Sensory Sensitivities with Autism

Understanding Sensory Sensitivities and Developing Supports and Accommodations

Based on the book AUTISM: Handle with Care! Understanding and Managing Behavior of Children and Adults with Autism By Gail Gillingham Arlington, TX: Future Horizons, Inc. (817) 277-0727, (800) 489-0727, ISBN#I-885477-14-7

TOUCHING-What Individuals Who Experience Autism Say ... "I was six months old when Mother noticed that I was no longer cuddly and that I stiffened up when she held me. When I was a few months older, Mother tried to gather me in her arms, and I clawed at her like a trapped animal." (Temple Grandin)

"I never used to like being picked up and cuddled. I screamed as though I was on a roller coaster if anyone tried to pick me up. I also hated it when my teacher, Mrs. Ingram, tried to make me hold my pencil properly or my parents tried to make me do up my laces or shirt buttons. They had no idea of what was wrong with me at the time. In addition, since I though it happened to everyone, I did not tell anyone. Nevertheless, I found such treatment excruciating... I do not like pressing my lips on spoons or hard glass either." (Darren White)

Indications of Tactile Sensitivity

* Rejection of human touch * Rejection or discomfort to the touch of clothing. * Sensitive hands and/or feet

* Avoidance of games that involve tactile contact  * Discomfort when sitting in one place for any length of time

* Sensitivity to extreme temperature changes *Aversion to grooming activities and clothing textures 

 The mouth is a very sensitive area.

The tips of the fingers are also very sensitive.

So, watch for problems holding things and doing tasks, especially where a firm grip is needed. 

There may be a great desire for cleanliness, a dislike for sticky or dirty hands.

Supports and Accommodations

* Control our impulse to touch those for whom we are providing care as they may be aversive to this and we want them to be in a calm parasympathetic nervous system state

* Do not take others withdrawal personally--it may mean protection for them. NEVER force hand over hand!  

* Explore the use of deep pressure sensory calming options to reduce "pain" and sympathetic nervous system responses 

*GET OT HELP ASAP as pediatric OT's are the experts in helping to calm their touch system  

Taste

What Individuals Who Experience Autism Say... "I remember sitting at the table and hating dinnertime - staring at my food knowing that it would make me gag if I tried to eat it and that would make my parents mad. Other people constantly teased me about how I ate my food. Kids are supposed to like chocolate, whipped cream and maple syrup; I did not. I do not like vegetables either. Cheese, creams, sauces, casseroles, salads - nothing. I hate being invited out or over to eat -it's never how I like to eat it. People keep telling me I would grow to like other foods, I'm still waiting." B. Kirby

"There are few foods that I can tolerate eating. Usually the ones can eat are soft textured. Italian seems to be the Limit. Sometimes I think it is a wonder that I am still alive."Thomas McKean

Indications of Diet Sensitivities * Refusal to eat certain foods. * An insistence on eating only a limited number of foods. *Gut issues like constipation or runny stools

Supports and Accommodations

* Respect refusal to eat certain foods {e.g., wheat or milk products) and try special diets as this can heal the gut and help them desire healthier foods- never force foods.  

*Play with foods, use play kitchen with real veggies and fruits, involve them safely in kitchen skills 

*Give them a plastic animal that "eats" the food to help improve tolerance in their sensory space first before asking them to eat the food.  

* High protein and low processed food diet often helps - see www.nourishinghope.com for more and nutrition links 

* Never limit liquid intake; their bodies need it and "sucking" on water is calming to them 

Auditory

What Individual's Who Experience Autism Say... "She told me she was much more comfortable, that she no longer heard street noises three blocks away, or people flushing their toilets at the other end of the building, or the blood rushing in her veins she had never been able to blowout the candles on her birthday cake because the sound of blowing had been so disturbing. "It sounded like monsters," she said, as had the puffing noise of the drain in the wall. People's breathing had upset her, especially when several adults were in the room. Why do you think I have so much trouble paying attention in the classroom? I hear everything that goes on every phone call that the principal makes in her office; every single time an eighteen-wheeler truck gears down on the highway three blocks away. I HEAR IT! I HEAR EVERYTHING! I hear people talking outside the school building, and I can understand their conversations. There are so many noises in my head that I cannot concentrate on what Mrs. Weaver tries to say. I cannot focus and pay attention to the teacher's, spoken words -I'm too distracted. In addition, why do you think I am so tired all of the time? It takes so much energy to pay attention that I am worn out. I TRY SO HARD AND I JUST CANNOT DO It!" Nicholas Bober

Indication of Auditory Sensitivity

* The appearance of deafness

* Grimaces when a sound occurs, or perhaps grimaces for no apparent reason.

