Using a Sensory Room as an Adjunct Therapeutic Modality in an Adolescent
Residential Treatment Center: An Outcome Study
Farrell Lindley, MOT, OTR/L
Mildy McDaniel, M.Coun., LCPC
ABSTRACT
Background:
Adolescents with a diagnosed psychiatric disorder(s) who are treated in a medical model
residential treatment center often present with atypical sensory processing patterns. The
use of a sensory room, created and staffed by Occupational Therapists, can be an
excellent adjunct therapeutic modality that is cost-effective and easily adaptable to
aftercare planning. This study explores how sensory systems relate to behavioral
organization and functional performance in an adolescent residential treatment setting.
Method:
Data from 144 adolescents presenting with co-morbid and dually diagnosed Axis 1
disorders treated in a locked RTC were examined, ALOS 101 days. This population was
introduced to the Sensory Room and the Sensory Suitcase by the Occupational Therapists
as an adjunct therapeutic modality in the Treatment Program. A self-rating scale was
completed pre- and post- Sensory Room and Sensory Suitcase intervention. Logs were
examined for a nine-month period and the data collected from 1) Sensory Room and
Sensory Suitcase self-rating scale; 2) Sensory Profile Outcomes; and 3) Primary and
Secondary Axis 1 diagnoses as determined, on discharge, by attending psychiatrist.
Results:
80% percent of patients presented, on admit, with atypical sensory processing patterns, as
determined by completion of the Adolescent/Adult Sensory Profile Self-Questionnaire.
The self-rating scale data found an 84% increase in positive, adaptive behavioral skills
post- use of the Sensory Room and/or Sensory Suitcase.
The data collected determined that assertively applying sensory strategies via the addition
of a sensory room, sensorimotor groups, sensory suitcases, and by merging occupational
therapy with a traditional clinical treatment team, the resulting adjunct therapeutic
modality increases adaptive behaviors and provides sensory coping tools for aftercare.
Discussion:
The authors have been fortunate enough at our RTC to have a licensed Occupational
Therapist on staff with training in sensory approaches. This OTs idea of adding a sensory
1
room to the RTC offered the other clinical staff an opportunity to learn more about the
role of sensory systems and behavior.
Occupational therapists observe how sensory systems relate to everyday living. When
observing a behavior, sensory trained occupational therapists, (OTs), look for triggering
factors. These include not only social and emotional causes, but sensorimotor issues as
well. OTs are looking for physical sensations that precede behavior. What was the child
seeing, hearing, feeling, doing; what was the child’s body position; what were the people,
animals, objects doing; what did the authors, as observers, not realize? Studies have
shown sensory defensiveness to have an 80% correlation with physical/sexual abuse,
emotional neglect, psychological trauma, traumatic injury, extended hospitalizations,
institutionalization, sensory deprivation and torture (Moore, K., 1998).
Mental health therapists, on the other hand, are most often trained to use a cognitivebehavioral talking therapy approach, studying the family history and considering the
more social and emotional aspects of behavior. It makes sense to combine these two
therapeutic approaches when it is considered that behavioral and/or cognitive techniques
do not often focus heavily on environmental conditions. Likewise, only addressing
sensory processing problems will not be fully advantageous when social and emotional
issues in a client’s history, such as abuse, are not considered (Hale, L., & Coy, A., 1997).
Occupational therapists examine how sensory systems, (our five senses plus two
sensations: proprioception and vestibular), correspond to behavior. Our olfactory system
is the only direct communicator with the limbic system, (emotion center of the brain) powerful functional considerations include: alertness, bonding, emotion, memory and
safety. The visual system unifies - it helps integrate and make sense of the other
sensorimotor systems. It is the most critical when interacting with the environment.
Gustatory is our sense of perceived flavor and taste. Because this oral-motor system is
linked to our cranial nerves, functional considerations include overall organization,
alertness, attention and focus and self-regulation. Our auditory system is important for
the functional considerations of hearing, balance, internal rhythm and safety. Our tactile
system relates to our skin – the largest organ in the body. Formed at the same time as the
nervous system, this sense has a powerful effect on emotion. The brain needs lots of
tactile input to maintain organization, enhance dopamine systems, and increase
regulation.
