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.

Environmental Enrichment (Multisensory Enrichment for Autism!)

Environmental Enrichment (EE) is an awesome protocol that has been shown to decrease autism symptoms and sensory issues and to increase receptive language and cognitive skills in children with ASD of all ages. It was designed as a low-cost program for parents to do at home. But, it can also be done in a school setting, or better yet, shared between home and school.

EE is a 6-month protocol with activities that change every two weeks. Parents/teachers select several multi-sensory activities from a list of 34 activities and do them for the two week period. They work with the child twice a day for about 15-20 minutes each. As the sessions progress, the child gains awareness of sensation and gains multi-sensory integration skills. The activities also build joint-attention skills, which are known to decrease autism severity.

The protocol is simply described in two published papers (listed below). They are open-access (available for free online). In addition, my Hands-On Activities book devotes 80 pages to the protocol, providing perhaps 200 activity variations and talking through program implementation details.

Give it a try and let me know how it goes!

References:

Woo, C. C., & Leon, M. (2013). Environmental enrichment as an effective treatment for autism: A randomized controlled trial. Behavioral Neuroscience, 487-97.

Woo, C., Donnelly, J. H., Steinberg-Epstein, R. R., & Leon, M. (2015). Environmental enrichment as a therapy for autism: a clinical trial replication and extension. Behavioral Neuroscience, 412-422.

Sensory and Autism - Differences in Brain Wiring

Today is a good day for research results. Here is a science digest synopsis of research showing that sensory and autism issues can be distinguished from each other using MRI DTI techniques. The entire article is open access and can be found here.

Update for Short Sensory Profile SDs

Last month I created a post explaining the method used to diagnose SMD (Sensory Modulation Disorder). I was missing a little data and promised an update ... It is now updated. Go here to read the updated post.

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 ...

1. Total Test score of less than 3.0 SD (standard deviations) below the mean; or
2. Less than 2.5 SD below the mean on two or more subtests; or
3. Less than 4.0 SD below the mean on one subtest

.... then the child has SMD.

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.

2012 Journal Tidbits - Autism

Here are some study findings from the Journal of Autism and Developmental Disorders - one of my favorite journals - that struck me as worth sharing. By the way, you have until Dec. 31st (2012) to browse this journal for free on line.

 1. Is picky eating due to sensory issues or due to food rigidity?
This article suggests that some picky eating problems are due entirely to rigidity in the child's food selection patterns. Treatment in this case is motivational. A child is told they will try a certain food. They are offered a choice of reinforcers (rewards). If they eat the food, they receive the reinforcer. They are also rewarded with accolades.  If they do not eat the food, they do not get the reinforcer.

When trying a new food, the authors followed a hierarchical pattern similar to Kay Toomey’s SOS Approach method:

1. Touches the food
2. Puts food to the lips,
3. Bites the food, bites
4. Puts in mouth but does not swallow
5. Chews but does not swallow
6. Swallows reluctantly
7. Accepts food without signs of displeasure.

After18 weeks, children were spontaneously requesting the new foods they had tried. The three children in the study, Ken, Robbie and Daniel accepted 5, 9 and 8 new foods respectively at the completion of the 22 week study.

Source: Koegel, R. L., Bharoocha, A. A., Ribnick, C. B.,Ribnick, R. C., Bucio, M. O., Fredeen, R. M., et al. (2012). Using individualizedreinforcers and hierarchical exposure to increase food flexibility in childrenwith autism spectrum. J Autism Dev Disord, 1574-1581.

  
2. What causes self-injurious behaviors in autism? The seven risk factors for self-injurious behaviors are 1) poor sensory processing, 2) low cognitive skills, 3) poor language / communication skills 4) poor social function, 5) age (18 mo. - 19 yrs.), 6) rigid behaviors and 7) gender. However, these factors account for just 29% of the self-injury cases seen, with sensory being the greatest factor of these (5-7%). The authors hypothesize that chronic pain and psychosocial factors may play a large factor in the remaining 71%. Clearly, there is more work to be done.

Source: Duerden, E. G., Szatmari, P., & Roberts, S. W.(2012). Toward a better understanding of self injurious behaviors in childrenand adolescents with autism specturm disorders. J Autism Dev Disord,2515-2518.

