Catherine Cavaliere, PhD, OTR/L
New Jersey Occupational Therapy
Association Annual Conference
October 1, 2011

Clinical Hypothesis:


“ Sensory integration intervention fosters neural
adaptations that thereby support behavioral
adaptations within the environment in children with
autistic spectrum disorders(ASD).”
Core assumption of SI theory:

“The goal of sensory integration intervention is to
improve the efficiency of the nervous system in
interpreting sensory information for functional use.”
(Parham & Malliouz, 2000)

Treatment efficacy study – pre/post test measure of neurophysiologic change


Lack of research to support
the theoretical assumption
that SI intervention fosters
neural change
Lack of information in
literature as to how
children, with and without
autism, respond to sensation,
neurophysiologically,
PERIOD!



“How do children with ASD
respond to sensation
neurophysiologically? Is
there a relationship between
this and their behavioral
responsivity to sensation?”
Measure and methods
Dr. Lucy Jane Miller and
colleagues – Sensory
Challenge Protocol (SCP)
DSM IV
 Social Interaction





Communication





Marked impairment in nonverbal behavior
Failure to develop age appropriate peer relationships
Lack of spontaneous seeking to share interests with others
Lack of social or emotional reciprocity
Delay in or lack of spoken language
Marked impairment in conversational skills
Stereotyped use of language
Lack of age appropriate pretend or social play
Stereotyped Patterns of Behavior




At least one restricted pattern of interest
Inflexible adherence to routines
Stereotyped or repetitive motor mannerisms
Preoccupation with parts of objects
(American Psychiatric Association, 1994)

70-97% of children with ASD – atypical patterns of
sensory processing (Ornitz, 1989; Adrien et al., 1992, Eaves et al., 1994; Kientz and Dunn,
1996; Greenspan and Wieder, 1997; Tomcheck and Dunn, 2007)


Children with ASD – early signs of deficits in sensory
processing – central to ASD diagnosis (Baraneck, 1999)
Children with ASD respond differently to sensation,
behaviorally, than do children without ASD (Dunn and Kientz,
1996; Dietz and White, 2000)

ASD – most severe sensory processing disorders (Bagnato and
Neilsworth, 1999)



Patterns of physiological responsivity (EDA) that are different than
typically developing children and other groups of children with
behavioral difficulties with sensation
Decreased magnitude of EDR – hypo-responsivity (Miller et. al., 2000)
2 groups – High arousal – higher magnitude EDR; Low arousal –
lower magnitude EDR – heterogeneous group ( Schoen,S.A, Miller, L.J., Brett-Green,
B., &Hepburn, S.L., 2008)

Lower vagal responses to auditory and tactile information (Schaaf and
Benevides, 2006)
(McIntosh, D., Miller, L. J., Shyu, V., & Hagerman, R., 1999; Miller et al., 1999; Donelon,- Mangeot et al., 2001; Miller, L.J., McIntosh, D.N.,
Reisman, J.E., Simon, J., 2001; Schaaf , R.C.,& Benevides, T., 2006; Schoen, S.A, Miller, L.J., Brett-Green, B., &Hepburn, S.L., 2008)
“The objective of therapy for the autistic child is to
improve sensory processing so that more sensations
will be effectively “registered” and modulated, and
to encourage the child to form simple adaptive
responses as a means of helping him to learn and to
organize his behavior… As we continue to treat
autistic children, we shall find out more about their
neurologic problems and develop ways of “reaching”
their brains with sensory experience.”
(Ayres, 1979)
Occupational Performance
Adaptive Interactions
Behavioral state– attention, arousal
Neuro-physiologic state
Autonomic Nervous
System
Parasympathetic
Nervous System
Restorative
functions
Cardiac Vagal
Tone
Respond to all
environmental
situations
Sympathetic Nervous
System
Highly active
stressful
situations
Electrodermal
Activity



Parasympathetic nervous system’s (PsNS) modulation
of heart rate via the vagus nerve
Respiratory Sinus Arrhythmia(RSA) - rhythmic heart
rate variability within spontaneous breathing
2 functional aspects of CVT:



Baseline – rest – high CVT
Vagal regulation – change from baseline to respond to
environment – drop in CVT
More variability indicating more efficient neural
control
 physiologically able to meet the demands of any
situation – adaptive interactions
Physiologic
Variability
Physiologic
Flexibility
Behavioral
Flexibility
Adaptive
Interactions
(Porges, 1992;1995)
Healthy Neonates
High Risk - NICU
Porges (1995)

Higher baseline VT correlated with greater self-regulation and
more positive developmental outcomes
( Porges et al, 1996; Fox, 1989; DeGangi et al, 1991; Fox and Porges, 1985; Huffman, L.C., Bryan, Y.E., delCarmen, R.,
Pedersen, F.A., Doussard-Roosevelt, J.A. & Porges, S.W., 1998; Gunnar, M.R., Porter, F.L., Wolf, C.M., Rigatuso, J. &
Larson, M.C., 1995; Stifer and Fox, 1990; Richards, 1985)




