Amy Yun &

Dianne Koontz Lowman

Things you already know…

  Vision

  Hearing

  Smell

  Taste

  Touch

Vestibular

Proprioception

Neurological Process Organizes sensation

from one’s body & the environment

Enables one to use body effectively within environment

OT Intervention: (OT-SI) Based upon theory Used to address difficulties

with neurological process

Theoretical framework for understanding brain-behavior relationships based on knowledge & assumptions about the nervous system

Ayres, 1972, 1989

Children are active agents Intrinsically motivated to

challenge self Development is influenced

by unique transactions with the environment (Blanche, 1998)

Neuroplasticity Nervous system has

capacity to change

Learning depends upon the ability to accurately

Take in sensations from the environment & body

Process & integrate this info within the CNS

Use information to plan & organize increasingly complex behaviors

Williamson & Anzalone, 2001

Action

Sensory Integration

& Modulation

Affect Attention

Arousal

Exists when sensory signals don't get organized into appropriate responses.

Results in observable problems Motor: clumsiness, postural instability

Cognitive: slower /incomplete processing

Behavior: avoidance, rigidity, aggression, withdrawal…

Affective: anxiety, depression

Functional: Problems participating within

& performing occupations ADL, play, school

May impair social relationships

"Is the child's problem getting in his way?

And if not, then is it getting in everyone else's way?“

C. Kranowitz

Sensory Based Motor Disorders Difficulties with praxis (conceptualize, plan, & execute new movements) Signs

Reaches motor milestones at later end of “typical” range Clumsy, difficulties with self care, productive & play activities Low self-esteem “Behavior problems” - Rigid, avoids, difficult transitions, manipulates

Sensory Discrimination Disorder Inability to distinguish between different stimuli, or organize temporal

& spatial qualities If you can not distinguish, you can not learn…

SPD Foundation

Sensory Modulation Disorder Person is not able to adjust

response in relation to environment

Neuro-modulation Reflects ability of central

nervous system to regulate arousal in response to environment

Frequency of stimulation Amplitude –intensity of

stimulation Multiple or single sensory

input(s) Duration of stimulation

Reflects balance between SNS & PNS

Davies & Gavin (2007) Ability to habituate typically develops over time Children identified as having SMD demonstrate

difficulties habituating to neurological stimuli compared with controls

Priming occurs with difficulties increasing with time & exposure to stimuli rather than decreasing

Schaaf, Miller, Seawall, & O’Keefe (2003) Children with SMD demonstrate vagal tone (PNS) Children with SMD do not habituate to repeated stimuli

McIntosh, Miller, Shyu, & Hagerman, (1999). Electro-dermal responses high amplitude orienting is

associated with poorer performance on the SSP

Neurological Thresholds

BehaviorIn accordance w/threshold

ResponsesTo counteract Threshold

High(habituation)

Poor registration Sensation Seeking

Low(sensitization)

Sensitivity to Stimuli

Sensation Avoiding

Evidence for Sensory Processing Problems in

Children with ASD Children with ASD demonstrate

Atypical auditory processing (Kulesza & Mangunay, 2008; (Zwaigenbaum et al., 2005)

Atypical visual processing Atypical responses to tactile (touch) (Zwaigenbaum et al., 2005)

Atypical abilities processing sensory information (Belemonte e t al 2004) Atypical performance on Sensory Profile (Kern et al 2007a)

Difficulties modulating response to environmental events Atypical vestibular processing compared to community controls (Kern et

al 2007b) Atypical sensory modulation compared with community controls (Kern, et

al 2008) Older people with ASD scored closer to community controls than

younger people with ASD Children with ASD showed more dys-regulation than children

with intellectual disabilities (Seynhaeve & Nader-Grosbois, 2008).

Atypical Structure of Elements of Central Nervous System of People

with ASD Brain Stem

Atypical medial superior olive (Kulesza, R. J., & Mangunay, 2008)

Function: localize source of sounds Atypical cell shape & orientation in people with ASD

Cerebellum Forebrain

Amygdala enlarged Function: emotions & emotional regulation

Enlargement associated with severe anxiety & decreased social & communication skills.

Most of the time we think about challenges associated

with Autistic Spectrum Disorders as simply existing

within the child with the disorder…

Maybe we need to think about this in a more sophisticated way…

Transactional Models

View development & brain organization as a process of transaction between (Fox, Calkins, & Bell, 1994)

Genetically coded programs for the formation of structures & connections among structures

Environmental influences

“is emotional & social competence in young children who are developing appropriately according to biology, social relationships, & culture”.