3. Is there a relationship between anxiety and repetitive behaviors? Yes, repetitive behaviors appear to be a cause of anxiety. "It is possible that, for some individuals, interventions focused on a reduction of behaviors, promoting flexibility and reducing repetitive play may consequently reduce anxiety." See the next article for more on this.

Source: Rodgers, J., Glod, M., Connolly, B., & McConachie,H. (2012). The relationship between anxiety and repetitive behaviors in autismspectrum disorder. J Autism Dev Disord, 2404-2409.

4. Are there interventions for quieting repetitive behaviors? Yes, if the child's behavior can consistently be triggered. For example, give a child with autism six cars, he will line them up. That behavior is triggerable and can be replaced with functional behavior. How about if the behavior is not triggerable? That's a harder problem. Not only do we not have interventions, we are not doing the research to look for them.

Sources:

1.  Boyd, B. A., McDonough, S. G., Rupp, B., Khan, F.,& Bodfish, J. W. (2011). Effects of a family-implemented treatment on therepetitive behaviors of children with autism. J Autism Dev Disorders,1330-1341.
2.  Boyd, B. A., McDonough, S. G., F., & Bodfish, J.W. (2012). Evidence-based behavioral interventions for repetitive behaviors in autism.J Autism Dev Disorders, 1236-1248.

5. Do children with autism also qualify for anxiety disorder? Yes, the diagnoses overlap often in children and young people (40-45%). Specifically, in children with high functioning autism, anxiety should be treated (medicine or stress reduction techniques) as a way of supporting other methods of increasing social skills.

Source: White, S. W., & Roberson-Nay, R. (2009). Anxiety, social deficits and loneliness in youth with autism spectrum disorders. J Autism and Dev Disord, 1006-1013.

Aromatherapy and Essential Oils

A recent study (1, 2) showed that essential oils reduce blood pressure and heart rate - but only if they are used for 15 - 60 minutes at a time. There is evidence that they reduce heart rate, but they can cause other issues (asthma, for example) in longer doses.

Aromatherapy is often touted to help reduce anxiety. The National Institute of Cancer (NCI) says this about it:

A large body of literature has been published on the effects of odors on the human brain and emotions. ... Such studies have consistently shown that odors can produce specific effects on human neuropsychological and autonomic function and that odors can influence mood, perceived health, and arousal. These studies suggest that odors may have therapeutic applications in the context of stressful and adverse psychological conditions.

The NCI (3) looked at a research done with cancer patients using aromatherapy to treat anxiety and other symptoms of cancer. The studies, which included children, show that aroma therapy can be effective - and especially when combined with massage. Here are some of the results. The full results are here.

• Chamomile combined with massage appears to work well.
• Smelling and tasting orange helped with physical symptoms of cancer treatment in children. There was no report on its effect on anxiety.
• Various essential oils (selected by patient) appear to reduce anxiety.
• Bergamat did not work and in fact, increased anxiety in children.
• Lavender did not appear to work as a relaxant in these studies. By the way, there is some evidence that exposure to lavender in boys and men can enlarge mammary glands.

As noted above, essential oils should be used for only 15 - 60 minutes at a time.
 
For more information on essensial oils and aromatherapy go to:

• The National Cancer Institute: Aromatherapy and Essential Oils
• A Brief History of Aromatherapy
•  Llewellyn's Complete Formulary of Magical Oils by Celeste Rayne Heldstab - A fun, but not evidence-based source of information.

References:

1. Chuang K-J, Chen H-W, Liu I-J, et al. The effect of essential oil on heart rate and blood pressure among solus por aqua workers. Eur J Prevent Cardiol, 2012 DOI: 10.1177/2047487312469474 
2. A synopsis of the above article is at ScienceDaily: Mind&Body:  http://www.sciencedaily.com/releases/2012/11/121129093419.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain+%28ScienceDaily%3A+Mind+%26+Brain+News%29
3. Study with cancer patients:  http://www.cancer.gov/cancertopics/pdq/cam/aromatherapy/healthprofessional/page7

Sensory Check Lists

I often get asked about a sensory check list for parents. I like the Sensory Processing Disorder Checklist from SPD Foundation because it looks at function, covers all ages and looks at modulation. Another list I like a lot is the Sense and Self-Regulation Checklist by Dr. Louise Silva. It was published in the Jan/Feb 2012 issue of AJOT, and is also available Dr. Silva's web site.

