Sensory Awareness Another piece of the jigsaw Barbara Strobel Karry Hrysicos Rosemary Swain Clinical Specialist Occupational Therapists- Learning Disabilities Hywel Dda University Health Board

Today we will explore: Sensory reasons for behaviour Sensory reasons for behaviour Brief overview of sensory processing theory and sensory systems Brief overview of sensory processing theory and sensory systems Ways OT can help and some self help strategies Ways OT can help and some self help strategies See behaviour- is there a sensory component? See behaviour- is there a sensory component?

Introduction We are all sensory beings We are all sensory beings We are all constantly receiving sensory information, every moment of the day We are all constantly receiving sensory information, every moment of the day How we experience the sensory information that we are receiving can affect how we manage in our world How we experience the sensory information that we are receiving can affect how we manage in our world

Questionnaire Activity

Sensory integration/sensory processing developed by Jean Ayres 1972 (Psychologist and Occupational Therapist) Sensory integration/sensory processing developed by Jean Ayres 1972 (Psychologist and Occupational Therapist) Theory of brain-behaviour relationships. Theory of brain-behaviour relationships. More evidence emerging to support the theory- (Russo et al 2010) More evidence emerging to support the theory- (Russo et al 2010)

Sensory processing Sensory processing refers to our ability to take in information through our senses, organize and interpret that information, and make a meaningful response. Sensory processing refers to our ability to take in information through our senses, organize and interpret that information, and make a meaningful response. For most people this process is automatic, e.g. we hear someone talking to us, our brains receive the input and recognise it as a voice talking in a normal tone and we respond appropriately For most people this process is automatic, e.g. we hear someone talking to us, our brains receive the input and recognise it as a voice talking in a normal tone and we respond appropriately

Sensory processing differences can vary widely between individuals in characteristics and how intense the difficulties are. Sensory processing differences can vary widely between individuals in characteristics and how intense the difficulties are. One sense can be affected or multiple senses One sense can be affected or multiple senses To make it even more confusing sensory difficulties can manifest in two different ways To make it even more confusing sensory difficulties can manifest in two different ways

Hyper sensitivity Hyper sensitivity An individual might feel pain from clothes rubbing against the skin/ clothing labels An individual might feel pain from clothes rubbing against the skin/ clothing labels Dislike being touched (particularly lightly) Dislike being touched (particularly lightly) Unable to tolerate loud sounds e.g. household appliances Unable to tolerate loud sounds e.g. household appliances May not be able to tolerate normal lighting levels May not be able to tolerate normal lighting levels Hypo sensitivity Hypo sensitivity An individual may have an unusually high tolerance to stimulation/sensations or can’t get enough of the sensation An individual may have an unusually high tolerance to stimulation/sensations or can’t get enough of the sensation High tolerance or ‘no awareness’ of pain High tolerance or ‘no awareness’ of pain

Some people are over –responsive to sensations and feel they are constantly being bombarded with sensory information- it is too much for them. They will try and eliminate/ minimise the sensory overload by avoiding being touched/ particular clothing/ situations which may increase likelihood of the sensation. Some people are over –responsive to sensations and feel they are constantly being bombarded with sensory information- it is too much for them. They will try and eliminate/ minimise the sensory overload by avoiding being touched/ particular clothing/ situations which may increase likelihood of the sensation. People who are hypersensitive / sensory defensive can be highly anxious, difficulty focusing/attending, become easily overwhelmed/ very stressed or withdraw/ shut down/ run away/avoid/lash out (overloaded) People who are hypersensitive / sensory defensive can be highly anxious, difficulty focusing/attending, become easily overwhelmed/ very stressed or withdraw/ shut down/ run away/avoid/lash out (overloaded) NB within this group some people may have a strong desire for sensory stimulation, NB within this group some people may have a strong desire for sensory stimulation, i.e. you can be tactile defensive and strongly seek tactile sensation at the same time.

Some people can seek out constant stimulation/sensations by doing extreme activities- play music loudly/ constantly move. They may not notice that objects are too hot or cold and may need more intense amount of the sensation to get involved in activities. Some people can seek out constant stimulation/sensations by doing extreme activities- play music loudly/ constantly move. They may not notice that objects are too hot or cold and may need more intense amount of the sensation to get involved in activities. Others may have difficulty distinguishing between different types of sensory stimulation or coping with multiple sources of sensory information simultaneously Others may have difficulty distinguishing between different types of sensory stimulation or coping with multiple sources of sensory information simultaneously Single channel/ mono processing. Some people with Autism can only deal with one sensory channel at one time. Single channel/ mono processing. Some people with Autism can only deal with one sensory channel at one time.

