Case study 4

Outline of case study

GH was referred to Middletown Centre for Autism following reports made by school staff and parents regarding an escalation in specific behaviours. These behaviours included GH harming himself by biting his hand and banging his head on walls, and also harm towards others, such as hitting and biting his parents and school staff. There were additional concerns that he may also harm himself by eating non-food items.

In school, the behaviours were most likely to happen during group activities, Assembly and the dining hall. Parents observed an increase in these behaviours when outside the home e.g. in the park, shops and restaurants. They also reported that GH would often hit or bite them when there were visitors in the house. When the behavioural incidents occurred, GH would immediately be moved to a quiet area, which was the calm room in school, his bedroom at home and the car when out with his parents.

GH appeared to be calmer when engaged in solitary or one-to-one activities, but even at these times, he would be constantly active and engaged in repetitive behaviours. Examples included flapping his hands in front of his eyes, pacing up and down the room, opening/closing doors and rocking in his chair. He often made a loud humming noise while engaging in these behaviours.

GH was non-verbal and used photographs to request objects he needed. He was able to follow a visual schedule using photographs and would transition independently around the classroom.

Assessment and analysis

A Sensory Profile (Dunn, 1999) was completed with parents and the Sensory Profile School Companion (Dunn, 2006) was completed with school staff. Observations were carried out at home and school. Analysis was combined with the assessment results from the specialist teacher, specialist speech and language therapist and behaviour intervention specialist. The information below focuses on GH’s sensory needs.

GH presents as sensory over-responsive with additional sensory seeking behaviours.

1. Sensory overresponsiveness

   Assessment highlighted that GH had significant sensitivity to noise and therefore group activities were difficult for him to tolerate. The noise levels in the dining hall and Assembly also contributed to his anxiety in response to auditory input. His agitation appeared to be a combination of hypersensitivity to loud volumes of noise and a fear of sudden and unpredictable sounds.   His behaviours were a means of escaping the unwanted noises as he had learnt that he would be immediately transitioned to a quiet area when he bit himself, banged his head or hit and bit staff.

   His over-responsiveness to noise was also evident in other settings such as shops, restaurants and family events. Sudden noises such as a dog barking, child crying or announcement over a tannoy system would often lead to the behaviours mentioned above and his parents responded by moving him from the setting to his bedroom or the car.

2. Sensory seeking

   GH craved a range of sensory input but for different reasons. Some of his sensory seeking behaviours were a means of regulating his over-responsiveness to noise while other sensory seeking behaviours seemed to be for enjoyment and exploration of his environment.

   He sought auditory input by humming loudly but only did this in noisy environments, indicating that this was his way of trying to block out unwanted background noise. The humming also provided him with a predictable sound which he controlled in order to calm himself when there were unpredictable noises around him.

   Biting his hand and banging his head are behaviours which provided deep pressure input. This type of input is often calming and regulating for children who are feeling distressed by external sensory input. These extreme behaviours provided GH with predictable and intense input which helped him to block out unwanted input in his environment e.g. blocking out sudden and loud noises. In addition, these behaviours had become a form of communication for GH as staff and parents responded by moving him to calm area. He had therefore learnt that if he engaged in these behaviours, he would be taken from the stressful situation and placed in a calm area which was more pleasant for him.

   GH sought movement input through pacing around the room and rocking in his chair. He often engaged in movement activities when he had been sitting at an activity for more than 10 minutes, indicating that he was seeking movement to keep himself stimulated and alert. GH, however, would also use the rhythmic movements of pacing and rocking to calm himself during times of increased agitation e.g. during group activities. Flapping his hands in front of his eyes also provided the dual purpose of stimulating him during quiet activities and calming himself when upset. This repetitive behaviour primarily provides visual input but also stimulates the movement (vestibular) system, and it provides a predictable and repetitive input which was helping GH to regulate his sensory responses.

   Eating non-food items, from a sensory processing perspective, indicated that GH was seeking tactile and gustatory (taste) input. This may have been due to a range of factors, including enjoyment of the sensations, a means of blocking out external sensory input and exploring objects in the environment.

Intervention strategies

1. ‘Calming’ communication cards

   A communication board was introduced during group activities. Photographs of calming choices were attached to the board so GH could request a calming activity instead of hitting/biting to communicate when he was distressed. The choices included a chewy tube, vibrating cushion and calm room. The chewy tube and cushion could be used within the group whereas the calm room involved leaving the group. The use of this communication board was initially taught by staff who directed GH to take a photo from the board when he was agitated and then exchanged the photo for the activity requested. He learnt to use this independently, which significantly reduced the incidents of biting, hitting and banging head.

   This strategy was gradually transferred to other contexts such as Assembly. At home, his parents used the strategy to allow him to request to go to the car when in shops and restaurants or to go to a quiet room at home or in other people’s houses.

2. Sensory diet

   A programme of activities was integrated into GH’s daily schedule to meet his sensory needs and to ensure he maintained a regulated state throughout the day. The activities provided a combination of movement, heavy muscle work (proprioceptive input), deep pressure and tactile input as these were the sensory stimuli he was seeking. Activities included:

   • Taking messages to the school office: the walk to the office provided movement input
   • Taking towels etc to the laundry: this again provided movement input, and carrying the basket provided heavy muscle work
   • Setting up the hall for PE: lifting benches and setting out mats provided heavy muscle work
   • Weighted blanket: The OT in school provided a weighted blanket which he used at scheduled times in the calm room. The scheduled times were after group activities (when anxiety was heightened) and before going home
   • Messy play: GH was scheduled for time to engage in a range of messy play activities, including water play, sand play, finger painting etc. These activities facilitated regulation as they met his need for tactile input but they also provided the foundation for motor skill development.
   • Space hopper: GH used the space hopper in the playground (or in corridors on wet days). This provided movement and proprioceptive input.

3. Tactile activities

   Tactile activities were integrated into GH’s curriculum to meet his need for tactile input and to facilitate the development of motor skills. Examples included tracing shapes in tray of shaving foam/sand/lentils, finding items hidden in boxes of rice and pasta, and making shapes and letters/numbers with play dough.

4. Differentiating non-food items

   Each time GH put a non-food item in his mouth, or attempted to do so, he was directed to place the item in a red box, indicating these were items he could not have. He was then directed to pick an item from the green box, indicating items he could have e.g. chewy tube, mouth spray, small packet of ‘Cheerios’.

5. Oral motor activities

   A programme of oral motor activities was introduced into GH’s daily schedule to reduce his need to mouth non-food items and to facilitate sensory/emotional regulation. Activities included:

   • Blowing bubbles in a tray of water through a straw
   • Blowing pieces of tissue paper and cotton wool along table/floor
   • Drinking water from a bottle with a sports cap
   • Eating yoghurt through a straw at Break time

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.