The gold standard for sensory questionnaires is the Sensory Profile with the Sensory Processing Measure being very good, as well. Both of these are standardized on large populations and available commercially from Pearson's and WPSpublishing respectively.

How about assessments? There is the SIPT, but it does not cover modulation. I am waiting for the Sensory Scales from SPD Foundation to be completed. They have standardized the SOR (sensory over responsivity) section on a few hundred children across the US, but have much work to do on the rest of the tool. By the way, the SOR section is being actively used by researchers.

SPD Conference

I am at the Sensory Processing Disorder Conference in Boston. Day 1 is for parents and others who want a crash course in all things sensory. Days 2 and 3 have sessions cover new research.

Diane Henry, author of Tools for Tots, Tools for Teens, etc. was the primary lecturer for Day 1. Her books and workshops are excellent with tons of good tips for helping children of all ages to self-regulate using sensory strategies.

We also heard a lecture by Doreit Bialer covering the A SECRET method of identifying sensory strategies for a particular child taking the child's emotional state, culture, relationships and environment into consideration. Ms. Bialer talked about a child who displayed chaotic behaviors in a grocery store. His mother changed this behavior by giving him responsibilities during shopping. He helped create the (picture) gorcery list, took it to the store, pushed the cart and deposited pictures into a bag once the grocery items were placed in the cart. His mother scaffolded these activities by working first with small lists and shopping in very small stores and then increasing the challenge with time.

HowdaHUG

In our "goodie bags" were both practical and fun items. My favorites include a very cool seat called HowdaHug that cradles and rocks a child. This is very light, very portable and comes in a variety of sizes. We also received a set of Soft Seamless Underwear for children who have difficulty wearing clothes. The cloth in the underwear is thick, soft (of course) and would provide good proprioception if a slightly smaller size was purchased. The garment has no elastic.

Sleep and Dental for Autism

Autism Speaks has published two guides that parents will want to download.

The first covers sleep habits and discusses bedtime routine (including sample PEX-style cards), sensory concerns (light, sound, tactile and temperature), the amount of sleep needed (children with autism appear to need less sleep), and strategies for problem sleepers. There is a wealth of good information in 8 pages.  Autism Speaks Sleep Tips

The second guide is a toolkit for dental professionals. It provides practical strategies for doing dental work on children with autism. Included topics are sensory strategies, picture schedules and social stories. There are handouts for dental workers to provide to parents regarding chemicals and procedures. The appendix contains parent medical checklists and parent handouts regarding the nature of amalgams and flouride. Autism Speaks Dental Tool Kit

Sensory Vs Behavior Approach

There is a bit of unnecessary tension between the fields of applied behavior analysis and sensory therapy. There needn't be. Both approaches have tons of research. Sometimes there is an overlap in the type of therapy one might consider for a given situation. Excellent! Both types of therapists can give a problem a "go". I am grateful to have colleagues to refer difficult cases to and am glad to help their clients, as well.

I've compiled, what I contend, are a list of truisms regarding the scope and overlap of these two types of therapies.

1. Yes, there is such a thing as sensory processing disorder. Yes, there is evidence. Do sensory interventions work? In many cases, yes. See the many, many papers written.

2. No, sensory techniques do not solve all sensory issues. Sometimes a child has developed negative habits and a behaviorist can provide the best therapy. In fact, for truly challenging problems, a behaviorist approach can be a God-send.

3. A behavior approach can be the therapy of choice for feeding problems - even those with textures and tastes. Why? Sometimes the child just needs to get past the weirdness of texture and tastes. There is a rule of 13 tastings. When a child tries a food (that they don't hate) 13 times, they acclimate to it. This is especially important for children who are at risk for failure-to-thrive due to feeding issues.

4. Using one of the BIG sensory therapies such as Therapressure™ (Wilbarger Protocol), sound therapy or a strictly followed sensory diet can change the life of a child with sensitivity (hyper-reactivity) to sensory input. These children suffer - we need to help them

5. "ABA"-based therapies have helped many children with autism to attend to lessons in a regular-education classroom. This can be a life-changer for a child.

