Intervention Strategies for Autism, Sensory and Behaviour Difficulties Anne Sunners Occupational Therapist Bachelor of Applied Science Occupational Therapy.

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Intervention Strategies for Autism, Sensory and Behaviour Difficulties

Anne SunnersOccupational Therapist

Bachelor of Applied Science Occupational TherapyGraduate Diploma Social Science, Counseling Masters in Social Science, Counseling Studies

Certificate in Bio EthicsNovember 2011

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Outline of Training PART 1 – AUTISM

Autism Spectrum Disorder (ASD) – definition; cause; diagnosis; features

Communication difficulties in autism Learning difficulties in autism Sensory and motor difficulties in autism/other disabilities Skills and strengths of people with autism

PART 2 - SENSORY AND COMMUNICATION INTERVENTIONS

PART 3 - BEHAVIOUR DIFFICULTIES AND INTERVENTIONS

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PART 1

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What is Autism ?

Autism is a disability with three main problem areas: 1. Social interactions

2. Communication

3. Restricted behaviours or range of interests This may include : Unusual or repetitive play Using objects in an unusual way(e.g. hold stick up to eyes and stare at it)

Resistant to accepting change in the environment

Unusual body movement (e.g.'flapping’ hands, rocking, walking on toes)

These difficulties are generally seen before the child is aged 3 years.

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Autism

First described by Leo Kanner in 1943

“Spectrum disorder”: this means there is a great variety of behaviors, abilities and difficulties. Each individual with autism is unique in their personality and abilities, but have common features

How common is autism?

Recent research indicates that the prevalence for ASD is 6 per 1000 people

The reason for increase in prevalence is unclear and subject to much debate. It may be linked to better diagnosis and understanding of ASD around the world

Group Discussion: Do you think there might be a lot of people with autism in Cambodia? If ‘yes’, why?

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Cause of Autism Spectrum Disorder

Cause is unknown

Recent research suggests a genetic link and possible environmental factors that may make autism happen to the child

No evidence to suggest link to immunization

Not caused by bad parenting

No cure; lifelong disability

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Some Related Disorders

Intellectual disability

Epilepsy

Some people with other disabilities may alsohave symptoms of autism (e.g. DownSyndrome)

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Diagnosis of AutismWithin many countries professionals diagnose different disabilities by reading a

manual (book) called the “DSM”

DSM stands for “Diagnostic and Statistical Manual of Mental Disorders”. DSM is written by the American Psychiatric Association (APA). The manual describes different mental disabilities

In Australia special doctors, speech therapist or psychologists can diagnose autism by looking at the DSM and doing assessments.

In Cambodia other people may decide a child has autism because they have knowledge about the disability

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Communication Difficulties in Autism

People with autism may demonstrate: • Receptive language difficulties (how we understand what people

say)

• Expressive language difficulties (how we communicate to others – some people with autism do not learn to speak)

• Echolalia (repeating phrases/words)

• Difficulty understanding communication as two way process (the need to communicate to someone else)

• Difficulty interpreting facial expression or gesture

• Difficulty expressing and identifying feelings

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Video 1: child on swing

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Learning Difficulties in Autism

• Research suggests approximately 70% of people with autism have intellectual disability.

• Some may have normal intelligence or be very smart

• May focus on very small detail of an object rather than whole object (e.g. look at wheels of car rather than whole car)

• May not notice the things in their environment that are important to pay attention to

• Small changes to a situation or an environment may confuse or upset people with autism (e.g. trainer changes her hair style; furniture in activity centre changed position)

• Trouble generalising learning from one setting to another (e.g. child may go to toilet at activity centre but not at home)

• Difficulty with important thinking skills called ‘executive functioning’ (paying attention, learning from mistakes, being aware of time, organising self to complete tasks)

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What is ‘Theory of Mind’? “Theory of mind” is the capacity we have to understand other people’s feelings,

desires, hopes and intentions.

Most people start to develop theory of mind from around 4 years of age

“Theory of Mind” is difficult for people with autism to develop. It is hard for them to understand that other people think and feel differently than them.

