Sensory Processing Volume 2

Research Bulletin Issue No. 26 July 2018 Sensory Processing Volume 2 3

Contents

Introduction 5

Interview with Professor Kelly Mahler 6

Research Articles Summarised 11

1. Meal Behaviour Difficulties but not Nutritional Deficiencies Correlate with Sensory Processing in Children with Spectrum Disorder 2. Auditory Processing and Sensory Behaviours in Children with Autism Spectrum Disorders as revealed by Mismatch Negativity 3. Brief Report: Assessment of Early Sensory Processing in Infants at High-Risk of Autism Spectrum Disorder 4. The Relationship between Sensory Processing and Anxiety on CARS Scale in Autism Spectrum Disorder 5. Sensory Over-Responsivity and Social in ASD: Effects of Aversive Sensory Stimuli and Attentional Modulation on Neural Responses to Social Cues 6. Sensory Processing in Autism Spectrum Disorders and Fragile X Syndrome – From the Clinic to Animal Models 7. Sensory Reactivity, Empathising and Systemising in Autism Spectrum Conditions and Sensory Processing Disorder 8. Behavioural, Perceptual, and Neural Alterations in Sensory and Multisensory Function in Autism Spectrum Disorder 9. Sensory Processing in Children with Autism Spectrum Disorder: Relationship with Non-Verbal IQ, Autism Severity and Attention Deficit/Hyperactivity Disorder Symptomatology 10. The Design and Implementation of a CBT-Based Intervention for Sensory Processing Difficulties in Adolescents on the Autism Spectrum 11. A Systematic Review of Sensory Based Autism Subtypes 12. The Interplay between Sensory Processing Abnormalities, Intolerance of Uncertainty, Anxiety and Restricted and Repetitive Behaviours in Autism Spectrum Disorder 13. Assessing Sensory Processing Dysfunction in Adults and Adolescents with Autism Spectrum Disorder: A Scoping Review 14. The Impact of Atypical Sensory Processing on Social Impairments in Autism Spectrum Disorder

Conclusion 43 Sensory Processing Volume 2 5

INTRODUCTION

This is the twenty sixth Research Bulletin Kelly has authored many books including: produced by Middletown Centre for Autism • : The Eighth Sensory System and it provides summaries of fourteen articles • The Comprehensive Assessment of spanning from 2014-2017. Interoceptive • Sensory Issues and High Functioning Autism The Bulletin commences with an interview with (with Myles and Robbins) - winner of National Professor Kelly Mahler. Parenting Publications Bronze Medal • Destination Friendship: Developing Social Professor Kelly Mahler is a parent, occupational Skills for Individuals with Autism Spectrum therapist, author, speaker and Adjunct Disorders or Other Social Challenges (with Professor of . She earned Benton, Hollis, and Womer) an MS in Occupational Therapy, as well as a • Hygiene and Related Behaviors for Children Post-Professional Pediatric Certificate from and Adolescents with Autism Spectrum and Misericordia University, Dallas, PA. As an Related Disorders - winner of Mom’s Choice and autism consultant Awards Gold Medal. she supports school-aged individuals and young adults with autism. Please note that the views represented in this document do not necessarily reflect the views of Middletown Kelly is co-founder of Destination Friendship, Centre for Autism. Reviewers have, where possible, an organisation providing fun opportunities used the original language of the article, which may targeted at developing friendship skills in young differ from UK and Ireland usage and the usage of a people with autism. She is also actively involved range of terminologies for autism. in multiple research projects pertaining to interoception. Kelly has presented numerous seminars and workshops at the international and national levels. 6 Middletown Centre for Autism Sensory Processing Volume 2 7

AN INTERVIEW WITH PROFESSOR KELLY MAHLER

1. A young person with autism’s sensory 2. Why do a young person’s responses 4. What is stimming and why do many 6. Could you explain the eighth experience of the world can have a to particular sensory experiences young people with autism engage ‘interoception’, and what impact profound effect on their life. As fluctuate from one day to the next? in stimming? having difficulties with interoception professionals how can we help to As with all of us, the ability to tolerate sensory Stimming, which is short for self-stimulatory might have on a young person solve these difficulties within the experiences fluctuates with a variety of factors behaviour, is usually a repetitive behaviour of in school? classroom/school environment? including our levels of stress, how much we slept some form like flapping hands, body rocking, Interoception is a sensory system that allows us to I believe one of the best solutions that we can use the night before or how predictable the situation spinning a string round and round, jumping up sense or feel our internal body signals. These as professionals is to proactively provide a sensory is at hand. A young person with autism is no and down, pacing back and forth, or making signals often come from body areas that many friendly school environment. Learn about each different. When a young person is stressed, sleep repetitive vocalisations. Autistic people report we can’t see, but we can still feel them. For young person and his or her unique sensory deprived or in an unpredictable situation, the that stimming is very soothing and calming (in example, we are able to feel our stomach growl, needs. Try to consider these sensory needs ability to tolerate sensory experiences goes down. fact, sometimes it is the only strategy that helps our heart speed, our throat grows dry and our throughout the school day and implement them feel calm in an otherwise overwhelming muscles tense because of interoception. These modifications that will maximise sensory 3. In your opinion, what are the most environment). signals are important to our emotional comfort. For example, if you know a student is accessible interventions supporting experience. When we clearly feel the signals from very sensitive to sounds, keep this in mind within children and young people with 5. Should stimming be encouraged or our body, they become clues as to what emotion the classroom by reducing any background sensory processing difficulties? prevented in school? we are experiencing. For example, when you feel noises, using a teaching approach that is low and your heart race, your stomach flutter and your With the advances in technology, and having Encouraged. As long as the stimming is safe and slow, and providing advanced notice if any loud muscles shake you know you are scared. Or when information at our fingertips, many interventions does not put a student at risk of injury. In most noises or activities are planned for the day (e.g. you feel your muscles tighten, your breathing are fairly accessible. Most people, including a cases, stimming can be one of the most powerful fire drills, assemblies, class party, etc). grows shallow and your voice grumble you know young person with sensory processing difficulties methods that a student can use to get them ready Additionally, when the student is calm, work you are frustrated. Or when you feel your eyes can virtually find countless techniques to use and engaged in the learning process. I always find together to create a plan, outlining steps the grow heavy, your muscles are sluggish, and your to modify the sensory environment and maximise it strange when I see behavioural programmes student can follow when the sensory environment is foggy, you know you are tired. comfort. designed to reduce the frequency of (safe) become ‘too much’. Keep in mind that the young stimming. In other words, these behaviour Interoception is the foundation of this body- person may not always recognise the of programmes are designed to reduce the frequency emotion connection. sensory overwhelm, so account for this in the of the individual using a calming strategy! That plan by adding in a secret signal that the student does not make much sense. wants the teacher to use. 8 Middletown Centre for Autism Sensory Processing Volume 2 9

7. How are anxiety, emotional 8. How can sensory knowledge and 10. Some young people with sensory regulation difficulties and sensory strategies improve anxiety/mental processing difficulties experience differences linked? health/wellbeing, for individuals difficulties with hygiene. What general You have to notice and understand exactly how with autism? advice would you give families for you feel in order to manage it effectively. When In terms of interoception, becoming more aware improving personal hygiene skills? we are able to clearly notice body signals, and of your body and emotions can have a drastic Improving personal hygiene is largely trial and connect the body signal to the corresponding effect on mental health and wellbeing. It gives a error, exploring a variety of ways to adapt hygiene emotion, this urges us into action. Interoception person more power to manage the way they feel. tasks to make them as sensory comfortable as serves as our motivation to seek out comfort in a Exploring and understanding sensory needs in possible. Use input from the young person timely manner. For example, if you notice a general can also have a profound effect on mental whenever possible. One of my young female pounding heart, fast brain and shaky muscles and health and allow a person to communicate needs clients just went to the local store with her father know these body signals mean you are anxious, to others and seek out strategies for reducing to find a brand of shampoo she would be willing you are urged to do something to restore the sensory discomfort. to use. They sat in the shampoo aisle for an hour comfort in your body (e.g. go for a walk). When a and smelled each one until they found one she person has interoception difficulty, it can result in 9. Top tips for improving/regulating a would try. You have to be willing to be flexible an unclear body-emotion experience. Challenges young person’s connection with their and creative to adapt the hygiene for the young in figuring out how you feel, can lead to great sense of interoception? person. However, it is also important to teach the difficulty managing your emotions. Cheyanne, a ‘whys’ behind good hygiene, provide the logical To improve interoception, we need to improve the young person with autism shared, “I would not reasons why good hygiene is so important. ability to notice and understand internal body realise I was anxious until I was in a full signals, thus building body-emotion connections. meltdown, hiding in a corner or under a table. I Many of the interventions that my colleagues and didn’t notice the anxious building in my I have developed are influenced by mindfulness, body.” Max, another young person with autism which is currently the only evidenced-based shared, “Teachers at my school would get upset technique for improving interoception. However, with me because I didn’t use my ‘emotion tools’ because mindfulness is extremely abstract for when I was anxious. The problem was that I never many young people, including children with noticed the need to use my ‘emotion tools’ – I autism, we took mindfulness-based strategies and never noticed that I was anxious until it was way made them very concrete, systematic and visual. too late.” We have an Interoception Curriculum coming out in October 2018 that will include these strategies as well as a step-by-step guide to improving interoception. For free information about interoception, check out www. mahlerautism.com or join our Facebook Group Interoception: The Eighth Sensory System. Sensory Processing Volume 2 11

