CHAPTER 16

Managing Sensory Issues

Our senses provide us with important information about our environment. Touch, smell, taste, hearing, sight, and sensations of balance, body position, and movement provide us with important cues such as whether something will taste good or whether something could be dangerous. Most of us learn fairly quickly what sensations we need to pay attention to and which ones we can ignore. For most of us, extraneous stimulation—for example, the slight flicker of a fluorescent light—is something we can quickly learn to ignore. For most children, hearing (especially what people say to you) and vision become the most important senses, particularly for communicating and learning about the world. For children with developmental challenges, particularly children with difficulties on the autism spectrum, the other senses may be just as relevant, if not more so. As a result, they may seem to overreact to some sensory stimuli and may have trouble filtering out other, less important stimuli—a tendency that can lead, in some cases, to higher levels of arousal and/or feelings of anxiety. Given the potential impact of this tendency on the child’s ability to learn and socially engage, such sensory issues should be considered in planning intervention. In this chapter, we talk about sensory issues in autism spectrum disorders. We’ll discuss hearing and vision (and screening for problems in hearing and sight), as well as some aspects of unusual sensitivities and sensory problems that children with autism spectrum disorders (ASDs) often have. As with other topics, please keep in mind that there are many individual differences. The child you know with autism or a related condition may not have any of these problems, although some children have many of them. It clearly is important to make sure that the child is hearing and seeing well so that he can take full benefit of his educational program.

SENSORY DIFFERENCES IN AUTISM

Unusual sensory features in autism were reported by Leo Kanner in his first description of autism. Many children with autism have some unusual sensory responses and interests, for example, being over- or undersensitive to the extraneous environment. What seems extraneous to most of us (typically developing) folks may not be so to the child with autism or ASD. While the social world seems much less relevant to them, the nonsocial environment may loom very large. Often, there seems to be a paradoxical combination of too much sensitivity (some sounds that you might not even notice will drive the child to distraction) and undersensitivity (the same child may not respond to his own name when it is called). Some children with autism are preoccupied with lights or patterns. Sometimes they bring things very close to their eyes and move them back and forth. Children with autism may also be preoccupied with the feel or texture of things or other sensory properties. For example, rather than play with the figures in a dollhouse and make up stories about them, they might repeatedly feel the wooden dollhouse furniture, spin the furniture around, or stack the pieces in a pile.

We don’t know why all these unusual sensory issues develop in children with ASDs. It is likely that these problems are intimately related to other problems in development, particularly social development and attentional abilities. We do know, however, that they can make life more difficult for the child, family, and teachers. Sometimes unusual sensory experiences pose problems at home or school, for example, by diverting the individual’s attention from what is most relevant (maybe the teacher or a lesson) and onto what is much less relevant (the light switch or the sound of the air conditioner or texture of the carpet on the floor). These behaviors also appear to peers to be very unusual and can result in isolation of the individual. At other times, unusual sensory sensitivities may be unpleasant for the person and their reactions may seem very odd indeed to onlookers as she becomes overly preoccupied with what, to the onlooker, seems a very minor detail!

Various theories have tried to account for these problems, but with only limited success. It is not clear whether the problems have to do with too much (or too little) processing, with anxiety, with difficulties in dealing with change, or with basic aspects of information processing and attention—although probably all of these are involved in some degree. The social problems so characteristic of autism and ASDs also likely contribute, that is, probably, most of us learn very early in life from other people what is, and isn’t, so important to focus on. Similarly most of us learn early in life to ask for help, one way or the other, when we need to cope with sensory stimuli or sensory overload, for example, by turning to parents or caregivers. As we’ll discuss later in this chapter, tests of hearing and vision in children with autism usually show normal sensory abilities, but it is interesting that some children who have visual impairments or deafness (but not autism) will show some unusual sensitivities and behaviors similar to those seen in autism.

Sometimes unusual responses to sensations are one of the first warning signs of autism. For example, a parent may notice that her infant won’t respond to her voice consistently but becomes very upset if the vacuum cleaner is running. For some children, unusual sensory problems become more dramatic with age. Other unusual sensory behaviors may include preoccupation with moving objects (fans) or staring at the hand/fingers, or sometimes children will dangle string in front of their eyes. Leo Kanner viewed these behaviors as an attempt for the child to “maintain sameness” and avoid new experience—yet another challenge for learning from the world.