Because of this the person with autism may

• Seem to lack empathy with other people.

• Have difficulty distinguishing whether actions are intentional or accidental

• Have difficulty interpreting listener’s level of interest in conversation

• Have difficulty understanding deception (not good liars)

• Have difficulty anticipating what other might think of their actions

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Social Difficulties in Autism

The person with autism may have social difficulties, as follows:

• Remember - many people with autism won’t be able to talk, or may not talk much. If they can talk, they may have limited topics for discussion. They may talk but not listen to others very well

• May repeat common phrases a lot

• May be very interested in their favourite things or topics and may not care much about other interests

• May be upset if their routine changes.

• May have difficulty understanding social rules e.g. of games/greetings, or customs (e.g. we do not touch people we do not know in a familiar way)

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Sensory Difficulties in Autism

‘Sensory integration’ is the organisation of sensations for use. Our senses give us information about our environment and our bodies

Sensory integration is an unconscious process of the brain – it occurs without us thinking about it.

Sensory integration allows us to act or respond to what we are experiencing in a purposeful manner

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What are our senses? 1. Tactile (touch, awareness of pain and heat/cold)

2. Vestibular (sense in our brain and ears to help with movement)

3. Proprioception (body awareness sense that is in our muscles and bone joints)

4. Olfactory (smell)

5. Gustatory (taste)

6. Vision

7. Auditory (hearing)

Group discussion: what senses are we using right now?

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What does our brain do with sensory information?

Our brain perceives or ‘notices’ the sensory information

Our brain then processes this sensory information

This is called sensory integration

– We can work out what sensory information to block out or ‘inhibit’.

– We can work out what sensory information we should pay attention to

– We can compare the sensory information to our previous experiences

– We learn to cope with combinations of sensory stimuli all coming in at the same time (e.g. we can look and listen at the same time; we can concentrate on our daily activity without having to worry about how our clothing feels on our body)

– We can then act on the sensory information in an appropriate way

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Examples• When I come to ATC I am wearing new clothes, they are stiff and bother me. But after a

short while I stop noticing the problem. My sense of touch tolerates this new feeling on my skin

• When I get in the Tuk Tuk the noise of the traffic is loud. My friend is talking to me. I learn to block out the traffic noise to concentrate on my friend talking (our voice is a noise too!)

• When I am getting out of the Tuk Tuk I use my eyes to help me see where to put my feet. I hold the rail and get out. I can do this because my senses are working well.

• When I come to training I learn to use many senses together. I listen and I look. I keep my body still in the chair and I may hold a pen to write notes. I tolerate the feeling of clothing on my body. At the same time my brain is coping with the smells in the room . My brain allows me to combine many senses

• When I taste a new food I have never had before, I think about what it is similar to. Have I tastes something like this before? Is the texture, appearance and smell familiar to me? I compare the tastes to my previous experiences.

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Why are Sensory Integration Difficulties a problem?

When sensory integration is a problem it can affect

the child’s development. The child will not be using his body

and brain the same way as other children.

Because of this the child :

• May have trouble learning physical skills such as sitting up, crawling, or walking . They may seem clumsy

• May have trouble learning tasks such as dressing or feeding themselves.

• May have trouble playing

• May have trouble paying attention

• May have trouble with learning at school

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• All people have sensory preferences. E.g. some people like spicy food, others do not. Some people like loud music, others do not.

• This means we are all different. It is not a problem.

• If the sensory difficulties are severe they may impact on the person’s life. E.g. if a child has difficulty with loud noises they may not be able to concentrate on school work. If a child has difficulty coping with the feeling of clothing on their skin they may not like to get dressed. All of us must wear clothing sometimes.

• People who may have sensory difficulties include those with intellectual disabilities or Down Syndrome

• People with autism often have severe sensory difficulties, much more than other people

Group discussion: what sensory experiences do you like? What do you dislike?

