Sensory Differences

Research Digest

Do we have sensory profiles of all students?

Apupil’ssensoryprofilewouldbeputtogetherbyamemberoftheOccupationalTherapyteamalongsidestaffwhoworkwiththatpupil.Inputfromparentswillalsobesought.Notallpupilswillhaveasensoryprofile,onlythosewho,basedontheprofessionaljudgementofthestaffandtherapyteam,mightrequiresupportoverandabovethatwhichisprovidedtosupportthesensoryneedsofallourpupils.Thisbaselinelevelofsensorysupportisinplaceasweknowthatallofourpupils,tovaryingdegrees,experiencedifferencesinthewaytheyreceiveandmanagesensoryinput.Thisweekwewilllookatsensorydifferencesandtheirimpact(thiswillbeatwoparter!).

Sensorydifferences

Therelationshipbetweendifferencesanddifficultiesinprocessingandintegratingsensoryinformationandautismiswellestablishedinboththeresearchliterature(Ben-Sassonetal.2008;Minshew,Sweeney,&Luna2002;Rogers,Hepburn,&Wehner,2003;Rogers&Ozonoff2005)andfirst-handaccounts(e.g.Grandin,2006;Higashida,2013;Kirby,Dickie&Baranek,2015;Williams,1992;1994).Sensoryfeaturesarealsonowincludedinthediagnosticcriteriaforautism(AmericanPsychiatricAssociation,APA,2013).Specifically,‘‘hyper-orhypo-reactivitytosensoryinputorunusualinterestinsensoryaspectsoftheenvironment’’qualifiesasoneoffoursub-criteria(twosub-criteriaarerequired)inthe‘restricted,repetitivepatternsofbehavior,interests,oractivities’diagnosticdimension(CriteriaB)oftheDSM-5(APA,2013).However,thetypesofsensorydifficultiesexperiencedareoftenhighlyidiosyncratictoeachindividual(Ausderauetal.,2014Lane,Molloy,&Bishop,2014).

AsinmanyotherareastherehasbeenlessworkonexaminingsensorydifferencesinPMLD,partlybecauseourPMLDstudentsdifferfromeachothertoanevengreaterextentthanourautisticpupils.Wedoknow,however,thatthesensoryworldexperiencedbyourPMLDpupilscanalsobemoreorlessintensethanneurotypicalpupilsoftenasaresultofspecificsensoryimpairmentsandtheresultantdifferenceinperceptioninothersensorysystems(soundforexampleinthosepupilswhoarevisuallyimpaired)(Gougoux,etal.,2005).MultisensoryapproachestocommunicationandlearningarealsowellestablishedmethodsforsupportingpupilswithPMLD(Goldbart,Chadwick&Buell,2014).

Typicallythefocus,inautism,hasbeenonlookingatdifferences(hyperorhyporesponsiveness)acrosssevensenses–sight,smell,taste,touch,hearing,vestibular(balance)andproprioception(awarenessofbodyinspace).However,anewareaofresearchhasbeenexaminingtheimpactofdifferencesin‘theeighthsense’–interoception.

IllustrationfromSmith-Myles,Mahler&Robbins,2014

IllustrationfromSmith-Mylesetal.2014

Illustration:ElanaRyznar

Heartfelt,gutfeeling

Thebasicprocessofinteroceptionrelatestohowsensorysignalsrelatingtointernalbodyexperiencessuchaspain,temperature,itch,sensualtouch,muscularandvisceralsensations,heartrate,hunger,thirst,fullness,nausea,needforthetoilet,tickleandemotionalstatessuchasanger,calmness,distraction,orfearreachourconsciousawareness(Craig,2003;2015).Interoceptionhelpstoallowustoanswerthequestion,"HowdoIfeel?".

