Case study 2

Outline of case study

CD was referred to Middletown Centre for Autism due to an increasing number of behavioural incidents. These incidents included physical harm to his teacher, classroom assistant and some classmates. He would engage in these behaviours when his teacher or assistant sat beside him to assist with work, yet at other times he would seek hugs from staff. His teacher also reported concerns that he was not completing work due to his inability to stay seated for more than 1-2 minutes at a time. She had observed that the best times to complete work with him seemed to be after Break and Lunch when he was able to sit for slightly longer periods. However, on wet days, his engagement in tasks would deteriorate and he would have behavioural outbursts when refused access to outdoor play.

Circle Time had become increasingly difficult with a number of behavioural incidents and so CD was now removed from the classroom at these times and instead went to the library with the classroom assistant. When he had been participating in Circle Time, he had repeatedly pushed classmates sitting near him and on occasion had pulled their hair and bitten them. He also tended to dominate the Circle Time activities, preferring to talk about his preferred topics of Dr Who and snakes.

Arrival at school each morning was challenging as CD would run down the corridor, crashing into others. When leaving the classroom, he would push and hit classmates standing near him in the line or he would refuse to stand in the line.

Reports from school and educational psychologist indicated above average performance IQ, and good expressive language skills with a broad vocabulary. CD would initiate interaction with classmates but was becoming isolated from them as his play was overly boisterous. He would not engage in playground games and he refused to follow the rules, preferring to run around and crash into others or wrestle them to the ground.

The parents stated that they were finding it difficult to manage behaviours at home and that CD was hitting, kicking and biting them on a daily basis. They noticed that he was calmer on days when they took him to the local park and when they engaged in rough and tumble play at home.

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.

CD primarily presents as sensory seeking but with some indicators of sensory overresponsiveness.

1. Sensory seeking

CD craves movement and therefore finds it difficult to stay in his seat or to sit still for circle time, and likes to run at speed down corridors. He needs movement to keep his brain alert; when he feels he needs movement he impulsively leaves his seat to stand up or run about the room. When CD engages in physical activity (e.g. in the park near home or in the playground), he appears calmer and more engaged because his sensory need has been met.

CD also seeks proprioceptive, or deep pressure, input. His enjoyment of rough and tumble play at home and in the playground demonstrates his need for intensive input to his muscles and joints. He likes tight hugs from adults because these offer deep pressure input. Unfortunately he does not understand that others do not seek similar input and that his overly boisterous play is hurting others. These sensory processing difficulties are further intensified by his limited social understanding. He is unable to read the cues from other children that his behaviours are upsetting them and he does not understand the rules of the playground games.

2. Sensory overresponsiveness

CD’s physical aggression towards others is due to tactile overresponsiveness. He hits, kicks and bites when others stand or sit too close to him e.g. at Circle time, standing in line or when staff sit beside him to assist with work. This close physical proximity of others provides light touch and unpredictable touch which he is unable to tolerate. His sensory processing difficulties mean that light and unpredictable touch is perceived as painful and so he engages in aggressive behaviours as a way of moving people who are too near him. He is able to tolerate hugs and rough and tumble play because these provide predictable input and deep pressure rather than light unpredictable input.

Circle Time was also challenging for CD because although he has good expressive language on his preferred topics, his receptive language skills were limited and so he did not fully understand the discussions.

Behaviour	Possible causes
Not staying in seat	Seeking movement inputLack of understanding of how long he was expected to sitLack of understanding of tasks
Running down corridor	Seeking movement inputAlso possibly related to tactile overresponsiveness as he may be trying to avoid others bumping into him in the corridor
Hitting, kicking and biting others (e.g. at Circle Time or when standing in line)	Tactile overresponsiveness/fear of light and unpredictable touchOn occasion these behaviours were CD’s attempt to initiate rough and tumble play as he was seeking proprioceptive inputAvoiding Circle Time as he did not understand the discussions
Refusal to stand in line	Tactile overresponsiveness
Rough and tumble play in playground and at home	Seeking movement and proprioceptive inputLack of understanding of rules in playground games
Requesting hugs from staff and parents	Seeking deep pressure input
Calmer/more engaged after outdoor play	Sensory needs (movement and proprioception) have been met and so he is more able to focus on tasks

