April 2, 2012 is World Autism Awareness Day and marks the “Light It Up Blue” initiative aimed to shine light on the growing public health concern of Autism. Iconic landmarks around the world will be lit in blue light to show support.  In light of this, today’s post in the Milestones Blog aims to shine light at the intersection of autism and occupational therapy.

If you have read my previous posts “Demystifying Sensory Integration, Parts 1 & 2”, great! This post builds on topics discussed there. If you haven’t, please take a moment to read those posts below as this will help you put this post into perspective.

Keeping with the Milestones Blog style, my aim is to make the content accessible to as many people as possible. This post is therefore tailored to those seeking an understanding of how Occupational Therapists working with a Sensory Integration frame of reference approach children with autism or traits on the autism spectrum. You may be a parent of a child who has recently had a diagnosis of autism, an educator or other health care professional looking for information on how occupational therapy can help children you work with. Regardless, I am glad you are here!

How does Autism Fit?

Consistent with the popular media coverage of Autism in the recent past, Occupational Therapists are seeing increasing numbers of children with autism for assessment and treatment. A recent study released by the Centers For Disease Control and Prevention showed a striking increase in the prevalence of Autism (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6103a1.htm?s_cid=ss6103a1_w).

This new data suggests that in the U.S., 1 in 88 children are now diagnosed with Autism (by 8 years of age). When broken down by sex, the prevalence is 1 in 54 for males and 1 in 252 for females making males almost four times more likely to have a diagnosis of autism than females.

In addition to the usual observations of difficulty with social interaction, language development, and behavior, children with autism quite commonly show a very high level of sensory integration dysfunction. From a sensory integration perspective, children with autism show difficulties with sensory processing, commonly in three areas:

• Sensory Registration (the brain’s ability to recognize sensory stimuli)
• Sensory Modulation (the brain’s ability to pay attention or ignore the stimuli)
• Wanting to do things (the “I Want To Do It” part of the brain).

Sensory Registration

In “normal” brains, information from our senses is filtered automatically depending on what you need to do in your environment. The start point of sensory integration is registration. In autism, the part of the brain that decides what information to register and what to do with it does not function properly. For example, you may walk to work taking the same route everyday for years, but one day notice a house on the corner that you think you have never seen before only to discover that it has been there all along. Your brain has always filtered out that information, but for whatever reason (maybe the sun was hitting the door just right etc.) decided to recognize it. With autism, this function is often very inconsistent. A child with autism may be able to recognize a stimuli one day but not the next. The same inconsistency can appear across all the senses as well. The child may have difficulty with a visual stimuli in one instance followed by not being able to recognize a touch or sound in another. Simply put, the child with autism just doesn’t have the brain wiring that allows it to be consistent with sensory registration from one day to another or from one task to another.

Sensory Modulation

Again, a “normal” brain “modulates” the sensory “input”. This means it automatically chooses to use incoming information and act on it, or ignores it and does not act on it. Not surprisingly in autism this function often struggles. Specifically, the child with autism has great difficulty with vestibular sensation (our body’s sense of recognizing gravity, head movement, and balance) as well as touch sensation. A high percentage of children with autism are resistant to movement and do not like even small heights above the ground because they struggle to make sense of  input from the vestibular system. They may not like rough play where they may get turned upside down both because the vestibular input is too great combined with the touch input of being grabbed assertively.

The difficulty with both registration and modulation contributes to the overall sensory integration dysfunction. Very simple but unfamiliar inputs can be greatly alarming to the child with autism. For example, when brought into a new classroom, the child may react with a high level of resistance for the first several times until he/she has recognized this as a familiar and safe environment. Then after feeling safe, become alarmed again when something has changed in the classroom several days later.

Wanting to Do Things

Motivation. We can all identify with times in our week where we simply don’t feel like doing something…getting out of bed to go to work, getting in our daily run etc. Other times, we feel very driven to accomplish these things. In the book “Sensory Integration and the Child” this is described as the “I Want To Do It” function. There is a part of the brain that is responsible for this function and again not surprisingly, often does not work very well.  Occupational Therapists understand that the situation is not that the child does not do anything; it is that the child cannot get him/herself to do something with purpose. This helps to understand common behaviors with autism such as playing in simple, repetitive actions. If one tries to show the child a more complex task, the child usually won’t want to do it. More puzzling and frustrating to parents and educators (and even O.T’s sometimes!) is that this behavior can easily be interpreted as the child being purposely difficult or defiant. How else can you explain that when you try to get your child to put on a pair of mitts to get out the door the child behaves indignantly.  But then four hours later, you see your child independently putting on the mitts!  The alternative explanation is that the child simply struggled to “turn on” the “I Want To Do It” part of the brain at that time. Finally, it is important to recognize that the child very often has the physical capacity to perform a basic task, but just can’t seem to fire up the part of the brain like you or I could most of the time.

