Today was a dentist day. Now, in spite of being over-sensitive to just about everything, I am good with going to the dentist. As a child, I had a great dentist who told me to focus on something else while he worked on my teeth. I did so and got through the procedure without too much discomfort. It was a good lesson.
But I didn't generalize on it until much later. I was in the midst of a home remodeling project and hammered my thumb instead of the nail :{ I was dramatically in pain. A friend told me I was a wuss, and that I should focus my attention on something else until the pain died down. I did it, and miracle of miracles, it worked. How did he know that and I didn't. He had played sports. I had not. Sensory kids don't.do.sports because it's noisy and you get bumped a lot. And that's the point of this post sensory kids naturally react differently to pain, bumps and sounds and they avoid activities like sports where kids get so many life lessons, including "think about something else".
If Zoey is playing in the sprinkler and gets water in her face, she can focus on it with discomfort, or she can shift her attention outward to something else, like the sprinkler itself, her chest or her hands. If Martin is standing next to an alarm that sounds for several seconds, he can bring his attention back into his body (and his hands over his ears) and in that way stay grounded.
This particular lesson is a game changer, and here's why. Our brain operates with great efficiency, always trying to guess what to be ready for. If I focus on sensory discomforts, the brain says, "That's what she wants to pay attention to", and so it prioritizes the brain's focus to discomforts. On the other hand, if I am able to ignore the discomfort, and focus on something else, discomfort loses priority. What a concept. Discomfort loses priority, and we don't attend to it. What a great lesson for our kids!
By the way the circuitry that processes priorities is in the right anterior insular cortex (rAI). It feeds priorities to the anterior cingulate cortex (ACC) which takes action: behaviors, motor and emotional reactions and cognitive redirection. ....but that's a post for another day.
Showing posts with label Modulation. Show all posts
Showing posts with label Modulation. Show all posts
Tuesday, August 16, 2016
Monday, July 25, 2016
Thoughts on Craving
Just a short post today. I'd like to refer back to the last two posts (here and here) which discussed stereotypy and sensory craving. I forgot to mention in the second post that the intervention used by Rispoli, et al. is the same approach I take to sensory craving in my book, Hands on Activities for Children with Autism and Sensory Disorders. In the book, I discuss how to explore sensory activities to find a preferred type of activity. The book also contains 50 or so fun interventions including crafts.
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.
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 preference. The 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.
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 preference. The 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.
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.
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.
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.
References
-
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.
Monday, June 27, 2016
My latest book, Hands-On Activities for Children with Autism and Sensory Disorders is available through my publisher, PESI.com, and at Amazon. It has all new interventions and focuses on sensory, especially multi-sensory, activities. Topics include Environmental Enrichment for children with autism, sensory enrichment for all children, and aerobics for the classroom. It's great stuff. Check it out!
As I begin to work on my next book: self-regulation strategies for the Pre-K to grade 2, I'll be previewing topics in my blog posts. So stay tuned for lots of great new material!
Teresa
As I begin to work on my next book: self-regulation strategies for the Pre-K to grade 2, I'll be previewing topics in my blog posts. So stay tuned for lots of great new material!
Teresa
Monday, December 31, 2012
Polyvagal Theory, Sensory Challenge and Gut Emotions
Have you heard about Dr. Stephen Porges' Polyvagal Theory? The theory, already 20 years old, replaces our old notions of how the sympathetic (fight/flight) and parasympathetic nervous systems (rest and recuperation) help to keep us calm, alert and safe. The area covered by Polyvagal Theory is huge. It impacts the way we understand our nervous system, senses, emotions, social self and behaviors. We see diagnoses like autism, sensory modulation disorder, borderline personality and others, in a new light.
Polyvagal Theory claims that the nervous system employs a hierarchy of strategies to both regulate itself and to keep us safe in the face of danger. In fact, it's all about staying safe.
Our "highest" level strategy is a mechanism Porges calls social engagement. It is a phenomenal system - connecting the social muscles of the face (eyes, mouth and middle ear) with the heart. You knew that your heart came alive with social interaction, and it's true! This system is regulated through a myelinated branch of the vagus nerve. In evolutionary terms, this is our most evolved strategy (mammals only) for keeping ourselves safe. We use this all the time to clear up misunderstandings, get help, plead for forgiveness, and so on.
The next mechanism, or strategy, is fight or flight. It's regulated by the sympathetic nervous system. This system is our fall-back strategy when social engagement isn't a good fit. (Think of seeing someone sneaking up on you!) Note that freeze is not a part of fight or flight.
Our freeze option is primal and is a remnant of our reptilian past. Freeze is a great strategy for turtles and lizards, but it's usually a bad idea for humans - think of fainting. Therefore, we typically use it last, when social engagement and fight/flight aren't going to work for us. But there are good uses for freeze. During severe injury, it shuts us down and turns off our registration of pain. We also make use of it during sex, and it helps women regulate pain and response to pain during labor.
Now these systems appear to work in tandem. The social engagement system puts the brakes on the other (fight, flight, freeze) strategies, thus keeping our heart and body active while we work through a situation. The social engagement system will release the brakes to engage a different response to the environment (i.e. running) if engagement doesn't help to get us into a safe situation.
What Can Go Wrong
We want our nervous system to operate using the social exchange most of the time. It is our most evolved way of being. It is restful and healthy because it allows our gut and other organs to do their job uninterrupted.
However, some of us are programmed from an early age to work from a fight/flight mode. Think of people who are sensory sensitive and recoil from sound, touch, smell or taste. Think of people with autism (in this case, the face to heart connection is not working). Think of people with borderline personality, depression and perhaps other disorders, too. When we are not able to work from our social engagement strategy, then we revert to a modified fight/flight strategy, which puts us in high alert. If we use too much of the fight/flight or freeze strategies, we may end up with gut issues because the gut comes to a halt and we stop digesting food during fight/flight activation.
The Polyvagal Theory has gained great acceptance over the years as pieces of it are shown to hold under laboratory findings. From a psychological viewpoint, it provides us with a rich understanding of self-regulation in the body. From a sensory processing viewpoint, it informs our understanding of sensory modulation.
If you are unfamiliar with the topic, check out the many articles on Dr.Porges' website. The most comprehensive article is The Polyvagal Perspective, and it is published here on the NIH Public Access site. It contains the physiological underpinnings of the theory as well as perspectives on development, emotions, trauma and many other topics. There is a short video of it here.
Sensory Connection
Two researchers looked at a biological marker of the social exchange system, RSA, in typical children and in children with sensory modulation issues. RSA is the measure of high-frequency fluctuation in the heart between heart beats. It is a window into the social exchange system. The researchers found that children with sensory modulation issues have a lower level of RSA than their peers, meaning that these children are better prepared to put the breaks on social strategies and instead use fight-or-flight strategies.
As part of the study, the children were (each in turn) given a sensory challenge. The chairs they were seated on tilted backwards unexpectedly. The level of RSA was monitored in each child throughout the incident. The RSA of typical children dropped quickly and then stayed low for a short time. The children with poor sensory modulation skills had a very brief drop of RSA and a quick rebound to their RSA baseline.
This implies that children with sensory modulation symptoms use different strategies to handle safety-related situations than their peers. At this time, it is harder to draw greater conclusions since we do not have an easy-access window into the fight/flight system or the freeze system. With time, we'll get a better understanding of this. The article can be found here.
Emotions
Perhaps the most interesting new work making use of the Polyvagal Theory is the work of A. D. (Bud) Craig. Mapping our emotions, this is what he found. (Read about it here.)
Emotions arise from feelings in our organs and gut. The feelings are sent via the vagus nerve to the Anterior Insular Cortex (AIC) in the brain. (There's a lot going on in the vagus nerve - think of it as a cable with lots of separate wires.) The AIC captures feelings over time and stores them as snapshots of feelings. This is our working emotional memory. These feelings are massaged and integrated with the social exchange to give us both an emotional response to the world around us as well as a safety-driven strategy.
