Sensory Sensitivities with Autism

Understanding Sensory Sensitivities and Developing Supports and Accommodations

Based on the book AUTISM: Handle with Care! Understanding and Managing Behavior of Children and Adults with Autism By Gail Gillingham Arlington, TX: Future Horizons, Inc. (817) 277-0727, (800) 489-0727, ISBN#I-885477-14-7

TOUCHING-What Individuals Who Experience Autism Say ... "I was six months old when Mother noticed that I was no longer cuddly and that I stiffened up when she held me. When I was a few months older, Mother tried to gather me in her arms, and I clawed at her like a trapped animal." (Temple Grandin)

"I never used to like being picked up and cuddled. I screamed as though I was on a roller coaster if anyone tried to pick me up. I also hated it when my teacher, Mrs. Ingram, tried to make me hold my pencil properly or my parents tried to make me do up my laces or shirt buttons. They had no idea of what was wrong with me at the time. In addition, since I though it happened to everyone, I did not tell anyone. Nevertheless, I found such treatment excruciating... I do not like pressing my lips on spoons or hard glass either." (Darren White)

Indications of Tactile Sensitivity * Rejection of human touch * Rejection or discomfort to the touch of clothing. * Sensitive feet * Avoidance of games that involve tactile contact such as kicking or catching a ball * Discomfort when sitting in one place for any length of time. * Genital manipulation or masturbation. Commonly a sign of lack of quality tactile experiences. . * Sensitivity to extreme temperature changes. Body temperature water can be almost obsessive. * The mouth is a very sensitive area. * The tips of the fingers are also very sensitive. So, watch for problems holding things and doing tasks, especially where a firm grip is needed. * There also may be difficulty in writing. * There may be a great desire for cleanliness, a dislike for sticky or dirty hands.

Supports and Accommodations * Control our impulse to touch those for whom we are providing care * Do not take others withdrawal personally--it may mean protection for them. * Explore the use of deep pressure and light touch to reduce "pain" * Lack of touch may be a way of showing respect

GET OT HELP ASAP

Taste

What Individuals Who Experience Autism Say... "I remember sitting at the table and hating dinnertime - staring at my food knowing that it would make me gag if I tried to eat it and that would make my parents mad. Other people constantly teased me about how I ate my food. Kids are supposed to like chocolate, whipped cream and maple syrup; I did not. I do not like vegetables either. Cheese, creams, sauces, casseroles, salads - nothing. I hate being invited out or over to eat -it's never how I like to eat it. People keep telling me I would grow to like other foods, I'm still waiting." B. Kirby

"There are few foods that I can tolerate eating. Usually the ones can eat are soft textured. Italian seems to be the Limit. Sometimes I think it is a wonder that I am still alive."Thomas McKean

Indications of Diet Sensitivities * Refusal to eat certain foods. * An insistence on eating only a limited number of foods. *Gut issues like constipation or runny stools

Supports and Accommodations * Respect refusal to eat certain foods {e.g., wheat or milk products) * High protein diet seems cut down the level of agitation. * Never limit liquid intake; their bodies need it. * Vitamin B6 and Magnesium supplements seem to help. * Keep poisonous substances locked safely away. , * Fatty, salty diet, especially in the morning, also seems to work well with some individuals.

Try special diets, go to Julie Matthews Nourishing Hope for more info on the resource page...

Auditory

What Individual's Who Experience Autism Say... "She told me she was much more comfortable, that she no longer heard street noises three blocks away, or people flushing their toilets at the other end of the building, or the blood rushing in her veins she had never been able to blowout the candles on her birthday cake because the sound of blowing had been so disturbing. "It sounded like monsters," she said, as had the puffing noise of the drain in the wall. People's breathing had upset her, especially when several adults were in the room. Why do you think I have so much trouble paying attention in the classroom? I hear everything that goes on every phone call that the principal makes in her office; every single time an eighteen-wheeler truck gears down on the highway three blocks away. I HEAR IT! I HEAR EVERYTHING! I hear people talking outside the school building, and I can understand their conversations. There are so many noises in my head that I cannot concentrate on what Mrs. Weaver tries to say. I cannot focus and pay attention to the teacher's, spoken words -I'm too distracted. In addition, why do you think I am so tired all of the time? It takes so much energy to pay attention that I am worn out. I TRY SO HARD AND I JUST CANNOT DO It!" Nicholas Bober

Indication of Auditory Sensitivity * The appearance of deafness * Grimaces when a sound occurs, or perhaps grimaces for no apparent reason. * Echolalia, or the parroting back of what you have just said. * Agitation or withdrawal from people, who talk fast, talk constantly or talk loudly. * Anxiety around people who have unusual vocal tones. * Yelling on your part, it will lead to tantrums from them. * Response to sounds you cannot hear.

Supports and Accommodations * Never assume individuals with autism are deaf. * Never shout. * Never insist they listen to sounds they obviously do not like because you consider it necessary for their development. * Speak as softly and clearly as possible. * Do not chatter on and on; do not repeat. * Give the person time to decipher what you have said. * Create a sound absorbent environment.

