Occupational Therapy & Speech and language Therapy Lenses on Assessment Jenny Jones Occupational Therapist Julie Mullis Speech and Language Therapist Clinical leads for ASD Services Cardiff and the Vale University Health Board

Aims To have a greater understanding of Sensory Processing and ASD To explain the valuable role OT and SLT have in the assessment and diagnosis of complex children To outline the benefits of joint working

Sensory – Perceptual Atypicalities and ASD “It is estimated that 90% of individuals with ASD have some abnormality of sensory and perceptual functioning and considered by some as CORE FEATURES” (Geschwind 2009)

ASD How does that look ? Sensory Processing Disorders 70-80% Atypical Sensory & Perceptual 90% ASD Synaesthesia Sensory distortions Sensory tune outs Sensory overload Overselectivity Perceptual dysfunction Sensory modulation

What are Sensory Processing Disorders? SENSORY INTEGRATION THEORY SENSORY PROCESSING DISORDERS REGISTRATION Perception of intensity of stimuli & the orientation to it MODULATION Under reactive Over reactive Fluctuating in response DISCRIMINATION Praxis Perceptual function for learning Postural & Motor Control SI is a long standing and growing area of practice in Occupational Therapy In the last 30 years the theory, conceptual constructs, evaluation and principles have been refined and validated by different scientific research studies The theoretical base of SI is unique in that ait deals specifically with the contributions of the subcortical areas of the brain to human behaviour.

Effects of poor sensory modulation on learning and behaviour Under- Normal Over- Reactivity Sensory Modulation Reactivity Under-Arousal i.e. misses non-verbal cues, slow affective responses Over-Arousal i.e. over-reacts to non- verbal cues, anxious, too alert Needs large amount of stimulation for arousal Impaired Social Behaviour Must attend to all stimuli as much as possible Defective Attending Behaviour i.e. fails to look, listen, process, and remember “Spacey” & “Slow” Distractible & Fragmented Learning is impaired

A Sensory hypothesis to Autism….. New or just the “in thing” ? 1943- Kanner rejected a sensory hypothesis 1949 – Bergman and Escalona offered the first version of a sensory hypothesis “The child's need to protect himself or herself from the sensory onslaught resulted in developmental distortions that eventually led to the symptoms that Kanner had first described”

Main hypotheses concerning Autism ….60s and 70s Specific sensory dysfunctions and their affects on motoric-social and cognitive functioning in Autism were recognised and empirical studies began…..

Still current today ……… Current clinical and treatment literature treats sensory dysfunction as an established core deficit in autism, with a theoretical focus on possible abnormalities in subcortical neural systems. Rogers & Ozonoff 2005

“The objective of therapy for the autistic child is to improve the sensory processing so that more sensations will be effectively ‘registered’ and modulated and to encourage the child to form simple adaptive responses as a means of helping him learn and organise his behaviour” Ayres 1979

Native Experts..90s “Difficulty in registering input in a meaningful way can often be felt as painful and confusing” (Grandin 95) “Any satisfactory comprehensive theory of autism must address sensory symptoms” ( Grandin 92, O’Neill &Jones 97, Williams 94)

The last decade……Research studies on sensory processing and ASD 2002 Baranek 2005 Rogers and Ozonoff 2006 Kern et al 2006 Adamson, O’Hare and Graham 2007 Kern et al 2007 Tomchek and Dunn 2007 Ben-Sasson et al 2010 Tomchek And the list goes on…………… Recently more research studies have been conducted to examine the relationship that exists between brain function and the behavioural manifestations of sensory processing disorder(Mcintosh et al 1999, Mangeot et al 2001, and Davies and Gavin 2007)

Occupational Therapy Assessment Sensory processing functions Developmental play and interactions with environment Motor planning/praxis and sequencing Postural motor control Bilateral integration Gross and fine motor skills Visual motor integration Prewriting and writing skills Functional abilities in different daily living activities

Why have an Occupational Therapist on Diagnostic and Assessment teams? A detailed assessment of atypical sensory behaviours helps to distinguish whether a child's symptoms result from SPD, autism or other co-morbid disorders Sensory integration approach provides an alternative explanation for behaviours Accurate diagnosis = appropriate intervention Sensory processing disorders may represent another core diagnostic criterion ASD-DSM-V

Play Observations Observations SLT Observations Not turning to name Not looking to mum for help with clothes discomfort Developmental delay No intentional communication – growls Poor awareness of environment and other toys around him. No exploratory or object play. No enjoyment from parental interaction and sharing of toy OT Observations Poor registration to the turtle, Possible dysregulation by the singing and flashing of the toy Interested in string of turtle not the turtle. Praxis- not sure what to do with the turtle? Clawing at clothes, hands often fisted or looking at them flicking – tactile defensive? visual seeker? Biting clothes, hitting head Distracted/distressed by fathers video game- auditory? Big point to make on this slide is that although it was a very small piece of footage, having two professional lenses on the assessment of play , doubles the observations that can be gathered and analysed and will direct further assessment and investigation. What is interesting about this little chap, is that he was given a diagnosis of developmental delay and SPD at the age of 18months and a diagnosis followed of ASD just before his second birthday. This supports Sassons work in 2007 whose findings point to the early onset of an extreme sensory profile in ASD.

Relational Play / Constructional Object / Exploratory Play Registration Social Play Sensorimotor Play PLAY Child’s main Occupation Modulation Praxis ideation Julie got handwritten notes for OT bit to Inc. in this slide….. Functional Play Symbolic Play

Principles of Assessment for Speech and Occupational Therapy On going process Skilled observations essential Observed in at least 2 different settings, over several visits and with a variety of people Assessment of child's sensory profile essential Detailed understanding of myriad of internal and external mechanisms that will influence child's communication and occupations

C A B Julie to summarise, and to outline the importance of a team approach to assessment and diagnosis …all have a very valuable lens! Cant do it with just one pair of glasses!!! !utilising all skills in my experience is best practice. D