8.2 Autism Spectrum, ADHD & Sensory Processing Differences

Autism Spectrum, ADHD & Sensory Processing Differences

Children with neurodevelopmental differences—including Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), and Sensory Processing Differences—frequently experience challenges in sensory modulation, attention, emotional regulation, and executive functioning. Certified Occupational Therapy Assistants (COTAs) collaborate with supervising OTRs to implement sensory diets, structured environmental modifications, visual supports, and self-regulation programs that support meaningful occupational participation across home, classroom, and community settings.

1. Autism Spectrum Disorder: Clinical Profile & Core Features

Under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Autism Spectrum Disorder (ASD) is defined by two primary core domains:

1. Persistent Deficits in Social Communication & Social Interaction:

   • Impairments in social-emotional reciprocity (e.g., difficulty sharing interests, engaging in back-and-forth conversation).
   • Deficits in nonverbal communicative behaviors (e.g., atypical eye contact, body language, facial expressions, gestures).
   • Difficulties developing, maintaining, and understanding relationships (e.g., adjusting behavior to suit varied social contexts, parallel vs. cooperative play).

2. Restricted, Repetitive Patterns of Behavior, Interests, or Activities (at least 2 required):

   • Stereotyped or repetitive motor movements, use of objects, or speech (e.g., hand flapping, spinning wheels, echolalia).
   • Insistence on sameness, inflexible adherence to routines, or ritualized patterns (e.g., extreme distress at small schedule changes, rigid transition rituals).
   • Highly restricted, fixated interests that are abnormal in intensity or focus.
   • Hyper- or Hyporeactivity to sensory input, or unusual interest in sensory aspects of the environment (e.g., adverse reaction to specific sounds/textures, excessive smelling/touching of objects, visual fascination with lights or spinning objects).

2. Dunn's Sensory Processing Framework (The Four Quadrants)

Dr. Winnie Dunn's Sensory Processing Framework conceptualizes how individuals receive, modulate, and respond to sensory stimuli. The model is structured around the interaction of two axes: Neurological Threshold (the amount of sensory input required for a nervous system to register and react) and Behavioral Self-Regulation Strategy (active vs. passive response).

+-----------------------------------------------------------------------------+
|                   DUNN'S SENSORY PROCESSING QUADRANTS                       |
|                                                                             |
|                                NEUROLOGICAL THRESHOLD                       |
|                          HIGH (Slow to Register)     LOW (Quick to Register)|
|                        +---------------------------+------------------------|
|  P   PASSIVE           |    1. LOW REGISTRATION    | 3. SENSORY SENSITIVITY |
|  R   (Acts in          | • Misses sensory cues     | • Notices everything   |
|  A   accordance        | • Appears sluggish, slow  | • Easily distracted    |
|  C   with threshold)   | • Low tone / unbothered   | • Hyper-reactive       |
|  T   ------------------+---------------------------+------------------------|
|  I   ACTIVE            |    2. SENSORY SEEKING     |  4. SENSORY AVOIDING   |
|  C   (Acts to          | • Craves intense input    | • Retreats from input  |
|  E   counteract        | • Fidgets, jumps, touches | • Rituals / rigid      |
|      threshold)        | • Fast-paced, noisy play  | • Covers ears / flees  |
|                        +---------------------------+------------------------|
+-----------------------------------------------------------------------------+

