Case study 6
Child’s name & age:
Main areas of concern:
Selective mutism in school, refusal to complete work; and to participate in class and sometimes to sit in class. Sensory over responsive, particularly with tactile and auditory input.
Outline of case study
KL is a 13 year old girl who attends main stream secondary school. Referral to MCA was made as a result of selective mutism in school and more recently, refusal to complete work, participate in class and sometimes sit in class. These challenges emerged in school because of a change in KL’s class peer-group.
When KL is calm, she has a good understanding of language, is able to follow instructions and participate in interactions in both home and school settings. When under stress her communicative abilities and behaviour deteriorate e.g. KL will sometimes ‘freeze’ or become very upset when approaching busy events in the school. Sometimes KL will engage in pacing backwards and forwards.
Along with her diagnosis of autism, KL presents with a range of difficulties including deficits in Social Communication skills, Sensory Processing difficulties and challenges around rigidity of thought.
Assessment and analysis
Prior to conducting assessments, observations of KL were carried out at home and school.
This was followed by a Sensory Profile (Dunn, 1999) assessment which was completed with KL’s parents. The Sensory Profile School Companion (Dunn, 2006) assessment was completed with school staff. The Adolescent/Adult Sensory Profile (Brown and Dunn, 2002) assessment was conducted with KL to afford her the opportunity to self-report. Analysis was combined with the assessment results from the specialist teacher, specialist speech and language therapist, specialist occupational therapist and behaviour intervention specialist. The information below focuses on KL’s sensory needs.
KL presented as sensory over responsive, particularly with tactile and auditory input.
- Sensory over-responsive
- KL reported having difficulty managing with unexpected, loud and background noises and demonstrates this by appearing to be stressed or anxious. She sometimes will ‘freeze’ or become very upset in a crowded or busy environment.
- KL will make noise (cough) when completing tasks, which added to her sensitivity of background and loud noise, resulting in group participation being difficult.
- Assessment highlighted that KL may not always register auditory cues particularly at home. However, she will notice small changes within the environment and others moving about, though KL reported that this is not a source of distraction.
- Although KL’s attention to detail is a strength, on occasion she will add more detail than is necessary to drawings and written work and sometimes is unsure of when to stop or know when an activity is finished. KL’s handwriting ability was also noted to require a lot of effort and pressure.
- The Sensory Profile indicated that KL is sensitive to touch particularly within the domain of personal caring e.g. showering, cutting hair. KL has also described certain types of clothing (tights, shirts and blazer) as irritating.
- The Specialist Occupational Therapist observed that KL tended to slouch and prop herself up when sitting, often appearing to have difficulty maintaining various positions against gravity and generally presenting as lethargic. KL often refused to take part in PE, instead preferring more sedentary activities.
- It was observed that KL often avoids eye contact.
|Becoming upset or ‘freezing’ in crowded or busy environments||
|Coughing or making noise during a task||
|Not listening at home||
|Noticing small changes in the environment||
|Adding too much detail, having trouble knowing when to finish a task||
|Finding some clothing and personal care irritating||
|Slouching in seat, presenting as lethargic and preferring sedentary activities||
|Sometimes avoiding eye contact||
- Reducing background noise as much as possible e.g. using traffic light system. If KL has to work intensively on a task in a noisy environment, she should be provided with breaks and opportunities to engage in activities that provide deep pressure which can have a calming and organising effect.
- As KL finds crowds difficult due to the background noise. It may be useful for KL to stand outside assemblies for the last few minutes and to work up to standing at the back of the hall, increasing the length of time gradually as tolerated.
- KL will make noise when completing tasks, for example she will cough, it is unclear if she uses this as a strategy to communicate when she is not speaking so that she can obtain the other person’s attention and to indicate her response or if she is a little anxious when completing a task. KL should be provided with opportunities to access a means of communicating her needs until she feels comfortable with the person she is interacting with. For e.g., using an iPad to type what she wants to say and/or using visual supports to highlight key pieces of information.
- KL reports that she may not always register auditory cues at home, therefore her attention should visually be obtained to indicate that it is needed.
- Instructions should be reduced and she should be given time to process the information (i.e. allow 10 seconds after issuing the instruction for KL to process what has been said before expecting her to complete the task at hand. Keep the instruction script the same).
- It may be helpful to use an animated voice to indicate when KL’s attention is required.
- Visual supports may be useful such as timers etc to cue KL when she needs to move on from an activity or she has to come from her bedroom etc.
- Visual clutter in the environment and around work areas should be kept to a minimum to enable KL to find items and visual clarity to organise her resources. This can include defining areas where KL should work, clarifying what she has to do, so that activities have an inherent start and finish, and to store work books, labelling drawers and cupboards, using visual supports for timetabling and colour coding to organise her resources.
To reduce anxiety, KL should engage in proprioceptive/deep pressure/ heavy work activities throughout the day to calm and move her into the calm-alert state. Facilitating KL to engage with some heavy work activities may also help to increase her body awareness. Examples of such activities may include:
- Pushing & pulling games,
- Wall press ups,
- Lifting or carrying heavy objects,
- Hill walking and walking (walking using weights)
- Bouncing up and down on a therapy ball
- Using ankle/arm weights and weighing the school bag
- Doing exercises that are isometrics, stretching, toning
- Carrying boxes/laundry basket/watering plants
- Head compressions
- Completing a message where the student has to carry something from one location to another
- Theraband activities
Personal Care Strategies
- Provide KL with clothing she finds acceptable and comfortable.
- A lycra vest worn under KL’s school shirt and heavy books in KL’s blazer pockets may help provide pressure which will enable KL to tolerate her uniform better.
- Visuals of the personal care activity (e.g. a video of getting hair cut), people involved and the utensils may help to prepare KL ahead of time.
- To reduce anxiety KL should engage in proprioceptive/deep pressure/ heavy work activities before and after the personal care activity.
- People involved in the personal care activity should be advised to use heavy rather than light touch. If the experience is shorter and more positive, it may get a little easier for her.
- Provide distracters such as completing an activity whilst the personal care activity is being completed.
- Schedule the child to do something very motivating afterwards. (consider the child’s interest/particular likes)
- Please note: The intervention strategies used with this child/young person were introduced after observations, comprehensive assessment and consultation with parents/caregivers and other professionals working with the child/young person. These strategies were individualised to his/her specific needs and will not be appropriate for every child/young person.
- Provide KL with clothing she finds acceptable and comfortable.