Meal Time Behaviour Difficulties but not Nutritional Deficiencies Correlate with Sensory Processing in Children with Autism Spectrum Disorder

BACKGROUND RESEARCH AIMS In addition to atypical behaviours at meal time, To offset the household confounder this study specific dietary habits and preferences are aimed to explore the feeding difficulties of recognised as behavioural criteria for the children with autism compared to their siblings diagnosis of children with autism. Due to atypical who live in the same household and as well as behaviours at mealtime there are concerns around with other typically developing children. Another the possibilities that this may be the cause of aim of this study was to evaluate the associations nutritional deficiencies. between mealtime behaviour, nutritional There are many studies that support the presence deficiencies and sensory profile in children of feeding difficulties in children with autism with autism. (food refusal, PICA disorder, limited variety of RESEARCH METHOD foods, food preparation preferences, rejecting/ preference for food; oral motor difficulties). A total of fifty children with autism, aged three to Regarding nutritional difficulties there are many six years, were compared in a case control study case study reports of children with autism to their typically developing (TD) siblings (aged experiencing a range of medical difficulties between three and 12 years) and a TD control (scurvy, rickets, vitamin A deficiencies). In group, matched by age and gender. addition to nutritional deficiencies, research has Exclusion criteria was applied for participation also indicated that some children with autism amongst all groups whereby children were not may have a preposition to be overweight. included in the sample if they used food Behaviours related to meals have also been linked supplements, had a metabolic disease such as to sensory processing difficulties (sensitivities to diabetes mellitus or celiac disease or followed textures, smells, colours, of food or different a gluten-free or casein-free diet. behaviours around mealtimes that may be linked to ) in children with autism, resulting in heightened anxiety in relation to nutritional consequences which in turn results in more stress at mealtimes. The authors in this study highlighted that some of these prior findings may be confounded by household preferences. 12 Middletown Centre for Autism Sensory Processing Volume 2 13

Measures used 1. Nine factor groupings characterising children IMPLICATIONS FOR PRACTICE Questionnaires - the Autism Screening by their responsiveness to sensory input, (by the authors) sensory seeking, emotional reactive, low Questionnaire was used to screen children Understanding that part of the difficulties with autism. endurance/tone, oral sensory sensitivity, inattention/distractibility, poor registration, children with autism display during meal time Weight, height and body mass index (BMI) was sensory sensitivity, sedentary and fine motor/ may be due to sensory issues is an important reported by parents with comparative measures perceptual. factor in building appropriate treatment and using the Wirkd Health Organisation AnthroPlus intervention for the child and their family. 2. Three sections quantify the ability to respond software between each of the three groups in The lack of differences between nutritional the study. to sensory processing, modulation, behavioural and emotional responses. deficiencies over the SP factors, sections and Demographic variables were collected using a quadrants from this study further indicated that self-administered questionnaire. 3. Quadrants measure the degree to which children who are at nutritional risk are not children miss, obtain, detect or are bothered necessarily those who display unusual reactions Nutritional consumption was obtained by parents by sensory input. to sensory stimuli. using a self-administered semi-quantified food diary to record the quantity of food consumed in FINDINGS The authors also posit that children with autism real time. Parents were instructed to complete two Results from this study indicated that mealtime who are less picky or whose parents might notice weekdays and one weekend day using a food behaviour difficulties were significantly more less atypical behaviours at mealtime, may have guide developed by the Department of Nutrition prevalent in the group of children with autism nutritional deficiencies, so it is also important of Public Health Services in the Israeli Ministry of compared to their siblings and the TD control that these children are also evaluated. Health. A registered dietitian reviewed the diet group. These differences were associated with a Furthermore, taking into consideration the records immediately after data collection with range of sensory regulation difficulties as opposed increased nutritional risk and the lack of nutrient consumption calculated using a specific to nutritional deficiencies, with household predictive tools which are adequate to assess for dietary programme. preferences having limited effect on food aversion risk, it is evident that these children will benefit from a comprehensive assessment. This should Behavioural problems during lunchtime - BAMBI scores of children with autism. include a nutritional assessment in addition to an questionnaire consisting of 18 items scored on a With regard to whether children who experience appraisal of sensory aversions and preferences. 5-point Likert scale was used to measure the more difficulties during mealtime would display frequency of mealtime behaviour problems more nutrient deficiencies, results indicated a unique to children with autism. The questionnaire significant correlation for “features of autism” and Full Reference is defined by a 3-factor structure: limited variety, the nutrient deficiencies. Findings further food refusal and features of autism. Shmaya, Y., Eilat-Adar, S., Leitner, Y., Reif, S. and indicated that difficulties around mealtimes Gabis, L. V. (2017). Meal Time Behaviour Sensory profile - this questionnaire was completed greatly influence the life of families of children Difficulties but not Nutritional Deficiencies only by the autism group. The Sensory Profile with autism. Significant differences between the Correlate with Sensory Processing in Children Caregiver Questionnaire was completed only by BAMBI results over the SP factors, sections and with Autism Spectrum Disorder. Research in the autism group. The questionnaire is a 125 item quadrants indicate that there are greater Developmental Disabilities, 66, p. 27-33. questionnaire, used among 3-10 year olds. The challenges for children with autism who express questions in this questionnaire are scored on a non-typical sensory processing at meal time. 5-point Likert scale, and may ask parents if their children behave in certain ways to sensory stimuli. Results from this measure are analysed in several ways: 14 Middletown Centre for Autism Sensory Processing Volume 2 15

Auditory Processing and Sensory Behaviours in Children with Autism Spectrum Disorders as revealed by Mismatch Negativity

BACKGROUND After psychometric testing the children Furthermore, to identity whether auditory Full Reference Problems in auditory processing are a commonly participated in a mismatch negativity (MMN) sensory processing was a moderator of the Ludlow, A., Mohr, B., Whitmore, A., Garagnani, reported sensory processing difficulty amongst task. During this task children were situated in a differences in the way words and pseudowords M., Pulvermüller, F. and Gutierrez, R. (2014). children with autism. Examples of atypical video-controlled, electrically shielded and sound were processed, findings revealed that as sensory Auditory Processing and Sensory Behaviours in responses to auditory stimuli may include the proofed space. Stimuli was delivered via sensitivity scores increased for children with Children with Autism Spectrum Disorders as child with autism placing their hands over their headphones, whilst watching a silent movie of autism, the lower their amplitude for words, with revealed by Mismatch Negativity. Brain and or having a preoccupation with a specific their choice; they were instructed to ignore any sensory sensitivity appearing to be the strongest Cognition, 86, p. 55-63. noise within the environment. Whilst much incoming acoustic stimuli. During this activity, sensory moderator of this effect. research has considered the differences between two refreshments breaks were provided. Electrical Furthermore, auditory sensory scores collated speech and non-speech stimuli, limited attention brain activity was recorded throughout the from the Adolescence Sensory Profile indicated has been directed towards the influence of experiment. Overall the experiment lasted that children with autism recorded significantly semantic content of the stimuli employing a 30 minutes. higher behaviours to auditory stimuli than mismatch negativity (MMN) task. FINDINGS typically developing (TD) children across three of the sensory quadrants (Low Registration, RESEARCH AIMS Results from this study indicated that children Sensation Seeking, Sensation Sensitivity, and with autism displayed significantly reduced MMN The current study aimed to examine whether Sensation Avoidance). responses to speech like stimuli (i.e. both words children with high functioning autism were and pseudowords) in the frontal regions of the impaired in auditory discrimination of speech IMPLICATIONS FOR PRACTICE brain, compared to typically developing children. sounds using a MMN paradigm using words and (by the authors) This effect was more pronounced between groups pseudowords. Although this study has indicated that sensory across the meaningful stimuli as children with behaviours may underlie differences in auditory autism displayed reduced activation in both the RESEARCH METHODS of speech-like stimuli in children with frontal and central regions of their for Eleven boys with an autism spectrum disorder autism, the authors have highlighted that results words. Differences for pseudowords were aged 11-16 years were matched for verbal and from this study should not be generalised to however only identified in the frontal regions of nonverbal IQ with eleven typically developing situations when meaningful stimuli is mixed with the brain. These findings correlated with previous boys to participate in a MMN model. Children meaningless noise which occurs within most studies which suggest that children with autism were recruited through local mainstream schools. social situations, nor should comparisons be have an altered functional connectivity, Parents provided confirmation that their children made when children with autism are explicitly prominently in the frontal cortex and circuits did not have any problems or any requested to attend to speech-like stimuli. lining frontal areas to other brain systems. psychopathological or neurological disorders. Also, as children with autism were recorded to In relation to whether auditory sensory Clinical and behavioural data was collected from have significantly higher behaviours to auditory processing is relevant to the way words are all children using the Adolescent/Adult Sensory stimuli than TD children further research is processed compared to pseudowords it was found Profile Questionnaire, the Edinburgh Handedness required to address the interactions between the that auditory responsiveness was the most Questionnaire, nonverbal IQ based on the Ravens different auditory sensory measures in addition to common and pervasive form of sensory Matrices and verbal IQ using the British Picture bearing in mind the impact of sensory behaviour amongst children with autism Vocabulary Scale. commonalities such as vision and tactile. compared to the neurotypical group. 16 Middletown Centre for Autism Sensory Processing Volume 2 17