For individuals with more language, sensory issues/problems may diminish over time—probably, in large part, because language helps them cope more effectively and thus makes them less likely to be disorganized by the environment. For these children, some important ways for the child to self-regulate may develop; for example, self-talk may function as a way of coping. Many higher functioning individuals (with autism or Asperger’s disorder) do report unusual sensory experiences and may be bothered by things that the typically developing person wouldn’t notice. For example, in some of the work done at Yale on eye tracking, we have had very able people with ASDs watch clips from movies, and through the use of a special infrared camera and various computers, we can see what exactly the person is focused on in viewing a scene. In one instance, a person with an ASD was watching a scene from the classic movie Who’s Afraid of Virginia Woolf, and as Richard Burton and Elizabeth Taylor were passionately kissing, the person with autism was focused on a light switch in the background!

EATING AND FEEDING ISSUES

Children with autism and related disorders can have a number of problems with eating and food. These often include:

• Unusual food preferences and sensitivities, which can lead to a restricted diet

• Pica (eating nonnutritive substances such as dirt or string)

In this section, we’ll consider some of these problems and potential solutions. Again, keep in mind that this is a general discussion with general suggestions and that when specific advice is needed various professionals can be of help; these include speech-language pathologists (SLPs), occupational therapists (OTs), and dietitians, as well as experienced teachers and parents.

Unusual Food Preferences and Sensitivities

Children with autism or other pervasive developmental disorders (PDDs) may have unusual eating habits. Some have pronounced likes and dislikes when it comes to food. Sometimes these habits keep the child from having a good diet. Some children are extremely sensitive to certain food textures or tastes or smells. Some children may eat only certain kinds of food (e.g., foods that are soft and mushy). Other children may resist new foods or may not tolerate foods of certain temperatures. Sometimes children eat the same foods over and over again. We’ve seen children who would eat only white food, who would eat only cold food, who would eat only French fries, and certain fast foods.

The attempt to introduce new foods at mealtimes can lead to temper tantrums and other difficulties. Occasionally, these escalate to the point that the child becomes malnourished, although this is unusual. These food preferences are not always easy to understand. They may be part of the difficulties children have in dealing with change or related to oversensitivity to smells and tastes.

Many parents of children with autism report some food sensitivities starting more or less from the moment that solid foods are introduced. It is interesting, however, that we’ve seen only a handful of children with autism who failed to gain weight appropriately as infants (sometimes called failure to thrive). When problems start early, they often seem to get worse as the child becomes a bit older, so it is worth trying to help the child when these problems first develop.

To some extent the unusual food preferences of some children with ASDs may be understood as having some resemblance to problems seen in typically developing toddlers where struggles over food are very common. The endless reminders from your mother to eat your peas or broccoli may come to mind! These problems are, however, often much more marked and severe in children with autism. Several things help the typically developing child cope—for example, being motivated to imitate the models provided by family members eating a range of foods or enjoying praise from parents for trying new foods. Unfortunately, children with ASDs often feel less social motivation and desire for praise. In addition to heightened sensitivities regarding food, rigidity and difficulties with change further complicate the attempt to introduce new foods into the diets of children with autism. These problems can be even more complicated when parents are also pursuing dietary interventions (see Chapter 18) that further restrict what the child can eat. It is possible to restrict the diet so much that a young child who otherwise responds to very few things other than food will no longer have that as an option.

THE ROLE OF DIETITIANS

Registered dietitians and dietetics technicians have had specific training in diet and nutrition. If your doctor suggests a consultation with the dietitian, he or she will talk with you, observe the child, and look at her medical records. The dietitian may be able to identify specific nutritional problems and can evaluate the child’s need for special vitamins, minerals, or other diet changes. He or she will also consider any special issues related to the child’s appetite, food preferences, medical history, and nutritional needs.