Fragile x– lower baseline (less heart rate variability) VT than boys
without (Boccia &Roberts ,2000)
SMD – lower baseline vagal tone than children without (Schaaf et al., 2003; 2010)
ASD – lower baseline vagal tone than typically developing
children (Schaaf and Benevides, 2006)
Significant relationship between vagal tone and adaptive
behaviors - ASD - lower vagal tone had less adaptive behaviors
(vineland adaptive behavior scales) (Schaaf and Benevides, 2006)

More consistency in suppressing vagal tone in
response to environmental stimuli/task, the greater the
social and attentional capacities and more even
temperament
(Porges et al, 1996; Huffman et al, 1998; Fox, 1989; Calkins, 1997; Suess, P.E., Porges, S.W. & Plude, D.J,
1994; DeGangi et al., 1991;Gunnar et al., 1995; Stifter and Fox.,1990; Richards, 1987 )
Author
Subjects - age
Testing period
Results - VT
Fracasso et al.,
1994
5,7,10,13 months
Every 3 months –
4 testing sessions
Moderate stability
(r=.50-.55)
Stifter & Fox, 1990 Neonates, 5
months
5 months apart – 2 Not Stable (r=.07)
testing sessions
Fox & Field, 1989
3yrs
6 months apart - 2 Stable (r=.89)
testing sessions
Calkins & Keane,
1994
2 yrs, 4.5 yrs
2.5 years apart – 2
testing sessions
Moderate stability
(r=.57)
DoussardRoosevelt et al.,
2003
5-6yrs
2 wks apart – 3
testing sessions
Moderate stability
(r=.58)
Porges, 1992
NICU Neonates
first day off
ventilator, every
day for 5 days – 6
testing sessions
Stable (r=.90)
Author
Subjects
Task
Results - VT
Calkins & Keane,
2004
2yrs, 4.5yrs
Attention,
empathy,
frustration,
problem solving
No stability
(r=.05-.29)
DoussardRoosevelt et al.,
2003
5 yrs – once a wk
– 4 wks
Negative affect
elicitor task
Modest stability
wks 1-2 (r=.40)
No stability
second 2 wks
(r=.08-.25)
El-Sheik, 2005
9,11 yrs
Cognitive task
Emotional task
Stability –
cognitive task –
(r=.60)
No stability –
emotional task –
(r=.06)




Infants/ young children with high baseline vagal tone
demonstrate greater self-regulation
Children with ASD and SMD have lower baseline
vagal tone than children without
Infants/ young children who consistently suppress
vagal tone in response to a challenge demonstrate
greater attentional and social interaction skills and
more even temperament
Reliability– mixed results




Reliability of vagal tone has not been established
Limited information on vagal tone in older children
(4+)
Limited information on vagal tone in various
diagnostic groups including autism
Inconclusive information on the relationship between
physiologic responsivity(CVT) and behavioral
responses to sensation



Is cardiac vagal tone a reliable measure of physiologic
responsivity to sensation in both typically developing
children and children with ASD?
Do children with ASD respond differently
(behaviorally and physiologically) to sensation than
typically developing children?
Is there a relationship between the behavioral and
physiologic responses to sensation in children with and
without ASD?

Sensory Profile (Dunn, 1999)
Caregiver questionnaire
 Profiles a child’s behavioral responses to sensation
 Construct validity – sensory processing (Dunn, 1997)
 Discriminant validity - differentiate children with
ASD from children without autism, ADHD, SMD

(Kientz &Dunn, 1997; Ermer & Dunn, 1998)

Positively correlate with physiologic measures of sensory
responsivity (EDR) using the SCP (Miller et al.,1999;2000)


Test re-test/ Multifactorial repeated measures
design
Independent variables
Group
 Sensation (SCP)
 Testing session


Dependent variables


Physiologic responsivity to sensation (CVT)
Behavioral responsivity to sensation (SSP)

Experimental group
 Males with ASD - 4-11 yrs.
 No other developmental/neurological conditions
 No medications

Control group
 Typically developing males – 4-11 yrs.
 No developmental/neurological conditions
 No medications





39 boys (16 typically developing; 23 with ASD)
Excessive artifact (n=5)
Technical Difficulties (n=3)
Inability to tolerate testing (n=4)
15 typically developing boys; 11 boys with ASD
 Typically developing (TD)– 8.7 years
 ASD – 7.3 years

Psylab stand alone monitor (SAM) acquisition
and analysis system (Contact Precision Instruments)
 Heart rate and electrodermal responsivity
 Synced with the Sensory Challenge Protocol

MxEdit analysis program (S.Porges,1985)
 heart rate converted to vagal tone index
 artifact identification and editing








Five domains of sensation (vestibular, auditory, visual,
olfactory, tactile)
10 trials of each sensation – 3 secs per trial
15-19 sec. between each trial – random intervals
20 secs between domains
Baseline and Recovery
15 mins without stopping
Testing can be paused
Domains can be skipped







Meet/greet parents; complete forms
Acquaint child with testing environment
Explain testing procedures in age appropriate language
Child signs assent
Child seated - electrodes placed on child
SCP started
End of SCP child picks a small gift

Question 1: Is cardiac vagal tone a reliable
measure of responsivity to sensation in
typically developing children and children
with ASD?

