ARC ANNUAL CONFERENCE Sensory issues in autism

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ARC ANNUAL CONFERENCE Sensory issues in autism
Richard Mills November 2007
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To be lightly touched made my nervous system
whimperGunilla Gerland
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About sensory issues

• Sensory issues long recognised as significant in
  autism
• Complex nature of the issue acknowledged but
  oversimplified?
• Noted in clinical observations and early studies
  
• e.g. Kanner 1943, Hermelin and OConnor (1965),
  Rutter et al (1977) Wing (1969, 1971)
• Specific research confirms differences in
  autistic subjects

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About sensory issues

• Despite this
• (in UK) in practice, surprisingly little
  attention in terms of
• diagnosis and assessment of sensory profile
• recognition of difficulties e.g.
• Sensory Processing Disorder and intervention
• OT (most interventions psychoeducational,
  behavioural or
  psychopharmacological)
• individual education and care plans
• programme design

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IntroductionSome behaviours in ASD linked to
sensory issues 1

• Outbursts following crowded environments or group
  conversations
• Bright lights uncomfortable/ dimness preferred
• Disorientated in environments rich with visual
  stimulation
• Plays with lights and shiny stuff
• Repetitive humming or loud outbursts
• Discomforted by loud or low frequency noise
• Delayed response or over reaction to sudden
  noises
• Over reaction to smells especially those
  
  no one else can detect

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IntroductionSome behaviours in ASD linked to
sensory issues 2

• Preference or insistence on (same) bland food
• Fascination with how people smell
• Aversion to perfumes and air fresheners
• Strong preference for gentle or firm touch or
  pressure
• Unusually high or low response to pain
• Unusually high or low response to
  temperature-highly sensitive
• Unhappy in new clothes, sensitive to how clothes/
  bedding feels
• Labels in clothing very problematic

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Coming up

• About autism
• About the senses
• Sensory issues in ASD
• Common problems
• Ideas for intervention
• Conclusion

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About autism
Wing
Asperger
Kanner
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Context

• About autism spectrum disorders
• Constellation of diverse neuropsychological
  conditions, referred to in ICD10 as Pervasive
  Developmental Disorders
• They include Childhood autism, Atypical autism
  and Asperger syndrome

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Context

• About autism spectrum disorders (continued)
• Qualitative differences in
• Reciprocal communication
• Restricted sterotyped repertoire of interests and
  activities and
• impaired social behaviour
• (Wing 1979)
• Sensory problems almost universally reported but
  are not part of diagnostic criteria (Gillberg et
  al 1992)
• Not included in ICD10

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Diagnosis of autistic spectrum disorder

• Diagnosis concerned with
• Presence of unusual developmental features
• Absence of usual developmental features
• Co occurring conditions

Ack. Lord 2004
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Most commonly reported co occurring problems in
autism and Asperger syndrome (n 1564)

Mills and Wing 2005
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Most commonly reported co occurring problems in
autism and Asperger syndrome (n 1564)

Mills and Wing 2005
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Normal curve and the sensory profile SD
overall (Dunn 1999)
Non autistic sample
2 14 68
14 2
Much less than most less than most
similar to most
more than most much more than most
Low registration (high threshold)
sensory sensitivity (low threshold)
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Context

• About sensory issues
• Various studies suggest present in 30 - 80 of
  individuals with ASD
• Presence of sensory problems should always be
  considered as one possible explanation for
  challenging behaviours
• These require modifications to programme and
  environment

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Context

• About sensory issues
• Strong anecdotal evidence
• Self reports, reports from parents, clinicians,
  researchers
• Relate to neurological threshold
• Amount of stimuli required for neuron or neuron
  system to respond
• Result in behavioural response
• How people act in relation to threshold - respond
  to counteract threshold - achieve equilibrium

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Outer and inner senses (Shore 2004)
sight
touch
hearing
Vestibular (Inner ear) Balance Proprioceptive (Mu
scles and joints) Sense of body in space
smell
taste
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The senses

• Other related factors
• Control of body temperature
• Sense of time

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• Spinning my body
• Brings some sort of harmony to my thoughts
• So that I can centrifuge away the black thoughts
• I realise the faster I spin- the faster I drive
  away the black
• When I am sure every speck of black- has gone
  away from me
• Then I spin back in the opposite direction -
• and pull blue thoughts into myself
• It depends how much blue I want
• If I want more blue I have to spin faster
• Otherwise not so fast - Its just like being a fan
• The trouble is when I stop spinning - My body
  scatters
• And its so difficult to collect it together
  again
• TITO

