Canadian Journal of Occupational Therapy 2014, Vol. 81(1) 29-38 DOI: 10.1177/0008417413520440

Article

Optimizing participation of children with autism spectrum disorder experiencing sensory challenges: A clinical reasoning framework

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Optimiser la participation des enfants atteints d’un trouble du spectre autistique ayant des troubles sensoriels : Un cadre pour le raisonnement clinique

Jill K. Ashburner, Sylvia A. Rodger, Jenny M. Ziviani, and Elizabeth A. Hinder Key words: Asperger syndrome; Autistic disorder; Client-centred enablement; Clinical reasoning; Sensation. Mots cle´s : habilitation centre´e sur le client; raisonnement clinique; sensation; syndrome d’Asperger; trouble autistique.

Abstract Background. Remedial sensory interventions currently lack supportive evidence and can be challenging to implement for families and clinicians. It may be timely to shift the focus to optimizing participation of children with autism spectrum disorders (ASD) through accommodation and self-regulation of their sensory differences. Purpose. A framework to guide practitioners in selecting strategies is proposed based on clinical reasoning considerations, including (a) research evidence, (b) client- and family-centredness, (c) practice contexts, (d) occupation-centredness, and (e) risks. Key issues. Informationsharing with families and coaching constitute the basis for intervention. Specific strategies are identified where sensory aversions or seeking behaviours, challenges with modulation of arousal, or sensory-related behaviours interfere with participation. Selfregulatory strategies are advocated. The application of universal design principles to shared environments is also recommended. Implications. The implications of this framework for future research, education, and practice are discussed. The clinical utility of the framework now needs to be tested. Abre´ge´ Description. Il y a actuellement peu de donne´es probantes sur les interventions sensorielles the´rapeutiques et ces interventions peuvent eˆtre difficiles a` mettre en œuvre pour les familles et les cliniciens. Il peut eˆtre judicieux de mettre l’accent sur l’optimisation de la participation des enfants atteints de troubles du spectre de l’autisme (TSA), en proposant des ame´nagements, de meˆme que des strate´gies d’autore´gulation de leurs diffe´rences sensorielles. But. Un cadre visant a` aider les praticiens a` choisir des strate´gies est propose´; ce cadre est base´ sur les diffe´rents aspects du raisonnement clinique, soit (a) les donne´es probantes; (b) l’intervention centre´e sur le client et la famille; (c) les contextes de la pratique; (d) l’intervention centre´e sur l’occupation; et (e) les risques. Mots cle´s. Le partage d’information avec les familles et l’encadrement forment la base de l’intervention. Les strate´gies spe´cifiques mises en relief e´taient les comportements d’aversions sensorielles ou de recherche sensorielle, les difficulte´s lie´es a` la modulation de l’e´tat d’e´veil ou les comportements difficiles lie´s a` des troubles sensoriels qui interfe´rent avec la participation. Les strate´gies d’autore´gulation sont pre´conise´es. L’application des principes de la conception universelle dans les environnements partage´s est e´galement recommande´e. Conse´quences. Les conse´quences de ce cadre pour la recherche, la formation et la pratique dans l’avenir sont discute´es. L’utilite´ clinique du cadre doit maintenant eˆtre teste´e.

Funding: No funding was received in support of this work. Corresponding author: Jill Ashburner, Autism Queensland, P.O. Box 354, Sunnybank, Queensland, 4109, Australia. Telephone: 617-3273-0075. E-mail: [email protected].

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iagnostic criteria for autism spectrum disorders (ASD) have consistently included social and communication impairments, restricted interests, and repetitive behaviours. The revised diagnostic criteria proposed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) also now include ‘‘hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment’’ (American Psychiatric Association, 2013, p. 50), in recognition of atypical sensory responses found within this population (Ben-Sasson et al., 2008). Accumulating evidence suggests that these unusual sensory responses can impact the capacity of children with ASD to participate in many daily life activities. For example, sensory sensitivities are reported to contribute to parent–child struggles over teeth cleaning, haircuts, and nail trimming (Dickie, Baranek, Schultz, Watson, & McComish, 2009); picky eating habits (Nadon, Feldman, Dunn, & Gisel, 2011); and reduced capacity to regulate behaviour in overstimulating environments (O’Donnell, Deitz, Kartin, Nalty, & Dawson, 2012). Because the sensory responses of children with ASD are seen to impact behaviour and occupational performance, they are routinely considered by occupational therapists.

