Response Patterns

Here are more blocks in the foundation of self regulation. Today I am reviewing and commenting on 3 interesting pieces of research that describe response patterns in children with autism and "typical" children. The articles cover 3 different areas: sensory input, affect and joint attention (a social skill).

Article 1: Response to Tactile & Vestibular Patterns
Bar-Shalita, T., Goldstand, S., Hahn-Markowitz, J., & Parush, S. (2005). Typical children’s responsivity patterns of the tactile and vestibular systems. American Journal of Occupational Therapy, 59, 148-156.

Summary
The article describes typical 3-4 year old responses to tactile and vestibular input. There was no noted differences in gender response. There was no significant difference in responses from age 3 to age 4. Children in this study showed no sensory modulation issues. That is, they were not seekers of this input and did not appear to be hypo-reactive and/or hyper-reactive in response to the input.

Comments
The study was performed in Israel, and so is valid for that population, but in fact supports data collected from U.S. researchers including Dunn, Ayers, Blanche and others.

The article is noteworthy for the excellent review of past and current literature in the areas of sensory modulation, tactile defensiveness, and hypo- and hyper-reactivity to movement.

Article 2: Response to Mood
Begeer, S, Meerum, T. Rieffe, C., Stegge, H., & Koot, H. M. (2007). Do children with autism acknowledge the influence of mood on behaviour? Autism, 11, 503-521.

Abstract
"We tested whether children with and without high-functioning autism spectrum disorders (HFASD) differ in their understanding of the influence of mood states on behaviour. A total of 122 children with HFASD or typical development were asked to predict and explain the behaviour of story characters during hypothetical social interactions. HFASD and typically developing children predicted at equal rates that mood states likely result in similar valenced behaviour. `Explicit' descriptions were used to explain predictions more often by children with HFASD than by typically developing children. However, `implicit' and `irrelevant' descriptions elicited fewer mood references among HFASD children. Furthermore, they less often referred to the uncertainty of the influence of mood on behaviour, and less often used mood-related explanations, in particular when they had to rely on implicit information. This may indicate a rote- rather than self-generated understanding of emotions in children with HFASD. "

Article 3: Response to Novel Input on Joint Attention Skills
Gulsrud, A.C., Kasari, C., Freeman, S., & Paparella, T. (2007). Children with autism’s response to novel stimuli while participating in interventions targeting joint attention or symbolic play skills. Autism 11, 535-546.

Abstract:
"Thirty-five children diagnosed with autism were randomly assigned to either a joint attention or a symbolic play intervention. During the 5—8 week treatment, three novel probes were administered to determine mastery of joint attention skills. The probes consisted of auditory and visual stimuli, such as a loud spider crawling or a musical ball bouncing. The current study examined affect, gaze, joint attention behaviors, and verbalizations at three different time points of intervention. Results revealed that children randomized to the joint attention group were more likely to acknowledge the probe and engage in shared interactions between intervener and probe upon termination of intervention. Additionally, the joint attention group improved in the proportion of time spent sharing coordinated joint looks between intervener and probe. These results suggest that generalization of joint attention skills to a novel probe did occur for the group targeting joint attention and provides further evidence of the effectiveness of the joint attention intervention."

Other Points Made
The authors conclude that the intervention worked for these reasons:
1. It violated the established routine for the child's session.
2. The focus of the session was already on engagement with other people, and so the child was not required to do something new (beyond engaging).
3. Children in the joint attention group were becoming more adept at shifting their attention and responding with flexibility to the environment, so the surprise intervention was simply an increase in the level of challenge.

Although there was an increase in initiation and duration of joint attention there was no significant change in the child's affect, non-verbal gestures and verbalizations.

The authors note that "sustained engagement in joint attention states has been linked to language development in typical children... may be important for the language development of children with autism."
Here is a working definition for sensory modulation.

My Comments
This is a very important finding that can be applied to SI interventions in that we can add a joint attention component to activities such as a swing or a trampoline, and add a surprise element into the mix. The authors treated for 30 minutes and interjected the random stimulus during the last 2 minutes - timelines that could easily work in a typical OT session.

A question worth asking is "If the children were engaged in an intervention aimed at increasing affect, would there have been a significant change in that area (and not in joint attention)?

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.

Glossary

Here is an informal glossary. It will grow over time.

Definitions of Modulation, etc.

Modulation: State of actitivy within an individual. This refers to movement, communicative expression and emotional expression.

Sensory modulation: the "capacity to regulate and organize the degree, intensity, and nature of responses to sensory input in a graded and adaptive manner" (Miller & lane, 2000, p3.).

Overactive / hyperactive: be in an excited state motorically or emotionally. For example, rarely stand still, alwasy on the move. This is often combined with emotional activity.

Underactive / hypoactive: be in a low state of arousal with slowed movements. This is often accompanied by an emotional state of low affect.

Overreactive: over-respond to input sensory stimuli. Some examples: scream when a door is slammed, not tolerate elastic or tags in clothing, cover eyes in the presence of bright light.

Underreative: ignore stimuli to one's sensory system. Some examples: not react to painful bumps and bruises or to questions or to noxious smells.

