TRANSCRIPT - Occupational Therapy and Sensory Efficiency SkillsLisa Ricketts - Focus 2024

>>Lisa: Hi, everyone! My name is Lisa and I'm an OT here at TSBVI and I'm going to talk about sensory efficiency skills. So, sensory efficiency skills are part of the IEP and the expanded core curriculum. And the way I view sensory efficiency skills is I ask myself, how is my student using their senses for learning or using their senses to access the environment? And so, if someone has low vision, I'm thinking to myself, how well are they using their low vision? But in combination with touching-- so, feeling things through the hands, the skin on the body, and in combination with listening and motor control-- all of these are sensory efficiency skills. And so, the big question for me is how successful is my student at using their senses for learning? It's sort of the broad view of sensory efficiency skills. And it's part of the expanded core curriculum. So, that's where I, as an OT, I'm writing most sensory information now is under the heading 'Sensory Efficiency Skills' in the ECC. I used to write OT goals up at 'Separate.' But I'm trying to make sure that my school-based therapy matches the educational needs of a student. And so, I'm trying to match my OT service to the IEP. And right now for sensory efficiency that's one of my best places to put information. Especially for some students that have maybe optic nerve hypoplasia, septo-optic dysplasia, or CVI. That's a really good place for me to put my OT information. And the visual medical diagnoses I want you to think of when we talk about sensory efficiency is really any vision or hearing diagnosis, any sensory loss, any motor loss. So, for us that might be CVI, cortical visual impairment. It might be traumatic brain injury, TBI. Optic nerve hypoplasia, septo-optic dysplasia. ROP, and autism. Retinitis pigmentosa. Really any diagnosis that you have a sensory loss, there's the potential for imbalances in sensory processing or sensory efficiency skills. Other diagnoses can include CHARGE Syndrome, Lebers, congenital amorous, diabetic retinopathy, hemianopsia, cerebral palsy. So, anything that's affecting the development just puts someone at risk for sensory processing difficulty. It doesn't mean that they will have difficulties. So, everything we do is through our senses essentially. So, our brain and body is constantly taking in information from the environment, from the environment out there- distance- but also our near environment and our internal environment. So, everything we do is really through sensory processing. There's a really great Neil Gaiman quote. He's a writer and a sci-fi writer and a graphic artist and graphic novelist. And he talks about the senses and memory as being the only place we can really go. We can only go to places that our memory in our sensory-- sensory experiences take us. So, everything we do is through sensory processing. Sensory integration is a term that is, an occupational therapy term in the respects that there's a sensory integration therapy treatment model. It's called 'a frame of reference' in OT. 

So, there's an entire therapy model- sensory integration- that's both medical in nature and educational in nature. And that's in the field of occupational therapy. And that was started in the 1960s by Dr. Jean Ayres. So, OT has this long history of developmental model in sensory integration. And there's a lot of clinics in town, for example, that have resources for children with autism-- therapy for children with autism-- that might be sensory-integration-based clinics. And that's great for OT, but it's also great for sensory issues overall. And there's so many cases now of children with autism that we're looking at this question a lot about how someone is processing sensory information and how it might be affecting their learning and their behavior. We have our five senses that we're really familiar with: vision, hearing, touch, taste, smell, movement. But we also have proprioception, vestibular sensation, and interoception. And so, proprioception is essentially limb position sensation. And it's a constant feedback system. So, just moving my arm, just moving my wrist and hand sends... a signal to my brain about my joint position all the time. So, this is unconscious. It's an updated body map that goes to the brain and it's a feedback system. So, every time I move, it's updated. So, we think if someone doesn't have good proprioception, they may not have much feeling in terms of how it feels to have a change in limb position or a change in motion through the joints. And so, sometimes you might see some extra movements. If you see a lot of like this kind of motion with someone who has autism, we sort of think that they're not getting great proprioceptive feedback through the joints. And so, instead, to keep a constant signal, they keep in motion. So, that's a little bit about proprioception. There's static proprioception, which is more about your posture and a still upright position. And there's dynamic proprioception, which is about body movement. 

