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On 26 June, I attended the fourth and final online webinar in the 2020 Autism Expert Series offered by the Autism Resource Centre Learning Academy. This webinar was titled ‘Supporting Sensory Needs in Individual Students’ and was presented by Dr Caroline Mills. This insightful presentation explored practical ways to determine and address individual students' sensory needs, using a collection of free tools developed by Dr Caroline Mills and her colleagues.
What is sensory processing?
Dr Caroline Mills began by explaining that, according to the sensory integration theory, sensory processing refers to the intake and organisation of senses by the brain for successful functioning in our daily activities and occupations. When sensory processing is impaired, this may result in academic, social/emotional, motor, and/or functional problems. Sensory differences are common in autistic children, which may lead to difficulties with task performance in school participation and activities of daily living, and may also be associated with mental health conditions like anxiety and depression.
Our senses have 3 main functions.
Protection. Will it hurt me? This protects the body from damage, and is known as the fight/flight/fright response.
Discrimination. What is it? This gives us more detailed information about objects and people.
Habituation. Do I need to keep paying attention? This helps us screen out irrelevant stimuli that we no longer need to pay attention to. For example, we typically stop paying attention to the feeling of clothing on our skin after ensuring we have put on our clothes in the correct orientation, but some autistic children who have sensory processing difficulties cannot stop paying attention to this sensation.
We have 8 senses, which can be categorised into senses that are generated from inside the body and senses that are perceived from the outside.
Inside senses:
Movement and balance (vestibular)
Body awareness (proprioception), which refers to the awareness of one's body’s position in space / where one's body stops and the rest of the world begins
Interoception, which refers to the awareness of one's internal bodily states
Outside senses:
Touch (tactile)
Sound (auditory)
Sight (visual)
Smell
Taste
Dr Caroline Mills highlighted that auditory filtering is more than sound processing. We have to screen in relevant noise and screen out background noise. It involves paying enough attention to the sound to understand it, which has an impact on language comprehension. Auditory filtering is one of the most significant sensory processing difficulties in autism. Auditory filtering problems are the largest barrier to classroom success for children with autism in mainstream classes, as they have difficulty receiving classroom instruction. Auditory filtering is also one of the factors associated with ‘maladaptive behaviours’ in autism.
Dr Caroline Mills proposed a 2-tiered model to support sensory processing, consisting of universal supports for everybody in general and individualised supports for specific people. For instance, as different children in the same classroom context may have different sensory needs, we can provide universal supports, as well as split the class into groups during sensory activities to provide individualised supports. Dr Caroline Mills also highlighted that providing individualised supports is not about equality, where everyone receives the same supports, but about equity, where different people receive different supports to gain equal access and enable participation.
What universal supports can we provide?
In terms of universal supports, we want to help to make the environment accessible. Dr Caroline Mills gave an example of an autistic woman who plans sensory downtime, i.e. time not to be bombarded with sensory information. We can structure this sensory downtime and offer autism-friendly self-calming choices. Dr Caroline Mills noted that some children may choose to engage in stimming or repetitive behaviour, which is usually seen as being non-functional and part of the diagnostic criteria for autism. However, Prue Stevenson, a young autistic artist, argues that stimming is important for self-regulation. He is leading a project titled ‘Stim Your Heart Out’, attempting to reclaim stimming for the autism community and make it socially acceptable. It is important that we listen to autistic people, and ask ourselves why we intervene when we intervene as professionals. A problem is not a problem unless it is a problem. Stimming might not pose a problem to an autistic person's participation, and may even help to calm them. Therefore, Dr Caroline Mills said that it may be acceptable to give the child an opportunity to engage in stimming if it helps the child to cope. However, there may be certain boundaries that need to be drawn, such as particular times of the day like morning assembly when it is not acceptable to engage in stimming.
Dr Caroline Mills gave another example of universal supports, the Supermarket Quiet Hour in Australia, which was crafted with the advice from autistic consultants. During a designated hour of the week at the supermarket, there are no public announcements, the music is turned down, the register and scanner volumes are reduced, and the lighting is reduced. This allows autistic people and other people with sensory issues to be less overwhelmed by going to the supermarket.
Dr Caroline Mills presented 4 steps for creating a sensory friendly environment. She also recommended using the accompanying free Sensory Friendly Environment Checklist to help in auditing the sensory environment, identifying potential issues, and developing strategies.
Step 1. Scan the sensory features of the environment
What can you see / hear / touch?
Moving vs being still?
Busy vs calm environment?
Are things out of place or out of routine?
