Carolyn and Julie wrote a guest blog on the allied.org.au website. This organisation is an advocacy organistion and very worthwhile to join. There is a mailing list for more articles and blogs on a range of allied health topics, including NDIS. This is a new website hoping to share many allied health and lived experience perspectives.

In part 1 of this 2-part series, the current evidence for using Sensory Modulation will be discussed. A fictional case study will highlight these issues. Note: Trigger warning for this article as behaviours of concern are discussed, such as self harm and restrictive practices. 

Sensory Modulation for Self-Regulation

Sensory modulation approaches involve the provision of sensory-based therapy tools and/or the creation of appropriate environments that engage the user’s senses to reduce the build-up of agitation and prevent the escalation of aggression (eg Chalmers et al 2012, Lee et al 2010). (O Sullivan and Fitzgibbon, 2017).

A significant driving force for services to adopt sensory modulation was the need to develop ‘alternative methods for managing distress, agitation and aggressive behaviour’ (O’Hagan, 2006) including to reduce seclusion and restraint practices.

Sensory Modulation is useful when there is a sensory trigger to a behaviour of concern, and then a sensory solution can be applied to reduce or minimise the sensory input. (eg using noise cancelling headphones to reduce overwhelming noise).

A sensation can act as a trigger due to a number of reasons including a past memory or traumatic association, intense dislike of a sensation or due to a person experiencing sensory overload or reaching their tolerance for sensory input as part of a hypersensitivity.   In some individuals, the intense need to avoid the sensation can lead to a behaviour of concern (eg running away from the sensation, pushing a person away to avoid a sensation).  

Verhulst et al (2022) found that “Visual, auditory and olfactory hyper reactivity, such as difficulties with bright, or flickering lights, sudden loud noises, and intense scents, have been commonly reported by autistic individuals and are associated with distress, overwhelm, and anxious responses. “ (MacLennan, et al 2021, Tavasolli et al 2016 cited in Verhulst et al 2022).

Sensory sensitivities are recognised in the Autism Spectrum Disorder diagnostic criteria and have also been found to be atypical in adults with schizophrenia, for example auditory sensitivities  (eg Adler, Waldo and Freedman,1985,cited in Soto et al ) and visual and somatosensory sensitivities (Andrade, Butler, Peters, Molholm and Foxe 2016 cited in Soto et al). Other mental illness’ shown to have sensory processing differences include Bipolar, Depression, Post Traumatic Stress Disorder (PTSD) and Obsessive Compulsive Disorder (OCD) (Brown et al, 2011). Other disabilities with sensory processing dysfunction include Intellectual Disabilities (Werkmen et al 2022) and Dementia (Champagne, 2018).

It is also important to note that for those people who do not have sensory processing dysfunction normally, when acutely distressed may become oversensitive to input such as noise and bright light or under responsive to other input such as visual cues. (Andersson et al 2021).

Wright et al (2020), stated that “Evidence suggests that the use of sensory modulation approaches can reduce a person's emotional distress and agitation (Adams-Leask et al. 2018; Chalmers et al. 2012; Cummings et al. 2010; Lloyd et al. 2014 cited in Wright et al 2020).

 

Unwin et al (2021) described benefits for controlling sensory stimulation for autistic children and adults:

Interventions to control sensory stimulation in everyday environments have shown benefits for autistic children and adults, including the use of headphones (e.g. Ikuta et al., 2016; Pfeiffer et al., 2019; Rowe et al., 2011) and modification in lighting (e.g. Kinnealey et al., 2012). Across the studies, these adaptations led to a range of improvements in attention (Kinnealey et al., 2012; Pfeiffer et al., 2019; Rowe et al., 2011), meeting individualised goals (Ikuta et al., 2016), mood and classroom performance (Kinnealey et al., 2012), and reductions in anxiety and challenging behaviours (Pfeiffer et al., 2019). Kinnealey et al. (2012) also report some improvement in social interaction, although only after several weeks of intervention. These findings are consistent with teacher reports that increasing autistic children’s control over the classroom environment helps them control unwanted sensory experiences, and that it is the uncontrollable and unpredictable nature of sensory stimuli that causes the most difficulty for their learning (Jones et al., 2020).

Sensory Modulation can also be used to support an individual’s self regulation and increase coping strategies, even when there is not a sensory trigger or sensory aspect. Sensory Modulation may include using sensory input to provide regulation, distraction, calming, grounding or to achieve a lower or higher sensory stimulation.