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Some Sensory integration problems

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Child moves too much

• May find it hard to sit or stay still

• May spin self around

• May spin wheels or objects

• May rock body or head

• May run a lot

• May walk on toes

Child does not move enough

• May prefer quite activities

• May seem scared of movement

• May find some physical tasks difficult (e.g. standing on one leg for pulling up pants, or going up stairs) because this makes them move their body more

Example – Tom runs around a lot. He finds it hard to sit at the desk to do school work.

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Child does not notice much touch

• May have less awareness of pain or temperature

• May not notice if they are touched

• May put things in their mouth to get more stimulation to their mouth

Child dislikes touch

• May hit if people touch them• May avoids hugs/touch except

when they want it• May avoid clothing or only want

to wear certain clothing• May avoid touching certain

textures• May not like touching or tasting

some foods • May not like the feeling of

cleaning their teeth, washing their body or combing their hair

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Child does not notice things with their eyes • May not seem to notice person or

object • May use eyes in an unusual way e.g. look at objects out of the

corner of their eyes, throw toys or sand or dirt to watch it fall

Child dislikes things they see with their eyes

• May seem to dislike bright lights• May close their eyes in an place

that has a lot of things to look at • May get upset when the

environment changes• May line up toys or objects

Example – David looks at his fingers a lot

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Video 2: child looking at counters

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Child does not notice sounds

• May not seem to notice sounds including speech

• May make some sounds repeatedly for own enjoyment to seek more stimulation

Child is upset by some sounds

• May get upset about particular sounds e.g. sirens, bells

• May block or cover ears• May become upset in noisy

places• May be easily distracted in noisy

places

Example – Sam does not notice when a door slams loudly

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Child is not noticing smells or tastes very much

• May try to smell things (e.g. toys, people, objects, food) or taste things a lot to get extra stimulation to their senses

• May seems unaware of smells/ tastes most people would notice (e.g. put poo in mouth)

• May crave certain tastes

Child dislikes some smells or tastes

• May notice very quickly if there is a new smell or taste

• May becomes upset with new or common smells e.g. soap, cleaners, perfumes, food cooking

• May reject new foods• May have a limited diet because

that is all they will try

Example – Tan gets upset when his mother is cooking food

- Jerry only likes rice, no meat or vegetables

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Common motor difficulties with autism and other disabilities

Common problems in autism and other conditions:

• Delayed gross and fine motor skills (big and small movements of the body)

• Low muscle tone (floppy muscles)

• Difficulty with postural control (ability to keep the body still when stationary, or when using arms and legs)

• Difficulty with awareness of the body

• Difficulty with motor planning (ability to plan and organise a sequence of movements of the body for a particular purpose)

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Video 3: group motor activity

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Video 4: child catching ball and jumping

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Strengths of people with autism• Good at learning visually

• May have a good memory

• Like routine and structure

• Less anxious when they know the rules

• Not as interested in social conversations as other people . This might help them focus on their work more efficiently

• May know a lot about a topic of particular interest to them

Group Discussion: How can we use this information in a positive way for people with autism in Cambodia?

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PART TWO

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Important methods to help autism

1. Learn about autism – communication, social and sensory difficulties - how do they impact for the person with autism?

2. use structure and routine to help the person with autism feel calm and help them learn

3. Use visual techniques – very important4. Use explicit teaching strategies – people with autism may

need to be specifically taught skills that other people acquire very easily; this includes social and communication skills

5. Use sensory interventions to help the person feel calm or more alert

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Intervention to help Sensory Integration Problems:

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Encourage the child to move in the day to get tired, then they can do their work

• Normal daily movement through tasks around home, school or centre

• Let them move a lot before you want them to concentrate

Use movement when trying to teach other skills

• e.g. Sit on big ball during table tasks

Help the child get calm

• Weighted items e.g. Heavy cushion

• Provide firm massage to help them be calm

To help the child who moves too much

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Bounce on ball Moving body and doing a puzzle – helps her concentrate

Rolling to get movement before he has to sit down

Sitting on the floor they can move their bodies while they play a game and then they don’t run around as often

