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From Chapter 5: How Does Sensory Dysfunction Affect My Child?

In Chapter 3 we discussed various abnormal behaviors that may result from a person taking in either too much or too little sensory information. In this chapter, we go deeper and look specifically at how various areas of daily functioning may be affected by sensory processing disorder. Further, we demonstrate how working with an occupational therapist can break down the sensory hurdles that prevent a child from engaging in learning, attention, play, socialization, sleep, and eating.

Learning

Case Study: Diego
Diego loves swings. If he had his way, he would sit on a swing all day long and have someone push him. His family is concerned about this being the one and only activity Diego seems to enjoy. They have tried to get him to play with his toys to no avail. Unfortunately Diego’s typical response is to throw his toys and run away.

It is very frustrating to try to engage a child who does not want to be engaged. Learning happens when a child is curious and motivated to interact with an object or person or engage in an activity. The activity may be one wherein the child learns through trial and error, such as throwing and catching a ball, or one that someone explicitly teaches him, for example, how to play a board game. It can be difficult to find an activity that will motivate a child with autism to play. It’s not hard to see that if Diego is unable to engage or interact--either with objects or people---learning will be stagnated. During therapy, Diego’s OT sets up a comforting scenario, looks for windows of opportunity to capture Diego’s attention, and then motivates him to engage in an activity. To start, Diego's OT places him on a platform swing in order to give him the sensory input (vestibular) that he craves. However, after the third swing, she stops the movement and asks him if he wants more. He squirms and begins to kick his feet. Even though the OT knows what he is trying to communicate, she does not give in. After about a minute, Diego looks up at her as his way of saying “start the swing” (active participation), and she begins the swing. After a few more times, she takes his hands and forms the sign language sign for “more.” The demand is now that he needs to bring his hands together to try to make the sign. After a minute, his hands come together to form an approximation of the sign and she begins to move the swing.

Neither one of his responses are “miracles.” The reason Diego responds is because he likes the sensation of the swing and wants more. Knowing that this is a motivating activity (that he wants to continue) the OT has tapped into the fact that vestibular movement is both enjoyable and alerting to Diego’s sensory system and this is where the learning process can begin. Using movement as the motivator, more demands can continue to be placed on Diego, which will help to improve his learning as he continues to enjoy the activity.

Eventually Diego will be expected to take an object and place it in a container, fit a puzzle piece, etc. (all being done while he is on the swing). The activities will eventually become familiar to him, and after a few months he may be able to sit at a desk to complete simple tasks after his body has received some vestibular input. By satisfying Diego’s need for vestibular input, which is alerting, his ability to attend to tasks is increased. Determining what motivates Diego and making him an active participate in this process resulted in an increase in his ability to focus and learning could begin.

Attention

Case Study: Kenny
Kenny is a four-year-old child with autism. He comes to his therapy session in a small stroller and becomes very upset if he is removed. Even when he is allowed to remain in the stroller, he often cries when toys are provided and he is asked to play. He refuses to hold anything in his hands and often turns his head to focus on the light on the ceiling.

Kenny is demonstrating an over-responsive reaction both to vestibular and tactile input. He is unable to gain any type of satisfaction from a toy since he is so concerned about the feeling of that toy in his hand. He is not able to focus on a task as his brain and central nervous system is engaged in the “fight or flight” mode. He views both movement and tactile input as aversive and he either becomes upset if demands are placed on him (“fight”) or shuts down (looking at light) to avoid the interaction (“flight”).