Engage an autistic consultant to look over the environment from an autistic point of view
Step 2. Manage the environment
Identify potential sensory issues and remove them e.g. Loud music
Pre-warning for sounds or other sensory stimuli, thereby making the environment more predictable e.g. Fireworks, hair clippers
Step 3. Empower the person
Listen to the person's point of view about their sensory needs, try to see the situation from their point of view
Teach the person coping strategies e.g. Taking a break, wearing headphones, accessing sensory activities, communicating their needs
Step 4. Change the task
Make the task easier
Provide clear visual steps and make your expectations clear
Incorporate strengths and interests
Provide choice and control e.g. When getting a child dressed in the morning, the child has to wear a shirt to go out, but they can choose the colour of the shirt
Dr Caroline Mills noted that these steps were part of a larger universal framework to support participation in the sensory aspect.
Information sharing and coaching e.g. Teaching others or the autistic people themselves how to cope with their sensory needs
Adapt tasks or environment e.g. Noise-cancelling headphones
Embed sensory input into routines e.g. Movement breaks using a trampoline
Behavioural strategies e.g. First-then board, choice board
Support the child with self-regulation
Universal design benefits everyone
How can we identify individual sensory needs?
Dr Caroline Mills reminded us that we should not provide individualised sensory support without assessment. The American Occupational Therapy Association recommends doing an assessment first to pinpoint the problem before deciding on a solution, which ensures that we can target strategies. A good place to start is to use The Sensory Form, a free sensory assessment and planning template. Research has found that The Sensory Form is effective in guiding occupational therapists in identifying sensory differences and linking with participation.
Dr Caroline Mills also emphasised the importance of considering individual aspects of a person's sensory processing, making a closer examination of each of the 8 senses. When we describe responses to the sense in detail, we can target strategies for support. For instance, in terms of vision, the person may respond differently to bright vs dim lighting, fast vs slow moving things, and high vs low contrast. In particular, we should think about how the person responds to each specific sense as well as the impact this might have on the person. She recommended using the free Individual Sensory Screening Tool for this purpose.
According to Dr Winnie Dunn, there are 4 sensory styles, which vary in terms of how under or over responsive they are, and how passive or active they are. However, the 4 sensory styles are not fixed. Children move in and out of the sensory styles depending on the context. Sensory processing changes across senses (e.g. Seek movement but avoid sound), within senses, in different children, in different times, and in different situations. Sensory difficulties are affected by factors such as amount of structure, too much or too little task demands, adult personality and communication style, stress level, changes in routine, visual or verbal method of instructional delivery, amount of rest, and home or school settings.
Registration / bystander
Characteristics:
Misses environmental cues
Less bothered by environment
Less active engagement with the environment
May appear dull and lethargic or "lazy"
Signs:
Does not hear things banging or name being called
Does not notice twisted clothing
Sedentary, clumsy, hard to get moving
Cause:
Under responding / not getting enough sensory input
Passive / does not actively seek more sensory input
Seeking /seeker
Characteristics:
Actively pursues sensory input
Very active
Difficulties staying on task or in one place
Jumping, spinning
Signs:
Likes banging objects, messy play
Likes bouncing, spinning, crashing into things
Likes chewing things
Cause:
Under responding / not getting enough sensory input
Active / seeks more sensory input in order to get the right amount
Avoiding / avoider
Characteristics:
Actively wanting to limit sensory input
Distressed around sensory input
Ritualistic, rule bound, uncooperative
Want to keep the environment the same so that there is no new input to process
May enjoy being excluded so that they are around fewer people and there is less information to process
Signs:
Fingers in ears, avoids messy play
Restricted diet
Fear of steps, avoids certain people or activities
Cause:
Over responding / getting too much sensory input
Active / tries to get away from sensory input
Sensitivity / sensor
Characteristics:
Notice things that others might miss
May find sensory input distressing but does not fight to get away
Passive avoidance strategies
Appear nervous around sensory input
Signs (hard to observe this style):
Stands on the edge of the playground
Fear of distress around sensory input
Not as active in avoiding input
Cause:
Over responding / getting too much sensory input
Passive / does not actively avoid sensory input
What individualised supports can we provide?
There are 4 steps in coming up with individualised sensory strategies.
Step 1. Is good autism practice in place?
Visual supports and communication supports
Structure, routine, predictability
Strengths and interests
Step 2. Environmental changes
Changes to the environment based on the person's specific identified sensory needs
E.g. Changes to lighting, decrease of visual clutter, changes to amount of noise, changes to amount of people, opportunities to withdraw from the environment, allow choice and perceived (not complete) control
Step 3. Sensory activities using a sensory activity schedule
Determine whether issues are sensory or behavioural
Following assessment, decide which senses are most impacted and target strategies for these senses
Consider the child's sensory style
Case study 1
Sensory seeking:
Do they seem to enjoy it?
Would it happen if no-one was in the room?
Do they do it when there's nothing else to do?