Brief Report: Assessment of Early Sensory Processing in Infants at High-Risk of Autism Spectrum Disorder

BACKGROUND RESEARCH METHODS IMPLICATIONS FOR PRACTICE Due to the HR parents all being second time Following a systematic review of the literature, it The ITSP was administered at 24 months to assess (by the author) parents, it could be assumed that they would be more aware of their child’s development given is acknowledged that atypical sensory responses a range of sensory inputs as described by parents. Clinicians: are frequently reported in children with ASD in It assesses sensory processing across five areas: their experiences and so their responses may be Although the hypothesis was only partially comparison to typically developing children, auditory, visual, tactile, vestibular and oral. The more reliable than first time parents. supported by the findings, the identification of although by itself, these sensory symptoms do not ITSP also assesses the child’s reaction to a sensory sensory differences in terms of auditory differentiate ASD from other disabilities. These experience within four quadrants: low Full Reference processing and low registration to all types of sensory symptoms could be informative in the registration, sensory seeking, sensory sensitivity sensory domains, could be potential risk markers Germani, T., Zwaigenbaum, L., Bryson, S., Brian, early detection of ASD as the sensory modulation and sensation avoidance. Diagnostic assessment of ASD amongst HR toddlers. The ITSP did not J., Smith, I., Roberts, W., Szatmari, P., Roncadin, and regulation behaviours of toddlers with ASD at three years, using the Autism Diagnostic identify differences in other sensory areas. But C., Sacrey, L. A. R., Garon, N. and Vaillancourt, T. has been reported as significantly different to Observation Schedule (ADOS) and the Autism they are sometimes reported to clinicians in (2014). Brief Report: Assessment of Early Sensory those without ASD. Diagnostic Interview (ADI-R), was conducted by young children with suspected ASD. Direct Processing in Infants at High-Risk of Autism a psychometrist, psychologist or developmental The Infant/Toddler Sensory Profile (ITSP) is the clinical observation and/or objective laboratory- Spectrum Disorder. Journal of Autism and paediatrician trained to research reliability, who measurement framework used to evaluate based sensory measures could be used in Developmental Disorders, 44, p. 3264-3270. was not aware of any previous study assessments. toddlers’ behavioural responses to sensory stimuli conjunction with the ITSP to provide multiple A total of 91 participants gave complete data, 31 as observed and reported by parents. In a perspectives for identifying ASD in young LR and 60 HR (15 HR-ASD; 45 HR-N). previous study, Mulligan and White (2012), used children. The authors recommend exploring the the ITSP to compare 13 high-risk (HR) infants RESEARCH FINDINGS link between temperament and sensory (they had an older sibling with ASD), against The results showed significant differences processing to identify differences in HR infants normative ITSP data. The results showed that the regarding auditory processing, with the HR-ASD for ASD. infants had less sensory-seeking behaviours. As group mean score being significantly higher than Researchers: this study was conducted on infants before they the HR-N and LR groups. There were no were diagnosed and did not follow through once Although the sample size was larger than in differences detected in the scores for visual, the diagnostic outcome of those infants was previous reports it was still relatively small. Future vestibular, tactile or oral sensory processing. In determined, it was unclear from the study studies should be larger and could include the quadrant scores, there was a significant group whether the differences found were related examining sensory profiles for children with ASD difference obtained for low registration (e.g. does to ASD. using symptom levels and functional abilities as not notice sensory stimuli), where again the mean the basis for understanding whether sensory HR-ASD score was significantly higher than the RESEARCH AIMS differences correlate with the severity of these other two groups. This is not specific to a certain dimensions. It is important to identify whether The aim of this study was to compare 24-month type of sensory domain but rather indicates the sensory processing differences exist between HR ITSP scores among three groups based on their overall behaviours of the toddlers to a range of infants and infants with other developmental diagnostic outcomes at three years. The group sensory inputs. There was also a non-significant disabilities to increase the use of the ITSP into were (a) a HR group who were later diagnosed trend that showed that the HR-ASD would other areas. This study has contributed additional with ASD (HR-ASD), (b) a HR group who were engage in sensory seeking behaviour (e.g. seeking information on the sensory differences that could not later diagnosed (HR-N) and (c) a low-risk out a sensory stimulating environment). group of infants with no first-degree family forecast ASD in an HR cohort, there is further history of ASD (LR). It was hypothesised that need to examine whether these findings can be there would be significant differences among the generalised to children with a family history. three groups with the parents of the HR-ASD group reporting the highest number of sensory differences. 18 Middletown Centre for Autism Sensory Processing Volume 2 19

The Relationship between Sensory Processing and Anxiety on CARS Scale in Autism Spectrum Disorder

BACKGROUND RESEARCH FINDINGS items related to levels of anxiety. The results into the difficulties people with ASD have with Challenges with sensory processing have always The CARS results were processed on the sample demonstrated that in each age group the sensory disorders, the final goal being to adapt been associated with autism spectrum disorders of 42 participants, of whom 32 were male and 10 occurrence of anxiety disorder related to ASD the approach and treatment to help individuals (ASD) but it is only since DSM-5 (2013) were female. The average age of those selected was was higher than in the general population. achieve better self-regulation and increase their that sensory problems were classified as a 23.81, with the youngest being 16 and the oldest The results of the study indicated that there is a level of adaptation and range of activities that crucial symptom. 35. The level of intellectual ability ranged from link between and the level of could help them socialise better into society. mild to profound mental retardation. The mean intellectual functioning as well as establishing the RESEARCH AIMS score of the scale, which determines the degree of relationship between of the severity of the autistic Full Reference The aim of this study was to determine the the autistic disorder, indicated that the degree of disorder and the level of intellectual functioning. Novakovic, N., Pejovic Milovancevic, M., Dukic connection between functional areas related to autistic disorder in the participants was severe. The relationship between the degree of ASD and Dejanovic, S., Paunovic, N., Jordanov, P. and sensory processing and anxiety in conjunction Broken down into gender, the female participants visual perception was stronger than other Vukovic, M. (2015). The Relationship between with the scale of autism in the adolescents and had higher mean scores than the male relations of sensory processing, whilst there was Sensory Processing and Anxiety on CARS Scale adults with ASD. A unique feature of this study participants. no connection identified between the intellectual in Autism Spectrum Disorder. Psihijatrija was that it included the population of adolescence The results showed that there was a statistically level of functioning and auditory perception or Danas-Psychiatry Today, 47(2), p. 139-150. and adults (15-35 years of age) who had a severe significant positive correlation between the near distance responsiveness. These results form of autism spectrum disorder. degree of autistic disorder as measured on the differentiate visual perception disorder to be a particularly significant symptom in ASD. RESEARCH METHOD CARS scale and the functional areas of unusual sensory interest, such as visual perception, IMPLICATIONS FOR PRACTICE The study was conducted on 48 participants auditory perception and near distance selected from an initial 63 potential subjects. The responsiveness. Also, there was a significant (by the author) results were generated on a sample of 42 subjects. positive correlation between the total score and There has not been a neurobiological basis Those examined were both male and female levels of anxiety. In addition, there was also a established yet to explain why sensory integration adolescents and adults, aged 15-35 with severe strong correlation between the items regarding disorders affect individuals with ASD but forms of ASD and with an intellectual disability, sensory perception and the level of anxiety. By there are several theories to the cause of the from Belgrade. The research was conducted at establishing a correlation between the level of sensory deficits. branch centres of the Day Care Centre for intellectual functioning and total CARS score, a In the neurotypical population stimulating the Children and Adolescents with Developmental correlation was found between intellectual pattern of sensory processing improved the array Disorders, Belgrade. functioning and the items which evaluated visual of the individual’s reactions and using perception. There was no correlation found The Childhood Autism Rating Scale (CARS) was multisensory methods could improve sensory between intellectual functioning and the items used to assess the severity of the participants’ function in the ASD population. Currently the related to auditory perception or near distance autistic disorder. From this assessment, the degree treatment of sensory integration is mostly based responsiveness. and severity of the autistic disorder could be on the subjective evaluation of occupational compared to the functional areas of sensory Once the data was processed, the results indicated therapists, which although practical, fails to make interests and anxiety. The CARS assessment was that there was a correlation between the severity strong empirical conclusions. performed by direct observation of subjects. In of the autistic disorder, measured using the CARS Further research around sensory symptoms the assessment the following areas were score, and the functional areas of sensory related to ASD could potentially indicate, in a evaluated: social, emotional, communication interests. Furthermore, a strong correlation was more wide-ranging way, the nature and skills, repetitive behaviour, play, organisational confirmed between the levels of anxiety and of this disorder and lead to new behaviour, every day behaviour and unusual sensory interests. A significant finding methods of effective treatment. The results from sensory interests. was that there was no correlation identified this study could be an incentive for further between age and the total CARS score or the research in this area to help get a better insight 20 Middletown Centre for Autism Sensory Processing Volume 2 21