Altering the environment by using calming features or moving to a less overwhelming context was the most common strategy reported for managing sensory overstimulation in Andersson et al 2021 study.  However, for many people including frail, aged, and those living with disabilities, it can be difficult to move themselves to a different/more suitable environment due to a range of factors. Such factors may include mobility issues, comprehension or communication difficulties, socio-economic constraints, environmental constraints, dependence on others to meet personal care needs

Sensory Modulation for Reducing Seclusion and Restraint

Sensory Modulation is a common practice intervention in Australian Mental Health Services and has policy support as a strategy to reduce Seclusion and Restraint in Mental Health Units (refer to blog 2 for further information).

In the United States in 2006, the National Association of State Mental Health Program Directors (NASMHPD) developed six core strategies to reduce seclusion and restraint. These strategies have been implemented by many other countries including Australia, New Zealand, the United Kingdom and a number of European countries. One of the core strategies recommends the use of ‘de-escalation surveys or safety plans, use of person-first language, environmental changes to include comfort and sensory rooms; sensory modulation experiences and other meaningful treatment activities. These tools actively support people to develop emotional self-management skills’ (Huckshorn, et al 2006 cited in  O’Sullivan and Fitzgibbon (2017).

The role of Sensory Modulation in reducing seclusion and restraint has been most researched within Mental Health Units and there are multiple studies to demonstrate its effectiveness. Studies include Andersen et al. 2017; Barton et al. 2009; Champagne & Stromberg 2004; Lloyd et al. 2014; Maguire et al. 2012; Sivak 2012; Yakov et al. 2017 cited in Wright et al , (2021)  and Seckman et al (2017) Bobier et al (2015). More recently, Zimmerman’s 2020 study on the implementation of a serenity/comfort room for sensory modulation found a decrease in chemical restraint, seclusion and mechanical restraint. Azuela, (2019)Gilbert  found that service users in a psychiatric unit reported that sensory modulation was preferred over in situ medication (PRN) as a calming strategy.  

In a study by Van den Boogert (2021) autistic adults with higher scores in sensory sensitivity had the highest risk of aggressive behaviour and thus applying detailed diagnostics on sensory processing difficulties when treating aggressive behaviour was recommended.

Sensory Modulation has also been used to decrease self harm. In one study (Matson et al  (2021) participants found that they were able to use sensory input to experience a sense of release that they would normally achieve from self harming, but without any different. This depended on the usual method of self harm and was different for each individual

Im (2021) reviewed treatment of Aggression in Adults with Autism Spectrum Disorder and found that both multisensory interventions and behavioural interventions had similar levels of evidence.

“Lower levels of evidence (e.g., nonrandomized N of 1 trials, prospective open trials, retrospective reviews) point to possible benefits, in adults with ASD and aggression, of behavioural interventions,56,57,67,85–88,91–95,99 multisensory environments,96,109 yokukansan,58,110 clomipramine,104 sertraline,46,103 clozapine,115,117 and aripiprazole.76,77,82,116 Among these interventions, multisensory environments and yokukansan are slightly more supported based on risk-of-bias assessments. While the level of evidence for these approaches is less robust than for controlled trials, the adverse effects and long-term risks associated with many of these treatments (in particular, behavioral interventions and multisensory environments) are significantly more favourable.”(Im, 2021)

 

In the area of dementia, there have been studies reporting a decrease in the number of  behavioural and psychological symptoms with the use of multi sensory environments (Maseda et al., 2014a; Minner et al., 2004; Riley-Doucet & Dunn, 2013; Staal et al., 2007; Ward-Smith et al., 2009), cited in  Unwin et al (2020).

Case Study: Bruce

Bruce was visiting the shops to buy groceries for dinner. He enjoyed cooking and was looking forward to preparing his favourite meal – chicken nuggets.  When Bruce was walking through the shops, a nearby child starting having a tantrum, which involved screaming and lying on the shop floor. Bruce and his support worker quickly moved further away, but Bruce could still hear the noise and it was driving him crazy! He held his hands over his ears and started rocking on the floor. His support worker wanted to support Bruce to leave the shops and started pulling on his arm to go. Unfortunately the situation quickly deteriorated, with the support worker physically restraining Bruce in an attempt to stop him from running away from the shops. When Bruce got home he started banging his head, and rocking back and forth into the wall.

Bruce discussed this incident with his treating team and it was identified that the sound of the child screaming was a trigger for him. They identified the strategy of using noise cancelling headphones if Bruce was out and heard an overwhelming sound. Bruce had always enjoyed using his Aunty’s rocking chair and it was identified that this could be a useful calming strategy at home as an alternative to head banging.

