Poster session presented at the 2007 ASHA Convention, Boston, Massachusetts
Lauren J. Hummel, Ph.D., CCC-SLP
Speech-Language Pathologist
Manager
Communication
Disorders Department
401-432-1145
[email protected]
Lorrie Massa, BS, OTR/L
Occupational Therapist
Coordinator SP-CMD Clinic
Clinical Specialist
Kathryn A. Sirr, MS, CCC-SLP
Speech-Language Pathologist
Clinical Specialist
401-432-1217
[email protected]
401-432-1440
[email protected]
Please email Dr. Hummel for a word version of this poster.
References and poster copy available on ASHA website
^
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Bradley Hospital
I Lifespan
Partner
1
Center for Autism and Developmental Disabilities
Bradley Hospital
1011 Veterans Memorial Parkway
East Providence, RI 02915
OVERVIEW
Sensory processing problems may underlie challenging behaviors in some
children with autism spectrum disorders (ASD). If this is true then collaboration with an
OT with expertise in sensory processing may help SLPs provide intervention for these
children. Against a backdrop of research and standards of care from the disciplines of
occupational therapy and speech-language pathology, a collaborative OT/SLP approach
to treatment of challenging behaviors of children with ASD is outlined. Two case
examples illustrate a process of diagnostic therapy and case review that leads to childspecific functional outcomes and caregiver acquisition of practical strategies that support
each child's positive behavior outside of treatment.
CHALLENGING BEHAVIORS, SENSORY PROCESSING
AND
CHILDREN WITH ASD
>
According to the DSM IV:
Challenging behaviors in children with autism include:
o stereotyped hand and/or whole body movement
o hyperactivity
o short attention span
o impulsivity
o aggression
o self-injurious behaviors
o tantrums
Odd responses to sensory stimuli seen in children with autism include:
o high threshold for pain
o oversensitivity to sounds or being touched
o exaggerated reactions to light or odors
o fascination with certain stimuli
(APA, 2000)
> IDEA 2004 lists unusual responses to sensory experiences among associated
characteristics in children with ASD.
> Sensory processing differences in individuals with ASD are widely described but
reports about prevalence rates vary (Baranek, 2002, 2006; McFadden & Bruno, 2006).
CLARIFICATION OF TERMINOLOGY
>
Sensory processing:
o how the central and peripheral nervous systems manage incoming sensory information
from the 7 peripheral sensory systems (e.g. auditory, visual, gustatory, olfactory, tactile,
vestibular, proprioceptive).
o involves reception, modulation, integration and organization of sensory stimuli.
o includes behavioral responses to sensory input.
(Miller and Lane, 2000)
>
Components of sensory processing include:
o Sensory registration: conscious realization of sensation and the ability to notice input.
Behavioral responses to sensory stimuli are influenced by a convergence of reliable
sensory information.
o Sensory modulation: ability to regulate arousal state so one can orient, focus attention on
meaningful sensory events, and maintain an alert but relaxed state for successful
performance of daily routines or for learning to occur.
o Sensory integration: is the neurological process of receiving multichannel sensory input
(from one's own body and the environment) and producing an adaptive response.
(Hanschu, 1997, Lane, Miller & Hanft, 2000)
Sensory Processing Dysfunction*
>
Sensory processing problems include impaired ability to process and make sense of three important
types of sensation:
o Vestibular (movement)
o Proprioceptive (muscles and joints)
o Tactile (touch)
Problems with these types of sensation interfere with a child's ability to generate automatic and
adaptive responses to internal and external sensory stimuli.
(Hanschu, 2002)
>
Adaptive responses include:
o the ability to adjust one's actions in response to an environmental demand.
o engage in goal directed response(s) to sensory experiences.
o master a challenge and learn something new.
(Ayres, 1979, cited in Lane, Miller and Hanft, 2000)
*The AOTA (American Occupational Therapy Association) is currently conducting an
evidence-based literature review re: occupational therapy for children and adolescents
with sensory processing disorder/sensory integrative dysfunction.
(S. Schefkind, personal communication, 10/22/2007)
SLPs
CHALLENGING BEHAVIOR AND CHILDREN WITH ASD
An SLPs role with children with ASD is to:
o assist communication partners in recognizing potential communicative
functions of challenging behavior.
o design environments to support positive behavior.
o assess and enhance functional alternatives to challenging behaviors.
