Sensory Integrative Dysfunction is one of the key presenting symptoms for people with autism spectrum disorder (ASD) but rarely will you find it mentioned in the top four descriptions of autism. As a result, a very important issue is often overlooked in many of the treatment approaches to helping people with autism. Many "behaviors" demonstrated by people with autism are often misunderstood, and reasons for meltdowns or tantrums are often assigned the wrong meaning or explanation.
As a trainer of individual support staff working with people with autism, one of the areas I spend a lot of time on in my training sessions is Sensory Integrative Dysfunction. I encourage all of my staff to undertake a Sensory Integrative Assessment with every client/consumer we work with, right from the start. In this article, I refer to the "child" but obviously, a teen or adult with ASD may also experience sensory issues, so please notice these issues when working with anyone with ASD, regardless of age.
It is not all that complicated to assess or to understand. Start by thinking about the sensory channels we all have. Typically, we might experience mild variations in our sensory processing. On a bright day, some of us are not comfortable unless we wear sunglasses. Others find no need to wear sun glasses. Some people can tolerate wearing all fabrics, but others may feel uncomfortable in wools and feel itchy. Some may like bland foods, other may love to add exotic or hot spices to enjoy their food. These are all typical variations.
But people with autism may have sensory experiences that are dramatically exaggerated. The sound of a blender or vacuum cleaner can terrify some individuals with autism. Some people with autism won't eat foods that touch each other on the plate or are certain colors or textures. Some people don't want to be touched, others will hug others so fully, it can feel like an assault. The list is endless. Later in this article, I offer many tips on how to do a more complete assessment.
To understand if a person with autism has sensory integrative issues, if the person is non-verbal, you will have to interview the person with ASD's parents, caretakers and teachers. Collectively, they will notice if certain foods are refused, if certain lighting in a room helps or hinders the person's experience, if certain sounds create a reaction, if a physical act of affection is well received or refused. Start making a list in each category: sight,/lighting; hearing/sound,; smells, tastes; physical sensations/active or limp body tone. Depending on the severity of the person with ASD's reaction to these sensory experiences (and also the lack of reaction as well) you will have completed a sensory integrative assessment that will explain so much. Once you understand these issues as provocations, you can either adapt the environment to minimize some of these experiences, or you can try methods to desensitize the individual (I will not go into this technique in this article.
Some of what you will read below comes from my own experience as a trainer, and some material comes from the following books and authors:
From: A Parent’s guide to Autism, Charles Hart, Simon and Schuster
From: Overview of Autism, Stephen M. Edelson, Ph.D, ASA Resource Library
From: Sensory Integration, Michael Abraham, McGraw-Hill Children’s Publishing
Autism is the term to describe a variety of neurological problems that affect thought, perception, and attention. This disability can block, delay, or distort signals from the eyes, the ears, and other sensory organs. This usually weakens a person’s ability to interact with other people, either through social activity or using communication skills such as speech.
Sensory Impairments:
Many individuals with autism seem to have impairments in one or more of their senses. This impairment can involve the auditory, visual, tactile, taste, vestibular, olfactory (smell) and proprioceptive senses (perception about our bodies condition or perception of our body in space). These senses may be hypersensitive (more excitable), hyposensitive (less than normal responsiveness), or may result in the person experiencing interference such as in the case of tinnitus, ( a persistent ringing or bussing in the ears). As a result, it may be difficult for individuals with autism to process incoming sensory information properly.
Sensory impairments may also make it difficult for the individual to withstand normal stimulation. For example, some individuals with autism are tactilely defensive and avoid all forms of body contact. Others, in contrast, have little or no tactile pain sensitivity. Furthermore, some people with autism seen to “crave” deep pressure. Another example of sensory abnormalities is hypersensitive hearing.
Approximately 40% of individual with autism experience discomfort when exposed to certain sounds or frequencies. These individuals will cover their ears and/or tantrum after hearing sounds such as a baby’s cry or the sound of a motor (hair dyer, vacuum cleaner, blender, power tools, etc.) In contrast, some parents suspect their children of being deaf because they appear unresponsive to sounds. Children with autism can also exhibit both). Auditory integration training, (listening to processed music in head phones for ten hours) is an intervention which is often used to reduce these sensitivities. Visual training is another sensory intervention designed to normalize one’s vision. There are several different methods of visual training. One popular program, developed by Dr. Melvin Kaplan, involves wearing ambient (prism) lenses and performing movement exercises which appear to reorganize and normalize the visual system.
Sensory integration techniques are often used to treat dysfunctional tactile, vestibular, and proprioceptive senses. Some of the techniques involve swinging a child on a swing in various ways to help normalize the vestibular sense and rubbing different textures on the skin, or brushing the skin to normalize the tactile sense. Joint compression techniques are used, weighted vests are used and Dr. Temple Grandin, (who herself has autism) developed a hug machine which provides individuals with deep pressure which appears to have a calming effect on the person.