Sensory Processing: Current Concepts and Therapeutic Approaches Although the impact of sensory responses on participation is widely recognized, disparities exist in the way that atypical sensory processing is described. Miller, Anzalone, Lane, Cermak, and Osten (2007) use the term sensory processing disorder to describe sensory processing issues that adversely impact daily routines or roles. In contrast, Dunn (2001) prefers the term differences to disorders, as she perceives ways of processing sensory information to be relatively stable lifelong traits, which are neither inherently good nor bad: ‘‘Sensory processing patterns are reflections of who we are. These are not a pathology that needs fixing’’ (Dunn, 2001, p. 617). Given that the core business of occupational therapy is to enhance occupational participation, there is no necessity to intervene on the basis of sensory differences alone. Intervention may, however, be required where challenges to participation related to sensory differences arise. Sensory challenges can emerge when there is a mismatch between the way the person processes sensory input and environmental demands. Occupational therapists have been criticized for their use of some sensory processing interventions because they lack empirical support. In 2012, the American Academy of Pediatrics published a policy statement recommending that paediatricians communicate with parents about the limited evidence to support sensory-based therapies. Recent reviews have reported a lack of evidence to support Ayres Sensory Integration Therapy (SIT; Ayres, 1972; National Autism Center, 2009), sound therapies (Sinha, Silove, Hayen, & Williams, 2011), and the Wilbarger protocol (Weeks, Boshoff, & Stewart, Canadian Journal of Occupational Therapy

2012; Wilbarger & Wilbarger, 1991). Interventions that have attracted most criticism have usually been remedial in nature. In this paper, the term remedial is applied to interventions with the stated aim of improving function by remediating the child’s underlying capacity to process and integrate sensory information (Schaaf & Miller, 2005; Sinha et al., 2011). For example, proponents of Ayres SIT (Ayres, 1972) advocate the use of sensory-motor activities on the premise that they are powerful mediators of neural plasticity, capable of shaping brain development (Schaff & Miller, 2005). Not all occupational therapists, however, favour the use of remedial interventions that aim to change the way that the nervous system processes sensory input. Many prefer to focus on optimizing the participation of children with ASD by accommodating and supporting selfregulation of the child’s sensory differences.

Clinical Reasoning Considerations Evidence-based practice has been defined as the use of clinical reasoning to integrate information from four sources: research evidence, client’s values and circumstances, practice context, and clinical expertise (Hoffman, Bennett & Del Mar, 2013). In this paper, strategies used to optimize participation of children with ASD experiencing sensory challenges will be examined in relation to the first three information sources: (a) research evidence, (b) client- and family-centredness, and (c) practice contexts. Some funding agencies are now scrutinizing the research evidence underpinning interventions for children with ASD, including sensory interventions, because they are concerned about the need to protect the public and prevent inappropriate expenditure of taxpayer money (Prior, Roberts, Rodger, Williams, & Sutherland, 2011). Financial investment by clients in services, which may not be effective, also raises ethical concerns. If, after having exhausted alternatives, a therapist reasons that an approach with limited evidence is worth trying, he or she has an ethical and legal responsibility to inform families of the current status of evidence and to methodically evaluate outcomes (American Academy of Pediatrics, 2012). In addition to reviewing research evidence, clinicians need to be mindful of issues of significance to the client and family, including ensuring that goals are meaningful and important and that interventions are acceptable (Foster & Mash, 1999). Issues of acceptability may include the compatibility of the intervention with the family’s routines and settings and costs in terms of money, time, and lost opportunities. Remedial sensory processing interventions are often expensive, time-intensive, and difficult to integrate into family routines. For example, Clark (2012) maintains that Ayres SIT (Ayres, 1972) should ideally entail at least 6 months of intervention and is therefore costly to families in terms of time. Where this service is not publicly funded, the financial cost may burden families of children with ASD, who on average have been found to earn 28% less than other families, largely because of the need to reduce paid employment to care for their children (Cidav, Marcus, & Mandell, 2012). Parents have also expressed concern about the 2-hourly implementation of the

