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Application of Sensory Processing Knowledge: Case Examples
Case Study 1: Mark
Currently, he misses the bus about 2 to 3 times a month. He hates missing the bus and typically takes 30 minutes to an hour to calm down enough to leave for school on these days. In addition, these delays affect his parents' schedules because one of them has to calm him and drive him to school, resulting in late arrival to work.
The parents expressed these concerns at the team meeting to plan Mark's educational program. The teacher agreed with the parents that getting ready was important for Mark's school day; when Mark comes in late, the teacher sees a much less effective school performance. Team members also noticed these "slow to start" patterns at school: Mark lays his head down on his desk, leans on furniture and other people, and is slow to respond to questions. Mark's Sensory Profile (Dunn, 1999) results also verified that he has low registration (i.e., misses information, is slow to respond to stimuli in the environment). The team decided that the occupational therapist (OT) and the parents would have a follow-up meeting to brainstorm strategies and initiate interventions at home, while the school team would identify ways to enhance Mark's classroom routines.
First, the OT explained low registration and Mark's need for more intensity of input so that he could notice and respond to cues. Then they brainstormed ways to increase Mark's sensory input during the morning routine at home. They discussed turning up the volume on Mark's radio and changing it to a station with upbeat music, to offer adequate auditory input for meeting Mark's high thresholds. They also decided to open the blinds in Mark's bedroom, to introduce natural light for help with waking up. After addressing the issue of getting out of bed, they turned their attention to the structure of the bathroom. Mark's father installed color-coded dividers into Mark's toiletries drawer to make a section for each set of supplies. This setup allowed for all of Mark's supplies to be more noticeable, which met his high-threshold need for visual information.
In addition, the OT and Mark's parents reevaluated Mark's home base--where he goes to calm himself when upset. Typically, he goes into his room, lies on his bed, and plays the radio loudly. They decided to add some additional sensory input that would simultaneously calm Mark and provide him with more intense information about his body to meet his thresholds. To accomplish this addition to home base, the family encouraged Mark to push his bed against the wall to create a nook. They added heavy pillows and beanbags for him to arrange while listening to his music (i.e., he could sit on some of them, and pile others on top of him). They also moved his radio to a higher place, so he would have to stretch his body to adjust the volume and other dials. While looking for a heavy container to hold his CDs, Mark found an old toolbox in the garage. He loaded the CDs into this metal box, and this provided additional input to his muscles and joints as he manipulated the box to make his selections. His family collected supplies with similar characteristics to take with them when the family went out (a stress ball, mini-video games on a key ring, travel games, etc.). These changes were helpful in getting Mark out the door in the morning. His mother also moved one of her scented candles into the bathroom to provide some olfactory input while Mark was washing his face, brushing his teeth, and so forth, and this seemed to help him also. The school team created routines for Mark to get him up and moving around the classroom more often. For example, they had him pass out worksheets, collect materials from other students, move books for reading groups, and wipe off the board for the teacher throughout the day. This concept also helped when the family ran errands: While shopping, they might have Mark push the cart, send him to retrieve items at the end of the aisle, or request that he locate intriguing items with unique or intense sensory features (fragrant foods or household items, clothing with specific textures, etc.). The teacher gave Mark some "smelly" markers to write with, and this seemed to help him during seatwork time. As the family and other team members understood Mark's needs, they contributed additional ideas to keep his thresholds activated throughout the day.
Case Study 2: Ben
Because Ben would engage in other activities instead of completing his homework, it was suggested that his family work to reduce those distractions. They set up a designated study space and removed all extraneous materials and activities. Ben's mother became frustrated because this actually made things worse; Ben kept coming into the kitchen to see what she was doing, roaming around the house to ask siblings questions, singing, and tapping on the walls. He would also find alternate uses for his homework supplies instead of completing the work. When his mother checked, his work was no further along.
The OT and Ben completed the Adolescent/Adult Sensory Profile (Brown & Dunn, 2002), and confirmed that Ben seeks more sensations than do other children. The OT met with Ben, his teachers, and his parents to discuss the situation with them. Although others are distracted by additional sensations, children like Ben require extra stimulation to be productive. When the family and teachers removed things, they reduced the information available to Ben, so he increased his "recruitment" behaviors to provide himself with the stimulation he needed. The complication was that when Ben did that, he stopped the focus activities to get the sensory input he needed. The challenge for the team was to find ways for Ben to get the extra sensory input during the focus activities (homework and chores), so that he continued to meet his needs while being productive.
Everyone decided that homework should be tackled first. For the homework area, the OT suggested introducing snacks that provided strong sensory input (e.g., apples or carrots for their crunchiness, strong mints, hard candy or popping gum for their intense flavor and texture in the mouth, a bowl of nuts for the texture to the hands). Ben could obtain additional sensory input with these snacks and continue to work on his homework. With their new understanding about Ben's needs, they offered to get headsets so Ben could listen to music. The OT suggested that they experiment with which kinds of music supported homework completion, limiting Ben's choices to that music that kept him working. They also moved a glider chair into the space, so Ben could move back and forth while studying.
