The Triad of Impairments

1. The Triad of Impairments Communication Imagination/ flexibility of thinking Socialisation Triad of Impairments

2. Beyond the Triad… Sensory processing Perception Additional features Cognition

3. Key features Communication Sensory Processing Perception Key features of ASD Imagination/ flexibility of thinking Socialisation Cognition

4. What is Sensory Processing Disorder (SPD) • SPD is the inability to modulate, discriminate, coordinate, or organise sensation adaptively for different functional tasks (Lane, Miller and Hanft 2000) • It has been proposed that SPD would be included in the next diagnostic manuals such as DSM and ICD as a condition in it’s own right.

5. “ My problem in infancy was not so much that I didn’t understand the world, but that I couldn’t stand it , because often bombarded with an overload of sensory information” Donna Williams . ( Autism. An Inside-out approach)

6. Sensory Processing Disorder (SPD) Sensory Modulation Disorder (SMD) Sensory-Based Motor Disorder (SBMD) Sensory Discrimination Disorder (SDD) Vision Dyspraxia SOR SUR SS Postural Disorder Hearing Touch Taste/Smell SOR = Sensory Over-Responsivity SUR = Sensory Under-Responsivity SS = Sensory Seeking / Craving Position/ Movement Classification of Sensory Processing Disorder Patterns and Subtypes (Miller L J 2007)

7. Review of the Sensory Systems • External Senses Visual Auditory Touch Taste Smell • Internal Senses Interoceptive (from organs) Vestibular (balance) Proprioceptive (movement)

8. Vision • Ocular motor control • Tracking • Convergence • Visual Perception • Visual discrimination • Visual memory • Figure ground • Closure

9. RED GREEN ORANGE BLACK PINK BLUE WHITE YELLOW We find it very difficult to see visual information without imposing meaning. Say the colours, don’t read the words

10. Auditory System • Hearing very primitive sensory system present in utero, detects volume, pitch, tone, directionality. • Difficulties inc: • Sensitivity • Poor filtering • Auditory discrimination

11. “ My hearing is like having a hearing aid with the volume control stuck on ‘ super-loud’. It is like an open microphone that picks up everything. I have two choices: turn the mike on and get deluged with sound, or shut it off. (Temple Grandin)

12. Touch / Tactile system • Primitive reflexes are based on tactile system • Receptors are specific • Pain • Temperature • Light touch • Deep pressure • Thresholds for responses vary • Receptor fields vary • Adaption rates vary

13. Taste • Bitter, sweet, salt and spice • Texture • Consistency • Closely linked with smell

14. Internal Senses

15. Introceptive senses • Sensation from internal organs • Essential for survival • Hunger, thirst, body temp, sleep • Unconscious / autopilot most of the time • Need to act leads us to conscious awareness of systems

16. Balance / Vestibular System • Receptor organs located in inner ear • Utricle + saccule • Semicircular canals • Linear movements and orientation to gravity • Circular movements • Maintain muscle tone • Postural stability (alongside proprioceptive system)

17. Movement / Proprioception • Receptors in muscles and joints • Balance and posture • Give unconscious constant feedback • Give us a map of body parts acting together in actions

18. Deficits in sensory systems system • Modulation – defensiveness or under responsiveness • Perception or Discrimination • Close links between systems • Limbic system (emotions) • Reticular system (attention)

19. Process • Detection • Discrimination • Modulation • Integration • Interpretation • Developing a plan • Response

20. Perception • Literal Perception • Fragmented Perception • Confusing sensory systems • Delayed Perception • Mono Processing • System shutdown

21. Literal Perception • Literal Perception – perceptions can be very pure and taken at face value without adding meaning, may account for special talents such as photographic memory.

22. Confusing sensory systems – child may experience a sound as a taste, smell as a visual image etc. • Delayed Perception – may be seconds, minutes, hours or longer, may explain some apparently bizarre and out of context behaviours. • Mono Processing – only one system at a time

23. Fragmented Vision

24. System Shutdown • Many children with ASD experience partial or complete system shutdown as a defence or solution to too much sensory input. They can either disengage and appear immune to input or actively shut out input.

25. Behavioural Threshold Neurological Threshold Passive Active High (habituation) Poor Registration Sensory Seeking Low (sensitisation) Sensitivity to Stimuli Sensation Avoidance

26. Behaviour Responses • Sensory Seeking • Sensory Sensitive / Defensive • Poor Registration • Poor filtering • Impulse control • Low endurance and Tone • Inattention / Distractibility • Emotionally Reactive • Fine Motor and Perception (Dunn 1999 The Sensory Profile)

27. Developmental Coordination Disorder Autistic Spectrum Disorder Sensory Integration Disorder Attention Deficit Hyperactivity Disorder

28. Interventions • Awareness • Profiling • Environment • Sensory Diet • Sensory Integration Therapy

29. Awareness of sensory preferences and thresholds • Everyone is different • Children with Neurodevelopmental disorders are more likely to be different • Young and less able children need adults to identify and decode their behaviours in relation to preferences • Older children can explore and understand cognitively their differences

30. Ways to increase awareness • Carry out sensory exploration activities • Use one sense at a time • Use an appropriate method of recording these so the children can access the information • Always be aware of over stimulation and have some ideas on how to calm or rebalance the child

31. What is sensory profiling • Using standardised assessment checklists to plot sensory behaviours we can then identify particular threshold patterns • Checklists can be completed by many different professionals. • Interpretation requires an OT or other professional qualified and or experienced in sensory integration

32. Observation • Within different settings - home, school • Isolate different senses • Look at mix of sensory input • Consider illness, time of day, weather etc • Look at grading of sensory input, where is the critical points

33. Sensory Profile (Dunn 1999)

34. Sensory Processing Grid Name: Date of Birth:

35. High Threshold Sensory seekers – give them organised input to meet the needs Poor registration – give background input to boost sensory input Low Threshold Sensory avoiders – alter environment and or activity to minimise impact Sensory sensitivity – Allow the child to defend and use deep pressure to calm Intervention Principles

36. Environment • Use the profiles and observations to create the optimal environment for learning • Plans need to be individualised even with similar children or conditions • May alter at different times of day, year etc • Be aware of difficult combinations of sensory profiles within class mix

37. The Alert Programme • Williams and Shellenberger, (1992 & 1994) • Principles of Sensory Integration • Awareness of sensory experiences • Cognitive skills • Improves awareness of self- regulation • Refers to the body as a ‘ car engine’ • Initially designed for children ages 8-12 yrs

38. Sensory Diet Wilbarger (1994) • Controlled sensory input can affect functional abilities (Wilbarger 2002) • Individualised • Based on Sensory Integration Theory • Use specific activities for a purpose • Activities to focus and alert • Activities to calm

39. SI Clinical observations • Set of tasks for the child to do to assess the systems, in particular vestibular, proprioception, tactile and vision. • Together with profiling and developmental history create a comprehensive picture of the child's sensory systems and a base for therapeutic interventions.

40. Sensory Integration Treatment • Therapeutic Environment • Goal to improve organisation and neural processing • Think Sensory • Planned and controlled sensory input to provide range of opportunities • Emphasis on adaptive responses and self organisation • Just right challenge

41. Child centred • Non directed purposeful activity • Facilitate and inhibit to achieve optimal arousal levels • Active participation • Use child's inner drive • Learn how to learn • Therapy must be fun

42. Evidence • Large amount of anecdotal evidence for the use of SI therapy in children with ASD and DCD • Small scale studies and difficulties with design etc hinder empirical evidence • Need for wider large scale studies to identify which interventions impact on which children.