Sensory Processing: Helping children belong and learn

Dr Jill AshburnerAutism Queensland

What is sensory processing?5 types of sensory receptors

Some more sensory receptors...

ProprioceptionReceptors in muscles, tendons and joints tell us about the position and movement of body parts.

Vestibular (balance and movement)Receptors in our inner ear tell us where our body is in space and about the speed and direction we are moving in.

Is this statement true?

The sensory receptors (e.g., receptors in the eyes, ears and skin) of children with sensory processing issues work differently.

How the brain interprets sensory

information

• Registering sensory information

• Filtering out irrelevant information

• Integrating sensory information from multiple senses

• Organising sensory information in the light of past experiences and understanding

• Creating an appropriate response

Sensory processing is the primary way we experience our world…

Children process sensory input in atypical ways: Who are they?

Children with Fragile X

Syndrome

About 5% of preschool children process sensory information in atypical ways (Ahn, Miller, Miberger & McIntosh,

2004)

Moderate heritability of tactile & auditory defensiveness (Goldsmith et al. 2006)

“Sensory Processing Disorder” (SPD) is not recognized in DSM-5 (American Psychiatric Association, 2013)

The American Academy of Paediatricians (2012) recommended against diagnosing SPD

Sensory processing of different diagnostic groups (Baranek et al. 2006 & 2007; Cheung & Sui, 2009; Rogers, Hepburn & Werner, 2003)

Most AtypicalTypical

Typically

developing children

Developmental

delay

Intellectual

disability

Language

disorder

Autism

Fragile X

Some

children

with ADHD

Unusual sensory responses:

Sensory seeking

Sensory over-responsiveness

Sensory under-responsiveness

Common examples of sensory over-sensitivity

Noises Bright lights

Touch sensations

Common examples of sensory under-sensitivity

Failure to notice things happening around them, such as people talking to them.

Under-sensitivity to pain

Under-sensitivity to temperature

Examples of sensory seeking behaviours

Making noises Smelling things Eating non-food substances

Watching spinning objects

Touching people Movement seeking

Relationship between sensory responses and arousal

Mid-range arousal Selectively attends to relevant sensory

input

Under-aroused Sensory hypo-sensitivity

Over-aroused Sensory hypersensitivity

The 4 A’s:

Arousal, Affect, Attention and Activity(Williamson & Anzalone, 2001)

Under-aroused, apathetic, disengaged, lethargic

Under-responsive to sensory input

Over-aroused, over-emotional, distractible, hyperactive

Over-responsive to sensory input

Alert, motivated, focused, calm/responsive

Selectively attends to relevant sensory input

What are your sensory preferences when…

….you need to sleep?e.g., auditory, tactile, visual, proprioceptive, temperature?• How do the sensory aspects of your environment

influence your Arousal, Affect, Attention and Activity• Is it only sensory issues that impact on your level of

arousal?

…you need to complete an assignment?e.g., auditory, tactile, visual, proprioceptive, temperature?• How do the sensory aspects of your environment

influence your Arousal, Affect, Attention and Activity• Is it only sensory issues that impact on your level of

arousal?

Autism-specific sensory issues

Autism-specific sensory issues

Video 1: Helen talking about noise sensitivity

Is this statement true?

• It is the intensity of the sensory input that causes people on the spectrum to over-react.

Video 2: Helen talking about disco dancing

Video 3: Helen talking about noises she likes

Is this statement true?

People on the spectrum are generally over-responsiveor under-responsive to sensory input, but not both.

Video 4: Helen talking about zoning out

Is this statement true?

The purpose of sensory seeking behaviours is to increase the amount of incoming sensory input so as to increase arousal and stay alert.

Video 5: Amethyst talking about stimming

Video 6: Michael talking about stimming

Difficulty filtering relevant from extraneous details...

Gunilla Gerland

The whole classroom was all wrong for me…The teacher prattling on was a background to other noises in my ears. The rustle of paper, the scraping of chairs, coughing I heard everything. The sounds slid in over each other and merged together. I couldn’t shut them out and put the teacher’s voice in the foreground.