Helping carry things gives him natural opportunities for movement during the day

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This boy had a big swing; now he can sit and concentrate better

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Heavy cushion on her lap helps her feel calm so she can listen to a story

Firm pressure to her head helps her feel calm

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To help the child who has problems with touch

For the child who does not notice much touch:

• Increase the tactile properties of daily objects to help the person be more aware of what they are touching (e.g. wrap cloth around a spoon handle)

• Provide tactile play activities to help improve awareness (e.g. sand/water play); Better body awareness helps make it easier for the child to complete daily activities

For the child who dislikes some touch

• Do firm massage to hands before the child has to touch something messy

• Do firm massage to head before hair care

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This boy is having firm massage to his hands, head and mouth. When he touches some textures or eats some food he vomits. The massage might help him cope better with textures and with food.

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For the child who does not notice much with their eyes

• Help them improve their visual skills by giving them toys that are visually attractive

• Use different colours or contrasting materials to gain visual attention (e.g. coloured paper)

• Some children will look at their work if it is in front of their face (e.g. paper stuck on the wall to draw or write on)

For the child who dislikes some of what they see

• Use soft or no lighting

• Try using sun glasses to make the light softer

• Try making work environments simple (e.g. do not put too many things on the table when they are working or they may become distracted)

To help the child who has problems with vision

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Showing pictures to help the child choose a song – visual material is clearly presented to the child

Choices for activities – clearly presented

The child is enjoying a nice visual toy

The lady is doing her work on an easel to help her pay attention better

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The child is having trouble paying attention to the activity. He was moved to a quiet area with less distraction and then he managed better

The child is having trouble paying attention to the activity. The materials were brought up closer to his eyes so he could focus better

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For the child who does not notice sounds

• Help the person become aware of sounds they should pay attention to with use of visual cues

• Try to see if they will pay better attention to you talking if you speak louder or even softer than normal –sometimes this helps!

For the child who dislikes some sounds

• Provide calm, quiet place for person to go

• Help the person learn to cover their ears to block out sound (e.g. using hands, wrapping cloth around their head, using hats

• Warn person before a noise will occur that they find upsetting

To help the child who has problems with hearing

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I am worried about the bell. I don’t like the sound. I don’t know when it is going to ring.

The teacher will warn me before the bell is going to ring. I will listen for the bell. The bell will ring five times and then stop. I will try to cope. When the bell finishes I will be happy

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For the child who is not noticing smells and tastes

• Sometimes these children put things in their mouth a lot. Try giving them one toy or item to chew.

• Try using smells in activities e.g. perfumes

For the child who dislikes some smells or tastes

• Change one part of a meal at a time (e.g. add a very small amount of food that the person dislikes into their food to help them get used to it.

To help the child who has problems with smell and taste

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Blowing bubbles and whistles helps the mouth muscles and breathing work better.

This boy has very floppy muscles in his mouth; he has food through a tube in his tummy. He has just learned how to blow a whistle! This might help his talking and eating as his muscles will be working better. Putting whistles in his mouth might help him cope with trying different food

This boy is chewing a special chew toy. It is given to him to chew instead of his clothing or furniture. It helps him to be calm when he is upset

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For the child who has problems with body awareness or motor skills

• Play physical activity games e.g. o Crawling under a table, climbing, being wrapped

up in a mat and rolled outo Let the person help with packing away

toys/objects, carry items

• Heavy play tasks that involve pushing, pulling, or carrying, all help with body awareness and motor skills

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Rolling up in a blanket Rolling on a ball

Riding a bicycle

playing with sand Balancing and climbing

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Communication InterventionsWhat is important about communication?

• Communication requires 2 people

• The communication of one person must be directed to

another person

• The second person responds to the first person

• We communicate for different reasons

• There are different forms of communication (speech, gesture, facial expression)

Helping people with autism and other disabilities with communication:

• Keep sentences simple and short

• Use visual intervention strategies

• Use songs and music to help with communication

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Visual interventionsVisual interventions – this means using visual materials to help a

person understand what is happening in their environment

• We may use words, drawings, pictures, photos, real objects

• This can help teach the concept of time

• This can help the child cope with changes to their routine

• They help the person cope with changing from one activity to another or from one place to another

• This can help motivate the person to complete an activity they do not want to do (more about this later!)