(ASHA, 2006b)
Commonly identified communication functions of challenging behavior in children
with ASD:
o "I need" attention, comfort, food/drink, stimulation, help, activity, or an
object.
o "I want to get away from" attention, discomfort, transition, demands, or
stimulation.
(Carr, et al., 1994, as cited in Buschacher and Fox, 2003)
Positive Behavior Support (PBS) is a recommended approach for children with ASD
and challenging behaviors. Team examination of the potential cause of a challenging
behavior is a key component (Buschbacher and Fox, 2003; ASHA, 2006a).
Typical communication interventions in PBS are:
o functional communication training (e.g. Teaching a child to sign or
exchange a picture to say "finished" when done playing with play dough
instead of throwing the play dough on the floor).
o visual schedules designed to aid comprehension.
(Bopp, Brown, & Mirenda, 2004; Buschbacher and Fox, 2003)
>
In clinical practice SLPs encounter obstacles when attempting to apply PBS with
some children with ASD:
The SLP attempts to teach the child to "put away" an activity he doesn't like
instead of biting himself. The child pulls away from the clinician's attempts to
shape "put away" and continues to exhibit the biting behavior. The SLP adds
a picture schedule depicting "toy" then "box." The child rips the pictures
and continues biting.
>
SLPs report that OTs using a sensory processing perspective can determine if there is
a sensory basis for challenging behaviors in children with ASD and provide strategies
to reduce the impact of those behaviors on communication intervention (Richard,
2000; Lessons from the Front Lines, ASHA website, 2007).
OTs
CHALLENGING BEHAVIOR AND CHILDREN WITH ASD
>
An OTs role with children with ASD is to enhance participation in and performance
of:
o activities of daily living (e.g., feeding, dressing).
o instrumental activities of daily living (e.g., community mobility, safety
procedures).
o education, work, leisure, play and social participation.
(AOTA, 2006)
>
Ayers identified aspects of sensory processing related to challenging behavior in
children with ASD, such as:
o input is not registered correctly in the brain.
o the child may not be able modulate sensory input well, especially
vestibular and tactile sensations.
o part of the brain that makes a child "want to do" or "interact with elements
of the physical environment" is not functioning adequately. This is
contributed to by the child not registering the meaning or potential use of
many things.
(Ayres, Robbins, Pediatric Therapy Network, & McAtee, 2005)
>
Anzalone and Williamson (2000) emphasize that self-injurious, challenging and
stereotypic behaviors may meet some sensory needs of children with ASD.
>
OT services for children with ASD:
o are defined by individual needs and participation goals.
o involve providing intervention to help a child appropriately respond to
information coming through the senses.
o may include intervention via developmental activities, sensory integration
or sensory processing, and play activities.
(AOTA, 2006)
> Ayers and Tickle (1980) identified sensory integrative procedures to be most
effective for children with ASD who have overarroused responsiveness to vestibular
and touch stimuli.
>
Williamson and Anzalone (1997) applied a sensory integration perspective to
assessing and treating children with severe difficulties relating and communicating.
They emphasized that children who are hypo-reactive to stimuli can demonstrate
some of the same challenging behaviors as children who are hyper-reactive to stimuli.
>
Anzalone and Williamson (2000) further elaborate how OTs applying a sensory
processing perspective can relate different sensory profiles children with ASD to
different treatment needs.
EVIDENCE SUPPORTING APPLYING AN OT PERSPECTIVE
WHEN TREATING
CHALLENGING BEHAVIOR IN CHILDREN WITH ASD
>
Some OTs suggest that certain strategies are helpful for replacing challenging
behaviors with more functional ways of meeting sensory needs. Others report some
strategies ineffective (Richter and Oetter, 1978 cited by Szklut, 1994; Zisserman,
1992).
>
Some SLPs suggest that co-treatment with an OT is helpful when beginning treatment
with children with ASD and severe behavioral issues (Simon, 2007).
>
There are promising anecdotal reports describing how OTs can examine challenging
behavior from a perspective that includes consideration for sensory regulation and
assist SLPs and other professionals in developing effective treatment strategies for
children with ASD (Sarracino, Dell and Milchick, 2002).