Bruce’s Occupational Therapist wrote a supporting letter addressing reasonable and necessary criteria to enable Bruce to use his NDIS funds to purchase  noise cancelling headphones and a rocking chair. Staff training was also completed on using sensory modulation interventions.  Bruce felt positive regarding his new strategy and found that it worked well for him, both at the shops and at home, thus preventing the need for further restraint.

Sensory Modulation is one of a suite of interventions to reduce seclusion and restraint. As this case study highlights, it needs to be tailored to the individual and accompanied by staff training and verbal de-escalation strategies. The NDIS could increase their support of Sensory Modulation items and interventions as a strategy to reduce seclusion and restraint and decrease behaviours of concern. In light of recent evidence from the NDIS Quality and Safeguards Commission highlighting a concerning increase in the use of restrictive practices including physical and chemical restraint, there is a strong case for exploring alternatives to these practices, and as described in this article and case study, sensory modulation has potential to be a viable strategy to reduce restrictive practice in the NDIS context. Alongside reducing restrictive practice, sensory modulation can have a positive impact on the  individual’s functioning and quality of life.

 

What could this mean for day-to-day work?

Allied health professionals trained to provide sensory modulation interventions can provide person centred and tailored strategies to reduce the need for restrictive practice for people with disabilities.

How can I influence change?

Raise awareness of the strong evidence-base and policy context for sensory modulation interventions through sharing with colleagues, policymakers and funding bodies.

 

Authors: Carolyn Fitzgibbon and Julie O’Sullivan

Carolyn and Julie are co-authors of the Sensory Modulation Resource Manual and co-directors of Sensory Modulation Brisbane.

 

References:

Helene Andersson, Daniel Sutton, Ulrika Bejerholm & Elisabeth Argentzell (2021) Experiences of sensory input in daily occupations for people with serious mental illness, Scandinavian Journal of Occupational Therapy, 28:6, 446-456, DOI: 10.1080/11038128.2020.1778784

Andersen, Kolmos, A., Andersen, K., Sippel, V., & Stenager, E. (2017). Applying sensory modulation to mental health inpatient care to reduce seclusion and restraint: a case control study. Nordic Journal of Psychiatry, 71(7), 525–528. https://doi.org/10.1080/08039488.2017.1346142

Azuela, Gilbert (2019). The implementation and impact of sensory modulation in Aotearoa New Zealand adult acute mental health services: Two organisational case studies

Bailliard and Whigham’s  (2017 cited in Wilson 2020) scoping review of 149 studies on Sensory Processing and mental illness  found that interventions targeting sensory processing skills such as sensory rooms may contribute to cognitive gains and improve occupational performance.

Brown, C., Stoffel, V., & Munoz, J. P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia: F.A. Davis Co. Chapter 22 Catana Brown, Patricia Steffen-Sanchez and Rebecca Nicholson

Champagne,T (2018) Sensory Modulation in Dementia Care: Assessment and Activities for Sensory-enriched Care, Jessica Kingsley Publishers, London, 2018, 168 pp., pbk £15.99, ISBN 13: 9781785927331. - Volume 39 Issue 8

Dorn, Emma, Hitch, Danielle and Stevenson, Christopher 2020, An evaluation of a sensory room within an adult mental health rehabilitation unit, Occupational therapy in mental health, vol. 36, no. 2, pp. 105-118, doi: 10.1080/0164212X.2019.1666770.

Im D. S. (2021). Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review. Harvard review of psychiatry, 29(1), 35–80. https://doi.org/10.1097/HRP.0000000000000282

Henriques-Gomes, L. 10 Nov, 2021 Guardian Australia

MacLennan, K., O’’ Brien, S., and Tavassoli, T (2021) In our Own Words: The Complex Sensory Experiences of Autistic Adults. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-021-05186-3

O’Sullivan, J and Fitzgibbon, C. (2017) Sensory Modulation Resource Manual.

Matson, R., Kriakous, S and Stinson, M (2021) The Experiences of Women with a Diagnosis of Borderline Personality Disorder (BPD) Using Sensory Modulation Approaches in an Inpatient Mental Health Rehabilitation Setting, Occupational Therapy in Mental Health, 37:4, 311-331, DOI: 10.1080/0164212X.2021.1933674

NDIS Quality and Safeguards Commission (2020).Regulated Restrictive Practices Guide. Penrith. Australia: NDIS Quality and Safeguards Commission.

