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.

Pre-Satiation Technique for Stereotypy and Craving?

In the previous post, I looked at the blurred lines across the (ASD) autism symptoms of stereotypy and sensory craving. This post focuses on an intervention that may help both types of symptoms. The intervention is a well-conceived combination of behavioral and sensory techniques that comes from a study by Rispoli, et al (2013).

The research team studied three children with stereotypic behaviors. Five-year-old Antonio has autism and vocal stereotypy in the form of a high-pitched squeal. Twelve-year-old Jeff has intellectual disabilities and seizure disorder. He hits tables, chairs and walls repeatedly with various hand-held objects. Four-year-old Joel has autism and bounces small things (balls, toys and breakable objects) onto the floor. 

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

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

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

Step 1: Analysis

1.     Analysis: You note a stereotypic behavior that appears to have a sensory component. Note which senses appear to be stimulated by the behavior. Remember that movement is also sensed by the body. It is the combination of the vestibular sense (head movement) and the proprioceptive sense (body movement). Unless you discover otherwise (see the "unmatched preference" of step three), assume that the child is craving sensation and that his stereotypic activities are satisfying that craving.

2.   To establish a baseline, count the occurrences of the behavior: count the number of times and the total amount of time he engages in stereotypy during a demanding activity. Also note when (time, place, type of activity) the child engages in the behavior.

Step 2: Discovering the Preferred Object

 

1. Identify possible preferred activities for satiation tasks: Put together some optional activities for him to engage in that might be just as engaging as the stereotypy. Attempt to find activities that stimulate the exact same senses in the same way. A good preferred activity may be more intense than his current one.

2.   Put all of the candidate preferred activities (toys to help with stimming) in an otherwise empty room with the child on a few occasions. Let him play and see if a preferred object emerges.
       If you are unable to find a preferred activity that is similar to the stereotypy, then try something else, perhaps access to a computer or a cause-and-effect toy. This is called an unmatched 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.

First, let the child have unlimited time doing the preferred activity, that is let him do it until he is satiated. Let’s say that he usually requires 22 minutes to be satiated, and then plan to have him start the preferred activity about 25 minutes prior to the next task.

Afterwards, as he engages in the demanding tasks, track his behavior to see if his stereotypy has diminished. Counting the number of times and the total amount of time he engages in stereotypy during the demanding activity. Do this over a period of several sessions. If it appears to be helping, continue with the intervention on a daily basis. If he acclimates to the preferred activity, then try replacing it with something a little more intense or demanding. In some cases, you may see that he no longer desires the preferred activity and that his stereotypy has decreased, as well. This good outcome is possibly the result of increased sensory integration skills.

In the study, the child was used as his own control. By performing the intervention every other session, his behavior on days that he was satiated could be compared to behavior on days that he received no intervention and was not satiated. They noted that after a few weeks, the behavior appeared to improve both on the days that the intervention was done and when it was not done.

Unfortunately, the researchers did not carry out the study long enough to see if the intervention would lead to extinction of the behavior--which is a shame, because it might do so. I have seen satiation work as therapy with children in my setting. I separately treated wo children who craved movement. When given unlimited time on a swing twice a week, both lost interest in the swing after a month. One boy with this result was then capable of sitting at attention in the classroom without getting out of his chair on  most days. Sensory integration theory suggests this outcome, but to my knowledge, this type of scenario has not been documented in the journals.

How long did the effect of the intervention last? Fifteen minutes? A few hours? The whole day? The authors don’t discuss this, but the intervention is similar in nature to the sensory diet which is thought to last 2 hours. In the sensory diet, children are given 15 minutes (or so) of sensory stimulation usually including  a movement activity every 2 hours as a means of increasing self-regulation. A significant difference between satiation and the sensory diet is the inclusion of movement which is on its own self-regulatory. (BTW, the sensory diet has not yet been sufficiently studied to validate its efficacy, but it is generally accepted as a good practice.)

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

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

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.

The Confusion of Sensory Craving, Stereotypy, Hyperactivity and OCD

It can be difficult to accurately distinguish between sensory craving and stereotypy. Both symptoms play a big role in autism and both are part of the ASD¹ diagnosis, so you might think they are distinct. But they're not. They can be easily mistaken for each other and even overlap. Does it matter that we identify exactly what is going on? Yes. How can we create successful interventions without pegging the problem correctly?

Look at the descriptions and examples below and see if you can pick out inherent problems. See if you notice the areas of overlap and blurry lines between them, and also with them and hyperactivity (ADHD²) and obsessive behaviors (OCD).

Stereotypy: Rapp and Lanovaz³ say, "Stereotypy is often characterized as repetitious, invariant behavior that generates its own reinforcing consequences (rewards)." Examples are vocalizations, flicking fingers, slapping things, nail biting, and similar habitual activities. The DSM describes it in terms of motor movement or use of objects and gives these examples: "simple motor stereotypes, lining up toys, flipping objects, echolalia, idiosyncratic phrases."

