Toilet Training and Autism Spectrum Disorder (ASD)

                                                   

   


Children with Autism Spectrum Disorder (ASD) often prefer structured routine in their life. It is important to understand child’s level of awareness, strengths and challenges before starting toilet training. Most of the times children with ASD or Developmental Delay have sensory issues and poor motor planning skills causing too much of difficulties while understanding and carrying out this essential and unavoidable life-skill task.

Parents are advised to carefully identify and understand the indicators or signs of “good time to start” toilet training of their child. Usually, children display different behavioural patterns such as being fidgety or distracted when they are wet. They may show gestures of discomfort. Sometimes children also express their concerns by pointing towards their nappies. This is a strong indicator that child has developed awareness about wee and poo.

Children with tactile defensiveness might display greater sensitivity towards wet or soiled nappies, however, those with tactile hyposensitivity might not have awareness of wetness, being soiled or when they started/finished weeing or pooing.

Developing a toileting routine can be an insurmountable problem which can cause a lot of frustration to both parents and the child. Changing routine from wearing diapers or nappies to using the potty or going to toilet is a challenge for every toddler or a very young person, however, small but consistent steps towards this ultimate goal can make child independent in toilet training. Due to lack of social motivation children with Autism may not demonstrate any interest or inclination to use the toilet. Moreover, sensory issues such as a sound of the flush, toilet lighting, or the sound of toilet extractor fan can cause anxiety among children.

Toilet training tips for toddlers or very

Infant development: Birth to 3 months

An infant’s physical development is the source of pride and happiness. Each step of developmental milestone, from rolling to sitting followed with standing to walking brings child one step nearer to his own physical and mental independence.  As the child grows he becomes much more alert and responsive. Apart from sleeping, crying, taking the feed and filling diapers, he begins to move his body smoothly.

For infants’ motor development, various activities are manifestations of early development. By end of one and a half months, the child develops better coordination especially in getting the hand to his mouth and recognising mother’s touch. During this time baby’s brain generate millions of neurones every day causing body’s development at the phenomenal rate. He receives information through all the senses which help him to learn and grow.

During this period, he moves his head side to side while lying on his stomach. And keeps his fists tight. He may flop head backwards if unsupported since head and neck control are not yet achieved milestones. He explores his hands and brings them to the mouth for sucking. He uses different sensory systems such as vision, touch (tactile), auditory to explore the environment around them.

Primary reflexes like sucking and rooting are present since birth which help a child in taking mothers feed. In simple terms, these reflexes are already programmed in child’s brain system and assist him in breastfeeding. They are usually present for -4 months and then disappear and gradually feeding becomes voluntary control.

More reflex (Arms open outward on being tilted backwards) is commonly seen among children of 0-3 months. This reaction to reflex means that child’s balance and movement sense are developing well. Moreover, being able to hold head up when lying on tummy tells about functioning of the vestibular system (the sensory system responsible for maintaining our relationship with gravity). This sense gives us information where our head and body are in space. Due to this sense, the baby is able to roll, sit, stand and walk well.

Emotional Security has major role every newborn's life since it establishes expressive protection, trust and acquaintance with mother or caregiver. After delivery, child’s first bodily contact with his mother or caretaker has great influence on child’s body system for rest of his life. After contact, the brain should interpret ate the sensations correctly and appropriately in order to form the first emotional attachment. Sometimes, it is also called as mother-infant bond. This bond is essential for the physical and mental development of the baby. This bonding later helps in developing body image and body awareness. It also provides a sense of himself as the physical body. 

Tactile (Touch): The sense of touch relates to Tactile System. We (children and adults) are nourished, calmed and attached to mother or caregivers (bonding) through touch. This is considered as the first language of communication. An infant and mother completely depend on touch until language, cognitive skills are matured and other developmental milestones are not achieved.

The tactile system starts developing since 5th week of pregnancy, supports child to influence recognise different types of touch sensations as he grows. It has very important on newborn for the rest of his life. 

Functionally, this system supports in two important aspects, sucking and establishing emotional security. It comforts baby in sucking, chewing and swallowing food. Children who have difficulties in sucking may face challenges in eating different textures of food later in their lives.

