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Amy Yun & Dianne Koontz Lowman. Things you already know…

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1 Amy Yun & Dianne Koontz Lowman

2 Things you already know…

3 Vision Hearing Smell Taste Touch Vestibular Proprioception

4  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

5  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

6 RegistrationOrientInterpret Organize Response Execute Response Williamson & Anzalone, 2001

7 Action Sensory Integration & Modulation AffectAttention Arousal

8  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 & p erforming occupations ADL, play, school May impair social relationships

9  "Is the child's problem getting in his way?  And if not, then is it getting in everyone else's way?“ C. Kranowitz

10  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 d istinguish between different stimuli, or organize temporal & spatial qualities If you can not distinguish, you can not learn… SPD Foundation

11 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

12  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

13 Neurological Thresholds Behavior In accordance w/threshold Responses To counteract Threshold High (habituation) Poor registrationSensation Seeking Low (sensitization) Sensitivity to Stimuli Sensation Avoiding

14 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).


16 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.

17 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…


19 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

20  “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.

21  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

22  Human brain growth spurt Begins in 3 rd 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)

23 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

24 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

25 “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).

26 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)

27 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.

28 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…

29 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.

30 Caregiver as Regulator  To regulate infant’s arousal, caregivers must 1 st 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?

31 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.

32  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

33 What is Stressful for an Infant?  Inability to regain homeostasis State changes Bodily needs-hunger, thirst…  Novelty Transitions Unpredictability

34  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 AutonomicBehavioral

35  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

36  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  HOME  Social Environment  Dyadic Assessment  PSI  Adult Adolescent Sensory Profile

37  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

38 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

39 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).

40 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

41  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

42  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?

43  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).

44 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

45 Target parental sensitivity & infant contingent 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…

46  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).

47 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

48  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

49  Concrete Assistance  Emotional Support  Non-Dydactic Developmental Guidance  Early Relationship Assessment & Support  Advocacy  Infant-Parent Psychotherapy

50  Involves clinical reasoning & case management  Hierarchy of needs help family meet basic “survival” needs until these are met, other needs recede into the background

51 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

52  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

53  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

54  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).

55  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)

56  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.

57  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

58 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

59  Increase their understanding of their child’s development Establish “developmentall y appropriate expectations” Anticipate what comes next

60  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).

61 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…

62  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

63  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…

64  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

65  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


67  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

68  Safety  Sensory environment  Make “appropriate” materials accessible to promote independence Set up Exploration Clean up  Limit access to unsafe/undesirable materials

69  Self-Regulation Physiological homeostasis Ability to modulate environmental stimulation Maintain attention Understand own behavior Communicate needs Delay gratification Understand others’ behaviors

70  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

71 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

72 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…

73  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.

74  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

75  Social & Emotional Skills are learned… Dyad Later larger groups  Self-awareness  Empathy  Interactions with others

76  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

77  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

78  Modulates adaptive responses  Improves social participation  Enhances sensorimotor abilities & experiences  Positively influences regulatory independence  Improves psychosocial well- being  Facilitates function across lifespan

79  Involves Helping families get their needs met Giving voice to the baby’s or parents’ perspective. Helps clarify the parent’s/child’s perspective

80  “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

81  “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?

82  Amy Russell Yun at 

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