Think of this: I am relaxing in a lounge chair on the beach. I feel safe. Suddenly, a beach ball hits me. My fight or flight instinct kicks in and the sympathetic nervous system stops everything that's happening (i.e. digestion) in my organs and gut. The gut passes the feeling of stoppage as "alarm" to the brain. This translates in the brain to fear and my body is set in motion. I quickly turn and see it's a ball and that a child is nearby and smiling at me. My social engagement strategy puts the breaks on my fight/flight response and also calms my heart. I smile at the child. This sends a sense of relief to my gut and it in turn sends a "warm" feeling to the AIC. My heart is still pounding from the surprise, but my response is guided by compassion.
In the above scenario, we specifically looked at a situation with a challenge to safety. But in fact, we spend much of our time worrying about safety. Unless I am completely safe, listening to quiet music in a locked room, I will most likely have safety challenges to respond to. The challenge may be from the scary book I am reading, or from the sense of anxiety I feel when I drop a spoon on the floor. Almost any activity will involve the combined interaction of the various strategies. The bottom line: we are constantly adjusting ourselves to meet the world. Polyvagal Theory gives us a look at how this works.
This is pretty complex stuff - and the theory is still in flux. It changes with each new study that looks at the implications of Polyvagal Theory on our response to the world. It is going to impact research greatly in the years ahead. As I mentioned at the beginning, Polyvagal Theory adds a new dimension to how we see autism, sensory issues and other disorders and will, I think, inform our interventions for those disorders in a big way.
References:
Polyvagal Theory claims that the nervous system employs a hierarchy of strategies to both regulate itself and to keep us safe in the face of danger. In fact, it's all about staying safe.
Our "highest" level strategy is a mechanism Porges calls social engagement. It is a phenomenal system - connecting the social muscles of the face (eyes, mouth and middle ear) with the heart. You knew that your heart came alive with social interaction, and it's true! This system is regulated through a myelinated branch of the vagus nerve. In evolutionary terms, this is our most evolved strategy (mammals only) for keeping ourselves safe. We use this all the time to clear up misunderstandings, get help, plead for forgiveness, and so on.
The next mechanism, or strategy, is fight or flight. It's regulated by the sympathetic nervous system. This system is our fall-back strategy when social engagement isn't a good fit. (Think of seeing someone sneaking up on you!) Note that freeze is not a part of fight or flight.
Our freeze option is primal and is a remnant of our reptilian past. Freeze is a great strategy for turtles and lizards, but it's usually a bad idea for humans - think of fainting. Therefore, we typically use it last, when social engagement and fight/flight aren't going to work for us. But there are good uses for freeze. During severe injury, it shuts us down and turns off our registration of pain. We also make use of it during sex, and it helps women regulate pain and response to pain during labor.
Now these systems appear to work in tandem. The social engagement system puts the brakes on the other (fight, flight, freeze) strategies, thus keeping our heart and body active while we work through a situation. The social engagement system will release the brakes to engage a different response to the environment (i.e. running) if engagement doesn't help to get us into a safe situation.
What Can Go Wrong
We want our nervous system to operate using the social exchange most of the time. It is our most evolved way of being. It is restful and healthy because it allows our gut and other organs to do their job uninterrupted.
However, some of us are programmed from an early age to work from a fight/flight mode. Think of people who are sensory sensitive and recoil from sound, touch, smell or taste. Think of people with autism (in this case, the face to heart connection is not working). Think of people with borderline personality, depression and perhaps other disorders, too. When we are not able to work from our social engagement strategy, then we revert to a modified fight/flight strategy, which puts us in high alert. If we use too much of the fight/flight or freeze strategies, we may end up with gut issues because the gut comes to a halt and we stop digesting food during fight/flight activation.
The Polyvagal Theory has gained great acceptance over the years as pieces of it are shown to hold under laboratory findings. From a psychological viewpoint, it provides us with a rich understanding of self-regulation in the body. From a sensory processing viewpoint, it informs our understanding of sensory modulation.
If you are unfamiliar with the topic, check out the many articles on Dr.Porges' website. The most comprehensive article is The Polyvagal Perspective, and it is published here on the NIH Public Access site. It contains the physiological underpinnings of the theory as well as perspectives on development, emotions, trauma and many other topics. There is a short video of it here.
Sensory Connection
Two researchers looked at a biological marker of the social exchange system, RSA, in typical children and in children with sensory modulation issues. RSA is the measure of high-frequency fluctuation in the heart between heart beats. It is a window into the social exchange system. The researchers found that children with sensory modulation issues have a lower level of RSA than their peers, meaning that these children are better prepared to put the breaks on social strategies and instead use fight-or-flight strategies.
As part of the study, the children were (each in turn) given a sensory challenge. The chairs they were seated on tilted backwards unexpectedly. The level of RSA was monitored in each child throughout the incident. The RSA of typical children dropped quickly and then stayed low for a short time. The children with poor sensory modulation skills had a very brief drop of RSA and a quick rebound to their RSA baseline.
This implies that children with sensory modulation symptoms use different strategies to handle safety-related situations than their peers. At this time, it is harder to draw greater conclusions since we do not have an easy-access window into the fight/flight system or the freeze system. With time, we'll get a better understanding of this. The article can be found here.
Emotions
Perhaps the most interesting new work making use of the Polyvagal Theory is the work of A. D. (Bud) Craig. Mapping our emotions, this is what he found. (Read about it here.)
Emotions arise from feelings in our organs and gut. The feelings are sent via the vagus nerve to the Anterior Insular Cortex (AIC) in the brain. (There's a lot going on in the vagus nerve - think of it as a cable with lots of separate wires.) The AIC captures feelings over time and stores them as snapshots of feelings. This is our working emotional memory. These feelings are massaged and integrated with the social exchange to give us both an emotional response to the world around us as well as a safety-driven strategy.
Think of this: I am relaxing in a lounge chair on the beach. I feel safe. Suddenly, a beach ball hits me. My fight or flight instinct kicks in and the sympathetic nervous system stops everything that's happening (i.e. digestion) in my organs and gut. The gut passes the feeling of stoppage as "alarm" to the brain. This translates in the brain to fear and my body is set in motion. I quickly turn and see it's a ball and that a child is nearby and smiling at me. My social engagement strategy puts the breaks on my fight/flight response and also calms my heart. I smile at the child. This sends a sense of relief to my gut and it in turn sends a "warm" feeling to the AIC. My heart is still pounding from the surprise, but my response is guided by compassion.
In the above scenario, we specifically looked at a situation with a challenge to safety. But in fact, we spend much of our time worrying about safety. Unless I am completely safe, listening to quiet music in a locked room, I will most likely have safety challenges to respond to. The challenge may be from the scary book I am reading, or from the sense of anxiety I feel when I drop a spoon on the floor. Almost any activity will involve the combined interaction of the various strategies. The bottom line: we are constantly adjusting ourselves to meet the world. Polyvagal Theory gives us a look at how this works.
This is pretty complex stuff - and the theory is still in flux. It changes with each new study that looks at the implications of Polyvagal Theory on our response to the world. It is going to impact research greatly in the years ahead. As I mentioned at the beginning, Polyvagal Theory adds a new dimension to how we see autism, sensory issues and other disorders and will, I think, inform our interventions for those disorders in a big way.
References:
- Porges, S. W. (2008, February). The Polyvagal Perspective. NIH Public Access, PMC1868418
- Schaaf, R. C., Benevides, T., Blanche, E. I., Brett-Green, B. A., Burke, J. P., Cohn, E.S., Koomar, J., Lane, S. J., Miller, L. J., May-Benson, T.A., Parham, D., Reynolds, S., Schoen, S. A. Parasympathetic Functions in children with sensory processing disorder. Front Integr Neurosci. 2010; 4: 4. Published online 2010 March 9. doi: 10.3389/fnint.2010.00004
- Craig, A. D. (2009).
Emotional moments across time: A possible neural basis for time perception in
the anterior insula. Philosophical Transactions of the Royal Society of London.
364,1933-1942.
Friday, December 28, 2012
Criteria for Screening SMD with the Sensory Profile
The time over the holidays is when I typically read everything I can get my hands on as a way of updating my workshop and keeping current in general. I sometimes run across elusive information such as this item.
Here is the criteria that Dr. Miller and her colleagues use to determine whether a child has Sensory Modulation Disorder (SMD). They screen using the Short Sensory Profile and if ...