In-Depth Breakdown of the Four Sensory Quadrants

| Sensory Quadrant | Threshold & Strategy | Observable Behaviors in Classroom / Home | COTA Intervention & Environmental Strategy | | :--- | :--- | :--- | | 1. Low Registration | High Threshold<br>+ Passive Strategy | • Does not notice name being called.<br>• Leaves face or hands dirty without awareness.<br>• Walks into obstacles; fails to notice environmental changes.<br>• Sedentary, low affect, delayed motor response. | • Increase Stimulus Intensity: High-contrast visuals, bright lighting, alerting tactile cues.<br>• Multi-sensory prompting (auditory chime + tap on shoulder).<br>• Movement breaks with fast, irregular vestibular input. | | 2. Sensory Seeking | High Threshold<br>+ Active Strategy | • Constantly touching objects and people.<br>• Chews on clothing, pencils, or fingers.<br>• Crashes into furniture, stomps while walking.<br>• Seeks loud noises, spinning, and fast swings. | • Provide Structured High-Intensity Input: Proprioceptive 'heavy work', chewable jewelry (chewelry), vibrating toys.<br>• Movement seating (wobble stools, therapy ball chairs).<br>• Scheduled gross motor obstacle courses. | | 3. Sensory Sensitivity | Low Threshold<br>+ Passive Strategy | • Startles easily at unexpected school bells or sirens.<br>• Complains about bright fluorescent classroom lighting.<br>• Highly distracted by background noises or visual clutter.<br>• Complains about clothing tags, sock seams, or food textures. | • Minimize Background Clutter & Irritants: Noise-dampening headphones, dim or natural lighting.<br>• Seamless clothing, tagless shirts, predictable environment.<br>• Gradual, child-controlled desensitization. | | 4. Sensory Avoiding | Low Threshold<br>+ Active Strategy | • Covers ears and screams in noisy cafeterias.<br>• Hides under desks or in closets to escape group activities.<br>• Rigidly refuses novel foods, new environments, or crowds.<br>• Emotional meltdowns when routines change unexpectedly. | • Create Safe Quiet Zones: Sensory calm-down corners with low lighting and cozy beanbags.<br>• Advance warnings before transitions using visual timers.<br>• Small group seating away from doorways and high traffic. |

3. Ayres Sensory Integration (ASI) & The Sensory Diet

Ayres Sensory Integration (ASI) is a specialized, evidence-based theoretical framework and intervention approach founded by Dr. A. Jean Ayres. ASI posits that adequate processing and integration of sensory information—especially tactile, vestibular, and proprioceptive inputs—form the neurobiological foundation for motor planning, emotional stability, and academic learning.

The Three Primary Sensory Systems in ASI

1. Proprioceptive System (Joint & Muscle Receptors):

   • Senses body position, muscle tension, and force calibration.
   • "Heavy Work" Activities: Pushing weighted carts, carrying heavy books, wall push-ups, pulling elastic resistance bands, climbing ropes, and animal walks (bear walks, crab walks).
   • Therapeutic Value: Proprioception is uniquely modulating—it acts as an organizing, calming regulator for hyper-reactive children and an alerting, stabilizing regulator for hypo-reactive children.

2. Vestibular System (Inner Ear Semicircular Canals & Otolith Organs):

   • Senses head position, movement through space, gravity, and acceleration.
   • Linear Vestibular Input (Slow, Rhythmic Gliding): Calming and organizing to the nervous system (e.g., linear hammock swings, glider chairs).
   • Rotational / Angular Vestibular Input (Fast, Irregular, Spinning): Highly alerting, stimulating, and disorganizing if unmonitored. Must always be balanced with proprioceptive heavy work.

3. Tactile System (Skin Mechanoreceptors):

   • Light, Unexpected Touch / Tickle: Highly alerting; triggers protective fight-or-flight sympathetic arousal.
   • Deep, Sustained Pressure: Calming; stimulates parasympathetic nervous system, lowering heart rate and anxiety.

4. Sensory Diets & Weighted Modality Safety Protocols

A Sensory Diet is a planned, individualized schedule of specific sensory-motor activities embedded throughout the child's daily routine to maintain an optimal state of alertness, attention, and self-regulation.

+-----------------------------------------------------------------------------+
|                WEIGHTED BLANKETS & VESTS: CLINICAL PROTOCOL                 |
|                                                                             |
|   [WEIGHT CALCULATION]       ---> Blanket: Maximum 10% of total body weight |
|                                   plus 1 pound (e.g., 50 lb child = 6 lb).  |
|                                   Vest: Typically 5% to 10% of body weight. |
|                                                                             |
|   [WEAR TIME DURATION]       ---> 15 to 20 minutes maximum per application. |
|                                   Remove for at least 20–30 minutes between |
|                                   uses to prevent nervous system habituation|
|                                                                             |
|   [SAFETY & CONTRAINDICATIONS]---> Never wrap tightly around neck/face.      |
|                                   Child must be capable of removing blanket |
|                                   independently. Contraindicated in severe  |
|                                   cardiopulmonary/respiratory conditions.   |
+-----------------------------------------------------------------------------+

[!WARNING] Weighted Modality Safety Rules:

1. Weighted vests and blankets must never be used as a physical restraint or punishment.
2. The child must have the physical strength and cognitive capacity to remove the weighted item independently.
3. Habituation occurs if worn continuously; after 20 minutes, mechanoreceptors adapt, neutralizing the therapeutic benefit.