Olfaction

Individuals with Autism say... ..."You liked the smell of certain foods, and hated the smell of others, Georgie, but what about people? And animals? How did they smell? " She looked sheepish. "I still have trouble, with that," she said. ", dogs and cats. And smells like deodorant and after-shave lotion, they smell so strong to me I can't stand it, and perfume drives me nuts. I cannot understand why people wear perfume, and I can smell hand lotion from the next room." Annabel & Georgie Stehli

Indications of Sensitivity to Odor * Stopping up nostrils with the fingers, covering the nose with the hand or constantly waving one's hand in front of the mouth and nose area. * Agitation in an environment that has a noticeable smell. (noxious or sweet) * Breathing through the mouth rather than the nose.

Supports and Accommodations * Concentrate on the environment, not on the behavior (e.g., don't punish for one plugging nose). * Keep tissues on hand and offer them. Be aware of odors. * Minimize perfumed products. Keep the environment clean and dry .Use scent-free products for laundry. * Monitor interactions with strong scents (e.g., feces) as they may over stimulate.

Visual

Individuals with Autism Say... "Dr. Marek's kitchen was a nightmare. The kitchen had fluorescent lights and yellow walls the worst combinations ever. Even from the doorway, I could see light bouncing off everything. In my tense state everything climbed to hyper, vision included. There were no whole objects in that room, just shiny edges and things that jumped off the yellow walls like sunshine on water. Dr. Marek wanted me to go in there and be blind. Forget it! . I stood in the doorway looking at the light, my eyes jumping from half object to half object trying to take things in. Maybe I could relax a bit and pay attention to this person I was supposed to meet. She was Mrs. Marek, a face upon which light danced maniacally, turning her into more of a cartoon than a human being. Welcome to Toon Town, Roger Rabbit. I wouldd like you to enter this torture chamber I call my kitchen and meet my wife, who is a 3-D cartoon. She just wants you to look at her in pieces, say hi whether you mean it or riot, and treat her like a human being. "I also remember one Christmas when I got a new bike for a present. It was yellow. I would not look at it. Extra red was added to the color making it look orange and it blurred upwards making it look like it was on fire. My favorite colors were those I could see more clearly than others. I also could not see blue clearly, it looked too light and it looked like ice (imagine the sea on a sunny day, it would look frozen over, in spite of the sun). The bike was painted purple, which I liked better because I could see it more clearly. " Darren White

Indications of Visual Sensitivity  * Squinting. * Sleeping problems. * Closed eyes, or eyes rolled up so only the whites show. . * Looking past people or seemingly through people. * Pointing directly at something while looking off in another direction. * Looking off to one side rather than straight ahead while walking, watching TV, or doing task. * Fear of bright shiny objects, mirrors and often certain colors, or of different color combinations * Attempts to mold the faces of caregivers. . * Constantly having to touch the environment (e.g., running hands along the wall as walks!) * Agitation or refusal to comply when exposed to certain colors. * Long periods of time spent staring directly into a bright light. * Finger fiddling in front of eyes, spinning objects, fascination with fans or other moving objects. * Fascination with spinning objects (tops, lids, wheels of toy cars, records and cassette tapes). * Fear of heights, stairs, dark tunnels, and movement. * Rubbing, touching or hitting eyes. * Agitation in environments that are loaded with visual stimuli, especially moving stimu1i * Agitation in room in which fluorescent lighting just used. * Poor depth perception (getting on elevators, walking down stairs) or walking over objects without apparently seeing them.

Support and Accommodations * Never assume person is blind or not looking at you, the task. * Respect peripheral vision. * Never force person to look directly at a task. * Monitor for visual over stimulation (neutralize environment) * Monitor use of bright lights, bright shiny objects. * Eliminate fluorescent lights (if possible). . * Consider colors, or color combination of objects, clothing or a room. . * Monitor clothes they wear, and what you wear (neutral colors, earth tones seem best). * Monitor colors in the environment (E.g., papered sections of walls in classrooms). * Monitor background visual distraction during tasks. * Utilize dimly lit rooms before bedtime to reduce serotonin production. Sleep in pitch black. * Do not insist on eye contact. * Allow person to develop a "visual map" of new areas-when only few people present.

Sensory Processing Differences Traci Diamond, OTR/L and Teresa Bolick, Ph.D Sensory functioning refers to the process by which our body perceives ("registers"), manages ("modulates"), and organizes ("integrates") incoming information. In addition to the five senses that we all learned about in school, human beings possess two other sensory systems: the vestibular system, which responds to movement; and the proprioceptive system, which tells us where our body and its parts are in space.

A student must perceive, manage and organize sensory input if he or she is going to participate in everyday life. Many students with autism/PDD have sensory processing differences. In other words, one or more of the processes of sensory perception, management, or organization works inefficiently for one or more of the sensory modalities. An example of a "simple" task is that of writing one's name at the top of a paper while sitting in the classroom. Such a "simple" task is actually quite complex from a sensory standpoint, as outlined below.

* The visual system is involved in seeing the paper, finding where to write the name, perceiving what one is writing, adjusting to the lighting (especially the strobe effect of fluorescent lights,) and recalling visual images of what the letters actually look like.

* The taste (gustatory) system is probably not used unless the child is chewing/sucking on something while writing.

* The smell (olfactory) system may be involved as a result of the odors of leftover snacks in the trash can, pencil shavings in the sharpener, cosmetics of the adult helping the child, the cafeteria aroma, wet jackets hanging on the hooks nearby, or even the classroom hamster.