Occupational therapists consider two additional sensations when observing behaviors:
vestibular and proprioception. The vestibular system involves rotation of the head in
space and gravitational security, (where our body is in space). This system interacts with
the reticular activating system – our brain stem’s center for filtering alerting and calming
impulses. Our vestibular system is commonly known as our mood modulator.
The proprioception sensations are located at each joint and involve movement,
compression, stretch, information of where body parts are; giving a person a sense of
“me.” The strongest proprioceptive feedback is when muscles are against resistance. This
2
resistance enhances our serotonergic system by making it more responsive and increasing
stimulation of endorphins.
Our central nervous system, (CNS), is the primary building block for intellectual
development. Tactile, vestibular, and proprioceptive sensations are the closest to our
CNS. These three powerhouses are used for treatment interventions because of this direct
relationship. Sensorimotor development, (body schema, coordination), and perceptual
motor development, (visual, language), lead to development of cognition and intellectual
functioning, (academics, daily living activities) (Williams, M., & Shellenberger, S. 1996).
Any dysfunction to these developmental building blocks may cause gravitational
insecurity, and/or sensory defensiveness resulting in observable behaviors such as
avoidance, distractibility and increased activity level (Fisher, Murray & Bundy, 1990).
When looking at self-regulation and modulation it is important to look at the brain’s
ability to maintain and change alertness appropriately for a given task or situation.
Sensory processing is how the brain, through the central and peripheral nervous systems,
manages incoming sensory information. It’s the brain’s ability to filter needed and
unneeded sensory input. Sensory processing considerations include the underlying
development of all motor and social skills; the ability to learn and perform complex tasks;
assist with situational and behavioral responses; problem solving; attention; and decision
making.
Dysfunctional considerations include increased need for sensory input through self-harm;
unpredictable explosions of emotions; lack of interaction with the environment; increased
distractibility; difficulty with transition in daily routine; social isolation, and difficulty
maintaining balance between hyper- and hypo- activity levels.
Once the idea of adding a Sensory Room was brought to fruition, the authors began
adding the standardized Adolescent/Adult Sensory Profile Self-Questionnaire (Brown,
C., & Dunn, W., 2001) to the Admissions paperwork for all of the RTC adolescents. For
this particular study, the authors elected to focus only on Typical, Mild, or Moderate
differences in sensory processing patterns, as evidenced by the Self-Questionnaire. This
data was merged with Primary and Secondary Axis 1 diagnoses, and the Sensory Room
and Sensory Suitcase Self-Rating ordinal and pictorial logs.
It may be beneficial to briefly review the diagnoses used in this study before examining
the outcomes, (DSM-IV-TR, 2000). It’s useful to keep in mind the OT’s, as well as the
mental health therapist’s, perspective.
Learning Disorders – Formerly Academic Skills Disorders, this is diagnosed when
academic achievement is low, there are observable social skills deficits, low self-esteem
and demoralization. OTs know that if learning difficulties are diagnosed, then there is
frequently a sensory deficit present. But for a learning disorder to be diagnosed, the
difficulties must be beyond what is usually observed as a sensory deficit.
Attention-Deficit/Hyperactivity Disorder – This diagnosis has become familiar to
almost everyone who works with adolescents. The criteria include inner feelings of
3
jitteriness and restlessness, distraction by trivial noises, etc. Often these adolescents
appear with “sensation seeking” behaviors.
Oppositional Defiant Disorder – This disorder describes deliberate, recurrent, defiant
behavior leading to significant impairment.
Reactive Attachment Disorder – A defining feature for this disorder is inappropriate
social relatedness associated with grossly pathological disregard for basic emotional
and/or physical needs. This disorder is frequently associated with sensory defensiveness.
