1. Copyright Cardiff University Rachel BrooksSenior Lecturer Elspeth Webb Reader Cardiff University Paediatric members of Cardiff Tertiary ASD Assessment team Copyright Cardiff University 1

2. Cardiff Tertiary ASD Assessment team Accept referrals only of children already assessed at secondary level ▫ Complex co-morbidity ▫ Diagnostic uncertainty ▫ Forensic concerns ▫ Child protection concerns Copyright Cardiff University 2

3. Sensory processing abnormalities (SPA): Challenges in the diagnosis & assessment of children referred for possible social & communication disorders 3 Copyright Cardiff University

4. Introduction SPAs – what are they ▫ Abnormalities in the neurological processing or interpreting of sensory stimuli ▫ Visual, auditory, fine touch, proprio-reception, smell, taste, pain How common are they in ASD ▫ Most recent work suggests that at least 80% (and perhaps all) children on the spectrum will have SPAs ▫ Large and growing academic literature This talk ▫ A personal view and personal approach to the challenge of SPAs in autism assessment based on 15 years experience and a lot of thinking Copyright Cardiff University 4

5. Various scenarios a)Children with SPA (with or without other co-morbidity) who do not have ASD b)Children whose SPA has shifted them, functionally, along the ASD spectrum (normal to pathological, mild to severe) c)Children with both conditions in which teasing out which particular neuro-pathology accounts for which symptoms can be challenging d)Children with multiple co-morbidities e)Demand avoidance – pathological or adaptive? Copyright Cardiff University 5

6. Children with SPA without ASD. Have adaptive behaviours which can appear: ▫ Odd and socially inappropriate  Hypersensitivity e.g.  to smell – either extreme avoidance (crisps and school dinners) or explore the world through smell (ooh your pen has been next to the chewing gum)  to textures - clothes ▫ Socially avoidant and withdrawn  hoodies, baseball caps, socks on hands, poor eye contact - all as a result of sensory defensive strategies Copyright Cardiff University 6

7. Children with SPA without ASD - Cont: Have adaptive behaviours which can appear: ▫ Averse to affection  - abnormal seeking of comfort ▫ Egocentric  exaggerated personal space (won’t share sofa) ▫ Repetitive  seeking proprio-receptive feedback Copyright Cardiff University 7

8. Case 1: Girl 12 years LDs ▫ co-morbid anxiety disorder and OCD (very strong FH of both with several family members diagnosed) Inappropriate school placement ▫ Quiet (almost elective mute) and still at school ▫ Aggressive and unmanageable at home Very poor proprio-receptive feedback ▫ Bizarre arriving home from school “ritual” Copyright Cardiff University 8

9. SPA shifting children along the spectrum Copyright Cardiff University AutismAutismCuspTraits“normal” (severe)(mild) SPAAnxiety Low mood 9

10. Case 2: Boy 14 years ▫ Isolated, but severe and missed, SPA  Autism diagnosed aged 12 on very high ADOS score ▫ Symptoms misunderstood by school and family  Avoidance of physical contact, including as a baby  Hidden friends and social network & hidden humour  “this computer is mine” – seen as repetitive behaviour  Shaved head every 6 – 12 months  Hated new clothes  Low mood, alienated and defended – lack of smiling mistaken for lack of facial expression ▫ Some Aspergian personality traits Copyright Cardiff University 10

11. Co-morbid ASD and SPA Explaining symptoms and planning intervention Sleep ▫ Poor clock or abnormal proprio-reception? Eating ▫ Limited repertoire - driven by sensory problems or repetitive behaviours? Aversion to physical contact ▫ Driven by sensory defensiveness or autistic aloofness? Aggression ▫ Sensory defensiveness or arising out of triad problems? (holding) Copyright Cardiff University 11

12. Multiple co-morbidities ADHD; ID; DCD; OCD; anxiety; depression; epilepsy; sensory impairment etc. Simply increases ▫ the complexity of the child ▫ the need for imaginative assessment ▫ and creative solutions ▫ provided by an experienced and knowledgeable multidisciplinary team who can work together in whatever combination a particular child needs Copyright Cardiff University 12

13. Conclusion Professionals assessing and managing children with possible or actual social and communication disorders need to be well versed in SPAs They mimic, exacerbate and change autistic symptoms OT is a crucial component of any ASD service, both at the level of assessment, and therapeutics Assessment requires a team who assess children in more than one setting Copyright Cardiff University 13