* The hearing (auditory) system allows the student to hear relevant information such as the instructions given by the teacher or paraprofessional. The student will need to ignore sounds such as peers talking, chairs scraping on the floor, teachers talking in the next room, or his/her own breathing.

* The touch (tactile) system includes the feel of the pencil and paper in the student's hand. It also may register distracting input such as the feel of the student's clothing, the hair or baggy sweater of the teacher as he/she leans over to help, the contours of the chair, or the brushing touch of a child passing by the desk.

* The movement (vestibular) system allows the child to sit upright in the chair and to maintain an appropriate level of arousal/alertness.

* The proprioceptive (body position) system allows the child to maintain position in the chair, stabilize the paper with one hand while writing with the other, handle the pencil with sufficient muscle tension, move the pencil against. The resistance of the paper, and stabilize the upper body while moving the hand and fingers. It also allows the child to inhibit movements such as tapping feet, wiggling legs, and wagging the tongue. Obviously, this simple task is far from simple. Youngsters with autism/PDD find such a task even more challenging that do many of their typically developing peers. As the classroom gets noisier, the "aromas" from the lunchroom become more intense, or the need to scratch that itch grows, the student struggles with managing the sensory overload and completing such a "simple" task. Over the course of your work, you may hear the people talking about the load of the task. "Load" refers to all of the internal (inside the body) and external (in the activity or environment) stimuli that a child has to manage in a given situation. Sensory dysfunction is often a significant aspect of that load.

Sensory Integration Cindy Hatch-Rasmussen, M.A., OTR/L Therapy Northwest, P.C. 

Children and adults with autism, as well as those with other developmental disabilities, may have a dysfunctional sensory system. Sometimes one or more senses are either over- or under-reactive to stimulation. Such sensory problems may be the underlying reason for such behaviors as rocking, spinning, and hand flapping. Although the receptors for the senses are located in the peripheral nervous system (which includes everything but the brain and spinal cord), it is believed that the problem stems from neurological dysfunction in the central nervous system--the brain.

As described by individuals with autism, sensory integration techniques, such as pressure-touch can facilitate attention and awareness, and reduce overall arousal. Temple Grandin, in her descriptive book, Emergence: Labeled Autistic relates the distress and relief of her sensory experiences. Sensory integration is an innate neurobiological process and refers to the integration and interpretation of sensory stimulation from the environment by the brain. In contrast, sensory integrative dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior. A general theory of sensory integration and treatment has been developed by Dr. A Jean Ayres from studies in the neurosciences and those pertaining to physical development and neuromuscular function. 

Sensory integration focuses primarily on three basic senses--tactile, vestibular, and proprioceptive. Their interconnections start forming before birth and continue to develop as the person matures and interacts with his/her environment. The three senses are not only interconnected but are also connected with other systems in the brain. Although these three sensory systems are less familiar than vision and audition, they are critical to our basic survival. The inter-relationship among these three senses is complex. They allow us to experience, interpret, and respond to different stimuli in our environment.

The three sensory systems will be discussed below.

Tactile System: The tactile system includes nerves under the skin's surface that send information to the brain. This information includes light touch, pain, temperature, and pressure. These play an important role in perceiving the environment as well as protective reactions for survival. Dysfunction in the tactile system can be seen in withdrawing when being touched, refusing to eat certain 'textured' foods and/or to wear certain types of clothing, complaining about having one's hair or face washed, avoiding getting one's hands dirty (i.e., glue, sand, mud, finger-paint), and using one's finger tips rather than whole hands to manipulate objects. A dysfunctional tactile system may lead to a misperception of touch and/or pain (hyper- or hypo sensitive) and may lead to self-imposed isolation, general irritability, distractibility, and hyperactivity. Tactile defensiveness is a condition in which an individual is extremely sensitive to light touch. Theoretically, when the tactile system is immature and working improperly, abnormal neural signals are sent to the cortex in the brain, which can interfere with other brain processes. This, in turn, causes the brain to be overly stimulated and may lead to excessive brain activity, which can neither be turned off nor organized. This type of over-stimulation in the brain can make it difficult for an individual to organize one's behavior and concentrate and may lead to a negative emotional response to touch sensations.

Vestibular System: The vestibular system refers to structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of the head For example, the vestibular system tells you when your head is upright or tilted (even with your eyes closed). Dysfunction within this system may manifest itself in two different ways. Some children may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary movement activities (e.g., swings, slides, ramps, inclines). They may also have trouble learning to climb or 'descend stairs or hills; and they may be apprehensive walking or crawling on uneven or unstable surfaces, As a result, they seem fearful in space. In general, these children appear clumsy. On the other extreme, the child may actively seek very intense sensory experiences such as excessive body whirling, jumping, and/or spinning. This type of child demonstrates signs of a hypo-reactive vestibular system; that is, they are trying continuously to stimulate their vestibular systems.