5. ADHD, Executive Functioning & Environmental Modifications

Children with Attention-Deficit/Hyperactivity Disorder (ADHD) experience challenges in sustained attention, impulse inhibition, working memory, and motor restlessness. COTAs implement physical and instructional accommodations to support task performance.

Classroom Environmental Accommodations

• Strategic Seating: Position the student near the teacher, away from high-distraction zones (windows, pencil sharpeners, hallway doors).
• Alternative / Active Seating:
  • Wobble Stools & Ball Chairs: Provide subtle vestibular and proprioceptive feedback, satisfying the child's neurological drive for movement without disrupting peers.
  • Inflatable Disc Cushions (Move-n-Sit): Place on standard chairs to allow dynamic pelvic tilting.
  • Bouncy Bands: Elastic resistance bands stretched across classroom desk legs allowing children to bounce their feet silently during seated work.
• Temporal & Task Structure:
  • Use visual countdown timers (Time Timer) to provide a concrete visual representation of elapsed time.
  • Chunking: Break multi-step assignments into single-step color-coded checklists.

6. Self-Regulation Frameworks & Visual Supports

Self-regulation programs provide children with a cognitive vocabulary and behavioral toolkit to monitor and adjust their internal arousal states.

+-----------------------------------------------------------------------------+
|                   THE ZONES OF REGULATION (4 EMOTIONAL ZONES)               |
|                                                                             |
|   [BLUE ZONE]   ---> Low alertness; Sad, tired, sick, bored, sluggish.      |
|                      Strategies: Jumping jacks, cold water, stretching.     |
|                                                                             |
|   [GREEN ZONE]  ---> Optimal alertness; Calm, focused, happy, ready to learn|
|                      Goal state for classroom academic engagement.          |
|                                                                             |
|   [YELLOW ZONE] ---> Heightened alertness; Frustrated, silly, excited, wiggly|
|                      Strategies: Deep breathing, heavy work, sensory break. |
|                                                                             |
|   [RED ZONE]    ---> Extreme alertness; Angry, explosive, terrified, yelling|
|                      Strategies: Calm-down corner, deep pressure, safe space|
+-----------------------------------------------------------------------------+

The Alert Program® ("How Does Your Engine Run?")

• Analogizes the central nervous system to a car engine:
  • High Engine: Hyperactive, racing, agitated, unfocused.
  • Low Engine: Sluggish, tired, lethargic, unmotivated.
  • Just Right Engine: Calm, attentive, regulated, ready for work.
• Children learn to identify their current "engine speed" and select appropriate sensory strategies (mouth, move, touch, look, listen) to bring their engine back to "Just Right."

Visual Schedules & Structured Teaching

• First-Then Boards (Premack Principle): Pair a non-preferred task ("First write 3 sentences") with a preferred activity ("Then 5 minutes of train play").
• Visual Schedules: Picture or icon sequences showing daily routines, reducing transition anxiety and increasing predictability.
• Social Stories (Carol Gray): Descriptive, perspective-taking narratives that clarify social expectations and provide coping strategies for challenging social situations (e.g., taking turns, fire drills).

7. Clinical Scenario: COTA Sensory & Self-Regulation Intervention

Clinical Case Vignette: An 8-year-old student diagnosed with ASD and sensory processing differences (Sensory Seeking + Low Registration) displays frequent disruptive behaviors during afternoon academic periods. The student repeatedly leaves their desk, hums loudly, chews on shirt collars, and crashes into hallway walls during line transitions.

COTA Treatment Plan & Session Protocol:

1. Sensory Diet Implementation:
   • The COTA establishes a scheduled 10-minute proprioceptive heavy work routine right before the afternoon work block (carrying a box of classroom library books, performing wall push-ups, and completing animal walks).
2. Classroom Workstation Adaptation:
   • An inflatable disc cushion is placed on the student's chair, and a Bouncy Band is installed on the desk legs to provide quiet sensory input.
   • A non-toxic silicone chewable pencil topper (chewelry) is introduced to substitute for clothing chewing.
3. Self-Regulation Training:
   • The student is taught to check their "Zones of Regulation" chart before sitting down; if feeling "Yellow Zone" (hyperactive/silly), the student performs 5 deep wall push-ups.
4. Outcome: The student remains seated at the desk for the entire 30-minute afternoon reading block, eliminates shirt chewing, and transitions safely without hallway crashing.