Vision (Seeing): At birth babies, may look at highly contrasting targets, however, their abilities develop much later to distinguish between two images. Their primary focus is on objects 8-10 inches from their face. During the first-month child’s eyes work in conjugation and vision improves rapidly. Infants begin to follow moving objects with their eyes and reach to things at around 3 months. Sometimes their eyes may appear to cross or wander but this is normal since eye coordination is still not well developed.

Auditory (Hearing): A month-old child startles to loud sounds and smiles when spoken to. He responds to mother’s voice and quiets if crying. By this time, he may make pleasurable sounds such as cooing. As the child progresses to 2-4 months, he starts moving eyes in direction of sounds and responds to changes in voice tone of known people. He starts expressing displeasure and excitement. He may coo in response to face to face contact.

Gustatory and Olfactory (Taste and Smell): Babies orients to a smell of their mothers breastfeed. They display preference for pleasant smells and displeasure for pungent smells such as spoiled food

Activities for Development of Senses:

• ·   Baby’s tummy time is essential as it helps in colic movement and helps core muscles to strengthen.
• ·        Rocking, swaying and baby helps to promote vestibular sense.
• ·        Post-delivery skin-to-skin contact is important.
• ·        Daily massage and sponge play important role in child’s growth and development
• ·        Maintain hygiene
• ·        Talk to baby softly and gently.
• ·        Keep the environment clean, and quiet to support his sleeping well.

What is A Sensory Diet?

                                                                         

A sensory diet is a carefully designed, personalised activity plan that provides sensory input to a child or adult who needs to stay focused and organised throughout the day (Occupational Therapist Patricia Wilbarger). It is developed by an Occupational Therapist specifically according to person’s sensory needs and abilities. It is developed to achieve particular goals considering child’s preferences, limitations, and available resources.

For example, a child having touch sensitivities will be given a sensory diet of activities which will have a calming effect since they support oversensitive children to decrease hypersensitivity towards sensory stimulation.Fast light- touch sensations increase arousal levels whereas slow sensations have calming effects (Schaaf and Roley, 2001).
Activities such as deep pressure massage, pushing-pulling, sucking hard candy or fruit, hand push-ups, rocking, swinging, running, obstacle courses are some of the generalised examples.

Heavy work (movement against resistance or weight) activities provide proprioceptive input. It helps to regulate arousal levels both the ways meaning in calming the child over-aroused child and stimulating the under-aroused child. 

Sensory Diet is similar to the nutritional diet of the human body. As food and water are basic requirements for body’s survival as well as functioning, similarly sensory diet is essential for reaching, maintaining and improving child’s ideal (optimal) level of alertness. The aim of sensory diet is to support the child in becoming more focused, organised, adaptable and skilful. It helps the child to perform a meaningful task in a successful manner.

A child with low arousal (under-aroused) levels needs alerting activities, whereas a child with high arousal (over-aroused) levels requires calming activities. Due to sensory reactivity or modulation issues, a child may have poor self-regulation and emotional regulation skills (Schaaf & Roley, 2001). Personalised sensory diet helps to improve attention span and concentration levels hence improving the quality of life and academic achievement.

According to the founder of Sensory Integration Approach, Dr A Jean Ayres (1972), the child should be actively engaged in activity or therapy session, and sensory experiences should be matched with a “just right” challenge that requires the child to give an adaptive response. For example, a child with hyperactivity and impulsivity can be given calming activities such as pushing the wheelbarrow or counted chair push ups as a movement break depending on his level of hyperactivity, age, and physique

                                                                  

Children with Autism, Attention Deficit Hyperactivity Disorder (ADHD), Developmental Coordination Disorder (DCD), Developmental Delay have difficulties in sensory integration and praxis deficits causing problems in reading writing, copying from the blackboard, listening and understanding instructions in the classroom. Minimal to moderate noise, an odour of different environmental objects, visual sensitivities towards fluorescent light are some of the examples that do not bother a typically developing child while working or sleeping. This happens since child’s body “tunes itself automatically” and gets adapted to environmental demands. However, in an atypically developing child “tuning” component does not work well, causing the child to struggle at each step and every moment since his body has to “tune itself manually” to get adapted to environmental demands.

