Occupational Therapists have much to offer the world of autism in the realm of treatment as well as understanding. Autism is a neuro-biological disorder and as such has many implications in terms of any developmental framework that co-occurs in both sensory processing work as well as in play. Any child, no matter the diagnosis, should be seen as an integrated whole in terms of the many facets we as humans hold dear. Every child has to follow the same developmental progression in order to grow and take in his/her learning environment. As sensory processing developmentalists we are in the unique position to test our hypothesis of where development went astray in each child we see.
An argument is made for the difficulty testing a child who may not be able to complete standardized tests. A counter argument is made that if we use our knowledge on the theory of sensory processing, which includes integration as well as modulation, we could essentially figure out sensory-behavioral patterns that allows us to formulate treatment. Brushing up our knowledge on early development becomes important and once we figured a sensory pattern, we could almost know it stems from the first year of development and build our way forward from there. Treatment programs struggle when we try to apply a program based on the cognitive level and not on the developmental level. Sensory processing is a subconscious development, not a conscious development and yet so many therapists the world over seek the child to understand their command first and then apply his / her central nervous system. Typical developmental progression demands this to be the other way around. We first need to be regulated and then we will be able to apply our cognition at its fullest ability. If occupational therapists did not carry this knowledge in treatment, the world of treating autism would lose one of the greatest tools in working with children on the spectrum.
Another difficulty that arises is if we focus so much on providing therapy with “age appropriate” activities. For sure we would like for this to be our goal, but it certainly is not the place we start. We have to find the place in each child’s system as close as possible to where it all began and we start a treatment plan from there. It is so easy, and very understandable, to be swayed by parent expectation and feel pressured to work according to the parent goals. “I am bringing him to you so he could learn to cut and write”, says mother. One glance at the child tells you that there is so much more that needed to be worked on first before we could even begin to write and cut. It is incumbent upon us to train the families that this will not be the most helpful place to begin to work. You would start your 10 to 12 sessions with an anxiety in yourself that certainly does not help the child to overcome his.
The most important aspect of treating a child with Autism is meeting them exactly where they are at in any particular moment in time. Jean Ayers focused on child-centered work and this is as true today as it was in her time. Pressures of the world may change, but development is still the same. It is not our or the family goals that counts (though of course you formulate them in your treatment plan), but in the treatment session you have to find where the child ‘s goal is, match it and work your way around to make him want to take one simple step further. Once a child trusts that you will not violate his control over any situation, you will be able to move mountains with him.
Let’s take stereotypical behavior (stimming) for example. Families see this occurrence as a behavior that makes their child look different than other children, especially in public. Behaviorists see these occurrences as behaviors that need to be “extinguished” and worked away. The Sensory Processing framework requires that we observe these behaviors to determine why this child has so much need of doing this. Children are resilient, on that most professionals agree. Children are also capable of finding out for themselves some ways to make them get what they need, just as surely as you would today shift your position in your chair when you become uncomfortable. When we understand that sensory processing is all about alerting or inhibiting the central nervous system, we can begin to understand that the child can use his own central nervous system in order to find ways of regulating himself. This frequently does not look like the ways typically developing children would use their innate functions, but it certainly are ways that work for the child with autism in a world where their sensory systems simply cannot make sense of their environments. If the child tends to flap his hands when excited or when with himself, he might possibly be needing to influence his vestibular position of his body in space or he might need to arouse a system that is staring to flag in the hyper vigilance that is required. Or if a child is finger flicking in front of the eyes, is he doing this because he can access vestibular input through his visual system? Is the child’s tendency to few visual objects through turning his head and using his peripheral vision because he is trying to avoid double vision or does get more proprioceptive feedback through his eyes by maintaining this tilt of the head? The examples are plentiful and clinical reasoning is required for each individual profile we see.