- Total Test score of less than 3.0 SD (standard deviations) below the mean; or
- Less than 2.5 SD below the mean on two or more subtests; or
- Less than 4.0 SD below the mean on one subtest
That leaves it to you to figure out the means using the manual :((( ..... or come back in a few weeks and I'll have it here. :)))
Update, January 9, 2013: I have not been able to locate published values for 2.5 SD and 4.0 SD of each of the SSP sections. It is a difficult mathematical exercise to produce the numbers without all of the data. So let's estimate some of these numbers for 2.5 SD. I will have to beg off estimating 4 SD at this time - it's a pretty tricky calculation.
The numbers for 1-2 SD and 2-3 SD are on p.66 of the Sensory Profile Manual. By the way, I am going to estimate 2.5 SD somewhat conservatively.
| Estimates | 2.5 SD | 3 SD |
| Tactile Sensitivity | 16 | 6 |
| Taste/Smell Sensitivity | 7 | 3 |
| Movement Sensitivity | 6 | 2 |
| Underresponsive/Seeks Sensitivity | 15 | 6 |
| Auditory Filtering | 12 | 5 |
| Low Energy/Weak | 14 | 5 |
| Visual/Auditory Sensitivity | 10 | 4 |
| Total Score | 89 | 37 |
Scoring examples:
1. If a child has a tactile sensitivity score of 16, he is 2.5 standard deviations (SD) below the mean. If he has a score of 2 on movement sensitivity, he is 3 SD below the mean. Since he has 2 scores of 2.5 SD or lower, he qualifies for a diagnosis of SMD.
2. If a girl's total score is 37 or less, she is 3 SD below the norm and qualifies for the SMD diagnoses.
Teresa
Reference:
1.
Miller
L. J., Reisman J. E., McIntosh D. N., Simon J. (2001). An
ecological model of sensory modulation: performance of children with fragile X
syndrome, autistic disorder, attention-deficit/hyperactivity disorder, and
sensory modulation dysfunction. In Understanding
the Nature of Sensory Integration With Diverse Populations, Smith S.
Roley, Blanche E. I., Schaaf R. C., editors. , eds (San Antonio, TX, The
Psychological Corporation; ), pp. 57–88.
Friday, April 6, 2012
MeMoves
MeMoves is an engaging exercise for small or large groups. Its developers describe it as "a kind of Western t’ai chi or yoga set to music". Children watch and imitate images of slow rhythmic movement and in the process get calm and improve attention skills. In children with autism it fascilitates the function of the mirror neurons.
The original product is a DVD with a variety of moves and costs $59. Watch the children below work to it.
There is also a MeMoves app for iPhone which helps with calming and focus, but without the whole-body movements. It is $10.
I've heard this described as a timing program - but I'm going to disagree with that. It is rhythmic, and the children are doing coordinated movement, but in what I've seen thus far, the stress is on calming and attention rather than on precise timing. In any event, it appears to be a great product! Find out more at ThinkingMoves.com
The original product is a DVD with a variety of moves and costs $59. Watch the children below work to it.
There is also a MeMoves app for iPhone which helps with calming and focus, but without the whole-body movements. It is $10.
I've heard this described as a timing program - but I'm going to disagree with that. It is rhythmic, and the children are doing coordinated movement, but in what I've seen thus far, the stress is on calming and attention rather than on precise timing. In any event, it appears to be a great product! Find out more at ThinkingMoves.com
Sunday, December 4, 2011
Screening SPD Modulation
There is now a way to actually measure sensory over-sensitivity (sensory over-responsivity) by measuring sweat on the palm (with electro-dermal equipment) and increased heartbeat. I'm hoping that this technique becomes standard practice and finally allows us to get a diagnosis for affected children - which it may once the next DSM is published.
In the meantime, I continue to rely on the Sensory Profile as a screening tool. I make heavy use of its modulation scoring which identifies over- and under-sensitivity, seeking (craving), and aversion/avoidance of sensory input. The test is published by Pearson. It is available for home or school and for several age groups. Scoring is standardized. A weakness is that being a questionnaire, it is only as reliable as the caregiver/teacher who fills it out. Nonetheless, I see good results. Sometimes I give copies to multiple caregivers or teachers if I am concerned about reliability.
A second tool is the SPM - Sensory Processing Measure, by WPS Publishing which solves that problem. The SPM can be passed out to both parent and teacher, plus the bus driver, the cafeteria lady and other important people in the child's life. The results are added together then scored. The drawback for SPM is that the modulation scores are not as rich as the Sensory Profile's.
In the meantime, I continue to rely on the Sensory Profile as a screening tool. I make heavy use of its modulation scoring which identifies over- and under-sensitivity, seeking (craving), and aversion/avoidance of sensory input. The test is published by Pearson. It is available for home or school and for several age groups. Scoring is standardized. A weakness is that being a questionnaire, it is only as reliable as the caregiver/teacher who fills it out. Nonetheless, I see good results. Sometimes I give copies to multiple caregivers or teachers if I am concerned about reliability.
A second tool is the SPM - Sensory Processing Measure, by WPS Publishing which solves that problem. The SPM can be passed out to both parent and teacher, plus the bus driver, the cafeteria lady and other important people in the child's life. The results are added together then scored. The drawback for SPM is that the modulation scores are not as rich as the Sensory Profile's.
Sunday, July 31, 2011
Blue Light at Night
Blue light waves are emitted from TVs, computer screens and some light bulbs including some fluorescent and the high efficiency light bulbs. Turns out that blue light is alerting and more than that, it can limit or prevent melatonin production in the evening when we need melatonin for our sleep cycle. After seeing blue light, it can take up to 90 minutes for the alerting effects to subside and melatonin production to kick in. During this time, you may have a very antsy child happy as a clam, dancing on his bed.
This problem can be avoided by limiting TV and computer in the evening. A child who is very sensitive to light may also benefit from wearing blue-light glasses at night 1-3 hours before bedtime. The glasses are orange and do not allow blue light waves to penetrate. There is evidence for the glasses working in adults. There is anecdotal evidence for children - but I haven't seen a formal study.
Another option is to install yellow light bulbs. They come in a variety of forms including the new energy-efficient cork-screw style bulbs, and can be purchased on-line. Stay posted - I'm going to buy one for the hallway outside my bedroom to see how well the yellow lights work in general.
Here is a web site to check out: LowBlueLights.com. They offer junior sizes of glasses and the yellow bulbs.
This problem can be avoided by limiting TV and computer in the evening. A child who is very sensitive to light may also benefit from wearing blue-light glasses at night 1-3 hours before bedtime. The glasses are orange and do not allow blue light waves to penetrate. There is evidence for the glasses working in adults. There is anecdotal evidence for children - but I haven't seen a formal study.
Another option is to install yellow light bulbs. They come in a variety of forms including the new energy-efficient cork-screw style bulbs, and can be purchased on-line. Stay posted - I'm going to buy one for the hallway outside my bedroom to see how well the yellow lights work in general.
Here is a web site to check out: LowBlueLights.com. They offer junior sizes of glasses and the yellow bulbs.
Wednesday, December 30, 2009
Overlap in Sensory, ADHD and Autism
I am doing tons of reading right now to prepare for a class on self-regulation I'm giving in April.
Current literature is looking at ways to separate out ADHD from Autism and to identify sensory characteristics of each. This is a technical post, but if you read lightly, you can find some interesting tidbits.
There is a technical term: nosology that refers to the hieracrchy of diagnoses. The new nosology for sensory processing disorder (SPD) has several layers. There are 3 types of SPD: Sensory Modulation, Sensory Motor Issues (motor planning and posture) and Sensory Discrimination. Here is a quick look at it. See the Miller article referenced below for details.
Sensory Processing Disorder (SPD):
1. Sensory Modulation
------Over response
------Under Response
------Seeking/ Craving
2. Sensory Motor Issues
-----Dispraxia (Motor Planning)
-----Posture Disorder
3. Sensory Discrimination
-----Visual
-----Auditory. touch, vestibular, proprioception, etc.
The reason I taxed you with the nosology is to highlight the modulation piece. Modulation from sensory causes appears similar to ADHD, but ADHD is not caused by sensory issues. An assessment such as the Sensory Profile can tease out which is which.