Whilstthereisagrowingbodyofresearchlookingathowemotionalexperienceisgovernedby

interospectiveawareness(Bechara&Naqvi,2004;Seth,2013)andtherelationshipbetweeninteroceptionandstress(Garfinkel&Critchley,2016a;Schulz&Vögele,2015)ithasonlyrecentlybeguntobeexaminedinchildrenandyoungpeople.Forexample,arecentreviewintosensoryfactorsandtheirimpactondailylifeforchildrenbyDunnandcolleagues(Dunn,Little,Dean,Robertson&Evans,2016)didnotincludeanyexaminationofinteroception,despitethegrowingevidencetosupportthevitalroleitplaysinourunderstandingofourselves,ouremotions,otherpeopleandthewiderworld(Murphy,Brewer,Catmur&Bird,2016).Inlightofthisunderstandingandsensorydifferencesexperiencedbyautisticindividualstherehasbeenanewfocusonlookingattherelationshipbetweeninteroceptiveawarenessandautism.

Theimportantroleinteroceptionplaysintermsofoursocio-cognitiveability,andourabilitytodistinguishselffromother(Quattrocki&Friston,2014;Sowden,Brewer,Catmur&Bird,2016)suggeststhissensemaybeexperiencedsignificantlydifferentlyinautisticindividuals.Therefore,despitethehugevarietyinwhichitisexpressed,theremaybeacommoninteroceptivefoundationtoautism(Seth&Friston,2016).Arecentreviewofresearchoninteroceptionandautismwhilstlimitedtojustfivestudies,doessuggestthatdifferencesininteroceptiveawarenessmayunderpinmanyofthedifficultiesourautisticpupilsexperience(DuBois,Ameis,Lai,Casanova&Desarkar,2016).However,theresearchtodateislimitedtolowerneedindividuals,partlyduetothefactoneofthemainmeasuresofinteroceptiveawarenesscomesthroughself-reportquestionnairesortaskssuchasanindividualhavingtorateifamusicalbeatortonematchestheirheartbeat(Garfinkeletal.,2016b).Alotmoreresearchisneeded,particularlywithhigherneedindividuals,tolookattheextenttowhichtheremaybeatendencytowardshyperorhyporesponsivitytointeroceptivesensationsbutalso,moreimportantly,howtosupportindividualstomanageandunderstandthishighlyinfluentialsensoryinformation-toknow‘howdoIfeel?’ Image:IanKelckneradaptedbyGraceBullock

Illustration:BenConnors,retrievedfromhttp://crae.ioe.ac.uk/post/145502740383/making-sense-of-sensory-differences

Sensorysubtypesinautism?

Sensorybehaviourshavehistoricallybeendividedintofourpatterns,includingsensoryhypo-reactivity,hyper-reactivity,sensoryseeking,andsensoryavoidance(Dunn,2001;Ben-Sassonetal.,2009).However,manyautisticindividualswillexperienceseveralofthesepatternsatonetime,withmixedpatternsbeingdisplayedacrosssensorydomains(taste,touchetc.)(Baraneketal.,2006;TomchekandDunn,2007;Lidstoneetal.,2014).Recentresearch,therefore,hastriedtoclassifysensoryprocessingdifferencesintospecificsubtypes(Laneetal.,2011,2014;Uljarevićetal.,2016),suchassensoryadaptive,sensorymoderate,andsensorysevere(Uljarevićetal.,2016),withaviewtoensuringsupportcanbeindividualisedfurther.

Whilstresearchershavecautionedagainstover-generalising,areviewpublishedthisyearsuggestedthatbetweenthreetofivesensorysubtypeswasanappropriate‘fit’toencompassthedifferentpatternsofsensoryresponsivityseeninchildrenwithautism:asubgroupmayhavetypicalsensoryfunctioning,whilstanothersuggestedsubgroupincludedchildrenwithsignificant,globalsensorydifferences(DeBoth&Reynolds,2017).Thereweremixed,lessconclusiveresultsforthosechildrenwhomayfallinbetweenthesetwo‘end-points’–thosewhohavespecificversusglobaldifferencesinresponsivity(i.e.,hyper-orhypo-responsivityorsensoryseeking),orwithinspecificsensorydomains(vestibular,tasteetc.)(DeBoth&Reynolds,2017).