* Echolalia, or the parroting back of what you have just said.

* Agitation or withdrawal from people, who talk fast, talk constantly or talk loudly.

* Anxiety around people who have unusual vocal tones.

* Response to sounds you cannot hear.

*Avoiding certain places due to noise levels 

Supports and Accommodations

* Never shout keep a calm voice 

* Never insist they listen to sounds they obviously do not like and leave environments that are stressful for them

* Speak as softly and clearly as possible.

* Do not chatter on and on; do not repeat verbal instructions- use visuals instead

 * Give the person time to decipher what you have said.

* Create a sound absorbent environment as much as possible and accommodations such as sound dampening headphones

*Seek auditory treatments such as Safe and Sound 

Olfaction

Individuals with Autism say... ..."You liked the smell of certain foods, and hated the smell of others, Georgie, but what about people? And animals? How did they smell? " She looked sheepish. "I still have trouble, with that," she said. ", dogs and cats. And smells like deodorant and after-shave lotion, they smell so strong to me I can't stand it, and perfume drives me nuts. I cannot understand why people wear perfume, and I can smell hand lotion from the next room." Annabel & Georgie Stehli

Indications of Sensitivity to Odor

* Stopping up nostrils with the fingers, covering the nose with the hand or constantly waving one's hand in front of the mouth and nose area.

* Agitation in an environment that has a noticeable smell.

* Breathing through the mouth rather than the nose.

* Fecal smearing to smell their own scent rather than the environment 

Supports and Accommodations

* Concentrate on the environment, not on the behavior (e.g., don't punish for one plugging nose).

* Offer calming scents and let them choose which ones they like in their environment

* Minimize perfumed products or high smell anything

*Keep the environment clean and dry

*Use scent-free products for laundry.

Visual

Individuals with Autism Say... "Dr. Marek's kitchen was a nightmare. The kitchen had fluorescent lights and yellow walls the worst combinations ever. Even from the doorway, I could see light bouncing off everything. In my tense state everything climbed to hyper, vision included. There were no whole objects in that room, just shiny edges and things that jumped off the yellow walls like sunshine on water. Dr. Marek wanted me to go in there and be blind. Forget it! . I stood in the doorway looking at the light, my eyes jumping from half object to half object trying to take things in. Maybe I could relax a bit and pay attention to this person I was supposed to meet. She was Mrs. Marek, a face upon which light danced maniacally, turning her into more of a cartoon than a human being. Welcome to Toon Town, Roger Rabbit. I wouldd like you to enter this torture chamber I call my kitchen and meet my wife, who is a 3-D cartoon. She just wants you to look at her in pieces, say hi whether you mean it or riot, and treat her like a human being. "I also remember one Christmas when I got a new bike for a present. It was yellow. I would not look at it. Extra red was added to the color making it look orange and it blurred upwards making it look like it was on fire. My favorite colors were those I could see more clearly than others. I also could not see blue clearly, it looked too light and it looked like ice (imagine the sea on a sunny day, it would look frozen over, in spite of the sun). The bike was painted purple, which I liked better because I could see it more clearly. " Darren White

Indications of Visual Sensitivity 

* Squinting. * Sleeping problems  * Closed eyes, or eyes rolled up so only the whites show

* Looking past people or seemingly through people 

 * Pointing directly at something while looking off in another direction

 * Looking off to one side rather than straight ahead while walking, watching TV, or doing task

* Fear of bright shiny objects, mirrors and often certain colors, or of different color combinations

* Attempts to mold the faces of caregivers 

 * Constantly having to touch the environment (e.g., running hands along the wall as walking) 

 * Agitation or refusal to comply when exposed to certain colors

* Long periods of time spent staring directly into a bright light.

* Finger fiddling in front of eyes, spinning objects, fascination with fans or other moving objects.