Since the autistic child’s system frequently is found to be in hyper mode (hyper vigilance), it becomes essential for him to access some place in their system where they could find solace or relief. Many children with autism exhibit a mixture of different profiles in that they avoid some activities that would have developed their ability to register information and then they seek information in other ways to make up for what they are avoiding or not registering. It becomes a complex muddle of sensory-behavioral patterns that need to be respected by professionals and not simply be acclaimed that he is doing it because he is “autistic”. Every morning coffee drinker will object if we simply took away their ability to have coffee simply because it was not acceptable to someone? Or asking you not to go to the bathroom because it simply is not acceptable to the person you are with?
The sensory “stims” we observe in children are essential needs for the autistic child’s regulatory system. The medical world uses it as an item on a diagnostic scale; we use it as a developmental perspective. We simply have to find out what it means and start treating it from a sensory processing perspective. Our role here becomes critical in understanding each individual child and validating what he brings to the table.
We can go further and discuss the flight, fright, and fight mechanism that is available to you and me and to every child struggling with an autism diagnosis or general developmental delay. Psychologists over the world agree that we have this mechanism available to us from the first day we are born and we use it very much in response to how we perceive the environment we are finding ourselves in. If a child is hyper vigilant with regards to his auditory environment (develops into sound sensitivity) and he uses it to determine what is coming at him, his analysis of information could cause him to go into any of the three modes of fight, fright and flight. He may respond to this situation solely on this perceived threat to his system and will not focus on the potential joy of the moment in it’s entirety. Similarly, a child who has difficulty perceiving the learning material visually, or might have light sensitivity, or may be seeing two lines to cut and not only one, will want to avoid these situations as potential threats to his system.
So frequently we hear from caregivers that the child is manipulative, as if he would like to live in perpetual avoidance of situations and make life difficult for everyone, including himself. This saddens me greatly as the child is doing exactly what you and I are doing everyday. We find situations of comfort during times that there is discomfort and when we act on it with typical central nervous system adjustments, we think nothing of it. Because the child with autism responds with the severity of his need, we believe this to be “unacceptable”. From the child’s point of view, he needs to get away, he needs to avoid, he needs to feel safe and he needs to rely on himself to find comfort in whatever way possible he can find. We observe an adaptation to the environment that is thrown into high gear due to a maladaptive system. When you are in fear or in stress, it does not help you to start a new training course does it? When we start viewing the child with autism with this lens a whole new world opens up to us. As occupational therapists working with a sensory processing framework, we become a crucial member of each child’s medical team.
When we understand these maladaptive responses with regards to developing profiles, we can steadily work with the child from a place of comfort to accepting change and challenge new pathways of learning. It does happen though, that sometimes we have done much sensory processing work and the child continuous to show these responses from time to time, yet we know the system is now in a “working order”. The therapist has to consider the problem of habitual triggering of old behaviors. It might simply be the memory of these responses in the past that continues to linger in the child’s system and is mostly triggered by anxiety. It is the same memory glitches you and I experience when we respond to current situations based on our experiences of the past that may or may not be real to the current situation. Therapy should not be stopped at this point, as the family will need understanding to get through this phase. Important to connect sensory processing work to emotional processing work and work with the child to enact his daily experiences through a developmental play framework that will enable the child to work through it. It may still look like a sensory response, but could essentially mostly be an emotional response.
Walk with me to the world and essence of motor planning (praxis). The medical community loves to talk about rigidity in the life of children with autism. In order to conceive a new motor idea, a child has to essentially be in a comfort zone with his regulatory system. If he is still caught in the fight and flight mechanism of being dysregulated, the most intense need will be to self protect and turn inward with little availability to think of a new idea. The same goes for initiating tasks that well meaning caregivers place in front of him. It is essential the central nervous system has achieved some semblance of order and comfort before this type of task application can take place. Sequencing through a given motor task frequently requires integration between the cognitive and sensory processing systems that are unavailable to the child. Completing a task within a certain rhythm and timing become impossible ventures for a child with autism, causing the very aspect of seeming incapable to shift their attention and transitioning from one activity to another. Then there is the aspect of gaining feedback into the system. The central nervous system gains feedback each time we start a new motor action and we rely on this feedback to repeat that same action again. If we “enforce” a certain motor task on a child and he completes this task in a maladaptive way, consider the fact that we may be laying down a maladaptive pattern of movement in the child’s system. In our well meaning capacity we would like to see 10 repetitions, but better to do in the correct position and sequence of movement that will enable the child to do it again, rather than please ourselves by saying the child completed 10 repetitions today to serve our own goal.