Sensory Over-Responsivity and Social Cognition in ASD: Effects of Aversive Sensory Stimuli and Attentional Modulation on Neural Responses to Social Cues

BACKGROUND FINDINGS Instructions, tactile condition – when tactile • Results indicate that when ASD individuals Sensory over-responsivity (SOR) presents as Sensory over-responsivity stimulation was added both groups showed were directed to pay attention to facial extreme sensitivity to stimuli such as touch or As expected the ASD group was rated as having increases in right pre- and postcentral gyri, right expression and tone of voice the tactile auditory input and is particularly common in significantly more severe tactile SOR symptoms auditory regions and insular/opercular regions. stimulation no longer caused decreases in autism spectrum disorders (ASD) (Ben-Sasson et on both sensory measures. ASD group also showed increases in left opercular brain activation. This suggests explicit al, 2008). Research has shown SOR is associated cortex and increases to medial prefrontal cortex direction to social cues lessens the effect of Accuracy with higher impairment in social and adaptive which differed from TD group. the distracter. Results indicated that tactile caused behaviour. These studies suggest individuals IMPLICATIONS FOR PRACTICE • The implications of these findings suggest accuracy to decrease in the No Instruction over-attend to extraneous sensory information interventions could focus on reducing condition, but to go up in the Instruction (by the authors) rather than social information. To date no studies environmental distractions as much as possible condition. Whereas in the TD group accuracy • This study found that ASD participants were have directly tested the effect of a sensory during social exchanges which in turn reduces was consistent across groups other than able to understand and differentiate sarcasm distractor on the brain’s ability to process the effort required to maintain attention to decreasing for Tactile only in the Instruction accurately which is consistent with previous social information. relevant social cues. The study found that condition. studies. Greater brain activation patterns for giving explicit instructions directing attention RESEARCH AIM the ASD group as depicted in the results fMRI results to relevant social cues helped to reduce effort This study used functional magnetic resonance section suggest more effortful processing to No instruction, no tactile condition – both groups for the individual with autism. imaging (fMRI) to examine brain activity when interpret the communicative intent in the case showed significant activation in bilateral primary processing social information in individuals with of sarcasm. • Further research is required using a larger auditory and visual cortices. The ASD group also group sample to investigate the relationship and without autism. • When the sensory distracter was used the ASD had significant activation in the right inferior between sensory and social symptoms with participants showed decreased brain activity to RESEARCH METHOD frontal gyrus. Between group comparisons brain activity during social tasks. Participants included 15 high-functioning indicated the ASD group had greater activation in areas including the frontotemporal language individuals with ASD and 16 age- and IQ- right temporal gyrus, left lateral occipital cortex processing region in comparison to TD group matched typically-developing (TD) controls aged and bilateral IFG. TD group did not show which showed increased activity. This suggests Full Reference 9-17.6 years. During the task participants viewed increased activity in any areas compared to the individuals with autism shifted attention Green, S. A., Hernandez, L. M., Bowman, H. C., 16 different scenarios; first they saw a picture with ASD group. away from the task towards the sensory Bookheimer, S. Y. and Dapretto, M. (2017). stimulus, therefore they were unable to sustain auditory narration followed by a picture No instructions, tactile condition – tactile stimulus Sensory Over-Responsivity and Social Cognition accompanied by either a sincere or sarcastic effortful processing of social information in ASD: Effects of Aversive Sensory Stimuli and was added; this stimulation was associated with during stimulation. In contrast to the TD remark. They were asked to respond whether the increased brain activity in the TD in comparison Attentional Modulation on Neural Responses to person meant what they said. The task was group the ASD group presented a slight Social Cues. Developmental Cognitive to a decrease in the ASD group in areas associated decrease in accuracy of the task when completed using a 2x2 design; with tactile sensory with social cognition and language processing. Neuroscience, 29, p. 127-139. distracter present or not present, and with and experiencing distraction of the sensory without instructions directing their attention to Instructions, no tactile condition – participants were stimulation. relevant social cues. given explicit instruction to attend to the • Increased activity in bilateral supramarginal speaker’s face and tone of voice., Both groups gyrus in response to the tactile stimulus Child sensory questionnaires were completed by showed activation in bilateral occipital and suggests that ASD individuals with higher SOR parents; short sensory profile (SSP), sensory temporal lobes, left and post central gyri and left pay more attention to the tactile stimulation. It over-responsivity inventory (SensOR) and IFG. The TD group also had activation in is likely the addition of the stimulus made it diagnostic and cognitive measures were and hippocampus. more difficult for ASD individuals with high administered at a clinical assessment. SOR to interpret the verbal statement, they may have compensated by paying attention to the visual clues to decide whether the narrator was sincere or sarcastic. 22 Middletown Centre for Autism Sensory Processing Volume 2 23

Sensory Processing in Autism Spectrum Disorders and Fragile X Syndrome – From the Clinic to Animal Models

BACKGROUND RESEARCH AIMS RESEARCH FINDINGS IMPLICATIONS FOR PRACTICE Our brains are constantly flooded with sensory This review focussed on investigating Sensory difficulties, particularly in the auditory (by the authors) information that needs to be filtered, processed, experimental approaches that measure sensory domain, are consistently seen in individuals with This study further evidences that responses categorised and appropriately responded to. processing in with autism and FXS, autism and individuals with FXS. to sensory stimuli happen at a sub-cortical People with autism or Fragile X Syndrome and in relevant rodent models. This study Different event-related potentials and behavioural level within the brain; and are often automatic (FXS) are often over- or under-reactive to outlines robust evidence of disrupted sensory measures can be used in humans and animal and therefore very difficult for the individual sensory stimulation, leading to a wide range processing in individuals with autism and FXS, models to assess sensory filtering. experiencing sensory difficulties to control. of behavioural responses. This altered sensory and in respective animal models, focusing on the This study offers autism researchers a unique processing may be caused by disrupted or atypical auditory (hearing) sensory domain. Basic sensory processing brain circuitry may be opportunity to understand the pathophysiology brain activity. easier to trace compared to brain circuits involved REVIEW METHOD in social communication and cognitive aspects of of autism and FXS at a brain circuit and cellular Difficulties with sensory processing usually fall autism. Brain circuitry involved in basic sensory level by investigating sensory processing. into one of two categories: Little detail is provided about how the authors sourced the articles included. However, studies processing may also be more conserved across Future studies are required to investigate the • Over-reactive or hypersensitive: children which investigated sensory processing related humans and mice compared to circuits involved auditory behaviours and brain circuits involved in who are overly sensitive, and often struggle brain activity, (such as electroencephalographic in cognitive and social communication. individuals with autism and FXS. with sleeping, dressing or any form of measurement of event related potentials, neural sensory input. oscillations and mismatch negativity, as well as Full Reference • Under-reactive or hyposensitive: children habituation and pre-pulse inhibition of startle) in who under-react to stimuli that should individuals with autism or FXS or animal models Sinclair, D., Oranje, B., Razak, K., Siegel, S. and otherwise cause them some discomfort, were included. Schmid, S. (2017). Sensory Processing in Autism such as or heat. Articles reviewed Spectrum Disorders and Fragile X Syndrome – From the Clinic to Animal Models. Neuroscience Individuals with autism and individuals with FXS This comprehensive review details recent and Behavioural Reviews, 76, p. 235–253. are known to have sensory processing difficulties. advances in understanding the sensory Several studies suggest the existence of similar processing disruptions underpinning sensory pathophysiological and anatomical mechanisms features of autism and FXS, focusing on the in autism and FXS, particularly in the sensory auditory sensory domain. It also evaluates processing domain. similarities and differences between auditory sensory processing deficits in autism and FXS Animal models provide an excellent opportunity to highlight aspects of their shared and distinct to examine common mechanisms of sensory pathophysiology. Emerging evidence from rodent processing difficulties in order to develop specific models is also explained, which sheds light on therapeutics. the possible neurobiological underpinnings of This review focussed on investigating individuals sensory deficits in autism, FXS and associated with autism or FXS or rodent models’ response neurodevelopmental disorders. to auditory stimuli as this can be objectively and non-invasively measured. Understanding how the brain processes and responds to sensory stimuli could offer hope for individually targeted, age-specific therapeutic approaches in the future. 24 Middletown Centre for Autism Sensory Processing Volume 2 25