6. Movement and other sensory-style breaks throughout the day help all children to attend better in class. This can help all children achieve higher grades.

7. New medical research is uncovering unusual issues in children with autism that affect their behavior. Treating a medical issue with sensory or aba-style therapies can be a waste of time.

That's the short list. What other things might you add?

"I'm Not Hungry"

At my book club last night, someone related the story of a friend whose child doesn't eat and so throughout the day, the mother chases the child through the house with food on a spoon saying, "Here, eat this! Eat this!". What a sad story. I've heard it before - a number of times, actually, from the different parents I speak with.

There are any number of reasons that a child will limit food intake. Today I'll focus on sense of hunger. In future blog entries, I'll discuss sensory and motor issues, gag reflex, as well as emotional and social causes.

Why would a child not feel hungry?
         1. We'll start with the obvious - he or she is snacking between meals and so does not get hungry. This is theoretically easy to fix. Limit the size and number of snacks. Space snacks carefully so that they are midway between meals and not too close to dinner.
         2.  She doesn't experience hunger, in other words, a medical issue and so a trip to the doctor is in order. An older child might be taught to eat certain portion sizes on a schedule. The portions sizes will have to be estimated for her age and body size and adjusted as necessary.
         3. He is on ADHD or other meds that cause decreased hunger. This is again reason to visit a doctor. It may be that using supplemental nutritional drinks such as PediaSure creates a workable solution. (But keep reading...)

         4. She is so consumed with her world (possibly due to autism) that she is not in touch with her body. Giving the child alerting activities (proprioception is always useful!) may help her to break free of that state. Once alert, she should show interest in food.

         5. He is so consumed with emotional issues that he is out of touch with himself. Have him take a second to check in with his stomach may solve the problem.

One such child I see in school missed lunch - he wasn't hungry. I saw him outside of his classroom in tears. His teacher, who had no clue about what was wrong was trying to keep him from meltdown. I noticed that the cafeteria workers had put all the food away and now the opportunity for eating had passed. I took a good guess at what had happened to him and brought him to my room.

Me: "Did you eat your lunch?

Jacob: "No, I'm not hungry."

Me: "Are you sure? I want you to feel the sensation in your stomach."

Within seconds, he asked if he could get his lunchtime meds from the office. We went there and passed the cafeteria. A worker found 2 boxes of Rice Crispies and a fruit cup. Jacob took his meds, and then wolfed down the food in record time.

The last three cases are really just this: the child needs to learn to check in with his/her body. This may involve some heavy work (play) -- especially with another person to help with attention -- to get grounded. Once done, the child may finally feel the need for food.

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.

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.

Imitation as therapy

Last week, a colleague passed along the book, "Mirror Neurons and the Evolution of Brain and Language", by editors Stamenov and Gallese. Mirror neurons exist in specific regions in the brain and have a unique mission: learn how to copy someone else's movements as a way of learning to do something new. For a child this might be: take a lid off of a jar, play hopscotch, or hopefully, for one of my clients, brush your teeth.

Alicia, a 5 year old girl with autism, refuses to let mom brush her teeth (without a big fight). Mom and I want to desensitize her mouth a bit, so that she more readily accepts brushing. I put a glove on my hand and played games with Alicia while she was swinging. I managed to touch her mouth, and even get a finger onto her gum without too much of a struggle. But she was done with the game long before I managed to massage her gums.

During the next session, after playing our game for a few minutes, I guided her fingers to her teeth. I touched my teeth with my fingers and asked her to touch hers. To make this easier for her to understand, we moved to chairs in front of the mirror and kept practicing touching teeth, then gums. Alicia "got it" and her mom, who had been watching, felt comfortable with following through with the game. It's too early to say, but we have hopes that Alicia will learn to desensitize her own mouth, and then learn to brush her own teeth. Whew.

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/

Auditory Fight or Flight

A large number of my pediatric clients have auditory issues. For most, the noise of a cafeteria or gym is too much to handle and they are put into fight or flight movement with unexpected or loud noises. They have been known to scream, run and cry in response to everyday situations making them very unpopular with teachers. In addition, they may talk to themselves or make unusual noises (vocal tics for example) that drive classmates nuts. These poor children have a very hard time making and keeping friends.