Since Kenny is fearful of movement, his therapist starts the session by meeting him “on his turf,” i.e., the stroller. While he sits in the stroller, the OT starts to gently move the stroller back and forth. Kenny does not seem to mind this and actually looks up at the therapist in anticipation of the movement. Kenny enjoys songs that rhyme and this is added to the activity. Once comfortable with this, the therapist slips a large blanket under his bottom and against his back and unhooks the stroller’s belt. While she moves the stroller and continues to sing the songs, she pulls him slightly forward with the blanket. Although initially upset, Kenny slowly begins to tolerate the input and again anticipates the action. Finally, Kenny is removed from the stroller and placed snugly inside the blanket. Together, the therapist and Kenny’s mother slowly begin to swing him back and forth in the blanket as though in a hammock. Kenny not only appears to enjoy the movement but is beginning to tolerate faster movement. This is the start of helping Kenny get out of the stroller and start to “feel” where his body is in relation to space. The slow, linear, vestibular movement is not only calming but helps him to organize his sensory system and increase his ability to attend and learn from an activity.

Play

Case Study: Kayla
Kayla is playing in the schoolyard during recess time. Although she is running in the midst of her classmates, she is not actually interacting with them. One child comes over and asks her to play tag with the group. She attempts to join in but trips several times and runs into another child so hard that he falls. After this scenario plays itself out on the playground several times, Kayla’s classmates tend to avoid her.

Kayla has poor body awareness in space and has limited motor planning skills. She tries to connect with other children, but she lacks the skills to control her movements and engage appropriately so she can play. Although some of her behaviors are related to her diagnosis of Asperger’s disorder, she’s also not properly processing incoming sensory information. This prevents her from running and tagging the other children with just the right amount of force. Without the ability to integrate sensory information and form a plan, Kayla runs around the playground fairly aimlessly and without much interaction with the other kids.

Kayla attends weekly OT sessions where she is learning how to improve both her body awareness in space and overall motor planning. Kayla loves to set up obstacle courses using large, foam blocks, fabric tunnels, and bolsters, but often becomes very overwhelmed and pulls out too many objects. She tends to run from one item to the next and when she either falls or doesn’t achieve what she wants, she goes to the next item, without truly mastering a task. So, her OT structures a game plan using only two or three items, and gives Kayla regular verbal cues to keep her on task. Kayla provides the motivation and the OT provides the “just right” amount of input that is needed in order for her to “feel” the movement and be successful.

The therapist usually knows when Kayla achieves the “just right” level as she will want to repeat the activity over and over. However, the therapist does not want Kayla to perseverate or get “stuck” on one activity but to be able to use the same action (e.g., balance, movement) in many different situations. To this end, the OT might change the obstacle course set-up. With ongoing therapy, Kayla is beginning to learn what it feels like to to move her body in space and by integrating these new skills she should be able to demonstrate more purposeful play skills.

Socialization

Case Study: Michael
Michael is a middle-schooler with Asperger’s disorder. A few times a year his family has a big party and all the relatives are invited. Once Michael is aware of the day of the party, he continuously talks about who he is most excited to see and recites stories about some of his favorite uncles. On the day of the party, he gets up early and waits outside for the relatives to arrive. He greets them at the door and seems very pleased that they are here. However, as more people arrive Michael retreats upstairs to his room and doesn't even come down for dinner. When his mother questions him about why he does not join in, Michael replies that it is too noisy and there are too many smells (perfume, deodorants, fabric softener, etc.).

For children on the autism spectrum, socialization is very difficult, and their attempts to engage with other people can be very awkward. Although this is generally the case with Michael, he feels comfortable with his relatives, who enjoy his company and listen to his stories. Sadly, when the whole family gets together, Michael wants to join in but becomes overwhelmed and unable to filter out all the smells and sounds in order to enjoy the event. While some of us may too feel uneasy in crowds, it's usually not enough to make us leave a party. So, Michael's mother has come up with some strategies to help him. When weather permits, she has the party outdoors where odors may not be intense. She also provides Michael with soft ear plugs that help muffle some of the extraneous sounds that bother him. In addition, Michael uses his favorite mint flavored lip balm to camouflage the competing odors. Although Michael is still only able to tolerate these events for short periods of time, these strategies allow him to participate and increase his socialization skills.

