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Enhancing the Behavior of Students with Autism & Sensory Over-responsivity

Over half of students with Autism Spectrum Disorders have sensory over-responsivity to tactile and auditory stimulation with reduced sensory limbic habituation (Green et al., 2015).  Their lack of habituation makes it physiologically more likely they will become distracted and have difficulty learning. Significant sensory modulation difficulties were related to attention and academic achievement challenges in children with Autism Spectrum Disorders. Students with Autism Spectrum Disorders and significant sensory modulation difficulties benefit from learning to use coping strategies that improve their attention, learning and behavior in the classroom. Among SBIs (sensory-based interventions) tactile massage intervention a minimum of 15 minutes, twice weekly for 3 months has the greatest research support for improving student behavior and learning (Wan Yunus et al., 2015).

Sensory coping strategies for students with Autism Spectrum Disorders who have sensory over-responsivity begin with teaching students to monitor their energy levels to determine if they are high, medium or low and whether their energy levels are OK for learning.

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Next, evidence-based environmental adaptations should be tried to minimize auditory (sound absorbing walls, noise canceling headphones, carpeting), visual (halogen lighting, study carols), and tactile distractions (specific seating so they will not accidentally touch peers). Finally, teachers and therapists should try to reduce the pace and volume as well as increase the salience of instructions, and use visual supports as indicated (Ashburner et al., 2008; Kinnealey et al., 2012). Breaks from learning involving deep pressure and linear movement (Murray et al., 2009), such as by having the student pass out books or deliver messages, can also promote learning. Given that over half of students with Autism Spectrum Disorders also demonstrate significant sensory over-responsivity, it is important to teach coping strategies that will maximize their learning. speechaudnevhandouts  ERI2017SBISupplement

References:

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.    

Green, S. A., Hernandez, L., Tottenham, N., Krasileva, K., Bookheimer, S. Y., & Dapretto, M. (2015). Neurobiology of sensory overresponsivity in youth with autism spectrum disorders. JAMA psychiatry, 72(8), 778-786.

Kinnealey, M., Pfeiffer, B., Miller, J., Roan, C., Shoener, R., & Ellner, M. L. (2012). Effect of classroom modification on attention and engagement of students with autism or dyspraxia. American Journal of Occupational Therapy, 66, 511–519.

Murray, M., Baker, P. H., Murray-Slutsky, C., & Paris, B. (2009). Strategies for supporting the sensory-based learner. Preventing School Failure: Alternative Education for Children and Youth53(4), 245-252.

Wan-Yunus, F. W., Liu, K. P., Bissett, M., & Penkala, S. (2015). Sensory-based intervention for children with behavioral problems: a systematic review. Journal of autism and developmental disorders, 45(11), 3565-3579.

 

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Sensory-Based Intervention Groups

Sensory-based intervention (SBI) groups can be useful in schools and clinical settings to improve sensory skills, behavior and learning.  SBIs are the guided use of sensory strategies to improve behavior by addressing specific sensory modulation or sensory discrimination challenges.  SBIs are commonly implemented in early intervention, school, and mental health settings through individual, group and consultative interventions. SBIs include directing other professionals in embedding goal-directed sensory activities into a student’s daily routine to improve behavior for learning.

It is important to distinguish occupational therapy utilizing SBIs from Sensory Integration Intervention. While SBIs and Sensory Integration both utilize the theory of sensory integration, they are distinct interventions with unique research efficacy. Sensory integration intervention, also referred to as Ayres Sensory Integration® is a developmental clinic-based, child-led intervention that follows specific core concepts.

SBIs can empower clients to actively substitute the sensory input provided through aggressive, inappropriate and self-injurious behavior with sensory coping strategies and adaptive equipment. SBIs are goal-directed and specifically matched to the client’s needs and preferences. The use of SBIs has been integrated into the evidence-based Greenspan Floortime Approach for Autism Spectrum Disorders, Collaborative Problem Solving Approach for children with oppositional defiant disorder, Dialectical Behavioral Therapy for adolescents with borderline personality disorder, and models for reducing restraint and seclusion in mental health facilities and schools a-reducing-restraint-and-seclusion OTPractSchoolOTRedAgg .