* Fascination with spinning objects (tops, lids, wheels of toy cars, records and cassette tapes).

* Fear of heights, stairs, dark tunnels, and movement.

* Rubbing, touching or hitting eyes.

* Agitation in environments that are loaded with visual stimuli

* Agitation in room in which fluorescent lighting

* Poor depth perception (getting on elevators, walking down stairs) or walking over objects without apparently seeing them.

Support and Accommodations

* Respect peripheral vision that can be alarming and cause stress if unexpected

* Never force person to look directly at a task.

* Monitor for visual over stimulation (neutralize environment calming colors, cover shelves, etc)

* Monitor use of bright lights, bright shiny objects.

* Eliminate fluorescent lights (if possible) or use calming colors over them

* Consider colors, or color combination of objects that can be overstimulting such as a very busy rug or wallpaper

 * Monitor clothes they wear, and what you wear (neutral colors, earth tones seem best).

* Monitor colors in the environment (E.g., papered sections of walls in classrooms).

* Monitor background visual distraction during tasks.

* Utilize dimly lit rooms before bedtime to reduce serotonin production. Sleep in pitch black.

* Do not insist on eye contact.

* Allow person to develop a "visual map" of new areas-when only few people present.

*Show videos of places before they go to help them take in info and make it familiar beforehand 

Sensory Processing Differences Traci Diamond, OTR/L and Teresa Bolick, Ph.D Sensory functioning refers to the process by which our body perceives ("registers"), manages ("modulates"), and organizes ("integrates") incoming information. In addition to the five senses that we all learned about in school, human beings possess two other sensory systems: the vestibular system, which responds to movement; and the proprioceptive system, which tells us where our body and its parts are in space.

A student must perceive, manage and organize sensory input if he or she is going to participate in everyday life. Many students with autism/PDD have sensory processing differences. In other words, one or more of the processes of sensory perception, management, or organization works inefficiently for one or more of the sensory modalities. An example of a "simple" task is that of writing one's name at the top of a paper while sitting in the classroom. Such a "simple" task is actually quite complex from a sensory standpoint, as outlined below.

* The visual system is involved in seeing the paper, finding where to write the name, perceiving what one is writing, adjusting to the lighting (especially the strobe effect of fluorescent lights,) and recalling visual images of what the letters actually look like.

* The taste (gustatory) system is probably not used unless the child is chewing/sucking on something while writing.

* The smell (olfactory) system may be involved as a result of the odors of leftover snacks in the trash can, pencil shavings in the sharpener, cosmetics of the adult helping the child, the cafeteria aroma, wet jackets hanging on the hooks nearby, or even the classroom hamster.

* The hearing (auditory) system allows the student to hear relevant information such as the instructions given by the teacher or paraprofessional. The student will need to ignore sounds such as peers talking, chairs scraping on the floor, teachers talking in the next room, or his/her own breathing.

* The touch (tactile) system includes the feel of the pencil and paper in the student's hand. It also may register distracting input such as the feel of the student's clothing, the hair or baggy sweater of the teacher as he/she leans over to help, the contours of the chair, or the brushing touch of a child passing by the desk.

* The movement (vestibular) system allows the child to sit upright in the chair and to maintain an appropriate level of arousal/alertness.

* The proprioceptive (body position) system allows the child to maintain position in the chair, stabilize the paper with one hand while writing with the other, handle the pencil with sufficient muscle tension, move the pencil against. The resistance of the paper, and stabilize the upper body while moving the hand and fingers. It also allows the child to inhibit movements such as tapping feet, wiggling legs, and wagging the tongue. Obviously, this simple task is far from simple. Youngsters with autism/PDD find such a task even more challenging that do many of their typically developing peers. As the classroom gets noisier, the "aromas" from the lunchroom become more intense, or the need to scratch that itch grows, the student struggles with managing the sensory overload and completing such a "simple" task. Over the course of your work, you may hear the people talking about the load of the task. "Load" refers to all of the internal (inside the body) and external (in the activity or environment) stimuli that a child has to manage in a given situation. Sensory dysfunction is often a significant aspect of that load.

Sensory Integration Cindy Hatch-Rasmussen, M.A., OTR/L Therapy Northwest, P.C. 