Due to slow information processing, any instruction or command given will take the time to process the information and then respond. The child will answer correctly to what has been asked, however, it may take a little time and hence person has to be patient.


The purpose of the sensory diet is to provide sensory “tune ups” throughout the day so that child keeps on getting input needed for information processing correctly. The activities recommended in a plan should have long lasting effect on behaviour as diet is the group of alerting, organising and calming tasks.

The child with sensory integration dysfunction needs an individualised diet of tactile, vestibular, auditory and proprioceptive nourishment that means all the activities should be based on these three sensory systems. Careful planning is the key to perfect sensory diet.



  What is Sensory Integration?       

As first described by Ayres (1972), sensory integration is defined as “the organisation of sensory information for use” (p.1). It is a neurological process that enables us to make sense of our world by receiving, registering, modulating, organising, and interpreting information that comes to our brains from our senses.

Researchers and clinicians have explored many aspects of sensory integration in a variety of populations including typically developing children, children with learning disabilities, Autism, Aspergers, and attention deficit hyperactivity disorder (ADHD). 

Recently Ayres Sensory Integration© trademark denotes the adherence to the core principles of Ayres original theoretical framework. This copyright distinguishes it from other often applied clinical practices.  Mailloux, Roley, and Glennon (2007) have been working on Ayres Sensory Integration Fidelity tool which is correlated to trademark.

Occupational Therapist's Role in Planning Sensory Diet:

Sensory Diets are planned by Occupational Therapy practitioners who use sensory integration therapy for intervention purpose. They are mostly trained in Sensory Integration which enables them to work precisely with children and adults having mental health issues. Due to the better understanding of child’s sensory processing difficulties and requirements they can formulate reliable and achievable goals along with intervention strategies. All the activities are aimed at enhancing the child’s ability to participate in the day to day chores within the school, home and community.

                                                                   

Referral: Occupational therapist receives a referral from  GP,  SENCO/ head teacher depending on Borough as each borough has different systems.On getting the referral, OT  communicates to family and makes observations from SI point of view.
OT efforts to discover child's strengths and areas of weaknesses as he assesses sensory challenges (e.g.- touch, smell, vision, movement, hearing) and motor difficulties such as  poor body awareness, handwriting difficulties, right and left discrimination and then  plans  activities according to child’s needs and abilities on discussion with child, parents or caregivers following the client-centred approach.

Comprehensive Assessment : The assessment and information gathering involves taking histories, structured interviews. The main sensory integration assessment involves touch, movement, sight, hearing, smell, pressure, and taste. Along with these areas, behaviour, body awareness, motor coordination, learning in a classroom, attention, emotional liability is also assessed within different settings. 
Sensory Checklists: Occupational Therapists carry out clinical observations in structured and unstructured environments, follow sensory checklists and  use the standardised assessment tool called as Sensory Integration Praxis Test (SIPT), SPM, and Sensory Profile. The OT should be trained and certified to administer SIPT assessment.

Education: Educates child and family about sensory Diet plan and how it works.

Setting Goals and Outcome Identification: Therapist sets achievable, flexible and systematic goals for the child. He selects and schedules activities according to child’s abilities and deficits. Therapist set’s appropriate goals which are compatible with family’s beliefs, ethics and religion. They should work well within a family routine.

Activities Selection & Sensory Diet Planning: Activities are planned in correlation with goals. Mainly activities involving three sensory systems - tactile, vestibular, and proprioceptive are chosen since they are baseline systems for all behaviours. For example, child doesn’t like to be touched or hair washed, happens due to deficits in touch system, likes too much of movement or rocking happens due to deficits in vestibular system (sensory seekers), lacks body awareness, happens due to proprioceptive difficulties or is a picky eater happens due to oral hypersensitivities.So the activities are planned depending on sensory system deficits and careful planning is the key to sensory diet.

Follow-up: After a period of time therapist re-analyses effectiveness of intervention Plan. Activities are changed as the child able to accomplish the "just right" challenge. Activity modification and task gradation while measuring the outcome of the intervention is an important part of therapy plan. 