The dietitian can help you design a better diet for the child and may also work on increasing independence in feeding and dietary skills. This can sometimes be done in conjunction with the child’s behavioral program. The dietitian may work with other professionals, including the child’s doctor, SLP, or occupational therapist. Information on diet and accredited dietetic professionals is provided on the American Dietetic Association’s web site (www.eatright.org).

Dealing with unusual food preferences is not easy. Strategies for coping with this problem are quite varied. One approach is to attempt very gradual change—very, very gradually introducing new foods. This might work well, for example, for a child who eats only white foods, where you could gradually begin to introduce color into the food. Blenders and food processors can be a real help in this regard. Sometimes unpopular foods can be hidden in other blenderized foods; this may make the texture more tolerable as well. Depending on the child’s preferences, it may be possible to add to foods she does like. For example, if she will drink milkshakes, you can try adding different kinds of foods to the shake.

For some children, varying the way in which the food is presented may be the trick. Sometimes freezing pureed vegetables into popsicles may make them more interesting. Or a child who would never eat cooked peas might respond if they were presented in frozen form. Other children might be willing to try dried peas. The usual rule of thumb is to try gradually introducing new foods. Even though it is a hassle, keep at it, since otherwise the tendency is often for the child to become even more rigid.

Sometimes children are delighted to try foods that they have been involved in preparing. This approach can also have payoffs if you need to plan school lunches or snacks. You can try a visual approach to help involve her in cooking. For example, make up a set of index cards with photos illustrating how to prepare spaghetti. Put them in order in a notebook or on a ring. (Photos might show the child getting the spaghetti box out of your cupboard, getting the pot out, and putting water in it, etc.) For children who can read, the printed words may be sufficient or the pictures may be gradually eliminated over time. For some children, eating what they have helped prepare is very helpful.

Parents can also try involving the child in grocery shopping to try to spark an interest in new foods. Parents can consult with the child’s school staff about ways to make this a positive learning experience. For example, you can make a visual shopping list ahead of time. Use a digital or instant camera and make photographs of the actual items the child will need in the store. You can put these onto a shopping list using Velcro tabs. This special list can help the child shop with you in the store. You can start with very simple foods and gradually increase the complexity as time goes on. This is a wonderful way to make grocery shopping a positive learning experience for the child and help her take pride in her abilities. Over time, other skills can also be involved, such as counting money, quantities, and so on. You also help encourage adaptive behaviors and important community and daily living skills.

Various behavioral approaches can also be used to help the child learn to tolerate a greater range of foods, such as those suggested by an occupational therapist or SLP. Often, a gradual, step-by-step approach is used with carefully selected rewards for more appropriate eating. The specific plan is individualized depending on the child’s needs and problems. Praise, time-limited meals, ignoring food refusals, and more frequent “mini-meals” (with limited snacks in between) can all be used in various combinations. As with everything else, it is important to weigh the pros and cons of the various approaches. Children whose limited diets put their growth and development at risk are the ones who will need the most intensive intervention programs.

Various professionals can be helpful to you in dealing with the food preference problem. Behavioral psychologists may help you design a plan for gradually introducing new foods and expanding the child’s range of foods. Especially if the child eats a very narrow range of food, it may be worth meeting with a dietitian to review the child’s diet and think about ways to supplement it. Often, it is the texture rather than the taste of food that seems to be a problem. SLPs or occupational therapists may be able to work with you in developing ways to help the child be able to tolerate a greater range of textures or help with other aspects of the “presentation” of foods.

Eating Nonfood Substances (Pica)

Some children with ASDs have a different problem; they have a tendency to eat things that are not food (this is technically called pica). This may include dirt, paint chips, string, or anything they find on the floor. Other children will chew on materials and/or keep them in their mouths without swallowing them (or sometimes swallowing them by mistake). These behaviors can lead to various medical problems, including bowel obstruction and increased risk of poisoning. Various strategies can be used for dealing with inappropriate eating and mouthing behaviors. The choice of strategy depends on the age and cognitive level of the child and on the specific behavior that is at issue. Some children like the experience of moving their mouth and/or chewing. If this is the case, you can try several different things, including crunchy foods or foods with interesting textures, gum, and so forth (be aware that there is potential for adding a lot of sugar to the child’s diet, so search for reduced-sugar or sugar-free chewing substitutes). The SLP or occupational therapist may have suggestions for nontoxic things the child could chew. Sometimes chewing is a reflection of overstimulation, and reducing the level of environmental stimulation may help. At other times, the use of an electric toothbrush (sometimes several times a day) can provide oral simulation (this also has the advantage of promoting clean teeth!).