Proprioceptive System: The proprioceptive system refers to components of muscles, joints, and tendons that provide a person with a subconscious awareness of body position. When proprioception is functioning efficiently, an individual's body position is automatically adjusted in different situations; for example, the proprioceptive system is responsible for providing the body with the necessary signals to allow us to sit properly in a chair and to step off a curb smoothly. It also allows us to manipulate objects using fine motor movements, such as writing with a pencil, using a spoon to drink soup, and buttoning one's shirt. Some common signs of proprioceptive dysfunction are clumsiness, a tendency to fall, a lack of awareness of body position in space, odd body posturing, minimal crawling when young, difficulty manipulating small objects (buttons, snaps), eating in a sloppy manner, and resistance to new motor movement activities. Another dimension of proprioception is praxis or motor planning. This is the ability to plan and execute different motor tasks. In order for this system to work properly, it must rely on obtaining accurate information from the sensory systems and then organizing and interpreting this information efficiently and effectively.

Sensory Implications: In general, dysfunction within these three systems manifests itself in many ways. A child may be over or under responsive to sensory input; activity level may be either unusually high or unusually low; a child may be in constant motion or fatigue easily. In addition, some children may fluctuate between these extremes. Gross and/or fine motor coordination problems are also common when these three systems are dysfunctional and may result in speech/language delays and in academic under-achievement. Behaviorally, the child may become impulsive, easily distractible, and show a general lack of planning. Some children may also have difficulty adjusting to new situations and may react with frustration, aggression, or withdrawal.

Evaluation and treatment of basic sensory integrative processes is performed by occupational therapists and/or physical therapists. The therapist's general goals are: (1) to provide the child with sensory information which helps organize the central nervous system, (2) to assist the child in inhibiting and/or modulating sensory information, and (3) to assist the child in processing a more organized response to sensory stimuli.

What is Sensory Integration? Sensory integration is the brain's ability to interpret and organize information from the senses-vision, hearing, taste, smell, touch, balance gravity, position and movement. Problems in sensory integration may result in learning problems, hyperactivity, distractibility, poor coordination, poor balance, and behavior problems, and may contribute to difficulties at school, at home, at work and in play. (from: the mission statement of Sensory Integration International)

RATIONALE FOR USE OF SENSORY INTEGRATION TO IMPROVE PERFORMANCE IN EDUCATION 1. The use of sensory integration is theoretically an appropriate technique to enhance learning and behavior in autism. Autistic children may demonstrate over reactions to sensation such as finding some sounds or touch painful. Other children may have difficulty with registering movement as demonstrated by repeated spinning of themselves without getting dizzy or not responding to pain as seen with self injurious behavior (SIB). All learning is through sensation, whether it be the visual sense for reading, processing auditory directions, or using the sense of touch to guide a pencil for writing. 2. Autism and sensory integration have a neurobiological basis. Dysfunction in processing of sensory input has long been recognized as a symptom in autism. (1)Sensory disturbances are required diagnostic criteria for eligibility for special education services under the autistic category. (2) Recent findings from magnetic resonance imaging (3,4) and positron emission tomography scans (5) support an organic basis for autism. Sensory integrative treatment is an approach, which has a neurobiological theoretical base. 3. Sensory integrative treatment seeks to fulfill sensory drives that create a lack of goal directed activity (self stimulation) in autistic children. The central nervous system may be craving certain types of sensory input due to neurobiological problems. Rather then engaging in activity a child with autism may rock. This would be considered as a drive for linear vestibular (movement) input, and the therapist would find ways to satiate the need. This would improve both functional performance and ability to engage in goal-oriented activity. Some types of activity indicate the child is over stimulated and calming activity such as deep pressure could be initiated. 4. Recent evidence has validated the view of the nervous system as a constantly changing system, which is influenced by the environment. (6)The sensory integrative approach strives to provide a just right environmental challenge to the child. Studies have demonstrated that patients recover at greater rate and to higher levels when they are engaged in motivating activity rather then those involved in a typical exercise program with repetition. (7) Also, plasticity is greater when the individual is in a state of homeostasis, or calm. (8) Sensory integrative treatment is important in calming, so that changes in the autistic child's function are easier to make. Plasticity is greater in the sensorimotor stage of development or in children ages seven and under. 5. Some studies support the use of sensory integrative treatment procedures with autistic children to improve behavior. Ayres and Tickle (9) studied a group of autistic children. They found children who were hypersensitive to input to be responsive to sensory integrative treatment. Temple Grandin (10), diagnosed as autistic in preschool years stated that tactile and vestibular stimulation had helped her calm her over reactive responses to environmental stimulation. A case study of M (11), an autistic child who begin sensory integrative treatment at age 3.5 years, slept only 5-6 hours per night and spent hours screaming and throwing tantrums. After two years of sensory integrative treatment, tantrums disappeared and her skills had improved in self-care, coordination, language and social responsiveness. An autistic child observed during occupational therapy sessions had increased speech sounds with self initiated vestibular stimulation. (12) After a year of therapy, a 14 year old autistic/retarded teenager had a 50% decrease in head banging, hitting, plate throwing and hair pulling. (13) A 13-year-old non-verbal autistic boy with severe mental retardation exhibited continuous selfinjurious and self-stimulatory behaviors. During the observation periods when the adolescent received deep pressure from the woven elastic bandages he wore on his extremities, he exhibited less selfstimulatory behavior, no self-injurious behavior and an increase in the number of interactions with others. Deep pressure, tactile and vestibular stimulation appeared to have a more marked effect in calming on days when the SIB and self-stimulation were the highest. (14) Case studies of autistic children support the effectiveness of treatment based on sensory integration theory. Improvements noted include improved sleep patterns, decreased screaming, improved self-care, improved coordination, increased language sounds, decreased self-stimulation and decreased SIB. Sandra D. Glovak 10/31/96 Sensory Systems Clinic, P.C.