Activities Activity A Activity A Split into groups of 3 Split into groups of 3 One person sits to do the activity, second person hold the mirror and a third person holds paper over the drawing. One person sits to do the activity, second person hold the mirror and a third person holds paper over the drawing. The person sitting down draws what they see in the mirror The person sitting down draws what they see in the mirror discussion discussion

Activities Activity B Activity B Put on gloves Put on gloves Take out object and unwrap Take out object and unwrap Discussion Discussion Weighted blanket Weighted blanket

Brain Is influenced by ongoing activity, sensori-motor activity can affect neural growth. We use an adaptive approach using a sensory framework when working with adults with autism Studies on individuals known to have Autism suggest that the brains neurones are not connected as they should be and the areas are not ‘talking’ to each other adequately Estimated approx 80% of people with ASD could have sensory modulation (processing) difficulties People can cope (adapt) more or less effectively in their daily lives with their sensory issues

Sensory systems Vision Vision Hearing/ Auditory Hearing/ Auditory Taste/ gustatory Taste/ gustatory Smell/ olfactory Smell/ olfactory Touch/ tactile Touch/ tactile Proprioception /positional sense (body awareness/position of body in space) Proprioception /positional sense (body awareness/position of body in space) Vestibular/movement sense (balance) Vestibular/movement sense (balance)

Common Sensory differences Visual- the strongest sense rely on this one most heavily, can be easily over stimulated. May not be reliable for the individual- may not see what other see. Visual- the strongest sense rely on this one most heavily, can be easily over stimulated. May not be reliable for the individual- may not see what other see. Sensitive to bright lights, objects, reflective surfaces, cluttered busy environments, TV/computer screen flicker/ fluorescent light (elephant) Sensitive to bright lights, objects, reflective surfaces, cluttered busy environments, TV/computer screen flicker/ fluorescent light (elephant) Auditory/hearing- most frequently impaired sense found in Autism. Auditory/hearing- most frequently impaired sense found in Autism. Hyper acute hearing can cause strong pain Hyper acute hearing can cause strong pain Certain pitches/ frequency of sound, screaming babies, humming, ticking of clocks Certain pitches/ frequency of sound, screaming babies, humming, ticking of clocks This affects concentration/attention, can be interpreted as non-compliance/ disinterest but the problem may be the person's inability to filter out ordinary sound This affects concentration/attention, can be interpreted as non-compliance/ disinterest but the problem may be the person's inability to filter out ordinary sound Tactile/touch- Tactile/touch- Hypersensitive to touch. A person may seem to overreact to light touch particularly, labels in clothing, clothing seams, hair/nail cutting, texture in mouth, avoid getting hands dirty Hypersensitive to touch. A person may seem to overreact to light touch particularly, labels in clothing, clothing seams, hair/nail cutting, texture in mouth, avoid getting hands dirty

Proprioception/ positional sense (body awareness/position of body in space) Proprioception/ positional sense (body awareness/position of body in space) Receptors in the joints/ muscles/ligaments/ tendons Receptors in the joints/ muscles/ligaments/ tendons It uses feedback from the muscles and joints to tell us where our body is in space It uses feedback from the muscles and joints to tell us where our body is in space Proprioceptive input can be calming Proprioceptive input can be calming

Vestibular/ movement sense (balance) Vestibular/ movement sense (balance) Apparatus in the ears Apparatus in the ears Sensory differences Sensory differences Individuals may trip over their own feet, seek surfaces to hold/touch/feel onto when walking. Person may appear clumsy. May use too much force/ mis -time movements Individuals may trip over their own feet, seek surfaces to hold/touch/feel onto when walking. Person may appear clumsy. May use too much force/ mis -time movements They may have gravitational insecurity- get anxious about taking feet of the ground/ negotiating steps/kerbs/ changes in surfaces, adverse response to moving head They may have gravitational insecurity- get anxious about taking feet of the ground/ negotiating steps/kerbs/ changes in surfaces, adverse response to moving head

Common behaviours Which sensory systems are people seeking when… Which sensory systems are people seeking when… Toe walking Toe walking Touching walls Touching walls Hand flapping Hand flapping Rocking Rocking Hands over ears Hands over ears The above could be interpreted as self management strategies of individuals/ sensory anchor to maintain a just right calm-alert state. The above could be interpreted as self management strategies of individuals/ sensory anchor to maintain a just right calm-alert state.