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Wilbarger protocol: ‘‘Try to do it . . . four or five times a day. No way! It’s just not happening’’ (Segal & Beyer, 2006, p. 505). Some reported implementing this program only twice daily, thereby compromising the fidelity of implementation. The potential stigma of interventions also bothers some children and families, for example, ‘‘brushing seemed stigmatizing to perform at school’’ (Segal & Beyer, 2006, p. 508). In relation to contemporary practice contexts, services are increasingly delivered in the child’s natural environments, such as home or school, so that issues relevant to the child’s regular routines and settings can be targeted and skills can be generalized. The focus is often on consultation with parents and/or teachers, rather than direct intervention with the child (Ashburner, Rodger, Ziviani, & Jones, 2013). Parent coaching is an example of a contemporary approach that promotes the generation of parent-directed goals and solutions, builds on parents’ capacity to identify and implement interventions, and typically occurs in contextually relevant settings, such as the family home (Graham, Rodger, & Ziviani, 2010). Some remedial sensory interventions are incompatible with contemporary practice contexts. For instance, Ayres SIT requires access to clinicbased settings with purpose-built equipment. Because the fiscal constraints of services often impede the capacity of therapists to deliver highly intensive remedial interventions, therapists often sacrifice the fidelity of implementation to fit with the limited time and resources available. Ashburner et al. (2013) found that 47% of therapists who use Ayres SIT and 32% of those who use the Wilbarger protocol in their work with children with ASD modify or use only selected elements of these interventions. An additional clinical reasoning consideration is the recognition that conditions on the autism spectrum are complex, encompassing cognitive, language, social, and emotional issues. Sensory processing is only one piece of this intricate puzzle. Consequently, it is important to view these children holistically and avoid overattributing their daily life challenges to sensory issues. Challenging behaviours may also be driven by anxiety, attention-seeking, task avoidance, or the acquisition of desired objects (Joosten, Bundy, & Einfield, 2009). Although sensory elements may be embedded within a task, a complex interplay of factors impacts the child’s behaviour. For example, fear of haircuts may be influenced not only by tactile sensitivity to the feel of hair clippers but also by a fear of being cut and apprehension about the need to interact with an unknown hairdresser. As multiple factors can impact participation, it is important to take a holistic, occupation-centred perspective that considers multiple hypotheses and strategies, rather than viewing behaviour exclusively through a sensory lens. The potential risk of interventions to address sensory challenges may also need to be considered. For example, strict safety protocols were developed following the death of a child attributed to inappropriate application of a weighted blanket (Autism Society of Canada, 2008).

Aim The aim of this article is to propose a clinical reasoning framework to guide clinicians in the selection of strategies to

optimize participation of children with ASD experiencing sensory challenges (see Figure 1). Because traditional remedial approaches can present challenges in terms of evidence, child and family factors, and contemporary practice contexts, the focus is on approaches that aim to accommodate sensory differences and support self-regulation. The literature underpinning the strategies within the framework is reviewed in terms of (a) research evidence; (b) client- and family-centredness, including financial and time costs, stigma, meaningfulness of goals, and acceptability of the intervention; (c) contemporary practice contexts; (d) occupation-centredness; and (e) potential risks.

Development of a Clinical Reasoning Framework: Strategies to Optimize Participation of Children With ASD Experiencing Sensory Challenges The framework depicted in Figure 1 was developed on the basis of an extensive literature review, the authors’ clinical experience, and contemporary family-centred and occupationcentred principles. With these principles in mind, the logical starting point when supporting individual children is to use mutual information-sharing and coaching to enable families (or others, such as teachers) to develop their own strategies to support their child’s participation (see Figure 1A). The specific strategy selected depends on the nature of the identified problem. In the case of sensory seeking or aversions that interfere with participation, adaptive strategies may be used (e.g., earmuffs to screen out excessive noise; see Figure 1B). If issues with the modulation of arousal are interfering with a child’s capacity to attend or learn, calming or alerting sensory input may be embedded within his or her routines (e.g., a movement break to settle a hyperaroused child; see Figure 1C). Where challenging behaviours related to sensory processing are particularly maladaptive or potentially harmful (e.g., pica), behavioural strategies may be helpful (see Figure 1D). Given that the sensory issues of people with ASD usually persist into adulthood (Crane, Goddard, & Pring, 2009), self-regulatory strategies should always be considered where the child has the capacity to reflect on his or her responses. Self-regulation can be used to manage all three categories of sensory processing issues (see Figure 1E). The framework also draws upon the principles of universal design (Center for Applied Special Technology [CAST], 2012), which promotes the design of environments to be as usable by as many people as possible. These principles can be applied to shared environments, such as classrooms and child care centres, with the aim of ensuring that their sensory properties are tolerable and accommodating for most children (see Figure 1F).