Vestibular sensation is referring to movement- generally- and balance. So, the vestibular system is deep in the inner ear and it's constantly updating your head position in relation to your eye position and in relation to the movements in the moment. So, vestibular system I equate as balance, gross motor movement. And it's the inner ear functions of the semicircular canals. Interoception is internal feelings. So, these are feelings of- like- hunger, thirst, body feelings, feelings that are about our circadian rhythms, sleep/wake cycles. This is interoception, but also in interoception are your feeling states. So, if I'm feeling sleepy or frustrated or tired or I'm feeling happy or anxious-- feeling states- emotional states- are also included in interoception. So, the entire sensory system for us is vision, hearing, touching, moving through space, taste and smell. Proprioception, which was our limb position sensation-- it's also pressure regulation. So, if I'm just picking up a pen and writing, my proprioception makes the pressure accurate so I don't use too much force or too little force. Vestibular functions, which is going to be our balance, gross motor skills, whole body movements... and interception, which is all the internal functions of the body and how we're feeling. So, all of that information- both internal and external- is coming into the brain all the time. And that's what we're using when we interact with each other and have conversations and go through our day. We're constantly processing sensory information. 

So, sensory integration, essentially, like we're saying, is just constant. Information is always coming in to you through the senses, and your brain and your body decide what to do with that information. Usually sensory integration is dominated by vision because vision is your dominant sense. If you don't have vision, though, that's completely fine. There are other ways to learn movement. There are other ways to learn... without vision, of course. We have-- I'm here at the blind school and we have actors and actresses and athletes and many of them have no vision. So, it doesn't mean that you don't learn great coordination. It just means you wouldn't be vision-dominant for learning movement. But not only is vision our dominant sense for those folks with vision, but it also tells us what the other senses are doing. So, it gives you a lot of information about the hearing world or the touch world. So, there's-- for me as a vision person, when I'm touching something I'm also looking at it. And when I hear something I can also confirm it by looking at it. So, not only is vision normally giving you the most information, but it's also, telling you what the other senses are doing. Quickest and easiest way to know what's happening out there at a distance as well as our close space is through vision. 

For sensory integration and development, the first seven to nine years of life are really just about the brain and body being a big sensory processing machine. There's all kinds of learning and things that happen through this time. But until you're about seven to nine years old, really what the brain has been doing is growing from the back, growing from the sensory processing areas more forward. So, it's growing from the back where sensory processing takes place towards the middle of the brain where motor planning takes place. And now towards the front of the brain where we have executive functioning and learning. So, the first seven to nine years in sensory integration theory, we call that 'sensory motor development.' 

The image that we have now about development just shows us kind of what I was just saying. So, sensory processing develops first. That information moves towards the front of the brain, towards the middle of the brain, and that becomes gross motor skills. And then fine motor skills. And then self-care skills. And then life skills, essentially. Life skills are attending school or holding a job or all the things we do in daily life. So, that's sort of the progression of the development of the senses and then looking at gross motor, fine motor, and then self-care. And then taking care of each other and daily life. The book 'Beyond Behaviors' is Dr. Mona Delahooke's book. And it's great... because it takes into account all the sensory possibilities. So, what she does is she talks about behavior in sort of a new way. And she reminds us that if a response appears to be sensory... in nature or a response to the environment, that that's not a deliberate or intentional behavior. That's information coming into the body and not information that you have direct control over. So, she helps us sort of separate the difference between what's behavior because it's goal-directed and intentional versus what's behavior because it seems to be a reaction to the environment. And so, if you have vision impairment, there could be other sensory responses related to vision impairment that might be auditory in nature. So, if I'm someone who has a difficult time processing the auditory world, I might literally cover my ears, I might get loud myself, or I might have difficulty tolerating the sound environment. And especially if you can't see, then you're relying on sound to be your far distant sense and your near sense. And if everything sounds the same to you, or if things are not easily discernible through sound, it's very exhausting. And there's a possibility of auditory defensiveness. And auditory defensiveness is just this idea that the sound world is causing me too much discomfort or startle. And I'm having a difficult time listening. And so, you might see students cover their ears. I've even seen students who are trying to use their cane but still cover their ears. Because information coming in is overwhelming. It is possible too to have pain in the ears. It's called hyperacusis. So, you can have sensory information coming in from the environment through the ears but it's also painful in nature. And so, we might try something like headphones that dampen sound. We might try music. We might try some things about the sound environment. But if you see someone covering their ears or having a difficult time with the sound environment, just keep in mind that without vision they're relying on their hearing to be their distant sense. But also, they're relying on their hearing to get their instructions and everything from their teacher all at the same time. And it's really difficult to do. 

Dr. Mona Delahooke, she also wrote a book for parents that's 'Brain Body Parenting' and she also now has a behavior chart that I've been using a little bit. As an OT, I do have evaluations and one part of my evaluation is behavior and communication. And so, now I'm trying to use this model to write about behavior. 

