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Autism Spectrum Australia (Aspect) 1 “It’s a Sensory Thing…” Classroom Based Sensory Processing Intervention for Children with Autism Caroline Mills, Occupational Therapist Dr Christine Chapparo, Senior Lecturer, The University of Sydney

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Page 1: “It’s a Sensory Thing” Classroom Based Sensory · PDF file“It’s a Sensory Thing” Classroom Based Sensory Processing Intervention for Children with Autism ... Short Sensory

Autism Spectrum Australia (Aspect) 1

“It’s a Sensory Thing…” Classroom Based Sensory

Processing Intervention for Children with Autism

Caroline Mills, Occupational Therapist

Dr Christine Chapparo, Senior Lecturer, The University of Sydney

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Autism Spectrum Australia (Aspect) 2

• What do we mean by Sensory Processing?

• Research in Sensory Processing

• Our research with sensory processing in ASD

– Method

– Intervention

– Results

– Discussion

What are we talking about?

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Autism Spectrum Australia (Aspect) 3

What is Sensory Processing?

Sensory Processing: (lay terms)

• Taking in information from all the senses and processing these

effectively

• Taking in information from the right senses at the right time

• Using the information effectively in day to day activities

Sensory Integration:

“the neurological process that organises sensations from one’s own

body and from the environment and makes it possible to use the

body effectively within the environment.” (Ayers, 1972)

Sensory Integration VS Sensory Processing

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Autism Spectrum Australia (Aspect) 4

Inside

Senses

Outside

Senses

The Seven Senses

movement and balance

(vestibular)

body awareness

(proprioception)

touch (tactile)

sound (auditory)

sight (visual)

smell

taste

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Autism Spectrum Australia (Aspect) 5

How common is it really?

• 70.5% of those with ASD showed ‘definite differences’ on

Short Sensory Profile (SSP) (Adamson, O’Hare & Graham, 2006)

• 84% showed definite differences on SSP (Tomcheck & Dunn,

2007), compared with 3.2% of controls

• 95% had definite or probable differences (Tomcheck & Dunn,

2007)

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Autism Spectrum Australia (Aspect) 6

Sensory Processing in Autism

• Sensory differences are more prevalent in ASD than typically

developing children or children with other types of

developmental disabilities. (Tomchek & Dunn, 2007; Baranek et al 2007;

Ben-Sasson et al, 2009; Boyd et al, 2010)

• Sensory differences vary between individuals with autism

(Grandin, 2009)

• Greater severity of ASD correlated with greater severity of

sensory difficulties (Adamson et al, 2006; Ben-Sasson et al, 2009)

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Autism Spectrum Australia (Aspect) 7

Sensory Sub-Types in Autism

• ‘Hyper’ (over responsive), ‘Hypo’ (under responsive) (Dunn,

2014)

• Behavioural responses (seeking/avoiding) (Dunn, 2014)

• Over focused/pre-occupied/Innattentive (Liss, et al, 2006; Lane, et al

2010)

• Links with specific modalities (taste/smell or movement) (Lane

et al, 2011)

• Links with motor planning and praxis (Roley et al, 2015)

• Enhanced Perception- linked with weak central coherence

account (Baron-Cohen et al, 2009)

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Autism Spectrum Australia (Aspect) 8

Impact on Participation

• Sensory difficulties have been associated with emotional

concerns (Baker et al, 2008).

• Hyper-responsive (over-responding) sensory style in Autism

was correlated with repetitive behaviours and a tendency for

sameness (Boyd et al, 2009), decreased participation in activities

(Little, et al, 2015) and anxiety (Green & Ben-Sasson, 2010)

• Auditory filtering and under responsive/seeks sensation

greatest impact on school functioning (Ashburner, Ziviani and Roger,

2008).

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Autism Spectrum Australia (Aspect) 9

• Choice to avoid certain situations

because of sensory experiences

• “Integrated” nature of sensory

processing (Kirby, et al 2015)

• Prefer sensations which are controlled

and predictable (Ashburner, et al 2013)

• Meta-cognitive strategies- planning,

focus, self talk

What do people with autism say?

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Autism Spectrum Australia (Aspect) 10

• All sensory responses are behavioural

• What is the function of the behaviour?