The new ESSA “Every Student Succeeds Acts” (2015) potentially expands the role of school therapists in helping at risk students and consulting with parents and teachers to improve school climate.  Under ESSA occupational, physical, speech/language, and school mental health therapists are designated as Specialized Instructional School Personnel (SISP) and given a role in helping at-risk regular education as well as special education students.  SBI’s can be included in interventions to educate students, staff and parents in enhancing student self-regulation school therapist consultations and group leadership.

Effectively using sensory-based interventions (SBIs) to improve functional behavior is different from the more common practice of randomly distributing adaptive equipment or using a single sensory strategy such as brushing for every student in a class. Using SBI adaptive equipment and sensory strategies to optimally promote functional behavior begins with an occupational therapy assessment, developing an individualized functional behavioral goal, gathering baseline data on the goal, and matching the client with the most appropriate individualized environmental adaptation.  Once a specific environmental adaptation has been implemented consistently for a month in conjunction with other professionals, it’s effectiveness is assessed to determine if the environmental adaptation should be continued, modified, or discontinued.

Sensory modulation is the ability to respond to functionally relevant sensory information while screening out irrelevant input.  Simply helping students understand their sensory modulation and/or sensory discrimination differences is an important first step in SBI.  Therapists can begin by discussing sensory modulation “energy levels” as low, medium and high, to help students identify when their energy levels are too high or low for behaving appropriately and learning.  Consistently using the color codes developed by the Zones of Regulation program can be part of the effort in helping students gain a better understanding of how their arousal levels affect their behavior and emotional regulation.

Once students have modulated their energy level, consider and intervene if sensory discrimination disorders are negatively impacting behavior.  When in the quiet alert state some students can still become dysregulated because of sensory discrimination disorders in which they have difficulty distinguishing, interpreting and organizing the information coming in from all their various senses.  For example, sensory discrimination disorder can involve problems organizing and combining information from the pressure, touch, and movement senses to appropriately print the “b”.

Sensory discrimination disorder can occur in any combination of ones sensory systems: tactile (touch), proprioceptive (muscle force/tension), interoceptive (internal organ states such as hung & pain), olfactory (smell), gustatory (taste), auditory, and visual.   it is most widely described in tactile discrimination disorder. A common assessment item regarding tactile discrimination from the Miller Assessment for Preschoolers involves the therapist having a client identify which finger is touched with eyes closed, with consistently accurate identification expected by age 3. Some high school students who are above grade level who had a trauma history and psychiatric disorder were inconsistently able to do this task. This difficulty alerts me to the need of increasing body awareness. Sensory Discrimination Disorders can involve the sense of: touch, proprioception (body awareness), vestibular (movement), vision, sound, taste, and/or smell. Interventions of sensory discrimination disorder are best done after basic sensory modulation has been addressed.

Recent research suggests that interoception can be a significant component of sensory discrimination disorders.  Interoception challenges involve confusion regarding internal body sensations such as hunger, thirst, and pain.  Exploring internal sensations through sensory mindfulness activities can help address interoception.  Research supports that mindfulness activities can be helpful interventions for individuals with somatic pain and post-traumatic stress disorder challenges.

mindfulnessSensory discrimination disorder contributes to difficulties with body awareness, embodiment, and organizational skills. Sensory discrimination disorder is more commonly seen in clients who experience early childhood post-traumatic stress disorder. It is hard to teach self-esteem and respecting others personal boundaries when clients don’t have adequate body awareness.

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It is important to help students learn to identify what they are feeling before they yell, hitting others or engage in problematic behavior “because they suddenly feel horrible”.   For students with developmental challenges it can be helpful to combine feeling faces with the color codes from the Zones of Regulation so they can use pictures to identify their negative feelings and arousal level and get assistance with finding self-regulation activities.

SBI involves the use of individualized adaptive equipment to improve specific goal-directed behavior, such as reducing noise and visual distractions with a study carol and noise-canceling headphones to reduce peer conflicts and increase attention.  It can also include massage, mindfulness activities, or embedded classroom tasks involving delivering a box of books for the teacher as a deep pressure movement break.  The most important and often neglected step is to identify and educate students regarding their specific sensory challenges related to behavior, and to reinforce all efforts to self-regulate.

Adaptive Equipment

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