Decoding and regulating sensory information, however, can be challenging and overwhelming for children with sensory integration (SI) dysfunction.
Children with SI dysfunction have a hard time knowing which sensory information is important and which is irrelevant. For them, adaptation does not take place naturally. They register sensations inconsistently, day in and day out. Sone days they appear to be focused, but on others they are not even aware of the task. These children simply do not have the efficient kind of brain functions that enable most people to be consistent from way day to another.
What is Sensory Integration?
The central nervous system develops after birth in response to incoming stimulation through the five senses. For example, the sense of space–the knowledge of where the limbs and trunk are and what they are doing–is critical to any developing child. For children with SI problems, this sense may not be intact. They have an irregularity in brain function. In the realm of tactile sense, for example, input from the touch of other people and objects of all kinds may not be processed or modulated correctly through the central nervous system. These children seem unable to organize tactile sensations, let alone coordinate them well with vision and hearing.The term ‘sensory integration dysfunction’ is used to characterize this disability. SSI may present itself in cognitive, motor, social/emotional, speech/language, or attention disorders.Children with SI dysfunction may be unable to respond to sensory information or to learn and organize accurately what they need to do in school or at home.
Sensory-Motor Integration Skills:
Equilibrium: refers to body movements or shifts to maintain or regain balance. The movement can be small, such as maintaining a sitting position in a car that is turning a corner, or large, such as protecting the body from a fall by using one’s arms and hands.
Kinesthetic: or proprioception pertains to information from inside the body–especially from muscles, joints and ligaments–about the body’s condition and position in space. It is the internal awareness about our body parts that allows us to perform tasks with coordination. Co-contraction involves activity of muscles on both sides of a joint contracting together. Co-contraction is a type of joint stability and is very important for coordinated movements. Motor Planning: refers to a persons ability to organize, plan, and then execute new and unpracticed motor tasks. The sensory systems, especially tactile, are of prime importance in motor planning.
Tactile: refers to the sensory messages received through our skin. Tactile information is a basis for learning about external objects as well as the condition of our body. If this information is not precise, it can hinder learning and coordination.
Vestibular: the vestibular mechanism is located in the inner ear and is activated by movement or by changing one’s head position. The vestibular system, o coordination with the kinesthetic and visual systems, directs the centralnervous system to the position in space and tot he force of gravity so the child can maintain equilibrium. Maintaining equilibrium is a result of a functioning vestibular system. Practice in this area promotes more efficient movement, balance, equilibrium, and vestibular processing and integration.
Bilateral Motor Coordination: is the ability to coordinate both sides of one’s body. Movements can beeither reciprocal or bilateral. Bilateral motor coordination can be achieved when tactile and kinesthetic information is processed.
Compromised Auditory and Visual Input:
Part of the brain in the limbic system (which decides which sensory input is to be registered and brought to our attention) also decides whether a person will do something about that information. Research shows that this part may not be working well in the brains of children with SI dysfunction. They do not register observations that everyone else notices. More often than with other sensory inputs, auditory and visual inputs are ignored or not registered. Sometimes the child may over-register one sound and under-register another. Visually they may stare through people or avoid looking them in the eyes. However, sometimes their brains will decide to give the most careful and prolonged attention to tiny details, such as lines on the floor or a small break on the edge of a cookie. Many individuals with autism also have a narrow or focused attention span; this has been termed ‘stimulus over selectivity’. Basically, their attention is focused on only one, irrelevant, aspect of an object. For example, they may focus on the color of a utensil, and ignore other aspects of the shape. In this case, it may be difficult for a child to discriminate between a fork or a spoon if he/she attends only to the color. Since attention is the first stage in processing information, failure to attend to the relevant aspects of an object or person may limit one’s ability to learn about objects and people in one’s environment.
Imagine trying to learn when sensations feel like an endless series of magician’s tricks.When poor sensory processing exists, children pay little attention or may overreact to a given task. They have little or no interest in doing things that are purposeful or constructive. Often these children are in motion. They may need to spin. These children may alternately avoid or covet touch, which in turn puts them in a state of motion. Often these children will not acknowledge levels of pain when experiencing a bump or a fall unless it is very intense. Some children are overly sensitive to the texture of things. They may resist certain foods because they don’t like the feel, smell, or taste. They may not be able to register certain odors; conversely, they may overreact to certain odors (and insist on smelling people closely). They may lack a sense of taste or require spicy/sour tastes.
Sensory input through muscles and joints may be greater for these children than through their eyes and ears. Pulling and pushing their arms and legs at the joints appears to feel satisfying. This important proprioceptive information helps to ground the children and gives them a feeling of security as the strong sensations are registered in their brains. These children may seek movement and vestibular stimulation strenuously or reject it entirely. Neither response is normal.