Children and adults with autism, as well as those with other developmental disabilities, may have a dysfunctional sensory system. Sometimes one or more senses are either over- or under-reactive to stimulation. Such sensory problems may be the underlying reason for such behaviors as rocking, spinning, and hand flapping. Although the receptors for the senses are located in the peripheral nervous system (which includes everything but the brain and spinal cord), it is believed that the problem stems from neurological dysfunction in the central nervous system--the brain.

As described by individuals with autism, sensory integration techniques, such as pressure-touch can facilitate attention and awareness, and reduce overall arousal. Temple Grandin, in her descriptive book, Emergence: Labeled Autistic relates the distress and relief of her sensory experiences. Sensory integration is an innate neurobiological process and refers to the integration and interpretation of sensory stimulation from the environment by the brain. In contrast, sensory integrative dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior. A general theory of sensory integration and treatment has been developed by Dr. A Jean Ayres from studies in the neurosciences and those pertaining to physical development and neuromuscular function. 

Sensory integration focuses primarily on three basic senses--tactile, vestibular, and proprioceptive. Their interconnections start forming before birth and continue to develop as the person matures and interacts with his/her environment. The three senses are not only interconnected but are also connected with other systems in the brain. Although these three sensory systems are less familiar than vision and audition, they are critical to our basic survival. The inter-relationship among these three senses is complex. They allow us to experience, interpret, and respond to different stimuli in our environment.

The three sensory systems will be discussed below.

Tactile System: The tactile system includes nerves under the skin's surface that send information to the brain. This information includes light touch, pain, temperature, and pressure. These play an important role in perceiving the environment as well as protective reactions for survival. Dysfunction in the tactile system can be seen in withdrawing when being touched, refusing to eat certain 'textured' foods and/or to wear certain types of clothing, complaining about having one's hair or face washed, avoiding getting one's hands dirty (i.e., glue, sand, mud, finger-paint), and using one's finger tips rather than whole hands to manipulate objects. A dysfunctional tactile system may lead to a misperception of touch and/or pain (hyper- or hypo sensitive) and may lead to self-imposed isolation, general irritability, distractibility, and hyperactivity. Tactile defensiveness is a condition in which an individual is extremely sensitive to light touch. Theoretically, when the tactile system is immature and working improperly, abnormal neural signals are sent to the cortex in the brain, which can interfere with other brain processes. This, in turn, causes the brain to be overly stimulated and may lead to excessive brain activity, which can neither be turned off nor organized. This type of over-stimulation in the brain can make it difficult for an individual to organize one's behavior and concentrate and may lead to a negative emotional response to touch sensations.

Vestibular System: The vestibular system refers to structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of the head For example, the vestibular system tells you when your head is upright or tilted (even with your eyes closed). Dysfunction within this system may manifest itself in two different ways. Some children may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary movement activities (e.g., swings, slides, ramps, inclines). They may also have trouble learning to climb or 'descend stairs or hills; and they may be apprehensive walking or crawling on uneven or unstable surfaces, As a result, they seem fearful in space. In general, these children appear clumsy. On the other extreme, the child may actively seek very intense sensory experiences such as excessive body whirling, jumping, and/or spinning. This type of child demonstrates signs of a hypo-reactive vestibular system; that is, they are trying continuously to stimulate their vestibular systems.

Proprioceptive System: The proprioceptive system refers to components of muscles, joints, and tendons that provide a person with a subconscious awareness of body position. When proprioception is functioning efficiently, an individual's body position is automatically adjusted in different situations; for example, the proprioceptive system is responsible for providing the body with the necessary signals to allow us to sit properly in a chair and to step off a curb smoothly. It also allows us to manipulate objects using fine motor movements, such as writing with a pencil, using a spoon to drink soup, and buttoning one's shirt. Some common signs of proprioceptive dysfunction are clumsiness, a tendency to fall, a lack of awareness of body position in space, odd body posturing, minimal crawling when young, difficulty manipulating small objects (buttons, snaps), eating in a sloppy manner, and resistance to new motor movement activities. Another dimension of proprioception is praxis or motor planning. This is the ability to plan and execute different motor tasks. In order for this system to work properly, it must rely on obtaining accurate information from the sensory systems and then organizing and interpreting this information efficiently and effectively.

