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Sensory Modulation in Autism-Handout 7/26/18 STRATEGIES FOR SENSORY MODULATION IN AUTISM SPECTRUM DISORDERS Gail J. Richard, Ph.D. CCC-SLP Professor Emeritus, Director, Autism Center Eastern Illinois University [email protected] Disclosures • Financial • Honorarium from FLASHA • Expenses paid by ASHA • Royalties on publications with ProEd (LinguiSystems) and Dynamic Resources • Revenue from courses with MedBridge • Non-Financial • Dr. Richard serves as Immediate Past President on the ASHA Board of Directors Current Status of Autism Spectrum Disorder Autism: Leo Kanner, 1943 “Self” Prevalence: 1 in 68 30% increase from 2012 to2014 no change from 2014 to 2016 (Center for Disease Control, 2016) Gender Ratio: Higher Incidence in Males (5:1) Males: 1 in 42 Females: 1 in 189 Siblings: Increased prevalence (19%) Increased risk in twins 1 7/26/18 Operational Definition: AUTISM A PHYSICAL DISORDER OF THE BRAIN THAT CAUSES A LIFELONG DEVELOPMENTAL DISABILITY POWERS, 1989, 2000 DSM 5: Autism Spectrum Disorder • A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history • Deficits in social-emotional reciprocity • Deficits in nonverbal communication behaviors used for social interaction • Deficits in developing, maintaining, and understanding relationships • B. Restricted, repetitive patterns of behavior, interest, or activities, as manifested by at least two of the following, currently or by history • Stereotyped or repetitive motor movements, use of objects, or speech • Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior • Highly restricted, fixated interests that are abnormal in intensity or focus • Hyper- or hypoactivity to sensory input or unusual interest in sensory aspects of the environment Note: Must specific severity in A & B using chart, based on social communication impairments and restricted, repetitive patterns of behavior. Intervention: Try to move from level 3 or 2 to 1 Severity Level Social Communication Restricted Repetitive Behaviors Level 3: Requiring very (description) (description) substantial support Level 2: Requiring (description) (description) substantial support Level 1: Requiring (description) (description) support 2 7/26/18 DSM 5: Autism Spectrum Disorder • C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). • D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning • E. The disturbances are not better explained by intellectual disability or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make co-morbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level Specify if: • With or without accompanying intellectual impairment • With or without accompanying language impairment • Associated with known medical or genetic condition or environmental factor • Associated with other neurodevelopmental, mental, or behavioral disorder • With catatonia ASD Data from Human Genome Study • ASD polygenetic – heterogeneous neurodevelopmental complex inherited disorder • Monogenetic – Fragile X and Rett’s • Continuum of neurocognitive features with shared aspects • Different types of mutant genetic changes associated with ASD • Severe loss of synaptic connectivity • Diverse levels of genetic buffering, pruning • Genetically based metabolic differences • Abnormality in brain structures and/or function during development DSM -5 Mislabeled the Disorder? • Spectrum implies different degrees of a single disease entity • Autism is NOT a single disease entity • Results from altered neuropathways in the brain • Found in many different genome configurations; no one gene is 100% of autism cases • Many possible comorbidities • No unique disorder entity that is autism • Should be autistic syndrome disorder • Coleman, M. & Gillberg, C., 2012 3 7/26/18 Autism is Lifelong Disorder • Research suggests etiology of autism based in DNA • Not caused post-birth; happens before born (NOT diet, vaccinations) • Intervention can positively impact evolution of the disorder, mitigate severity of symptoms • Cannot “cure” the disorder • Symptoms should modify with age and treatment “No two autistic children are alike… The goal is to observe and find the specific pattern of response each child exhibits…” Temple Grandin Emergence: Labeled Autistic Primary Behavioral Characteristics ■Reciprocal Social Interaction Deficits ■Averted or indirect eye contact ■Minimal facial expression and use of gestures ■Lack of join attention on focus on others ■Egocentric verbal and social interactions ■Communication Impairments ■Developmental apraxia of speech ■Echolalia, verbal perseveration ■Monotone, robotic vocal