Provide safe opportunities to seek:
Cameron engaged in sensory seeking movements in the classroom such as running and climbing, which interrupted his participation in work tasks. The goal was to provide safe opportunities for Cameron to climb, do heavy work, and receive deep pressure. The occupational therapist presented Cameron with sensory activities visually, e.g. 1. Circle time, 2. Sensory activities, 3. Work desks, 4. Treasure box. In doing so, the occupational therapist was not rewarding bad behaviour, as she scheduled sensory activities into Cameron's school routine purposefully, rather than giving him those sensory activities at the time of his behaviour.
Case study 2
Sensory avoiding:
Are they uncomfortable? How do you know?
Do you see the behaviour after a specific sensory trigger?
Does the behaviour stop if you remove the sensory trigger?
Provide safe opportunities to avoid / cope / control:
Nikki refused to go to assembly as it was all too much. The goal was to offer Nikki choice and perceived control over the environment. The occupational therapist allowed Nikki to choose quiet, preferred activities to do in the assembly, e.g. playing games at the back of the assembly room and moving closer to her classmates over time. Subsequently, the occupational therapist got Nikki to help with setting up the assembly room, e.g. arranging the chairs. By starting small and moving slow, Nikki eventually participated in assembly after 5 weeks. In doing so, the occupational therapist was not rewarding avoiding behaviour, as she simply worked with Nikki's autism and went at her pace in order to achieve a good outcome.
After getting an idea for sensory activities, there are some factors to consider, which can also be found in the free Individual Sensory Activity Planning document.
Frequency: How often will the sensory activity happen? How many times per day or per session?
Duration: How long will the sensory input or sensory break last? Is it a 5 minute or half an hour sensory break?
Timing: When will it occur? Sensory input has a short lived effect for around an hour, so the timing may need to be targeted, such as just before desk work
Intensity: What kind of intensity of sensory input does the person seek or need? E.g. Sensory input with hands versus whole body sensory input using gross motor activities like climbing, falling, and swimming (though we must consider the feasibility of incorporating such activities in school and at home)
Who: The person themselves, teachers, teacher's aides, parents, grandparents, home helpers, self directed, or peer cooperation?
Step 4. Teaching coping strategies
Teaching skills and strategies for the person to self-manage sensory differences or issues in the future; these skills may look different depending on the age and capacity of the person with autism
E.g. The Alert Program is a self-regulation intervention programme that uses the analogy of physiological arousal as 'engine speeds'. It asks children, 'How does your engine run?' Engines can run too fast, just right, or too slow. Sensory activities are used to ‘change your engine speed’.
E.g. Zones of Regulation is a self-regulation intervention programme that talks about how a person is feeling in terms of 4 coloured zones. It provides children with a sensory toolbox of activities to help in each zone.
E.g. Sensory self-advocacy involves knowing when and how to approach others in order to disclose information about one's sensory needs and ask for accommodations. According to Dr Stephen Shore, self-advocacy allows the person with autism to negotiate desired goals, build better mutual understanding and trust, and thereby achieve independent, productive, and fulfilling lives. Indeed, it is important to teach self-advocacy skills for life success, as we may not always be available to advocate on behalf of the person with autism. There are 4 steps in creating a script, which can involve talking, writing, or using pictures.
Identify the sensory issue / difference, e.g. Script: 'Hi there, I have an issue with bright lights and it's a bit bright in here.'
Explain the issue / difference, e.g. Script: 'When the lights are too bright or flickering, this hurts my eyes and affects my concentration.'
Ask for an accommodation / explain the accommodation needed, e.g. Script: 'Is it ok if I wear my hat or hoodie inside? / Is it possible to dim the lights a bit? / Is it ok if I take regular breaks outside to help me manage?'
Say thank you and be polite, e.g. Script: 'Thank you for this. It really helps me to participate in this setting / space / class.'
Dr Caroline Mills wrapped up by reminding us to evaluate the individualised supports we implement, checking if we are on track to achieving what we set out to achieve. To know if our individualised supports are working, we should ask ourselves every 4 weeks:
What did we set out to achieve? E.g. Cameron’s participation in doing classroom tasks, Nikki's participation in assembly
What was the specific and targeted problem/issue we wanted to overcome?
What was the problem with participation?
All in all, my main takeaway was that we can create a sensory friendly environment to provide universal supports that benefit everyone. In addition, we can provide individualised supports by organising sensory activities that address children's sensory seeking or sensory avoiding styles for specific senses. While I have seen caregivers, educators, and therapists incorporating sensory activities into early intervention programmes during my past internships, it was enlightening to see Dr Caroline Mills break down the background work involved in designing successful individualised supports. Dr Caroline Mills has generously shared several free documents to facilitate the process of identifying and meeting individual students' sensory needs, which can be downloaded at the following links.
All blogposts on 2020 Autism Expert Series:
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