Assessment for Effective Intervention

http://aei.sagepub.com/ Sensory Assessment for Children and Youth with Autism Spectrum Disorders
Louann Rinner Assessment for Effective Intervention 2002 27: 37 DOI: 10.1177/073724770202700106 The online version of this article can be found at: http://aei.sagepub.com/content/27/1-2/37

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Sensory Assessment for Children and Youth Spectrum Disorders

Louann Rinner University of Kansas Medical Center

with Autism

generally accepted that children with autism spectrum disorders (ASD) face varying levels of challenges processing sensory information (Ayres, 1979; Baranek & Berkson, 1994). The literature reports that persons with autism process sensory experiences differently than persons without autism (Dunn, Myles, & Orr, in press; Grandin, 1995; Short, 2001; Stehli, 1991; Williams, 1994). The purpose of this article is to present considerations for assessing sensory issues in individuals with ASD as a means of gathering information useful to families and professionals in understanding children and designing intervention

It is

strategies that support success

across

environments.

Comprehensive understanding of the complex and often-confounding behaviors exhibited by children and youth with autism spectrum disorders (ASD) requires that professionals look beyond diagnostic criteria to examine the underlying foundation and reasons for what we see. It is generally accepted
that children with ASD face varying levels of challenges processing sensory information (Ayres, 1979; Baranek & Berkson, 1994). While sensory disorders are not part of the diagnostic criteria, clinical features frequently associated with autism as defined by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSMIV-TR, 2000) address a range of behavioral symptoms including &dquo;odd responses to sensory stimuli&dquo; (p. 72). Further, the literature supports that persons with autism process sensory experiences differently than persons without

range of observed hypo- and hypersensitivities to sensory input. Contemporary first-hand

of individuals with Asperger Syndrome and their family members report

accounts

sensory abnormalities that interfere with their ability to interact with the environment

(Shore, 2001; Willey 1999). Finally, preliminary research, while limited, indicates that children and youth with Asperger Syndrome
have distinct difficulties with sensory processing (Dunn et al., in press) and may appear similar to cognitively challenged children with autism (Rinner, 2000). Using a sensory processing frame of reference yields meaningful information that may contribute to understanding everyday behavioral manifestations often viewed in isolation from precipitating events. Further, regarding the characteristics and impairments thought to be essential to the diagnosis of ASD from a
may

sensory

processing perspective expands possi-

(Anzalone & Williamson, 2000; Grandin, 1995; Stehli, 1991; Williams, 1994). Clinical and associated features of Asperger Syndrome, also within the category of pervasive developmental disorders, do not
autism

currently

include direct reference

even

to

sensory

processing problems

though

Hans
a

bilities for meaningful intervention. The purpose of this article is to present considerations for assessing of sensory issues in individuals with ASD as a means of gathering information useful to families and professionals in understanding children and designing intervention strategies that support
success.

Aspergers (1944) original

work describes

37
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38

The Sensory Systems and Sensory Processing Examination and debate continue as professionals strive to reach consensus about the terminology used to describe sensory processing as a construct arising from sensory integration and neurodevelopment theories

we

(Ayres, 1968/1974a, 1968/1974b; Cook, 1990).

Lack of response or overreaction to sensory may reflect how a child &dquo;registers&dquo; or &dquo;notices&dquo; information from the environment. Parents of children with ASD frequently report that their children do not seem to notice noises or fail to respond when persons call their name yet cover their ears at other sounds, leading them to suspect some sort of hearing difficulty. To rule out a co-occurring hearing loss the American Academy of Pediatrics recommends formal audiologic evaluation for children birth through 36 months of age with developmental delays, especially those who represent with delays in language and social development (Filipek,

learn

input

(Miller

&

Lane, 2000). Ayres (1979),

an

occupational therapist, defined sensory integration as &dquo;the organization of sensation for use&dquo; (p. 5). The individual sensory systems
(tactile, vestibular, proprioceptive, auditory, visual, gustatory, olfactory) have receptors, or specialized cells, throughout the body that provide the starting points for delivering messages to the central nervous system (see Table 1). The typically developing central nervous system regards the input with ongoing, dynamic interplay and comparison, or processing, of information from all sensory systems at a cellular level. The integration process results in observable responses and behavioral manifestations to given situations and reflects multiple contributing factors from the external and internal environments. For example, while watching television a child hears his mother tell him to put on his coat in preparation for a shopping trip. Following registration of this auditory information, the child visually scans the room looking for the red coat, ultimately located in the comer of the room under his backpack. Not wanting to visually disengage from the television program, he walks sideways until his foot bumps the backpack on the floor. Bending his knee with this left arm and hand outstretched, he differentiates the feel of his nylon coat from the canvas backpack. He flips the coat over his head and shoulders and &dquo;feels&dquo; for the sleeve openings, adjusting the angles of his shoulder, elbow, and wrist joints accordingly. Sliding each hand down to the ends of the separating zipper, he then shifts his visual attention to his fingers to complete the task. The resulting perception of self and the surrounding world influences subsequent interactions with people and objects in the environment, providing the foundation for how

Accardo, Ashwal, Baranek, Cook, Dawson, et al., 2000).

