sensory processing and influence on participation in asd

Sensory processing and influence

on participation in ASD?

Dr Dido Green Oxford Brookes University

Manchester 1st July 2016

Autism Show

Evidence of Sensory Processing Disorders in Autism

Sensory Processing and Participation

Person:Environment interactions influencing participation

Specificity vs universality of sensory behaviour

Classifications and subgroups/subtypes

Relationship of Sensory Processing to Mental Health

Comparison with other developmental disorders 24.05.2016 Dr Dido Green

Green 26 09 2015

Concepts of Sensory Processing Dysfunction (Miller et al., 2007)

Discrete

Simultaneous

REGISTRATION

DISCRIMINATION

Sensory-Based Motor Disorder

MODULATION

MODULATION

Under-responsivity

Over-responsivity

Sensory Defensivenness

Tactile Defensiveness

Aversive Response to Mov’t

Gravitational Insecurity

Sensory Seeking/Craving

DISCRIMINATION

Praxis and Organisation

•Vestibular-

•Proprioceptive

•Tactile

•Gustatory & Olfactory

•Auditory/Visual

•Dyspraxia •Postural Disorders

Sensory Modulation Disorder

• Defined as a problem in regulating and organising the degree, intensity and nature of responses to sensory

input in a graded manner.

• Affects: - an individual’s ability to achieve and maintain an optimal range of performance, and to adapt to challenges in daily life.

• SMD includes - over-responsivity, under-responsivity and sensory seeking-craving.

(Miller et al., 2007)

Empirical Evidence for Sensory Modulation Disorders?

•Over (under) reactivity = discomfort or avoidance to tactile input in ASD and FXS (Miller et al 1999; McIntosh et al 1999; Lane 2012;2014)

•Over inhibition to vestibular stimuli in ASD (Bauman, 1996) including:Hypo & hyper sensitivity to movement

•Increased risk of tactile over-responsivity in ADHD with evidence of raised tactile discrimination (Parush et al 1997)

•Presence of SMD across other disabilities/disease entities influences skill development and participation (Green et al., 2003; Van Hulle et al., 2012; Bar Shalita et al., 2008).

McIntosh,DN.,Miller,LJ.,Shyu,V.,Hagerman,

RJ. (1999). Sensory-modulation disruption,

electrodermal responses, and functional

behaviors.

Developmental Medicine and Child

Neurology, 41, 608-615.

-4

-3

-2

-1

0

1

Taste** Visual Auditory Under-

responsive

* FXS and ASD differ from Typical at p<.01

** FXS and ASD differ from Typical at p<.001

Short Sensory Profile Subsections

Typical

FXS

Autism

From Miller, Reisman, McIntosh, Simon 2001

Sensory Processing and Participation

0

20

40

60

80

100

120

140

160

Level of participation Enjoyment of participation

Frequency of Participation

SMD

Typical

P=.001 P=.001 P=.007

Level Enjoyment Frequency

Use of Weighted Blankets to improve Sleep in Children with Autism Spectrum Disorders

P Gringras, D Green, B Wright, C Rush, M Sparrowhawk, K Pratt, V Allgar, N Hooke, D Moore, Z Zaiwalla, L Wiggs

Funded by Research Autism

PEDIATRICS Volume 134, Number 2, August 2014

Deep Pressure

Edelson, Edelson, Kerr, Grandin T (1999).

Behavioral and physiological effects of

deep pressure on children with autism: A

pilot study evaluating the efficacy of

Grandin’s hug machine. The American

Journal of Occupational Therapy. 1999,

53, 2 145-152.