Seckman, Angela ; Paun, Olimpia ; Heipp, Biljana ; Stee, Marie ; Keels‐Lowe, Vonda ; Beel, Frank ; Spoon, Cari ; Fogg, Louis ; Delaney, Kathleen R, Evaluation of the use of a sensory room on an adolescent inpatient unit and its impact on restraint and seclusion prevention Journal of child and adolescent psychiatric nursing, 2017-05, Vol.30 (2), p.90-97

Tavassoli, T., Bellesheim, K., P, M,. Wang, A. T., Halpern, D., Gorenstein, M., Grodberg, D., Kolevzon, A., and Buxbaum, J.D. (2016) Measuring Sensory Reactivity in Autism Specrum Disorder: Application and Simplification of a Clinician-Administered Sensory Observation Scale. Journal of Autism and Developmental Disorders, 46 (1), 287 – 293. Hyyps://doi.org/10.1007/s10803-015-2578-3

Van den Boogert F, Sizoo B, Spaan P, Tolstra S, Bouman YHA, Hoogendijk WJG, Roza SJ. (2021) Sensory Processing and Aggressive Behavior in Adults with Autism Spectrum Disorder. Brain Sci. 14;11(1):95. doi: 10.3390/brainsci11010095. PMID: 33466570; PMCID: PMC7828723.

Verhulst, I., MacLennan, K., Haffey, A., & Tavassoli, T. (2022, January 12). The perceived casual relations between sensory reactivity differences and anxiety symptoms in autistic adults.

Unwin, K. L., Powell, G., & Jones, C. R. (2021). The use of Multi-Sensory Environments with autistic children: Exploring the effect of having control of sensory changes. Autism. https://doi.org/10.1177/13623613211050176

Werkman, M.F., Landsman, J.A., Fokkens, A.S. et al. (2022) The Impact of the Presence of Intellectual Disabilities on Sensory Processing and Behavioral Outcomes Among Individuals with Autism Spectrum Disorders: a Systematic Review. Rev J Autism Dev Disord https://doi.org/10.1007/s40489-022-00301-1

Wilson, Haley, "Mental Health Inpatient Hospitalization: What Nursing Can Learn From "Sensory Rooms."" (2020). Honors Theses. 3315. https://scholarworks.wmich.edu/honors_theses/3315

Wright, L. Bennett, S, Meredith, P (2020) ‘Why didn't you just give them PRN?’: A qualitative study investigating the factors influencing implementation of sensory modulation approaches in inpatient mental health units https://doi-org.ezproxy.library.uq.edu.au/10.1111/inm.12693

Zeanah, C. (2018) Handbook of Infant Mental Health Fourth edition. Chapter 19: Sensory Over-responsivity Timothy W Soto, Vivian Ciaramitaro, Alice Carter.

Zimmermann, D. P. S. (2020). Use of a serenity room for sensory modulation (Order No. 28002838). Available from ProQuest Dissertations & Theses Global. (2420652212). https://www.proquest.com/dissertations-theses/use-serenity-room-sensory-modulation/docview/2420652212/se-2?accountid=14723

 

Australian National Policies, Reports and Frameworks that contain references to Sensory Modulation, Sensory Items, Sensory Rooms or Sensory Approaches.

• NDIS QUALITY & SAFEGUARD COMMISSION (2020) Regulated Restrictive Practices Guide

• National Mental Health Commission

• National Principals to Support the Goal of Eliminating Mechanical and Physical Restraint in Mental Health Services (Mental Health Commission)

• Australian National framework for recovery-oriented mental health services: Guide for practitioners and providers (2013)

 

State Policies, Reports and Frameworks that contain references to Sensory Modulation, Sensory Items, Sensory Rooms or Sensory Approaches.

• Mental Health Act 2016 Chief Psychiatrist Policy Mechanical Restraint, QLD (2020) :

• Mental Health Act 2016 Chief Psychiatrist Policy Physical Restraint, QLD (2020) :

• Admission of children and adolescents to acute mental health inpatient units – Queensland Health Guideline (2021)

• Suicide Prevention Health Taskforce – Phase 1 Action Plan (2017) Qld Health

• Mental Health Safety and Quality NSW

• Chief Psychiatrist Restraint and Seclusion Standard A standard to reduce and eliminate where possible the use of restraint and seclusion applied under the Mental Health Act 2009 (2021) South Australia:

• South Australia Policy: Guideline Restraint and Seclusion in Mental Health Services Policy Guideline

• Health framework for reducing restrictive interventions Victoria: Victoria Positive Practice Framework

• Attachment and Trauma in People with an Intellectual Disability (2008), Positive Solutions in Practice, Office of the Senior Practitioner.

• Mental Health Restraint Policy West Australia(2020) West Australia Prevention and early intervention strategies