Vol. 23 Issue 18
Rehabilitation, Disability and Participation
Sensory-based Treatment for Adults With Developmental Disabilities
One facility's experience
In recent years there has been increased focus on sensory-based and sensory-integrative treatment with adults with developmental disabilities, similar in theory and practice to that for children. (Pfieffer and Kinnealey, 2005) Specific assessments have been developed with the adult population in mind. (e.g., Hanschu and Reisman, 1992)
Adults with profound mental retardation may have problems with severe self-injurious behavior (SIB). In some cases, sensory-based treatment has been found to be effective in reducing this problem. (Reisman, 1992) In other cases, sensory-based treatment has reduced agitation and promoted relaxation in adult clients with developmental disabilities (DD).
In one facility in Minnesota, the success of a sensory-based treatment approach in reducing problem behaviors led to widespread support of the program by the majority of the staff, not just the therapists. (Hanschu, 1998)
In general, sensory-based treatment is most effective when it is done frequently and consistently. (Reisman, 1992) This suggests that frequent access to sensory equipment or modalities is helpful. It is essential as well that all staff be provided education and understand the nature of sensory-based treatment.
My facility, Fircrest Habilitation Center, a residential facility near Seattle, serves a population of which 90 percent are adults with profound/severe mental retardation and/or severe physical disabilities or other developmental disabilities. Many of the residents have behavior problems that have prevented their successful community placement.
The sensory treatment area at Fircrest is within the occupational therapy department, and sensory evaluation and treatment are administered by an occupational therapist. The sensory room contains a swing and an electric vestibular table, the surface of which is raised to make it about 2.5 feet from the ground and more accessible to clients. The room also contains a large, spiny ball to sit and bounce on and a platform supported by springs to jump and bounce on as well. There is a wobble board for balancing and a raised mat table for exercises. There is also a variety of tactile toys, balls and vibrating objects.
The room contains a CD player and a variety of kinds of music and sound CDs.
Lavender oil is applied to a fan in the room.
Let's look anecdotally at sensory-based treatment, a common but not yet accepted or fully understood practice, in four selected residents with developmental disabilities and their response to it.
Variables not controlled included other types of treatment, and milieu. Medication changes were not noted during the time the clients were observed.
The assessment we used here for determining sensory dysfunction in four particular patients was the Sensory Integration Inventory-Revised for Individuals with Developmental Disabilities, developed by Hanschu and Reisman. (1992)
Definition of Terms
Modulation is defined as the ability to regulate arousal. A deficit can be a problem with either over- or under-arousal.
Registration is defined as the ability to notice sensory input.
Defensiveness is defined as the degree to which one cannot "correctly interpret input so a fight, fright or flight response is not triggered (unnecessarily)."
Integration is defined as "the ability to take in and make sense of...(sensory input) and use it to produce an adaptive response." (Hanschu 1997)
After considering appropriate treatments for problems indicated by the Sensory Integration Inventory-Revised, we allowed client preference to direct our treatment choices and modalities. All of the clients were exposed to the scent of lavender oil during their treatments.
One of the clients had been receiving vestibular stimulation on an electric vestibular board on a regular basis for some months prior to this observation. Another accepted vestibular stimulation almost immediately, but preferred to sit on the vestibular board, not lie on it as the first did. The third client was just beginning to accept short periods of vestibular stimulation, and his main treatment consisted of auditory stimulation. Another was being seen for lack of coordination but received sensory treatment to enhance his gross-motor treatment.
Harry (not his real name) was 54 and had a diagnosis of severe mental retardation associated with prenatal hypoxia, and anxiety disorder. Based on results from the Sensory Integration Inventory-Revised, he had deficits in sensory modulation. He was reported by caregivers as showing signs of agitation such as tearfulness, rushing around the living unit and self-injurious behavior.
He lay on the vestibular board with a switch attached so he could turn on the device. The lights were low, and he listened to a Calming Rhythms® CD or an "Ocean Sounds" white noise CD during his treatment time. Lavender oil was applied to a tissue tied to the front of an electric fan.
Harry quickly learned that the sight of the therapist and the smell of lavender oil meant time in the sensory treatment area. He would jump up and come along readily. During the first six months, Harry required verbal cuing to activate the switch. Finally, the therapist stopped cuing the client and found that he was motivated to initiate finding and activating the switch himself. This seemed to support the theory that he really enjoyed the activity.
