10/11/2017

1

Making Sense of

Paediatric Sensory

Assessments through

the use of Case

Studies

Presented by Amy Schulenburg OT Consultant Pearson Clinical Assessment

Case Study 1 – SP2

Case Study #1 - John

• 13yr old male

• Currently in Grade 6 in a mainstream school setting

• Referred for assistance with transition to high school

• Teacher had concerns about sensory issues impacting on

behaviour affecting participation in class.

• Staff report following obsessive behaviours:

• Video games

• reading comic books

• likes to get up to change his pencil

• touching and sniffing classroom objects

• Noise is an area of sensitivity – particularly assemblies • Meltdowns frequently, which are disruptive to peers. • Often refuses to do work • Enjoys:

• Activities on the iPad or computer • music (both playing and listening) • going to the library • going on errands for the teacher (e.g. canteen run,

returning forms to the office, etc)

• Watching people and scenery

3 3

Sensory Hypothesis

John is likely to have a profile of “more than others” for sensory sensitivity in the area of auditory processing. He might also be low registration or sensory

seeking in area of movement processing. John is likely to be “more than other” in

school factors 3 (tolerance of school environment) and school factor 4 (availability for learning).

Sensory Profile Results

5 6

10/11/2017

2

School Factor 1

• Measures need for external supports to

participate in learning

• Encompasses Seeking and Registration patterns

(high threshold)

• Need extra sensory input to prepare for learning

• Key descriptor “Under-stimulated”

School Factor 2

• Measures student’s awareness and attention

within the learning environment

• Includes Seeking and Sensitivity patterns

• Need to have controlled sensory input to direct

attention appropriately

• Key descriptor “Distractible”

School Factor 3

• Represents student’s range of tolerance for

sensory input within the learning environment

• Composed of Sensitivity and Avoiding items

(low threshold)

• Easily overloaded therefore stimuli need to be

reduced during learning tasks

• Key descriptor “Overstimulated”

School Factor 4

• Level of availability for learning

• Includes Avoiding and Registration patterns

• Student is disengaged so needs ‘just right’

stimulation to increase participation

• Key descriptor “Disengaged”

Auditory Processing HOME FORM

SCHOOL FORM

• All of these items map to school factor 3 – Tolerance of school environment.

• What are some ways we could adapt the environment or the task to support John’s participation? What are some strategies we could teach John?

Visual Processing HOME FORM

SCHOOL FORM

• The first three items map to school factor 1 – Need for external supports

• This is not an issue in the home environment. How might we adapt the visual features of the environment or tasks within the school environment? What strategies could we teach John?

Movement Processing/Body Position Processing

HOME FORM

SCHOOL FORM

Social Emotional and Behavioural Responses HOME FORM

SCHOOL FORM

Let’s consider what input John Seeks HOME FORM

SCHOOL FORM

10/11/2017

3

Additional notes HOME FORM

SCHOOL FORM

Notes from Mum:

“He gets very upset when he is rushed to complete a task. I have learned to allow extra time for the activities that seem to cause him particular stress so that I don’t have to rush

him. He also gets upset when an activity he likes (such as a video game or a tv show) gets interrupted.”

“When he is feeling overwhelmed or stressed, he retreats to either a tent which is set up

in his room or the cubby house outside. He likes to wear tight-fitting clothes and likes to be tucked in tightly when he goes to sleep at night.”

Notes from Teacher:

“John has started implementing the strategy of sitting away from large crowds during activities such as assemblies and recess.”

“I’m not sure what specific strategies he used, but during a recent all-school event he

was much more composed and regulated than usual. That type of event in the past would have caused a melt-down.”

How will we piece this

information together to

guide intervention?

Let’s keep in mind the Person Environment Occupation model • How might this information be used to support

intervention at the person level? • How might this information be used to support

intervention at the environment level? • How might this information be used to support

intervention at the occupation level?

14

Intervention • You work together with John, his parents and teachers to

identify areas where he feels like he would like to increase

his participation and areas where he already feels like he is having success or had success in the past.

• John identified that he feels most calm and in control when he’s in a small space with a book or

music. He also likes walking and watching the world go by

• He identified that he would like to have more success at school. He wants to do well but finds it

hard when it’s noisy or when he feels rushed to complete his work. He also would like to have at

least one good friend.

• You explore appropriate ways to increase the sensory experiences that help regulate John throughout the day

(rocking, walking, smelling, deep pressure, fidgeting). For example consistent jobs he has in the school

environment, exploring using a hokki stool instead of a chair, wearing compression clothes under his school

uniform or giving him appropriate fidget objects that won’t be distracting to classmates.

15

Intervention Continued • You also work with John and his teacher to identify

options to decrease the stimulation that he finds

overwhelming. For example during assemblies, allowing him to sit at the back of the room. During individual work,

allowing him to wear headphones to block out noise. Perhaps finding a “safe space” where he can take a five

minute break to reorganise himself.

• You help John with strategies to organise his visual space

so that he can focus better on the relevant parts. Use highlighting or a cut-out board for worksheets so that he focuses only on one section at a time.

• You also work with John to better recognise situations that are likely to be stressful or overwhelming and teach

coping strategies such as positioning himself differently in the room and breathing/relaxation exercises.