Methodology The literature underpinning each strategy category in the clinical reasoning framework was reviewed through examination of the studies and is summarized in Supplementary Table 1 (available online at http://cjo.sagepub.com/supplemental). The

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SUPPORTS TO OPTIMIZE PARTICIPATION OF CHILDREN WITH ASD EXPERIENCING SENSORY CHALLENGES

SUPPORTS FOR INDIVIDUAL CHILDREN

These approaches may be used simultaneously.

Where specific sensory aversions or seeking behaviours interfere with parcipaon:

Where challenges with modulaon of arousal impact on engagement & learning:

Where challenging behaviours related to sensory processing persist:

A Use mutual-informaon sharing and coaching to support families to develop soluonsa

B

C

Adapt tasks or environment to enable parcipaona

Embed sensory input within daily rounes to modulate arousala

D Use behavioural strategies for challenging behaviours related to sensory processinga

SUPPORTS FOR MULTIPLE CHILDREN IN SHARED ENVIRONMENTS

Where sensory properes of shared environments (e.g., classrooms or childcare centres) are challenging for most children:

F Use universal design principles to opmize sensory properes of shared environmentsa

If child is able to reflect on his/her responses:

E Support child to develop own self-regulaon strategiesa

Figure 1. Clinical reasoning framework: Optimizing participation of children with autism spectrum disorder experiencing sensory challenges. a Further research is required to substantiate the effectiveness of these intervention strategies.

categorized strategies included in the review are highlighted in black and labeled A to F in Figure 1. Studies involving participants with ASD reported in peer-reviewed journals written in English published from 1990 to May 2013 were sourced through searches of three electronic databases—CINAHL, PsycINFO, and Web of Knowledge—using the search terms sensory, autism, and intervention. As the framework does not include remedial strategies, studies pertaining to strategies such Canadian Journal of Occupational Therapy

as Ayres SIT (Ayres, 1972) and the Wilbarger protocol (Wilbarger & Wilbarger, 1991) were excluded. Reference lists from sourced articles were also searched. One hundred and fifty-eight articles were found using this strategy. Because the Oxford Centre for Evidence-Based Medicine (OCEBM Levels of Evidence Working Group, 2013) recommends the use of systematic reviews in preference to individual studies where available, the authors did not review individual studies included in

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systematic reviews separately. Four systematic reviews and 24 individual studies, published subsequent to the systematic reviews, that relate to the strategies in the framework were identified and included in the Supplementary Table 1. The Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (OCEBM Levels of Evidence Working Group, 2013) was used to assign a level of evidence to each study (see the bottom of Supplementary Table 1 for details). The evidence and limitations of the studies were appraised by the first author and then reappraised independently by a research assistant with a doctoral qualification. Any discrepancies were discussed and resolved through consensus. The evidence to support each category of strategy and positive and negative issues in relation to client- and family-centredness, occupation-centredness, practice contexts, and risk are summarized in Supplementary Table 1 and discussed below. In most cases, evidence was found to be limited with further research required.

The Framework Use mutual information-sharing and coaching. Empowering families and others (e.g., teachers) who support children with ASD to generate their own strategies is likely to produce workable solutions that are compatible with their routines and more able to be generalized to other situations. Dunn (2001) highlighted the essential gift of occupational therapists as being ‘‘our sensory processing knowledge’’ (p. 617), enabling families to better understand their children. The only study identified in this category was by Dunn, Cox, Foster, Mische-Lawson, and Tanquary (2012). Parents were guided using coaching principles to select strategies that considered the child’s activity settings, daily routines, and sensory processing patterns to achieve parent-selected goals (e.g., managing trips to the supermarket). Multiple factors, including but not restricted to sensory processing issues, were considered in achieving these goals. Significant positive outcomes included achievement of parent-identified goals, improved parental feelings of competency, and reduced parental stress. The costs were moderately high (10 one-hour sessions), but the intervention had many positive attributes, including ecological relevance and family- and occupation-centredness. Adapt tasks or environments to enable participation. A raft of innovative adaptive strategies to circumvent issues with specific sensory aversions or seeking behaviours that interfere with participation have been developed by occupational therapists (Anderson, 1998; e.g., the use of study carrels to reduce visual distractions, chewable pencil toppers as a socially acceptable alternative to chewing shirts). The effectiveness of these strategies has, however, rarely been tested empirically. The only two studies identified in this area addressed auditory processing challenges of students with ASD in the classroom (see Supplementary Table 1 online). This issue appears to be problematic for students with ASD, as they frequently report being distressed by classroom noise (Saggers, Hwang, &