SENSORY DIET Prepared by Christy E. Yee, OTR Definition of Sensory Diet: "The daily total of sensorimotor experiences needed by a person to adaptively interact with the environment." -Hanschu- Purpose of the Program: To assist child in self-regulation. Unusual behaviors may be a result of poor regulation from the nervous system. Goal: To utilize sensorimotor strategies to attain an appropriate state of readiness (calm alert state) to learn during the day. Types of input utilized: Vestibular, Proprioceptive, Oral Motor, and Tactile

DEFINITIONS: 1. VESTIBULAR: The vestibular system affects balance, muscle tone, equilibrium responses, the ability to use both sides of the body together, coordination of the head, neck and eye movements, auditory language, and plays a role in arousal. Vestibular stimulus involves the movement of head through space and can include linear, angular, orbital, or rotary directions. Considerations: Input typically lasts 12-14 hours after 15 minutes of movement. Never force vestibular input; enable individual to control speed, direction of input, and stopping. Peripheral vision is alerting. Watch for undesirable side effects such as flushed face, nausea, decreased balance.

2. PROPRIOCEPTION: The proprioceptive system gives the nervous system input on the position of muscles, joints and tendons. This is important as it provides the person with information on how far to reach, how much pressure, where we are in space, and what our body scheme is. Proprioceptive stimulus involves movement, compression, or stretching at a joint. Consideration: Special care for individuals who have poorly articulated joints, joint deformities, or arthritic joints; give extra support and stop if there is pain or discomfort. For individuals who have low tone or too much slack in joints give slow stretch or alternate compression and stretch in rhythmic pattern and avoid quick changes of joint position. Pay attention to proper joint alignment. Be aware of poor reflex integration and lack of protective responses. The strongest, fastest, and most dramatic affects are activities which involve the spine, head/neck, or hip joints. Heavy work tasks are great for proprioceptive input; add weight, promote reaching and stretching during these activities.

3. ORAL MOTOR: Oral motor skills are used to regulate state of arousal. Infant and toddlers use sucking as a way to fall asleep or calm down; children and adults may use the oral motor area to concentrate (chew gum, suck through straw or bite nails), and comfort (foods). Considerations: Oral motor activities must be constantly and consistently monitored for safety. Be aware of food and non-food allergies when considering oral motor activities.

4. TACTILE: The tactile system is designed to alert us to threats, gives us body boundaries, and combined with proprioception, gives us our basis for body image. Considerations: Light touch is easily misinterpreted as pain and can cause the nervous system - to go onto a state of fight or flight (autonomic nervous system; sympathetic). Always provide deep pressure when in contact with the child.

GENERAL GUIDELINES: 1. HOW TO KNOW WHEN IT IS APPROPRIATE TO GIVE VESTIBULAR INPUT: Vestibular input can be placed in two different categories calming and excitatory. Vestibular input that is calming is most often utilized when a child is over-aroused (decreased attention, moving around the room with little or no purpose, unable to follow simple and familiar directions, self-abusive behaviors, self-stimulating behaviors). Vestibular input that is calming are those that provide linear (back and forth) movements on suspended equipment or those that provide a slow rocking motion. Proprioceptive activities can be used with calming vestibular activities to further help the child to calm. A therapist most often utilizes excitatory vestibular input when a child appears under aroused. (i.e. listless, floppy, unmotivated). Vestibular activities that are excitatory are those that involve fast movements on suspended equipment and may include quick changes of direction and speed; as well as those activities that have a rotary or orbital movement component.Contradictions to excitatory vestibular input: It is with extreme caution that excitatory input is imposed on a child by a therapist. Some children who appear under-aroused are actually in a nervous system state known as shutdown. These children are so over-aroused that their nervous systems, as protection, have turned them "off" to input and they appear quiet, listless, and unmotivated. Excitatory input at this stage can cause deeper levels of shutdown. For the purpose of this sensory diet, imposed excitatory vestibular input should never be given. Excitatory vestibular that is driven by the child should be monitored carefully for the following: 1. Is this a child that needs excitatory input or is he or she already too excited to follow directions? * If already too excited -impose proprioception * If child-driven excitatory input is appropriate monitor child for symptoms of over load: -Nausea/vomiting - Pupils dilated - Dizziness - Flushed or pale skin Stop activity at first sign of above symptoms and give calming proprioceptive input. A child that is truly under-aroused and not seeking child-driven excitatory input to increase arousal state should be allowed to bounce on a ball or trampoline quickly to help alert. Stimulating environment with lights on and upbeat music will also help to increase arousal level. Also, consider increasing the volume and speed of your voice and your own arousal level to help stimulate the child.

