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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
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
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.