Weighted Blankets in Autism

Champagne et al (2007). AOTA: http://www.ot-

innovations.com/content/view/33/63

Olson LJ, Moulton HJ (2004). Use of weighted vests in

pediatric occupational therapy practice. Physical and

Occupational Therapy in Pediatrics, 24, Issue 2/3

Actigraphy

Weighted Blanket N of 1 ‘Snuggledown’

With Blanket

Sleep efficiency 76%

Sleep latency 8 mins

Without Blanket

Sleep efficiency 67%

Sleep latency 52 mins

Blanket discontinued here

Snuggledown

• 73 young people (5-17yrs) with ASD – (London, Oxford, York)

• Poor sleepers – (>1 hour to fall asleep+/- <7 hours continuous)

• Crossover study with weighted blanket and control blanket (2 weeks each)

• Primary outcome – Total sleep time actigraphy

• Secondary Outcomes – Sleep diary data/behavioural data/sensory data/parent &

child evaluation of intervention

Results

• 67 children completed the trial

• No change in total sleep time, sleep latency, night wakings or sleep efficiency.

– Based on objective actigraphy and subjective sleep diary measures

• Subjectively:

– No group differences in sensory or child behaviours

– Parents and children preferred the weighted blanket

– Parents said sleep was better and children calmer with weighted blankets

1 = Sensory Adaptive n=84 2 = Taste/Smell Sensitive n=92 3 = Postural Insecurity n = 23 4 = Generalised Sensory Difference n = 29

https://disabilitymatters.org.uk

Standard Page 50:50 layout

Sensory Processing > Overview 4

Select the hyperlinks below. The way in which we interact with the sensory world influences how we feel and contributes to our learning and the way we develop new skills (Fig 1). Similarly, the way in which we experience and react to the sensory world (our sensory preferences and sensitivities) are unique to us as individuals (Fig 2). With this in mind, take the opportunity to consider the sensory aspects of the things you do, the objects around you and the environment you are in. Questions to consider

Standard Page 50:50 layout (with Links)

Fig 1 The way in which we interact with the sensory world contributes to our learning and the way we develop new skills ALT (delete if not required) Filename: istock_9022876

Standard Page 50:50 layout

Fig 2 Our sensory preferences and sensitivities are unique to us as individuals ALT (delete if not required) Filename: istock_2180720 and istock_42169762

Continuation page

Questions to consider How do you like to start your day (e.g. a coffee, something sweet, morning exercise)? How do you stay focused in a long meeting (e.g. shift in your chair, chew gum, click your pen)? How do you prefer to relax (e.g. with quiet or loud music, read a book, go for a walk)? Do you ever feel overwhelmed in an environment (e.g. a crowded supermarket, an indoor swimming pool, perfume counter at a department store)? What is it about that environment which makes it uncomfortable (e.g. noise, smell, lights, people bumping into you, etc)?

Consider each of the experiences shown on the right. Now rank the things shown in the pictures according to whether they make you feel calmer or more alert. Drag the labels on the right into the correct order on the left, then select Submit.

Doing a bungee jump

Drinking a cup of espresso

Listening to music

Taking the dog for a walk

Going to an exercise class

Having a hot bath

Drag & Drop – Order

Sensory Processing > Activity 5

Most alerting

Most calming

Fig 1 A selection of sensory experiences ALT (delete if not required) Filename: lds_06_005_05_01_50

Standard Page 50:50 layout Continuation page Case study

Ben was always extremely distressed on arriving at school. From the school bus, he was shunted into a cramped cloakroom and then directed into circle time on the floor where he was jostled by other students. We identified that slow rocking movements were calming for him and purchased a rocking chair for the school;modified to ensure more rhythmic gentle movements. The chair was placed in a quiet room and Ben went there for 10 minutes when he first arrived in school. He then joined the class when his sensory system had had some calming input. Other ‘hotspots’ included lunch time, so the rocking chair was made available just before then. Ben was allowed to take lunch after all the other pupils had settled so that he wasn’t jostled. His lunch area was placed so his back was against the wall so other children did not brush past him. He was then allowed to play on the swings after lunch.

