Using a Sensory Room as an Adjunct Therapeutic Modality in an Adolescent Residential Treatment Center: An Outcome Study
Farrell Lindley, MOT, OTR/L
Mildy McDaniel, M.Coun., LCPC
ABSTRACT
Background:
Adolescents with a diagnosed psychiatric disorder(s) who are treated in a medical model residential treatment center often present with atypical sensory processing patterns. The use of a sensory room, created and staffed by Occupational Therapists, can be an excellent adjunct therapeutic modality that is cost-effective and easily adaptable to aftercare planning. This study explores how sensory systems relate to behavioral organization and functional performance in an adolescent residential treatment setting.
Method:
Data from 144 adolescents presenting with co-morbid and dually diagnosed Axis 1 disorders treated in a locked RTC were examined, ALOS 101 days. This population was introduced to the Sensory Room and the Sensory Suitcase by the Occupational Therapists as an adjunct therapeutic modality in the Treatment Program. A self-rating scale was completed pre- and post- Sensory Room and Sensory Suitcase intervention. Logs were examined for a nine-month period and the data collected from 1) Sensory Room and Sensory Suitcase self-rating scale; 2) Sensory Profile Outcomes; and 3) Primary and Secondary Axis 1 diagnoses as determined, on discharge, by attending psychiatrist.
Results:
80% percent of patients presented, on admit, with atypical sensory processing patterns, as determined by completion of the Adolescent/Adult Sensory Profile Self-Questionnaire. The self-rating scale data found an 84% increase in positive, adaptive behavioral skills post- use of the Sensory Room and/or Sensory Suitcase.
The data collected determined that assertively applying sensory strategies via the addition of a sensory room, sensorimotor groups, sensory suitcases, and by merging occupational therapy with a traditional clinical treatment team, the resulting adjunct therapeutic modality increases adaptive behaviors and provides sensory coping tools for aftercare.
Discussion:
The authors have been fortunate enough at our RTC to have a licensed Occupational Therapist on staff with training in sensory approaches. This OTs idea of adding a sensory room to the RTC offered the other clinical staff an opportunity to learn more about the role of sensory systems and behavior.
Occupational therapists observe how sensory systems relate to everyday living. When observing a behavior, sensory trained occupational therapists, (OTs), look for triggering factors. These include not only social and emotional causes, but sensorimotor issues as well. OTs are looking for physical sensations that precede behavior. What was the child seeing, hearing, feeling, doing; what was the child’s body position; what were the people, animals, objects doing; what did the authors, as observers, not realize? Studies have shown sensory defensiveness to have an 80% correlation with physical/sexual abuse, emotional neglect, psychological trauma, traumatic injury, extended hospitalizations, institutionalization, sensory deprivation and torture (Moore, K., 1998).
Mental health therapists, on the other hand, are most often trained to use a cognitive-behavioral talking therapy approach, studying the family history and considering the more social and emotional aspects of behavior. It makes sense to combine these two therapeutic approaches when it is considered that behavioral and/or cognitive techniques do not often focus heavily on environmental conditions. Likewise, only addressing sensory processing problems will not be fully advantageous when social and emotional issues in a client’s history, such as abuse, are not considered (Hale, L., & Coy, A., 1997).
Occupational therapists examine how sensory systems, (our five senses plus two sensations: proprioception and vestibular), correspond to behavior. Our olfactory system is the only direct communicator with the limbic system, (emotion center of the brain) - powerful functional considerations include: alertness, bonding, emotion, memory and safety. The visual system unifies - it helps integrate and make sense of the other sensorimotor systems. It is the most critical when interacting with the environment. Gustatory is our sense of perceived flavor and taste. Because this oral-motor system is linked to our cranial nerves, functional considerations include overall organization, alertness, attention and focus and self-regulation. Our auditory system is important for the functional considerations of hearing, balance, internal rhythm and safety. Our tactile system relates to our skin – the largest organ in the body. Formed at the same time as the nervous system, this sense has a powerful effect on emotion. The brain needs lots of tactile input to maintain organization, enhance dopamine systems, and increase regulation.