>
Koomar and Bundy (1991) discuss how "slow linear movement, deep pressure, and proprioceptive
input" in combination or with other sensory inputs produce positive responses in children with sensory
modulation dysfunction.
>
Murray and Anzalone (1991) presented a case example in which an OT combined sensory integration,
sensory stimulation and behavioral approaches with parent and teacher consultation in treating a child
with autism and challenging behaviors. Improvements reported included tolerance for touch and ability
to follow the classroom routine
>
Frick (1989) presented a case study of a child with autism who was hyper-responsive to tactile,
auditory, olfactory, and vestibular input. After provided tactile (brushing) and proprioceptive input
(e.g. joint compressions) for three weeks the child had fewer tantrums and more participation in daily
routines.
>
Case-Smith and Bryan (1999) used a single-subject research design to document positive behavioral
changes in five children with autism following use of sensory integration techniques (e.g. vestibular
stimulation emphasizing use of suspended swings, tactile stimulation via brushing and proprioceptive
input to trunk and limbs).
>
Downs and Richard (2004) presented some empirical evidence of individual differences in the impact
of sensory stimulation (alerting, calming, no stimulation) on off task behavior in children with ASD.
OUR EXPERIENCE
In our work in a multidisciplinary team serving an inpatient and day school
program for children with both ASD and psychiatric disorders, we see children who have
"failed" multiple intervention and educational attempts. Many of these children have
fluctuating sensory presentations (moment by moment, daily, and across months and
years) that appear to be impacted by a wide range of factors.
In our work in an outpatient clinic, we have anecdotal evidence in the form of
case examples and parent testimonials suggesting that for children with sensory
processing dysfunction and maladaptive communicative means, by addressing sensory
issues first, we can accomplish a functional goal and provide caregivers with helpful
strategies to support positive behavior within a reasonable timeframe (10 weeks).
Across settings, the OTs on our team find that an effective strategy for many
children is to upgrade or downgrade expectations and/or modify a treatment approach
based on a child's presentation in the moment. This is one of the reasons that SLPS on
our team find that OTs with expertise in the area of sensory processing dysfunction can
help with understanding and overcoming treatment obstacles presented by some children
with ASD and severe behavioral problems.
FUNCTIONALLY BASED
ASSESSMENT AND TREATMENT COMPONENTS
>
Collaboration of an occupational therapist (with expertise in sensory processing
dysfunction) an SLP and the child's primary caregiver(s).
>
Combining principles of Positive Behavior Support and a sensory processing
perspective with an emphasis on improving a child's functioning within the natural
environment.
>
Discipline specific functional assessments, with data collection planned and
implemented collaboratively as sensory and communicative inputs/demands are
varied:
o OT: Sensory inventories, clinical sensory trials
o SLP: Communication inventories, comprehension probes
o Caregiver interview
o Caregiver observations
>
Development of Joint Hypotheses re: interdependencies of challenging behavior,
sensory processing breakdowns and communication breakdowns.
>
Establishment of a shared functional goal based on caregiver priorities.
>
Collaborative diagnostic therapy used to identify strategies to prevent or decrease
challenging behaviors.
>
Child's response to strategies frequently reviewed with caregivers and modified via
diagnostic therapy.
>
Conclusion of treatment trial when functional goal is achieved and caregiver positive
behavior support strategies are identified.
COMPETENCIES RECOMMENDED
FOR EFFECTIVE COLLABORATION
>
For OTs:
o basic theory/knowledge of assessment and intervention principles re:
communication disorders.
o knowledge of common forms of assistive and augmentative
communication, including visual supports.
o how to implement communication strategies.
o how to recognize clinical indicators suggesting the need for a referral to a
speech-language pathologist for an evaluation.
>
For SLPS:
o how sensory processing problems may impact a developing nervous
system with respect to arousal state modulation.
o how to recognize potential sensory barriers for adaptive functioning for
children with ASD.
o how to implement sensory strategies and make environmental
accommodations that may maximize a child's learning potential.
o behavioral indicators of sensory processing dysfunction that indicate a
need for evaluation by an OT qualified in sensory processing.
RESEARCH NEEDS
1. Exploration of factors that influence changes in a child's sensory profile.
2. Co-occurrence of sensory processing dysfunction and severe challenging
behaviors in children with ASD.