“Normal paths of development serve as reference points to assess infant competence”

Charles Zeanah, M.D.

Individual Client Factors Temperament Development Body Structures & Body Functions Meaning Sensory Processing Cognition

Process

Context Relationships Routines Risk factors Attachment

Client Story

Client History

Infant Caregiver Dyad Family Environment

Human brain growth spurt Begins in 3rd trimester - 24 mos

(Dobbing & Sands, 1973) Brain generates genetic materials

Programs developmental processes

Directly influenced by events in social-affective environment (Schore, 1994).

Consumes more energy than at any other stage

Requires Nutrients (fatty acids (Dobbing,

1997) Regulated interpersonal

experiences for optimal maturation (Levitsky & Strupp, 1995; Schore, 1994).

Critical periods- “specific critical conditions or stimuli are necessary for development & can influence development only during that period” (Erzurumlu & Killackey, 1982, p. 207).

Conditions & events occurring in “critical” or “sensitive” early periods of brain development have long-enduring effects. Brazelton & Cramer (1990)

Fundamental Biological Adaptation Strategy CNS reacts & modifies itself in

relation to environment. (Schore, 2001)

Cortical & subcortical networks Hyper generation of neurons &

synapses Competitive interaction

‘environmentally driven process - selects connections that most effectively relay information.’

Activity-dependent (Chechik, Meilijson, & Ruppin, 1999; Schore, 1994).

Environmental experiences may enable or constrain structure & function of the developing brain.

BioEnvironmental-Biosocial Brains (Gibson, 1996)

“Enriched environment” can be coupled with psychoneurobiological construct of a “growth-facilitating” interpersonal environment (Schore, 1994)

“Biological variables not only influence behavior & environment …behavioral & environmental variables also impact on biology.” Cairns & Stoff, 1996

Attachment Patterns Shape Brain Structure & Function for Life

Attachment interactions allow for the emergence of a biological control system that functions in the organisms state of arousal (Bowlby, 1969)

Attachment theory = Regulatory Theory (Schore 2000) Typically the secure mother intuitively regulates

baby’s shifting arousal levels & emotional states Dys-regulated children pose challenges for parents

“the longer an individual continues along a maladaptive ontogenetic pathway, the more difficult it is to reclaim a normal

developmental trajectory”

(Cicchetti & Cohen, 1995, p. 7).

Stress & Stress Response Subjective experience

induced by a novel, potentially threatening or distressing situation

Behavioral or neurochemical reactions

Designed to Promote adaptive responses to

physical & psychological stimuli

Preserve homeostasis. . . .

Mediated by Central Nervous System Autonomic Nervous

System SNS Energy-expending PNS conserves energy

Survival depends upon ability to maintain homeostasis in response to challenges by stressors (Weinstock 1997)

Critical Periods Stress & Coping Pre/post-natal periods are “critical period” of limbic–

autonomic circuit development (Rinaman, Levitt, & Card, 2000)

Shapes ongoing synapse formation. Subcortical SNS & PNS components of ANS Cortical limbic components of CNS Especially for right hemisphere (Chiron et al., 1997) which matures

earlier than left

Maturation is experience dependent (Schore, 1996, 2000). Events that influence ANS–limbic circuit development are

embedded in the infant’s ongoing affect regulating attachment transactions.

Infants, Coping with Stress

Interactive regulatory transactions that co-create secure attachment bonds influence development & expansion of infant’s regulatory systems involved in appraising & coping with stress (Schore, 2001)

Subtle differences in care-giving affect infant attachment, development, & physical well-being (Champoux, Byrne, DeLizio, & Suomi, 1992)

Variations in care serve as the basis for a non-genomic behavioral transmission of individual differences in stress reactivity across generations (Francis, Diorio, Liu, & Meaney, 1999).

Caregivers who can accurately perceive infants stress signals help the infant develop an increasingly complex capacity to cope with increasingly challenging situations…

Affect, Synchronicity & Attachment

Infants & caregivers work to co-create a secure attachment bond & emotional communication (Papousek & Papousek, 1997)

Baby Experience-dependent neuro-maturation allows more complex

responses for coping to emerge

Caregiver works to regulate baby

Affect synchrony Infant led, caregiver follows the infant’s lead Allows partners to match states & adjust their social attention,

stimulation, & arousal to each other’s responses

Synchronicity - match between caregiver’s & infant’s activities that promotes positivity & mutuality in play & other functional activities.

Caregiver as Regulator To regulate infant’s arousal,

caregivers must 1st be able to regulate own arousal state.