Sensory Implications: In general, dysfunction within these three systems manifests itself in many ways. A child may be over or under responsive to sensory input; activity level may be either unusually high or unusually low; a child may be in constant motion or fatigue easily. In addition, some children may fluctuate between these extremes. Gross and/or fine motor coordination problems are also common when these three systems are dysfunctional and may result in speech/language delays and in academic under-achievement. Behaviorally, the child may become impulsive, easily distractible, and show a general lack of planning. Some children may also have difficulty adjusting to new situations and may react with frustration, aggression, or withdrawal.

Evaluation and treatment of basic sensory integrative processes is performed by occupational therapists and/or physical therapists. The therapist's general goals are: (1) to provide the child with sensory information which helps organize the central nervous system, (2) to assist the child in inhibiting and/or modulating sensory information, and (3) to assist the child in processing a more organized response to sensory stimuli.

What is Sensory Integration? Sensory integration is the brain's ability to interpret and organize information from the senses-vision, hearing, taste, smell, touch, balance gravity, position and movement. Problems in sensory integration may result in learning problems, hyperactivity, distractibility, poor coordination, poor balance, and behavior problems, and may contribute to difficulties at school, at home, at work and in play. (from: the mission statement of Sensory Integration International)

RATIONALE FOR USE OF SENSORY INTEGRATION TO IMPROVE PERFORMANCE IN EDUCATION

1. The use of sensory integration is theoretically an appropriate technique to enhance learning and behavior in autism. Autistic children may demonstrate over reactions to sensation such as finding some sounds or touch painful. Other children may have difficulty with registering movement as demonstrated by repeated spinning of themselves without getting dizzy or not responding to pain as seen with self injurious behavior (SIB). All learning is through sensation, whether it be the visual sense for reading, processing auditory directions, or using the sense of touch to guide a pencil for writing.

2. Autism and sensory integration have a neurobiological basis. Dysfunction in processing of sensory input has long been recognized as a symptom in autism. (1)Sensory disturbances are required diagnostic criteria for eligibility for special education services under the autistic category. (2) Recent findings from magnetic resonance imaging (3,4) and positron emission tomography scans (5) support an organic basis for autism. Sensory integrative treatment is an approach, which has a neurobiological theoretical base. 

It is vital that a child with ASD be calm in order for progress to occur and to help them in all environments.  

3. Sensory integrative treatment seeks to fulfill sensory drives that create a lack of goal directed activity (self stimulation) in autistic children. The central nervous system may be craving certain types of sensory input due to neurobiological problems. Rather then engaging in activity a child with autism may rock. This would be considered as a drive for linear vestibular (movement) input, and the therapist would find ways to satiate the need. This would improve both functional performance and ability to engage in goal-oriented activity. Some types of activity indicate the child is over stimulated and calming activity such as deep pressure could be initiated.

4. Recent evidence has validated the view of the nervous system as a constantly changing system, which is influenced by the environment. The sensory integrative approach strives to provide a just right environmental challenge to the child. Studies have demonstrated that patients recover at greater rate and to higher levels when they are engaged in motivating activity rather then those involved in a typical exercise program with repetition.  Also, brain plasticity is greater when the individual is in a state of homeostasis, or calm.

Sensory integrative treatment is important in calming, so that changes in the autistic child's function are easier to make. Plasticity is greater in the sensorimotor stage of development or in children ages seven and under.

5. Some studies support the use of sensory integrative treatment procedures with autistic children to improve behavior. Ayres and Tickle  studied a group of autistic children. They found children who were hypersensitive to input to be responsive to sensory integrative treatment. Temple Grandin  diagnosed as autistic in preschool years stated that tactile and vestibular stimulation had helped her calm her over reactive responses to environmental stimulation. A case study of an autistic child who begin sensory integrative treatment at age 3.5 years, slept only 5-6 hours per night and spent hours screaming and throwing tantrums.

After two years of sensory integrative treatment, tantrums disappeared and her skills had improved in self-care, coordination, language and social responsiveness.

An autistic child observed during occupational therapy sessions had increased speech sounds with self initiated vestibular stimulation.

 After a year of therapy, a 14 year old autistic/retarded teenager had a 50% decrease in head banging, hitting, plate throwing and hair pulling.