Autonomic storm- recognise this? The bubble- Fidgeting, swearing, making noises, grimacing, tapping feet, refusing to co- operate, name calling, verbal threat Fidgeting, swearing, making noises, grimacing, tapping feet, refusing to co- operate, name calling, verbal threat Warning signs being given. The person is trying to cope with noxious sensation/ overload. They may be sensory defensive Warning signs being given. The person is trying to cope with noxious sensation/ overload. They may be sensory defensive

The boil Acting impulsively, emotional, explosive, destroying property, self injury, screaming, biting, hitting, kicking Acting impulsively, emotional, explosive, destroying property, self injury, screaming, biting, hitting, kicking Intensity of sensory input to block out/ try and calm system has increased to cope with the situation Intensity of sensory input to block out/ try and calm system has increased to cope with the situation This leads to the meltdown /shut down (person is overwhelmed)

Just right calm -alert challenge Through understanding how an individuals sensory systems might be working we can work out strategies to help the person to regulate/ adjust/ adapt themselves and maintain the ‘just right’ state. Through understanding how an individuals sensory systems might be working we can work out strategies to help the person to regulate/ adjust/ adapt themselves and maintain the ‘just right’ state. When an individual is getting sensory overloaded, (bubble behaviour) the aim is to divert from reaching the boiling point behaviour by using sensory strategies i.e. we can use calming strategies to return to their normal/ calm -alert state. When an individual is getting sensory overloaded, (bubble behaviour) the aim is to divert from reaching the boiling point behaviour by using sensory strategies i.e. we can use calming strategies to return to their normal/ calm -alert state. Some people need more sensory input than others to be alert enough to engage in activity Some people need more sensory input than others to be alert enough to engage in activity

Overcoming sensory challenges- strategies Self management- People very often develop their own strategies- e.g. use classical music for someone who has sensitive hearing Self management- People very often develop their own strategies- e.g. use classical music for someone who has sensitive hearing Think about when it is not a problem-what features of this situation/set up are beneficial to the person Think about when it is not a problem-what features of this situation/set up are beneficial to the person Self regulation. Can the person adjust in situations. How does this happen/ what is going on Self regulation. Can the person adjust in situations. How does this happen/ what is going on Stimulation- what, how, when Stimulation- what, how, when What is going on in the environment What is going on in the environment What happened prior to the behaviour- interactions/ level and quality of engagements What happened prior to the behaviour- interactions/ level and quality of engagements Unstructured time/ transitions/ changes- plan these Unstructured time/ transitions/ changes- plan these Is there too much sensory input/ overloaded? Reduce sensory stimulations particularly if there are many different sources going on at the same time. Is there too much sensory input/ overloaded? Reduce sensory stimulations particularly if there are many different sources going on at the same time.

Strategies- examples If person is sensitive to light unexpected touch, approach from the front so they can see you coming If person is sensitive to light unexpected touch, approach from the front so they can see you coming Think about position in group situations- end of row in cinema/queuing may be difficult- avoid crowded places- shop when not so busy Think about position in group situations- end of row in cinema/queuing may be difficult- avoid crowded places- shop when not so busy Take out labels in clothing/ lycra garments which provide constant pressure can be calming Take out labels in clothing/ lycra garments which provide constant pressure can be calming Weighted lap pad/ blanket. Deep pressure can be calming. Safe use requires understanding and there are safe practice guidelines. (Warning- misuse has proved fatal) Weighted lap pad/ blanket. Deep pressure can be calming. Safe use requires understanding and there are safe practice guidelines. (Warning- misuse has proved fatal) Deep active proprioceptive input, before activity/task- carry heavy items, use back pack when out Deep active proprioceptive input, before activity/task- carry heavy items, use back pack when out

Autism friendly environments Consider….. Colour Colour Noise Noise Lighting Lighting Placement of utility appliances Placement of utility appliances Space- opportunity to pace Space- opportunity to pace Contain cooking smells Contain cooking smells Level access where possible Level access where possible Fixtures/fittings Fixtures/fittings Think safety Think safety Plan and aim to get it right first time Plan and aim to get it right first time

Each person will present differently Each person will present differently Therapists where appropriate do assessment following specific higher level sensory processing training involving assessment, observation and questionnaires of person and carers Therapists where appropriate do assessment following specific higher level sensory processing training involving assessment, observation and questionnaires of person and carers Occupational therapy is tailored to meet needs of the whole person within the resources available and focuses on improving independence/ functional performance Occupational therapy is tailored to meet needs of the whole person within the resources available and focuses on improving independence/ functional performance Provide strategies and activities to assist in daily management Provide strategies and activities to assist in daily management

Conclusion Clinical analysis of sensory issues is complex particularly in adults. Sensory factors should always be considered alongside other alternative explanations, as part of the jigsaw. Sensory factors should always be considered alongside other alternative explanations, as part of the jigsaw. See behaviour- think is there a possible sensory contributing factor? See behaviour- think is there a possible sensory contributing factor?

Useful further information National Autistic society National Autistic society Sensory integration network- Sensory integration network