Intervention strategies

1. Movin’ sit cushion

A Movin’ sit cushion is a wedge shaped cushion lightly inflated with air. The cushion was provided for times when CD was required to sit to complete pieces of work. This cushion provides additional movement input, which meets his sensory need without CD needing to leave his seat. The wedge shape also provides additional proprioceptive input as it pushes him forward on to his legs, increasing input to muscles and joints.

2. Therabands

Theraband is a band of stretchy material which provides resistance to the muscles. A piece of Theraband was attached to the front legs of CD’s chair so that he could kick his feet against it when he needed movement and proprioceptive input. Provision of this foot fidget again helps him to stay in his seat for longer times.

3. Sensory Diet

A programme of movement activities was introduced to CD’s daily routine. He engaged in 10 minutes of movement activities when he arrived at school in the morning and again mid-morning and in the afternoon. These activities provided the movement and proprioceptive input he craved, subsequently helping him to sit for longer periods. The programme of movement activities also reduced his boisterous behaviours in the playground as his sensory needs were being met at other times. The movement breaks are included on his visual schedule so he can see when he will access activities. The range of activities included:

• Lying on his tummy over a small exercise ball to complete activities e.g. throwing beanbags at a target, completing a jigsaw
• Bouncing on a space hopper
• Crawling through a tunnel
• Propelling a scooter board
• Hopscotch
• Star jumps
• Running on the spot

In addition to the movement break, CD’s teacher or assistant will observe if CD is becoming fidgety or disengaged and direct him to stand up and do 10 stretches before sitting again to work. When CD is older, it is anticipated that he will be able to independently request a movement break when he feels his attention deteriorating.

4. Backpack

CD was given a small backpack with a tin of baked beans inside to act as a weight. He wears this when coming into school each morning which helps to regulate him and has reduced the need to run down the corridor. He now carries this when transitioning through corridors at other times of the school day, and when out with his parents e.g. walking to the park, walking around the shopping centre.

5. Mat at circle time

CD was given a small mat to sit on during Circle Time and he is positioned beside the teacher. His classmates were informed that they could not sit on or near the mat. This has reduced CD’s fear that someone is going to sit too close to him and has therefore helped him to sit for longer times in Circle Time.

6. Standing at the back of the line

CD now stands at the back of the line to avoid unpredictable physical contact from others. He is scheduled for turns to be the leader, and at these times he is at the front of the line, and the person behind is instructed to keep one arm’s length behind CD.

7. Visual strategies

Alongside the sensory strategies described above, visual strategies have been implemented to facilitate communication and subsequently address some of the behavioural concerns. Although CD appeared to have extensive expressive language skills, these tended to be limited to topics of his choice (e.g. Dr Who, snakes, insects). Assessment indicated difficulties in receptive language skills, meaning that CD did not understand many of the tasks which were presented verbally in the classroom. This also explained some of the behaviours in Circle Time as he was overwhelmed by the levels of verbal communication, and so used the behaviours as a means of withdrawing from Circle Time.

The following visual strategies were introduced:

• Visual schedule: This helps CD to understand when he is to work and when he will have a movement break. This reduces anxiety and has a positive effect on behaviour.
• Structured tasks: A greater level of visual structure was introduced to CD’s work tasks due to his difficulties in understanding verbal instructions. The visual structure provides clear instructions and shows CD when a task is finished. This, alongside the sensory strategies, helps him to sit for longer periods to engage in work and complete tasks.
• Visual timer: This is used to show CD how long he has to sit to do work and how long he needs to sit in Circle Time.
• ‘Whose turn’ card: This is used in Circle Time to show CD when it is his turn to speak.

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.