By: Rona Silverstein OTR/L
Self stimulation behaviors can be the most challenging to therapists as the children appear to get stuck in a loop of movement that they cannot break out of and can return to this movement frequently throughout their day. These children often present with delays in their development and are highly variable in their presentation. The focus of this article is to understand how best to help these children. These behaviors will be defined and described with a historical view of intervention strategies.
Sensory stimulation behaviors, self-stimulating or stereotyped behavior or movement is “repetitive bodily movement which serves no apparent purpose in the external environment” (Harris & Wolchick, 1979, p. 185). These behaviors frequently interfere with the ability to function independently and therefore must often be addressed before any significant improvement in function can be accomplished through intervention (Harris & Wolchick).
The etiology of these behaviors are not clearly understood, but theorized as being one of the two explanations. First, it may be due to these behaviors that are reinforcing as they are stimulating to the tactile, proprioceptive and other sensory stimulation that cannot be achieved through conventional adaptive means. On the other hand, these behaviors may be used to selfregulate or calm when the sensory information is difficult to receive and interpret (Smith et.al, 2005).
The types of self stimulation are widely varied and individualized. They can be visual, auditory, tactile and/or proprioceptive and vestibular. A fairly comprehensive list has been gathered entitled “The Stim List” at http://www.ican-do.net/stim_list.htm.
Over the recent years, treatment for these children has been widely varied. In 1973, a journal article professed !overcorrection” as a means to reduce these behaviors and used punishment and rewards to eliminate the self stimulation behaviors (Foxx & Azrin, 1973, pp.1-14). Less severe and moving in a kinder direction was the sensory stimulation theory that recognized learning takes place when the senses are stimulated (Laird, 1985). Building on this approach and noting when children get entrenched in repetitive motor movement pattern, in 2001, the neurodevelopmentalists write of “sensory play” as “negative, self-perpetuating, self-isolating behavior” (Coots & Ringoen, 2001). Development stops when these compulsive behaviors interrupts normal development causing a child with delays to become further delayed.
The field of occupational therapy often focuses on the effects of sensory input as it impacts developmental motor milestones. In particular, children with developmental delays may exhibit self stimulation behaviors due to a variety of reasons, and are responsive to a sensory integration approach. Research articles and studies began to emerge pertaining to this interesting topic. A small but significant study in 2001 by Fertel-Daly detailed the effects of wearing a weighted vest on attention to task and decreasing the self stimulatory behavior. It was found that the deep pressure provided by a weighted vest helped increase attention and decrease self stimulation behaviors. Although the study was small, it appears to be the preliminary evidence to suggest that proprioceptive input does decrease the repetitive behaviors seen in children with delays.
In 2005, in the American Journal of Occupational Therapy, Smith et.al, finds that sensory integration is helpful to children with self stimulation behaviors in that it helps decrease those behaviors. The conclusion of this small study of seven children 8–19 years of age with pervasive developmental delay and mental retardation, the students benefitted from activities that provided sensory input in the areas of vestibular, tactile, and proprioception. Classroom teachers concurred that an hour after the intervention, the children”s sensory processing needs were beneficial in reducing the maladaptive behaviors.
Self stimulation behaviors also may be referred to as “stereotyped movements” (American Psychiatric Association, 2000 and Schopler, 1995) and a defining characteristic of autism. A study was done and reported in 2010 by Gal, Dyck and Passmore, who investigated the severity of sensory processing disorders was associated with the severity of stereotyped movement. It was found that moderate to strong relationships exist between sensory processing disorders and stereotyped movements. The study suggests that clinicians use behaviors as indicators for how their sensory system is functioning and extend the focus from behavioral based interventions to the individual”s sensory functioning and how to adapt the sensory environment.
Currently, occupational therapists educate the child”s family and teachers on a “sensory diet” and recommend to implement this throughout the child”s day. Patricia Wilbarger, an occupational therapist, originally coined the term “sensory diet” to include what children with sensory needs require in order to get through their day. A sensory diet is unique to that child”s needs. For a child that is over-reactive to sensation, calming activities would be provided. For a under-reactive child, alerting sensations would be provided.
According to Michelle Morris of Sensory-Processing-Disorder.com, for most people to function at an optimum level, a certain level is needed that is neither too high or too low. When the nervous system is not working properly, the child feels compelled to seek the proper sensory input. For children seeking this sensory stimulation, they tend to go to the areas of the body where there are many nerve endings: hands, feet, mouth and scalp are the most common places.
Occupational therapists have a variety of strategies all centered around this sensory diet concept to meet the varying needs of children with self stimulation behaviors. The effects are often immediate and cumulative. Children learn that the self stimulation behaviors are no longer needed as their neurological system begins to work well and there is an increasingly appropriate response to external stimuli.