3. Relationship between lack of progress in functional communication training and
sensory processing dysfunction.
4. Efficacy of collaborative treatment vs. periodic consultation.
5. Experimental validation of the proposed collaborative approach.
FINAL THOUGHTS
We have found that for some children with ASD and challenging behaviors,
sensory-based intervention is a prerequisite to functional communication training. When
this is the case, the SLP provides support to the OT and the child to assist the child in
knowing when he will get his sensory needs met or get relief from overwhelming sensory
input. Once the child is "ready" other communication expectations can be made. At that
point, the SLPs role is to assist the child in developing higher-level adaptive means of
communicating.
We believe that for some children with multiple challenges, intervention
should be viewed as a process that does not always lead to a final stable outcome.
For the OT, this means providing sensory strategies so a child can achieve a calm
relaxed state to attend to an activity, participate in an interaction, or maybe just one
component of a task. For the SLP, this means providing communication supports so a
child will understand expectations and get needs met in the immediate moment.
JOHN
Age: 16 years old
Diagnoses: Autism, Mood (feeling) Disorder NOS (Not Otherwise Specified)
Inpatient School Program
Functional Assessment
Presenting Complaints:
1. unpredictable disruptive vocalizations when approached
2. throwing objects
3. kicking others
4. scratching/pinching others
5. pacing and running around the room
6. isolated from peers
7. not participating in any classroom routines
SLP said, "I cannot get near him, he keeps kicking me."
Teacher wishes: John could join group activities.
Hypotheses:
1. Overwhelmed by multi-sensory input in high stimulus environments (e.g.
classroom, community, cafeteria, and gym assemblies).
2. Uses pacing as a self-stimulating activity.
3. Predominance of maladaptive communication means secondary to sensory
problems.
4. Poor tolerance of multi-sensory input contributes to maladaptive behaviors.
Plan:
1. Address modulation to maintain a calm state with changes & transitions within an
environment or between environments without eliciting a fight or flight response.
2. As strategies are identified, review with teacher for trials in other settings.
Functional Goal:
Participate in a classroom-based group with peers (training a therapy dog to perform
tricks).
Sessions 1-4
Tx Plan:
Explore how to provide modulation to John during group (e.g. try using pressure vest and
fidgets). Maximize opportunities for visual orientation.
Outcome:
Effective Strategies:
Wearing pressure vest and using fidgets during group, having him sit in doorway of
classroom.
Positive:
No aggression.
Remained in doorway for entire group.
Teacher reports using these strategies results in similar positive outcomes during morning
meeting.
Behaviors that Persist:
Loud vocalizations.
Unrelated echolalia ("I went to Walmart", "I said prayers").
Running around.
Sessions 5-8
Tx Plan:
Needs greater focus on modulation so add pressure vest use throughout the day. Not
ready for communication or language processing demands, but provide John
opportunities to reach for objects to request or refuse. Increase sensory input and visual
cues during group (e.g. standing while holding weighted container of dog treats, move
chair into circle of classmates).
Outcome:
Effective Strategies:
Being dosed with strategies throughout his day. Wearing pressure vest during group,
standing while holding weighted container with reward for dog (provides sensory input
and object cue for comprehension), sitting where he can see classmates.
Positive:
No aggression.
Sitting among other students.
Occasional spontaneous group related talking ("Where's the dog?").
Behaviors that Persist:
Unrelated echolalia and disruptive vocalizations.
Head down, withdrawn.
No peer interactions.
Sessions 9-12
Tx Plan:
Maintain supports for modulation, increase supports for understanding where he is and
what he is doing. Increase verbal prompts.
Final Outcome:
Effective Strategies:
Pressure vest, standing while holding objects, gesture cues (e.g. peers held out hand for a
dog treat), simple verbal prompts during group, "John, look!" provided by both peers and
staff, preparatory cues provided by teacher and SLP (e.g. handing out materials before the
group, reviewing group schedule).
Overall Profile:
1. Participating in the entire group with classmates.
2. Related spontaneous language predominates.
3. Periodically loud.
4. Rare aggression.
5. Stays in classroom for whole day.
6. Teacher reports he is able to do some sorting activities.
Functional strategies and environmental accommodations for classroom use:
1. Ongoing need for sensory input (e.g. pressure vest, standing while holding
objects).
