Wednesday, July 20, 2016

Pre-Satiation Technique for Stereotypy and Craving?

In the previous post, I looked at the blurred lines across the (ASD) autism symptoms of stereotypy and sensory craving. This post focuses on an intervention that may help both types of symptoms. The intervention is a well-conceived combination of behavioral and sensory techniques that comes from a study by Rispoli, et al (2013).
The research team studied three children with stereotypic behaviors. Five-year-old Antonio has autism and vocal stereotypy in the form of a high-pitched squeal. Twelve-year-old Jeff has intellectual disabilities and seizure disorder. He hits tables, chairs and walls repeatedly with various hand-held objects. Four-year-old Joel has autism and bounces small things (balls, toys and breakable objects) onto the floor. 

All three boys were unable to engage in demanding group tasks because of their stereotypy. The researchers posed the question: If each child were allowed to engage in his behavior until he stopped of his own volition (was satiated), would he then be able to engage in the demanding group tasks.

To test this, they set up a three phases process. First they analyzed each child’s behavior to see if he was a good fit for the study. Second, they looked for toys that matched the child's stereotypy and had him play with them to discover which toy was preferred. Last, they tested over a 4-5 week period to see if pre-satiation with the preferred toy before a demanding 15-minute group activity decreased the amount of stereotypy during the group activity and allowed each boy to focus on his work. (The answers were yes and yes.) The study while small used good methods; it was a blind, controlled study.

The implementation details are below. The interventions (step three) can easily be done at home or school by a parent or teacher. The first two steps are the domain of behavioral or sensory therapists, but may be accomplished by an astute parent or teacher. Let's look at the details for putting this in place.

Step 1: Analysis
1.     Analysis: You note a stereotypic behavior that appears to have a sensory component. Note which senses appear to be stimulated by the behavior. Remember that movement is also sensed by the body. It is the combination of the vestibular sense (head movement) and the proprioceptive sense (body movement). Unless you discover otherwise (see the "unmatched preference" of step three), assume that the child is craving sensation and that his stereotypic activities are satisfying that craving.
2.   To establish a baseline, count the occurrences of the behavior: count the number of times and the total amount of time he engages in stereotypy during a demanding activity. Also note when (time, place, type of activity) the child engages in the behavior.

Step 2: Discovering the Preferred Object


1. Identify possible preferred activities for satiation tasks: Put together some optional activities for him to engage in that might be just as engaging as the stereotypy. Attempt to find activities that stimulate the exact same senses in the same way. A good preferred activity may be more intense than his current one.
2.   Put all of the candidate preferred activities (toys to help with stimming) in an otherwise empty room with the child on a few occasions. Let him play and see if a preferred object emerges.
       If you are unable to find a preferred activity that is similar to the stereotypy, then try something else, perhaps access to a computer or a cause-and-effect toy. This is called an unmatched preferenceThe preferred toy for Antonio was a musical camera. Jeff was given an object he could use to strike walls and tables that would not hurt them. The choice for Joel was obvious; he was given a ball.
Here are examples:
a.       For the child who lines things up, show him how to stack and line-up Legos, and see if that becomes a preferred activity. This is a big one for many kids.
b.      For the child that flicks his wrist, try a punch balloon.
c.       If he is in constant motion, try a small trampoline, a swing (this is huge!), climbing equipment or a ball pit (if you have access to one). An older child may like riding a bike—perhaps on a bicycle-built-for-two with the parent in front.
d.      Finally, an example of an unmatched preference: the child flicks his finger, but you’ve discovered that given the opportunity, he would play with a cause and effect toy for a long time. This is his preferred activity.
3.     Practice with the preferred activity: On successive sessions, let the child engage in the activity for as long as he wants--until he has had enough. You will need to know how long it typically takes for him to be satiated, so keep track of the time. This is the satiation time.

Step 3: The Intervention

The intervention can be done prior to a demanding activity, as a way of helping the child to self- regulate.
First, let the child have unlimited time doing the preferred activity, that is let him do it until he is satiated. Let’s say that he usually requires 22 minutes to be satiated, and then plan to have him start the preferred activity about 25 minutes prior to the next task.
Afterwards, as he engages in the demanding tasks, track his behavior to see if his stereotypy has diminished. Counting the number of times and the total amount of time he engages in stereotypy during the demanding activity. Do this over a period of several sessions. If it appears to be helping, continue with the intervention on a daily basis. If he acclimates to the preferred activity, then try replacing it with something a little more intense or demanding. In some cases, you may see that he no longer desires the preferred activity and that his stereotypy has decreased, as well. This good outcome is possibly the result of increased sensory integration skills.
In the study, the child was used as his own control. By performing the intervention every other session, his behavior on days that he was satiated could be compared to behavior on days that he received no intervention and was not satiated. They noted that after a few weeks, the behavior appeared to improve both on the days that the intervention was done and when it was not done.

Unfortunately, the researchers did not carry out the study long enough to see if the intervention would lead to extinction of the behavior--which is a shame, because it might do so. I have seen satiation work as therapy with children in my setting. I separately treated wo children who craved movement. When given unlimited time on a swing twice a week, both lost interest in the swing after a month. One boy with this result was then capable of sitting at attention in the classroom without getting out of his chair on  most days. Sensory integration theory suggests this outcome, but to my knowledge, this type of scenario has not been documented in the journals.
How long did the effect of the intervention last? Fifteen minutes? A few hours? The whole day? The authors don’t discuss this, but the intervention is similar in nature to the sensory diet which is thought to last 2 hours. In the sensory diet, children are given 15 minutes (or so) of sensory stimulation usually including  a movement activity every 2 hours as a means of increasing self-regulation. A significant difference between satiation and the sensory diet is the inclusion of movement which is on its own self-regulatory. (BTW, the sensory diet has not yet been sufficiently studied to validate its efficacy, but it is generally accepted as a good practice.)

I still have additional articles to review from Behavior Modification's 2013 special issue  on Stereotypy. So stay tuned for that.

An update: Rachel Scalzo's 2015 PhD thesis on satiation of stereotypy has made a significant addition to the literature by clarifying the intervention process. I'll keep an eye out for future journal articles from her. In the meantime, here is her thesis abstract.

    Rispoli, M., Camargo, S. H., Neely, L., Gerow, S., Lang, R., Goodwyn, F., & Ninci, J. (2014). Pre-session satiation as a treatment for stereotypy during group activities. Behavior Modification, 392-411.

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