Occupational therapists consider two additional sensations when observing behaviors: vestibular and proprioception. The vestibular system involves rotation of the head in space and gravitational security, (where our body is in space). This system interacts with the reticular activating system – our brain stem’s center for filtering alerting and calming impulses. Our vestibular system is commonly known as our mood modulator.
The proprioception sensations are located at each joint and involve movement, compression, stretch, information of where body parts are; giving a person a sense of “me.” The strongest proprioceptive feedback is when muscles are against resistance. This resistance enhances our serotonergic system by making it more responsive and increasing stimulation of endorphins.
Our central nervous system, (CNS), is the primary building block for intellectual development. Tactile, vestibular, and proprioceptive sensations are the closest to our CNS. These three powerhouses are used for treatment interventions because of this direct relationship. Sensorimotor development, (body schema, coordination), and perceptual motor development, (visual, language), lead to development of cognition and intellectual functioning, (academics, daily living activities) (Williams, M., & Shellenberger, S. 1996). Any dysfunction to these developmental building blocks may cause gravitational insecurity, and/or sensory defensiveness resulting in observable behaviors such as avoidance, distractibility and increased activity level (Fisher, Murray & Bundy, 1990).
When looking at self-regulation and modulation it is important to look at the brain’s ability to maintain and change alertness appropriately for a given task or situation. Sensory processing is how the brain, through the central and peripheral nervous systems, manages incoming sensory information. It’s the brain’s ability to filter needed and unneeded sensory input. Sensory processing considerations include the underlying development of all motor and social skills; the ability to learn and perform complex tasks; assist with situational and behavioral responses; problem solving; attention; and decision making.
Dysfunctional considerations include increased need for sensory input through self-harm; unpredictable explosions of emotions; lack of interaction with the environment; increased distractibility; difficulty with transition in daily routine; social isolation, and difficulty maintaining balance between hyper- and hypo- activity levels.
Once the idea of adding a Sensory Room was brought to fruition, the authors began adding the standardized Adolescent/Adult Sensory Profile Self-Questionnaire (Brown, C., & Dunn, W., 2001) to the Admissions paperwork for all of the RTC adolescents. For this particular study, the authors elected to focus only on Typical, Mild, or Moderate differences in sensory processing patterns, as evidenced by the Self-Questionnaire. This data was merged with Primary and Secondary Axis 1 diagnoses, and the Sensory Room and Sensory Suitcase Self-Rating ordinal and pictorial logs.
It may be beneficial to briefly review the diagnoses used in this study before examining the outcomes, (DSM-IV-TR, 2000). It’s useful to keep in mind the OT’s, as well as the mental health therapist’s, perspective.
Learning Disorders – Formerly Academic Skills Disorders, this is diagnosed when academic achievement is low, there are observable social skills deficits, low self-esteem and demoralization. OTs know that if learning difficulties are diagnosed, then there is frequently a sensory deficit present. But for a learning disorder to be diagnosed, the difficulties must be beyond what is usually observed as a sensory deficit.
Attention-Deficit/Hyperactivity Disorder – This diagnosis has become familiar to almost everyone who works with adolescents. The criteria include inner feelings of jitteriness and restlessness, distraction by trivial noises, etc. Often these adolescents appear with “sensation seeking” behaviors.
Oppositional Defiant Disorder – This disorder describes deliberate, recurrent, defiant behavior leading to significant impairment.
Reactive Attachment Disorder – A defining feature for this disorder is inappropriate social relatedness associated with grossly pathological disregard for basic emotional and/or physical needs. This disorder is frequently associated with sensory defensiveness.
Substance-Related Disorders – Adolescents with this diagnosis show recurrent substance abuse leading to clinically significant impairment or distress.
Schizoaffective Disorder – Remembering that “affect” is defined as the combination of bodily sensations and emotions, this disorder manifests with delusions and disorganized speech. The full criteria must be met for both schizophrenia and mood disorder. Vestibular disorganization is a common observation with this disorder.