Over the course of eight months, the staff reported a decrease in Harry's agitated behaviors, and medical staff reported an improvement in his posture (he was walking more upright).
Louis (not his real name) was 55, with a diagnosis of profound mental retardation, seizure disorder and infantile autism. Staff reported a history of agitation, apparent anxiety and violence. The Sensory Integration Inventory-Revised suggested deficits in Louis' sensory modulation and defensiveness. He had a habit of poking his eye, a self-stimulating behavior that was sometimes injurious. This client was being readied for eventual eye surgery and wore a helmet to prepare him for after the surgery, when he would need to keep his fingers out of his eye. The staff thought sensory-based treatment might help him relax.
Louis also quickly learned to recognize the scent of lavender oil that accompanied the therapist and would come along with her to the sensory treatment area. His treatment consisted of sitting on a moving vestibular board while listening to music of his preference (oldies). Louis would smile and hum to the music. According to the psychologist's behavior graph, Louis' behavior of eye-poking decreased significantly after the start of this treatment program.
Mel (not his real name) was 22, with a diagnosis of non-specific developmental disability and motor delays, attributed to his mother's medication during the first trimester of her pregnancy. He was referred to occupational therapy because he was tripping, falling and hurting himself. The Sensory Integration Inventory-Revised indicated deficits in his sensory registration and integration. Mel's primary OT goal was to improve his balance and coordination, but we used sensory modalities to help him achieve a state of readiness to perform the other tasks.
Mel lay on the electronic vestibular board at the beginning and end of the session, sat in the swing while catching a beach ball, and jumped up and down on a "bounce board" similar to a mini-trampoline. He also spent time on a wobble board that stimulated lower-extremity joint proprioceptors.
Eventually Mel requested and received his own vestibular board for his living unit. We set up a spare bedroom as his sensory room, with an electric vestibular board, an inexpensive chair massager "topper," a foot massager and a CD player with soothing music CDs. Staff encouraged Mel to use the room after work and reported that he enjoyed and looked forward to it.
Recreation staff reported that Mel's coordination improved to the point where he was able to participate in ski trips. The data showed that the client had fewer falls after participating in therapy.
George (not his real name), 63, had a diagnosis of severe mental retardation of unknown cause and bipolar disorder. He had a history of seriously injuring staff. George was not on the occupational therapy direct programming caseload and was not formally assessed; but at the request of the staff, we brought him to the sensory room several times to try an electric foot massager and the electric vestibular board. He stated he enjoyed them both.
George was then taken to a sensory room on a living unit that had the same equipment, on a daily basis for a number of weeks. The staff reported that he would ask to go to the sensory room when he began to feel anxious, and that going there stopped an escalation of agitation.
A variety of sensory treatments were used with these DD clients with varying success. The successes were noted by staff other than just occupational therapy. On the whole, the clients enjoyed the sensory-based treatment modalities and, in some cases, were more relaxed and seemed less prone to self-injurious behavior. In some cases, sensory-based treatment seemed to calm agitated clients and decrease assault and self-injurious behavior.
Several modalities involving movement, olfactory stimulation and auditory stimulation were used together (e.g. vestibular board, music, rhythm, white noise, bird song CDs and lavender oil).
The effect of aromatherapy alone was not noted, but it was found that the clients began to associate the smell of lavender oil with a pleasant experience, and so it was useful as a secondary reinforcer.
The direct care staff was impressed enough with the results that additional sensory equipment was requested and ordered for the living units so the clients could have access to them at times other than therapy sessions. The medical staff supported this as well. The success of the sensory-based treatment program has led to facility support.
At the very least, the clients who took part in sensory-based treatment enjoyed and anticipated it, as evidenced by their response to seeing the therapist and smelling the lavender oil. The importance of pleasurable activity as a factor in improving a client's behavior, not to mention quality of life, cannot be underestimated. Feeling pleasure leads to many health benefits. (Charnestski and Brennan, 2001)
The use of sensory-based treatment with adult clients with developmental disabilities is promising and merits further investigation.
References available at www.advanceweb.com/OT or upon request.
Jeanne Shepard, MS, OTR/L, is an occupational therapist at Fircrest Residential Care Facility, near Seattle.