2. HOW TO KNOW WHEN IT IS APPROPRIATE TO GIVE PROPRIOCEPTIVE INPUT: Much like vestibular input, proprioceptive input can also be excitatory or calming. Excitatory proprioceptive activities are activities that have an excitatory vestibular component (like fast bouncing on a ball to increase muscle tone) or proprioceptive activities that are done in an excitatory (stimulating) environment. For example, one child jumping on a trampoline can be calming; three children jumping together on a trampoline can be excitatory. Excitatory proprioceptive activities should be utilized for an under-aroused child that is not seeking child- driven excitatory vestibular input (as previously mentioned under General guideline #1). Remember: A. If you are unsure if a child is in shut down or truly under-aroused give calming input first. B. If the child continues to be inactive move to more excitatory proprioceptive: activities. C. If child becomes excited by calming proprioceptive activities, they are moving out of shutdown into over aroused, continue to impose calming activities until the child is in a state of calm, alert, and ready to work. D. Most proprioceptive activities are calming and should be imposed if a child is over-aroused (decreased attention, moving around the room with little or no purpose, unable to follow simple and familiar directions, self-abusive behaviors, and self-stimulating behavior). E. Calming proprioceptive input and calming vestibular input can be utilized together or independently.

3. HOW TO KNOW WHEN IT IS APPROPRIATE TO GIVE ORAL MOTOR INPUT: As previously mentioned, oral motor activities help children and adults to calm, focus, and concentrate, and can be utilized either immediately before fine motor task or during fine mo1or tasks to help the child come to midline and concentrate. Experience has taught that oral motor activities (like lollipops) may also become a distraction (as the child pulls the lollipop in and out of mouth usually with dominant hand and therefore stops the fine motor activity). If food is the oral motor activity of choice, choose foods that remain in the mouth to help decrease distractions.

4. HOW TO KNOW WHEN IT IS APPROPRIATE TO USE TACTILE INPUT: Tactile input can also be excitatory or calming. Generally speaking, light touch (including tickle, itch, scratch) is excitatory, especially to a sensory defensive child, and should be avoided at all times. Tactile input that is calming involves firm pressure touch and is commonly called "brushing" or "Wilbarger Technique. " It is highly recommended that you learn this technique directly from Patricia Wilbarger or a professional trained by Ms. Wilbarger. Activities that have a tactile component are frequently utilized in therapy as part of a "multisensory approach." By bringing in a tactile component, a child is more likely to remember and sequence the activity more efficiently. Medias like shaving cream, rice, finger paint, can also help a child with decreased attention to concentrate. Making letters in shaving cream is more motivating, for example, than familiar pen and paper activities and most times a more effective learning tool. However, a child with sensory defensiveness may not tolerate these tactile activities and instead they can over excite the child. Follow a child's lead with tactile activities. If not tolerated, a firm pressure touch protocol should be 'utilized first, to help reduce sensory defensiveness.

SUMMARY: 1. Assess the child's current state of arousal, by observing motor behaviors: Under-aroused, overaroused, or calm alert. Calm alert is used to refer to the optimal state of arousal to perform work. . * If under-aroused (not shutdown) impose excitatory proprioceptive activities, monitor childdriven excitatory vestibular input, provide a stimulatory environment. * If over-aroused, provide calming proprioceptive activities and/or calming vestibular activities and/or firm pressure touch protocol. * If in shut down, impose calming proprioceptive and/or calming vestibular input. Remember, if unsure if child is under-aroused or in shutdown impose calming activities first and then reassess the state of the nervous system. 2. If calm alert, child is ready to perform fine motor tasks, sequencing/praxis activities, and new learning can occur. 3. Usually gross motor activities lead into fine motor activities.

ACTIVITIES: The following is a list of vestibular, proprioceptive, oral motor and tactile activities that can be used throughout the day to help prepare a child's nervous system for work. It is by no means a complete list of activities and not all activities may be appropriate for all children or for a particular environment. Use what experience has taught you works for the child and his or her environment, add, and delete activities as needed. Some activities have components of more than one sensory input (bouncing for example has both a vestibular component and a proprioceptive component). You may find an activity duplicated under two or more sensory inputs. In most cases, an activity will be found under that sensory input that is its biggest component per discretion of the author. Excitatory vestibular activities will not be listed as it is not appropriate for this sensory diet to impose such activities (please see General Guidelines #1 for more information). 1. CALMING VESTIBULAR ACTIVITIES (V) V-1 Rock in rocking chair V-2 Scrub floor (real or pretend) V-3 Run/Jog V-4 Ride bike V-5 Dance V-6 Do yard or house work V-7 Stretch/shake body V-8 Rolling (make sure head is uncovered and clear) V-9 Swinging- platform, hammock, net, horse, inner tube, tire, glider, playground swing in linear direction V-10 Scooter board in linear direction V-11 Wagon rides V-12 Bounce on mini trampoline, cushion, mattress (with supervision) V-13 Marching V-14 Imitate head movement V-15 Movement activities/exercise V-16 riding on moving equipment (wheelchair, elevator, car) V-17 Climbing up and down steps V-18 Therapy bal1/hippity hop ball- bounce, lay over it and roll (with supervision) V-19 Roller skating/blading V-20 Sledding V-21 Lie on couch or chair with head down and look up at the ceiling. Pretend the ceiling is the floor! How calm and clean it looks! (Having head lowered calms - haying the head erect alerts.) V-22 Slide and climb on playground equipment V-23 Jump rope V-24 Log rolling on carpet, grass, flat surfaces, or down inclines V-25 Pretend swimming on carpet or floor mat with textures trying to pull or push self around