Various professionals may also be helpful in reducing pica. The SLP or occupational therapist may help you think about new ways to cope with the problem and give the child alternative behaviors. A psychologist or physician with experience in developmental disabilities may also be helpful in suggesting behavioral interventions to try. Sometimes you can find a substitute or alternative behavior such as eating ice chips (with or without flavor). Sometimes your reactions to the behavior may be an important part of what keeps it going. You may need to learn to ignore the behavior if it is not endangering the child’s health, while simultaneously providing plenty of praise and attention for more appropriate behavior.

HEARING PROBLEMS

The most common sensory sensitivities reported among children with ASDs are probably those that involve sensitivity to sounds and noises. This can take the form of seeming either undersensitive or oversensitive. Often, the parents’ initial concern may be that their child is deaf because of his apparent lack of sensitivity to some sounds. At the same time, the child may seem to respond exquisitely to some sounds from the inanimate (nonsocial) environment such as sirens, planes, or the rustle of a candy wrapper.

Deafness occasionally is associated with autism. As we mentioned in Chapter 10, children can sometimes have some degree of temporary hearing loss due to recurrent ear infections leading to fluid in the middle ear. On the opposite side of the coin, sometimes children with deafness may initially look somewhat autistic, but they improve markedly when provided with assistance devices such as hearing aids or implants, or when taught to use communication programs such as sign language.

Assessment of Hearing Ability

Good hearing is a prerequisite to developing the ability to speak. And it is also important in the development of good social skills. Accordingly, hearing testing is typically conducted in very young children when autism or related problems are suspected and when a child has delayed speech and language skills. It is particularly important if the child seems to respond to no or very few sounds.

Apart from genetic testing for fragile X, hearing testing is the additional medical test that is almost always important in autism. Many states are starting to require that a hearing test be done on all newborns before they are discharged from the hospital. This early screening will be very helpful in picking up congenital hearing problems. Your pediatrician or family doctor may be able to assess the child’s hearing in his or her office. If not, you will be referred to an audiologist, an individual trained and licensed to assess hearing impairment. If possible, the audiologist should be experienced in working with children with developmental problems.

Types of Hearing Loss

There are different kinds of hearing loss. Conductive hearing loss occurs when there are difficulties in the transmission of the sound as it enters the ear canal through the middle ear and the small bones in the middle ear. This type of hearing loss in children is usually the result of fluid in the middle ear following recurrent infection or allergies. Impacted wax in the ear canal can also cause conductive hearing loss. Your pediatrician can usually remove the wax. One problem with conductive hearing loss is that only certain sounds may be heard due to the way different levels of fluid affect the way the eardrum responds to different sound frequencies. At different times, different sounds may be muffled or distorted in different ways by the fluid. Obviously, when specific speech sounds do not sound the same from day to day, it can be very confusing—especially for children who are just learning language. Conductive hearing loss is usually reversible.

A sensorineural hearing loss occurs less often. It results from a problem in the transmission of sound further along in the pathway between the middle ear and the brain and indicates that there has been damage to the inner ear or to the auditory nerve. There are many possible causes of sensorineural hearing loss. This type of hearing loss may run in the family, either as the sole problem or associated with certain genetic disorders that also cause other difficulties (such as heart problems). It can be associated with some in utero infections, very high bilirubin levels in the newborn, bacterial meningitis, and the use of certain antibiotics. This kind of hearing loss is generally permanent and does not improve with age.

Some children may have a mixed hearing loss involving both conductive and sensorineural hearing loss. Children with autism can have any of these types of hearing loss.