Withregardstoautisticindividualswithhigherneeds,includingthosewithadditionalintellectualdifficultiesand/orlimitedverbalcommunication,therehasbeensomeconsensusthattheymayexperiencehypo-responsivityandhigherratesofsensoryseekingbehaviour(Patten,Ausderau,Watson,&Baranek,2013;Watts,Rodgers&Riby,2016).Hyper-responsivityontheotherhandhasbeenassociatedwithsleepproblems(MazurekandPetroski,2015)andfooddisorders(Cermaketal.,2010;Nadonetal.,2011),particularlyinveryyoungchildrenandinfants,suggestingearlysensorybasedsupportsmayhelpaddressthesedifficulties(Taumanetal.,2016).Sensoryhyper-responsivenesshasalsobeenlinkedtogastrointestinal(GI)problems(Mazureketal.,2013)moreexternalizingbehaviors,andincreasedparentingstress(Ben-Sassonetal.,2013).Again,theimplication,therefore,isthatabetterunderstandingofdifferentsensoryprofilesandtherefore

moreindividualisedsensoryinterventionsandsupportmayhelptoaddressthesedifficulties.Thereisalsoawidercallforfutureresearchtolookatsensorysubtypesineverybodytohelpunderstandifsensorysubtypesinautisticindividualsarerepresentativeofgeneraldifferencesinsensoryprocessing(DeBoth&Reynolds,2017).

Illustration:KellyDillon

Impactofsensorydifferences

Overtwentyyearsagointheirbookontheimportanceofsensoryintegration,WilliamsandShellenbergerputforwardadevelopmentalmodeloflearning,thefoundationsofwhicharesensory(althoughtheydidnotincludeinteroception)(Williams&Shellenberger,1996).

PyramidofLearning(Williams&Shellenberger,1996)

Whilstthismodelprovidesagreatvisualreminderoftheroleofphysiologicalprocessesincognitioningeneral,theimpactofsensorydifferencesforautisticindividualsisfarmorepervasiveandunderstandingthesedifferencesineachindividualisevenmorecrucialtounderstandingtheirspecificneedsandbehaviour(Schaaf&Lane,2105)

Managingsensorydifferencesprovidesoneofthemostchallengingobstaclesforchildrenandyoungpeoplewithautism,impactinguponadaptivebehaviour,participationinactivitiesinthecommunity,andreducingqualityoflife(Baraneketal.2006;Bakeretal.2008;Ben-Sassonetal.2013;O’NeillandJones1997;O’RiordanandPassetti2006;Schaafetal.2011).

Difficultywithsensoryregulationhasalsobeenconsideredtobemotivatingstereotypic

behaviour.Indeed,repetitivebehavioursinautism,havelongbeenassociatedwithfluctuatingstatesofunder(hypo)andover(hyper)sensoryarousal,andstereotypicorrepetitivebehavioursareameansoftryingtofiximbalances(self-regulate)inarousalinthefaceorunpredictable,potentiallyoverwhelmingsensoryinputtoachieveoptimalstimulation‘calmalert’(Lidstoneetal.,2014;Matsushimaetal.,2016;Zentall&Zentall,1983).

However,differenttypesofrepetitivebehavioursmayservedifferentfunctionsforregulatingsensoryarousalwithvaryinglevelsofsuccesstheseare:InsistenceonSameness(IS)andRepetitiveSensoryandMotorBehavioursRSMB).

