Effec t of individualized use of a multisensory environment on engagement in preschool children with autism spectrum disorders

Objective: In keeping with client-centered practice in support of occupational performance, we examined the use of a multisensory environment (MSE) on engagement in preschool children with Autism Spectrum Disorders (ASD), comparing two different methods: an individualized approach and a protocol-driven approach. Method: Fifteen children, ages four to seven years, participated. A randomized, counterbalanced design was used to measure engagement in the protocol-driven condition and the individualized condition. In the protocol-driven sessions, the equipment was turned on in a slow, sequential manner. In the individualized sessions, participants were free to play and engage the MSE as desired. Engagement was measured across four variables: 1) The number of requests/initiations, 2) the duration of engagement /play, 3) affect, and 4) desired and undesired behaviors identified by the parents. Sensory processing patterns were determined through the Sensory Profile (Dunn, 1997). Parents were asked for their opinion of the use of the MSE under the two conditions. Results: Results were not significant in terms of increased engagement in an MSE in the individualized approach. However, most parents valued the use of the MSE with their children. Conclusion: This study provides a picture of engagement within MSEs for preschool children with ASD. Given the results, occupational therapists should select between the individualized and protocol-driven approaches according to their own clinical judgment. Further research is needed to guide best practice use of MSEs. MULTISENSORY ENVIRONMENTS AND ASD 3 Effect of Individualized Use of a Multisensory Environment on Engagement in Preschool Children with Autism Spectrum Disorders Autism Spectrum Disorders Autism is receiving more coverage by the media because it is the fastest growing severe developmental disability in the United States (Centers for Disease Control and Prevention [CDC], 2010). Ten years ago, one in 10,000 children born in the United States was diagnosed with autism; today that number is one in every 68 children (CDC, 2014). The term Autism is credited to Swiss psychiatrist Eugen Bleuler, who coined it in 1910 to describe a group of symptoms related to schizophrenia (Kanner, 1943; Kuhn & Cahn, 1910/2004). As a developmental disorder, it was first described by American psychiatrist Leo Kanner in 1943. The National Institute of Child Health and Human Development (NICHD) defines Autism as a multifaceted neurobiological disorder of development that spans the lifetime (NICHD, 2005). Autism, classified as a developmental disorder, is one of an array of conditions collectively known as Autism Spectrum Disorder (ASD). In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ([DSM-5] American Psychiatric Association, 2013) classified ASD to encompass these four disorders: autistic disorder, Asperger’s disorder, childhood integrative disorder (CID), and pervasive developmental disorder, not otherwise specified (PDD-NOS). ASD typically emerges between the ages of 18 to 24 months of age, though signs and symptoms may not be apparent until the ages of 24 months and 6 years of age (Autism Society of America [ASA], 2004a). It is estimated that four million children are born in the United States each year, and approximately 24,000 of those children will be diagnosed with ASD (CDC, 2009). ASD can occur in all racial, ethnic, socioeconomic and intellectual groups and, on average, are four to five MULTISENSORY ENVIRONMENTS AND ASD 4 times more likely to occur in boys than in girls (CDC, 2010; Fombonne, 2003). The specific cause for ASD is unknown but studies suggest that genetic, environmental, and neurochemical factors influence brain functions and structures leading to abnormalities (ASA, 2004c). Medical conditions such as phenylketonuria, tuberous sclerosis, and Fragile X syndrome are frequently occurring conditions in persons with ASD (American Psychological Association, 2004). Other related conditions may include cognitive disability, seizures, chronic constipation and/or diarrhea, sleep problems, pica, low muscle tone, pain, allergies/suppressed immune system, hearing and visual impairments, and sensory processing difficulties (ASA, 2004b). The characteristics of ASD in children include impairments in social interaction, communication, behavior, and sensory processing (CDC, 2010). Each of these