prosody ■Literal /concrete in language acquisition and interpretation ■Restricted Repetitive Patterns of Behavior ■Self-stimulatory movements ■Motor perseveration and/ or fascination ■Obsessive preoccupation and attachment to items ■Reliance on routines and rituals 4 7/26/18 Sensory System Differences • Hyper (over) and Hypo (under) responsiveness to sensory stimuli • Tactile defensiveness • Hyperacusis • Picky eating • Self-regulation problems with sensory stimulation • Fail to modulate volume • Seek inappropriate sensory stimulation • Hypotonia • Low muscle tone • Fine motor deficits • Gross motor deficits Incremental Model of Personality Development SOCIAL INTERACTIONS Based on learned skills, behaviors emotional tone of experiences PERCEPTUAL CONSTANCY Makes it possible to predict, learn, & organize into memory SENSORY INTEGRATION Organized vision, hearing, smell, feedback from movement; Based on bilateral organization SELF-AWARENESS Where am I? = vestibular system; Body parts = proprioception Boundaries of self = tactile system SURVIVAL Air, Food, Water, Warmth Individual Differences n Understand how neurological systems reacts and interprets stimuli n Individual Differences (Greenspan & Wieder (1998) n sensory modulation (hyper / hypo responsiveness) n processing n motor planning & sequencing n Nature vs. Nurture Dance n Brain partially wired at birth; Rest occurs after birth; genes & environment interact together n Plasticity through puberty n Support biology to overcome /compensate for deficits n Brain creates itself through experiences; every experience helps create connections 5 7/26/18 Sensory Processing Disorder • Immature or delayed myelination in neurological development will result in sensory system differences • Sensory deficits can occur independent of autism spectrum disorder • Often accompany medical syndromes (i.e., Down Syndrome, Fragile X, Rett Syndrome) and cognitive/intellectual impairments Sensory processing abnormalities • Cross-sectional study examined auditory, visual, oral, and touch sensory processing as measured by Sensory profile • 104 subjects with diagnosis of ASD • 3-56 years of age • Gender and age matched to community controls • ASD had abnormal auditory, visual, touch, and oral sensory processing significantly different than controls • Lower levels of abnormal sensory processing in later ages • Conclusion: Global sensory abnormalities in ASD involving several modalities; potential to improve with age Kern et al. 2006 NEUROLOGICAL CONNECTION CORTEX PROCESSING RETICULAR FORMATION SCREENER AROUSAL VESTIBULAR SYSTEM Richard, 1997 6 7/26/18 ABERRANT SENSORY SYSTEM RESPONSES HYPER-RESPONSIVE HYPO-RESPONSIVE Taste Sight Smell Hearing Movement Touch Muscles Vestibular Light Touch Deep Touch & Organ Temperature or Pressure Joints Richard, 1997 Biochemical Teeter-Totter Endorphins Anxiety Anxiety Endorphins Pendulum of Emotions Overload Low High Energy Underload Energy Quiet Alertness Optimal Level 7 7/26/18 SENSORY INTEGRATION “The neurological process that organizes sensation from one’s own body and from the environment and makes it possible to use the body effectively within the environment.” Jean Ayres, 1979 Sensory Integration n Designed to build up filtering n Desensitization is to balance excitation and inhibition n Myelin – insulation on axon so stimulus propelled more efficiently and accurately n Pruning process defective (over and under) – leads to brain that has trouble adapting to world Interrelated Components for Sensory Integration • Sensory Registration: Aware of sensory event/ stimulation – Hyper-reactivity • Light sensitivity • Sound sensitivity • Discomfort with certain textures (clothing) • Aversion to certain smells and tastes • Irrational fears – Hypo-reactivity • Disregard sudden or loud noises • Unaware of injury (bump, bruise, cut) • Lack of attention to environment, people, things • Delayed responses • Orientation: Pay attention to the sensory information and modulate through inhibition or facilitation • Interpretation: Determine response – “fright, flight, or fight” – Sensory Defensive Behaviors – Touch or tactile defensiveness – Gravitational Insecurity – Auditory Defensiveness – Visual Defensiveness – Oral Defensiveness • Organization of Response: Determine if response necessary and choose behavioral response. – Physical, Emotional, Cognitive options • Execution of Response: Motor planning 8 7/26/18 Signs of Sensory Integration Dysfunction • Hyper-sensitivity, hyposensitivity, or mixed sensitivity to stimuli • Avoids sensory
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