ADHD as you probably know has characteristics of impulsivity, poor attention, hyperactivity, etc. that can also be found in SPD. Typically, ADHD is treated with therapies, patience, etc, etc or meds. SPD is treated with sensory therapy. Completely different.
Now we get into autism. What they are finding is that 42-88% of children with autism have sensory processing disorder. Some also have a sensory modulation disorder. 50%-80% of children with autism have ADHD. However (back to nosology) ADHD in the DSM-IV (Psychiatric Manual) is a level 2 disorder. Autism is a level 1 disorder and takes precedence. So technically, if a child has autism, they cannot be also diagnosed with ADHD (a disservice in my opinion).
Children with ADHD have communication and social issues, but they are not the same sort of issues as those found in autism. Hartley & Darryn (2009) pose the question "Is high functioning autism distinguishable from ADHD and from anxiety in older children?" The short answer is yes, but they share a number of seemingly similar characteristics in the areas of communication skills, social skills, and repetitive behaviors. Lots of overlap to sort through with children who are neurotypically different than their peers.
1. Miller, L., Anzalone, M., Lane, S., Cermak, S., & Osten, E. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy , 61, 135-140.
2. Hartley, S., & Darryn, M. S. (2009). Which DSM-IV-TR criteria best differentiate high-functioning autism spectrum disorder from ADHD and anxiety disorders in older children? Autism , 13, 485-509.
Current literature is looking at ways to separate out ADHD from Autism and to identify sensory characteristics of each. This is a technical post, but if you read lightly, you can find some interesting tidbits.
There is a technical term: nosology that refers to the hieracrchy of diagnoses. The new nosology for sensory processing disorder (SPD) has several layers. There are 3 types of SPD: Sensory Modulation, Sensory Motor Issues (motor planning and posture) and Sensory Discrimination. Here is a quick look at it. See the Miller article referenced below for details.
Sensory Processing Disorder (SPD):
1. Sensory Modulation
------Over response
------Under Response
------Seeking/ Craving
2. Sensory Motor Issues
-----Dispraxia (Motor Planning)
-----Posture Disorder
3. Sensory Discrimination
-----Visual
-----Auditory. touch, vestibular, proprioception, etc.
The reason I taxed you with the nosology is to highlight the modulation piece. Modulation from sensory causes appears similar to ADHD, but ADHD is not caused by sensory issues. An assessment such as the Sensory Profile can tease out which is which.
ADHD as you probably know has characteristics of impulsivity, poor attention, hyperactivity, etc. that can also be found in SPD. Typically, ADHD is treated with therapies, patience, etc, etc or meds. SPD is treated with sensory therapy. Completely different.
Now we get into autism. What they are finding is that 42-88% of children with autism have sensory processing disorder. Some also have a sensory modulation disorder. 50%-80% of children with autism have ADHD. However (back to nosology) ADHD in the DSM-IV (Psychiatric Manual) is a level 2 disorder. Autism is a level 1 disorder and takes precedence. So technically, if a child has autism, they cannot be also diagnosed with ADHD (a disservice in my opinion).
Children with ADHD have communication and social issues, but they are not the same sort of issues as those found in autism. Hartley & Darryn (2009) pose the question "Is high functioning autism distinguishable from ADHD and from anxiety in older children?" The short answer is yes, but they share a number of seemingly similar characteristics in the areas of communication skills, social skills, and repetitive behaviors. Lots of overlap to sort through with children who are neurotypically different than their peers.
1. Miller, L., Anzalone, M., Lane, S., Cermak, S., & Osten, E. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy , 61, 135-140.
2. Hartley, S., & Darryn, M. S. (2009). Which DSM-IV-TR criteria best differentiate high-functioning autism spectrum disorder from ADHD and anxiety disorders in older children? Autism , 13, 485-509.
Sunday, September 13, 2009
More on Calming Rhythms
I was recently asked about using Calming Rhythms by REI Institute in the school setting, so I revisited the REI Inst. site to see what is new. Jeff Strong has updated his web site and formalized his program offerings. He offeres customized programs for children, training for therapists and non-customized CDs that can be used for calming.
The REI program is noteworthy because it does not require headphones. The thearpy is less for auditory processing than for rhythm and structure. OTs and SLPs that have clients using the program say that the children are more grounded, calmer and happier. The customized CDs been used for many children with autism and ADHD.
A therapist can get trained for $275. Parents can have a 10 week custom program created (and edited, if necessary) for their child for $495. Not bad. I would try the custom program on children from whom the traditional sound therapy does not work (due to head phones).
As for non-customized solutions: The "Calming Rhythms" CD is a powerful recording that I found to work for some children and to be counter-productive for others. It is not a one-size-fits-all solution. REI Institute claims that it can be used with groups, but from what I've seen, it is not appropriate for the classroom. In any event, at $35, it may be worth a try. Here is my earlier blog entry on the Calming Rhythms CD.
The REI program is noteworthy because it does not require headphones. The thearpy is less for auditory processing than for rhythm and structure. OTs and SLPs that have clients using the program say that the children are more grounded, calmer and happier. The customized CDs been used for many children with autism and ADHD.
A therapist can get trained for $275. Parents can have a 10 week custom program created (and edited, if necessary) for their child for $495. Not bad. I would try the custom program on children from whom the traditional sound therapy does not work (due to head phones).
As for non-customized solutions: The "Calming Rhythms" CD is a powerful recording that I found to work for some children and to be counter-productive for others. It is not a one-size-fits-all solution. REI Institute claims that it can be used with groups, but from what I've seen, it is not appropriate for the classroom. In any event, at $35, it may be worth a try. Here is my earlier blog entry on the Calming Rhythms CD.
Saturday, October 4, 2008
Another Blog
I am starting up and new blog and that will slow my activities on this blog. The new blog will cover some of the same territory, but be focused on new interventions, technologies and clients aged 12 - 99. The new blog is called Brain Tune-Ups - that's the name of my Ann Arbor clinic. The blog is at http://braintuneups.blogspot.com/
A big factor for the change is that a small flood destroyed all of my research articles on peds and autism. But the change would have come in any event, since I am shifting my practice into teens and adults away from children. The title of this blog just doesn't do justice to where my practice is heading. I will continue to work with clients whose main concerns are self regulation or the symptoms of autism and so I will continue to have material for this blog.
On the Brain Tune-Ups site, I will continue to write about Interactive Metronome, Therapeutic Listening, Samonas, stress reduction, etc. And I'll publish the results of the adult study there.
By the way, my clinic's website is http://www.braintune-ups.com/
A big factor for the change is that a small flood destroyed all of my research articles on peds and autism. But the change would have come in any event, since I am shifting my practice into teens and adults away from children. The title of this blog just doesn't do justice to where my practice is heading. I will continue to work with clients whose main concerns are self regulation or the symptoms of autism and so I will continue to have material for this blog.
On the Brain Tune-Ups site, I will continue to write about Interactive Metronome, Therapeutic Listening, Samonas, stress reduction, etc. And I'll publish the results of the adult study there.
By the way, my clinic's website is http://www.braintune-ups.com/
Wednesday, July 23, 2008
Summer Combos
The summer goes by so quickly as I see kids individually and in groups. The groups at our clinic are called summer combos. There is (in order) 1 part music therapy, 1 part OT and 1 part speech. My aide and I run a group of five 5-7 year olds. They are delightful, but quite a handful. One of the boys has ADHD, another has a sensory modulation disorder. When one "goes off", the other follows. (During the first session, the aide and I learned this the hard way!)
After 6 sessions, we are finally able to run a structured obstacle course in our open gym without both boys making their own agenda. But we worked hard to get them modulated in our environment. I think that our successful formula during the first 5 sessions was this: for the first 1/2 hour, we gave them free play - but with limited options. For example, 3 on a bench swing, 2 in the ball pit, then switch. This let them blow off a lot of steam, but in a semi-controlled manner as they rev-up in the ball pit and then cool-down on the swing. The next 1/2 hour was spent at a table top activity, and so was quite structured. At the end of the hour, they were able to march off to speech (and snack) and sit (relatively) quietly for another hour.
I can't say that combos are my favorite part of the day - I am completely worn out, but I am very glad for these children to have the opportunity to work through modulation issues under adverse conditions.
