Sensory Integration through the Lifespan

Presenter: Nicole Kristal, M.S. OTR/L

She studied Psychology and Sociology at the University of California, Santa Cruz. She obtained her Master’s degree in Occupational Therapy from San Jose State University. She currently works as a pediatric Occupational Therapist for children with neuromuscular disorders. She has many years of experience working with children with autism spectrum disorders, including several years spent as an Applied Behavioral Analysis Therapist, working in a private sensory integration clinic, and in several recreational settings as a coach for therapeutic sporting activities.

By Dr. Marci Schwartz, Founder, Altitude: Partnering with Families, and Dr. Louise Kindell, Clinical Director, Altitude: Partnering with Families.

Studies within the field of cognitive neuropsychology have shown that those with autism spectrum disorders appear to have significant difficulties with executive functioning. Executive function is a complex and dynamic set of neurological processes that allow a person to effectively plan ahead and problem-solve. It includes behavioral regulation such as inhibition of response, shifting attention, and emotional control. It also includes metacognitive processes, or “knowing about knowing.” These processes include initiating a task, working memory, planning and organizing, organization of materials and self-monitoring (Ozonoff et al., 1991).

In real life, children with executive functioning difficulties may be resistant to change a fixed routine, rely too heavily on rote memory, struggle to solve everyday problems, are fact oriented, become overwhelmed when presented with too many options, cannot generalize learned rules or information, and demonstrate an overly strict adherence to rules. They often become “stuck” or struggle to “get going.” Many children will display anxiety around change and have significant trouble with transitions. They will become upset if others do not follow their rules, have a fierce sense of justice/injustice, cannot calm without closure and demonstrate extreme frustration with organizational tasks. Often they become overloaded and shutdown or have significant temper tantrums or meltdowns.

While executive functioning difficulties cannot be cured, there are various interventions designed to help compensate for such challenges. Such compensation programs typically provide additional external support. This additional environmental structure helps to organize the individual, clearly defines environmental expectations, and includes incentives to provide the necessary motivation (Marlowe, 2001 and Levine et al., 2001).

Imagine a person who has lost a leg, and they have been fitted with a prosthetic device.  The purpose of this “new leg” is to compensate for the loss of the leg.  This individual can still walk, run, or do most other things they had done prior to the loss. However, it is not the same as having their leg back.  That is what we are doing in creating executive functioning compensation programs.  We are creating a way for the child to meet their obligations as a child, sibling, student, etc. while using strategies that help.  It will take more effort, and it won’t be the same as if they did not have the challenge.  But they can work to compensate to the best of their ability.  Helping children with executive functioning challenges develop schedules with purpose that is meaningful to them will help them to compensate for the challenges.

Incorporating structure into a child’s day is important to help them understand what they need to accomplish, understand what others expect them to do, and be productive.  For children with challenges in planning, organization and time management, the schedule becomes their tool to productively meeting their responsibilities to themselves, family and community.  Schedules can take many different forms. They may be done solely with pictures (i.e., icons, photographs, drawings), be a mixture of pictures and words, or words only. The following is a sample schedule that incorporates productive times with much needed breaks:

7:00 wake up

7:10 brush teeth, brush hair and get dressed

7:30 breakfast

7:45 computer time (Break)

8:15 be in car with backpack and lunch

8:20 access to hand held device for ride to school (Break)

In the example above, the reward for the child getting ready on time was the computer time.  If the child was able to get off the computer with only one warning, he earned use of the hand held in the car.  A main point of this type of schedule is to help the child create purpose for doing his morning chores.

Helping children with executive functioning challenges create purpose to their tasks is important to build success.  For many of us, the purpose of doing our morning chores and getting ready for school on time is the understanding of our role as student to arrive at school on time, and our role of child to listen to our parents and respect their rules.  These are abstract concepts and difficult for some children to integrate.  Helping them by creating purpose that is meaningful to them is important to helping them learn the skill of following a schedule.