InsistenceonSameness(IS)

ISbehavioursinclude:collectingorhoardingitemsofanysort,insistingonthingsremainingthesame,gettingupsetaboutminorchangestoobjects,insistingonaspectsofroutineremainingthesame,insistingondoingorre-doingthingsinacertainway,playingthesamemusic,game,video,bookrepeatedly.Thesetypesofbehavioursarelinkedtoover-arousalasaresultofsensorysensitivity(hyper-sensitivity).Therefore,thesebehavioursmayfunctionbybeingsensationavoidingandallowtheindividualtonarrowsensoryinput–theyprovideafocustohelpblockoutothersensoryinput.However,thelinkbetweentheseISbehavioursandanxietyindicatesthatthesebehavioursmaynotbethebestwayofregulatingarousalandtheymayevenservetocreateandmaintainanxiety.

RepetitiveSensoryandMotorBehaviours(RSMB)

RSMBsinclude:repetitivelyfiddlingwithtoysetc.,spinningselfaroundandaround,rockingbackwardsandforwards,pacing/movingaroundrepetitivelyandrepetitivehand/fingermovements.Thesetypesofbehavioursmaybemuchbetterathelpingtoregulatearousalwithoutcreatingormaintaininganxiety,byprovidingstimulationthroughsensationseekinginthecaseofunder-arousal(hypo-sensitivity)andthroughsoothingandavoidanceoutcomesinthecaseofover-arousal(hyper-sensitivity).Howeverthesebehaviourshavealsobeenpositivelyassociatedwithparent-reportedsleepproblems(Hundley,Shui&Malow,2016).

Overall,whenlookingatritualisticbehaviourssuchasthosedescribedabove,currentopinionisthattheydevelopasacopingmechanisminresponsetoanxiety.Thisinturncomesfromprimarydifficultiesinmodulatingsensoryinput(Bart,Bar-Shalita,Mansour&Dar,2016).ThisrelationshipbetweenanxietyandsensorydifferenceswillbethemainfocusofPart2ofthisdigestwhichexploresthecloserelationshipbetweensensoryregulationandanxietyfurther(Magiatietal.,2015;Samsonetal.,2014).

Seephysicalthinksensory

Onefinalthingtokeepinmindisthatwemustconsiderthatmuchphysicalbehaviourismotivatedbysensoryneedsand,asmentionedabove,maybeachildoryoungpersonmaybetryingtoregulatetheiranxietyorsensoryneeds.Thismayincludeself-injuriousbehaviourswhichmaybeconsideredmoreintensestereotypic/repetitivebehaviours(Gal,Dyck&Passmore,2009).

Foralongtimephysicalbehaviourinautismwasmisunderstood.UnlikeotherareasofdifferencesuchasTourette’s,asocialratherthananeurologicalinterpretationofbehaviourwasappliedsothat“whichiscalleda“tic”inapersonwithTourettesyndromeismostoftenassumedtobea“behaviour”(andoftenaconsciouschoice)inapersonwithautism.Forsymptomsinterpretedthroughaneurologicallens,individualstendtobeappropriatelysupported.Inautism,symptomsareviewedfrequentlyasbehaviourstobereducedoreliminatedoftenwithanegativeinterventionandresults”(Donnellan,Hill&Leary,2013).Donnellanandcolleaguesfurtherpointoutthatasocialinterpretationofthesesensorymotivatedbehavioursoftenleavespeoplewiththeassumptionthattheyoccurasamatterofchoiceorapathy,whereaspredominantlythebehaviourisrelatedtostress,includingthestressofexcitement(Donnellan,Hill&Leary,2013).

Whilstunderstandingthattheremaybephysiologicaldifferencethatcouldbemotivatingsensorybehavioursitisalsoimportantthatwerememberthatwecanstillsupportourpupilstolearnotherwaysofregulatingthemselves,andindeedtobecomemoreabletocopewithsensoryinputthatmaybeprovokinganxiety.Simplistic,neuroessentialist(biologicallybased)explanationsofdifferencescanoftenleadtowardsanincreaseinstigma,lessempathyandaclosedmindsettowardsassumingthatdifficultiesindividualsmayfacearefixed(Lebowitz&Ahn,2014;Schultz,2015).

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