Sensory craving: I'll venture this definition: goal-driven behavior to satisfy a sensory need. The DSM more broadly talks about "unusual interest in sensory aspects of the environment ... such as ... excessive smelling or touching of objects, visual fascination with lights or movement."

Did you catch any problems? Stereotypy is defined in terms of motor, craving in terms of the senses—as if the two inhabit separate worlds or separate people. But they don’t. Let’s look at a few cases and see how the symptoms might occur in real life.

We’ll start with the example of the child who frequently vocalizes simple sounds or phrases. Is it echolalia--a motor repetition? Or is it sensory seeking: fascination with the sounds she produces, or the sensation in her throat? Or is she doing it for some other reason such as attention seeking? Without knowing what is driving the behavior, it's hard to classify it. In fact, the behavior may be driven by all of these factors. The stereotypy may co-exist with sensory seeking, and once the child learns that her behaviors draw attention, she may use them to do so. 

How do school professionals view this behavior? It will likely be a mixed bag. First, behaviorists⁵ and sensory therapists will agree that the child is being rewarded by the sensation of certain sounds. She is craving sensory stimulation; but she is also engaging in stereotypy: behavior that generates its own reward. While there is definite overlap of stereotypy and sensory craving here, they will probably name it stereotypy and sensory therapists will look for any connection to craving. Teachers, who are with children for long periods and can see patterns in their behaviors, will be more attuned to the possibility of attention seeking.

Now let's explore this a little further. What about the child who has vocal tics. Does he fall into the categories of stereotypy or craving? No. Tics are involuntary speech and are usually the result of stress and anxiety.

How about a child who talks constantly? We see this in Asperger's Syndrome and it is often pegged as repetitive behaviors, but constant talking is also a symptom of ADHD hyperactivity. How do you distinguish between impulsive talking and self-rewarding ("He just likes to hear himself speak") stereotypy? For the unpracticed observer, the signs seem subtle, but the give-away to it being a repetitive behavior is constant talking about a single topic (such as types of aircraft). Finally, is the non-stop talking a sensory behavior? That's possible, but less likely.

Let's look briefly at a few more examples: children who touch everything or sniff things. Are these considered sensory cravings? Almost certainly, but it may be more than that. Some children learn about their world using alternate sensory paths: smell or touch instead of vision and hearing, and so the seeking behaviors may be a form of learning. But which came first: the craving or the learning pattern? It’s hard to know. And to further complicate things, the behavior can also be tagged as stereotypy, if she smells or touches the same things over and over in an “invariant pattern”.

Finally, let’s ask if a behavior that looks like stereotypy is actually obsessive compulsion (OCD). Hmm, it could be. The child who touches things in a certain prescribed way, may have OCD. The motivation for the behavior will be fear-based: "If I don't move in this exact sequence, something bad will happen", rather than the reward-based behavior of stereotypy. (The topic of differentiating OCD from stereotypy is explored in an article by Chok and Koesler in the September, 2014 issue of Behavior Modification journal, a special issue devoted to stereotypy, and I may blog on that at a later time.)

You can see that symptoms can be easily confused. In my years of teaching classes on the topic of self-regulation, I heard numerous accounts of doctors confusing craving or stereotypy with hyperactivity or OCD and giving children ADHD or OCD meds. It's truly important to distinguish the nuanced behavior so that the correct intervention is given.

In my next post, I'll look at the approaches taken by behavioral and sensory therapists to stop these behaviors. Sometimes the interventions are surprisingly alike.

 Footnotes and References

1. Autism Spectrum Disorder
2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Association.
3. Attention-Deficit Hyperactivity Disorder
4. Rapp, J. T., & Lanovaz, M. J. (2014). Introduction to the special issue: Assessment and treatment of stereotypy. Behavior Modification, 339-343.
5. 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.
6. Chok, J. T., & Koesler, B. (2014). Distinguishing obsessive compulsive behavior from stereotypy: A preliminary investigation. Behavior Modification, 344-373.

Intro Post: Distinguishing Sensory Craving, Stereotypy, Impulsivity, Tics and Obsessive Compulsion

The ASD¹ (autism) symptoms of sensory craving and stereotypy are described separately within the ASD diagnosis in the DSM-5², so you might think they are distinct from each other. But that is not the case. They can be easily mistaken for each other, and at times they overlap with each other. In the next two posts, I’ll take a look at the blurry lines between them and with other similar issues: the hyperactivity of ADHD³, tics, and obsessive compulsion. I'll discuss the implications for both assessment and intervention.

References

1. Autism Spectrum Disorder
2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Association.
3. Attention-Deficit Hyperactivity Disorder