• In terms of friendships, you ask for the teacher’s support

in identifying another child who enjoys video games or who might enjoy similar comic books or music as John to

have a common interest/activity that interaction can focus around to take the pressure of social skills.

Case Study 2 - SPM

Case Study #2 - Sam

• Currently in Primary School • Referred due to challenging behaviours

(aggression, unpredictable changes in behaviour) disrupting his and others’ learning in class.

• School team referred to OT to review sensory processing skills to facilitate participation in the school program and to assist team with exploring whether sensory processing issues are influencing

challenging behaviours at school. • School team reports behaviours as:

• Undressing frequently with regression in toilet skills noted

• Aggressive towards staff & peers – lots of

lashing out • Lots of crying and yelling when asked to

participate in activities • Increased risk-taking behaviours, climbing

on furniture, etc • Enjoys rough play, outdoor activities involving water

and fantasy play

10/11/2017

4

Sensory Hypothesis

Sam is likely to have SI vulnerabilities that are seeking or under-responsive in the area of body awareness .

Sam is likely to have SI vulnerabilities that are over-responsive in the area of touch.

Sensory Processing Measure Results

20

HOME FORM

SCHOOL FORM

SOC VIS HEA TOU BOD BAL PLA TOT

Raw Score 28 11 8 14 12 15 23 65

T-Score 69 41 43 56 52 57 67 51

Typical

(40T-59T) x x x x x x

Some Problems

(60T-69T) x x

Definite

Dysfunction (70T-80T)

SOC VIS HEA TOU BOD BAL PLA TOT

Raw Score 31 8 13 12 16 18 30 71

T-Score 69 48 65 63 67 64 72 64

Typical

(40T-59T) x

Some Problems

(60T-69T) x x x x x x

Definite

Dysfunction (70T-80T)

x

SCHOOL FORM

Social HOME FORM

SCHOOL FORM

Touch HOME FORM

SCHOOL FORM

• Although Sam was classified as having “Some Problems” in the area of Touch on the School Form, do you agree based on the distribution of the teachers’ answers?

• Both items answered as “Frequently” are categorised as “Under-responsive” in terms of SI Vulnerability

Body Awareness/Balance & Motion

HOME FORM

SCHOOL FORM

• 4 of the above items are categorised as “seeking” SI vulnerabilities • Additionally, he had two items in the “hearing” category on the school form

that were “seeking” (frequently makes noises and always yells/screams) • The other 2 (poor coordination from both forms) are categorised as “postural

control”

Planning and Ideas

HOME FORM

SCHOOL FORM

• Across both settings he struggles with both aspects of praxis: motor planning and ideation

10/11/2017

5

A few thoughts…

• The biggest challenges for Sam across both settings are in the areas of Social and Planning & Ideas

• These are both higher order integrative

processes that are influenced by more than just sensory processing (e.g. cognition, environmental factors)

• Going back to some of the original concerns such as:

• Lots of yelling and crying • Climbing furniture • Avoiding activities in class

Could these be due to praxis issues – not knowing what to do or how to do it?

Intervention • When it’s unclear what is causing a behaviour, the first

step to intervention is completing behaviour analysis. We

need to know more about the ABCs. Plenty of worksheets are available online.

• Once you have determined a more rigorous hypothesis about what is causing the behaviour, you can develop an

action plan, but that will depend very much on what you believe the cause of the behaviour is.

26

How do we determine if the

observed behaviours are

due to sensory processing?

• Consider one behaviour at a time. Start with the one that is creating the biggest barrier to participation

• Complete a behaviour analysis worksheet

• Track the behaviour over time to look for trends in

terms of antecedents and consequences. Are there environmental stimuli that seem to be triggers? Is it

during certain activities? Is it when certain expectations are being placed on Sam? Is it always during a certain time of day? Consider the E and O in the PEO model. What is the consequence of the behaviour from Sam’s perspective?

• Consider times when Sam has had success in the

classroom – what factors contributed to his success?

27

A Few Examples

• Removal of clothes

• If this is truly stemming from sensory causes, then we would need to consider the

sensory properties of the clothes (is it only certain clothes that trigger him to do

this?) and the sensory properties of the environment (e.g. temperature). It is

unlikely that this is sensory in nature as he got scores of “never” on items such as

“becomes distressed by the feel of new clothes” and “seeks hot or cold

temperatures by touching windows or other surfaces”

• If it is stemming from a different cause such as seeking attention or avoiding an

activity, then a sensory intervention will not have any impact on the behaviour.

• Aggression towards staff and peers

• Again if this is stemming from sensory causes, we would need to consider the

antecedent (noise, someone brushing up against him, any new smells in the

room, etc). But aggression due to sensory issues normally stems from children

who are over-responsive. Sam, on the other hand tends to be seeking and under-

responsive. He got scores of “never” for items like “is distressed by accidental

touch of peers” and “shows distress at loud sounds”.

• It’s possible that he has such intensity of seeking behaviour that it is seen as

aggressive. In this instance, we would substitute more appropriate means for

meeting Sam’s sensory needs. (e.g. squeeze toys/fidgets, a safe crashing space,

giving him “jobs” that will give him lots of proprioceptive input).

Thanks for your attention!

Any questions?

29

amy.schulenburg@pearson.com

0407 259 317