Must be able to accurately identify infant’s state

Must be able to respond in a way that meets the infant’s needs

This is what “typically” happens

What happens when parents are observing atypical responses?

Typical Amplification Infant’s attachment motivation synergistically

interacts with caregiver’s motivation

Infant experiences increasing levels of accelerating, arousal states amplified by caregiver

If attuned, each partner monitors behaviors of other

Results in coupling between output of one partner’s loop & input of the other’s to form a larger feedback configuration & amplification of positive state in both.

Output of one partner’s loop & input to the other’s do not align

Feedback is provided in an in manner incongruent with needs/expectations of partners

Amplification of negative state may occur in both partners.

Increased stress

What is Stressful for an Infant? Inability to regain homeostasis

State changes Bodily needs-hunger, thirst…

Novelty Transitions Unpredictability

Yawning Sneezing Hiccupping Sweating Gagging Spitting up Breathing Irregularly Changes to Skin Color Abrupt State Changes Voiding

Fussing & Crying Grimacing Sighing Starting Stiffening Splaying Averting Gaze Pushing Away Arching Back Staring into space

Autonomic Behavioral

Child Context

Physical Social-Caregiver, family

members… Cultural

“Goodness of Fit” Child & Context

Caregivers Physical Environment Cultural Environment

Occupations Activity Demands Performance Patterns

Habits Roles Routines

What we Typically Think of for EI Assessment

HELP E-LAP Mullen (MELS) TIME

Specifically for Sensory Processing

Infant Toddler Sensory Profile

Infant Toddler Symptom Checklist

Sensory Integration Observation Guide for Children from birth – three

Test of Sensory Functions in Infants

Early Coping Inventory

Environment/ “goodness of fit”?

Physical Environmental Assessment

HOMESocial Environment

Dyadic AssessmentPSIAdult Adolescent Sensory Profile

Family/Caregiver Report Concerns/Comments Developmental history

Pre & post natal

Qualitative Observations Structured Unstructured Multiple environments

Assess the environment in addition to the child!!! Assess performance patterns of child & family Formal Assessment

Early Identification of ASD

What you should look for Behavioral Signs

Failure to respond to name by 8-10 mos (Werner, Dawson, Osterling, & Dinno, 2000).

By 12 months, infants with ASD distinguished from typical infants by

Failure to respond to name (Baranek, 1999; Osterling & Dawson, 1994; Osterling et al., 2002)

Decreased looking at faces of others (Osterling & Dawson, 1994)

Low rates of showing things to others & pointing to request/share interest (Adrien et al., 1993; Maestro et al., 2002; Osterling & Dawson, 1994; Osterling et al., 2002; Werner & Dawson, 2005).

Poor eye contact & failure to respond to name distinguishes children with ASD from infants with developmental delay but without autism (Baranek, 1999; Osterling et al., 2002

Autism Observation Scale for Infants (Bryson, McDermott, Rombough, Brian, & Zwaigenbaum,

Visual attention Response to name Response to a brief still face Anticipatory responses Imitation Social babbling Eye contact Social smiling, Reactivity Affect Transitioning Atypical motor & sensory behaviors

Were not sufficient for diagnostic purposes at 6 mos Subset of children later diagnosed exhibited

impairments in Responding to name Unusual sensory behaviors.

By 12 mos could distinguish Atypical eye contact Visual tracking Disengaging visual attention Orienting to name Imitation Social smiling Reactivity Social interest Sensory-oriented behaviors Poor gesture use & understanding

of words (Mitchell et al., 2006).

Assessments First Year Inventory

(Watson et al., 2007) Parent questionnaire Assess behavioral

symptoms related to autism in 12-mos.

screening instrument for autism

Autism Observation Scale for Infants (Bryson, McDermott, Rombough, Brian, & Zwaigenbaum, 2007)

Visual attention Response to name Response to a brief still face Anticipatory responses Imitation Social babbling Eye contact Social smiling, Reactivity Affect Transitioning Atypical motor and sensory behaviors

Help family to understand Reframe behavior in terms of sensory processing Help caregivers identify patterns & anticipate problems Develop caregivers capacity to

Read child’s cues Support reciprocal interactions Establish an environment that supports the child’s performance

Developmentally appropriate expectations Anticipate challenges & problem-solve Develop routines that will work for entire FAMILY

Facilitate “Goodness of Fit” Refer to Occupational Therapist skilled in identifying &

treating children with sensory processing disorders

Remember you are an important part of the child’s context… How does your ability to process sensory

information influence your ability to work with a particular child & family?

Now apply this understanding to the child’s primary social context How do caregivers/family members’ abilities

interact with the child’s?