Substance-Related Disorders – Adolescents with this diagnosis show recurrent
substance abuse leading to clinically significant impairment or distress.
Schizoaffective Disorder – Remembering that “affect” is defined as the combination of
bodily sensations and emotions, this disorder manifests with delusions and disorganized
speech. The full criteria must be met for both schizophrenia and mood disorder.
Vestibular disorganization is a common observation with this disorder.
Mood Disorders – These disorders, for the purposes of this study, represents depressive
and NOS disorders. The mood disturbance is the predominant feature.
Bipolar Disorder – The authors looked at Bipolar 1- recurrent manic, and Bipolar 2 recurrent depressive. During severe manic episodes, violent or abusive behavior may
occur.
Obsessive-Compulsive Disorder – This is an ego-dystonic disorder. The obsessions are
intrusive and inappropriate, they consume at least one hour of time per day, and the
repetitive compulsions are used to neutralize the obsessive thoughts.
Posttraumatic Stress Disorder – Diagnostic features include either witnessing, or being
involved in, or learning about violent harm, serious injury, or threat to one’s self or
family member. Adolescents with this diagnosis will sometimes exhibit low responsivity
levels and will avoid stimuli associated with the trauma. OTs will often observe tactile
defensiveness in adolescents with this disorder.
Eating Disorders – Either anorexia nervosa or bulimia nervosa disorders can cause
repressed initiative and emotional expression. There is a frequency of depressed mood
and personality disorders.
Intermittent Explosive Disorder – The criteria include a lack of resistance to aggressive
impulses with resulting destruction of property or other assaultive acts.
Adjustment Disorder – The descriptive feature of this disorder is an identifiable stressor
that causes a psychological response which results in clinically significant symptoms,
either emotional or behavioral.
Adoption – This category was added because Intermountain Hospital opened its’ first
Sensory Room simultaneous to beginning a specialty track for adolescents who have been
adopted. Our OT’s have observed generalized sensory processing difficulties with this
population.
Results of Data from Sensory Profile were as follows: (N=144)
Diagnoses
Learning Disorders
Attention Deficit Hyperactivity Disorder
Oppositional Defiant Disorder
Typical
Mild
Moderate
0%
18%
33%
0%
41%
22%
100%
41%
45%
4
Reactive Attachment Disorder
Substance-Related Disorders
Schizoaffective Disorder
Mood Disorders NOS
Bipolar Disorder
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Eating Disorders
Intermittent Explosive Disorder
Adjustment Disorder
All Diagnoses
Adoption
0%
22%
0%
22%
17%
40%
20%
20%
0%
40%
20%
21%
50%
39%
40%
24%
38%
20%
33%
0%
50%
0%
32%
41%
50%
39%
60%
54%
45%
40%
47%
80%
50%
60%
48%
38%
The above results proved that 80% of patients presented, on admit, with atypical
sensory processing patterns. The authors then needed to gain data to show if the Sensory
Room interventions would indeed increase adaptive behavioral functioning, by compiling
outcomes from the self-rating scales. These scales gave the adolescents choices of
describing their level of alertness as LOW, JUST RIGHT, and OVERDRIVE. Results are
as follows:
Pre-Sensory Room Intervention
Post-Sensory Room Intervention
3%
10%
35%
61%
4%
87%
LOW (pre)
JR (pre)
Over (pre)
LOW (post)
JR (post)
Over (post)
5
Next, the authors needed to examine the data from the mobile Sensory Suitcases logs to
determine if there was an increase in adaptive behavioral functioning. The same selfrating scales were used as described above.
Motor Levels Prior to Sensory Suitcase
Intervention
22%
Motor Levels After Sensory Suitcase
Intervention
7%
6%
3%
75%
Low In
87%
Just Right In
Overdrive In
Low Out
Just Right Out
Overdrive Out
Conclusion:
The Sensory Profile helped us to classify adolescents with atypical sensory processing
patterns. This data was then merged with the Axis I diagnoses. The findings suggest that
this subgroup benefited from the use of the Sensory Room and Sensory Suitcases, and
furthermore, as an adjunct therapeutic treatment modality, occupational therapy provides
a beneficial addition to the overall mental health of adolescents. By merging occupational
therapy with a traditional clinical treatment team and by assertively applying sensory
strategies, adaptive behaviors and sensory coping tools for aftercare are increased.