Video 7: Michael talking about auditory filtering

• The brain integrates sensory information from multiple senses

• Research suggests this process may be less efficient in people on the spectrum (Kwakye et al. , 2011, Stevenson et al., 2014; Woynaroski et al. 2013)

• People without autism process speech better when they can see the speaking, but people on the spectrum are not assisted to the same extent by seeing the person speaking.

Multi-sensory Integration

Video 8: Helen talking about multi-sensory processing

What is the impact of atypical sensory responses on the everyday lives of

children?

Anecdotally children can become stressed and agitated in over-stimulating environments such as in a busy playground or shopping centre.

Sensory processing issues have been associated with high levels of anxiety and maladaptive behaviours (Baker et

al., 2007; Ben-Sasson et al., 2008; Lane, Young, Baker & Angley, 2009; Pfeiffer et al., 2005).

Regulation of emotions and behaviour

Struggles with self-care

Reduced participation in self-care skills (Bar-Shalita,

Vatine & Parush, 2008; Jasmin et al., 2009; White, Mulligan, Merrill & Wright, 2007)

Parents report struggles with hair combing, teeth cleaning, hair cuts & nail trimming (Dickie et al.

2009)

Classroom behaviours

Auditory filtering difficulties (e.g., difficulty listening to the teacher in a noisy classroom) and sensory seeking can interfere with classroom participation and performance (Ashburner, Ziviani &

Rodger,2007; Zingerevich & Vesser, 2009)

Children with sensory processing issues appear to have difficulty following verbal instructions and may fidget a lot.

Mealtime behaviours

Sensory over-responsiveness has been associated with picky eating habits (Nadon, Feldman, Dunn & Gisel, 2011; Suarez,

Nelson & Curtis, 2014).

Picky eating habits can lead to battles at mealtimes, and concerns about nutritional intake (Dickie et al. 2009) .

Atypical sensory responseshave been associated with sleeping difficulties in children on the spectrum (Mazurek & Petroski, 2015; Reynold, Lane & Thacker (2012)

Sleeping issues

What are some evidence-informed strategies that can help when sensory issues interfere with a child’s daily life?

Differing perspectives on sensory processing

Described as differences rather than disorders (Dunn,

2001)

Focus is on accommodating sensory differences (Dunn, 2001)

Described as “Sensory Processing Disorder” (Miller, Anzalone,

Lane & Cermak (2007)

Focus on remediationof disorder

Strategies to overcome sensory processing challenges

Remedial strategies aim to improve underlying capacity to process and integrate sensory information

Management strategies aim to:• addressing the mismatch between

the child’s sensory processing preferences and the sensory properties of tasks and environments

• teaching children to self-manage sensory issues

Remedial approaches

• Recent reviews suggest insufficient evidence

Sensory Integration

Therapy (National

Autism Center, 2015; Wong et al., 2014)

WilbargerProtocol

(Weeks et al., 2012).

Sound therapies (e.g., auditory integration training, Therapeutic

Listening) (Sinha et al. 2011; National Autism

Center, 2015)

Ineligible for funding by Helping Children with Autism Package due to lack of evidence

Costly in time and money for families due to high intensity

Often incompatible with services provided at school or early educational settings

Often not used as intended (e.g., greatly reduced frequency, in a group instead of one-on-one)

Remedial approaches

Management approaches

• Many therapists help children and families manage rather than remediate sensory challenges

• Do not aim to change the way the nervous system processes sensory input.

“Sensory processing patterns are reflections of who we are. These are not a pathology that needs fixing”

Adapt tasks or environment

Reduce exposure to aversive stimuli, or make it more

predictable e.g.,

Use ear muffs or iPod in noisy

environments

Sensory input can be embedded within child’s day at key times to help them maintain an optimal level of arousal for learning.

Sensory input to modulate level of arousal

Optimal level of arousalSelectively attends to relevant sensory input

Under-aroused - drowsy, lethargic Under-responsive to sensory input

Over-aroused - anxious, distractible Over-responsive to sensory input

Weighted products and

pressure garments

Dynamic seating options

Exercise/movement breaks

Embed sensory input within daily routines to modulate arousal.

