Interview with Lorna Jean King, OTR, FAOTA
Lorna Jean King (LJK) is one of the pioneers of sensory integration therapy. Ms. LJK is an international lecturer on this topic, and is the Founder and Director of the Center for Neurodevelopmental Studies, Inc. in Phoenix, Arizona. This interview was conducted by Stephen M. Edelson (SE) on June 9, l996.
SE: How did you get involved in the area of sensory integration as well as autism?
LJK: My interest in sensory integration started when I was the Director of Rehabilitation at Arizona State Hospital. I was very interested in the literature which indicated that the vestibular system seemed to be involved in schizophrenia; that is, many schizophrenics do not have normal responses to vestibular stimulation. They have little or no post-rotary nystagmus.
SE: Does this apply to those with childhood schizophrenia, since autism was, at one time, confused with schizophrenia; or does this apply to schizophrenia in general.
LJK: It seems to apply to what is termed "negative symptom" schizophrenia, or early onset schizophrenia, but not always to childhood schizophrenia. There have been many research studies over the years showing involvement of the vestibular system in schizophrenia. I knew that Dr. Jean Ayres, whom I had known earlier, was working on the vestibular system which was involved in her sensory integration theory. We began using sensory integrative treatment with chronic schizophrenics and had quite marked success in improving their ability to function. We also had a children's unit at the State Hospital which housed several autistic children. Since we had an opportunity to work with them, we used sensory integration therapy with them and also had some very encouraging results.
SE: Can you briefly describe what is the goal of sensory integration?
LJK: The goal of sensory integrative therapy is to facilitate the development of the nervous system's ability to process sensory input in a more normal way. Sensory integration is a term for a process in the normal brain which pulls together all of the various sensory messages in order to form coherent information on which we can act. Basically everything we do requires sensory integration. This normal process can be missing or very badly organized in some people, notably autistic individuals.
SE: I assume there are many theories of what went wrong with respect to integrating different senses.
LJK: Yes, there are many theories, and several of them make sense. Many years ago Bernard Rimland's book, Infantile Autism, suggested that the problem with these children might be in the reticular formation. This area in the brain is responsible for keeping the brain alert and organized. Research by Bauman and Kemper, and Courchesne has shown that the cerebellum is involved in autism and I think it is also a good candidate for the root of the problem.
SE: What should parents look for when deciding whether or not to have their child receive an evaluation for sensory integration?
LJK: Parents should look for things that indicate that the balance system is not quite normal; for example late motor milestones, or the child who falls and hits his face because he isn't getting his arms out to break his fall. The child who is unusually fearful of movement, or who lacks normal fear of falling, may not have normal balance (vestibular) sense. The child who is very hyper-sensitive to sensory stimulation is a candidate. These sensitivities include over-reaction to noise, disliking to be touched or held. These are the children who stiffen up rather than liking to be cuddled, scream when their hair is combed or washed, or when they are bathed or dressed. These are the types of behaviors which are most common in children whose sensory integration systems are not functioning well.
SE: There appear to be three major areas which are addressed with sensory integrative therapy - - vestibular, proprioceptive, and tactile. Could you describe each one for us?
LJK: The vestibular system, located in the inner ear, relates us to gravity. It gives us our sensation of the weight of our body. It also tells us where we are in space, standing up, or on our head; whether we are falling, or turning our head. It monitors our head and body movements in any direction. It works 24 hours a day, and therefore is a very big source of input.
The proprioceptors are the neuroreceptors in tendons, muscles and joints. They tell us where our foot is when we pull it back to kick a ball, or how high our hand is when we reach up to comb our hair. Because the proprioceptors are getting input whenever we move, they also are a large source of sensory input. Proprioceptive input can vary in intensity. When one jumps on a trampoline, there is more intense input to the ankles, knees, and hips than there is in walking. Pushing a wheelbarrow full of cement is more intense input to the wrists, elbows and shoulders than pushing an empty wheelbarrow.
The tactile or touch system has three different types of receptors. One responds to light touch, like touching a hair on one's hand. This is a protective, alerting sense which makes us check on what is touching us in case it might be dangerous, like a bug crawling on the skin. The second receptor is for discriminative touch, for example when you reach in a pocket and know by feel whether you are touching your house key or your car key. We learn a great deal more than we generally realize through this sense of discriminative touch. The third set of touch receptors are those which receive information about heat, cold, and pain.
Interestingly enough, children who do not process sensory information efficiently often do not have good reception of heat, cold, and pain input. As sensory integration becomes more efficient through therapy, they often become more normally aware of heat, cold and pain. Sensory integration therapy seeks to help the child be less hypersensitive to light touch, better able to use discriminative touch to learn, and more able to respond appropriately to heat, cold, and pain, and thus be more safe from harm.
SE: When a therapist offers sensory integration therapy, does it also involve other senses, such as smell, taste, vision and hearing? Or does sensory integration focus only on vestibular, tactile and proprioception?