2. PROPRIOCEPTIVE ACTIVITIES (P) Remember proprioceptive activities can become excitatory when coupled with a strong vestibularcomponent or a stimulating environment. P-1 Steam roller, roll large ball over and back of child, or another person roll over top of back (gently) P-2 People sandwich: children lying on top of each other can add blankets or furniture cushions or pillows or bean bags to the sandwich. P-3 Play catch with large ball or heavy ball P-4 Horseback riding P-5 Snow angel- begin this exercise by lying down on the floor. Keep your toes pointed toward the ceiling as you slide your legs out to the side. Do not let your legs roll so that your feet point out to the side. Now pull your legs together (but do not let them roll so your feet point in.) P-6 Hand pressed together P- 7 Table pushes P-8 Chair pushups P-9 Chair pushes P-IO Wall pushes with shoulders P-l1 Wall push with back P-12 Wall push with arms P-13 Theraband stretches P-14 Therapy putty or modeling clay P-15 Neutral warmth -such as snuggling in a blanket P-16 Slow back stroking with firm pressure or constant firm pressure on back with no movement. P-17 Weighted backpack, fanny pack, wrist weights, or weighted vest at 20-30 minute intervals. P-18 Heavy work activities -vacuum, moving furniture, digging in the garden P-19 Pushing or carrying heavy objects -wagon, shopping cart, grocery bags, laundry basket, books, etc. P-20 Bar on playground that he/she can hang from P-21 Stacking chairs at the end of the day P-22 Weight bearing activities, i.e. working over a chair or wedge while on stomach P-23 Animal Walks A) Frog jump -Squat on the floor, placing hands on floor in front of you. Move both hands forward, then bring feet up to hands in jumping motion (remain in squatting position) B) Bear Wa1k -With hands and feet on floor, move right arm and leg forward simultaneously, then move left arm and leg. If this is too difficult, try it on hands and knees. C) Inchworm -Squat on floor with hands in front. Keeping feet stable, walk hands forward as far as you can so that your are stretched out. Then keep hands stable and walk feet up to hands back to squatting position. D) Elephant walk -Bend over with arms dangling toward floor. Clasp hands together to form trunk. Maintain position while walking, swinging trunk from side to side. E) Kangaroo jump -Squat on floor, hands at sides, raise up and jump forward, sinking back into squatting position as you land. F) Crab walk -Lean back and put hands on floor (supine with buttocks off floor) walk backwards, using hands and feet alternately. G) Duck walk- Squat on floor with hands at sides. Remain in position while walking (waddling) forward. P-24 Cooking- making ice cream with a hand crank, churning butter, kneading bread. The planning as well as the activity are good for organizing and sequencing, and the end product is very rewarding P-25 "Stack em up and knock em down" Use taped up cardboard shoeboxes, used spice containers, cereal boxes, wood, or plastic blocks Have child stack blocks from various positions i.e. standing, side sit, half kneel, cross leg sit, kneel stand, side laying, hand and knees, squat, prone on elbows, sitting on small ball or adult's lap. Find various sizes and weights of balls to throw and kick to knock down "tower" using the different positions listed above. Add sand to some of the boxes to add variety and challenge. Have child stack from biggest to smallest box and heaviest to lightest box. P-26 Gardening is a great sensory experience. Some may enjoy covering seeds with dirt, digging, using a watering can, or moving dirt in a wheelbarrow from one place to another. P-27 Car wash -all you need for this is a bucket of water and a sponge. Your child can help wash/wipe (good for range of motion and coordination) your car or bike/kiddy car, etc. Let them try operating the nozzle on the hose to rinse. P-28 Wash table, chairs, blackboard P-29 Hot dog game -Have the child lie on stomach: rub arms, legs, back. Roll the child up snuggly in a blanket, and then rock gently with one hand on child's shoulder, other on hip. You can hum orsing with rhythm of the movement. P-30 Wheelbarrow walk -hold you child's legs securely while they walk on their arms. P-31 Jump up and down in place. Jump rope. P-32 Play wrestling. P-33 Play Rock of Gibraltar by getting down on al1 fours position next to each other and trying to push each other over. P-34 Martial arts with appropriate discussion with teacher. P-35 Tug-of-War. P-36 Crawling (army crawl or on "all fours" through and/or over an obstacle course P-37 Playing in a ball pit P-38 Pushups -Lie down on your stomach with your body in a straight line and your hands flat on the floor next to your shoulders. Push down and lift you body up with you arms, Try to keep your body stiff as you do this. If you can't do a pushup with your body stiff, then lift your shoulders first, or bend your knees as you come up so you end up on your hands and knees. P-39 Bear hugs (full body) P-40 Squeeze toys P-4l Sanding wood P-42 Sit on hands or feet P-43 Climbing rope, suspended ladder, or stairs. P-44 Swimming P-45 Tap toe, heel, foot, in sitting P-46 Therapy ba1l/hippity hop ball for bounce P-47 Scrub floor (real or pretend) P-48 Joint compressions as part of Wilbarger technique -firm pressure touch protocol P-49 Vibration- Vibration runs on the same pathway in the nervous system as conscious proprioception and therefore can be calming, However, vibration has an element of light touch that can be noxious to the sensory defensive child. Let the child 1ead vibration activities, Vibration activities include: A) Vibrating hand held toys B) Massagers/pillows C) Electric toothbrush D) Vibrating pens and electric scissors E) Vibrating games (Cut it out and Bed Bugs) CONTRAINDICATION FOR VIBRATION: Low vibration: can be nauseating-keep batteries charged and replace frequently.