After 6 sessions, we are finally able to run a structured obstacle course in our open gym without both boys making their own agenda. But we worked hard to get them modulated in our environment. I think that our successful formula during the first 5 sessions was this: for the first 1/2 hour, we gave them free play - but with limited options. For example, 3 on a bench swing, 2 in the ball pit, then switch. This let them blow off a lot of steam, but in a semi-controlled manner as they rev-up in the ball pit and then cool-down on the swing. The next 1/2 hour was spent at a table top activity, and so was quite structured. At the end of the hour, they were able to march off to speech (and snack) and sit (relatively) quietly for another hour.
I can't say that combos are my favorite part of the day - I am completely worn out, but I am very glad for these children to have the opportunity to work through modulation issues under adverse conditions.
Friday, April 18, 2008
More about Listening & Rhythm
I continue to be pleasantly surprised at the results of Therapeutic Listening (TL) in my practice. The kids get calmer, attention improves, meltdowns decrease and with that, comes real growth. One boy used the headphones for just 4 weeks, and then Interactive Metronome (IM) for another several weeks. Mom reports that he is calm (TL) and has confidence in himself (IM). I've noticed increaed postural control and motor planning, too. Unfortunately, not all children can use TL. Some children do not tolerate headphones or the music through them at all - whether this is due to actual hearing problems such as tinnitus (ringing in the ear) or perhaps a severe tactile issue isn't always clear with some of our non-verbal population.
Therapeutic Listening and Interactive Metronome have overlapping territory in the area of motor planning - although each product works in a unique way. There is rhythmic feedback with IM in which the person actively attempts to increase their rhythmic precision. (See my entry about this, or check out the IM site.) TL is a passive system in which the person receives modulated auditory stimulation through rhythm and music. The therapist can add active components to TL therapy in the form of sensory stimulation, play or exercise.
A third program I have checked into is Samonas. I'll devote a blog to this at some future date. It comes from Germany and is a very high quality listening program that would appeal to adults as well as to children. There are 5 levels of CDs offered. Levels 1-4 require direction from a trained therapist. An introductory set of CDs is available to the general public. The recorded music and nature sounds are gorgeous. I tried a level 1 CD for 15 minutes and felt some powerful broad effects that included auditory refinement, emotional release and energy. I was pleased with it. Samonas offers a series of Listening Programs for the general public specifically aimed at areas including emotional, social, communication, organization, motor planning, etc. The Samonas web site can be very confusing. You can find web-based training programs for professionals at this location. They will be offering live training classes in the fall in New York and Florida. I'll write more when I get the details.
Therapeutic Listening and Interactive Metronome have overlapping territory in the area of motor planning - although each product works in a unique way. There is rhythmic feedback with IM in which the person actively attempts to increase their rhythmic precision. (See my entry about this, or check out the IM site.) TL is a passive system in which the person receives modulated auditory stimulation through rhythm and music. The therapist can add active components to TL therapy in the form of sensory stimulation, play or exercise.
A third program I have checked into is Samonas. I'll devote a blog to this at some future date. It comes from Germany and is a very high quality listening program that would appeal to adults as well as to children. There are 5 levels of CDs offered. Levels 1-4 require direction from a trained therapist. An introductory set of CDs is available to the general public. The recorded music and nature sounds are gorgeous. I tried a level 1 CD for 15 minutes and felt some powerful broad effects that included auditory refinement, emotional release and energy. I was pleased with it. Samonas offers a series of Listening Programs for the general public specifically aimed at areas including emotional, social, communication, organization, motor planning, etc. The Samonas web site can be very confusing. You can find web-based training programs for professionals at this location. They will be offering live training classes in the fall in New York and Florida. I'll write more when I get the details.
Sunday, April 6, 2008
Calming Rhythms
I have begun to work with a product called "Calming Rhythms" from REI Institute. Calming Rhythms is a CD with three 20-minute pieces of music/alpha-rhythms that are played for a calming affect. Jeff Strong, the head of REI, has tested the product on children with autism and found it to be quite effective, but with a few occasional side-effects - acting out behaviors in some children.
To get a feel for the therapy, I tried it out on myself. I tried it under 3 conditions:
1. At night before bed for 2-3 nights. This is per the instructions from the REI site. I slept deeply, awoke with deep calm and felt like I could handle anything.
2: During the day, during very stressful occasions. I didn't notice anything while it was playing, but within 30 minutes, I was very cranky, and snapped at someone. Later, I became even more irritable. Was it the music or the stressful situation? I am typically very easy-going and handle stress well. The next morning, I was calm and happy.
3. Several times for a few minutes throughout the day under stress-free conditions (on a Friday while treating children in the clinic) . Seemed fine at the time, and all weekend I've had a wonderful sense of calm and perspective as I deal with another stressful situation.
My conclusions: use it when the client is in a good mental state for just a few minutes at a time or at bedtime.
One of my clients,, Tommy, has what appears to be an undiagnosed case of ADHD. I am doing 15-20 minutes of Interactive Metronome (IM) with him once a week as part of his OT session. Since the IM can be very arousing, I thought to counter it with the Calming Rhythms. Jeff Strong told me that other therapists are using this same approach. I gave Tommy's mom the CD and instructions and suggested she try it at night over the weekend. I warned her to watch out for acting-out behaviors. Can't wait to hear how he did.
I think that this will be a good option for my hyperactive kids. By the way, if you want to try it, Jeff Strong offers a free demo download at his site.
4/18/08 Update: 3 parents tried the Calming Rhythms CD for 10 minutes just before bedtime for a few nights. One boy made noticeable decrease in hyperactivity. A second mom reported no change. The third boy, Tommy, liked the rhythms, however, his mom reported that he got up in bed and danced to them ... not exactly what we were hoping for ... but she planned to try it for another night or two and report back.
To get a feel for the therapy, I tried it out on myself. I tried it under 3 conditions:
1. At night before bed for 2-3 nights. This is per the instructions from the REI site. I slept deeply, awoke with deep calm and felt like I could handle anything.
2: During the day, during very stressful occasions. I didn't notice anything while it was playing, but within 30 minutes, I was very cranky, and snapped at someone. Later, I became even more irritable. Was it the music or the stressful situation? I am typically very easy-going and handle stress well. The next morning, I was calm and happy.
3. Several times for a few minutes throughout the day under stress-free conditions (on a Friday while treating children in the clinic) . Seemed fine at the time, and all weekend I've had a wonderful sense of calm and perspective as I deal with another stressful situation.
My conclusions: use it when the client is in a good mental state for just a few minutes at a time or at bedtime.
One of my clients,, Tommy, has what appears to be an undiagnosed case of ADHD. I am doing 15-20 minutes of Interactive Metronome (IM) with him once a week as part of his OT session. Since the IM can be very arousing, I thought to counter it with the Calming Rhythms. Jeff Strong told me that other therapists are using this same approach. I gave Tommy's mom the CD and instructions and suggested she try it at night over the weekend. I warned her to watch out for acting-out behaviors. Can't wait to hear how he did.
I think that this will be a good option for my hyperactive kids. By the way, if you want to try it, Jeff Strong offers a free demo download at his site.
4/18/08 Update: 3 parents tried the Calming Rhythms CD for 10 minutes just before bedtime for a few nights. One boy made noticeable decrease in hyperactivity. A second mom reported no change. The third boy, Tommy, liked the rhythms, however, his mom reported that he got up in bed and danced to them ... not exactly what we were hoping for ... but she planned to try it for another night or two and report back.
Sunday, February 24, 2008
Interactive Metronome Research
I wrote earlier of being "blown away" by the capabilities of the Interactive Metronome™ (IM) product. The literature shows that IM increases mental fluency which in turn increases the efficiency (and skill level) of many brain and body functions including motor planning. (See the TickTockBrainTalk blog and the IM site, for much more on this!)
There has been substantial research done on IM for children. (The article cited below finds that IM "appears to facilitate a number of capacities, including attention, motor control, and selected academic skills in boys with ADHD.) There are a few studies on the effects of IM on adults in rehabilitation recovering from varied disabilities such as stroke, TBI and loss of limb. None of the studies I've seen address softer issues such as stress, organization, or well-being.