In October, 2004, the authors presented this data for the first time in a workshop for
faculty and students at Sargant College at Boston University. The attendees were part of
the occupational therapy graduate program. The ensuing discussion further strengthened
our goal of a collaborative approach. Further discussion focused on the campaign of
several distinguished OTs, and part to add a Sensory Processing Disorder to the DSM-V.
At that juncture, sensory strategies will be widely recognized as a necessary adjunct
treatment modality contributing to the overall mental health of adolescents.
6
References
Brodsinsky, D., Schechter, M., & Marantz, R. (1992). Being adopted; the lifeline search
for self. (14-16). New York, NY: Random House, Inc.
Brown C., & Dunn, W., (2002). Adolescent/Adult Sensory Profile. San Antonio, TX:The
Psychological Corporation.
Carvebil, G.E., & Simmons, D.J. (1996). Abnormal tactile experiences in life disrupts
active touch. Journal of Neuroscience, 16, 2750-2757
Champagne, T., & Schubmehl, J., (2002, November). OT innovations for psychosocial
practice. Conference presentation. Provo, Utah
David, S. (1990). A case study of sensory affective disorder in adult psychiatry. Sensory
Integration Special Interest Section Newsletter, 13,4
Dunn, W., (2003, October). Living a sensational life, OT’s gift to humanity. Conference
presentation. Boise, Idaho
Goldberg, S. (2000). Clinical neuroanatomy made ridiculously simple (2nd ed.) Miami,
FL: MedMaster, Inc.
Gupta, M.A., & Schork, N.J. (1995). Touch deprivation has an adverse effect on body
image: some preliminary observations. International Journal of Eating Disorders,
17(2), 88-89.
Hale, L.H.B. & Coy, A.H. (1997). Collaboration & cross-referral in the treatment of
sexually reactive youth. Sensory Integration Special Interest Section Quarterly,
20,2.
Hanschu, B., (2003). Evaluation and treatment of sensory processing disorders.
Conference presentation. Boise, Idaho
Kranowitz, C. (2003). The out-of-synch child. New York, NY: Penguin Putman, Inc.
La Croix, J., Johnson, C., & Parham, L.D. (1997, March). The development of a new
sensory history: The evaluation of sensory processing. Sensory Integration
Special Interest Section Quarterly, 20, 3-4.
Mailoux, Z. (1992). Tactile defensiveness: some people are more sensitive. Sensory
Integration Quarterly
Mailiux, Z. (1993). The vestibular system: why is it so critical? Sensory Integration
Quarterly
7
Moore, K. (1998). Handout; University of Massachuttes Medical Center
Oetter, P., Ritcher, E., & Frick, S. (1995). MORE: Integrating the mouth with sensory
and postural functions. Hugo, MN: PDP Press, Inc.
Parlato; L., Lloyd, C., & Bassett, J. (1999). Young occupations unlimited: An early
intervention program for young people with psychosis. British Journal of
Occupational Therapy, 62(3).
Royeen, C.B., & Lane, S.J. (1991). Tactile processing and sensory defensiveness. A.G.
Fisiher, E.A. Murray, & A.C. Bunday (Eds.), sensory integration: theory &
practice (pp.108-136). Philadelphia:F.A. Davis
Williams, M., & Shellenberger, S. (1996). How does your engine run; a leader’s guide to
the alert program and self-regulation. (1-1-1-11). Albuquerque, NM:
Therapyworks, Inc.
Youngstrom, M., J., Brayman, S. J., Anthony, P., Brinson, M., Brownrigg, S., et al.
(2001). Occupational therapy practice framework. The American Occupational
therapy Association, Inc. Bethesda, MA.
8