2. Ongoing need for support with orientation (e.g. object cues and simple language).
CHRIS
Age: 12 years old
Diagnoses: Autism, Mood (feeling) Disorder NOS (Not Otherwise Specified)
Outpatient Clinic Client
Functional Assessment
Presenting Complaints:
1. hitting/kicking
2. screaming
3. scratching, head butting
4. object flapping
5. face slapping
6. throwing
7. fleeing
Mom reported: unable to do ADLs, lack of leisure activities, and rarely uses the signs
(e.g. more, eat, finished, drink) that he knows.
Mom wishes: for him to be able to play a game with her.
Hypotheses:
1. Hits and screams to block out overwhelming stimuli.
2. Overwhelming auditory, movement and tactile sensory input cause
Flight/Fright/Fight behaviors.
3. Uses visual self-stimulation to soothe.
4. Predominance of maladaptive communication means secondary to sensory
problems.
5. Unable to attend to environmental cues.
Plan:
1. Address modulation with initial focus on acceptance of interactions without
eliciting a fight or flight response.
2. As strategies are identified, review with mother for trial and implementation in
other settings.
Functional Goal:
Play a game with Mom.
Sessions 1-4
Tx Plan:
Improve modulation/tolerance for interaction via implementing dosing of tactile and
proprioceptive input (e.g. brushing & joint compressions) in school & home
environments, incorporate jumping & bouncing during treatment sessions only, limit
communication demand to pre-symbolic opportunities but provide objects to reach
for/push away. Assess benefit of visual supports. Coach mom in effective strategies in a
separate room from where Chris was being seen.
Outcome:
Effective strategies:
Brushing, joint compressions, jumping, bouncing, 1-2 word verbal input, providing
objects to reach for/push away, microschedule paired with Chris removing pictures as
tasks were completed. Having mom provide input at home and train in home staff to do
so as well. Having mom ask teacher to do the same at school using home/teacher
logbook. Teacher able to call clinicians with questions.
Positive:
Transition into a session without aggressing to mom and wait for mom to return at the
end of session without crying.
No more fleeing, head butting, or throwing.
Mom reported improved ability to sit in chair to complete tasks (5-10 minutes in school
& at home).
Behaviors that Persist:
Hitting.
Screaming.
Scratching.
Frequent face slapping.
Sessions 5-8
Tx Plan:
Continued need to improve modulation. Continue brushing and joint compressions but
add dosing of jumping & bouncing in home and school environments. Add vestibular
input via swinging with compression in sessions. Provide more support to Chris so he
will know how long he has to tolerate input (e.g. how long he has to jump on the
trampoline). Have mom in the treatment room for strategy training and participation in
session.
Outcome:
Effective Strategies:
Brushing, joint compressions, jumping, bouncing, swinging with compressions, 1-2 word
verbal input, providing objects to reach for, micro-schedule, visual representation of time
using colored squares that Chris removed as task progressed.
Positive:
Engages in a game with two people (action turns, standing and tossing a ball).
Attending to visual supports; increased repertoire and number of activities within session.
Signs occasionally.
Behaviors that Persist:
Occasional aggression.
Screaming.
Foot stomping.
Whining.
Occasional face slapping.
Sessions 9-12
Tx Plan:
Increase expectation to communicate via sign ("finished" "more" "help" "drink") or
head nod (e.g. yes/no to answer questions), modify communication expectations based on
sensory state, continue using visual supports to aid understanding of scheduled events.
FINAL OUTCOME:
Effective Strategies:
Dosing with tactile and proprioceptive input at school and home; participation in
naturalistic activities (e.g. errands, walking, riding in a car; catch with a basketball) that
have enriched sensory (proprioceptive/vestibular/tactile) input. When arousal level is
high use more visual supports, including a microschedule and modify communicative
output expectations (instead of signs and photos accept gestures and objects).
Overall Profile:
1. Plays games with mom.
2. Can do 5 activities for up to 30 minutes.
3. Able to communicate even when distressed.
4. Spontaneously makes requests via sign.
5. Occasionally reaching for pictures from picture schedule to make requests.
6. Rarely cries at school.
Functional strategies and environmental accommodations for home & school use:
1. Sensory Strategies.
2. Visual representations of time for expectations.
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