Problems With Sound Sensitivities

If the child has normal hearing and exhibits sensitivities to sounds, there are several things to do. At school, a minimally distracting and less noisy environment may well help. Some school buildings and classrooms seem almost perversely designed to complicate life for the child with an ASD. Concrete block construction and linoleum floors all contribute to an “echo chamber” effect. Sometimes simple steps can be taken to reduce auditory “clutter” in the classroom. For example, if the classroom is carpeted or if the bottoms of chairs are modified to make less noise, this may help reduce the overall sound level. Seating the child near the teacher and away from sources of noise (e.g., air conditioners) also may be helpful. Closing doors when possible will reduce noise. For some individuals the use of earphones to block out extraneous noises may help. Other things that have been tried include special amplifiers that amplify speech sounds for the child (similar to hearing aids) to help the child focus on the sounds that are most important (i.e., the speech of the teacher or peers). FM sound systems may help some children cope with an intrusive auditory (i.e., noisy) environment. It can be helpful for the child to learn to let the teacher know when sound levels are too much or he or she is feeling overwhelmed by sounds. Some alternative treatments also focus on reducing sound sensitivity (see Chapter 18), but research support for these is somewhat limited.

For some children, the sounds (and unpredictability) of things like fire alarms can lead to tremendous anxiety and behavioral difficulties. As discussed in Chapter 11, safety procedures are important and the teacher can work with the child in advance using pictures or stories to help prepare the child for the inevitable fire drill. Again, when possible, the emphasis should be on helping the child learn to self-regulate; thus, if the child is very sensitive to noise, the story can have him pull out a pair of headphones to muffle the noise as he is leaving the room or, for a verbal child, having a specific script he can “run through” to reassure himself may be helpful. Having a practice run-through may also be a good thing to try; we’ve even had firefighters who could help with this. Often, the practice will make it easier for the child when a real fire drill happens. This is something teachers should work on as part of basic safety teaching (see Chapter 11).

Other accommodations for the child who is very sensitive to sounds in the classroom can include use of earplugs (with or without the option of music). For the child who tends to be less responsive to auditory input, it is important that teachers and parents try to err on the side of speaking loudly, that is, exaggerating their voice to help the child focus.

VISUAL PROBLEMS

For many children with autism, some aspects of visual skills represent an area of strength (e.g., visual spatial skills of the type used in putting together puzzles). However, unusual visual preferences may also be seen. Some children will spend long periods of time engaged in visual stereotypies (such as flicking a string back and forth in front of their eyes) or may be interested in unusual visual aspects of materials (focusing on minor details of a toy). These visual abnormalities are often related to other behavioral difficulties (motor mannerisms or odd movements) and problems in self-regulation. In addition, many children with ASDs have striking difficulties with social gaze, that is, in making eye contact while talking with others. It may seem (and may be) that the child is attempting to avoid new experiences by engaging in some repetitive activities.

Children born with visual problems sometimes exhibit unusual body movements that may be mistaken for those seen in autism. Obviously, normal vision is important for development and learning. If you suspect that the child is not seeing clearly, you should speak with your doctor.

Assessment of Vision

Visual testing that requires the child’s cooperation and understanding on the part of the child may be hard to perform in children with ASDs.

Most typical children can cooperate with vision screening by the age of 3 or 4 years. There are special picture charts that have been developed for children who are not yet reading. They use figures such as a house, an umbrella, or a circle. Children are asked to say which one of these is being pointed to by the examiner instead of naming letters as with the regular adult eye chart. A nonverbal child can be given a card with pictures of the objects on it and be asked to point to the one shown on the eye chart.

If there are significant concerns about vision and if the primary care provider can’t test the child’s vision, he or she will probably refer the child to an ophthalmologist (doctor who specializes in eye problems) or a pediatric ophthalmologist (who specializes in children’s eye problems).

Solutions for Vision Problems

If the child does need glasses, it may be difficult to get her to keep them on. For some children, it may be helpful to get bands that go around the head to help the glasses stay on. It is probably worth the extra expense to buy a lifetime warranty when you purchase the glasses. At least that way you can get them repaired or replaced for free if they are broken or lost.

If the child has strabismus or amblyopia, the eye doctor may recommend that one of the eyes be patched part of the time. An alternative to patching is the use of eye drops. They are put in the better eye to blur the vision in that eye instead of patching it. This forces the child to use the poorer eye. While not easy, for some autistic children the drops may be easier than trying to keep a patch in place.