Making sense of continually changing sensory information in terms of intensity, frequency, duration, complexity and novelty

requires modulation. That is, the central

vous

ner-

inhibit some disregard system sensory messages while regarding other messages with increased attention. When modulation is effective, our reaction or response matches the demand. Ineffective modulation of sensory information, however, may result in behaviors like rocking, spinning, extreme visual inspection, licking or smelling nonedible surfaces and objects, self-inj uring or increased contact with another body or resistant surface. Excessive responses reflect pattems of sensation seeking. Conversely, avoidance patterns may also be evident as as result of poor modulation of sensations. For example, a child may avoid foods with certain textures, move her body stiffly to prevent a change in head position or limit vision by frequently squinting. Ayres and Tickles study (as cited in Mailloux & Roley, 2001) identified both hypo- and hyperesponsive patterns in children with autism whereas Kientz and Dunn (1997) found common patterns of auditory and tactile defensiveness as well as visual fixations.
must
or

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39

Table 1 Location and Functions of the

Sensory Systems

____

From: Myles, B.S., Cook, K.T., Miller, N.E., Rinner, L., & Robbins, L.A. (2000). Aspergers Syndrome and Sensory Issues: Practical Solutions for Making Sense of the World. Shawnee Mission, KS: AAPC. www.asperger.net Used with

permission

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40

Motor

Planning
depends on our ability to concep-

Movement that results in coordinated

interactions

tualize or ideate, plan and carry out an unfamiliar action. While development of new skills initially requires motor planning, or praxis abilities, no motor planning for repetition of the skill is necessary as long as the situation is familiar (Ayres, 1979). Routine and stereotyped motor activities like walking and running are often easy for children with ASD; however, motor skills requiring adjustments in initiation, timing, sequencing, speed and direction of movement may be more difficult. The individual with praxis difficulties may choose to interact with the static qualities of an object or engage in familiar and repetitive motor schemas rather than the unpredictable patterns and movements of people. Poor motor planning abilities limit the ability to expand play repertoires or engage with others and should be a consideration when attempting to understand the functional deficits of ASD (Mailloux, 2001).

sideration of sensory impact must regard the childs performance within the context of the task demand. The complexities of different environments, including inherent sensory characteristics, offer varying supportive cues and barriers to performance. Dunn, Brown and McGuigan (1994) expand on this interrelationship between person and context to include physical, temporal, social and cultural elements in the Ecology of Human Performance framework, a structure for considering context as a key variable in assessment and intervention planning.
In

general,

transdisciplinary approach

to

contributes multiple perspectives to understand the whole child. Transdisciplinary teams may include a speech language patholoassessment

gist, physical therapist, occupational therapist,

audiologist, nutritionist, psychologist, physician, or other specialists as deemed appropriate for the childs unique needs. The family of the child with an ASD realizes significant impact. Therefore, parents and caregivers are essential team members, providing valuable information and input for evaluation and intervention

Assessing Sensory Processing Issues The pervasive nature, global delays, and behavioral challenges often exhibited by children with ASD impact academic, behavioral, social/emotional, leisure, and vocational areas of functioning in the home, school, and community. Sensory processing issues influence these areas as well. Neuroscientists are leaming more and more about sensory processing and behavior although definitive cause-effect relationships are not yet clear. Current &dquo;best practice&dquo; in assessment techniques reflects this growing knowledge and its application to sensory processing in everyday life. The potential impact and variability of sensory processing among individuals with ASD warrant at the least a preliminary investigation regardless of the evaluation purpose. However, sensory difficulties do not lie only with the performance abilities and skills of the focus individual. Comprehensive con-

planning. Occupational therapists typically

have a foundation of understanding about sensory processing and task analysis that enables skilled observations of children to gain sensory information. In addition, they can administer and interpret a variety of assessment tools currently used to gather information about sensory processing abilities.
Assessment Tools A

single tool or measure for all assessment

purposes in all environments for all children

suspected to have or diagnosed with an ASD may not yield complete or accurate informavariety of instruments exists that provide valuable information about sensory processing. Formal assessments include norm-referenced and standardized instruments that compare an individuals profile to those of typically developing peers. Informal assessments, on the other hand, consist of review of
tion. A