• This can help reduce anxiety

• This can help understanding

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Children who can benefit from visual interventions

• Visual interventions have been found to be very valuable for people with autism because they learn best when material is presented to them visually. They have trouble understanding spoken language

• People with intellectual disabilities can also benefit greatly from the use of visual interventions

• We all use some form of visual cue (e.g. we may use diaries, notes). This is part of normal life

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How to use Visual Interventions

• Single picture

This can be shown to someone so they know it is time to look at a book

This can be shown to the child to teach them to ‘STOP’ what they are doing. At my work place, we have a sign saying ‘STOP’ to teach children not to turn the light switches on and off

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• Schedules

Pictures are used to help motivate a child to complete tasks they do not want to do. To get the toy, the child must do 1. colouring , 2. use scissors, then 3. have toy

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This schedule is used in a day program for preschool aged children. It has the morning schedule on it: play, pack up, singing, work at the table, toilet, and snack When each task is completed it is taken off the board and put in the box at the bottom that says ‘finished’.

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Videos 5 and 6: using visual schedules

• To help a child make a choice

Having a choice helps build independence and communication.

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Video 7 - Child making choice

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Social stories

• Social stories are stories that help teach the child what they are supposed to do and how they should behave.

• You can read the story to the child if they cannot read; use pictures to help them understand.

• (Refer to the internet ‘Carol Gray’s Social Stories’)

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Example• When I come to the activity training centre I see my

friends

• I will try to say ‘hello’

• When I say hello my friends are happy • And I am happy too!

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PART 3

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Behaviour difficulties and Interventions

• Group activity: What behaviour difficulties do you see with the children you work with? What behaviour is the most difficult for you to manage?

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What causes behaviour difficulties? Communication problem

• the child may not understand what is expected of them

• the child may be trying to communicate how they are feeling or what they want

Sensory problem

• the child may be upset by sensory stimuli

Doing activities

• the child may not be getting enough exercise or stimulation

• The child may be given tasks that are too difficult for them to manage

Physical problem

• the child may be sick, uncomfortable , tired, or in pain

Developmental problem

• the child with a developmental problem may behave like a much younger child (e.g. a boy of 17 years may get angry like a 2 year old child and bite someone or throw something

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Important methods to help with behaviour difficulties

• Try to reward good behaviour and teach new skills. Do not just punish bad behaviour

• Sometimes we can ignore annoying behaviour. But, we must not ignore behaviour that may hurt the child or another person

• Consider all the possible causes of behaviour difficulties when planning your intervention

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Intervention with behaviour difficulties

1. Define the problem • WHO does it?

• WHAT is it that they do?

• WHERE do they do it?

• WHEN do they do it?

• Is the behaviour directed at someone or something?

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2. Develop a plan

Record behaviour over one week using behaviour chart

Discuss what is recorded in behaviour chart with people involved

Plan may include:

• use of a timer or bell to tell the child it is almost time to finish/start something

• use of visual strategies to help the child understand what is happening;

• use of a reward chart for being cooperative

• Learn ways to help the child feel calmer

• Teach staff how to protect themselves from injury from hits, kicks or bites

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3. Implement the plan

4.Evaluate the plan

Group discussion on behaviour intervention

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Specific teaching of new skills Some children will need to be specifically taught new skills to replace the

difficult behaviour. Children with autism need very specific teaching.

We may need to teach a child:

• Better ways to communicate

• Better ways of having needs met

• Better ways to cope with stress and emotions

• Better social/play skills

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Protecting yourself from injury

• To stop being hurt by a kick or hit

• Dealing with a bite

• Dealing with a pinch

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The End !

Thank you for welcoming me to Cambodia and sharing your work with me. I have learned a lot and have enjoyed my visit.

Annie Sunners