Autism and Occupational Therapy Treatment

Given all of the above, the question now is how do occupational therapists treat children with autism. OTs that work with children with autism are often assessing and treating using the Sensory Integration Frame of Reference (see my previous blog posts).

The objective of occupational therapy using this approach with autism is “…to improve sensory processing so that more sensations will be more effectively “registered” and modulated, and to encourage the child to form simple adaptive responses as a means of helping him to learn to organize behavior” (from Sensory Integration and The Child, p. 135).

Relating this to the previous discussion, the child with autism can often be motivated to register sensory input if given an appropriate incentive.  So one of the basic underlying goals of treatment is to help the child with autism “turn on” the “I Want To Do It” part of the brain through skillfully graded activity to assist in the registration of sensation. The pleasure of motion during therapy helps to motivate the child and allows the brain to process other sensory inputs over time.

What does treatment look like? Well, it looks like playing. Take a look at this video which is a great introduction. 

Stephan Bourassa BMR(OT), OT Reg. (Sask)

Occupational Therapist

Milestones Occupational Therapy for Children

www.milestonesOT.ca

Saskatoon, Canada

In my last blog post, I briefly discussed how the “normal” brain takes in all kinds of information from our five senses. I called this information the “input” that the brain uses to create a behavior, which I termed “output”. I also explained, hopefully on a very basic level, how the output could go wrong in a brain with sensory integration issues.

I hinted that beyond the five senses (sight, sound, taste, smell, touch) that tell our brains what is going on outside our bodies, there are actually two additional senses. These last two senses are complex but are very important in the understanding of Sensory Integration Dysfunction – hopefully I will help make it easy to understand. Are you ready? Drum roll please….the two forgotten senses are:

• A sense of our body’s position in space and movement in space.
• Our body’s sense of recognizing gravity, head movement, and balance.

I always, always try to live by the Keep It Simple Stupid (KISS) rule, but I have to cross the line here and use a technical word to describe the sense that recognizes our body’s position in space and our body’s movement in space. This is called PROPRIOCEPTION. Say it with me…Pro-Pri-O-Cept-Tion. Good. Now that you have it down, I am just going to use this word from now on.

Proprioception is the sense that picks up “inputs” from the movement of our muscles (contracting them and stretching them); joints (bending, straightening, pulling apart, pushing together); and the bones themselves. All of these things have built in “sensors” that pick up the inputs, and pass the information back to our brains. These sensors are aptly named “proprioceptors”. This sense is constantly sending messages to the brain because they are active whether we are moving or not.

The “output” of proprioception is movement. Proprioception helps us move. If our proprioception sense is not very good, our movements will be clumsier, slower, and less precise, and will take a lot more effort. One example of how proprioception works would be if you closed your eyes and I bent your elbow ninety degrees without telling you how much I moved it – you could tell me exactly what position your elbow was in without seeing it.

OK, let’s turn to the second point … here comes another technical word … this sense is called our vestibular sense. This is the other forgotten sense that recognizes gravity, our head movements, and balance. Did you know that your ear isn’t just for hearing? Deep down inside each of our ears is a complex of bone structures that pick up inputs related to gravity. Since we can’t escape the force of gravity, the brain is under constant bombardment of input from the inner ear, especially as we move our heads side to side or up and down. The inner ear also senses when our head moves fast, slow, or changes direction.

To put it all together, the vestibular sense gives our brain the information that allows it to understand where exactly we are related to gravity – whether we are moving, how fast, in what direction, or just standing still.  To simply illustrate this, you can “fool” your vestibular sense. Remember when you were a kid and you spun yourself around and around? Then when you stopped, you felt dizzy, like the room around you was still spinning? Well, that was your vestibular sense getting confused into thinking you were still moving. Another example is that your vestibular sense is like a gyroscope in an airplane. A gyroscope is one tool that allows a pilot to fly an airplane at night or in fog and keep the plane level in the air without being able to see the ground or other references. If the gyroscope breaks, the pilot will end up flying in spirals or circles. Likewise, if your vestibular system “breaks”, your brain will receive poor inputs (from the inner ear) and will be confused. You might stumble, have motion sickness, or be dizzy.

So you can see that the often forgotten vestibular sense and proprioception are really the basic building blocks of movement. In fact, the vestibular system brings all the other senses together – at the end of the day, movement is performed by integrating information from the other five senses in reference to the vestibular system.

I keep saying that these two senses are often forgotten. This is true not only for the general person on the street, but also extends to professionals such as doctors, physical therapists and occupational therapists. Thus, issues with vestibular function in a child are often overlooked simply due to lack of awareness. It takes a skilled professional such as an occupational therapist with a deep understanding of sensory integration dysfunction to uncover vestibular issues that may be expressed through clumsiness, perceived poor vision, or poor behavior, for example.