In the classroom, accommodations for the child who is easily overstimulated visually can include reducing the amounts of visual stimulation. For example, the child might work in a carrel or other area where visual distractions are reduced. For other students, visual stimulation may be used as a reward, for example, computerized screen savers, lava lamps, or other materials with slow but continuing movement. Be careful that, if these are used, they don’t serve as too much of a distraction but are used as rewards and for times of relaxation.

OTHER SENSORY PROBLEMS

In addition to having problems with the senses of vision and hearing, children with autism can be over- or undersensitive to other types of sensations, including touch, movement, smell, and taste. Again, we do not know why these sensitivities are so common in autism. There are many different theories. Below are a few examples of ways that sensory problems may manifest themselves in a child with autism:

• Movement sensitivities. Some children enjoy twirling themselves around; others hate it. Many children like the feeling of swinging in an outdoor swing or hammock. Some children will walk in unusual ways, for example, on their toes; others may have a peculiar gait. For individuals with movement sensitivities, opportunities for physical exercise (which has been shown to decrease stereotyped movements) is helpful. Swinging and rocking and similar activities may help children with issues in the area of vestibular stimulation.

• Tactile (touch) responsivity. Some children with autism have tactile defensiveness. That is, they cannot tolerate touching or being touched by things that are a certain texture, consistency, temperature, and so on. For example, some children will find the feeling of certain kinds of cloth intolerable or won’t be able to wear clothes with any labels in them (the labels being a source of constant annoyance to them).They may find the seasonal change of clothes difficult, for example, going from long sleeves and pants to short sleeves and short pants. Other children can’t stand to have their hair combed or their face washed. Some will seem less than normally sensitive to temperature change and won’t mind being cold in winter or hot in summer. Solutions include removing labels from clothes and being careful to note what types of cloth/clothing children are sensitive to. You can also give access to sensory activities the child may enjoy, for example, a ball or object they can squeeze, materials that have interesting textures, and so forth to distract them from irritating changes. For some children, wearing tight clothes or weighted vests may help them have a better sense of their body.

• Smell and taste sensitivities. Sometimes these unusual sensitivities extend to food so certain textures, tastes, smells, or colors of food are avoided. A few children will respond dramatically to smells that the rest of us would generally not have a problem with. In the classroom, be attentive to things that may be a distraction, for example, if teachers or aides apply perfumes/ colognes/after shaves. If the child has problems with the level of conflicting smells at lunchtime, one option might be for the child to eat in a different area. Some students may be interested in things with characteristic odors, for example, candies with strong scents or markers that smell. For children who seem to have a strong need to chew, use of gums and chewy foods may help.

Unusual sensitivities to light, touch, and balance (technically what is referred to as proprioception or the sense of one’s body in space) may be closely related to self-stimulatory behaviors. For example, the younger child with autism might want to flick a string in front of his eyes, while an older child might want to spin or body rock (both behaviors that stimulate the balance system of the body). Behavioral interventions (Chapter 14) and sometimes medications (Chapter 15) may be helpful as well.

ASSESSMENT OF SENSORY DIFFICULTIES

Various professionals are often involved in assessing sensory difficulties. As mentioned earlier, tests of vision and hearing should be a standard part of the assessment of any child with an ASD. Dietitians and SLPs may be involved for problems with smell and taste sensitivities and the resulting issues with feeding. Usually, occupational and physical therapists are involved in dealing with unusual sensory responses—particularly those involving the child’s ability to feel and have a sense of his body; these professionals can also work well as part of the treatment team at school in developing functional abilities across the school day, thus making the child more available for learning. We talked about some issues in motor and sensory assessments earlier in this book (Chapter 3).

As a general rule, physical therapists are most involved in assessing gross motor skills, balance, posture, and movement; occupational therapists may be involved in assessing fine motor movements, self-care, sensory and regulatory capacities, and other adaptive skills. There are a few tests of motor abilities and sensory responsiveness; often, an evaluation will focus a lot on real-world situations and the kinds of responses that cause the child trouble.