LJK: Sensory integration therapy works with all the senses, but the vestibular, tactile, and proprioceptive senses are important because they are such large sources of input. Of course, they are connected to everything else. For example, the vestibular system and the visual system are very closely associated, and often a child's ability to use his eyes in a coordinated way will improve as he/she receives enough vestibular input. Hearing is also very important, of course, and one of the things that we offer is "auditory integration training" which aims to help balance the way the nervous system receives auditory input so that the child will not be hyper-responsive to particular sounds or to auditory input in general. This is a promising field.
SE: Have you yourself seen changes as a result of auditory integration training?
LJK: Yes, we have had some children who have shown increases in language and a decrease in sound sensitivity. Not all children show improvement. Some children show marked improvement, and others show a little improvement.
SE: Well, that statement is true for a lot of treatments out there. What advice do you give to parents of a recently diagnosed child?
LJK: I advise them to do a lot of movement activities with the child. They should not force things on them, but encourage climbing, walking, swinging. These activities will help develop the vestibular system. For children who are hypersensitive to touch, a massage with lotion or powder, or an extra-long rub down after a bath may help to overcome oversensitivity. Many of the activities one might suggest are things that one normally does with ordinary children, but that are needed in much larger quantities by the autistic child.
SE: If it is not obvious that a child has any sensory problems, would you still suggest that he/she have a sensory evaluation?
LJK: Yes, I would. Based on our experience, which has been pretty extensive, I would say that 85 to 90 percent of autistic children have sensory integration problems. Some are much more obvious than others. A therapist's trained eye may pick out subtle signs which may be quite significant, but which a parent might not realize were important. Often small gains in helping the child be less sensitive to sensory input can make big changes in behavior.
SE: Do you think these sensory issues are more common in those who have a severe form of autism versus those who have a few autistic symptoms?
LJK: I believe there are sensory integration problems across the spectrum, but, yes, there are more severe problems in some children than others. This does not correlate with intelligence. Function in some realms may be quite normal, but the child may be totally handicapped by extreme fears which are often sensory-based.
SE: What are some things people might see soon after going through sensory integration therapy?
LJK: I think the first thing that parents often observe is a decrease in tantruming, less panic reactions, less fear, and more willingness to interact with other people. Often eye contact increases within two to three months, sometimes after only a week or two.
SE: What about their arousal level? Are they calmer?
LJK: Yes, They are usually calmer, and they are more able to handle ordinary stimuli. Parents often report that they can take their children to the restaurant without their becoming upset. After a few months to a year, I think parents will notice improvements in communication. We may see an improvement in oral communication, but almost always there is a greater ability to communicate needs either using gestures, signs, or pointing to pictures. As a result, the frustration from not being able to communicate lessens. We also see an improvement in the child's ability to learn, - learning the meaning of numbers and the basic concepts needed for reading.
SE: Is a person ever too old to benefit from sensory integrative therapy?
LJK: No, not really. We know that the nervous system develops by making new connections between neurons throughout life. As some connections disappear through disuse, other connections can be formed as a result of new experience. So the brain is able to make adaptations at any age. We have had good results with teenagers and adults. A 39 year old is the oldest person we have worked with recently, and that person made tremendous gains. Initially, he was not able to be in any kind of a day care program because of his aggressive behavior. After about six months of weekly treatment, where his parents continued the treatment at home, he was able to be in a day treatment program with no further problem. So the changes in behavior can often be very important in older people.
SE: How much sensory integrative therapy does a person need? Or does it just depend on the individual?
LJK: I think that usually more is better. In our program we work with children five hours a day, five days a week. Unfortunately, this is not often possible. In the public schools a therapist may see a child for a half-hour a week. This is not very adequate. I am not saying that these children will not benefit, but it could be a much faster process. Treatment does not go on forever. The goal is to return the child to a normal classroom or a normal community setting as soon as possible. Ideally, if we are able to start with a pre-school age child, intensive treatment might go on for a year or two and then could be scaled back to a follow-up schedule.
SE: When families see a private practitioner, it is usually once a week. Would you suggest that parents also provide some type of sensory integration therapy for their children at home?
LJK: Yes, I think that is important. However, I think that what is crucial is that parents understand the rationale for doing these things and that this is not some sort of witchcraft. Basically, there are good neurological reasons for swinging the child, doing lotion rubs and things of this kind. I also think it is important that parents do not feel victimized by the need to do therapy. We believe that the whole family is important, not just the handicapped child. The siblings and the parents need time for themselves, so we try to give the parents activities that are fun, that siblings can take part in, and that the whole family can do. We tell them that if there are days when you just don't have the time, or it becomes a real chore, then skip that day. The child knows if the parent is not enjoying the activities, and they won't want to do it either. It is important that it not be a burden. It has to be fun.
SE: Should parents ask the therapist for suggestions on what to do at home?
LJK: Absolutely. They certainly should ask. And most therapists will give them lists without being asked. But if they have not been given a list, they certainly should ask.
SE: Your program uses Temple Grandin's Hug Machine. How is this working out?