I have launched a small research project studying the effects of the IM protocol on parents of children with special needs. It's a convenience study being done at Building Bridges therapy Center, where I work. I am asking the question: Does IM help parents of children with special needs become better organized such that they are better able to accomplish their goals. And does this is turn help reduce their stress levels? These parents operate at a very high level of challege and stress (lots 0f OT journal articles have documented this).
I may also look at another factor -- SI. Since many of the children at my clinic have autism and sensory integration issues, as a result, I may assess parents for sensory integration issues using the Adult/Adolescent Sensory Profile. If indeed they do, I wonder if any symptoms lessen at the end of the study....and if not, perhaps, I could re-enlist them in another short study with a different intervention. H-m-mm.
Article
Shaffer, R. J., Jacokes, L. E., Cassily, J. E., Greenspan, S. L., Tuchman, R. E., & Stemmer, P. J., Jr. (2001). Effects of Interactive Metronome™ training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162.
Abstract
(This was copied from the IM site)
The purpose of this study was to determine the effects of a specific intervention, the Interactive MetronomeÒ, on selected aspects of motor and cognitive skills in a group of children diagnosed with attention-deficit/hyperactivity disorder (ADHD).
The study included 56 boys, age 6 to 12 years, pre-diagnosed as having ADHD who were pre-tested and randomly assigned to one of three matched groups. The 19 children receiving 15 hours of Interactive MetronomeÒ rhythmicity training exercises were compared with a group receiving no intervention and a group receiving training on selected computer video games.
A statistically significant pattern of improvement across 53 of 58 variables favoring the Interactive Metronomeâ treatment was found. Additionally, several statistically significant differences were found among 12 factors on performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior.
There has been substantial research done on IM for children. (The article cited below finds that IM "appears to facilitate a number of capacities, including attention, motor control, and selected academic skills in boys with ADHD.) There are a few studies on the effects of IM on adults in rehabilitation recovering from varied disabilities such as stroke, TBI and loss of limb. None of the studies I've seen address softer issues such as stress, organization, or well-being.
I have launched a small research project studying the effects of the IM protocol on parents of children with special needs. It's a convenience study being done at Building Bridges therapy Center, where I work. I am asking the question: Does IM help parents of children with special needs become better organized such that they are better able to accomplish their goals. And does this is turn help reduce their stress levels? These parents operate at a very high level of challege and stress (lots 0f OT journal articles have documented this).
I may also look at another factor -- SI. Since many of the children at my clinic have autism and sensory integration issues, as a result, I may assess parents for sensory integration issues using the Adult/Adolescent Sensory Profile. If indeed they do, I wonder if any symptoms lessen at the end of the study....and if not, perhaps, I could re-enlist them in another short study with a different intervention. H-m-mm.
Article
Shaffer, R. J., Jacokes, L. E., Cassily, J. E., Greenspan, S. L., Tuchman, R. E., & Stemmer, P. J., Jr. (2001). Effects of Interactive Metronome™ training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162.
Abstract
(This was copied from the IM site)
The purpose of this study was to determine the effects of a specific intervention, the Interactive MetronomeÒ, on selected aspects of motor and cognitive skills in a group of children diagnosed with attention-deficit/hyperactivity disorder (ADHD).
The study included 56 boys, age 6 to 12 years, pre-diagnosed as having ADHD who were pre-tested and randomly assigned to one of three matched groups. The 19 children receiving 15 hours of Interactive MetronomeÒ rhythmicity training exercises were compared with a group receiving no intervention and a group receiving training on selected computer video games.
A statistically significant pattern of improvement across 53 of 58 variables favoring the Interactive Metronomeâ treatment was found. Additionally, several statistically significant differences were found among 12 factors on performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior.
Friday, February 8, 2008
Modulation Case Study
Article Review
Roberts, J.E., King-Thomas, L., & Boccia, M. L. (2007). Behavior indexes of the efficacy of sensory integration therapy. American Journal of Occupational Therapy, 61, 555-562.
The authors performed a single-case study on a boy age 3 years and 5 months with sensory modulation disorder (as diagnosed by the Sensory Profile which noted tactile and auditory processing issues and sensory seeking behaviors) and delayed communication skills. He had been given a reduction in school hours due to classroom behaviors of phycial and verbal aggressive, throwing objects, mouthing objects and touching others within a classroom setting. Treatment was given in an ABAB format: 2 weeks of no treatment, 5 weeks of intense SI therapy (3 times per week), 2 weeks of no treatment, and 2 weeks of treatment. Success was gaged by teacher report of observed behaviors. The SI treatment was provided by a therapist trained by Jean Ayers.
At the end of the study all aggression and mouthing behaviors had diminished. There was a 50% decrease in teacher intensity needed to manage the child's behavior and he was engaged in classroom activities for 70% of the time, a 40% increase from the start of the study.
The child continued with once per week OT which was reduced to once per month over a 3 year period. At the age of 6 he was diagnosed with ADHD.
My Thoughts
This is a nice look at the early stages of a boy with ADHD and the affect of intense early intervention.
See also the article by Ermer & Dunn regarding the using the Sensory Profile to differentiate typically developing children, children with ADHD, autism, and other disabilities.
Ermer, J. & Dunn, W. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52, 283-290.
Roberts, J.E., King-Thomas, L., & Boccia, M. L. (2007). Behavior indexes of the efficacy of sensory integration therapy. American Journal of Occupational Therapy, 61, 555-562.
The authors performed a single-case study on a boy age 3 years and 5 months with sensory modulation disorder (as diagnosed by the Sensory Profile which noted tactile and auditory processing issues and sensory seeking behaviors) and delayed communication skills. He had been given a reduction in school hours due to classroom behaviors of phycial and verbal aggressive, throwing objects, mouthing objects and touching others within a classroom setting. Treatment was given in an ABAB format: 2 weeks of no treatment, 5 weeks of intense SI therapy (3 times per week), 2 weeks of no treatment, and 2 weeks of treatment. Success was gaged by teacher report of observed behaviors. The SI treatment was provided by a therapist trained by Jean Ayers.
At the end of the study all aggression and mouthing behaviors had diminished. There was a 50% decrease in teacher intensity needed to manage the child's behavior and he was engaged in classroom activities for 70% of the time, a 40% increase from the start of the study.
The child continued with once per week OT which was reduced to once per month over a 3 year period. At the age of 6 he was diagnosed with ADHD.
My Thoughts
This is a nice look at the early stages of a boy with ADHD and the affect of intense early intervention.
See also the article by Ermer & Dunn regarding the using the Sensory Profile to differentiate typically developing children, children with ADHD, autism, and other disabilities.
Ermer, J. & Dunn, W. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52, 283-290.
Thursday, February 7, 2008
Therapeutic Listening
Article
Hall, L. & Case-Smith, J. (2007). The effect of sound-based intervention on children with sensory processing disorders and visual-motor delays. American Journal of Occupational Therapy, 61, 209-215.
Leah Hall conducted a study with 10 children ages 5y 8m - 10y 11m who were diagnosed with sensory processing disorder (they were rated "Definitely different" in 3 or more areas of the Sensory Profile). Children were given home programs of four weeks with a sensory diet followed by 8 weeks of continued sensory diet with Therapeutic Listening. Significant results were found at the end of the first 4 weeks and at the end of the 12 weeks. Children gained an average of 71 points on the Sensory Profile with the biggest gains in the area of auditory processing and behaviors associated with sensory processing. Children with specific issues (such as auditory hyper-sensitivities, tantrums and hyperactivity made significant gains in some of those areas, as well). In addition, significant gains were made in handwriting (as assessed by the Etch program, and visual processing (as assessed by the VMI). Parents noticed large changes in overall behavior included improved attention, social interactions, self awareness, communication and sleep patterns. One child on medication for ADHD was given a reduction in dosage.
Hall, L. & Case-Smith, J. (2007). The effect of sound-based intervention on children with sensory processing disorders and visual-motor delays. American Journal of Occupational Therapy, 61, 209-215.