Video Description Credit: Unique Prints

                                                                     

In My Sensory Box!

                                                   

                                                  


A child with the Sensory Integration Dysfunction may find everyday experiences more challenging than any other typically developing a child. According to Dr A Jean Ayres, the founder of Sensory Integration theory, it is important to understand child’s needs and structure the environment accordingly since this process helps brain with poor processing to preserve stability and function properly.

Children with SI Dysfunction often display poor behaviour within the classroom and home setting. As per Dr Ayres theory, poor processing of brain leads to ineffective behaviour. She also concluded that SI dysfunction is not a disease that will get worse however, it impacts child’s life to a great extent. 

Children with SI Dysfunction may have learning difficulties and may often feel uncomfortable about themselves. It is difficult for them to cope with ordinary situations and can easily be stressed or anxious at home, classroom or public places.

Some issues like lack of focus within the classroom, handwriting difficulties, hyperactivity, impulsivity, inattentiveness, clumsiness, falling from chair frequently, difficulties in copying from blackboard are seen among SI dysfunction children within classrooms.

Sensory reactivity issues such as tactile defensiveness, sensory seeking behaviours (spinning, jumping, touching everything, not being able to sit still), disorganisation, sensitivity towards minimal noise, reading and writing difficulties, getting frequent headaches by end of day, are some of sensory issues that occur due to lack of brain’s registration and modulation.

To combat above stated sensory integrative difficulties and improve child’s focus within the classroom Occupational Therapists often set up sensory boxes having different sensory items that can be helpful for 

children.

 Items such as a weighted vest, lap weight, shoulder weight provides deep pressure to larger body part dampening the tactile defensiveness. Due to deep pressure proprioceptive receptors cause calming effect on body helping the child to stay focused within the classroom. Weighted items reduce the hyperactivity and impulsivity. Likewise, fidgets help the child to concentrate and reduce high levels of anxiety. 

 Concept Of Sensory Box

Sensory Box is a large container having different sensory items in it. These items support the child in being focused and engaged on given task, attentive and well-organised in his daily routine activities within the classroom.

This is a smart concept to simplify lives of everyone (pupil, teacher and parents) which involves utilising different sensory resources that support child’s self-regulation, learning, positive behaviour. These boxes help the child to provide sensory input needed to keep him alert, oriented and calm.

Weighted Items:

Shoulder and neck weights, lap weights, wrist, ankle weights, snakey weights,

weighted scarfs are weighted products for:

ü  Calming down child and works well to reduce anger, aggression

ü  Reducing impulsivity and hyperactivity

ü  Providing tactile-proprioceptive input, as the body gets consistent deep pressure.

ü  Supporting to stay focused on the task.

Pencil grips:

ü  Supports in improving handwriting legibility.

ü  Provides tactile-proprioceptive input. Resource

Sponge ball and other Fidget Toys:

ü  Stress Ball: Reduces anxiety levels in different environments such as a

classroom or shopping mall. Facilitates attention and concentration.

ü  Use of different magnetic balls can work as a fidget. They are quite handy and can be easily purchased from online retailers.

ü  Older kids can use paperclips, Blue Tac, or mechanical pencils. While sitting at a desk, manipulating, or linking paper clips together can work as the incentive in class.

ü  Doodling on paper is another way to keep oneself busy while focusing in the classroom.

ü  Making bracelets and fidgeting with that can be helpful too.

ü  Play -Doh can also work as fidget toy as it helps to improve hand strength too. 

ü  Other common fidgets can be giant nut and bolt, key chains, fidgeting fleece bags, finger squeezers, tactile balls (koosh ball), pencil Topper fidgets, sensory ruler.

Wobble Cushion and Wedge:

ü  Wobble cushion can be an important classroom tool for seating and focus.

ü  It provides tactile-proprioceptive input

ü  Encourages dynamic sitting which causes improved balance and postural control.

ü  Strengthens core body muscles and back pain.

ü  It improves the posture of child and reduces slouching

Weighted Vest:

ü  Provides Proprioceptive input and supports in calming down a child as the body gets consistent deep pressure.