Mercer, 2011) and may have auditory filtering difficulties that have been associated with academic performance difficulties (Ashburner, Ziviani, & Rodger, 2008). Alcantara, Weisblatt, Moore, and Bolton (2004) found people with ASD to have difficulty processing speech against background noise. Rowe, Candler, and Neville (2011) found noise-reduction headphones to be effective in enhancing attention to task during independent classroom work of a boy with autism. However, this study was limited to one case, and interrater reliability of classroom observation was not established. In a study involving seven students with ASD, Schafer et al. (2013) evaluated the classroom use of personalized FM systems, which aim to improve the perception of the teacher’s instructions in noisy classrooms. When using FM systems, the speech-innoise perception of the children with ASD improved to the level of the typically developing controls, and their on-task and listening behaviours significantly improved. The use of headphones and FM systems, therefore, warrants further investigation. Both are readily used in classroom settings. Noisereduction headphones are inexpensive, but the initial purchase cost of FM systems is relatively high. Some students may find these appliances stigmatizing, unless they are also used by their classmates. Embed sensory input within daily routines to modulate arousal. The regulation of arousal and emotion has been identified as a key challenge for children with ASD, as they are often in an under- or overaroused state, or they fluctuate between these two extremes (Prizant, Wetherby, Ribin, & Laurent, 2003). A child in an underaroused state is likely to be passive, inattentive, and underresponsive to sensory input. Dampening environmental sensory input can reduce arousal (e.g., a quiet room, comfortable bed, and low light are conducive to sleep). A child in an overaroused state is likely to be distractible, hyperactive and impulsive, and overly responsive to sensory input. Intense sensory input, such as loud noise, bright lights, and movement, can induce an overaroused state. Midrange arousal, attention, and affect are considered optimal for engagement and learning. Occupational therapists commonly advocate embedding sensory input within daily routines to optimize the child’s level of arousal. The rationale is that some forms of sensory input can have either a transient calming or an alerting effect. The desired outcomes therefore include (a) increases in behaviours indicative of optimal arousal, such as in-seat and on-task behaviour and academic engagement, and (b) reductions in behaviours indicative of over- or underarousal, such as inattention, off-task behaviour, aggression, and stereotypy. Stereotyped behaviours are thought to serve a homeostatic function, as they are used to cope with under- and overstimulation (Gal, Dyck, & Passmore, 2002). As movement breaks, dynamic seating options, vestibular input, and weighted vests are often used with the aim of modulating arousal. Research on these approaches is reviewed below. Exercise/movement breaks embedded to modulate arousal. Movement breaks are commonly used to keep school students alert and focused. Systematic reviews by Petrus et al. (2008)