Areas evaluated by occupational therapists often include eye-hand coordination, spatial awareness, quality of movements of the hand and body, muscle tone, and sensory integration abilities (see below). Usually, there will be a strong focus on functional skills needed by the child in day-to-day activities. Particularly for younger children, there may also be a focus on play (ability to imitate).

SOLUTIONS FOR OTHER SENSORY PROBLEMS

Occupational therapists can draw on a wonderful range of materials to try to help the child. For example, drawing materials might include chalk, paint, special pens and pencils, and markers—with the idea being to try to find materials that will interest the child or that provide special help for a child with unusual sensitivities. Children who have trouble touching or holding things (tactile defensiveness) may be helped by being introduced to a range of new materials—clay, Play-Doh, sand, shaving cream, bubbles. Difficulties with motor planning can be addressed by breaking down tasks into subparts and working on them. Eye-hand coordination can be worked on with ball play. For children who have trouble having a good sense of their bodies, materials like a weighted vest might be used to help them stay focused on a task. Specially adapted materials like chairs and tables may also be helpful. Children who spend excessive time spinning or rocking can be helped by providing opportunities for swinging/rocking during movement breaks. Occupational therapists can also work on learning readiness skills, that is, organizing the child’s sensory experiences to help secure attention and promote active engagement and learning.

Occupational therapists can also work quite well with other professionals, such as SLPs, on specific issues such as difficulties with the mouth and eating. Physical therapists tend to focus on body movement and posture problems. They work on the bigger muscle groups in the body and focus on problem areas like balance, stability of the body, muscle strength, and flexibility. Various tests of motor abilities are available. Activities might include swinging or jumping, walking on a balance beam, and other balancing activities. The physical therapist will typically work with you and the classroom teacher to be sure that everyone is working toward the same end.

SENSORY INTEGRATION THERAPY

Sensory integration refers to the process by which we take in, sort out, and organize information from our senses and then use the information to understand and respond to the entire situation. For example, waking disoriented in the dark on your first morning of vacation, you may be aware that the mattress beneath you is unusually hard and that there is a soft rumbling sound outside the window and a faint whiff of salt in the air. Putting all these sensory clues together, you remember that you are staying at a bed-and-breakfast by the sea.

Sensory integration (SI) therapy was developed by A. Jean Ayres, an occupational therapist, with the goal of helping people with sensory problems better integrate their sensations. It is based on the observation that children with autism and other developmental disabilities often have unusual sensitivities or responses. The hope is that helping the child learn to be more tolerant of different sensory experiences will lead to gains in the child’s developmental functioning.

A basic idea behind SI therapy is that repeated experience with the environment will help the child develop better abilities to cope with potentially distracting sensory experiences. Goals include decreasing sensitivity to bothersome sensations, increasing the child’s awareness of times when the environment is becoming overwhelming, and helping the child learn techniques for calming herself. The treatment may include a “sensory diet” designed to provide the child with a range of materials addressing the child’s sensory needs. Massage, stimulation of the sense of balance, joint compression, or a weighted vest might be used. Brushing (using a soft brush) on the arms, legs, and back may be combined with other techniques. Some aspects of the intervention can be adapted to include more complicated problem solving for higher functioning individuals, for example, in helping the person be aware of their perceptions and dealing with overstimulation. You may find a range of therapists trained in SI techniques, including occupational therapists, physical therapists, and SLPs.

The theoretical basis for sensory integration is not very strong. However, many of the techniques used attract the interest of the child and may help her deal with difficult aspects of the environment that are difficult for them. Particularly when done as part of a broader intervention program, the methods may be helpful in some ways. Children may attend better, sleep better, and have lower activity levels. Evidence for cognitive gains is not, however, very strong.

SUMMARY

Children with ASDs often have unusual sensitivities or responses to the environment. These problems can take the form of over- or underresponsiveness to the environment or can include a mix of both; these can pose difficulties for the child and can complicate the task of providing a good educational program. These sensitivities can also limit opportunities for activities in the community, since unusual preoccupations and sensitivities can also complicate peer interaction. Occupational therapists and other professionals can help you and the child learn to better cope with his sensitivities; there are also medications that can help with some self-stimulatory behaviors linked to sensory sensitivities.