• Some behaviours have multiple functions

Is it Sensory or is it Behaviour?

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Autism Spectrum Australia (Aspect) 11

What about intellectual disability?

• Children with ASD have ID up to

70% of the time, different needs to

those with ASD alone (Matson & Goldin,

2013; Matson & Shoemaker, 2009)

• “Confounding variables”

• Need for an evidence base for

children with Autism and ID with

sensory processing difficulties

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Autism Spectrum Australia (Aspect) 12

There is no single instrument which can

comprehensively measure the range of sensory

features in autism (Schaaf & Lane, 2015)

Sensory Interventions are inconsistently defined (Case-Smith et al, 2015)

…insubstantial treatment outcomes, weak

experimental designs, or high risk of bias.

…insufficient evidence exists to support their use (Barton et al, 2015)

…but what can we do to help these children?

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Autism Spectrum Australia (Aspect) 13

So

what

did we

do?

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Autism Spectrum Australia (Aspect) 14

Background to the Research

Why is he doing that?

How can I help him to meet his sensory needs so he can learn?

Sensory based

behaviour happens

for a reason

Sensory activities

or opportunities

The need for

suitable

replacement

behaviours

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Autism Spectrum Australia (Aspect) 15

Background

• Children with ASD, ID, autism specific special

school in Sydney

• Pilot Study

Research Question: What is the impact of an In-

Class Sensory Activity Schedule (SAS) on

task mastery and cognitive strategy application

children with autism?

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Autism Spectrum Australia (Aspect) 16

Name Age Diagnosis

M 7 y 10 mo Autistic Disorder, moderate intellectual

disability, severe language delay

B 5 y 7 mo Autism spectrum disorder, intellectual disability

L 6 y 3 mo Autistic disorder, moderate intellectual disability

C 6 y 8 mo Autistic disorder, moderate intellectual disability

A 6 y 9 mo Autistic Disorder, moderate intellectual disability

Meet the Participants n=5, mean age= 6.6yrs

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Autism Spectrum Australia (Aspect) 17

• Single System AB design: non-concurrent, repeated measures

• Teacher designed desk work tasks were rated including cutting,

sticking, put in tasks, puzzles and matching.

• Sampling of class task performance was videotaped by school

staff

Method

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Autism Spectrum Australia (Aspect) 18

Informal Assessment:

• Teacher report and classroom observation

• ‘Off task’ behaviour- sensory seeking- climbing on

furniture/staff or sensory avoiding function- hiding from the

group, frustrated, fixed in routine- quite upset with

changes, difficulties transitioning

Formal Assessment:

Short Sensory Profile (McIntosh, Miller & Shyu, 1999) findings

summary: All total scores showed definite difference

Assessment for Inclusion

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Autism Spectrum Australia (Aspect) 19

Intervention: Sensory Activity Schedule

(SAS)

• Terminology should be clarified (QLD DET, 2011)

• Difficulties with sensory aspects of task

performance

• Based on the ‘sensory diet’ (Wilbarger & Wilbarger, 1991)

• Brushing (Deep Pressure Proprioceptive

Technique) was not used (Wilbarger & Wilbarger, 1991)

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Autism Spectrum Australia (Aspect) 20

• Administered by teacher’s aide and teacher.

• Morning session- after morning circle, before desk work.

• Used classroom based equipment

• 10-15 mins

Sensory Activity Schedule (SAS)

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Autism Spectrum Australia (Aspect) 21

Sensory ActivitiesExample of Sensory Activities

Movement activities while wearing tight lycra

Jumping on a mini-tramp and crashing into cushions

Squashing games with a bean bag

Rolled over a therapy ball, bouncing on therapy ball

Tactile activities

Jumping on a mini tramp

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Autism Spectrum Australia (Aspect) 22

Sensory Activity Schedule (SAS) Key Components

Evidence of Need- assessment of sensory differences (formal

and informal)

Use of Sensory Activities- deep touch, proprioception,

vestibular, selected as they appeared to benefit the student

Task Specific- Activities were used before specific tasks to

improve performance in those tasks.

