A Michigan day treatment program uses SI protocols with adult clients

By Kelley Phillips Kozloff

What do you picture when you think of sensory integration treatment? You may see Dr. Jean Ayres treating children on swings and scooterboards in her clinic. Maybe you think of a school-based therapist, using "How Does Your Engine Run?" strategies to help third graders pay attention in class. But is sensory integration treatment only beneficial for children?

A day program for adults with mental retardation and developmental disabilities in Canton, MI, reports great success in using a sensory integration framework for treatment with its clients. Community Work Opportunities/Quest Inc. (CWO) started its sensory program in 1994. At the time, it was a vocational day program for adults with mental retardation and developmental disabilities (MR/DD).

Elaine Lamontagne, program director, reported that sensory integration was very new to the community mental health system at that time. She had read many articles on sensory integration and thought the approach could help some of her clients who had behaviors that appeared to be related to sensory dysfunction.

"From what I read, I knew we needed an occupational therapist to start the [sensory integration-based] program," Lamontagne stated.

Once CWO had an OT, five or six of its most behaviorally involved clients began heavy sensory treatment every day. And the clinic found that physical aggression, property destruction and self-abusive behaviors decreased.

Currently, CWO's sensory program has 50 clients. Seventy-five percent of the current clients are male and range in age from 23 to over 50 years old. Most of the clients have diagnoses of both mental retardation and autism. Nearly all of them live in group homes and have at some point in their lives resided in institutions.

According to Lamontagne, all of them have been in other vocational day programs or school programs that did not work out for them.

Sensory Needs of the Population

The theory is that as developmental milestones were delayed or never met, CWO's clients' sensory systems did not have the opportunity to fully integrate. In addition, many of these adults with MR/DD also have endured traumatic events in their lives that have affected their sensory preferences. In response, they have developed adaptive behaviors to meet their sensory needs. However, many of the adaptive strategies limit the clients' ability to form relationships with peers, participate in daily activities and/or be active members of their communities.

"Everyone in the sensory program is referred for maladaptive behaviors, communication difficulties, inability to do activities of daily living, or psychiatric problems," said Lamontagne. "These are all encompassed by the presence of their sensory deficits."

For each sensory system there are associated adaptive behaviors in response to sensory processing deficits. For vestibular input, there is often hypersensitivity or under-registration; CWO's clients are either extremely hesitant to move, or they seek constant motion. Auditory hypersensitivity is also common and often is the impetus for clients' negative behaviors (to make the input stop).

The majority of the clients are very tactile-defensive. To protect themselves from unwanted touch, they isolate themselves or become aggressive if others come near. One client stays in his bedroom for hours under a sheet on his bed, pressing his arms and legs and head against the sheet until it is taut, to feel secure. Several clients wrap their arms into their shirts to feel a similar sense of security.

These adaptive behaviors interfere with their participation in daily activities and development of relationships with peers. But once the underlying sensory needs that these behaviors fulfill are met through sensory activities, the clients learn that there are other actions they can take to meet their sensory needs.

CWO Sensory Diets

OT evaluates every client referred to the program–they interview the client along with his or her home staff and family. OT observes the client at home and at CWO. Based on the results of the evaluation, OT plans the client's sensory diet, which will be followed during the client's daily sessions at CWO.

Each client's sensory diet is individually written based on the client's sensory needs and the goals the client and his support circle have chosen. Examples of these goals include:

• allowing others into their personal space,

• increasing verbal communication,

• preparing for vocational training,

• exploring leisure activities,

• having positive experiences on community outings, and

• making friends with peers who have similar interests.

Activities on the sensory diets include environmental modifications (earmuffs, being in darkened area, sitting near a visual display) and activities to stimulate each sensory system (swinging, smelling aromatherapy scents, or playing tactileey, for example). Not every client needs activities for all of the seven sensory systems, but most sensory diets address the majority of the systems.

The sensory diet is organized as a monthly chart in which participation and reaction to each activity can be efficiently recorded. The charts also include a listing of functional activities in which the client can participate once he has engaged in his sensory activities.

Clients attend CWO three and a half hours a day, five days a week. There are separate morning and afternoon groups to accommodate the program's growing size. Direct care staff assists clients with their sensory diets and records the clients' responses to each activity.

The staffing ratio is one staff per four clients. If one-on-one staffing is required for a client, it is provided by his or her home staffing agency, and the staff is trained by CWO.

Angela Robb is a direct care staff member who has worked for CWO for seven years and has been a sensory program staff member for the past year.

"I have learned a lot of techniques to help the clients," she said. "I have seen a lot of changes in their behaviors over the year."

Natasha Sneed, program supervisor, explained that with experience, direct care staff learn how to anticipate what situations may lead to a client's negative behavior and use sensory activities to assist the clients through these situations.

The Sensory and Tasking Areas

The program's clinic includes two separate areas: the sensory area and the tasking area. The sensory area is the where most clients initially begin if they are in a state of overarousal. There are four rooms designed to provide a sensory environment that is calming yet has many opportunities to participate in positive sensory experiences.