Sleep

Case Study: Adam
Adam is a four-year-old boy with autism. He attends a preschool program daily and also gets weekly private OT and speech services at a local hospital. He stays pretty active throughout the day and does not take naps. Following his dinner, his mother tries to provide a routine to prepare him for bed. This includes a warm bath, reading favorite stories, and listening to calming music. Once in bed, though, he tosses and turns and begins to cry. Nothing seems to work except having his mother lie beside him with her arm over him until he finally falls asleep (sometimes not until eleven o’ clock). She notes that the later Adam falls asleep, the more “out of it” he is the following day. The routine is beginning to wear on the entire family and Adam’s mother admits to his OT that she is running out of patience.

Anyone who has ever tried to coax an overtired infant to sleep is well aware of the anxiety and frustration this can cause. When children are very young, a parent will often need to go into the child’s room numerous times until he settles down. Usually after a few days or weeks, the child learns how to calm and fall asleep on his own. Given that Adam is already four years old and still having trouble falling asleep on his own, it’s not hard to see this current arrangement is negatively affecting Adam’s entire family.

Adam’s OT feels that Adam has a sensory modulation problem. She confirms that many of the techniques Adam’s mom is using are right on target, but that Adam may simply need more. During his OT sessions, she notices that Adam responds well to deep pressure. She recommends the family purchase a large body pillow and fill it with dry beans to weigh it down. When Adam’s mother puts him in bed, instead of lying beside him, she is to wedge the pillow against his body where she used to lay. At the OT’s suggestion, she covers him with a heavy blanket and tucks him in tightly. She then reads him a few stories and continues to play soft, calming music in the background. After performing the same routine for about a week, she notices that when she kisses Adam goodnight and leaves the room, he is not getting out of bed. Although there is some whimpering, he usually falls off to sleep within fifteen minutes. Research has shown that deep pressure from pillows can be an effective way to help decrease one’s arousal level (Williams & Shellenberger, 1996).

Eating

Case Study: Kenny
Kenny, from our earlier case study, is tall but underweight for his age. He does not have any specific oral motor concerns (difficulty chewing or swallowing food safely) but is very adamant regarding what types of food he will eat. He likes chicken nuggets but will only eat them after picking off all of the coating. He will eat potato chips and crackers, Cheerios without milk, pasta without sauce, and the rest of the foods he prefers are mostly smooth (e.g., yogurt, pudding, ice cream). If his family tries to encourage him to eat what is being served for dinner, he usually screams and kicks, and mealtime becomes unpleasant for everyone at the table. Although his mother is concerned about his selective eating habits, she feeds him what she knows he will eat since she wants him to continue to gain weight and grow.

Kenny has tactile issues related to eating. While he eats different textures--both smooth and crunchy--he becomes upset if two textures are in his mouth at the same time (e.g., soft chicken meat and crispy coating). His sensory system cannot handle that much information and is displaying an over-response to the input from the food. Children with autism often have issues related to feeding, which can be similar to Kenny’s, or different, i.e., they may only want to eat a certain colored food or items with certain brand names. These types of behaviors are most likely related to the diagnosis of autism. If a food aversion is caused by a sensory problem, there is a good chance the child may be able to slowly learn to increase tolerance for textures or food choices.

Because the OT knows that Kenny (from our earlier case study) is most comfortable in his stroller, she allows him to remain there while she offers him a food that he likes--yogurt. He is given two or three spoonfuls and truly seems to enjoy the taste. His therapist takes a portion of the yogurt and crushes very tiny crumbs of Cheerios into it. Kenny is provided the next spoonful with this mixture and eats it. He is aware of the texture, and although he gags slightly, he swallows the food. The OT then gives him two or three more spoonfuls of the plain yogurt, which he readily accepts. When she again attempts the Cheerios yogurt mixture, he tolerates two spoonfuls before he realizes that there is something different. She then goes back to the plain yogurt.

The therapist trains Kenny’s mom in this strategy and reminds her to observe and respect Kenny’s behavioral responses. To see true progress will take a great deal of time and daily practice. The goal is for Kenny to not only accept two mixed textures but to gradually increase the size of pieces that are added to the mixture until he is able to tolerate and eat higher level foods.