Green 23.06.08

Sensory Processing and Behaviours that Challenge

Clinical Case 1

28 year old male - Stereotypical behaviour: rocking, posturing and eye rolling/poking

Pharmacological and behaviour interventions unsuccessful in the past

Green 23.06.08

Research Case 1

34 year old Stereotypical behaviour: rocking and eye poking

Self-injurious behaviour: screaming, biting self, head-banging

Green 23.06.08

Figure 1 - Ms D, Incidents of screaming

Incident and quality of scream by study phase

Incidence during baseline or treatment phases

Treatment B2

Treatment B2

Treatment B2

Treatment B2

Baseline A2

Baseline A2

Baseline A2

Baseline A2

Treatment B1

Treatment B1

Treatment B1

Treatment B1

Treatment B1

Baseline A1

Baseline A1

Baseline A1

Baseline A1

Baseline A1

Qua

lity

of S

crea

m

5

4

3

2

1

0

A1 B1 A2 B2

Green 23.06.08

Research Case 2

28 year old male

Severe learning disability, autism and epilepsy

Stereotypical behaviour: repetitive tapping, rocking

Self-injurious behaviour: breath-holding, biting, ear pulling, head-banging

Green 23.06.08

Data point

211470

time

in s

econ

ds

500

400

300

200

100

0

-100

Target Behaviour

tapping

covering ears

Breath holding

Figure 3 - Chart of Targeted behaviours by treatment phase

A1 = baseline; B1 = treatment; A2 = baseline

B1 A2 A1

Child and Adolescent Symptom Inventory-Depressive symptoms subscale (CASI-D) Gadow & Sprafkin 2010) Sensory Profile (SPr) (Dunn, 1999)

β (stand) = .406, R2 = .165,

F (change )= 28.82 p<.001

Anxiety or Sensory?

Symptoms of Anxiety in Children

“I feel scared….” “I feel troubled…” “I get a funny feeling in my stomach” STAIC

Generalised anxiety: e.g. “I worry about things working out for me”,

Separation anxiety, inc. school phobias e.g.. I don’t like being away from my family, I am scared to go to school

Social phobia e.g. “ I don’t like to be with unfamiliar people”

Panic disorder e.g. “When frightened, my heart beats fast”

Obsessive compulsive disorder e.g. “I have thoughts that frighten me”

Traumatic stress disorder e.g. “I have frightening dreams about a very aversive experience”

Specific phobias: animal, blood-injection-injury of situational (e.g. flying phobia) type.

Deficits in Sensory registration / orienting response or Anxiety?

Difficulty orienting/focusing attention

Lacks flexibility, disregards novel stimuli

Minimal variety in behavioural responses

Over or Under active

Lacks regard for other’s needs

Emotional lability

Inefficient nervous system - poor planning

Sensory responsivity mediates between baseline and outcome measures

Figure 1 Mean withdrawal responses – Higher values indicate higher withdrawal

From Schneider et al., 2008

Feather

Opsoclonus Myoclonus Syndrome (OMS)

ACUTE

Abnormal eye movements, exacerbated by excitement/anxiety

Abnormal head/limb movements

Ataxia – postural deficits affecting balance and gait

Dyspraxia – motor planning difficulties/clumsiness

Dysarthria – speech difficulties

Sensory-Motor Functioning in Opsoclonus Myoclonus Syndrome

CHRONIC

60% motor problems,

66% speech abnormalities,

51% learning disability,

46% behaviour problems

Another 46% having behaviour problems into adulthood (Brunklaus et al., ADC 2011).

OMS - usually has a chronic and relapsing course (Cooper et al., 2001; Dale, 2003).

Anonymous Questionnaire Design Distributed by the Dancing Eye Syndrome Support Trust

Parent Report Questionnaires: Short Sensory Profile (Dunn, 1999)

Sensory Behaviour Questionnaire (Green, 2009)

Vineland Adaptive Behaviour Questionnaire (Sparrow et al., 1984)

Developmental Behaviour Checklist (Stewart et al., 1989)

Questions for research Prevalence of Sensory Modulation Disorder (SMD) in OMS Relationship of SMD to Anxiety Impact of SMD on daily functioning Profile – Acute versus Chronic Chronicity of SMD.