3. ORAL MOTOR ACTIVITIES (O) 0-1 Blowing bubbles 0-2 Blow Ping-Pong or cotton ba11 across table with straw. 0-3 Tugging/biting washcloth, therapy tubing. 0-4 Crunchy snacks. 0-5 Blow toys, i.e. windmills, Kazoos, whistles 0-6 Blow up ba1loons 0-7 Chewing gum 0-8 Vibrating toothbrushes 0-9 Resistive sucking- i.e. sports bottle, drink boxes, straw, crazy-straws, thicker liquids 0-10 Foods: popcorn, crackers, bagel, beef jerky, fruit rollups, tootsie rolls, starburst fruit chews, and pretzels 0-11 Chewing crushed ice, fruit (non-sugar) Popsicles, frozen bananas 0-12 Chew on coffee swizzle sticks 0-13 Suck on sugarless hard candy 0-14 Suck on sugarless gummy candy 0-15 Suck on sugarless jawbreakers 0-16 Slow, deep breaths; about twenty REMEMBER: Monitor for safety and always check for food and non-food allergies.

4. TACTILE ACTIVITIES (T) T -1 Rub child's body all over "With towels. T -2 Rub lotion or powder on child while identifying body parts. T -3 Pretend to paint body with clean paintbrush, then rub part off with towel. T-4 Water play -pouring water on child. T -5 Find hidden shapes and objects (i.e. small game pieces, coins, buttons) in dry beans or rice in a tub or container T -6 Playing with foam soaps in bathtub. T -7 Blowing bubbles and "popping them". T-8 Papier-mâché T-9 Make collages using fabric pieces, yarns, and papers T-10 Squeeze cheese in can dispensers~ squeeze in fingers and eat. T-11 Feely-Meely game- use bag or box filled with a variety of objects, then reach in and try to identify. T-12 Chalkboard: cover with chalk, and then rub out objects, numbers, letters, and shapes. One could also use chalk on carpet squares -then "'erase" with hands for additional tactile input. T-13 Soap paint on body (available at children's toy stores). T-14 Sandbox play -May also use container of dried beans, peas, macaroni noodles and Styrofoam packing balls. A) Hide toys throughout box and have child find them, i.e. parts to a puzzle, game pieces, stacking rings, pop beads, then have child complete the task, game puzzle, etc. B) Place cups, bowls, and spoons in box and have child scoop, pour, and spoon sand from one container into another. Add water to double the challenge and fun. C) A11ow child to play in sandbox "With only shorts on to get good tactile input all over body. Encourage weight bearing positions on hands/la1ees, prone on elbows, kneel stand to give additional tactile stimulation. T-15 Pudding and Finger Painting or shaving cream -Tack white trash bag to ground or table -Place child in swimsuit on a warm day. -Place various colors of water-soluble finger paint or pudding on plastic surface and let your child go to it. -Encourage making lines, circles, squares, faces, houses, etc. -Add dried beans, rice, sand, and noodles to vary texture -Make finger or feet prints on paper -Wash off outside with water hose or sprinkler T-16 Coloring with crayons on sandpaper T -17 Shaving cream on bathtub wall T-18 Dot spot-put "dots" of powder or chalk on child and have him/her rub it off T-19 Wilbarger Technique -Firm pressure touch T-20 Fidget with a Koosh bail or other small tactile toys. T-21 WATER PLAY A) Identify body parts when rinsing sand off you. B) Just sit and play at the waters edge. Just letting the waves come up and cover your legs, watching the water rush back to the lake is not only fascinating but a great tactile experience. C) Swimming or pre-swimming motions are excellent for building up muscles as well as maintaining range of motion and overall endurance. This also helps the child learn to coordinate both sides of the body. D) Playing motorboat is fun and good for those children who need to strengthen their trunk muscles; support child several ways i.e. one arm under the child's armpits and the other under his/her hips, both hands on each side of the child's underarms. Place the child on the surface of the water on back or tummy and move through the water in circular movements, as the child feels more comfortable, you may hold his forearms or hands and pull through the water. (Blow "raspberries" to make a motor sound while doing this.) E) Ball or Frisbee is also fun in the water and good exercise for the shoulders and arms. F) Try throwing stones or shells into the water. G) Playing at sink in cold or cool water. Look for hidden objects -pretend you are at the North Pole. Use variety of objects, such as textured dish scrubbies, "octopus" soap holders. T -22 PLAY DOUGH ACTIVITIES A) Pinch off small pieces between thumb and index finger B) Roll out long snakes on the table or between palms. C) Make different size balls of play dough on the table, between two palms, between two fingers in one hand. D) Use rolling pins and cookie cutters to cut out shapes. E) Place pegs, beads, blocks, and puzzle pieces to pick out and complete. F) Add objects to add texture i.e.: raisins, nuts, and rice. G) Make bracelets and rings to place on hands and feet. PLAY DOUGH RECIPE 1-cup flour 1-cup water 1 cup flour 1 cup water ½ cup of salt 1 Tbsp. Cooking oil 2 tsp. Cream of tartar Food coloring Mix all ingredients and stir constantly over medium heat. While stirring, add food coloring to desired color. Mixture will quickly turn into dough-like substance and form a ball. Take out of pan and knead with fingers. Store in an airtight container or plastic bag.

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