Child A, for example, is seen in Early Intervention, a home-based program. His diagnosis is global developmental delay. Child A over-reacts to auditory and tactile sensation and does lots of hand flipping of toys. Repetitive self stimming behavior seen with straps, blinds, and spinning toys. There is a paucity of purposeful movement outside of the stimming behavior. The parents started Child A on the Wilbarger Therapressure Protocol which included therapeutic brushing and joint compressions every 2-3 hours, usually during diaper changes. Emerging purposeful movement is noted. Although not walking to date, Child A, loves being upright in supported standing. Proprioceptive and vestibular activities are both thoroughly enjoyed with notable calming and improved focus toward fine motor tasks. The stimming behavior is slowly being reduced. When very upset, spinning toys are permitted for a short period of time, then transitions to non-stimming toys. Parents report that the brushing seems most helpful for their son and are glad to see him pick up and hold his toys, interact with his brother and appears more aware of his environment.
A child in elementary school, however, Child B, has mild delays and is mainstreamed in the classroom but her teacher notes she is having trouble keeping up with the classroom activities, including she tends to rock hard against her chair and desk. As part of the IEP”s recommendations, the occupational therapist provides recommendations to the teacher on how best to meet this child”s needs for optimum functioning in the classroom and to enhance learning. The occupational therapist recommends some accommodations such as prior to writing tasks to allow the child to go to a wall and do !wall pushups”, do “heavy tasks”, both for proprioceptive input. Also recommended is a bungee cord attached to the bottom of her chair for his foot to push against, and use of fidget toys to help with movement. Providing a more complete sensory diet, this helps modulate this child”s nervous system and she has improved attention and focus.
Often with children with self stimming behavior, if the school day can be presented as in a routine way, this is much easier for them to tolerate. There is a comprehensive list of accomodations for teachers to implement in the book: Answers to Questions Teachers Ask About Sensory Integration by Jane Koomar, Carol Stock Kranowitz and Stacey Szklut (2004). Of the many recommended, the following are especially helpful to children with self stimulation behaviors:
- Provide quiet “time out” spaces when needed throughout the school day.
- Forewarn the child of loud noises that may occur (bells, alarms).
- Allow the child to pass out papers so he or she can get up from the desk and walk around the room.
- To prepare the child for transitions, giving them warnings such as: 2 more minutes, or use a timer.
By implementing the above recommendations, this will remove the stress from a child who is over or under reacting to the classroom environment.
In conclusion, over the years, therapists, parents, educators and physicians have evolved their view of self stimulation behaviors and how to manage them. Only a few decades ago treatment consisted of !overcorrection” with punishment and rewards to extinguish the behavior. Now, in 2011, we understand the role our neurological system plays in interpreting our environment and interacting with it and within ourselves. Sensory integration is the modality to use to best help children with these behaviors. Now we know that it isn”t the behavior but the underlying cause that is the concern and the treatment is addressing not the behavior but the sensory-seeking or sensory avoiding that is presented.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders(4th eds, text rev.). Washington, DC: Author.
Biel, L. (March-April 2010). A sensory diet happens 24/7. Web. December 27, 2010. [url]http:// http://www.autismdigest.com[/url].
Coots, M.N., & Ringoen, C. “Sensory Play”. 2001. Web. December 27, 2010. [url]http:// http://www.ican-do.net/sensory_play.htm[/url].
Coots, M.N., & Ringoen, C. “ The Stim List”. 2001. Web. December 27, 2010. http://www.ican-do.net/stim_list.htm.
Fertel-Daly, D., Bedell, G., & Hinojosa, J. (2001). Effects of a weighted vest on attention to task and self-stimulatory behaviors in preschoolers with pervasive developmental disorders. American Journal of Occupational Therapy, 55:6, 629-640.
Foxx, R.M., & Azrin, N.H. (1973). The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 6, 1-14.
Gal, E., Dyck, M.J., & Passmore, A. (2010). Relationships between stereotyped movements and sensory processing disorders in children with and without developmental or sensory disorders. American Journal of Occupational Therapy, 64, 453-461. doi: 10.5014/ajot.2010.09075.
Harris, S. L., & Wolchik, S. A. (1979). Suppression of self stimulation: Three alternative strategies. Journal of Applied Behavior Analysis, 12, 185–198.
Koomer, J., Kranowitz, C.S., Szklut, S., Balzer-Martin, L., Haber, E., & Sava, D.I. (2004). Answers to questions teachers ask about sensory integration (4th ed.). Las Vegas: Sensory Resources, LLC.
Morris, M. “Hair pulling and self stimming behaviors in the SPD Child…what can they mean?”. 2007. Web. December 27, 2010.
Schopler, E. (1995). Parent Survival Manual. New York: Plenum Press.
Smith, S.A., Press, B., Koenig, K.P., & Kinnealey, M. (2005). Effects of sensory integration intervention on self-stimulating and self-injurious behaviors. American Journal of Occupational Therapy, 59, 418-425.
This Months Featured Author:Rona Silverstein OTR/L
Rona Silverstein is an occupational therapist who has been practicing for 18 years since graduating from the occupational therapy program at Wayne State University in Detroit, MI. With a variety of experiences, Rona currently works with the pediatric population and was recently hired by PediaStaff. Rona is credentialed in early intervention, a specialist in feeding issues, as well as a generalist in a variety of diagnoses and disabilities.