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41

records, inventories/checklists,
and observations. Formal Assessments
Four formal
assessments are

interviews

sensory stimuli

(auditory/visual/vestibular,
disand ground&dquo; language or facial
anxious
or

etc.) and their ability to modulate their reactions

efficiently. Examples from each of these

categories include &dquo;Becomes

summarized
&dquo;Doesnt perceive

tressed when feet leave the

here: (a) the Sensory (b) the Short Sensory

Profile (Dunn, 1999a); Profile (Dunn, 1999b); (c) Adolescent/Adult Sensory Profile; and (d) Sensory Integration and Praxis Test (SIPT) (Ayres, 1989). Table 2 overviews these measures.

body expressions,&dquo; respectively (Dunn, 1999a). The Sensory Profile also provides a description

Sensory Profile (Dunn, 1999a). Someone who is very familiar with the child can respond to this 125-item norm-referenced questionnaire through an interview format or independent completion. This may include parents, educators, paraprofessionals, therapists, and childcare providers. The items on the profile describe childrens behavioral responses to different sensory experiences, such as their reactions to processing specific
Table 2 Formal Assessment Measures

of emotional and behavioral responses associated with sensory processing difficulties such as &dquo;Jumps from one activity to another so that it interferes with play&dquo; (Dunn, 1999a). The person completing the profile reads each description and determines how often the child engages in the behavior (always, frequently, occasionally, seldom, or never). Further classification of responses into Typical Performance, ProbabLe Dif ference, or Definite Dif ference ranges indicates degree of sensory processing challenge when compared to a normative sample of children without disabilities.

Note.

OT=occupational therapist; PT=physical therapist.

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42

falling within the Probable Difference and Definite Difference ranges are indicative of challenges in the childs ability to process sensory input and modulate or regulate responses to sensory input. Interpretation of profile results to determine patterns of performance requires a solid understanding of sensory processing and how it can affect a childs ability to
Scores

about preferences and for program planning.

participate

in activities.

Short Sensory Profile (Dunn, 1999b). This 38-item abbreviated form of the Sensory Profile is appropriate as a screening tool to determine whether more in-depth sensory
assessment

leaming styles useful Beyond observation, obtaining a sensory history through interviews or checklists helps identify behaviors indicating sensory processing dysfunction. The course of completing the sensory history of the child engages the family in the evalua, tion process and provides opportunities for discussing values and priorities relevant for maintaining a family-centered focus to intervention. This section includes a summary of six possible informal measures (see Table 3).

is necessary.

Adolescent/Adult Sensory Profile (Brown & Dunn, in press). This upward expansion of the Sensory Profile enables adolescents and
evaluate themselves through a quespossible contributions of sensory processing to their daily patterns. As a means for intervention planning, this profile presents possibilities for increasing client insight about performance as well as potential development of coping strategies. Sensory Integration and Praxis Test (SIPT) (Ayres, 1989). This standardized battery of tests identifies patterns of function and dysfunction in sensory integration and motor planning (praxis). While some individuals with ASD may be able to respond reliably in a standardized test situation, more often difficulties in multiple areas rule out the use of this type of testing for these individuals. Test results are available by mailing protocols to the publisher or by using a purchased scoring computer disk. Competent administration and interpretation of this assessment measure requires specific training and certification provided by Sensory Integration International or Western Psychological Services. adults
to

Sensory Integration Inventory-Revised (SIIHanschu, 1992). (Reismann & tool by someone of this screening Completion
R)
familiar with the child or as a result of a semistructured interview requires responses describing behaviors as typical, not typical, or dont know. Four sections, tactile, vestibular, proprioceptive, and general reactions, contain clusters of related items. Therapist interpretation of combined items is required with no numeric scores provided. A scoring grid, Ready Approach - Key for Interpreting the Sensory Integration Inventory for Individuals with Developmental Disabilities (Hanschu, 1998), helps identify whether or not the observed behaviors are indicative of sensory defensiveness, sensory modulation difficulties,

tionnaire for

registration difficulties, or sensory integration difficulties. The grid provides specific intervention protocols or strategies based
sensory
on

which area is most evident. Checklist for Occupational

Therapy

(Occupational

Therapy

Associates-

Watertown, 1997). This series of four checklists for infants, preschool-age children, school-age children, and adolescents-adults,
information about certain behaviors and the frequency with which they are exhibited. The items look at behaviors that are potentially related to sensory processing difficulties with categories of behaviors changing across the age ranges. The infant-through-school-age checklists query whether a behavior occurs frequently or not, whereas the adolescent-adult checklist uses a

respectively, provides

Informal Assessments
One
sensory
can

gather information about a childs

in ways other than formal Observing the childs interac-

processing

measurement.

tions at

play and work yields

information

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43

Table 3 Informal Assessment Measures

Note. NS=not

specified; OT=occupational therapist; PT=physical therapist; SI=sensory integration.