Intraclass correlation Coefficient (ICC)
 Baseline measures of cardiac vagal tone
 Vagal changes in response to sensations

Question 2: Do children with ASD respond to
sensation (behaviorally and physiologically)
differently than typically developing children?


Repeated Measures ANOVA – within group patterns
of responsivity
Multivariate ANOVA – between group differences –
SCP and SSP

Question 3: Is there a relationship between
physiologic and behavioral responses to
sensation in children with ASD and typically
developing children?

Pearson Correlation Coefficient –vagal scores SCP
and SSP scores
Question 1: Is cardiac vagal tone a reliable
measure of responsivity to sensation in typically
developing children and children with ASD?
SCP Domain
_________________________________________________________
Total
Typical
ASD
M
SD
ICC
M
SD
ICC
M
SD
ICC
Baseline
6.36
1.20
.830
6.80
.981
.702
5.77
1.27
.889
Tones
6.57
1.16
.782
7.0
.933
.525
6.01
1.25
.905
Visual
6.59
1.05
.830
6.91
.847
.650
6.11
1.71
.911
Sirens
6.59
1.01
.828
7.01
.775
.724
6.03
1.07
.819
Olfactory
6.42
1.24
.920
6.91
.929
.923
5.74
1.33
.881
Tactile
6.55
1.17
.912
7.0
.779
.810
5.85
1.27
.916
Vestibular
6.76
1.11
.916
7.31
.711
.837
6.01
1.13
.896
Recovery
6.42
1.17
.851
6.90
.899
.710
5.77
1.21
.899
Av. Response
6.57
1.11
.894
7.04
.865
.801
5.94
1.18
.901
______________________________________________________________________________
Question 2: Do children with ASD respond to
sensation (behaviorally and physiologically)
differently than typically developing children?



Baseline - t(20)=2.58, p=.018
ASD – lower baseline vagal tone – less heart
rate variability at rest
Covariate


TYP (M=6.80, SD=.981)
ASD group (M= 5.77, SD=1.27)
F=3.04, p=0.13
P=.008
SSP
Sig._(a)__
TYP
M
175.0
32.3
18.5
SD
15.4
2.5
5.5
ASD
M
128.0
28.4
11.6
SD
16.4
5.1
6.2
SSP total
.000
Tactile
.013
Taste/Smell
.011
Movement
sensitivity
13.8
2.4
14.6
.81
.298
Under resp./
32.3
3.0
18.3
4.2
.000
seeks sensation
Auditory Filter
26.9
2.9
17.0
5.7
.000
Low energy
28.6
4.1
21.6
7.7
.012
Visual Auditory
24.2
1.7
16.4
4.5
.000
___________________________________________________________________
a Adjustment for multiple comparisons: Bonferroni
Question 3: Is there a relationship between
physiologic and behavioral responses to sensation
in children with ASD and typically developing
children?
SSP
TYP/ASD sessions combined
SSP total
Auditory
Visual/auditory
Visual/auditory
Visual/auditory
Visual/auditory
Visual/auditory
ASD sessions combined
Visual/auditory
SCP domain
r_______________
vestibular
vestibular
vestibular
olfaction
tactile
av. response
vestibular
.510
.526
.668
.509
.558
.542
.569
tones
.627
ASD session 2
Visual/auditory
sirens
.555
Visual/auditory
olfaction
.606
Visual/auditory
tactile
.551
Visual/auditory
vestibular
.708
Visual/auditory
av. response
.613
________________________________________________________________________



ASD - 99.9% of the vagal responses to sensations across
sessions were correlated (<.75) – Ex: visual 1 to
olfaction 2
Little physiologic variability across time and across
sensations
TYP- 77.5% - more variability across time and across
sensation



Overall high stability
ASD - high stability – little variability across
time (.819-.916)
TYP- mixed stability – more variability across
time (.525-.923)



ASD – sig. lower baseline vagal tone than TYP – less
heart rate variability at rest
Supports previous findings (Schaaf et al., 2003; 2010)
Supports reliability findings- pattern of less
physiologic variability - ASD
Less
Physiologic
Variability
Less
Physiologic
Flexibility
Less
Behavioral
Flexibility
Rigid/
inflexible
behaviors
Decreased
Adaptive
Interactions
(Porges, 1992;1995)
F=3.04, p=0.13