Creating meaningful purpose for children can be done in many ways.  For children who have a poor concept of time or are struggling with a difficult task, or have challenges with focus, immediate rewards after a task may be necessary.  For example, after completing a homework problem, an immediate reward of a sticker their favorite item (e.g., dinosaur, train, etc.) or a few minutes reading their favorite story may be necessary.

For children who can delay rewards, using a daily schedule without many rewards within the schedule is possible, and these children can earn points for completing the schedule each day.  For completing the schedule each day of the week, they may be able to have a reward over the weekend.  Children can earn rewards for completing chores at home such as sweeping, emptying the dishwasher, folding clothes, etc.

Developing an appropriate reward system for your child can feel challenging and overwhelming to many parents.  It is a different way of parenting, and initially takes extra time and effort on the part of the parent to get it going and successful.  Some important concepts to keep in mind to work towards success are the following:

• Make sure you have a good understanding of how your child understands time.  This will impact how much help they will need to keep to the schedule as well as how long they can wait for a reward before they give up. Often children with a limited understanding of how time “feels” do well with a Time Timer, an hour glass, etc, where time is expressed in a more visual and concrete manner.

• Look to see if there is a balance between how compelling the reward is for the child and how difficult the task is.  If the task is really challenging to the child but the reward is not that interesting to the child, the chance of success is small.  If the balance is good between task and reward, there is a greater chance of the child completing the task and earning the reward.

• It is important to remember that children want to be successful.  If the system you create is not generating success, then we must look to an element of the system that is not working.  For example, maybe the task is too difficult for the reward. If we increase the reward or modify the task, we might get better success.  Remember that children want to be successful and need us to help them achieve that success. Using what the child is naturally interested in, and modifying their interest into an incentive, is usually a good place to start.

Children by nature are always changing and growing.  They will grow and master some skills and be ready to move on to others.  In addition, they will lose interest in some motivators and move on to other interests.  It is important for parents to keep the program going by anticipating new rewards in order to maintain momentum in creating structure with purpose that is meaningful to the child.

While it is a long and dynamic process, the goal of various structural supports is to help children create effective routines and integrate the importance of having a structured schedule in their lives, continuing to use the tools they learn in childhood to create success for themselves as adults.

This is a book written for middle school age kids that introduces the main character, Jarvis.  Jarvis shares his input and observations about various social happenings on the middle school campus.   Dr. Levine provides fun activities and questions that can help the young readers think more deeply about social situations they can encounter at school.

This book provides a plethora of intervention strategies to support the child with HFA in the regular education setting.  The book does an excellent job of clearly describing the social –cognitive, executive functioning, sensory and cognitive challenges of the HFA child, as well as strengths and capabilities, and outlining specific strategies to enhance a child’s skills in the classroom and promote independence.   Teachers will find the material well organized, understandable and easy to translate into effective classroom practices.

An excellent resource for parents and providers who are interested in learning more about and implementing relationship based approaches to building social skills.  Gutstein’s approach complements more structured and cognitively based social skill programs.

Another excellent book.

This is a terrific workbook that can be used in therapy or at home.  It describes the unique strengths as well as challenges that are associated with Asperger’s.  I like how it is written from the child’s perspective and as the workbook is completed, it becomes a narrative not only about Asperger’s, but about the child’s own history (family, interests, friendships, schooling).  Creating a cohesive narrative is a key accomplishment of healthy development and this workbook has helped me help children and middle-schoolers do just that.

This is a nicely illustrated children’s book that helps with teaching progressive muscle relaxation in a fun way.  We can all relate to being angry like the octopus in the story.  It is playful and a helpful visual to teach this important relaxation strategy.  Even though this is a children’s book, a middle-schooler could read it to use the strategies.

This is a another nice book by Lori Lite.  In this story, tons of cute sea otters learn deep breathing.  Again, a nice visual reminder of how to teach children to calm their breathing so that they can relax and sleep.