Food sensitivities and eating issues can also be problems. Some children may have limited food preferences, and still others may eat nonfood substances. If food problems are really substantial, a dietitian, nutritionist, or another professional (occupational therapist or SLP) may be needed.

In addition to understanding the unusual sensory responses, it is important to be sure that the child has normal hearing and vision. Obviously, if the child is having a hearing or vision problem, it is important to try to correct this as a major aspect of the intervention program. For individuals with unusual sensitivities to the environment, a number of different steps can be taken, depending on the situation, to make the person more comfortable and better able to learn.

■ READING LIST

Anderson, L., & Emomons, P. G. (2005). Understanding sensory dysfunction: Learning and development and sensory dysfunction in autism spectrum disorders, ADHD, learning disabilities, and bipolar disorders. London: Jessica Kingsley.

Baranek, G. T., Boyd, B. A., Poe, M. D., David, F. J., & Watson, L. R. (2007, July). Hyper-responsive sensory patterns in young children with autism, developmental delay, and typical development. American Journal on Mental Retardation, 112(4), 233-245.

Baranek, G. T., David, F. J., Poe, M. D., Stone, W. L., & Watson, L. R. (2006). Sensory Experiences Questionnaire: Discriminating sensory features in young children with autism, developmental delays, and typical development. Journal of Child Psychology and Psychiatry, 47(6), 591-601.

Baranek, G. T., Parham, D. L., & Bodfish, J. W. (2005). Sensory and motor features in autism: Assessment and intervention. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd ed. , pp. 831-862). Hoboken, NJ: Wiley.

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■ QUESTIONS AND ANSWERS

1. A child with autism is included in my first-grade classroom. Particularly during some activities, he gets very involved in visual self-stimulation at school. This seems to happen during art, recess, and gym. I’ve heard from our consultant that this behavior may reflect overstimulation, but these seem to be the times most students are more relaxed. This child will look at his fingers and flick them back and forth. Sometimes he looks at things out of the corner of his eye. All these things seem very odd. What can be done about this?

The behaviors you describe are fairly common in autism, and your consultant is correct that often they reflect overstimulation (it can also happen for children who are understimulated!). The main feature that all the times you mention have in common is that they are probably less structured and more “free-form” and more social. What may seem like a relaxing situation to you may be making the child with autism more anxious. Take a look at the classroom during these times. How included is the child? Are there more distractions than usual? See if giving the child a specific agenda/visual schedule or prompts helps. It may be that giving special activities (one on one or small group) during these periods may be helpful.

2. My daughter loves to put all kinds of things into her mouth. This includes dirt and stuff she has picked right up off the floor. What can I do about this?

In the first place, be sure the environment is lead free and have your daughter’s lead level tested. Talk to the school psychologist, speech pathologist, occupational therapist, or behavior specialist. Often, these are the same people who will be working on the problem at school. If your daughter has a strong need to chew, try providing something safe to chew (avoid things that stick to the teeth and cause cavities, though—notably, fruit sticks are bad!). Sometimes crunchy foods or access to materials that can be chewed without swallowing will help. Occasionally, children respond well to activities that include blowing or sucking.

3. My 9-year-old son likes to body rock a lot. This makes him seem very odd. What can I do about it?

Sometimes giving the child more opportunities for physical activity during the day can help. This can include running and other, more strenuous activities but could also include use of a rocking chair or swing. Sometimes using seats that have a degree of “give” (large therapy balls or cushions) can help with this. You can talk with your occupational therapist about other ideas.

4. A 22-year-old woman with autism has come to work in our restaurant with a full-time supporter. I notice that she hums a lot, particularly when we get busy at lunchtime. We’d like to keep her as an employee but wonder why she does this and if there is any way to control it?

You mention that this is worse in one setting—likely a time when things are most busy and noisy in your restaurant. Talk with her supporter. Our suspicion is that she is overwhelmed with auditory input at the busy times and may be attempting to compensate by producing her own sound. If reducing the sound level is not an option, think about giving her a small portable music player so that she can play her own music. Even just wearing the earplugs or listening to white noise may help.