Teacher Directed- Consultation- sensory activities and

classroom tasks

Contextual Fit- Considers the child’s school environment

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Autism Spectrum Australia (Aspect) 23

PERCEIVE RECALL

PLANPERFORM

Outcome Measure:

PRPP System of Task

Analysis

- Criterion referenced

- Four processing

areas (Quadrants)

- Cognitive disorder-

mismatch between

task, person’s

capacity,

environment

Perceive, Recall, Plan, Perform (PRPP) System of Task Analysis (Chapparo & Ranka, 2011)

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Autism Spectrum Australia (Aspect) 24

Data Collection Procedures

• Task performance was videotaped by school staff

• 125 videos were rated using PRPP Stage One and Two

Analysis (55 Baseline and 70 Intervention)

• Videos were randomly ordered and scored by researchers

• PRPP Stage One and Two Analysis was completed

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Autism Spectrum Australia (Aspect) 25

• Procedural task analysis

for teacher designated

desk work tasks in the

classroom.

• Steps containing errors

were recorded

• Percentage of error free

performance was

calculated

PRPP Stage One

Put in Task

Errors

Sit down

Take plastic bottle

Take bottle cap

Place in bottle

Take bottle cap

Place in bottle

Put bottle in finish tray

ERROR FREE- 5/7 71.4%

X

X

Data Analysis- PRPP Stage One

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Autism Spectrum Australia (Aspect) 26

Results- PRPP Stage One

Performance Mastery

50

55

60

65

70

75

80

85

90

95

100

1 2 3 4 5 6 7 8 9 10 11

Pe

rce

nta

ge

Sco

re

Task Performances

Phase A- Baseline Phase B- SAS Intervention

p=0.038, p<0.05Two band standard deviation method (Ottenbacher, 1986)

M

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Autism Spectrum Australia (Aspect) 27

50

55

60

65

70

75

80

85

90

95

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Pe

rce

nta

ge

Sco

re

Task Performances

Phase A Baseline Phase B SAS Intervention

p=0.01, p<0.05

Performance MasteryB

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Autism Spectrum Australia (Aspect) 28

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

1 2 3 4 5 6 7 8 9 10 11 12

Pe

rce

nta

ge

Sco

re

Task Performance

Phase A Baseline Phase B SAS Intervention

p=0.502, p>0.05

Performance MasteryL

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Autism Spectrum Australia (Aspect) 29

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Pe

rce

nta

ge

Sco

res

Task Performances

Phase A Phase B

p<0.001

C Performance MasteryC

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Autism Spectrum Australia (Aspect) 30

Performance Mastery

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Pe

rce

nta

ge

Sco

res

Task Performances

Phase A Phase B

p=0.01, p<0.05

A

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Autism Spectrum Australia (Aspect) 31

Results Summary PRPP Stage One

*Mann Whitney U statistic

** Significance at the 0.05 level, *** Significance at the 0.01 level

Child Stage One Task Mastery Result Statistics*

Baseline (A) Intervention (B)

M 69.5% 82.64% p=0.038**

B 86.67% 95.88% p=0.01***

L 81.32% 84.39% p=0.502

C 85.2% 98.18% p<0.001***

A 73.23% 85.24% p= 0.01***

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Autism Spectrum Australia (Aspect) 32

• 4 out of 5 showed improved task mastery following a

classroom based SAS as measured by Stage One

PRPP

• Why was intervention effective for 4 out of 5 children?

• A targeted opportunity to meet a child’s sensory needs

contributed to better self regulation prior to completion of

work tasks in the classroom.

• L’s results were not significant- baseline not stable, trend

lines showed improvements

• L needed a longer baseline

Discussion- PRPP Stage One

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Autism Spectrum Australia (Aspect) 33

PERCEIVE RECALL

PLANPERFORM

Outcome Measure:

PRPP System of Task

Analysis

- Criterion referenced

- Four processing

areas (Quadrants)

- Cognitive disorder-

mismatch between

task, person’s

capacity,

environment

Perceive, Recall, Plan, Perform (PRPP) System of Task Analysis (Chapparo & Ranka, 2011)

Perceive- Attending- Sensing- Discriminating

Perceive- Attending- Sensing- Discriminating

Recall - Recall Facts- Recall Schemes- Recall

Procedures

Plan- Mapping- Programming- Evaluating

Perform- Initiating- Continuing- Controlling

Perform- Initiating- Continuing- Controlling

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Autism Spectrum Australia (Aspect) 34

• Cognitive strategies are scored

based on observation of task

performance.