OMS - Participants

Group Age (months)

At study time

Time (months)

since diagnosis

Mean (SD) range

Gender VABS %ile

Mean (SD) range

< than 5 years

N=6

32.5 (10.0) 21-50

14.8 (7.8)

6-21

4 females,

2 males

12.8 (7.8)

4-21

>5 years

N=10

129.1(32.2)

77-168

107.7 (36.3)

53-147

9 females,

1 male

13.8 (29.1)

1-5 (90b)

Total n=16

From 30 (53£)

92.8 (54.7)

21-168

72.9 (54.5)

6-147

13 females,

3 males

32.5 (10.0)

21-50

b=one outlier with a percentile score of 90

RESULTS Numbers of children above and below cut-off for

SPD on Short Sensory Profile

0

1

2

3

4

5

6

7

8

9

SSP score cut-off

Typical SP

At Risk of SPD

Definite SPD

Numbers of children meeting criteria for Anxiety in relation to presence/absence of sensory behaviour on SSP (cut-off scores)

Profile of Scores across Domains on the SSP by presence/absence of Anxiety

P<0.01

Significant placebo effect pre- to post Rx in patients with ID (g = 0.468, p = 0.002): “subjective outcomes” (g = 0.563, p = 0.022) “objective outcomes” (g = 0.434, p = 0.036). Higher IQ = higher placebo response (p = 0.02) No placebo response in ID patients + comorbid dementia. Higher placebo responses in treatment of younger patients (p = 0.02)

Conclusion

High incidence of Sensory Processing Disorders in ASD

Not universal but when present affect participation

Specificity vs Universality of Sensory Behaviours unclear

Relationship to Anxiety and Depression warrants more research

More questions ?

Thanks to: Dancing Eye Syndrome Support Trust

And families of children with OMS Research Autism and Waterloo Foundation And individuals with ASD and their families

Dido.green@brookes.ac.uk

https://www.disabilitymatters.org.uk/ Participation – Sensory Environments

KEY REFERENCES Ayres, A.J., Tickle, L. (1980) ‘Hyper-responsivity to touch and vestibular stimulation as a predictor of

responsivity to sensory integrative procedures by autistic children’ AJOT, 34, 375-381

Barenek GT, et al (1997) Tactile defensiveness and stereotyped behaviours American Jour of OT, 51, 91-95

Bar-Shalita T, et al (2008)‘Sensory modulation disorder:a risk factor for participation in daily life

activities’.DMCN 50:932-37.

Bart O, Bar-Haim Y, et al. Balance treatment ameliorates anxiety and increases self-esteem in children with

comorbid anxiety and balance disorder. ‘Res Dev Dis 2008; 30, 486–495.

Brett-Green et al. (2010) An exploratory event-related potential study of multisensory

integration in sensory over-responsive children.Brain Res 1321, 67-77.

Ben-Sasson A, et al. ‘Can we differentiate sensory over-responsivity from anxiety symptoms in toddlers?

Perspectives of Occupational Therapists and Psychologists. ‘ Infant Mental Health J 2008; 28: 536-558.

Brunklaus et al., (2011 ) Outcome and prognostic features in opsoclonus-myoclonus syndrome from infancy

to adult life. Arc Dis Child.

Dunn W. (1999) Sensory Profile San Antonio:Therapy Skill Builders.

Green D., Beaton L et al (2003) Clinical incidence of Sensory Integration difficulties in Adults with

Learning Disabilities and Illustration of Management, BJOT, 66, 454-463

Lane SJ. Schaaf RC (2010) Examining the Neuroscience Evidence for Sensory-Driven Neuroplasticity:

Implications for Sensory-Based Occupational Therapy for Children and Adolescents. AJOT 64,:375-90.

McIntosh DN Miller, LJ et al ‘Sensory-modulation disruption, electrodermal responses, and functional

behaviors. DMCN 1999; 41, 869-872

Miller LJ, McIntosh et al Electrodermal responses to sensory stimuli in individuals with Fragile X

syndrome: A preliminary report. Amer J of Medical Genetics 1999;83, 268-279

Miller et al. (2007) Concept evolution in sensory integration: a proposed nosology for diagnosis. Am J

Occup Ther, 61: 135-40

Reynolds S, Lane SJ. Diagnostic validity of sensory over-responsivity: a review of the literature and case

reports. JADD 2008; 38:516-529.