In the early days, before psychiatrists understood the neurological nature of autism, they thought patients had escaped into their minds to shut out the world. That theory has since been disproved, but many still speak in those terms! Why? Because the gestures and appearance of people with autism “look like” escapism and isolation. Many however, avoid eye contact, because they don’t recognize subtle signals of interest or attention in the gaze of others. If we had visual processing problems, we might ignore eye contact too. Perhaps children with autism avoid affection or eye contact because they respond differently to common sensations like a soft touch on the arm or the sight of a smile, or the sound of a lullaby being sung. Unbeknownst to their caretakers, they may hear singing as chalk screeching down a blackboard or feel touch as electricity, or translate a toothy smile as a hostile growl.
An individual with autism may have unusual responses to any and all of the five basic senses. A child who is hyper-sensitive to sound may find household noises and every day sounds painfully loud, even frightening.
Ineffective Modulation:
Modulation is the brain’s regulation of its own activity and involves helping neural messages to produce more of a response, inhibiting other messages to reduce extraneous activity (overflow). In some children, their brains fail to vary the intensity of vestibular sensations (e.g., spinning, jumping, swinging) and touch. In turn, these children can resist movement and become insecure because they cannot control sensation. They can become extremely anxious about their relationship to gravity and space. With sensory processing problems, it is understandable that when new experiences are presented, these children may react with alarm and resistance. Some children may have so much trouble registering the spacial elements of their environments that they can be upset whenever anything is changed in a room at home or at school.
Preparing the Environment:
Prepare the room with as little sensory stimulation as possible.
Reduce the number of papers on the walls, reduce hanging projects, reduce noise levels, be aware of/avoid flourescent lighting and intense sunlight through the windows(filter if necessary with sheers or shades), (consider other light bulb replacements, natural lighting, spot incandescent lamps etc.)
Use neural colors on work stations (beige or off white) bright colors can be used sparingly and most effectively when they appear in contrast to a neutral background.
Present lessons at child’s eye-level for child’s orientation
Avoid “highs” within the learning atmosphere, rather strive toward a calming atmosphere.
Increase attention span by removing distracting objects within the visual field of the child (A cardboard screen can be used)
Don’t present equipment until after the verbal directions are given and the child is ready to use them. (Otherwise he child may be distracted by the materials and not listen to you)
Encourage children to help put the equipment away when done and develop responsible behaviors.
Interventions must strive to foster three things:
1. focus and concentration
2. engagement in the human world
3. two-way intentional communication
Pay attention to the child’s regulatory difficulties. Does the child learn best in the realms of visual, auditory, tactile, or vestibular stimuli. Is the child reactive or underactive to these stimuli?
READ: Sensory Integration, by Michael Abraham, McGraw-Hill Children’s Publishing (Addressing Learning Differences) pages 58-117 for SI activities to try to address all types of SI Dysfunctions.
See pages 48-51 for a Pre-Referral Motor Screening Checklist (helpful in identifying symptoms pointing to SI Dysfunctions and recommending an OT evaluation.
Use short, direct, simple instructions (try to get the child to “look at me, while I talk) put your face close to his/herd (but don't over do that approach if they refuse), use finger to point to your eyes to bring attention to your face.
Set up home with routines and orderly structure.
Allow free play periods and intermittent breaks.
Use music, a low tone, or slowly modulating light to signal closure (give time warnings, 5 minutes until we leave, 2 more minutes until we stop, etc.
Keep activities short to accommodate short attention spans.
Break down learning steps (chain/reverse chaining).
Repetition of skills allows the child to succeed.
Do activities that stimulate both sides of the body (‘Simon says, touch your right ear with your left hand’, balancing, crawling, jumping, running, swinging, climbing hand-over-hand, moving on a balance beam, using large manipulatives, or materials requiring two hands.
Do activities to develop upper arms and shoulders (helps with hands and finger coordination, such as fine-motor control for writing skills) Climbing on jungle gyms, wheel barrel walking, crawling through tunnels and under obstacles, working at the easel, making exaggerated arm movements during songs.
Through manipulation of small play objects, they learn to use their hands and fingers efficiently.
Children that have many opportunities to move their bodies in a predetermined sequence (as in an obstacle course or a movement song) are learning the abstract sequencing skills of beginning, middle, and end–how to order and plan, anticipate the next segment, and experience closure (these help on the abstract level for reading comprehension and creative thinking). Through large, full-body movements, they learn how to relate themselves to the space around them.
In summary, one of the best ways to get a complete assessment of sensory issues and also specific ways to respond to such dysfunctions is to seek out a consultation with an experienced occupational therapist that has broad experience in treating Sensory Integrative Dysfuntions and also experience in working with people with autism.
For more information on Sensory Integrative Dysfunctions, contact us at: www.myarchway.org
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