed within the family’s home. While Mario listened, his mother would sit with him and play quiet activities each afternoon or evening as tolerated. Session times ranged from a few minutes up to 30 minutes in one sitting. They finished the five Hours over the course of a few weeks.
Prior to the family supporting Mario through his listening journey, his mom was educated and coached on how to co-regulate with her children. The use of co-regulation was vitally important and used throughout the delivery of the SSP. Sensory strategies, such as dim lighting, a heavy blanket and toys that provided some deep pressure input, were also used during listening.
Using the SSP with an attention to building safe relationships and fulfilling sensory needs has greatly impacted Mario. Almost all of his current OT goals for the year have been achieved, with the exception of a little more work needed around food acceptance.
It has been noted that Mario is more interested in play and is more open to trusted individuals’ ideas when it comes to play. His experience of big emotions have significantly decreased, going from episodes almost daily to now just a few per month. He is able to attend his entire school day with the help of his in-class aid, with whom he has developed a special relationship. His family reports more overall flexibility and capacity to participate in routines with less struggle. Everyone is very pleased, including Mario!
His therapist Daphne Boucher shared the following: “Watching my client change has been special. Seeing more curiosity and engagement has brought joy to our OT sessions and a wider capacity for challenging skill areas and building resilience through tricky tasks. His family is so pleased that their son appears less agitated and able to participate in his life with more pleasure. His school has also noted an increase in participation in activities, even those that were once avoided.”
Using the Safe and Sound Protocol “has been such an amazing learning opportunity to understand how the state of the nervous system can affect participation,” Daphne said. Prior to these learnings, Daphne said she may have focused more on pushing Mario by using behavioral strategies, such as external rewards, or more “first, then” language to push him along. She now knows “that approach would have completely backfired on me when it came to a kiddo like Mario; Mario needed safety more than anything.”
Daphne reports that the SSP worked because it not only supports the feelings of safety but also supports co-regulation. Co-regulation is the process through which individuals co-regulate their internal states in response to social cues from others (Bernier, Calkins, & Bell, 2016). The SSP helped to create a deeper connection between child and parent as they spent this delicate time supporting each other’s nervous systems co-regulating.
Mario’s parents thought the Safe and Sound Protocol (SSP) was worth trying because of his enjoyment of music and the regulation support. His parents had also heard some feedback about the SSP from other families.
What they noticed the most after the SSP was increased engagement, eye contact, and Mario
“asking for his music.” During listening times, he would engage in reciprocal play, such as throwing a ball back and forth with good eye contact, which they had never observed prior to using the SSP. They noticed that Mario was very calm and regulated after listening sessions and enjoying tactile input, such as deep pressure, massage or being close to the parent doing the session with him. Before the SSP, Mario was very tactile defensive and did not enjoy massage.
His parents shared, “The process was easy once it was set up. The biggest challenge was that it was on a screen, which meant he wanted to push the buttons and ended up pausing it quite a bit. Once he knew the routine, it became easier and we were able to spend more and more time listening to the music. We also enjoyed finding new activities we could do together during the sessions.”
Daphne shared the following overall learnings:
“I have learned that before any intervention we use in OT, whether it be for fine motor, gross motor, feeding, etc., it is vitally important to build a safe and trusting relationship first. To do so, we must attune to our client on a deeper level so that we are able to notice the clues which indicate where their nervous systems [are] at.
“We also need to respect and hold space until the client reaches a state of regulation. And it is only until they are in a ventral vagal or ‘regulated state’ that we can assist our clients in working on other goals. Safety is everything when it comes to trust and participation in the world around us and is critical for our clients’ success.”
Bernier, A., Calkins, S. D., & Bell, M. A. (2016). Longitudinal Associations Between the Quality of Mother-Infant Interactions and Brain Development Across Infancy. Child development, 87(4), 1159–1174. https://doi.org/10.1111/cdev.12518
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