Contributes to the development of a healthy, emotionally responsive parent & child relationship

Promotes the baby’s development by fostering the parents’ competence in their parental role

Perspective is one of capacity building & strength rather than one of deficit & weakness (Perez, Peifer, & Newman, 2002).

Interventions focused on promoting caregiver sensitivity were more effective than the combination of all other types of interventions (Bakermans-Kranenburg, Van Ijzendoorn, & Juffer,

2003) Effective interventions

Involved < 16 sessions Used video feedback

Target parental sensitivity & infant Target parental sensitivity & infant contingent respondingcontingent responding

Parents who have appropriate expectations of their infant develop richer & more positive interactions & provide enhanced environments

This is associated with better developmental outcomes for the child…

Interventions need to take into account the individual characteristics of both members of the dyad, and be sensitive to the “dance” that the dyad performs together (Poehlmann & Fiese, 2003).

Attachment Patterns Shape Brain Structure & Function for Life

Attachment interactions allow for the emergence of a biological control system that functions in the organisms state of arousal (Bowlby, 1969)

Attachment theory = Regulatory Theory (Schore 2000) Typically secure caregiver “intuitively” regulates

the baby’s shifting arousal levels & emotional states

R-E-S-P-E-C-T People first

Children, even young ones should have a voice & vote

Teach the child to advocate for self

Avoid placing blame- i.e. “dysfunctional family”

Family is the constant Regardless of where child

lives -he/she is always part of their family

Parents are the expert on the child

Give them the information they need to make decisions

You may not always agree with their choices

Concrete Assistance Emotional Support Non-Dydactic

Developmental Guidance Early Relationship

Assessment & Support Advocacy Infant-Parent

Psychotherapy

Involves clinical reasoning & case management

Hierarchy of needs help family meet basic “survival”

needs until these are met, other needs

recede into the background

It means eliciting, listening to, & thinking about parents’ descriptions of their experiences, & small children’s expressions of theirs” (St. John & Pawl, 2000)

It also means observing behavior, hearing the message of the behavior & helping the person ‘use words’ to explain it

Acknowledge that parenting is difficult 24/7/365

Assist families with identifying & accessing supports they have/need

May involve referrals to or be done in conjunction with other disciplines- social work

Help identify which “supports” are supportive

By responding to the child’s needs for care & his/her specific abilities, the interventionist helps parents

Recognize what the baby is doing

Anticipate the next step of development or skill that will emerge.

Encourage positive/playful interactions through modeling

Observing interactions of parents with their infants & using “in the moment” comments to

Reinforce positive interactions Identify the infant’s responses that the parent might

misinterpret Ghosts in the nursery refers to the perspective parents bring to

their role as parents Parents are influenced positively & negatively by what they

experienced as children (Fraiberg, Adelson, & Shapiro, 1975).

Infant–caregiver relationships are open systems

Relationships include infant’s & caregiver’s Interactive behaviors (external-observable components of relationship)

Internal representations (subjective experiences of infant & caregiver comprise the internal components)

Memories

Representations of the history of interactions of the dyad

Interventions aimed at 1 component must have an impact on other components of the system (Stern-Brushweiler & Stern 1989)

Insight into the meaning may come from considering the organization of those behaviors. Clinicians account for the goals & contexts of

observed behaviors as a way of evaluating their meaning.

Consider how the caregiver represents the infant & the relationship

May assess subjective experience of caregivers by attending to narrative patterns in descriptions of relationship experiences. (Main, Kaplan, & Cassidy, 1985)

What caregivers say may be less important than how they say it, (Zeanah, 1993).

Reflect back the meaning of what you hear to clarify… You may sometimes be wrong, but if you reflect back you

Give the caregiver an opportunity to correct you Likely will assist the parent gain a deeper perspective

Improve ability to “read” their child Listen Learn- how the caregiver views their child’s

behavior “Watch, Wait, & Wonder…”

Educate Infant states, cues, behavior, response patterns Non-verbal communication State Modulation

Increase their understanding of their child’s development

Establish “developmentally appropriate expectations”

Anticipate what comes next

Parents who display higher levels of synchronization & contingent responses during interaction have children with ASD who develop superior communication skills over periods of 1, 10, & 16 years (Siller & Sigman, 2002).

Early nonverbal communication, (esp joint attention) strongly related to language outcomes for children with ASD & typical development (Brooks &Meltzoff, 2005; Dawson et al., 2004; Sigman & Ruskin, 1999; Toth, Munson, Meltzoff, & Dawson, 2006).