� 3- no errors and no assistance.

� 2- some prompting.

� 1- deficit or excessive prompting.

• Total sub-quadrant raw scores are converted to percentage scores.

PRPP Stage Two

PERCEIVE RECALL

PLANPERFORM

• Cognitive Task Analysis- How cognitive strategies were used

• The four quadrants are further divided into 12 Sub-Quadrants.

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Autism Spectrum Australia (Aspect) 35

Results- PRPP Stage Two

Sub-quadrant Analysis- PRPP

Significant Improvements in Recalling Facts (p=0.028) :

“knowing what you need to know to do what you need to do”

Recall - Recall Facts- Recall Schemes- Recall

Procedures

A displayed more labelling during task performance. Recognition of tasks-spelling words

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Autism Spectrum Australia (Aspect) 36

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

PR

PP

Recall

Qu

ad

ran

t P

erc

en

tag

e S

co

re

Task Performances

PRPP Recall Quadrant Scores

Phase A-

baseline

Phase B-

intervention

B

CL A

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Autism Spectrum Australia (Aspect) 37

Significant improvements in Plan:

“coping with novel, complex and difficult situations,

knowing the goal and keeping it in mind”

Plan- Mapping (p= 0.012), Programming (p= 0.017),

Evaluating (p= 0.012)

Results- PRPP Stage Two

Sub-quadrant Analysis

Plan- Mapping- Programming- Evaluating

Both M and B self correcting-

matching task (evaluating),

A- questioning when asked to spell

out words.

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Autism Spectrum Australia (Aspect) 38

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

PR

PP

Pla

n Q

uad

ran

t P

erc

en

tag

e S

co

re

Task Performances

PRPP Plan Quadrant Scores

Phase A-

baseline

Phase B-

intervention

M

B

L A

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Autism Spectrum Australia (Aspect) 39

ResultsPRPP Stage Two Quadrant Analysis

PRPP Quadrant Statistical Analysis

Perceive Z=-1.68, p= 0.093

Recall** Z=-2.521, p= 0.012**

Plan** Z= -2.521, p= 0.012**

Perform Z= -1.82, p= 0.069

TOTAL Z= -2.521, p= 0.012**

** Statistically significant differences between baseline and interventionWilcoxon signed ranks test

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Autism Spectrum Australia (Aspect) 40

PRPP Stage Two: Improvements in Plan and Recall,

but not Perceive

• Significant improvements in Plan (all sub-quadrants) and

Recall (recalling facts).

• No Significant improvements in Perceive

• Perceive traditionally associated with sensory processing

(Attending, sensing, discriminating)

• Discriminating is a strength for children with ASD

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Autism Spectrum Australia (Aspect) 41

PRPP Stage Two Discussion

• Improved cognitive strategy application as

measured by Stage Two PRPP

• Statistically significant improvement in planning

and recall, not perceive or perform.

• We hypothesise:

– Children didn’t get better at perceiving information,

– they got better at using the information for task

performance

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Autism Spectrum Australia (Aspect) 42

• Benefits observed in specific sensory intervention

• Key components that make up SAS intervention

• Qualitative feedback from teachers confirmed statistical

results

• PRPP is a suitable tool to use to measure task mastery

and cognitive strategy use in context

• Small pilot study, many limitations

• Real life research

Overall Discussion

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Autism Spectrum Australia (Aspect) 43

Where to Next?

• Randomised Control Trial (RCT)- in progress

• Seven autism specific schools

• Approximately 40 students and 30 teachers

• Sensory Activity Schedule intervention for least one

school term (9 weeks)

• Quantitative and qualitative measures of occupational

performance in the classroom

• Guidelines for practice

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Autism Spectrum Australia (Aspect) 44