Definitions of Autism, ADHD, etc.
These are formally defined by the DSM IV, and I will paraphrase the criteria. However, OT literature has added a wealth of information about sensory processing & modulation for persons with autism that is not yet covered by the DSM, and so I will add that material. ADHD is added to this list because 1) a number of children with autism also are diagnosed with ADHD and 2) it is interesting to see the differences between ADHD (with autism) and autism (without ADHD).

Autism:
Aspberger's Syndrome:
PDD/NOS:
ADHD:

References:
Miller, L. J., & Lane, S. J. (2000, March). Toward a consensus in terminology in sensory integration theory and practice: Part 1: Taxonomy of neurophysiological processes. Sensory Integration Special Interest Section Quarterly. 23, 1-4.

Bibliography

I have a large stack of journal articles from AOTA (American Journal of Occupational Therapy) articles, "Autism", a journal published by Sage Publications -- http://aut.sagepub.com/ and a handful of other journals. I currently have over 100 articles to sort through, review and write about in semi-daily entries in my blog. Once that is done, I'll begin to search through the Canadian Journal of Occupational Therapy and then move to the UK and Australia plus other interesting journals. There is so much out there, I hope to bring the data to one spot (here) so that all of us can make sense of it. We need to see what we know and what we don't know in these area so that we can build on our knowledge in a systematic fashion. Too much of our research is random points in the problem space.

Here is a start at organizing the topics and articles to be covered in weeks ahead. Some of the articles can be found in multiple categories. If all goes well, this list will become the index to the site.

Asperger's Syndrome:
1. Pfeiffer, B., Kinnealey, M., Reed, C., & Herzberg, G. (2005). Sensory modulation and affective disorders in children and adolescents with Asperger’s disorder.
2. Macintosh, K. & Dissanayake, C. (2006). A comparative study of the spontaneous social interactions of children with high-functioning autism and children with Asperger’s disorder. Autism, 10, 199-220.
3. Rinehart, N.J., Bradshaw, J.L., Moss, S.A., Brereton, A.V., & Tonge, B.J., (2006). Pseudo-random number generation in children with high-functioning autism and Asperger’s disorder: Further evidence for a dissociation in executive functioning? Autism, 10, 70-85.
4. Bledsoe, R., Myles, B.S., & Simpson, R.L. (2003). Use of a social story intervention to improve mealtime skills of an adolescent with Asperger syndrome. Autism, 7, 289-295.
5. Dougal, J.H., Jones, S., & Evershed, K. (2006). A comparative study of circadian rhythm functioning and sleep in people with Asperger syndrome. Autism, 10, 565-575.
6. Hare, D.J., Jones, S., & Evershed, K. (2006). A comparative study of circadian rhythm functioning and sleep in people with Asperger syndrome. Autism, 10, 565-575.
7. Ducharme, J.M., Sanjuan, E., & Drain, T. (2007). Errorless compliance training: success-focused behavioral treatment of children with Asperger syndrome. Behavior Modification, 31, 329-344.
8. Howard, B., Cohn, E., & Orsmond, G.I. (2006). Understanding and negotiating friendships: perspectives from an adolescent with Asperger syndrome. Autism, 10, 619-627.
9. Kaland, N., Mortensen, L., & Smith, L. (2007). Disembedding performance in children and adolescents with Asperger syndrome or high-functioning autism. Autism, 11, 81-92.
10. Beaumont, R., & Newcombe, P. (2006). Theory of mind and central coherence in adults with high-functioning autism or Asperger syndrome. Autism, 10, 365-382.
11. Hedley, D., & Young, R. (2006). Social comparion processes and depressive symptoms in children and adolescents with Asperger syndrome. Autism, 10, 139-153.
12. Stewart, M.E., Barnard, L., Pearson, J., Hasan, R. & O’Brien, G. (2006). Presentation of depression in autism and Asperger syndrome: A review. Autism, 10, 103-116.
13. Jennes-Coussens, M., Magill-Evans, J., & Koning, C. (2006). The quality of life of young men with Asperger syndrome: a brief report. Autism, 10, 403-414.
14. Meyer, J.A., Mundy, P.C., Van Hecke, A.V., & Durocher, J.S. (2006). Social attribution processes and comorbid psychiatric symptoms in children with Asperger syndrome. Autism, 10, 383-402.
15. Tregay, Jennifer. (2006). Book review: sensory perceptual issues in autism and Asperger syndrome: Different sensory experiences – different perceptual worlds. Autism, 10, 117.
16. Freitag, C. M., Kleeser, C., Schneider, M., & von Gontard, A,. (2007). Qualitative assessment of neuromotor function in adolescents with high funtioning autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 37, 948-959.
17. Myles, B.S., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., & Becker, S. (2004). Sensory issues in children with Asperger syndrome and autism. Education and Training in Developmental Disabilities, 39, 283-290.

Auditory
1. Myles, B.S., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., & Becker, S. (2004). Sensory issues in children with Asperger syndrome and autism. Education and Training in Developmental Disabilities, 39, 283-290.
2. 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.