Leah Hall conducted a study with 10 children ages 5y 8m - 10y 11m who were diagnosed with sensory processing disorder (they were rated "Definitely different" in 3 or more areas of the Sensory Profile). Children were given home programs of four weeks with a sensory diet followed by 8 weeks of continued sensory diet with Therapeutic Listening. Significant results were found at the end of the first 4 weeks and at the end of the 12 weeks. Children gained an average of 71 points on the Sensory Profile with the biggest gains in the area of auditory processing and behaviors associated with sensory processing. Children with specific issues (such as auditory hyper-sensitivities, tantrums and hyperactivity made significant gains in some of those areas, as well). In addition, significant gains were made in handwriting (as assessed by the Etch program, and visual processing (as assessed by the VMI). Parents noticed large changes in overall behavior included improved attention, social interactions, self awareness, communication and sleep patterns. One child on medication for ADHD was given a reduction in dosage.
Wednesday, February 6, 2008
Parameters of Modulation
I recently read the March/April, 2007, Sensory Integration issue of AJOT. Lots of great articles. I was especially interested in the lead in article that describes the push for three SI diagnosies in the DSM. They are Sensory Modulation Disorder, Sensory-Based Motor Disorder and Sensory Discriminiation Disorder. With this breakdown (and some sub-categories underneath them) we come closer to being able to perform meaningful research in the area of modulation. Although we have diagnostic and therapeutic tools for motor and discrimination, these are not in place for modulation.
For example, we have developmental scales and excellent assessments for a child's motor skills. They are quite specific, and provide a therapist working with a child with motor delays with a measure of the disability as well as indicate an enumerated set of goals to reach.
Similar OT-based tools for modulation will tell us what modulation behaviors are typical for children at various ages. This in turn will allow us to create assessment tools for children with sensory disorders (including autism) and will allow us to estimate the degree of problem a child has, as well as where they are on the developmental scale. Good assessments will give us milestones for our treatment, and allow us to determine if indeed our treatment is effective. On a larger scale, these tools will allow us to perform quantitative research interventions on large populations. (This topic is also addressed in depth in other articles within the same issue of AJOT).
We need to know precisely the qualities of modulation and their developmentaly characteristics. According to Williamson and Anzalone, the qualities of modulation for infants and toddlers include arousal, attention, affect, and attention. Can we quantify these, assess them in clinical (and other) contexts? For example, can we talk about joint attention, object manipulation, object play, etc.? I am guessing that there are many subtleties here. I hope that we can find specific assessable qualities that are general enough to give us a picture of the child (as the motor assessments do). A resource I have not yet looked at is the zero-to-three foundation's publications (with the exception of the book cited below).
Sources:
1. Miller, L.J., Anzolone, M. E., Lane, S. J., Cermak, S. A., & Olsten, E. T. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy, 61, 135-140.
2. Williamson, G. G., & Anzalone, M. E. (2001). Sensory integration and self regulation in infants and toddlers: helping very young children interact with their environment. ZERO-TO-THREE: National Center for Infants, Toddlers and Families.
For example, we have developmental scales and excellent assessments for a child's motor skills. They are quite specific, and provide a therapist working with a child with motor delays with a measure of the disability as well as indicate an enumerated set of goals to reach.
Similar OT-based tools for modulation will tell us what modulation behaviors are typical for children at various ages. This in turn will allow us to create assessment tools for children with sensory disorders (including autism) and will allow us to estimate the degree of problem a child has, as well as where they are on the developmental scale. Good assessments will give us milestones for our treatment, and allow us to determine if indeed our treatment is effective. On a larger scale, these tools will allow us to perform quantitative research interventions on large populations. (This topic is also addressed in depth in other articles within the same issue of AJOT).
We need to know precisely the qualities of modulation and their developmentaly characteristics. According to Williamson and Anzalone, the qualities of modulation for infants and toddlers include arousal, attention, affect, and attention. Can we quantify these, assess them in clinical (and other) contexts? For example, can we talk about joint attention, object manipulation, object play, etc.? I am guessing that there are many subtleties here. I hope that we can find specific assessable qualities that are general enough to give us a picture of the child (as the motor assessments do). A resource I have not yet looked at is the zero-to-three foundation's publications (with the exception of the book cited below).
Sources:
1. Miller, L.J., Anzolone, M. E., Lane, S. J., Cermak, S. A., & Olsten, E. T. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy, 61, 135-140.
2. Williamson, G. G., & Anzalone, M. E. (2001). Sensory integration and self regulation in infants and toddlers: helping very young children interact with their environment. ZERO-TO-THREE: National Center for Infants, Toddlers and Families.
Sunday, November 25, 2007
Creating a Foundation
Today's post lays a stone in the foundation of this site with a review of a journal article about modulation and visual attention. My comments follow the article summary.
Article review: Liss, M., Saulnier, D.F., & Kinsbourne, M. (2006). Sensory and attention abnormalities in autistic spectrum disorders. Autism, 10, 155-172.
I read the article by Liss, et al. this afternoon. The authors conducted a large study looking for patterns in modulation, overselective attention and exceptional memory in children with autism. They hypothesized that sensory overreactivity is a response to over-arousal. They expected to see that children with sensory overreactivity will additionally show these attributes: not being able to quickly shift attention, perseveration due to unshifting attention and exceptional memory for "self-selected material". In a population of 144 children with autism, 12% of the children did indeed exhibit a correlation of these behaviors. These children tended to be older (11 years) than the average age in the study (8.5 years) and higher functioning, but with poor social skills. The authors divided the 144 children into 4 clusters based on scores (from many tests).
Cluster 1: (12%) labeled, "Overfocused". The children displayed sensory overreactivity inability to quickly shift attention, perseveration due to unshifted attention and exceptional memory for "self-selected material". They demonstrated poor social and imitative play skills and showed the best fit to the DSM-IV definition of autism. They also displayed the least impairment of receptive and expressive communication skills, but the highest functioning level. They also demonstrated sensory seeking behaviors.
Cluster 2: The second cluster (25%) was labeled "No sensory problems" and was relatively high functioning with few functional issues.
Cluster 3: (30%), labeled "Low functioning". These children registered low in adaptive functioning, high in underreactivity and also in sensory seeking. They had poor social skills and poor receptive and expressive communication skills.
Cluster4: (33%) "Mildly overfocused", was quite similar to cluster 1 but higher functioning and only mildly over-focusing.
Cluster 1 had social skills equally impaired as cluster 3.
There was a lengthy and interesting discussion section. Here are some highlights:
1. Cluster 1's sensory seeking behaviors might be explained as a way for them to create soothing stimuli in the face of noxious sensory input.
2. Kinsbourne is cited in an earlier article (1991) as saying that the overfocused subgroup represents a "dimension of personality that extends the continuum of autistic behavior into normality". That is, it is also found in normally functioning individuals without autism.
3. Hussman (2000) described over-arousal as occurring due to noise in the cortex. Normal sensory input must compete with this noise and causes overreactivity.
4. Finally, the authors suggest that overselective attention and perseverative behaviors help an individual to create predictable and repetitive events for themselves as a way of moderating over-arousal. This group had the oldest mean age - a little less than 12.
Thoughts on unshifting attention:
Given that there is a continuum in shifting attention to unshifting attention, how long does it take the average person to shift thoughts? What is the reason that others shift more slowly? Are they absorbed in thought? Are they emotionally engaged? Are they enjoying sensations?
The authors said that the condition of overfocused attention occurs in the typical population - presumably scholars and meditators are among this group. The ability to shift attention will probably vary according to how deeply enmeshed in thought a person is as well as to cognitive function.
1. Emotional shifting: I have a friend, Kate, who needs 20 minutes to return to her normal state after seeing a scary film. You can't talk to her about anything during that time because she is reactive. Kate says that she is still emotionally involved in what she saw. It seems that Kate is over-aroused by the events in the film and then over engages with the emotional content and then overreacts (by not being able to return to normalcy) in turn -- just as Liss, et al., suggest happens in clusters 1 & 3 above. (Does she also have an excellent memory for emotional content? Good question!) Kate tells me that she tends to read books with predictable stories. Her hobbies are solitary: solving puzzles, work on her house and crafts. Kate is an example of a person with poor modulation of emotional input. She is able to lead a normal life by limiting emotional input.