Acknowledgements

Julie Fardell, Allyce Cunningham, Lydia Hicks, Jamie Togle, Lara Cheney,

Rebecca Fitzroy, Nala Simmons, Yasmina Adamson, Ashwini Reddy,

Rowena Perritt, Tamara Freeburn, Nicole Maskell, Janet Milhouse, Karen

Horne, Pam Lea, Jen Crawford, Lauren Rolfe, Liz Murray, Sally Hewett,

Kelly Karlson, Philippa Sherrington, Kristy O’Sullivan, Bruce Rowles,

Belinda Harris, Gio Gulli, Catherine Thompson, Michelle Lee, Dr Debra

Costley, Dr Trevor Clark, Dr Susan Bruck, Mark Schlosser

Dr Joanne Hinitt, Dr Rob Heard

Participating students and families, teachers, teacher’s aides

Aspect Elizabeth Hoyles Fellowship

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Adamson, A., O’Hare, A. & Graham, C. (2006) 'Impairments in Sensory Modulation in Children with Autistic Spectrum Disorder.’ British Journal of Occupational Therapy, 69(8): 357-364

Ashburner, J., Ziviani, J., & Rodger, S. (2008). Sensory processing and classroom emotional, behavioral, and educational outcomes in children with autism spectrum disorder. American Journal of Occupational Therapy, 62: 564–573.

Ashburner, J., Bennett, L., Rodger, S. & Ziviani, J. (2013) 'Understanding the sensory experiences of young people with autism spectrum disorder: A preliminary investigation.' Australian Journal of Occupational Therapy 60: 171-180.

Ayres, A. J. (1972). ‘Sensory integration and the child’. Los Angeles: Western Psychological Services

Baker, A.E.Z., Lane, A., Angley, M.T. & Young, R.L. (2008) ‘The Relationship Between Sensory Processing Patterns and Behavioural Responsiveness in Autistic Disorder: A Pilot Study.’ Journal of autism and developmental disorders,38: 867–875.

Baranek, G.T., Boyd, B.A., Poe, M.D., David, F.J. & Watson, L.R. (2007) 'Hyperresponsive sensory patterns in young children with autism, developmental delay and typical development.' American Journal on Mental Retardation, 112 (4): 233-245

Baron-Cohen, S., Ashwin, E., Ashwin, C., Tavassoli, T., & Chakrabarti, B. (2009). Talent in autism: Hyper-systemizing, hyper-attention to detail and sensory hypersensitivity. Philosophical Transactions of the Royal Society, 364, 1377–1383.

Barton, E.E., Reichow, B., Schnitz, A., Smith, I.C. & Sherlock, D. (2015) Review article: A systematic review of sensory-based treatments for children with disabilities Research in Developmental Disabilities 37: 64–80

References

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Autism Spectrum Australia (Aspect) 46

Ben-Sasson, A., Hen, L., Fluss, R. Cermak, S.A., Engel-Yeger, B. & Gal, E. (2009) 'A Meta-Analysis of Sensory Modulation Symptoms in Individuals with Autism Spectrum Disorders' Journal of autism and developmental disorders, 39(1): 1–11

Boyd, B.A., Baranek,G.T., Sideris, J., Poe, M.D., Watson, L.R. Patten, E. & Miller, H. (2010) ‘Sensory Features and Repetitive Behaviors in Children with Autism and Developmental Delays.’ Autism Research, 3(2): 78–87.

Case-Smith, J., Weaver, L.L. & Fristad, M.A. (2015) 'A systematic review of sensory processing interventions for children with autism spectrum disorders' Autism 19(2):133-48. Chapparo C. & Ranka, J. (2005) ‘PRPP Task Analysis Research User’s Training Manual- Research Edition’. Sydney: The University of Sydney.

DET QLD (2011) Best Practice Guidelines for Department of Education and Training Occupational Therapists: Supporting Students with Sensory Processing Challenges. Department of Education and Training, Queensland, Australia.

Dunn, W. (2014) ‘Sensory Profile 2.’ Bloomington, MN, USA: Pearson Psychcorp.

Grandin, T. (2009) ‘Commentary: Visual Abilities and Sensory Differences in a Person with Autism.’ Biological Psychiatry, 65: 15–16

Green, S.A. & Ben-Sasson, A. (2010) 'Anxiety Disorders and Sensory Over-Responsivity in Children with Autism Spectrum Disorders: Is There a Causal Relationship?' Journal of Autism and Developmental Disorders, 40:1495–1504.

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Start where you are.

Use what you have.

Do what you can.

Arthur Ashe

Questions…

Contact: Caroline Mills, [email protected]

www.autismspectrum.org.au