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and Lang et al. (2010) found physical exercise to be effective in (a) reducing self-stimulatory behaviours, aggression, and offtask behaviour and (b) improving on-task behaviour and engagement in academic tasks in children with ASD. Oriel, George, Peckus, and Semon (2011) and Nicholson, Kelhe, Bray, and Van Heest (2011) also found evidence of positive effects on academic engagement. A systematic review by Kasner, Reid, and McDonald (2012) found positive effects on stereotypical behaviours but deemed the results inconclusive due to methodological limitations in the studies reviewed. Lang et al. concluded that vigorous exercise, such as jogging, was more effective than less strenuous exercise, such as walking. Occupational therapists frequently recommend resisted movement or ‘‘heavy work’’ activities for children with ASD (Anderson, 1998), but the effectiveness of this type of exercise has not been compared to other forms of exercise. Lang et al. found that the effects of physical exercise were temporary, lasting 40 to 90 min. This finding suggests that movement breaks need to be embedded at regular intervals within the child’s day. Despite some methodological limitations, the emerging evidence appears promising overall. Movement breaks are low in cost and easily implemented. As whole groups of children can be involved, movement can be employed in an inclusive, nonstigmatizing way. The health benefits of physical exercise are likely to outweigh the risk of injury. Use of dynamic seating to modulate arousal. Dynamic seating options, such as ball chairs and inflatable cushions, are designed to enable children to move while seated without disturbing others. They are relatively low in cost and readily implemented within inclusive settings. However, three small studies involving children with ASD have reported mixed effects on task engagement and in-seat behaviour. Of the studies involving therapy balls, Schilling and Schwartz (2004) reported positive outcomes, while Bagatell, Miriglini, Patterson, Reyes, and Test (2010) reported a negative impact on two children with poor postural stability, a positive impact on one movement-seeking child, and no impact on three others. Umeda and Deitz (2011) found inflatable cushions to have no effect on in-seat or on-task behavior. They attributed this finding to inflatable cushions being less posturally demanding and allowing less movement than therapy balls. The mixed findings of Bagatell et al. suggest, however, that therapy balls may be effective for a few, but certainly not all, children with ASD and may be contraindicated for children with postural instability. Consequently, if dynamic seating is recommended for individual children, its effectiveness needs to be systematically evaluated. Children who are sensitive about appearing different may be concerned about the stigma of using alternative seating. Risks of fatigue and musculoskeletal contraindications also need to be considered. Vestibular input embedded to modulate arousal. Slow, rhythmical linear movement is thought to have a calming/organizing effect, while movement with rapid changes in speed and direction is thought to have an alerting effect (Anderson, 1998). Van Rie and Heflin (2009) found that slow linear movement on a swing increased correct responses to instruction in an active Canadian Journal of Occupational Therapy

and distractible child, while fast bouncing on a therapy ball was effective for a hypoactive, lethargic child. Negative or inconclusive results were found for two other children with ASD. If this form of intervention is recommended for individual children, systematic evaluation is required. While vestibular input is low in cost and readily implemented in specialized settings, it may be stigmatizing and challenging to implement in inclusive settings. Use of weighted vests to modulate arousal. Weighted vests are intended to provide deep pressure, which is believed to have a calming/organizing effect (Stephenson & Carter, 2009). A systematic review by Stephenson and Carter (2009) did not support the effectiveness of weighted vests for children with ASD. Six small studies published subsequent to Stephenson and Carter’s review reported no impact on engagement, selfstimulatory, self-injurious, or problem behaviours (see Cox, Gast, Luscre, & Ayres, 2009; Davis et al., 2013; Hodgetts, Magill-Evans, & Misiaszek, 2011a; Leew, Stein, & Gibbard, 2010; Reichow, Barton, Sewell, Good, & Woolery, 2010; Quigley, Peterson, Frieder, & Peterson, 2011). Hodgetts, Magill-Evans, and Misiaszek (2011b) found weighted vest use to be associated with a small decrease in off-task behaviour in 3 of 10 participants with autism, but the effect was minimal compared to other factors. No significant differences in outcome were found when different weights were used (5% as compared to 10% of body weight; Hodgetts et al., 2011a; Quigley et al., 2011). The use of weighted vests may be an attractive option for clinicians, as time requirements and costs are relatively low. However, there is currently limited evidence to support their use. The social acceptability of weighted vests and the risk of biomechanical stress may also be contraindications. A number of other interventions to modulate arousal are often recommended for children with ASD but as yet have not been empirically tested. They include weighted blankets (principally to overcome sleeping difficulties), pressure vests, oral-motor strategies, and fidget toys. In summary, the use of movement breaks or physical exercise is the most promising of the strategies reviewed. Use behavioural strategies for challenging behaviours related to sensory processing. For some children, a negative sensory experience associated with particular objects or activities can develop into an irrational fear. Prizant (2012) highlighted the potent influence of emotional memories on the behaviours of children with ASD and suggested that their ASD-specific memory style may heighten their tendency to associate past events with particular emotions. For example, an aversive sensory experience, such as the sound of a vacuum cleaner, may develop into a phobia about vacuum cleaners. Similarly, an enjoyable sensory experience, such as watching a crystal reflecting light, can develop into an ongoing obsession with sparkling objects. ‘‘Abnormal, idiosyncratic negative responses to specific sensory stimuli’’ and ‘‘unusual sensory interests’’ are items on the gold-standard diagnostic tool, the Autism Diagnostic Interview–Revised (Rutter, Le Couteur, & Lord, 2003, pp. 26–27), because they were found