Behavioural, Perceptual, and Neural Alterations in Sensory and Multisensory Function in Autism Spectrum Disorder

BACKGROUND RESEARCH AIMS sensory-specific changes. The study also Full Reference Sensory difficulties within ASD are reported The purpose of the current study is to investigate stresses the importance of applying a more Baum, S. H., Stevenson, R. A. and Wallace, as one of the most significant symptoms, in up the importance of sensory processing and dimensional approach to enhance knowledge M. T. (2015). Behavioural, Perceptual, and to 87% of cases), and yet it has taken up until highlight the sensory features within ASD. It and understanding of the neurobiology and Neural Alterations in Sensory and Multisensory recently (2013) to be included in the diagnostic also aims to emphasise current knowledge and pathophysiology of autism. Function in Autism Spectrum Disorder. measure (DSM-5) as a core symptom of ASD. demonstrate how sensory processing fits within IMPLICATIONS FOR PRACTICE Progress in Neurobiology, 134, p. 140-60. modern contemporary models. The research also Social and cognitive symptoms of ASD have been (by the authors) the main focus, however, sensory processing examines differences within neural processing of • Further studies are much needed to enhance difficulties have been identified as prevalent by those with ASD and those without ASD focusing our understanding of the neurobiological those such as caregivers. on sensory and social communication. The study investigates deficits within multisensory building blocks of ASD. Information integration is a process which integration as a core characteristic of ASD • There is a greater need for empirical is necessary for the construction of durable and the importance of multisensory processing identification of both sensory function and perceptual representations. It is also in building both cognitive and perceptual dysfunction in ASD. arguably essential for constructing cognitive representations. representations and abilities. Daily sensory • Measuring numerous facets of sensory information is presented in various forms which RESEARCH FINDINGS function could highlight sensory specific is processed through the senses. Essentially, The review focuses on studies within four main changes for each individual with ASD. the nervous system combines and synthesises areas of ASD. These include: • Complete identification and characterisation the information so that it is understood as a 1. A typical sensory processing in ASD. of each change within the senses could lead to complete whole. The information may need to the possibility of determining the specificity of be integrated or segregated depending on the 2. Theories of altered sensory and cognitive the changes which are relevant and necessary source and whether it is related or unrelated. If functioning in ASD. for sensory integration throughout all of the the information cannot perceptually represent, 3. Evidence for alterations in neural processing sensory systems. and interpret the world, it will present great relevant to sensory function in ASD. difficulties for communicating with and relating • Neuroimaging based research which although to the environment effectively. 4. Plasticity and Remediation Therapies in ASD. is timely and expensive, could detect correlations between sensory function and The review makes for an interesting read, as Within the brain there are numerous regions cognitive performance. specifically for combining and integrating it deliberately concentrates on examining multisensory information. Neuronal circuits ASD primarily from a sensory dysfunction • The revelation of establishing the relationships and responses are key in the role of coding such framework. It dissects current knowledge and linking brain function, connectivity and information. theories on ASD to emphasise how relevant genetic diversity could be a key to sensory brain regions are for functionality and understanding ASD. However, disruptions within these areas, how they can impact so greatly on the empirical particularly those that are multisensory, may • The authors of the review also suggest more evidence of current studies. The research directs be of importance when examining difficulties work should be carried out to examine shared us to question modern knowledge. Findings within ASD. characteristics of ASD with neuropsychiatric suggest that the information surrounding conditions, focussing on shared deficit areas. sensory dysfunction within ASD is both inadequately recognised and characterised. The review highlights the need for expansion of measuring numerous facets functioning within the same children to identify and characterise 26 Middletown Centre for Autism Sensory Processing Volume 2 27

Sensory Processing in Children with Autism Spectrum Disorder: Relationship with Non- Verbal IQ, Autism Severity and Attention Deficit/Hyperactivity Disorder Symptomatology

BACKGROUND Procedures RESEARCH FINDINGS Recommendations for future research Historically it has been reported that sensory Non-verbal IQ was evaluated by the school Regarding IQ, the authors did not find a relationship Future research should aim to analyse the processing impairments are highly prevalent psychologist in a distraction free environment. between non-verbal IQ and the presence of sensory relationship between sensory processing and in children with ASD. According to sensory Parents and teachers provided the psychologist with issues or social participation or praxis deficits. the performance of attention (visual and integration theory, the processing and integration an interview to provide demographic information auditory attention). and information about the severity of autism. Regarding the severity of ASD symptoms, the of sensory inputs strongly affect development. authors found that the higher the dysfunctions Future research should also consider other Sensory processing impairments involve Measures on the sensory processing measure, the variables that can influence sensory processing a neurological dysfunction that may affect The authors used the following measures: higher severity of autism symptoms across in children with ASD such as parental stress, behavioural responses to sensory input. Sensory 1. Raven’s Coloured Progressive Matrices Test both environments. personality characteristics, the educational style issues can affect the successful performance of (RCPM). This is a non-verbal test, which used and differences in gender. adaptive responses and therefore have an impact Regarding the relationship between ADHD measures the ability to solve problems without on one’s ability to engage in daily activities. symptoms and sensory processing, social relying on previous knowledge. It was used to Sensory functions are also related to praxis, which participation and praxis characteristics, the Full Reference obtain the non-verbal IQ score of each child in authors reported that in the home environment, is the ability to plan and organise movements in Sanz-Cervera, P., Pastor-Cerezuela, G., Maria- the study. both the inattentive and hyperactivity/impulsivity order to carry out unfamiliar motor tasks. Difficulties Inmaculada Fernández-Andrés, M. I. and showed the higher the dysfunction on the sensory with poor motor planning may limit the ability 2. Gilliam Autism Rating Scale, Second Edition. Tárraga-Minguez, R. (2015). Sensory Processing processing measure, the higher the number of for one to expand play or engage with peers. This is a screening scale that helps to identify in Children with Autism Spectrum Disorder: ADHD symptoms. This had greater weight at the severity of autism. The scale consists of 42 Relationship with Non-Verbal IQ, Autism RESEARCH AIMS home than in the classroom environment. items that measure three domains associated Severity and Attention Deficit/Hyperactivity The purpose of this study was to analyse the with ASD: stereotyped behaviour, Regarding the relationship between ADHD Disorder Symptomatology. Research in relationship between sensory processing, social communication, and social interactions. The symptoms and sensory processing characteristics, Developmental Disabilities, 45-46, p. 188-201. participation and praxis impairments as well as higher the value obtained on the global index, specifically touch and hearing, the authors some characteristics of the children such as non- the greater the probability of autism. reported that the hearing score was the only verbal IQ, severity of ASD symptoms, and the 3. The Sensory Processing Measure (SPM). The variable that had a marginally significant number of ADHD symptoms, across home and SPM is an integrated system of rating scales percentage in the inattentive score in the main school environments in a selection of children that assess sensory processing issues, social classroom setting. with ASD. In addition, sensory processing, praxis participation and praxis in children aged and social participation was measured in relation 5-12 years old. IMPLICATIONS FOR PRACTICE to functional performance during daily activities. (by the authors) 4. Behavioural rating scale of inattention and RESEARCH METHODS hyperactivity/impulsivity for parents and The authors have suggested that because of the teachers from the DSM-IV-TR. Parents and possible relationship between sensory processing Participants teachers filled in a questionnaire asking and ADHD symptoms, especially inattention, Forty one children with a clinical diagnosis of about the presence of ADHD symptoms in that attention difficulties could be secondary to ASD participated in the study along with their the child, both inattention and hyperactivity/ sensory problems in children with ASD. They parents and teachers. The children where aged impulsivity behaviours. hypothesised that if this were the case then it between 5 and 8 years old. The children all had would be advisable to first apply intervention non-verbal IQ ranging from 75 to 135 on the 5. Questionnaires developed by the authors. measures aimed at reducing sensory difficulties in Raven’s Coloured Progressive Matrices Test. Parents were asked a variety of questions about order to improve attention. Simplifying classroom their child’s gender, age, educational level etc. acoustics, minimising verbal instructions by Teachers answered a socio-demographic using visual strategies and presenting verbal questionnaire about their gender, age, number information at a reduced pace may help of years teaching experience etc. with attention. 28 Middletown Centre for Autism Sensory Processing Volume 2 29