The music room is lit with rope lighting on the walls and a corner light board that flashes in sync with the music it plays. Clients swing on a porch swing or bouncer chair as they watch and listen as they participate in their sensory diet activities. Each client has an individual storage box for his sensory diet equipment (i.e., Wilbarger brushes, vibrating massagers, neoprene pressure vests, weighted hats and spandex wrist supports), which accompanies him as he moves about the sensory rooms.

The most secluded room is darkened but has light displays on the walls and a fish tank to create visual focal points. In this room, there are large floor mats and wedges so clients with limited mobility can experience numerous positions while looking at the visual displays or while participating in sensory activities from their sensory diets. It is the quietest area in the building, and staff is asked to speak quietly to maintain this calm and soothing atmosphere.

The adjacent room is focused on tactile activities, although activities for all sensory systems are available. A ball pit with bolsters provides an area for one client to receive proprioceptive input and maintain her personal space; in response, she stops rocking herself and biting her wrists. Beanbag chairs on a mat provide a whole-body tactile experience as clients play in sand, water and shaving foam. Two clients swing together on the porch swing as the direct care staff offers them squeeze bottles of calming aromatic scents. Instrumental music plays in the background; however, one client prefers to listen to a country music CD through his headphones, and sways and claps along.

In the sensory gym, there are many options for people seeking vestibular input. But even time in the leaf swing becomes a multi-modal sensory experience as the client is provided headphones to listen to instrumental music and a weighted blanket on her lap to provide calming proprioceptive input as an image from the light projector slowly rotates on the wall beside her. A trampoline, scooter boards, balls and a sky chair swing are also available in this area.

When a client demonstrates that his sensory processing is improving (by a decrease in occurrence of targeted behaviors) and that he is ready to make the transition, he moves into the tasking area. Here, clients continue to follow a sensory diet; however, the focus is moved to performing functional tasks.

Functional activities include making lemonade as a group, using a paper shredder (which has evolved into a micro-business for several clients), accepting grooming activities, using a communication device, performing household cleaning tasks and participating in weekly community outings.

Program Goals and Positive Outcomes

The overall goal is to promote engagement in daily activity. All clients who currently attend CWO's sensory program have shown improvement in reducing their targeted behaviors, many of which were the result of sensory processing deficits. Targeted behaviors include physical aggression, self-abuse, property destruction, yelling, pacing and stripping of clothing.

As these behaviors decrease, it opens the door for the client to develop trusting relationships with staff and peers. He can begin to explore and see what purposeful activities he enjoys.

After participating in the program, many clients begin to use picture-based communication systems. Several have moved on to CWO's community and vocational programs, and three of the clients have transitioned to jobs in the community using a job coach.

Keys to Success

Consistency, fighting low expectations and patience are all necessary for success in using a sensory integration framework to treat adults with MR/DD. One client in particular comes into CWO screaming and hitting himself, but calms within 30 minutes of receiving his sensory diet activities. Unfortunately, this peacefulness stops the minute it is time to leave the sensory area. The three hours a day provided at CWO in a sensory environment that meets his needs is an achievement, but he requires more. For overall long-lasting change to occur, consistent sensory activities and environments need to be part of his home life as well, as they do for all of CWO's clients.

Many of the direct care staff working at group homes in the county CWO serves have been exposed to sensory diets in the past. Unfortunately, the CWO OT has found that most of them have a negative attitude toward home-based sensory programs due to failed attempts in the past. There are many possible factors why they did not see good results, although the OT cites a few primary reasons:

• The sensory programs included activity but no documentation of environmental modifications to make in the area in which the sensory activities are completed. For example, if there is a client who is tactilely defensive and has auditory hypersensitivity, we can try to brush him all day; but if there isn't anywhere in the house that is quiet, the client may never be able to relax enough to accept the brushing.

• The physical and emotional environment created around the client is also crucial to the effectiveness of the specific sensory activities written on their sensory diet. The clients need to trust the people assisting them with their sensory program. They need to feel secure in their environment, which requires assessing and meeting their sensory needs.

It does not take thousands of dollars and a sensory gym to make sensory-based programming work at home. Most of the environmental modifications the CWO OT recommends can be completed for less than $50. The goal of most environmental modifications for CWO clients at home is to reduce sensory information so the client will have the opportunity to focus on specific sensory or functional activities.

Reducing background noise can be as easy as shutting a door or turning off a television. Reducing the light in a room can be done with dark material and Velcro™—a cheap and durable alternative to curtains. Once a home provides the client with the sensory experience she needs, and she'll have the opportunity to consistently use sensory integration principles to her benefit, there is long-lasting improvement toward her goals.

It takes many baby steps of improvement before families or home staff members see the potential for real change in the behavior of their loved one. Or, if a client is doing much better than he had in the past, it can appear to be "good enough."

Patience is necessary for all parties involved in the process of sensory integration-based programming for adults with MR/DD. Change and improvements are possible, but the changes are often slow and come in small amounts.