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to be strong predictors of autism. The possible impact of emotional memories must therefore be considered when addressing phobias or obsessions about an object or activity with a sensory component. Behavioural interventions have been successfully used to address phobic responses to objects or activities with a sensory component. Typically, these interventions involve (a) graduated exposure, (b) modeling, and (c) reinforcement strategies. Graduated exposure involves gradually exposing the child to steps along a hierarchy of anxiety-provoking stimuli from least to most anxiety provoking. Modeling involves the therapist demonstrating a nonfearful response to the anxiety-provoking stimulus. Reinforcement involves providing a reward contingent on approach of the anxiety-provoking stimulus. Three studies examined the effectiveness of these techniques to help individuals with ASD to tolerate (a) the tactile sensation of applying skin care products (Ellis, Ala’i-Rosales, Glenn, Rosales-Ruiz, & Greenspoon, 2006), (b) the sound of a telephone ringing (McCord, Iwata, Galensky, Ellingson, & Thomson, 2001), and (c) household appliance and toy noises (Koegel, Openden, & Koegel, 2004). All participants in these studies were able to tolerate these sensations by the end of the studies and at follow-up. Behavioural interventions may also be used to manage persistent sensory-seeking behaviours that are potentially harmful, such as pica. A systematic review of 34 studies by Hagopian, Rooker, and Rolider (2011) reported that 25 studies demonstrated more than 80% efficacy, with 21 of these studies demonstrating more than 90% efficacy in reducing pica. The most effective studies used reinforcement strategies (e.g., reinforcing eating foods and/or discarding of potential pica materials) and response reduction strategies (e.g., providing alternative sources of stimulation). Although these approaches are likely to be timeconsuming, emerging evidence is promising. The benefits may, therefore, outweigh the risks of potentially harmful/or stigmatizing behaviours (e.g., avoiding the use of sunscreen or pica) or behaviours that interfere with daily-life participation (e.g., phobic responses to the sound of toilets flushing), where these are problematic for families. These interventions usually incorporate generalization to ecologically relevant settings. Support children to develop their own self-regulatory strategies. Self-regulatory behaviours can be used to address a range of sensory challenges. For example, Sensory Stories1 (Marr, Mika, Miralgia, Roerig, & Sinnott, 2007) can remind children to use adaptive strategies, for example, ‘‘I can put on my special headphones so that noises don’t bother me.’’ Although the Alert Program1 (Williams & Shellenberger, 1996) has not been evaluated with children with ASD, it is often used to teach them sensory strategies to alter their arousal level to meet situational demands. Self-talk may also be used to reduce fearful responses to innocuous stimuli (e.g., ‘‘That’s the sound of a toilet flushing—it can’t hurt me’’). Both Marr et al. (2007), who investigated the efficacy of Sensory Stories, and Thompson and Johnston (2013), who investigated the efficacy of individualized Social Stories™