Sensory Reactivity, Empathising and Systemising in Autism Spectrum Conditions and Sensory Processing Disorder

BACKGROUND RESEARCH METHODS IMPLICATIONS FOR PRACTICE Full Reference Sensory processing refers to the way the The study included 210 participants: 68 parents (by the authors) Tavassoli, T., Miller, L., Schoen, S., Brout, J., brain receives, processes and responds to the of children with autism, 79 parents of children Given that children with higher empathy Sullivan, J. and Baron-Cohen, S. (2017). Sensory continuous stream of sensory information from with SPD and 63 parents of typically developing scores had fewer sensory symptoms, this Reactivity, Empathising and Systemising in the world around us. The successful completion children. The Sensory Processing Scale Inventory study emphasises that children with autism Autism Spectrum Conditions and Sensory of every activity in life (e.g. washing, dressing, was used to measure sensory symptoms, the and children with SPD, having higher sensory Processing Disorder. Developmental Cognitive eating, having a conversation etc.), requires Autism Spectrum Quotient (AQ) to measure symptoms and lower empathy scores may Neuroscience, 29, p. 72-77. accurate sensory processing. Individuals with autistic traits, and the Empathy Quotient (EQ) have challenges with empathising with others; autism often report unusual sensory processing and Systemising Quotient (SQ) to measure therefore, may have difficulty relating to peers symptoms such as heightened sensitivity to touch cognitive styles. Parents completed all four and establishing friendships. or noise. questionnaires on line. Understanding how sensory difficulties can Although the DSM-5 added sensory processing RESEARCH FINDINGS contribute to atypical or challenging behavioural, difficulties as a criterion for autism, there is a social and emotional responses is important. This This study found that in general: group of children who display similar sensory study further evidences the association between difficulties but do not have autism; children • Typically developing children had no sensory processing and social skills. with sensory processing disorder (SPD). Many heightened sensory symptoms and Children with autism and sensory difficulties may defining symptoms between both groups of average levels of parent reported empathy benefit from additional support and education children are similar, (e.g. an apparent disinterest and systemising. focusing on empathy relayed topics such as in peers), as such, diagnostic confusion exists. • Children with higher empathy scores had understanding emotions, emotional regulation RESEARCH AIMS fewer sensory symptoms. and friendship skills. To aid diagnosis between children with autism • Children with autism and children with SPD, and children with SPD, this study aimed to test showed significantly more sensory symptoms whether children with autism and SPD can be than typically developing children. differentiated on sensory symptoms and/or • Children with autism showed lower empathy cognitive styles in empathy and systemising. and higher systemising compared to the • Empathy is the ability to identify and SPD group. understand the thoughts and feelings of • Children with SPD showed empathy and others and to respond to these with systemising skills within average levels. appropriate emotions. • There was also a trend for lower empathy • Systemising refers to how strongly, easily scores on the SPD group, with children with and quickly a person is affected by other SPD scoring marginally lower than TD people’s feelings. children on the EQ (p=0.06). Together, this suggests that sensory symptoms alone may not be adequate to differentiate between children with autism and children with SPD but that cognitive style measures (such as empathy and systemising) could be used for differential diagnosis. 30 Middletown Centre for Autism Sensory Processing Volume 2 31

The Design and Implementation of a CBT-Based Intervention for Sensory Processing Difficulties in Adolescents on the Autism Spectrum

BACKGROUND sessions during school hours lasting 45 minutes. Qualitative analysis • The intervention was positively evaluated by Many individuals with autism experience unusual Session content included typical elements of All seven adolescents completed the programme, participants, results show increased ability to reactions to sensory input which now form CBT interventions with some adaptations from total attendance rate was 92.8%. Each adolescent self-regulate and modify behaviour. However, part of the diagnostic criteria for autism. These existing CBT programmes for individuals completed between 10-25 sensory pictures in consideration would need to be given to features are common and often have a significant with autism. total. All took part in post-intervention focus increased participant anxiety related to the groups (adolescents) and interviews (parents). intervention. impact on individuals and their families. Previous FINDINGS studies have been based on measurement of Quantitative analysis • Future research is required by means of sensory experience ignoring the role of cognition. Adolescents’ of the intervention randomised trials with larger samples of They have produced few validated interventions Analyses indicated no significant change in adolescents to further test the efficacy of this Participants reported positive experiences of the scores over the three -time points on the primary to remedy adverse sensory experiences felt by programme. Five themes were identified from eight week CBT-Sensory based programme. individuals with autism. outcome variables (SSP and AASP). There focus group discussions; raised awareness of was also no significant change between pre- sensory experiences, new-found self- expression, RESEARCH AIM intervention and follow-up for the secondary Full Reference motivation for using coping strategies, This study explores the feasibility of an eight week outcomes variables (SCAS-P and RBQ). generalisation of learning and improvements to Repeated-measures ANCOVA analyses showed Edgington, L., Hill, V. and Pellicano, E. (2016). CBT-based, group intervention for self-regulation the programme. Within these themes adolescents The Design and Implementation of a CBT-Based of sensory processing difficulties. This differs no significant effect for both the AASP score and reported increased awareness of the relationship SSP. However, effect sizes as estimated by partial Intervention for Sensory Processing Difficulties in from previous research studies which are largely Research in between thoughts, feelings and behaviours, new eta squared are moderate-to-large. Analyses Adolescents on the Autism Spectrum. based on applying knowledge of neurological vocabulary acquisition and had the opportunity Developmental Disabilities, 59, p. 221-233. sensory sensitivities to measurement of sensory of secondary measures (RBQ and SCAS-P) to experience a supportive group dynamic. They also showed no significant effect. Researchers experiences and resulting interventions as it self-report using coping strategies acquired in the includes the role of cognition. surprisingly identified an increase in parent- programme to relieve stress, avoid conflict and reported anxiety and repetitive behaviours based RESEARCH METHOD self-motivate across new situations. on means from SCAS-P and RBQ. Parents’ perceptions of the intervention Seven male adolescents with autism aged 11-16 IMPLICATIONS FOR PRACTICE years from one mainstream secondary school Five themes were identified from parents’ (by the authors) participated. Inclusion and exclusion criteria responses; challenges to parental involvement, stipulated participants must have an independent importance of open communication with parents, • In terms of feasibility, results indicate this clinical autism diagnosis, sensory issues as positive post intervention changes, importance study successfully achieved its aim, which was reported by school, functional hearing and of group dynamics and improvements in future to increase adolescents’ awareness of their vision, an IQ of 70 or above and not taking support and delivery. Parents reported it to be sensory experiences and how it may differ to psychotropic medications. difficult to obtain direct information on session others. It increased participants’ expressive content from adolescents and were positive about language in relation to sensory difficulties and Measures of sensory reactivity, anxiety and the facilitators’ ability to aid communication and equipped them with new coping strategies. repetitive behaviours were taken at baseline, understanding on a weekly basis. They reported post-intervention and at follow-up eight weeks • High attendance rates and student engagement observing their young person to use new coping post programme including Adolescent/Adult in the programme demonstrates its feasibility tools and having a “safe space to think”. Sensory Profile (AASP), Short Sensory Profile to be successfully incorporated within the (SSP), Repetitive Behaviour Questionnaire complex environment of a mainstream (RBQ), Spence Children’s Anxiety Scale- secondary school. This fits with initiatives to Parent (SCAS-P). Researchers also conducted increase mental health support in schools. semi-structured interviews and focus groups. Intervention consisted of eight weekly group 32 Middletown Centre for Autism Sensory Processing Volume 2 33