This article cannot cover the fullness of breadth and depth of the effects of deficient praxis that a child experiences on the autism spectrum. It essentially decreases the child’s ability to harness learning from new and novel tasks or new and novel environments. In order to stay “safe”, the child will want everything to stay the same, eating the same foods, playing the same games, lining up objects in the same way and so the list goes on. Praxis is a multifaceted issue and cannot be treated if all is status quo and the child is not challenged by new and novel exposures. If the therapy session looks the same every time and we have successfully avoided a “melt down”, we may look good in the eyes of the family, but we have achieved a “good” session, and perhaps not an integrative experience from which he could develop forward.
How does one provide new and novel challenges for motor planning, while at the same time honoring the child’s need for a comfort zone? We have to spend time in developing a relationship of trust first, so the child would know that you would keep him safe. We have to decrease the triggering anxiety that causes a self protect mode. In this safety zone, the therapist also has to work with the family on the same aspects, as one good weekly session is not enough. The child has to generalize the feelings of safety and new learning to other environments as well and the best opportunities are at home.
We can linger for a moment on the aspect of transitions and talk further what we have discussed above. Once a child is working or playing on a task that he has now gained some comfort in, he is finding some modicum of enjoyment, maybe even accomplishment in achieving the task. His system is relaxing as the effects of the fight, fright and flight is lessening. The activity is becoming familiar and easier to engage in. Now we require the child to transition to a new activity and what we are essentially asking the child to do is an enormous task. He has to let go of the very essence of calmness he searches for every day and switch to a task that he might not know what to expect, not have any idea how long it will be taking him away from his current activity, and he knows that now he has to “re-gear” his entire system to adjust to another sequence of events. We take our systems for granted and we shift our attention relatively easily, but we also know that even our typically developing frames find new change to be a situation of increased energy and stress.
Children in learning and school environments as well as in therapy sessions have to face these transitions to the essentially “unknown” multiple times a day. You may argue, but why would the child not want to transition to an activity that he was engaged in multiple times before? Simply speaking, because of the maladaptiveness of the central nervous system, the child has not acquired the skill of automaticity in that particular task that habituation brings. The child has to essentially readjust his central nervous system each day as if he is learning or doing this the first time. His cognitive system may recognize the activity as familiar, but his central nervous system has not adjusted habitually to the onslaught of expectations the activity brings. We can all bring children to mind, on the autism spectrum or not, that we feel we have to re-teach the same action, the same material over and over again, even when they appear to have sufficient cognitive capacities.
Working with a child on the spectrum is very special and very rewarding. It is most likely the most severe sensory profile amongst diagnosis that a therapist can work with from a developmental perspective. The first order of the day is to meet the child where he is sensorily and emotionally and gain his trust. It is important that your families understand this process and do not rush their expectations on this delicate process. We truly understand and empathize with the family’s pain and anguish, but this simply cannot take over the needs of the child. The second important aspect is to become a keen observer of what interests the child in order to follow his lead. His lead of interest becomes the next scaffold for you to add one more step by your example (modeling) or your enjoyment that would woo him into your world and make the expectation seem safe. The child will learn if we are able to pull his intrinsic motivation into the situation.
An equally important notion to uphold at all times is to value what the child brings to the table as wonderful and to create in him a sense of power over his world. He has felt a “victim” of his environment for his short life thus far until he was brought to you and you have the power to empower him. It is the greatest gift we can give to anyone and as occupational therapists that understand sensory processing; we have a contribution to make that literally can change the entire future life of each child we treat.
Maude Le Roux, OTR/L
SAISI Journal South Africa, July 2012