LJK: We have some children who like it a lot. They spend quite a bit of time, almost every day, in it. But there are also children who are not interested. The Hug Machine is a good method for applying sustained pressure, which is one of the most effective calming techniques. Some children prefer other methods of getting sustained pressure, such as being wrapped in elastic bandages for a time.
SE: Could you comment on the relationship between behavior and sensory needs?
LJK: People need to be re-educated to understand that behavior is always communication, - it is always telling us something. People often use the word "behavior" to mean "bad behavior". Often the child does not know any other way to tell us. It is our business to find out what the behavior is communicating. Often sensory sensitivities are actually painful and the child's behavior is an attempt to escape. By being observant, finding out what triggers the "behavior", we can modify the environment, and help the child find acceptable ways to cope, such as teaching him to wear ear phones to protect himself from too much noise. As we use sensory integrative therapy to raise the child's threshold for arousal, and provide calming inputs, we can see improvements in "behavior".
SE: Let's talk about problems at school and how to handle them.
LJK: There are many problems at school that can be dealt with effectively by simply changing the student's environment, such as protecting the child from noise. One of the important ways is for the teacher to use a very low tone or to whisper when she really wants to get a child's attention, rather than raising the voice. The teacher may try to teach all of the children to use quiet tones. In our program, we talk about using "your indoor voice" inside, which means talking quietly.
We also find that sitting on a beach ball or a T-stool can help the child attend. This provides extra vestibular and proprioceptive input which helps the nervous system organize and process information better. We have a large box at our Center that is lined with pillows and a bean bag chair. When we see that a child is beginning to get upset or stressed, we invite the child to get in the box and look at a book or listen to a tape. We use this as a preventive method to short-circuit "bad" behavior. In other words, we give the child a respite from a situation that is getting too stressful. We have found that this works quite well. We do not use "time out" as a consequence for disruptive behavior, because that may be rewarding, if all the child wants is to get out of a noisy, stressful situation. We find that prevention works much more effectively.
SE: How about the home environment? I guess it would also be a good idea for parents to have a secure quiet place for their child if things become too stressful?
LJK: Yes, it is important to have a place where the child can retreat for a little while. The child should not be allowed to retreat all the time, but he or she can retreat when things are too stressful. It is also important to find ways that are calming for a particular child. It may be as simple as having a rocking chair in their room, or having a swing . It could also include wrapping the child in a nice big quilt for just a few minutes. This can be very calming. Basically, parents need to find out what works with their child.
SE: What about stereotyped or self-stimulatory behavior?
LJK: In general, self-stimulating behaviors are attempts at calming - behaviors that a child has found which make him or her less upset and more calm. Sucking the thumb and biting the nails are examples of stress relieving mechanisms that normal people use. The autistic child's calming methods may seem bizarre, but they usually involve biting or chewing or sucking, or rhythmic rocking - another universal calming input. We try to help the child find socially acceptable methods of relieving stress. Sometimes giving the child something to have in his/her hands to play with will discourage hand flapping, for example. Things such as playing with a "koosh ball" or a musical toy may work.
SE: When children chew their shirts as well as other things, I often suggest to parents to give their child a toothbrush to chew. The bristles are stimulating, and it is somewhat socially appropriate.
LJK: I agree. Actually, the best toothbrushes for this are called "nook brushes". This is the toothbrush that babies are usually given. There are other alternatives. For instance, we may get a length of aquarium tubing or a boat key float and put a loop around the child's neck. When the child starts chewing on his shirt or his wrist, we say "here, chew on this for a while". It has a very satisfying chewy texture. Often the inappropriate chewing will diminish in a few weeks. Chewing is definitely a stress-related reaction.
SE: Some therapists and teachers allow the child to engage in self-stimulatory behaviors as a reward after the child works on a task for a certain length of time. What do you think about this method?
LJK: I think it is better than forbidding the child to engage in these behaviors, but I think it is even better to give them a more socially acceptable alternative behavior. If you let them engage in these behaviors as a reward, you are essentially saying that the behavior is socially acceptable.
SE: What do you think of those programs that teach a child to inhibit these self- stimulatory behaviors?
LJK: It depends on how important the behavior is in relieving stress. If the behavior is important to the child in calming himself and relieving stress, he will probably just develop another one, which may be even less socially acceptable. The long-range solution is two-fold. Through therapy, facilitate the raising of the child's threshold for arousal, and help the child learn self-calming techniques that are acceptable.
SE: Could you describe the Center for Neurodevelopmental Studies?
LJK: The Center is a non-profit corporation founded in 1978 to provide the most advanced neurodevelopmentally based therapeutic methods for autistic and other developmentally delayed children and adolescents. The Center's main program is a state certified school called The Developmental Day School. At present there are 39 students ranging in age from two to twenty two. Most, but not all, of the students are autistic. The school provides a tightly integrated program which combines occupational therapy, speech therapy and music therapy with academic or pre-academic training. The staff to student ratio is one and a half to two. In addition to the school, the Center also provides individual therapies to children from other schools.