Mood Disorders – These disorders, for the purposes of this study, represents depressive and NOS disorders. The mood disturbance is the predominant feature.
Bipolar Disorder – The authors looked at Bipolar 1- recurrent manic, and Bipolar 2 - recurrent depressive. During severe manic episodes, violent or abusive behavior may occur.
Obsessive-Compulsive Disorder – This is an ego-dystonic disorder. The obsessions are intrusive and inappropriate, they consume at least one hour of time per day, and the repetitive compulsions are used to neutralize the obsessive thoughts.
Posttraumatic Stress Disorder – Diagnostic features include either witnessing, or being involved in, or learning about violent harm, serious injury, or threat to one’s self or family member. Adolescents with this diagnosis will sometimes exhibit low responsivity levels and will avoid stimuli associated with the trauma. OTs will often observe tactile defensiveness in adolescents with this disorder.
Eating Disorders – Either anorexia nervosa or bulimia nervosa disorders can cause repressed initiative and emotional expression. There is a frequency of depressed mood and personality disorders.
Intermittent Explosive Disorder – The criteria include a lack of resistance to aggressive impulses with resulting destruction of property or other assaultive acts.
Adjustment Disorder – The descriptive feature of this disorder is an identifiable stressor that causes a psychological response which results in clinically significant symptoms, either emotional or behavioral.
Adoption – This category was added because Intermountain Hospital opened its’ first Sensory Room simultaneous to beginning a specialty track for adolescents who have been adopted. Our OT’s have observed generalized sensory processing difficulties with this population.
Results of Data from Sensory Profile were as follows: (N=144)
Diagnoses Typical Mild Moderate
Learning Disorders 0% 0% 100%
Attention Deficit Hyperactivity Disorder 18% 41% 41% Oppositional Defiant Disorder 33% 22% 45%
Reactive Attachment Disorder 0% 50% 50%
Substance-Related Disorders 22% 39% 39%
Schizoaffective Disorder 0% 40% 60%
Mood Disorders NOS 22% 24% 54%
Bipolar Disorder 17% 38% 45%
Obsessive Compulsive Disorder 40% 20% 40%
Post Traumatic Stress Disorder 20% 33% 47%
Eating Disorders 20% 0% 80%
Intermittent Explosive Disorder 0% 50% 50%
Adjustment Disorder 40% 0% 60%
All Diagnoses 20% 32% 48%
Adoption 21% 41% 38%
The above results proved that 80% of patients presented, on admit, with atypical sensory processing patterns. The authors then needed to gain data to show if the Sensory Room interventions would indeed increase adaptive behavioral functioning, by compiling outcomes from the self-rating scales. These scales gave the adolescents choices of describing their level of alertness as LOW, JUST RIGHT, and OVERDRIVE. Results are as follows:
Next, the authors needed to examine the data from the mobile Sensory Suitcases logs to determine if there was an increase in adaptive behavioral functioning. The same self-rating scales were used as described above.
Conclusion:
The Sensory Profile helped us to classify adolescents with atypical sensory processing patterns. This data was then merged with the Axis I diagnoses. The findings suggest that this subgroup benefited from the use of the Sensory Room and Sensory Suitcases, and furthermore, as an adjunct therapeutic treatment modality, occupational therapy provides a beneficial addition to the overall mental health of adolescents. By merging occupational therapy with a traditional clinical treatment team and by assertively applying sensory strategies, adaptive behaviors and sensory coping tools for aftercare are increased.
In October, 2004, the authors presented this data for the first time in a workshop for faculty and students at Sargant College at Boston University. The attendees were part of the occupational therapy graduate program. The ensuing discussion further strengthened our goal of a collaborative approach. Further discussion focused on the campaign of several distinguished OTs, and part to add a Sensory Processing Disorder to the DSM-V. At that juncture, sensory strategies will be widely recognized as a necessary adjunct treatment modality contributing to the overall mental health of adolescents.
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