Effect of physical exercise/movement breaks

aggression & off-task behaviour

on-task behavior, engagement and

academic performance

As positive effects lasts 40-90 minutes, children need regular movement breaks during the day

Vigorous exercise has been found to be more effective than less strenuous exercise

Weighted and pressure products

Weighted vests: The bulk of evidence (7 studies) reports ineffectiveness (Cox et al. , 2009; Davis, et al. 2013, Hodgetts et

al., 2011a; Lee, et al. 2010; Reichow et al., 2010; Quigley et al. 2011, Stephenson & Carter, 2009)

Pressure vests: Two small studies report ineffectiveness (Reichow et al. 2009; Watkins & Sparling, 2014)

Deep pressure thought to have a calming/organizing effect. Research has explored impact on engagement, self-stimulatory, self-injurious, and problem behaviours

Dynamic seating options

Dynamic seating options enable children to move while seated.

Research suggests that dynamic seating options are effective for some children, but not others (Bagattell, Miriglini, Patterson, Reyes & Test, 2010;

Schilling & Shwartz, 2004; Umeda & Deitz, 2011)

Not recommended for children with poor postural stability

Hokki stoolMove n’ SitDisc’ O’ Sit

Exercise ball

Other sensory strategies used to modulate arousal, as yet largely untested…

Fidget toys? Oral-motor gadgets?

Behavioural approaches to phobic responses to sensory stimuli typically involve:

graduated exposure

modeling

reinforcement strategies

Behavioural strategies for challenging behaviours related to sensory processing

Some children have phobic responses to objects or activities with intense sensory properties (41% with autism as compared to 5% without autism)

…have been used to manage phobic responses to:

Behavioural strategies…

Skin care product application

Noise-making household appliances

Sound of flushing toilets

(Ellis et al. 2006; Jackson & King, 1982; Koegel, et al., 2004)

…used to address pica behaviours (eating non-food substances) (Hagopian et a., 2011; Lange et al., 2010)

Behavioural strategies…

…used expand restricted diets e.g., gradually exposing the child to new foods with textures and tastes similar to accepted foods (Ledford & Gast, 2006, Marhsall et al. 2014)

Sensory Story® about

coping with noise

I sit on my sitting spot

I can use my fidget balls

Social Story to encourage sitting at circle time

Teaching children to manage their sensory issues

Programs to help children recognise and self-regulate their level of arousal

The Alert Program

The Incredible 5-point Scale I am feeling upset.

I need to calm down. What do I do?

Take deep breaths.

Jump on the

trampoline

Go to a quiet place.

Enhancing the sensory properties of environments:

Enhance salience of important/relevant information

Ensure movement needs are met

Reduce extraneous, distracting sensory input

Enhance predictability

Reducing extraneous visual clutter/distractions

Sheet to cover computer screen when not in use

Rolling room divider placed in front of

distracting areas e.g., doorway

Storing teaching materials in boxes

Fabric to cover contents of shelf

Reducing extraneous noise/auditory distractions

Sound absorbing materials on walls, floor and windows

Low tech noise level

meter

High tech noise level app

Relocate communication situation away from noise source

Structured turn-taking protocol to reduce simultaneous speaking

Noise reduction headphones for children with sound sensitivity

Reducing extraneous tactile input/crowding

Position students with touch sensitivity at front or end of lines

and edge when sitting on the floor.

Sitting spots for circle time

Visual cues includes quiet feet and hands

Enhance salience of important information though visual instruction

Visual instructions

• Highly predictable and concrete

• Can be referred back to as often as needed (not transient)

• Reduces dependence on adult prompts

Visual supports for transitions Video-modelling

Visual skill sequences

Clear physical and/or visual boundaries help children know what activities occur in each area.

Enhance salience of important information though classroom structure

Individual workstations minimise distractions

Enhance salience of important information: Amplifying teacher’s voice

Personal FM system Sound field amplification system

Enhance predictability

Incorporate regular movement breaks

Think sensory!!

Design environments with sensory issues in mind (4 principles).

If you suspect sensory issues are impeding a child’s capacity to participate, seek help from an OT

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Proudly funded and supported by the Queensland Government