Case study 5

Outline of case study

IJ is a 16 year old boy with a diagnosis of autism, severe learning disability and ADHD.  IJ was referred to Middletown Centre for Autism following reports made by school staff and parents regarding significant episodes of aggressive and negative outbursts during transport to and from school and in the classroom. It was also reported that IJ had some toileting and self-care issues.

IJ communicates his needs through physical movements, visual aids and some vocalisations. In school, IJ was observed to cover his ears, shout and occasionally hit out when faced with an activity, lesson or situation he did not like. This has been observed in the school environment in response to noise and other auditory stimuli and at home in response to hair-cutting, nail-cutting and showering. It was hypothesised that IJ’s difficulty processing sensory stimuli may have contributed to some of his outbursts.

In school IJ demonstrated difficulty remaining on task, was easily distractible and vigilant.  He responded positively to 1-1 adult support with all tasks and was prompt dependent and unable to work independently.  He seemed nervous and anxious in noisy environments and in engaging in novel activities or unpredictable environments.  When sitting during table top activities it was observed he continually kept moving and would flap objects such as towels and jumpers.

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, specialist occupational therapist and behaviour intervention specialist. The information below focuses on IJ’s sensory needs.

IJ has significant difficulties in the processing and regulation of sensory input.  The Sensory Profile indicates that overall IJ presents as sensory over-responsive with additional sensory seeking behaviours.

1. Sensory over-responsive

   • Assessment highlighted that IJ was sensitive to noise and therefore group activities or tasks in a noisy classroom were difficult for him to tolerate, often causing him distress which he displayed by making noise himself and/or placing his hands over his ears and pacing. IJ would also self-talk and make noise when completing tasks as a strategy to remain on task. 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.
   • It was observed that IJ was very visually vigilant of others in his environment which is a strength but this meant he often got distracted by this visual stimuli.
   • IJ’s sensory profile indicated that he was sensitive to touch particularly within the domain of personal care. IJ demonstrated his sensitivity to touch by refusing to stand in line in school and engaging in aggressive behaviours during group activities which resulted in him being removed from the group activity. He had therefore learnt that if he engaged in aggressive behaviours, he would be taken from the stressful situation and placed in a calm area which was more pleasant for him. Additionally, IJ may find it threatening if someone was in his space.

2. Sensory seeking

   • IJ actively seeks sensory stimuli in the form of visual stimuli.
   • It was reported that IJ liked to fidget with and flap different materials such as a tea towel or jumper though this was a sensory seeking behaviour the Special Occupational Therapist noted that this was usually an anxiety response.
   • IJ’s sensory profile indicated that he liked deep pressure.

Displayed Behaviour	Causes
Making noise himself and/or placing his hands over his ears	Method of communicating that he is distressed (due to noisy environment) and wants to be taken to a quiet area Predictable input to block out unpredictable input around him
Pacing	Seeking movement input to keep himself alert Seeking rhythmical movement to keep himself calm and regulated
Self-talk during tasks	Predictable input to block out unpredictable input around him This could also indicate that IJ is anxious when completing a task because he was unsure of expectations
Aggressive Outbursts in noisy environments and during group activities or standing in line	Method of communicating that he is distressed (due to noisy environment or tactile over-responsiveness) and wants to be taken to a quiet area Method of avoiding an activity or situation Provides some deep pressure input to calm and regulate
Distracted easily	IJ is over-responsive to visual input, therefore  he has difficulty filtering out the varying visual stimulation in the classroom which can cause the IJ to be easily distracted and in more extreme cases he may feel overwhelmed and highly anxious
Difficulty with personal hygiene tasks	These activities involve light tactile sensations e.g. when having hair cut the hairs falling on his skin caused IJ distress. It may be that his neurological system interprets the light touch as alerting and painful.
Fidgeting with and flapping different materials	Sometimes seeking visual input to keep himself alert Sometimes seeking visual input to block out unwanted sensory input around him Predictable input which is calming and regulating

Intervention strategies:

Auditory Strategies

Reducing background noise as much as possible.

Providing IJ with breaks if he has to work intensively on a task in a noisy environment or allowing IJ to access a quiet area to continue his work there.

Provide IJ with a quiet/ calm area which he can access regularly and when needed using a sensory break card.

IJ may make noise himself and/or place his hands over his ears, pacing to indicate that a noise or environment is bothering him.  It is important to identify and be vigilant of triggers to anticipate when this might occur as it will help to inform strategies such as reducing the amount of time he has to spend in an environment where he will be exposed to noise.

IJ should be given advance notice where possible when he will be exposed to noise and directed to engage in a calming activity, such as deep pressure or weighted items, following exposure.

Additionally if there are occasions that IJ is in environments where he may have difficulty managing because he will be exposed to loud or unpredictable noises, headphones or ear defenders may help him manage.

Visual Strategies

Visual clutter in the environment and around work areas should be kept to a minimum to enable IJ to find items and visual clarity to organise his resources.  This includes:

1. Defining work areas
2. Clarifying what IJ has to do, so that activities have an inherent start and finish, labelling drawers and cupboards, using visual supports for timetabling and positive behaviour management.
3. Limiting visual distractions using a visor around his desk may also help.
4. Timing and pacing of activities will assist IJ in sustaining his attention on task.

Tactile and Proprioceptive Strategies

When individuals experience sensitivity to touch they may seem to react emotionally or aggressively when they experience light touch and this may influence the level which he may participate in his activities of daily living and practical subjects at school.  Therefore, standing in line or in gatherings may be difficult for IJ as the potential for someone to come into his space is unpredictable and therefore his anxiety levels would be raised.

To reduce anxiety IJ should engage in proprioceptive/deep pressure/ heavy work activities/ or use of weighted items throughout the day to calm and move him into the calm-alert state before engaging in activities which are known to trigger emotional or aggressive outbursts.  Proprioceptive / Deep pressure activities can have both calming and alerting effects.  The resistive input obtained through heavy work activities is generally calming, organizing and can improve attention, arousal level, body awareness and muscle tone. Examples of deep pressure activities include:

1. wall presses
2. going on walks while wearing ankle weights or small weights/ heavy books in pockets
3. swimming
4. participating in chores or functional activities
5. Bear hugs
6. Using squeeze balls and doing stretches

IJ should be placed at either the first or last in the line and be given something to carry either when in a line or transitioning through gatherings as this will provide him with some deep pressure which may assist to calm.

IJ should be given some warning when someone is going to enter into his space and if he is to be touched, touch firmly instead of light touch.

IJ should be given fidget items and access to materials he likes to touch.

Personal Care Strategies

IJ doesn’t like the feel of the tags on his clothing being next to his skin and therefore the tags should be removed.

Instead of cutting nails try filing nails.

Visuals of the personal care activity (e.g. a video of getting hair cut), people involved and the utensils may help to prepare him ahead of time.

To reduce anxiety IJ should engage in proprioceptive/deep pressure/ heavy work activities before and after the personal care activity and may benefit from a weighted item like a lap pad placed around his shoulders during the 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 him.

He can also be given distracters such as completing an activity whilst the personal care activity is being completed.

He can be scheduled to do something very motivating afterwards.

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.