Parents find it more difficult to respond sensitively to infants who have regulatory difficulties and who have less reciprocal interaction styles (Kelly, Day, & Streissguth, 2000; O’Connor, Sigman, & Brill, 1987; Tronick & Field, 1986; Yehuda et al., 2005).

Remember Children with ASD showed more dys-

regulation than children with intellectual disabilities (Seynhaeve & Nader-Grosbois, 2008). Children are less able to follow caregiver’s lead

Consider the impact this has on the caregiver…

Orchestrate their child’s activities in a responsive manner

Routines Choice of materials, timing,

people…

Scaffold children’s occupations within their own occupations

Laundry & play

To cope effectively & assist the child with developing effective coping strategies (Williamson & Szczepansky, 1999)

Develop positive self value & beliefs Accurately determine meaning of event Manage challenging event Evaluates the effectiveness of efforts

Managing stress is easier said than done…

Parent needs to “know the child” What is going to set him/her off? What are his/her limits?

Communicate with child Convey clear expectations Establish routines Teach self-regulation Modify environment to meet child’s needs Address undesirable behaviors

What we really want to know about infant development is neither the infant’s nor the environment’s contributions, but rather the infant’s subjective experience of the world. Escalona (1967)

Attend to Infant & caregiver interactive behaviors Systematic formal study of caregiver’s subjective

experience Bio-behavioral cues from infant

Routines vs. Schedules “Flexible Predictability” Clear Expectations Developmentally appropriate expectations

Within child’s ability level & within his learning style

Give child choices within their ability Appropriate responsibilities Time to complete activities & make decisions

Safety Sensory environment Make “appropriate” materials accessible to

promote independence Set up Exploration Clean up

Limit access to unsafe/undesirable materials

Self-Regulation Physiological homeostasis Ability to modulate environmental

stimulation Maintain attention Understand own behavior Communicate needs Delay gratification Understand others’ behaviors

When considering Sensory Input, consider all sensory channels Think about the stimuli’s

Intensity Duration Rhythm Meaning to the child

Learning happens quickly, what learning has already occurred?

Think about the child

Intense stimulation Frequent or long lasting Arrhythmic /unpredictable/irregular

Input may be from different sensory channels… Make sure you understand the neurological

habituation principles of receptors you are stimulating & interactions between channels.

Vest Wilbarger Protocol

Often, less intense May or may not be long lasting… Rhythmical/Predictable-

child anticipates input, has time to plan & execute a response

Consider different sensory channels

Make sure you understand how this relates to neuro-

Be aware of spatial & temporal summation…

Family-centered approach provides sensory input to meet needs of a specific child within his/her context

Involves specific activities designed to help child modulate his/her arousal level so he/she can participate within daily activities

Activities are planned around child & family’s needs & embedded within their routines.

Should be designed by an OT with specialized training in sensory integration theory & intervention

May be supervised by parents, or other professionals.

Make sure you collaborate with a therapist who has completed the proper training & supervision in techniques used

Be aware of how stimulation you provide impacts the child’s nervous system

Habituation Length of time stimuli reverberates within the system Interactions with medical conditions &/or medications

Seizures Medically Fragile Children

Cardiac Respiratory problems

Allergy medications

Social & Emotional Skills are learned… Dyad Later larger groups

Self-awareness Empathy Interactions with others

Enhance Communication Skills PECS Sign Language/Baby Sign Videos

Enhance ability to explore the environment Enhance ability to organize behavior

Picture Schedules Pictures for clean up

Enhance Parental Support Enhance Parental Understanding of Development

eHealth

Successful development requires the ability to identify & control emotions & arousal levels

Self esteem is gained when children control their responses & make positive self-regulatory choices

Relating emotional feelings to arousal levels increases relevance of choices made

Modulates adaptive responses

Improves social participation Enhances sensorimotor

abilities & experiences Positively influences

regulatory independence Improves psychosocial well-

being Facilitates function across

lifespan

Involves Helping families get their needs met Giving voice to the baby’s or parents’

perspective.

Helps clarify the parent’s/child’s perspective

“thoughtful exploration about parenthood & the infant or toddler’s continuing needs for care” (Weatherston, 2000)

This is completed only by a properly credentialed psychotherapist Other team members often relay many

important insights

“There is no such thing as a baby, there is a baby & someone…” (Winnacott, 1987)

Werner-DeGrace (2004) suggests we ask ourselves Are we creating supports to help the family

participate together in positive health promoting daily life activities or are the interventions we provide interfering with shared family occupations?

Email Amy Russell Yun at russelax@jmu.edu

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