A Systematic Review of Sensory Based Autism Subtypes

BACKGROUND Articles Reviewed RESEARCH FINDINGS Further research is required to define sensory Children with autism often present with sensory Seven of the eight eligible articles were rated as The literature consists of a small number based subtypes that could provide a logical processing difficulties. Sensory processing meeting evidence criteria of a level IV and one of descriptive studies with little consensus mechanism for assigning children to treatment abilities vary considerably in children with study met criteria for a level III. on subtypes. groups for research studies or selecting appropriate intervention techniques. autism. Parent report measures have long The results from the systematic review suggest Findings indicate that sensory-based subtypes identified that as a group, children with autism that only a limited number of studies have in children with autism were developed using have significant differences in all or many sensory examined sensory-based subtypes within this primarily parent-report instruments that assess Full Reference domains compared to neurotypical children. population and that the focus of this work differences in sensory responsivity. DeBoth, K. and Reynolds, S. (2017). A Systematic Sensory-based subtypes or categories have been has been on aspects of sensory modulation as Several different subtyping schemes were Review of Sensory-Based Subtypes. Research in proposed as a means to better understand the opposed to the more inclusive factors associated presented, suggesting between three to five Autism Spectrum Disorders, with sensory processing disorder (i.e. the studies 36, p. 44-56. unique sensory qualities in children with autism. subtypes as an appropriate fit to encompass the do not include measures of praxis or sensory Having distinct subtypes could help clinicians different patterns of sensory responsivity seen in discrimination). prioritise interventions and deliver more targeted children with autism. therapeutic strategies. Most of the reviewed studies based their sensory Several studies suggest that a subgroup of this based subtypes on results of parent report RESEARCH AIMS population has typical sensory functioning, and measures (Sensory Profile instruments or Sensory a subgroup exists with significant, global sensory The purpose of this systematic review is to Experiences Questionnaire), however one used differences. Mixed results were found for those synthesise information about sensory-based a semi-structured play-based observational children who fall in between, who have specific subtypes that have been reported in the literature assessment rather than parent rating (The Sensory versus global differences in responsivity (i.e. for children with autism. Processing Assessment). hyper- or hypo-responsivity or sensory seeking), REVIEW METHODS The subtypes categorised within the measures are or within specific sensory domains. as follows: PRISMA guidelines informed this review process. IMPLICATIONS FOR PRACTICE Included articles were published in the last 12 • The Sensory Profile instruments: Seven groups years, specific to children with autism between (tactile, taste/smell, movement, under- (by the authors) the ages of 2–18 years old. The authors of this responsive/seeks, auditory, low energy/weak, Clinicians should be aware that there is a study performed a systematic literature search visual/auditory) and overall sensory subset of children with autism who appear to using a range of electronic databases. Search responsivity. The full Sensory Profile score have typical sensory modulation abilities; for terms were designed to answer the following expands the characterisation of sensory this subtype, professionals should be explore research question: responsivity patterns into nine factor alternatives that may better support other causes of atypical behaviour as sensory modulation may What sensory-based subtypes have been used to groupings (responsivity, seeking, emotional not be a casual factor. classify children with autism? reactivity, low endurance/tone, oral sensitivity, inattention/distractibility, registration, More global sensory processing deficits may A total of 361 articles were identified through sensitivity, sedentary, fine motor). greatly impact functioning in other performance the initial database searches. After removal of areas, and occupational therapists will play a duplicates and application on inclusion criteria, • The Sensory Experiences Questionnaire: Four critical role in supporting these needs. eight articles were selected for review. Across the sensory factors (hyper-responsivity, hypo- eight articles, 1643 children with autism were responsivity, sensory interests and repetitive/ Aspects of sensory modulation, such as hypo- included in this review. On average 83.6% (range seeking behaviours, and enhanced perception). or hyper-responsivity may have a direct link to 79.9–91%) of the subjects were male and the • The Sensory Processing Assessment: Uses an individual’s ability to successfully complete overall age range of the subjects included across observations of child responses rather than everyday activities such as washing, dressing, studies was five months to 12 years. strictly parent rating scales. writing etc. 34 Middletown Centre for Autism Sensory Processing Volume 2 35

The Interplay between Sensory Processing Abnormalities, Intolerance of Uncertainty, Anxiety and Restricted and Repetitive Behaviours in Autism Spectrum Disorder

BACKGROUND RESEARCH METHODS IMPLICATIONS FOR PRACTICE Full Reference Sensory processing difficulties are a recognised The sample was 53 children with autism aged (by the authors) Wigham, S., Rodgers, J., South, M., McConachie, challenge for children and young people 8-16years comprising 47 boys and six girls. The researchers acknowledge that this research H. and Freeston, M. (2015). The Interplay diagnosed with autism. These difficulties The parents of the children completed a screening was based on a small sample size and that it is the between Sensory Processing Abnormalities, can impact on the individual’s experience of measure for autism and a range of measures first research to address the role of intolerance Intolerance of Uncertainty, Anxiety and the sensory world, leading to sensory under relating to the child’s sensory difficulties, anxiety, of uncertainty on sensory experiences and Restricted and Repetitive Behaviours in Autism responsiveness, sensory over responsiveness and intolerance of uncertainty and restrictive and restrictive and repetitive behaviours. The impact Spectrum Disorder. Journal of Autism and sensory seeking behaviour. These can often occur repetitive behaviours. The results of these were of intolerance of uncertainty on the children led Developmental Disorders, 45, p. 943–952. within the same sensory system demonstrating subject to statistical analysis in order to determine to a range of implications for practice detailed by the complexity of the sensory systems and the any relationships or correlations. the researchers. These were: need for further research in this area. It has been • There is a need for further research into suggested that the experience of anxiety and what RESEARCH FINDINGS intolerance of uncertainty in autism and in is called intolerance of uncertainty may influence The research findings indicate that the child’s autism and anxiety sensory related behaviours e.g. restricted and sensory responding i.e. under responding and repetitive activities. Understanding the role of • Heightened levels of intolerance of uncertainty over responding had an impact on restrictive anxiety and intolerance of uncertainty and their led to more restrictive and repetitive and repetitive behaviours. The children who relationship with the experience of sensory behaviours so interventions that address were reported by their parents as presenting with difficulties and any behaviours related to this will intolerance of uncertainty may lead to a under responding to sensory input generally be useful in developing supportive strategies for reduction in restrictive and repetitive presented with both insistence on sameness, children and young people with autism. behaviours. restrictive repetitive behaviours and motor RESEARCH AIMS restrictive repetitive behaviours. The children • Practitioners should teach behavioural and who were identified by their parents as presenting cognitive strategies that build resilience to The aim of this research was to examine the with over responding to sensory input generally uncertainty. relationship between sensory processing presented with insistence on sameness, restrictive • Increased restrictive and repetitive behaviours difficulties and repetitive behaviours and to repetitive behaviours. In all cases the presentation examine the impact, if any, of intolerance of may indicate increased levels of anxiety and of restrictive repetitive behaviours was also intolerance of uncertainty. uncertainty and anxiety in children and young influenced by the child’s anxiety levels and the people with autism. child’s ability to tolerate uncertainty. In all cases • Simple strategies such as providing reassurance intolerance of uncertainty drove up both anxiety and visual timetables and schedules may and restrictive and repetitive behaviours. reduce uncertainty and this may have an impact on behaviours. 36 Middletown Centre for Autism Sensory Processing Volume 2 37

Assessing Sensory Processing Dysfunction in Adults and Adolescents with Autism Spectrum Disorder: A Scoping Review

BACKGROUND The second phase (Grey Literature search) Qualitative interviews IMPLICATIONS FOR PRACTICE Sensory Processing is known to be associated identified studies that were relevant, directing Research identified this method as favourable in (by the Authors) their research around clinical guidelines of with and part of the current diagnostic criteria its flexibility in structure and ease for collecting • Outline the need for a variety of assessment all ASD organisations which are national for ASD. Little research has been conducted information. It can be individualised, therefore approaches that combine both measures and associations as well as regulatory bodies within into assessing sensory processing difficulties in client specific which again is highly significant techniques. both adolescents and adults with ASD. Evidence varying countries including the United States of for ASD. They found that clients were more • Assessments are required that are specifically suggests that sensory symptoms are significant in America, Canada, the United Kingdom, Australia inclined to share more information through this designed for adolescents and adults with ASD, adolescents and adults with ASD. and New Zealand. A screening process and data methodology. Although they also bring their extraction was also applied to phase two of the attention to the skill of the clinician and how particularly accounting for the prevalence of RESEARCH AIMS study. Furthermore, a data synthesis of both this can have an impact on the result, it is very concurrent IDD. The primary aim of this study was to identify empirical and clinical studies was employed. time consuming for the professional conducting • Identified a need for more research particularly approaches that have been used to measure Utilising such an approach the authors identified the interview and there needs to be a strong advising a systematic review around results of sensory processing within current literature. The 4769 articles and a total of 12 clinical guidelines. theoretical understanding and knowledge questionnaires, compared to psychometric research also aimed to both describe and compare surrounding sensory processing in adults with ASD. properties. RESEARCH FINDINGS best practice guidelines that could possibly be Psychophysical methods • More research would be recommended as the integrated into future evidence-based practice. Following the intensive screening process, 66 Interestingly it was discussed that this method current collection of assessments for sensory The review aspired to be informative in sensory relevant articles were discovered and reviewed was currently not within any of the reviewed profile are limited. processing assessment techniques which are recognised for this study. Assessment approaches were clinical guidelines. The authors state that this and consistent internationally and interdisciplinary pinpointed as relevant. These included: Self- and • Clinical practice could be improved through method could provide vital baseline sensory across the lifespan of those with ASD. Proxy-Report Questionnaires, Psychophysical the addition of newly established information which could potentially improve Assessment, Direct Behavioural Observation, questionnaires such as SR-AS as add-ons for clinical decisions. RESEARCH METHODS Qualitative Interview Techniques, and current assessments. The review considered scientific databases and Neuroimaging/EEG. Direct behavioural observation • Clinical guidelines that are both international grey literature ranging from January 1987 to This was the first review to systematically identify Research demonstrated a gap within the literature and interdisciplinary could bridge the gap in May 2017. The authors identified that the most instruments to assess sensory processing in which currently exists around behavioural sensory processing research. The authors effective methodology for analysing such complex adolescents and adults demonstrating a range of observation. Most of the research surrounding suggest doing this through an expert information qualitatively and quantitatively was options other than the AASP. observable behaviours and sensory processing conference specifically for sensory processing. through the implementation of a scoping review. difficulties employed a functional behaviour • Clinical education should be implanted in This was carried out using a two-phase approach Self and proxy report measures assessment (FBA). The authors found that this sensory processing knowledge. which included a comprehensive search of the It was found that the most predominant was a limited assessment tool for measuring empirical literature available, followed by a assessments currently in use are Self- or Proxy- sensory processing difficulties. systematic search of the grey literature. report measures (71.1%). Eleven were found in Full Reference Neuroimaging During the first phase (Empirical Research) the scoping review, mostly within cross-sectional DuBois, D., Lymer, E., Gibson, B. E., Desarkar, Although this measure is costly and difficult the authors ascertained relevant studies which studies focusing on sensory processing in ASD. P. and Nalder, E. (2017). Assessing Sensory to obtain the research ascertains the potential included ‘ASD’, ‘sensory processing’, and ‘methods’ Reviewers highlight the strengths of this Processing Dysfunction in Adults and strength of this method for advancing knowledge or ‘tools’ to ‘assess sensory processing’. Detailed method outlining the ease of implementing such Adolescents with Autism Spectrum Disorder: A around sensory processing particularly if eligibility criterion was applied outlining those assessments, the vast amount of information that Scoping Review. Brain Sciences, 7 (8), p. 108-131. combined with various other methods. articles to be included and excluded within the can be collected promptly and how the individual review. The reviewers also employed article doesn’t necessarily need to be present as they can screening and data extraction processes to focus easily be done online or over the telephone. their study. 38 Middletown Centre for Autism Sensory Processing Volume 2 39