2. Activity shifting: Children with autism have difficulty moving from one activity to another unless they are given time to adjust to the change. Likewise, they often overreact to loud noises or disruptions. There are a number of techniques used to help them with transitioning from one activity to another in a classroom setting - the chief being to follow a schedule (be it a picture schedule or a written schedule). However, on-the-spot interruptions are hard for them and can cause meltdowns. I work with a boy (Lonnie) who will not work in therapy unless he follows a schedule - and then he is quite compliant. I have begun the process of unstructuring the schedule. I create a written schedule (a list of numbered activities) and then beside the list write other possible (alternate) activities. Part way through our therapy session, I substitute an alternate activity for the next thing planned. I put it on the list, and Lonnie does it without complaint. He is able to shift within just a few seconds that way. He has been given warning, even though it was not highly structured. My next step with him is to make an unordered list of activities. I think that he is ready to follow it.
3. Sensory shifting: When kids seek sensory stimulation (swinging, visual perseveration, crashing against things), they can have difficulty pulling away. They are getting input that they apparently need (or so our sensory integration (SI) literature tells us). They are presumably calming themselves (i.e. self-regulating!). For some reason it takes a while for them to do so. Think of Kate and her slow movement out of an intense place and back into the real world. The SI theory states that if we can finally satiate the sensory need, the seeking will abate ... and this is true for many of the kids I treat. (Amazing to see, actually!)
4. Habit/addiction/compulsion: Other topics that comes to mind are addiction and compulsion. So many people are addicted to video games. We exhibit seeking behaviors when we do it ... however, it is not input that is necessarily good for us (certainly not when it interferes with our life, or with having a life). Worse, not all of us are able to finally become satiated and get back to our lives.
5. Cognitive shifting: I think that all of the above topics fall also fall under the heading of cognitive shifting, with habit and addiction being the most relevant.
It's all here. My friend Kate appears to demonstrate a similar pattern to clusters 1 & 4. She is not and never was autistic, but she certainly is able to focus deeply (is forced to due to over-arousal). Is she on the continuum of behaviors that eventually become described as autism? Probably. I read recently that we tend to over diagnose autism (and ADHD) in kindergarten. Not all kids are equally social - and teachers become worried by those who are more solitary. Perhaps those children grow up to become Kate or a skate-boarder (Sensory seeking), a habitual video game user or a gambler. When we fail to learn to modulate our inner and outer experiences, we fail to develop habits that allow us to find peace within ourselves - and this is all at the expense of typical social interaction.
Article review: Liss, M., Saulnier, D.F., & Kinsbourne, M. (2006). Sensory and attention abnormalities in autistic spectrum disorders. Autism, 10, 155-172.
I read the article by Liss, et al. this afternoon. The authors conducted a large study looking for patterns in modulation, overselective attention and exceptional memory in children with autism. They hypothesized that sensory overreactivity is a response to over-arousal. They expected to see that children with sensory overreactivity will additionally show these attributes: not being able to quickly shift attention, perseveration due to unshifting attention and exceptional memory for "self-selected material". In a population of 144 children with autism, 12% of the children did indeed exhibit a correlation of these behaviors. These children tended to be older (11 years) than the average age in the study (8.5 years) and higher functioning, but with poor social skills. The authors divided the 144 children into 4 clusters based on scores (from many tests).
Cluster 1: (12%) labeled, "Overfocused". The children displayed sensory overreactivity inability to quickly shift attention, perseveration due to unshifted attention and exceptional memory for "self-selected material". They demonstrated poor social and imitative play skills and showed the best fit to the DSM-IV definition of autism. They also displayed the least impairment of receptive and expressive communication skills, but the highest functioning level. They also demonstrated sensory seeking behaviors.
Cluster 2: The second cluster (25%) was labeled "No sensory problems" and was relatively high functioning with few functional issues.
Cluster 3: (30%), labeled "Low functioning". These children registered low in adaptive functioning, high in underreactivity and also in sensory seeking. They had poor social skills and poor receptive and expressive communication skills.
Cluster4: (33%) "Mildly overfocused", was quite similar to cluster 1 but higher functioning and only mildly over-focusing.
Cluster 1 had social skills equally impaired as cluster 3.
There was a lengthy and interesting discussion section. Here are some highlights:
1. Cluster 1's sensory seeking behaviors might be explained as a way for them to create soothing stimuli in the face of noxious sensory input.
2. Kinsbourne is cited in an earlier article (1991) as saying that the overfocused subgroup represents a "dimension of personality that extends the continuum of autistic behavior into normality". That is, it is also found in normally functioning individuals without autism.
3. Hussman (2000) described over-arousal as occurring due to noise in the cortex. Normal sensory input must compete with this noise and causes overreactivity.
4. Finally, the authors suggest that overselective attention and perseverative behaviors help an individual to create predictable and repetitive events for themselves as a way of moderating over-arousal. This group had the oldest mean age - a little less than 12.
Thoughts on unshifting attention:
Given that there is a continuum in shifting attention to unshifting attention, how long does it take the average person to shift thoughts? What is the reason that others shift more slowly? Are they absorbed in thought? Are they emotionally engaged? Are they enjoying sensations?
The authors said that the condition of overfocused attention occurs in the typical population - presumably scholars and meditators are among this group. The ability to shift attention will probably vary according to how deeply enmeshed in thought a person is as well as to cognitive function.
1. Emotional shifting: I have a friend, Kate, who needs 20 minutes to return to her normal state after seeing a scary film. You can't talk to her about anything during that time because she is reactive. Kate says that she is still emotionally involved in what she saw. It seems that Kate is over-aroused by the events in the film and then over engages with the emotional content and then overreacts (by not being able to return to normalcy) in turn -- just as Liss, et al., suggest happens in clusters 1 & 3 above. (Does she also have an excellent memory for emotional content? Good question!) Kate tells me that she tends to read books with predictable stories. Her hobbies are solitary: solving puzzles, work on her house and crafts. Kate is an example of a person with poor modulation of emotional input. She is able to lead a normal life by limiting emotional input.
2. Activity shifting: Children with autism have difficulty moving from one activity to another unless they are given time to adjust to the change. Likewise, they often overreact to loud noises or disruptions. There are a number of techniques used to help them with transitioning from one activity to another in a classroom setting - the chief being to follow a schedule (be it a picture schedule or a written schedule). However, on-the-spot interruptions are hard for them and can cause meltdowns. I work with a boy (Lonnie) who will not work in therapy unless he follows a schedule - and then he is quite compliant. I have begun the process of unstructuring the schedule. I create a written schedule (a list of numbered activities) and then beside the list write other possible (alternate) activities. Part way through our therapy session, I substitute an alternate activity for the next thing planned. I put it on the list, and Lonnie does it without complaint. He is able to shift within just a few seconds that way. He has been given warning, even though it was not highly structured. My next step with him is to make an unordered list of activities. I think that he is ready to follow it.
3. Sensory shifting: When kids seek sensory stimulation (swinging, visual perseveration, crashing against things), they can have difficulty pulling away. They are getting input that they apparently need (or so our sensory integration (SI) literature tells us). They are presumably calming themselves (i.e. self-regulating!). For some reason it takes a while for them to do so. Think of Kate and her slow movement out of an intense place and back into the real world. The SI theory states that if we can finally satiate the sensory need, the seeking will abate ... and this is true for many of the kids I treat. (Amazing to see, actually!)
4. Habit/addiction/compulsion: Other topics that comes to mind are addiction and compulsion. So many people are addicted to video games. We exhibit seeking behaviors when we do it ... however, it is not input that is necessarily good for us (certainly not when it interferes with our life, or with having a life). Worse, not all of us are able to finally become satiated and get back to our lives.
5. Cognitive shifting: I think that all of the above topics fall also fall under the heading of cognitive shifting, with habit and addiction being the most relevant.
It's all here. My friend Kate appears to demonstrate a similar pattern to clusters 1 & 4. She is not and never was autistic, but she certainly is able to focus deeply (is forced to due to over-arousal). Is she on the continuum of behaviors that eventually become described as autism? Probably. I read recently that we tend to over diagnose autism (and ADHD) in kindergarten. Not all kids are equally social - and teachers become worried by those who are more solitary. Perhaps those children grow up to become Kate or a skate-boarder (Sensory seeking), a habitual video game user or a gambler. When we fail to learn to modulate our inner and outer experiences, we fail to develop habits that allow us to find peace within ourselves - and this is all at the expense of typical social interaction.
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