ü  The steady application of pressure helps a child in reducing the self-stimulatory behaviour.

ü  Improves attention and concentration level.

ü  Reduces distractibility, impulsivity, meltdowns and emotional liability.

   Weighted Vest should be always prescribed by an OT as she is trained to understand how much weighted vest is needed by the child to provide just right amount of deep pressure depending on his age and level of sensory integrative difficulty.

Squease Jackets:

ü  Are inflatable vests meant for providing receiving deep pressure evenly across the torso

ü  They contain a hand pump which can be used for inflating and deflating the air pressure.

ü  Provides the amount of deep pressure suitable to child’s needs.

ü  Easy to wear and operate hand pump.

ü  Helps in self-regulation. Resource

Ear Defenders:

ü  Helps to reduce auditory sensitivities and distraction.

ü  Improves concentration within a classroom

ü  Reduces non-attending behaviour such as getting up frequently from the seat and moving around in the classroom, fidgeting.Resource

Writing Slope:

ü  Supports inappropriate writing.

ü  Provides ergonomically correct posture, supporting hands and wrist.

ü  Reduces strain on neck and shoulder muscles as the child leans forwards.

ü  Aids in writing and holding tools correctly.Resource 

Massage Roller:                                    

     

ü  Provides proprioceptive and tactile input

ü  Good source of relaxation.

ü  Quickly calms child.

ü  Can be used while studying or while listening to teacher’s instructions. Resource 

Timers:

ü  Good source of organisation. Timers assists the child in keeping a check on time while completing any written task in hand.

ü  Digital times: Assists child in reading hours, minutes, seconds and milliseconds.

ü  Sand times: This resource is used as better visual support for young children who get confused with numbers and have time reading difficulties. Resource 

Thera-bands and Stretchy Tubes:

ü  Provides stretch release to the whole body                 

ü  Provides sensory input to joints and ligaments (proprioceptive input).

ü  Helpful for movement break.

ü  Good resource of exercise. Resource

Chewy Tubes:

ü  Prevents thumb-sucking

ü  Has calming, focusing and organising response.

ü  Reduces anxiety levels

ü  Substitute for nail biting and chewing

ü  Substitute for oral stimulation and sensory input (kids putting crayons, fingers, pencils, sweatshirt, cloth strings)

ü  Reduces self-stimulating behaviours (hand flapping, rocking, spitting)

ü  Provides sensory input (tactile, proprioceptive) to mouth which has a calming effect.Resource 

Bridging the Gap: A Sensory Friendly Classroom

                                                 

A classroom is an important practice environment where pupils improve their learning skills and develops a better understanding of life and the community. They get equipped with education to follow their future dreams, however, interference of sensory processing difficulties can hinder a child’s learning abilities and self-esteem to a great extent. 

At the same time inclusion of child within the school brings opportunity for teachers and members of staff to support one more child in becoming independent to her maximal potential, though, it also brings unseen responsibilities on class teacher to understand child holistically from diverse perspectives which may or may not be the part of academic teaching and learning process.

As an Occupational Therapist in a special needs school, I realised that educating and supporting teachers along with other members of staff, regarding the inclusion of Sensory Smart classrooms and related strategies is an indispensable part of my job role.

Often, teachers welcome sensory strategies and sensory integration tools within their classroom settings, suggested by Occupational Therapist in the first place, however feeling themselves ill-equipped to understand the appropriate utilisation of sensory tools, the sensory intervention is discarded or evaded very soon, considering as a waste of time or not their area to work in.

It is imperative for an occupational therapist to reassure, assist and collaborate with teachers in designing sensory-friendly classrooms and implementing sensory strategies among children. Educating and supporting the whole staff regarding sensory environment will aid in developing knowledge for sensory needs and behaviours are often seen among Autistic, ADHD, and Sensory Processing Disorder (SPD) children.

Modifying tasks and classroom environment can make significant changes in child’s learning potential and behavioural patterns. The classroom affords enormous amounts of sensory stimulation and distractions which lead to “sensory overload”. 