These sensory kids may or may not have autism - and it seems that a lot of them are on a sort of continuum from "typical" to "high functioning autism". My first step is to give the children strategies to keep their cool. I recommend earplugs (with a pediatrician's approval), or headphones in noisy environments. There are chewy necklaces and pencil grips that can provide them with oral input and serve to limit the vocal tics. Then I discuss ways to self-calm using breathing and focus on breathing. With one bright child, I explained what fight or flight means and suggested that she provide herself with self talk by telling herself that she is safe and that her reaction to noise is just an over-reaction by her body.

These strategies help, but not all children can use them independently. My next stage of therapy is twofold - vestibular stimulation and a listening program. We have Therapeutic Listening at our clinic.

Vestibular Stimulation
Given that the vestibular and auditory "organs" are in close physical proximity, it is common for a child with auditory issues to have vestibular problems as well. I look for dizziness or fear, and treat it by finding the plane (lateral, vertical, horizontal) and type of movement (rotational, linear, stationary, head down, etc) that makes the child dizzy or fearful. I then acclimate the child to the difficult positions and types of movement by alternating them with safe movement (usually linear swinging). I count out loud so that the child knows when the movements will start and end. This helps to remove fear. I have them check themselves for dizziness, and report on progress. These types of vestibular problems usually heal in just a few 15-minute sessions. It is harder to accomplish with a child with moderate-severe autism because they may not pay attention to what I am telling them (or may not initially trust me) and so go into a state of fear. The trick with them is to go slow and back off if it looks like it's going to backfire.

Listening Program
I am still new to listening programs, but have seen progress with my kids and my colleague's clients, too. Therapeutic Listening (TL), as I mentioned in another post, has 4 classes of CDs: self regulation, time and space, praxis and connectivity (to the environment). I use the self-regulation CDs to help reduce the fight or flight response and the time and space CDs to help with correcting the auditory imbalance itself. After that, I move to the connectivity CDs to try and help re-integrate the child into his/her environment, with the hope that it'll help with social issues.

The self-regulation CDs appear to make a person more passive - which can be good or bad. I tried a week's worth myself and had a friend do so, too. We both became noticeably calmer, but more passive. I stopped standing up for myself. I certainly don't want that to happen with my clients. So, when I see that symptom, I move to a third stage - Interactive Metronome (IM). Perhaps not a full program, but certainly enough to break the passivity and induce a shot of confidence. With one client, I moved in and out of TL and IM in the hopes that he would find an easy place to settle. It appears to have worked and he is discharged. I'll check back in a few months to see if he is still doing well.

Sensory Profile Score Gains

I had an opportunity to check gains in the sensory processing skills of a 7 year old girl who had undergone 6 months of SI. Her clinic-based OT consisted primarily of vestibular & tactile interventions was 1/2 hour weekly sessions with modulated music playing in the backgound. This was followed by 1/2 hour sessions with a music therapist. In addition, she received 6 weeks (so far) of Therapeutic Listening and a very good sensory diet program at her school.

She made significant gains in her parent's eyes and it also registered on the Sensory Profile (SP). She now accepts hugs from her family without tactile defensiveness (talk about huge!). On the SP, She gained 10 points overall (from 497 to 487). Her Touch Processing score moved from definite difference to probable difference and the Sedentary Factor moved from probable difference to typcial.

Sensory Profile Factors

Article

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.

Here is an older study done in Kansas that looks at the factors (1-9) in the Sensory Profile for positive correlations to autism and ADHD. (The authors note that this process can be done for other disabilities, as well. I vote for Fetal Alcohol Syndrome!)

ADHD can be distinguished by high scores in Factors 1 and 5, sensory seeking and inattention/distractibilty and low scores in factors 4 and 9, oral sensitivity and fine motor perceptual.

Autism can be distinguished by high scores in Factors 4, 5 and 9, sensory seeking, inattention/distractibilty and oral sensitivity and low scores in factor 4, fine motor perceptual.

The study results had a statistical error, the assumption of homogeneity of variance was violated for the control group, and so these results must be used conservatively.

Questions for research:
1. Will these results pass muster on a larger population?
2. What does the factor profile look like for FAS, ODD, CD, etc.?

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)?