5 scale, with 1 being never and 5 always. The authors emphasize that completion of this instrument requires no special training.
1
to

Building Bridges Through Sensory Integration (Yack, Sutton, & Aquilla, 1998). This screening instrument asks respondents to consider behaviors across sensory areas (vestibular, tactile, proprioceptive, visual, auditory, and

olfactory/gustatory) within the context of specific daily tasks such as general self-care, dressing, eating, school/work, play, and social
interaction tasks. This instrument is teacher-

parent-friendly as well as effective for designing intervention strategies for use throughout the day to address identified senand
sory issues.

Indicators o f Sensory Processing Di f f iculties (Abrash, n.d.). Respondents completing this

checklist mark observed behaviors

across sev-

eral sensory and regulatory areas including tactile, proprioception, vision, auditory, gustatory, olfactory, vestibular/kinesthetic, chemical regulation, arousal, and attending and social consciousness. Hypo- and hyperreactive divisions in the tactile and vestibular/kinesthetic areas provide additional information about the ability to modulate sensory input. Similarly, vision behaviors break down into areas of acuity, oculomotor function, visual perception, and hyperreactivity. Questions to Guide Classroom Observation (Kientz & Miller, 1999). This tool provides a format to guide classroom observations conducted by teachers, therapists or others familiar with sensory processing. A series of 38 questions address the following areas: (a) child, (b) task, (c) physical environment, (d) social context, and (e) cultural context. The

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44

design of the questions enables the observer to analyze the childs behavior, the degree of
environment in which The questions can be performance used with other formal or informal measures to compare and contrast the impact of senso-

participation, and the

occurs.

able and nonthreatening as possible for the child with ASD. One example is the use of melodic intonation. The ability of children with ASD to process the paralinguistics of speech is often considered a relative strength.

ry

processing

across

environments.

Thus, presenting assessment and/or diagnostic instruction using a melodic tone may increase
childs attention to the examiner, which may future delivery of the examiners verbal directives. Consideration of the sensory characteristics of multiple variables can become complex but cannot be discounted.
a

Motivation Assessment Scale

(Durand

&

be useful for if a has a sensory behavior determining specific function or cause, based upon the premise that all behaviors serve a communicative and purposeful function. It is up to those who live and work with the child to determine the communicative intent in a given situation. The Motivation Assessment Scale contains 16 items in the (a) sensory, (b) escape, (c) attention, and (d) tangible areas. Use of a 6-point Likert scale reflects frequency of behaviors as occurring never, almost never, seldom, half the dme, usually, almost always, or always. This instrument does not break the behavior into specific sensory areas but merely identifies whether it has a sensory basis. Identification of sensory issues as a probable reason for a given behavior warrants followup with measures typically administered to provide more comprehensive and specific sensory processing information.

Crimmins, 1992). This scale

can

guide

Interpretation
As

mentioned, occupational therapists

or

found to be with for children ASD, process supportive evaluation creates a more dynamic assessment of abilities. Increased information about what a child can do, even with supports, expands considerations for intervention planning. Understanding the sensory characteristics of supports that appear to be successful help us to identify similar cues in the environment or design new strategies that support performance. Manipulation of the assessment process with the possibility of facilitating success lends the possibility for increased understanding of the individuals potential for learning. Kientz and Miller-Kuhaneck (2001) suggest strategies for making the assessment session as comfort-

Dynamic Assessment Utilizing strategies generally

with sensory integration often training interpret results of sensoassessments or observations. Skilled ry-related and comprehensive assessment requires observation of the child across environments, under various settings, and with different adults and peers. In all cases, diagnostians must be careful not to go beyond the intention of the instruments. To be useful, recommendations stemming from an assessment must be detailed enough for implementation by the many staff members and parents who have contact with the child. The sensory information will help teachers and parents develop programming strategies that support the childs success in various environments. For example, if an assessment revealed that a student has vestibular processing issues appearing to impact ability to sit still and attend to task, a team discussion of strategies that provide vestibular input may be valuable. Such strategies may include using an inflatable camping pillow as an alternative seating, providing vestibular input that will enable the student to sit in his chair and pay attention. Close discussion and collaboration among the occupational therapist and other team members in implementing the recommendation is essential to ensure that (a) recommendations are implemented effectively and safely, and (b) other

professionals
most

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45

that the interventions are directly addressing the childs needs and supporting performance
across

environments.

Summary
Evaluation of children with ASD presents challenges due to the complex and unique characteristics of each child. Consideration of the sensory processing issues of individuals and the interplay between sensory characteristics and the external environment lends greater understanding to the often-confounding behaviors that impact daily living in the home, school, and community. Moreover, opportunities for successful performance are possible when information gathered from sensory assessment contributes to interventions designed to improve the daily life of children and their families. References
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