So the next time you see a child that looks clumsy all the time but just can’t figure out why, consider proprioception and/or vestibular sense. It may take an Occupational Therapist to do an in depth assessment to come to a better understanding of the issue, but hopefully this will give you a couple more tools in your tool box to help understand the child with possible sensory processing/integration issues.

Stephan Bourassa BMR(OT)

Occupational Therapist

Milestones Occupational Therapy for Children

www.milestonesOT.ca

Saskatoon, Canada

If you are a parent who has been told your child has “sensory integration issues” or a teacher who is struggling to understand what “Sensory Integration” is all about, this post is for you. There is much jargon and terminology one encounters when looking at Sensory Integration problems and can be very difficult to break it down to its most basic meaning.

But what if you just want the basic bare bones, meat and potatoes nitty gritty primer- you just need a starting point. Keep reading. This is my way of sifting through the medical jargon, using simple normal language to help us understand what Sensory Integration is all about. What I am about to describe is a gross simplification. In future posts, I will develop a more complex understanding of Sensory Integration problems and how Occupational Therapy can help.

At its most basic, fundamental level, I understand Sensory Integration is really all about inputs and outputs.

Let's start with a “normal brain”, if there is such a thing (my mother-in-law always says “normal” is just a setting on the dryer!). The normal brain automatically and unconsciously absorbs inputs from the world around us; thinks about it and then decides what to do with it. These inputs are sensations (we know them well- touch, sight, taste, smell, hearing-there are actually 2 more, but we won’t go there right now!). The brain may ignore some or all of what it just took in or it may decide to use the input.

The brain then decides on how to translate that input into an act. The act could be a physical movement (or lack of movement) or a verbal response (i.e. saying or yelling something) for instance. These are examples of an output.

At its most basic level, this is how I understand the process of Sensory Integration. It is the brain’s ability to organize information it receives from the world around us and to put it to a use. This process allows us to effectively move, learn, and behave in our environments.

The “normal brain” is relatively organized and efficient. For children with Sensory Integration problems, the brain can be unorganized and inefficient. This brain does a poor job of sifting through the inputs and organizing them to produce a useful output. It has trouble putting it all together. The result is that the outputs are of poor quality.

For example, let's consider walking down a sidewalk with a big crack in it. In response to seeing the big crack, the normal brain takes the input from our sense of vision, calculates our speed as we walk down the sidewalk and makes an action plan to step over the crack without tripping. The brain ignored all other irrelevant information and just focused on what it needed to do to get over the crack.

In the child with sensory integration problems, the brain has trouble sifting through all the information in the environment in order to make and execute a physical plan to get over the crack. If you delve a little deeper, you may realize that this brain is actually trying to organize all kinds of inputs- the noise of the school bus that just drove by, the dog barking across the street, the breeze blowing across the skin, the smell of the rose bushes near by, etc. This unorganized and inefficient brain is on overload and as the sidewalk crack gets closer and closer it struggles to get a signal down to that foot at the right time to clear the crack. The child trips and falls.

You can imagine the frustration the child must feel when facing multiple failures like this everyday with such seemingly simple tasks his or her peers accomplish without a seconds thought. A secondary output to the repetitive struggles faced are behavioral. The child may cry easily, verbally express anger that seems out of proportion to the situation or even become physically aggressive. Without the knowledge of how Sensory Integration works at a basic level, this child may be labeled a “bad kid” and may even create a perception of poor parenting. But, if you put your Sensory Integration detective glasses on, you may come to understand the child in a different way.

I hope this helped you to understand on a very basic level, problems with Sensory Integration. Check back often as I plan on building on the points discussed here. Maybe we will even talk about the two forgotten senses mentioned above….but I won’t reveal those until then!

Stephan Bourassa BMR(OT)

Occupational Therapist

Milestones Occupational Therapy for Children

www.milestonesOT.ca

Welcome to the first entry to the milestones blog! First an introduction. My name is Stephan Bourassa and I am the Occupational Therapist behind milestones occupational therapy for children, a new pediatric occupational therapy practice serving Saskatoon, Saskatchewan, Canada. I am looking forward to sharing my thoughts about all things related to children’s health and wellness from the perspective of an Occupational Therapist. I will be blogging about a range of issues that catch my attention. Anything from childhood obesity to hand writing difficulties in children to assistive technology to sensory integration disorders is fair game. And you don’t have to be an Occupational Therapist to visit my blog! You may be a parent, a teacher, a physical educator, a recreation therapist, a doctor, a Speech Language Pathologist; a child psychologist….the list could go on forever. The point is, if you interact with kids chances are there will be a topic that speaks to you.

So I invite you to bookmark me and check back to see what I am thinking about. And between blog entries, see what I am up to by following me on twitter @MilestonesKids.

Thanks for checking in!

Stephan Bourassa BMR(OT).

We are happy to call this our home on the web.  Please check back often as this blog will be updated frequently.

- Stephan