Vestibular system – central integrator (Cool, 1987) -
Spatial map – body, head, position and orientation - understand
our environment in relation to self
“reference base “against which all sensory input and motor output
must be evaluated ( Cool, 1987)
CN VIII - posterior parietal lobe (cerebellum and brainstem)
“bridge” between sensory inputs and motor outputs (Ayres, 1979)
Only sensory system that also has direct motor innervations (CN
VIII) at spinal level – muscle tone and arousal – low in ASD (Miller et. al,
2001)

Stereotyped behaviors – body sense driven (vestibular, proprioceptive
and tactile)

Vestibular - critical role as central integrator

Examples: body rocking, head banging, darting, rigid inflexible

Stereotyped behaviors - seeking out vestibular stimulation (Bender, 1947, 1956).



Clinically – stereotyped behaviors - child’s attempt to seek out
vestibular input
Treatment – large vestibular component
Goals of treatment - modulate arousal; increase body awareness;
improve sensory modulation; attention and interaction



ASD - demonstrated hypo-responsivity to
sensation (Miller et. al., 2000)
Our findings support this – physiologic hyporeactivity to vestibular information as compared
to TYP
Results - provide preliminary evidence to
support this clinical assumption : Stereotyped
behaviors - fulfill a need for additional vestibular
input in order to make sense of their environment


ASD – sig. lower scores on all sections of SSP except movement sensitivity
- TYP scoring lower
Vestibular Based – body position, orientation
 Questions related to safety awareness:
“ Becomes anxious/distressed when feet leave ground”
“Fears falling or heights”
“Dislikes activities where head is upside down”
 TYP –more behaviorally sensitive to movement because they more
efficiently react to vestibular information thereby providing them
with a greater safety awareness and better body awareness
Less physiologic
reactivity to
vestibular
Seek out
vestibular
input
Stereotyped
Behaviors
Less
behavioral
reactivity to
vestibular
SSP
TYP/ASD sessions combined
SSP total
Auditory
Visual/auditory
Visual/auditory
Visual/auditory
Visual/auditory
Visual/auditory
ASD sessions combined
Visual/auditory
SCP domain
r_______________
vestibular
vestibular
vestibular
olfaction
tactile
av. response
vestibular
.510
.526
.668
.509
.558
.542
.569
tones
.627
ASD session 2
Visual/auditory
sirens
.555
Visual/auditory
olfaction
.606
Visual/auditory
tactile
.551
Visual/auditory
vestibular
.708
Visual/auditory
av. response
.613
________________________________________________________________________

Visual/auditory section- single sensory system
 “holds hands over ears to protect from loud sounds”
 “is bothered by bright lights”
 “covers or squints eyes to protect from light”.

Other sections – multimodal
 “has a weak grasp”
 “has difficulty paying attention”
 “has difficulty standing in line close to other people”

SCP domains – single system based

Multimodal sensory experiences to SCP



Children with autism demonstrated less reactivity to
vestibular information both physiologically (vagal
responses )and behaviorally (score on movement
sensitivity section)
Support this clinical assumption that the stereotyped
behaviors - fulfill a need for additional vestibular input
in order to make sense of their environment
relationship between physiology and behavior



Small sample size
Not age matched
Initial testing anxiety



Preliminary info on reliability of vagal tone
Differences in physiologic responsivity
between groups – ASD less physiologic
variability
Relationship between physiology and behavior
Combined these findings provides preliminary
evidence to support the theoretical and clinical
assumptions that neurophysiologic state affects
behavior




Replicated - larger sample size
Compare these results to SNS measures
Modify the SCP to include some multimodal
sensory experiences
*Intervention studies
“The objective of therapy for the autistic child is
to improve sensory processing so that more
sensations will be effectively “registered” and
modulated, and to encourage the child to form
simple adaptive responses as a means of helping
him to learn and to organize his behavior… As we
continue to treat autistic children, we shall find out
more about their neurologic problems and develop
ways of “reaching” their brains with sensory
experience.”
(Ayres, 1979)






Dr. Genevieve Pinto-Zipp, EdD, PT
Dr. Susan Simpkins, EdD, PT
Dr. Valerie Olsen, EdD, PT
Dr. Raju Parasher, EdD, PT
Barbara Schupak, OTR/L, MPH
Michele Parkins, MS/OTR/L






Dr. Lucy Miller, PhD, OTR/L
Dr. Roseann Schaaf, PhD, OTR/L
Teal Benevides, MS/ OTR/L
Celebrate the Children School - Michele
Parkins, MS/OTR/L
Pediatric Therapeutics – Missy Briody,
MS/OTR/L
Bergen Pediatric Therapy – Lisa Koo,
MS/OTR/L






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