Difficulty with changes in routine is a hallmark for people with autism; therefore, adjusting to a new program and accepting sensory activities take time. The direct care staff is taught about the relationship between autism and difficulty with change and transition; however, constant reinforcement is needed to boost their patience as well.

The clients provide the best motivation to the direct care staff member as they show progress, because each direct care staff knows that he had a large part in assisting that client in reaching important goals.

For more information

Contact: Elaine Lamontagne at elainecwo@yahoo.com.

Kelley Phillips Kozloff, MS, OTR, was the OT and supervisor for the sensory program at Community Work Opportunities. She now practices in Boston. She can be reached at kelleycwo@yahoo.com.

Jonathan's Experience at CWO

When Jonathan was referred to Community Work Opportunities (CWO) in February of 2004, the 22-year old diagnosed with autism had already been placed out of his public high school into one-on-one tutoring off-campus for over a year due to an incident in which he threatened his staff. In his teenage years, Jonathan endured several traumatic events and he had a history of physical aggression toward his family, elopement from his home and other maladaptive behaviors.

In 2002 he moved out of his family's home into his own house with direct care staffing. His parents also chose to stop using medication for Jonathan's behavior. At the time of his initial evaluation at CWO, Jonathan's home staff reported that he played with his spit, bit his hands and twirled his fingers in his hair constantly. Jonathan spoke minimally—two or three words at a time—despite having spoken three languages fluently as a child. His movements were slow and his overall arousal level was low.

During his initial visit to CWO, it was very clear to the program director that Jonathan had sensory processing deficits. "The noise from the office refrigerator was over-stimulating to Jonathan," reported Elaine Lamontagne, program director. She offered him a pair of earmuffs, which he accepted.

Also at that time, Jonathan would hold others' hands but would not manipulate objects in his hands or readily use his hands for activities. He liked to walk but would stop every few steps for up to a minute before continuing on. Jonathan's hands were often in his hair, twirling and pulling. He appeared distraught when attempting to communicate what he wanted.

CWO staff started treatment very slowly with Jonathan. At first, he worked directly with Lamontagne in her office. Environmental noise was reduced as much as possible. Lamontagne began proprioceptive activities such as brushing and joint compression for calming and spent a lot of time building trust with Jonathan.

When the current OT started in March, she and the program's assistant supervisor worked with Jonathan individually for two hours a day, five days a week. Treatment focused on increasing tolerance to tactile input to his hands, vestibular activities to increase arousal level and continued proprioceptive activities for calming.

In April, Jonathan began wearing a weighted vest and a baseball cap, which significantly decreased his hair pulling and twirling. When he was not preoccupied by twirling his hair, he demonstrated greater attention to conversation and began speaking more. The same effect was found to occur when Jonathan began to accept shaving cream play with his hands. It broke the ritualistic behavior with his hair and allowed him greater concentration on communication. The OT and Lamontagne encouraged Jonathan to use a variety of communication systems, but he appeared intent on using verbal communication although for several months it remained at only two or three word phrases. After three months, Jonathan began to explore the sensory area rooms to swing and started to show interest in the other CWO staff and customers.

Jonathan's school district also approved funding for the CWO OT to evaluate Jonathan's home to develop a home-based sensory program in conjunction to his sensory diet at CWO. The OT made recommendations for environmental modifications and sensory activities that addressed Jonathan's auditory hypersensitivity, his increasing interest in tactile play and the role of proprioceptive inputs (weighted vest and blanket, brushing and joint compressions) when Jonathan displayed signs of over-arousal.

The OT trained Jonathan's home staff in sensory integration theory and instructed them in the specific activities of his sensory diet. Jonathan's home manager was a very perceptive man who had already found a sensory solution to one of Jonathan's sensory needs that was getting in the way of his daily activity. Jonathan would not eat his cereal until he put his hands into it and felt it for an extended amount of time. So his home manager poured him two bowls, one for tactile play and one to eat. Jonathan liked this solution, since he could eat his breakfast and still have a bowl of cereal to put his hands in.

On a trip to a family reunion last summer, Jonathan's staff did not do his sensory diet activities with him for the first three days. After an incident on the third day in which he was aggressive to a family member, they resumed his sensory activities. "The sensory diet really helped him get through the rest of the vacation," explained his mother, Beth.

Jonathan has been participating in his sensory diet activities for over six months. He does not display signs of auditory hypersensitivity as he did upon intake. His verbal communication to staff and his peers at CWO has increased greatly. And his tutor reports that his oral reading skills have taken off since they resumed class in September.

Jonathan is currently attending CWO but is now with a staff in the tasking area, where he interacts with his peers in a number of games and activities. With his staff, he walks to the mailbox and takes the office manager her mail. He greets everyone with huge smiles, hellos and, often, a hug.

"I now feel safe enough to be alone with him," added his mother, "And this is the first time in a long time."

–Kelley Phillips Kozloff, MS, OTR