Halogen lights, front wall decorations, much written information on the white board, cluttered desks and surroundings, background noise or poor acoustics, children moving around are some of the physical environment factors that don't allow the child to concentrate well and pay attention to task in hand. Taking too much of information within can lead to flight, fright and freeze reactions.
These strategies can be recommended by school’s Occupational Therapist according to child’s primacies and requirements. Sensory Diet which is a personalised activity strategy plays a pivotal role in child’s academic achievement, learning, and positive behaviour. It should be planned in collaboration with class teachers to achieve the potential outcome from the sensory diet plan.

A child’s future depends on team collaboration, effort, and coordination within a learning institute. It will be injustice with the pupil and the parents who establish their trust in school system believing that their child is in right hands and being armed with best quality education, environment, and social ethics to face the challenging world and live a

OT recommended strategies for Sensory-friendly classroom.

Sensory Box:

It is a large container having different sensory items in it. These items support a child in being focused and engaged on given task, attentive and well-organised in his daily routine activities within the classroom. 

This is a smart concept to simplify lives of everyone (pupil, teacher and parents) which involves utilising different sensory resources that support child’s self-regulation, learning, positive behaviour resulting in increased self-esteem. For example, use of ear defenders helps to improve engagement and attention span on the task in hand within the classroom or home setting. 

It reduces various sources of auditory distractions (e.g., classroom noise, outside classroom voices, birds chirping, children shouting in the playground) that can be the potential threat to children as learning. 

These distractions will hardly bother anyone without Sensory difficulties, however, do have a great impact on the child with auditory hypersensitivity.

Sensory Diet:

It is a carefully designed, personalised activity plan that provides sensory input to a person needs to stay focused and organised throughout the day. It is developed by an Occupational Therapist specifically according to person’s sensory needs and abilities. It is developed to achieve particular goals considering child’s preferences, limitations and available resources. 

For example, a child having touch sensitivities will be given a sensory diet of activities having a calming effect such as deep pressure massage, heavy work, pushing-pulling, sucking frozen candy or fruit, hand push-ups, rocking, swinging, running, obstacle courses. Moreover, activities will be devised depending upon child’s choice and developmental age. 

Sensory Diet is similar to the nutritional diet of the human body. As food and water are basic requirements for body’s survival as well as functioning, likewise sensory diet is essential for reaching, maintaining and improving child’s ideal (optimal) level of alertness. The aim of sensory diet is to support the child in becoming more focused, organised, adaptable and skilful. It helps the child to perform a meaningful task in a successful manner.

Handwriting:

Children with handwriting difficulties should be given proprioceptive input

by utilising different positions, pen grip alternatives and related modifications. Here’s the link for handwriting strategies.

Homework Alternatives:

Provide homework printouts or give assignments in writing and not verbally. Most times it is better to post homework on school website so it is easier for parents and kids to understand the given assignments. Most of ADHD kids have difficulties in copying from whiteboard of blackboard due to distractibility and inattention to focus

Writing Slope:

• Supports inappropriate writing.
• Provides ergonomically correct posture, supporting hands and wrist.
• Positions reading and writing text inappropriately.
• Reduces strain on neck and shoulder muscles as a child leans forwards.
• Aids in writing and holding tools correctly.

Movement Break Activities:

• Star Jumps: These are good to involve whole body coordination.
  
• Animal Walks: Walking like bear, elephant will improve body sense
• Marching: This also involves coordination between both sides of the body, can be difficult. Initially start with feet marching, once mastered, then include arms.
• Play Hopscotch: This will give distance and space judgement
• Commando Crawling: Involving both hands and feet.
• Body Paint: Ask the child to paint his particular body parts such as a right-hand or left-hand index finger.
• Body Image: Ask a child to draw around his partner’s body on the large sheet and label body parts.

Colour coding:

It is best to colour code each and every subject and study material. For example, all maths folders, binders and handouts can be colour coded with red or green. Similarly, DT can be blue or yellow. This will help the child to organise and manage papers easily and conveniently. 

Moreover, it saves a lot of time and energy from being wasted which can be drained in locating one assignment sheet or revision paper. It is better to involve child when doing colour coding of the particular subject since he may have different perceptions about varying colours. 

Logically, colour coding gives visual stimulation and a clue to the brain regarding reference subjects.