(Gray, 2004), reported an increased frequency of desired behaviours in children with ASD. However, in both cases, it is possible that results were due to improved understanding of behavioural expectations rather than the sensory strategies the children were taught. These interventions can be used in classroom settings but may be moderately intensive. Use universal design principles to optimize sensory properties of shared environments. It is not uncommon for shared environments, such as child care centres and classrooms, to have sensory properties that are fundamentally challenging for many children. Interactive learning, group discussion, and group seating arrangements have impacted the sensory properties of modern classrooms. Although these changes have many benefits, numerous studies have found mainstream classrooms to have unacceptably high levels of background noise, often exceeding the volume of the teacher’s voice (Nelson & Soli, 2000). As the auditory figure-ground skills (the capacity to attend to one sound against a background of sounds) of typically developing children do not mature until around age 13, high classroom noise levels are thought to impact the attention and learning of many students (Nelson & Soli, 2000). Classroom noise is likely to be especially problematic for children with ASD, given their speech-in-noise perception difficulties (Alcantara et al., 2004). Modern classrooms are often visually cluttered by numerous projects and artworks. Students are also frequently exposed to unexpected tactile input as a consequence of crowded and loosely defined seating arrangements. ‘‘Universal design’’ is a philosophy that promotes the design of environments to be as usable by as many people as possible (CAST, 2012). Dunn (2009) advocated the application of universal design principles to the sensory properties of environments. This area has received limited research to date. Although they have methodological limitations, two small studies suggest that this approach should be further explored. Mostafa (2008) found that the attention span of children with ASD improved, and their response time and self-stimulatory behaviour decreased, when they were located in a room with (a) improved acoustics and (b) improved spatial sequencing (e.g., workstations to reduce visual distractions). Kinnealey et al. (2012) found that the attention to task of students with ASD improved following installation of sound-absorbing walls and when fluorescent lighting was replaced with halogen lighting. A focus solely on individualized strategies may not be a productive use of the therapist’s time if the sensory environment is inherently challenging for many students, including those without sensory differences. For example, if the classroom is so excessively noisy, crowded, and visually cluttered that the majority of students are distracted and hyperaroused, seating the student with ASD on an inflatable cushion is unlikely to make a significant difference. The use of universal design strategies in conjunction with individualized strategies is therefore recommended. Most children are likely to benefit from adaptations that (a) reduce extraneous stimuli, such as background noise or visual

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clutter; (b) increase the salience of task-relevant input (e.g., presenting information in a clear visual format); and (c) ensure their movement needs are met. Nevertheless, therapists are often reluctant to recommend environmental adaptations because some of them can be costly (e.g., the use of sound-absorbing walls). Other modifications, however, may be relatively inexpensive (e.g., reduced visual clutter and sound-absorbing, soft furnishings). Therefore, it may be worthwhile for occupational therapists to invest time in spreading the word about the need to improve the sensory properties of shared environments (e.g., at school staff meetings). A mutual information-sharing and problem-solving approach that respects the rights of staff to control their work environments and incorporates their preferences is more likely to achieve feasible solutions. Because universal design principles may potentially help many students, the benefit-to-cost ratio is likely to be positive. It is nonstigmatizing because it is a whole-class intervention.

Conclusion In summary, the proposed clinical reasoning framework recommends starting with an information-sharing and coaching approach that enables families to develop their own solutions. Strategies may be used to support children with sensory aversions or seeking behaviours, challenges with modulation of arousal, or sensory-related challenging behaviours. Selfregulatory strategies are advocated for children capable of self-reflection. The application of universal design principles to the sensory properties of environments is also recommended because the sensory properties of shared environments are often inherently challenging for many children. This framework has important implications for the way that occupational therapists address participation challenges associated with sensory differences. Remedial interventions continue to lack empirical support and are often expensive, time-intensive, difficult to integrate into family routines, and incompatible with contemporary practice contexts. Current professional development programs and practices often focus on narrow remedial interventions. It may be timely to redirect the focus of future research, education, and practice to occupation-centred, child- and family-centred approaches that optimize participation by accommodating sensory differences and supporting self-regulation. The review of literature underpinning this framework has highlighted many gaps in the evidence base underpinning these approaches and therefore provides a platform for directing future research. Further research is also required to evaluate the clinical utility of this framework in a variety of practice contexts.

Supplemental Material The online supplementary table is available at http://cjo.sagepub.com/supplemental. Canadian Journal of Occupational Therapy

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Author Biographies Jill K. Ashburner, PhD, BOccThy, is Manager, Research and Development, Autism Queensland, P.O. Box 354, Sunnybank, QLD 4109, and Adjunct Lecturer at the School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072 Australia. Sylvia A. Rodger, PhD, MEdSt, BOccThy, is Professor, Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072, Australia. Jenny M. Ziviani, PhD, MEd, BAppSc(OT), BA, is Professor, Children’s Allied Health Research, Queensland Health, and Conjoint Professor, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072, Australia. Elizabeth A. Hinder, BOccThy(Hons), is Senior Advisor– Occupational Therapy, Department of Education, Training and Employment, Darling Downs–South West Queensland Regional Office, Toowoomba, QLD 4350, Australia.

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