Behavior
1. Begeer, S, Meerum, T. Rieffe, C., Stegge, H., & Koot, H. M. (2007). Do children with autism acknowledge the influence of mood on behaviour? Autism, 11, 503-521.
2. Matson, J. L., Santino, V. L. (2008). A Review of Behavioral Treatments for Self-Injurious Behaviors of Persons With Autism Spectrum Disorders. Behavior Modification 32, 61-76.
3. 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.

Eating
1. Whiteley, P., Rodgers, J., & Shattock, P. (2000). Feeding patterns in autism. Autism, 4, 207.
2. Bober, S.J., Humphry, R., Carwell, H.W., & Core, A.J. (2001). Toddlers’ persistence in the emerging occupations of functional play and self-feeding. American Journal of Occupational Therapy, 55, 369-376.
3. Bledsoe, R., Myles, B.S., & Simpson, R.L. (2003). Use of a social story intervention to improve mealtime skills of an adolescent with Asperger syndrome. Autism, 7, 289-295.

Family Perspectives
(This will be covered in a separate blog)

Modulation
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.
3. 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.

Neuromotor
1. Freitag, C. M., Kleeser, C., Schneider, M., & von Gontard, A,. (2007). Qualitative assessment of neuromotor function in adolescents with high funtioning autism and Asperger Syndrome. Journal of Autism and Developmental Disorders, 37, 948-959.

Play
1. Gulsrud, A.C., Kasari, C., Freeman, S., & Paparella, T. (2007). Children with autism’s response to novel stimuli while participating in interventions targeting joint attention or symbolic play skills. Autism 11, 535-546.

Sensory
1. Leekam, S.R., Carmen, N. Libby, S.J., Wing, L., & Gould, J. (2007). Describing the sensory abnormalities of children and adults with autism. Journal of Autism and Developmental Disorders, 37, 894-910.
2. Myles, B.S., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., & Becker, S. (2004). Sensory issues in children with Asperger syndrome and autism. Education and Training in Developmental Disabilities, 39, 283-290.
3. 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.

Sleeping
1. Dougal, J.H., Jones, S., & Evershed, K. (2006). A comparative study of circadian rhythm functioning and sleep in people with Asperger syndrome. Autism, 10, 565-575.
2. Hare, D.J., Jones, S., & Evershed, K. (2006). A comparative study of circadian rhythm functioning and sleep in people with Asperger syndrome. Autism, 10, 565-575
3. Salls, J.S., Silverman, L.N., & Gatty, C.M. (2002). Brief Report – The relationship of infant sleep and play positioning to motor milestone achievement.

Social Skills
1. Gulsrud, A.C., Kasari, C., Freeman, S., & Paparella, T. (2007). Children with autism’s response to novel stimuli while participating in interventions targeting joint attention or symbolic play skills. Autism 11, 535-546.

Tactile Sensory Processing/Discrimination
1. Bar-Shalita, T., Goldstand, S., Hahn-Markowitz, J., & Parush, S. (2005). Typical children’s responsivity patterns of the tactile and vestibular systems. American Journal of Occupational Therapy, 59, 148-156. Read Review.
2. Myles, B.S., Hagiwara, T., Dunn, W., Rinner, L., Reese, M., Huggins, A., & Becker, S. (2004). Sensory issues in children with Asperger syndrome and autism. Education and Training in Developmental Disabilities, 39, 283-290.

Vestibular Processing
1. Bar-Shalita, T., Goldstand, S., Hahn-Markowitz, J., & Parush, S. (2005). Typical children’s responsivity patterns of the tactile and vestibular systems. American Journal of Occupational Therapy, 59, 148-156. Read Review.

Visual Processing
1. Brenner, L. A., Turner, K. C., & Muller, R-A. (2007). Eye movement and visual search: Are there elementary abnormalities in autism? Journal of Autism and Developmental Disorders, 37, 1289-1309. Read review.

2. Baranek, G.T., Barnett, C.R., Adams, E.M., Wolcott, N.A., Watson, L.R., & Crais, E.R. (2005). Object play in infants with autism: Methodological issues in retrospective video analysis. American Journal of Occupational Therapy, 59, 20-30.



Teresa

Introduction

I have been looking for a way to share information about treating children with autism. There is so much to know, and no two cases are alike. I read the journals, scour the Internet for information, talk with parents of children with autism and learn from my colleagues. I plan to write about what I read and hear. I hope that this blog attracts others who want to share what they know, too.

My chief area of interest is self regulation. This covers a lot of ground. Children with autism have difficulty managing very simple aspects of their lives. Sleeping, eating, food aversion, verbal output (and vocal tics), emotional and social behavior, seeking behaviors (vestibular, proprioceptive, tactile, mouthing inedible objects, perseveration on objects), sensory regulation & sensitivity (overt such as hearing, touch, vision, etc. and more subtle such as being in touch with their bodies and having a stable inner experience), modulation, hyperactivity, hypo-activity, and on and on. There is a lot to say here. I hope that you will join me in attempting to unravel the mysteries.

Who am I? I am an occupational therapist working in a pediatrics clinic. I have a master's degree in occupational therapy and have SIPT and Interactive Metronome certifications.