Case study 1

Outline of case study

AB was referred to Middletown Centre for Autism due to an increased frequency in touching his penis and bottom in the classroom and public places. He had recently started to pull faeces from his bottom and spread on desks in school and on the walls at home. His parents reported this behaviour was also emerging in public places, such as shops and on a recent trip to the zoo. AB’s teachers and parents could not identify any triggers for these behaviours or any changes which may have elicited behavioural changes. When he engaged in these behaviours, he would be removed from the classroom, and sometimes had to be showered after smearing faeces. When out in public places, his parents would take him back to the car, and then he would be showered at home if necessary.

His parents reported that he had not had his hair cut in over a year and the dentist had been unable to check his teeth over the last 2 years. When he was younger, they had been able to hold him and apply deep pressure to keep him calm, but he had become too strong and was now resisting this input and refusing to stay in the seat for the hairdresser or dentist.

AB has limited verbal language and participates in minimal interaction with others. He is slow to respond to verbal instructions in the classroom, and often seems to not hear others speaking to him. He engages in several repetitive behaviours at home and school, including pacing, flapping his hands in front of his eyes, humming loudly and turning on taps to play with water in basins. His teacher has had difficulty in finding functional activities in which he will participate.

Assessment and analysis

A Sensory Profile (Dunn, 1999) was completed and observations were carried out at home and school with data collected over a 2-week period. Analysis was combined with the assessment results from the specialist teacher, specialist speech and language therapist and behaviour intervention specialist.

AB presents with a mixed profile of sensory overresponsiveness, sensory underresponsiveness and sensory seeking.

1. Sensory overresponsiveness

   AB’s refusal to have his hair cut and teeth checked indicated a hypersensitivity to tactile input, especially light touch and unpredictable input from others. Observations indicated overresponsiveness to noise as his repetitive behaviours increased significantly in noisy environments (e.g. noisy classroom activities, shops, the zoo).

   His habits of touching his private parts and smearing faeces appeared to be part of this over responsiveness pattern as these behaviours were an effective way of being removed from situations he found difficult to tolerate (e.g. shops, noisy classroom activities, the zoo). These situations provided high levels of unpredictable sensory input (noise, people standing too close, moving visual stimulation) which caused him anxiety and resulted in these sensory avoidant behaviours.

2. Sensory underresponsiveness

   AB was under responsive to verbal interaction with others. He did not respond to his name or follow verbal directions. This is indicative of a pattern of auditory under responsiveness and is further compounded by his limited understanding of verbal language. He did, however, show immediate interest when visual strategies were employed.

3. Sensory seeking

   AB seeks out frequent tactile input, as indicated by playing with his private parts, smearing faeces and playing with water. In these behaviours, he is in control of the tactile input and so it is predictable and pleasant for him, (whereas hair cutting and dental treatment is unpredictable input outside his control).

   Further analysis of these behaviours showed that they often occurred when he was under stimulated in the classroom and not engaged in functional activities. These behaviours would escalate during less structured times, such as Choice time and Break time. These behaviours were therefore being dually used to avoid sensory input (as described in sensory over responsiveness above) and to provide input when under stimulated.

   It was hypothesised that AB may also have been motivated to smear faeces as he enjoyed being removed for a shower as it provided an opportunity for water play which he enjoyed.

   Other sensory seeking behaviours, such as humming and flapping hands in front of his eyes, were part of his sensory over responsiveness pattern. He engaged in these behaviours when there was increased sensory stimulation around him (e.g. external noise, people standing close to him, people moving around him) and was therefore using these behaviours to block out such stimulation and to calm himself.

Intervention strategies

1. Tactile Activities

   A programme of tactile activities was introduced to AB’s daily routine and these were incorporated in his visual schedule. He engaged in at least 3 tactile activities each day for up to 15 minutes each time (sometimes longer, depending on the activity). The range of tactile activities included:

   • Water play
   • Sand play
   • Finger painting
   • Gardening
   • Dough
   • Finding objects in tactile boxes (boxes filled with uncooked rice, lentils and pasta)

   This programme of activities met AB’s need for tactile input and subsequently reduced sensory seeking behaviours, such as playing with penis and poking bottom.

   Tactile choices were made available to him during Choice Time and play times. This ensured he was appropriately stimulated at these times and therefore reduced his sensory seeking behaviours.

2. Redirection to sensory alternative

   At times, AB still touched his private parts and smeared faeces. Although the programme of tactile activities had reduced these behaviours, additional strategies were required. When he engaged in these behaviours, he was shown the ‘Stop’ symbol and then redirected to either water play or dough. This provided him with a sensory alternative for the tactile input he was seeking.

3. Calm breaks

   Calm breaks were provided during activities which AB found challenging (e.g. Music, Assembly, trips to shops and other noisy environments). He was scheduled for breaks in these activities, ensuring that he did not become overwhelmed by sensory input. Staff and parents also monitored signs of stress (e.g. hand flapping, humming, pacing) and directed him for a calm break when these behaviours were observed. This then reduced the more extreme challenging behaviours. It was important to provide the calm breaks before he became totally overwhelmed by the environment.

   Calm breaks involved transitioning AB to a quiet area using a photograph of this quiet area. He was given a range of tactile objects which he found calming (koosh ball, stress ball, gel toys).

4. Hair cutting

   Several strategies were used to desensitise AB to hair cutting:

   • Head massage: AB was given a head massage using firm pressure for a few minutes before the hair cut.
   • Deep pressure input: A weighted lap cushion was placed across AB’s lap to assist in keeping him calm during the hair cut.
   • Distractors: AB was given familiar structured activities (matching and sorting) to keep him distracted while his hair was cut. These activities incorporated tactile materials which was also calming for him.
   • Desensitisation: AB’s mother cut his hair at home. His hair was cut once a week which allowed him to become more used to the input, rather than waiting several weeks between hair cuts. The length of time spent cutting his hair was gradually increased each week as his tolerance improved. On week 1, the hair cut only lasted 30 seconds and then the length of time was extended by 30 seconds each week until he was able to tolerate a 3 minute hair cut. It was then possible to reduce the hair cuts to every other week and eventually monthly.
   • Dentist: A visual system was used to show AB how many times the dentist would look in his mouth. This system consisted of 3 photographs of a dentist examining a person’s mouth. This showed AB that he would have to open his mouth 3 times for the dentist and then he would receive a reward (water play). This was immediately effective and AB gradually became more used to the dentist examining his mouth.

5. Visual communication system

   Visual communication strategies were introduced to facilitate AB’s understanding of instructions. These strategies included:

   • Individual visual schedule (using photographs).
   • Transition cards to direct AB to check his schedule and transition to the next activity.
   • Choice boards using photographs of activities available to AB.
   • Choice boards at Break and lunch using photographs of food choices.
   • Structured activities to clarify to AB what he was expected to do in different activities.

The intervention strategies used with this child/young person were introduced after comprehensive assessment.  These strategies were individualised to his/her specific needs and will not be appropriate for every child/young person.