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The sensesSMELL (Olfactory system)
Hyper (Sensory sensitivity) Sensation avoiding
Hypo (Low registration) Sensation seeking
behaviours
Ignores bad smells Eats inedible stuff
Overwhelmed Panic Refuses to enter particular
environments e.g. toilets (Urine-air
fresheners) Intolerance to people (perfumes-
cigarettes)
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The sensesSight (visual system)
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
Things appear brighter Distortion of
objects Highly sensitive to light (particularly
fluorescent light) Reacts violently to
light Objects jump around Distorted
perspective Insistence on gloom
Things appear darker Relies on peripheral
vision Blurred vision Clumsiness Terror in dimly
lit places
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The sensesHearing (auditory system)
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
Sounds partially heard Sounds are muffled No
response to sound (may appear deaf) Enjoys/seeks
loud noise
Sound distorted or magnified Inability to filter
or discriminate Acute painful hearing Overwhelmed
by sound Reacts violently to sound Holds hands
over/fingers in ears Disturbed or distracted by
background sound (e.g. fridge) Tunes out
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The sensesTouch (tactile system)
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
Low response to pain Poor reporter of illness At
risk of harm (burns) Clumsy Cannot handle
tools Weak grasp
Overwhelmed Avoids certain fabrics (e.g.
wool) Reacts violently to touch Refusal to wear
clothes Avoids hair/nail cutting Even light touch
may be painful BUT May enjoy and seek out firm
consistent pressure/ touch
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The sensesBalance (vestibular system)
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
Hyperactivity Restlessness Rocking Spinning
Twirling Swinging Jumping Hitting self
Excitability Fear of being moved Panic if feet
leave floor Refusal to travel in
vehicles Preference for sitting or lying
Avoidance of all physical activity Marked
reaction to movement (vomiting)
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The sensesBody position (proprioceptive system)
Hyper (Sensory sensitivity) Sensation avoiding
Hypo (Low registration) Sensation seeking
behaviours
Poor body awareness Crashes into things Falls
over a lot Weak compared to same age peers Tires
easily Props self up during activity Clumsy Chews
clothing
Fidgety Difficulty with fine motor control and
manipulation of objects eg Laces, buttons Rigid
body posture and movement- will turn whole body
around to look at something Poor or erratic sleep
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Other related factorsBody temperature
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
Active Thirsty Distractible Strips off Prefers
light clothing whatever the weather
Feels cold Insists on warm or heavy clothing
whatever the weather
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Other related factorsSensory processing(central
auditory processing disorder)
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
Slow processing of language Getting
stuck Repetitive thoughts If interrupted -
having to go back to beginning Need for
prompting Catatonic type states
Thoughts jumbled Excitable Poor
concentration Unable to process language unless
written down Unable to discriminate foreground
from background Interrupting/ speaking over
people ADHD type problems
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Other related factorsSensory integration
Hypo (Low registration) Sensation seeking
Hyper (Sensory sensitivity) Sensation avoiding
behaviours
No response to stimulation Unable to orient
Variable response to different stimuli Under
arousal
Too many inputs at once Unable to
regulate Sensory overload meltdown Problems
with sequencing and discrimination Over arousal
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Other related factors

• Synaesthesia
• Input from one sense interrupted by another e.g.
  seeing sound, tasting colour, hearing light etc
• Scotopic sensitivity
• Relates to visual cortex
• Light sensitivity
• Problems with depth and distance perception

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Other related factors

• Agnosia
• Not recognising objects
• Prosopagnosis
• Not recognising faces

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Challenging behaviours in ASD

• Looking for explanations- (sensory issues are not
  the only one)
• Health related issues (e.g. pain-illness)
• Cognitive issues (autism thinking)
• Functional analysis (of communication)
• See Durand- Motivation Assessment Scale
• (Escape-Tangible- Attention- Sensory)
• Other co occurring conditions

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• A view from the inside 1
• Stephen Shore
• Author of
• Beyond the Wall
• Personal experiences with
• Autism and Asperger Syndrome

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A Personal view from Stephen ShoreCommon sensory
reactions
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A Personal view from Stephen ShoreCommon sensory
reactions (continued)
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• View from the inside 2
• Donna Williams
• Somebody Somewhere
• You must escape because you hear the roar of
  tidal waves (it is the sound of blood rushing
  through the contracting muscles in your own ears)

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Thoughts on intervention

• A few examples

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Thoughts on intervention

• Mixed evidence base for sensory therapies as
  curative
• e.g. AIT, Sensory integration
• BUT
• Good evidence in support of specific
  interventions (involving changes to the
  environment and programme) to reduce negative
  behaviours and improve quality of life

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• Other approaches
• Sensory diet
• Routine activities designed to aid the
  regulation of the nervous system to lower levels
  of arousal and serve as calming e.g.
• Horse riding
• Brushing (Wilbarger)
• Walking on rough terrain
• Carrying heavy rucksack
• Weighted body warmer
• Carpentry
• Bread making
• Housework - use of vacuum cleaner etc

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New research

• Kern et al (2006) found that sensory
  abnormalities
• Differ markedly between autistic subjects and
  controls
• Are global in nature (affecting several
  modalities)
• Change with age (except for low threshold touch)
  - younger subjects more severely affected
• Have the potential to improve over time

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Conclusion

• Sensory issues common in ASD but often ignored
• Reported across the spectrum not just the less
  able
• May be complex (but often straightforward- e.g.
  tactile defensiveness)

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Conclusion

• Assessment of sensory profile in ASD is important
  
• Ideally a standardised instrument e.g. Dunns
  Sensory Profile
• Sensory type important but individuals may
  exhibit different aspects of sensory processing
  at any given time (e.g. seeking and avoidance)

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• I didn't eat tomatoes for over a year after
  a cherry tomato had burst in my mouth while I was
  eating it.
• The sensory stimulation of having that small
  piece of fruit explode in my mouth was too much
  to bear and I was not going to take any chances
  of it happening again
• Stephen Shore

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• Notice

This presentation may not be reproduced in whole
or in part without permission
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• Acknowledgements

Mary Coleman Winnie Dunn Gunilla
Gerland Christopher Gillberg Jacqui Jackson Janet
Kern Catherine Lord Stephen Shore Donna
Williams Lorna Wing
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Thank you

• Richard Mills
• Director of Research
• The National Autistic Society
• Richard.Mills_at_nas.org.uk