The Impact of Atypical Sensory Processing on Social Impairments in Autism Spectrum Disorder

BACKGROUND RESEARCH AIM RESEARCH FINDINGS Olfaction and Gustation Prior research focusing on sensory processing The relationship between sensory and social Vision The authors found that despite there being limited research on olfaction and gustation in autism, and autism has found that up to 95% of parents processing can occur at many hierarchical levels Differences in vision is one of the earliest markers eating behaviour and sensitivity to smell are of children with autism report some atypical and atypical behavioural outcome can reflect a of autism; atypical has been common concerns for individuals with autism. sensory behaviour in their child. Sensory breakdown at any point within the hierarchy. widely documented in individuals with autism. Overall there is evidence of atypical responses processing difficulties are reported across all The aim of this review was to examine Perception of social cues is crucial in social to both however, future studies to examine the ages and levels of symptom severity. Previous behavioural and neurobiological studies on social development and interpersonal interactions as relationship between them and social functioning research also identified that sensory processing and sensory processing in autism across multiple it drives visual attention patterns. The authors is needed. difficulties adverselyff a ect both daily functioning modalities; vision, auditory, tactile, olfaction, outline how atypical visual processing spanning and academic performance. The behavioural, gustation, and , with the gaze processing, face processing and biological Multisensory integration neurophysiological and anecdotal evidence of purpose of exploring the relationship between motion processing can have cascading deleterious The integration of multisensory stimuli is sensory impairment as a prevalent characteristic sensory deficits and social functions in autism. effects on subsequent social functioning. feature of autism is acknowledged in the DSM-5. essential for social functioning and complex Theoretical models of autism and their Auditory social interactions. The integration of senses Sensory receptors are stimulated by provides more information than the separate implications for the relationship between sensory Hearing is an important aspect of successful environmental stimuli and sensory information components, thus creating predictability which and social functioning were also discussed in social-communication interactions. Abnormal is relayed to the brain to create a subjective influences how an individual interacts socially. this paper. auditory processing, which is consistently neural representation. This process is known Even if the perception of each individual sense is reported in autism, stems from atypical sensation, as perception. Sensation and perception are RESEARCH METHOD intact, the integration of senses into a perceptual inter-related constructs however a breakdown altered perception, and lack of preferential In this review paper, behavioural and whole may fail thus impacting on social of sensation results in a lack of perception, and attention to auditory stimuli. The review found neurobiological studies relating to social and functioning. The review details how language similarly, without perception the activation of a that oversensitivity to speech and prosody sensory processing in autism were examined. development, emotion recognition, imitation and sensory receptor is meaningless. An additional results in individuals being unable to filter out More specifically, authors investigated the developmental considerations of impairments in concept in this process, is attention. An individual background noise, attend to speech and other possible mechanisms by which atypical sensory multisensory integration in autism impacts on may sense and perceive a stimulus but fail to relevant social cues thus impacting negatively on processing across the five basic senses could social functioning. attend to it in an expected way, therefore it can be decoding and reciprocity in social exchanges. manifest in social deficit characteristics of difficult to disentangle these constructs to identify autism. Furthermore, the authors reviewed Tactile whether sensory, perceptual, or attentional deficit existing hypotheses which attempted to integrate Touch is important for developing social bonding. is underlying a given response. these features as well as reviewing evidence The review found that individuals with autism Prior research often focuses on the sensory and from neuroimaging studies which highlighted display abnormal detection of tactile stimuli as social features of autism independently, however differences in sensory and social representations well as a lack of habituation to tactile stimuli. new theoretical and empirical evidence suggests often observed in autism. In addition, three According to the authors these irregularities in a stronger relationship between the two than theoretical models of autism were outlined and touch and tactile perception may be associated previously thought. implications for the relationship between sensory with broad levels of social dysfunction in autism and social functioning were addressed. but that future research on the importance of tactile perception in orienting and self-regulation as well its impact on other social domains is needed. 40 Middletown Centre for Autism Sensory Processing Volume 2 41

IMPLICATIONS FOR PRACTICE Full Reference (by the author) Thye, M. D., Bednarz, H. C., Herringshaw, Sensory characteristics across autism are varied, A. J., Sartin, E. B. and Kana R. K. (2017). The with features ranging from intact, enhanced to Impact of Atypical Sensory Processing on Social impaired. Dysregulated sensory processing is Impairments in Autism Spectrum Disorder. considered universal in autism. Developmental Cognitive Neuroscience, 29, p. 151-167. According to the authors, this paper consolidated the evidence emerging from behaviour, neuroscience, and other modalities of research on sensory and social processing in autism and identified their inter-relationship in autism. Atypical sensory processing in autism can impact on the individual’s ability to attend to social stimuli, decode intentions, engage in social reciprocity, and adhere to social norms of behaviour. Atypical sensory processing can also impact on the individual’s ability to engage and obtain an accurate assessment and consequently access intervention and therapy. As sensory issues can differ across individuals with autism, they play a key role in social and communicative difficulties in autism. Future research should give consideration to sensory needs when designing intervention plans for children with autism. There are several cognitive and neurobiological mechanisms through which sensory processing abnormalities might either cause or exacerbate many of the social impairments seen in autism. The authors found that altered sensory processing and sensory integration in autism affect language, communication, emotion, response to reward, and interpersonal functioning in individuals with autism. It is important that practitioners continue to build models of autism that incorporate both the social and sensory domains of autism. This acknowledges that the two core domains of autism are interrelated therefore require intervention that targets both domains in conjunction. Sensory Processing Volume 2 43

CONCLUSION Your Opinion

This Bulletin provides summaries of fourteen The Centre trusts that you have found this Research Bulletin informative. articles addressing a range of issues involving It would be appreciated if you would take a few minutes to provide the Centre sensory processing in autism. The articles address with feedback in relation to this bulletin by clicking on the survey link below. areas from childhood through to the assessment of sensory issues in older children and adults, which is an area that requires development. Research Bulletin Feedback Sensory Processing (Volume 2) For parents, people with autism and practitioners there are broad implications for practice to be taken from the summaries. Some of the more salient implications are: • Sensory characteristics across autism are varied, with features ranging from intact, enhanced to impaired. Dysregulated sensory processing is considered universal in autism. • Assessments are required that are specifically designed for adolescents and adults with ASD. • Increased restrictive and repetitive behaviours may indicate increased levels of anxiety and intolerance of uncertainty. • Children with autism and sensory difficulties may benefit from additional support and education focusing on empathy relayed topics such as understanding emotions, emotional regulation and friendship skills. • CBT style training may increase adolescents’ awareness of their sensory experiences and how it may differ to that of others. The Centre’s Research and Information Service welcomes any correspondence including suggestions for future Bulletins to: [email protected]

Middletown Centre For Autism 35 Church Street, Middletown, Co. Armagh BT60 4HZ T +44 (0)28 3751 5750 E: [email protected] W: www.middletownautism.com J G Cooper: Chief Executive, Registered in Northern Ireland, No. NI063661