 A 13-year-old non-verbal autistic boy with severe mental retardation exhibited continuous selfinjurious and self-stimulatory behaviors. During the observation periods when the adolescent received deep pressure from the woven elastic bandages he wore on his extremities, he exhibited less selfstimulatory behavior, no self-injurious behavior and an increase in the number of interactions with others.

Deep pressure, tactile and vestibular stimulation appeared to have a more marked effect in calming on days when the SIB and self-stimulation were the highest. (

 Case studies of autistic children support the effectiveness of treatment based on sensory integration theory. Improvements noted include improved sleep patterns, decreased screaming, improved self-care, improved coordination, increased language sounds, decreased self-stimulation and decreased SIB. Sandra D. Glovak 10/31/96 Sensory Systems Clinic, P.C.

SENSORY DIET Prepared by Christy E. Yee, OTR Definition of Sensory Diet: "The daily total of sensorimotor experiences needed by a person to adaptively interact with the environment." -Hanschu- Purpose of the Program: To assist child in self-regulation. Unusual behaviors may be a result of poor regulation from the nervous system. Goal: To utilize sensorimotor strategies to attain an appropriate state of readiness (calm alert state) to learn during the day. Types of input utilized: Vestibular, Proprioceptive, Oral Motor, and Tactile

DEFINITIONS:

1. VESTIBULAR: The vestibular system affects balance, muscle tone, equilibrium responses, the ability to use both sides of the body together, coordination of the head, neck and eye movements, auditory language, and plays a role in arousal. Vestibular stimulus involves the movement of head through space and can include linear, angular, orbital, or rotary directions.

Considerations: Input typically lasts 12-14 hours after 15 minutes of movement. Never force vestibular input; enable individual to control speed, direction of input, and stopping. Peripheral vision is alerting. Watch for undesirable side effects such as flushed face, nausea, decreased balance.

2. PROPRIOCEPTION: The proprioceptive system gives the nervous system input on the position of muscles, joints and tendons. This is important as it provides the person with information on how far to reach, how much pressure, where we are in space, and what our body scheme is. Proprioceptive stimulus involves movement, compression, or stretching at a joint.

Consideration: Special care for individuals who have poorly articulated joints, joint deformities, or arthritic joints; give extra support and stop if there is pain or discomfort. For individuals who have low tone or too much slack in joints give slow stretch or alternate compression and stretch in rhythmic pattern and avoid quick changes of joint position. Pay attention to proper joint alignment. Be aware of poor reflex integration and lack of protective responses. The strongest, fastest, and most dramatic affects are activities which involve the spine, head/neck, or hip joints. Heavy work tasks are great for proprioceptive input; add weight, promote reaching and stretching during these activities.

3. ORAL MOTOR: Oral motor skills are used to regulate state of arousal. Infant and toddlers use sucking as a way to fall asleep or calm down; children and adults may use the oral motor area to concentrate (chew gum, suck through straw or bite nails), and comfort (foods). Considerations: Oral motor activities must be constantly and consistently monitored for safety. Be aware of food and non-food allergies when considering oral motor activities.

4. TACTILE: The tactile system is designed to alert us to threats, gives us body boundaries, and combined with proprioception, gives us our basis for body image. Considerations: Light touch is easily misinterpreted as pain and can cause the nervous system - to go onto a state of fight or flight (autonomic nervous system; sympathetic). Always provide deep pressure when in contact with the child and ask permission. 

SUMMARY:

1. Assess the child's current state of arousal, by observing motor behaviors: Under-aroused, overaroused, or calm alert. Calm alert is used to refer to the optimal state of arousal to perform work.

* If under-aroused (not shutdown) impose excitatory proprioceptive activities, monitor childdriven excitatory vestibular input, provide a stimulatory environment.

* If over-aroused, provide calming proprioceptive activities and/or calming vestibular activities and/or firm pressure touch protocol.

* If in shut down, impose calming proprioceptive and/or calming vestibular input.

Remember, if unsure if child is under-aroused or in shutdown impose calming activities first and then reassess the state of the nervous system.

 If calm alert, child is ready to perform fine motor tasks, sequencing/praxis activities, and new learning can occur. 

 Usually gross motor activities lead into fine motor activities.

PLEASE seek the advice of an OT for help!

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