is reviewed below. The American Academy of Child and Adolescent Psychiatry (2010) list disturbances in social interaction commonly seen in children with ASD as difficulty in making friends, limited eye contact, flat affect, lack of social engagement, lack of enjoyment in being held, dislike of physical contact, and loneliness. Notable communication disturbances, including verbal and nonverbal communication, vary in severity with the most severe including not speaking at all and echolalia. Case-Smith and O’Brien (2010) note additional language and speech deficits as “syntax problems, atonal and arrhythmic speech, pronoun reversals, and lack of inflection and emotion during communication” (p. 171). Behavioral disturbances include patterns of behavior described as stereotypical: Repetitive, obsessive, ritualistic and perseverative (CDC, 2010). A distraction or change in routine from these behavioral patterns can be met with violent outbursts and self-injurious behavior. Observable, stereotypical motor patterns include hand flapping and body rocking. Other visible movement patterns include banging and rolling the head, lunging, swaying, darting, toe walking, and showing a lack of coordinated movement (Baird, Cass, & MULTISENSORY ENVIRONMENTS AND ASD 5 Slonims, 2003). It is also commonly noted that children with ASD have sensory processing difficulties in which they struggle to manage sensory stimulation through the visual, auditory, tactile, proprioceptive, kinesthetic, and olfactory senses (Baranek, et al., 2007; Dahlgren & Gillberg, 1989). In a sample of 287 children diagnosed with ASD, 95% had sensory processing difficulties (Tomcheck & Dunn, 2007). An estimated 30% of individuals with developmental disabilities have sensory processing difficulties, which includes people with ASD (Baranek, et al., 1997). Sensory processing and perceptual disturbances occurring in children are described in the research literature (Ayres, 1979, Parham, 2002, Dunn, et al., 2002, Miller, et al., 2007). Coping with these disturbances in everyday life is difficult and often restricts children from participation in daily activities, including play. Children with sensory-processing challenges can be underresponsive or over-responsive to sensory stimuli, resulting in different behavioral outcomes (Baranek, 1999; Baranek, et al., 2007, Tomcheck & Dunn, 2007). Dr. Temple Grandin, who herself has ASD and is an advocate in the field, explained that the central nervous system (CNS) becomes overwhelmed with constant sensory input and with limited output, and the CNS is unable to regulate itself, resulting in discomfort (Grandin & Scariano, 1986). This conflict within the CNS is often referred to as sensory modulation disorder. Affleck and colleagues (1984) noted that “if the body does not find a way to regulate itself, a state of chronic stress results” (p. 20). The influx of sensory stimuli, coupled with emotional and environmental factors, stimulate a stress response, and “stress is perceived by the [body] systems as a threat to its existence and leads to the fight or flight response” (Affleck, et al., 1984, p. 19). The fight or flight response is regulated by the autonomic nervous system (ANS). The ANS is always working and is comprised of two main branches. In stressful situations like fight or flight, the sympathetic MULTISENSORY ENVIRONMENTS AND ASD 6 nervous system (SNS) causes an increase in pulse, respiration, and heart rate as the blood flows to the lungs, heart, and muscles to ready the body for action. At the same time, the parasympathetic nervous system (PNS) is activated allowing the opposite actions in order to maintain homeostasis and a symbiotic relationship. Dr. Herbert Benson, professor at Harvard Medical School and co-founder of the BensonHenry Institute for Mind Body Medicine at Massachusetts General Hospital, asserted that one way to counter the state of fight or flight is through the Relaxation Response (RR). The RR is a physiological response characterized as generalized decreased SNS activity and possible increased PNS (Hess, 1957, as cited in Benson, 1982). Four basic elements are usually necessary to elicit the RR (Benson, 1974): 1. Sustained focus on a repetitive mental activity or stimuli, 2. A carefree, passive attitude, 3. Decreased muscle tone, and 4. A quiet environment. According to Benson and colleagues (1974), the RR should be elicited in a calming environment and in conjunction with other therapeutic interventions. This might include multisensory