Currently Ben uses a calendar to record his assignments. The therapist suggested modifying this visual schedule to another media that would meet Ben's need for information to meet his high thresholds. The teachers offered to email Ben his assignments so that he had an opportunity to click through all the computer menus to get them each day. They also agreed to receive his work via e-mail attachments, giving Ben more visual cues to employ to send his work (e.g., using the word processing and the e-mail programs together requires toggling back and forth, creating a more varied and interesting visual environment than paper and pencil). The OT suggested that Ben select a different auditory cue for each class so he would know which class an e-mail pertained to; Ben asked if he could add a signature sound for himself to let the teachers know it was him.
The family decided to apply these ideas to chores at home. With Ben's help they designed a calendar for chores. Ben took it upon himself to find intricate, active singing icons for his chores, which helped him in following the visual schedule. Ben's sisters suggested that the family use the concept of increasing sensations at restaurants when the entire family went out to eat. They sought out restaurants that offered a visually busy environment, buffets where he could walk to get his food, and tables with paper and crayons to supply him with proprioceptive input while he colored.
Occasionally, Ben would refuse to do his homework in favor of a preferred activity. The family had a social story to address this issue, yet had difficulty maintaining Ben's attention while reviewing it. Thinking about Ben's needs for additional input, the family recorded the story on videotape using animated voices. They added sounds effect, such as his dog barking, to affirm a point, or a favorite song in the background to emphasize responses. Because it increased the visual and auditory input, the story matched Ben's high thresholds and he was more successful at using his social story to guide him. The family applied these concepts for his other social story themes, such as how to act when at the grocery store, how to behave at restaurants, and so forth.
Once the school personnel and family began to understand the sensory processing aspects of Ben's behaviors, everyone was able to generate ideas and talk with Ben about strategies. Ben also became more aware of his own needs and came up with ideas on his own.
Case Study 3: Miranda
Although Miranda performed above her peers academically, she struggled with social issues. For example, teachers and family members commented on her always "messing with her hair," to the point where she was pulling out large clumps. During the interview with the OT, Miranda revealed that she was bothered by the light touch of her hair brushing against the side of her face. Utilizing interviews, observation, and the Adolescent/Adult Sensory Profile (Brown & Dunn, 2002), the team refined their interpretation of this behavior. They originally assumed that Miranda sought out sensation, when actually she was sensitive to the light touch of her hair, and pulling it firmly helped her cope with the distracting sensation.
Miranda had worn her hair in a shorter style in the past but preferred it longer because the coverage "protected" the nape of her neck, and she liked the weight against her shoulders. Her family had used rubber bands or scrunchies to pull it back but were not able to keep it tight enough. Her mother now styles it in a French braid every several days. It is taut enough that Miranda likes the feel of the pull and it keeps it off her face. She has not pulled strands of hair from the braid to manipulate, and as a result, hair growth is returning to the bald spot she had created. Miranda is in the process of learning how to braid her own hair.
In addition, the Adolescent/Adult Sensory Profile revealed a difference in Miranda's sensory-avoiding score. Her family and peers especially noted this in social environments. Miranda shared an interest in having more friends (including boys), but the thought of unexpected touch made the possibility for close friendships stressful to her. She went to the fall dance with a male friend but did not hold hands or wear the corsage he purchased for her. Therefore, the team brainstormed for strategies to increase her enjoyment of the upcoming winter dance and going out afterwards with a group.
Miranda and her mother shopped for a long-sleeved dress with tight-fitting gloves. This setup offered consistent pressure and minimized contact with her arms. Wearing long-sleeved and fitted clothing has been helpful with her school wardrobe, also. Because the dance music was loud, her date typically gained her attention by tapping her on the shoulder. Miranda asked her date to get her attention visually instead. Furthermore, she requested that they dance at the fringe of the group, so she could avoid bumping into people.
After the dance, the group planned on going to a restaurant. Miranda expressed concern about the large size of the group and all that it entailed (background noise, multiple smells, people bumping into her chair, etc.). Miranda's family offered strategies for addressing her sensitivity to the smells in the restaurant. They packed some vanilla lotion and berry-flavored lipstick into her purse, and encouraged her to apply it before entering the restaurant and intermittently during the meal (Miranda enjoys and is familiar with these scents). The proximity of the scents on her hands and face screened out the background smells of the restaurant.
Remembering her preference to be in a low-traffic area on the dance floor, her date offered her a chair in an out-of-the-way location in the restaurant. He also invited a "laid-back" couple to sit near them, thereby decreasing sensations in her immediate environment. Miranda and her family had also brainstormed ideas regarding potential home bases in the restaurant. They decided the restroom would be an easily accessed alternative that would enable Miranda to further decrease auditory and touch sensation, should it become problematic for her.
Her family and educators utilized similar concepts in her home bases at home and school. Miranda and her dad created a special area in her room; she arranged firm pillows so that they faced her favorite posters, and added a lava lamp. In addition, they reviewed her music collection to explore what songs would help her relax the most. At school, the team utilized similar constructs by offering a comfortable chair, headphones, and a study carrel, to cut down on visual input.
Reflection Exercise #6