So, a distinction that Dr. Mona Delahooke makes in her book that is really helpful is this idea between what's the difference between a top-down behavior and a bottom-up behavior? Or body-up behavior. So, a body-up behavior is a sensory response. So, it's a response to the environment. Body-up behaviors are here at birth and some of them are lifelong. We always have a startle reflex. So, if there's a loud, unexpected noise in a room, your entire body will jump a bit. That's a startle reflex that's lifelong. And that's an example of a reaction to the environment. And that's what body-up behaviors are. They're reactions to the environment. Top-down behaviors begin a little later. And so-- between the ages of three and four, children are starting to be able to make top-down behaviors. Meaning like you can maybe give an instruction of, 'Oh, take a deep breath' or 'let's try this together.' So, top-down behaviors means being able to use your thoughts in the moment to modify your behavior. So, you have to be a little bit older to be able to do that. And I also think in some cases if you have a sensory processing problem, you might get stuck in these body-up behaviors or behaviors that are in reaction to the environment. With vision we can look and see and we can turn off stressors if we need to. So, if I hear a loud sound in a room and I don't know what's caused the sound, my whole body will go towards the sound and I will look. And if I need to I'll move and look and make sure the situation is safe. But it's my vision that ultimately gave me the sense of safety. So, I'm feeling an alarm until I know what it is. I see what it is or I find out what it is. This alarm goes off. So, I think about our students, who a lot of times don't get the message that everything is safe after being maybe alerted to a sound or a touch experience. 

If we go back to our thinking about the triangle and we have our vestibular, tactile, and proprioceptive system at the bottom of this triangle-- because actually those are developed before vision and the auditory systems and then learning, cognition is on top of that. So, if we're thinking about information coming into the body and if it's a sensory input, a sound input, or a touch input-- especially an unexpected touch input-- that would be a body-up response. But if we were able to think about, listen to instructions, and follow instructions, and think about our behavior, modify behavior, that's a top-down response. Sometimes I find that students can say some of the top-down things, but it's really hard to do them. So, we're trying to practice together, lots of practice of deep breathing. Of simple mindfulness. Of listening together. Trying to practice and use the terminology of when you're feeling worried or when you're feeling upset or stressed, we can try or think of these things. And we do have a lot of information specific to optic nerve hypoplasia and septo-optic dysplasia. And I chose that diagnosis because most of my caseload is students with this diagnosis. And also, they really have a difficult time with sensory efficiency, sensory processing, and sensory integration. And so, I think it's a great diagnosis to talk about these issues with. 

I'm trying to do this every year, simulate someone's vision on my caseload. So, I sorta get a feel for why they might be turning their head a certain way, or moving their body in such a certain way. And right now, I have a simulation that I've been using for RP- retinitis pigmentosa. And, in this case, there's no more vision in one eye and there's a little bit of remaining tunnel vision in the other eye. And when I wear these for just a super, super short amount of time, I begin to move just like my student does. And what he's doing is he's using one eye with a tiny, tiny, tiny visual field to try to see so much that he often is doing a lot of this extra head turning, which is a bit unsafe as someone using a cane. He's also newly adjusting to vision loss with RP. So, every now and then, I would find a way to simulate some of your students' eye diagnoses because it's really, really helpful. I mean, one of the things I learned is it's really tiring. It's really tiring to try to focus your vision in such a small spot. And so, he looks to me sometimes like he does just kind of check out a little bit visually, almost as though his eyes are just, like, a little bit, like, overwhelmed. But that makes sense here. And then the other one I have is for a student with CVI. And same thing. This is a really hard student for me to understand. So, I have some cues for myself for the top. He has really severe field cuts and really pretty good vision in one eye-- that's something called checkerboard. So, it's not clear vision and not good vision in the other eyes. So, the same thing with these when I wear them, even for a short time, I very much do what he does, which is he sort of finds the best place to see... and he stays in this position a lot, even though he's moving through space. But he's trying to find the best angle to see so that he doesn't fall and trip on things down here is sort of my... sort of my feeling trying to look through this was really, really difficult. So, I would just do that some. And when I have OT intern students, we always do some vision simulation as well as some-- some blindfold work. So, if we continue to look at, like, a CVI vision simulation, for example, and we wear it just a short amount of time, we sort of find that we have to get our head in just the right spot in order to use the vision. But in addition to that, we're also holding the head still in a certain way, possibly in a different position than the rest of the trunk, and moving in a certain way, even though the sound environment is still bringing in information to both sides of the ears, and you're getting information from how you're moving your body. So, if you're kind of stuck in certain positions, that information is not as clear or continuous or as easy to recognize. The best way to be able to hear something is to have a midline posture and both ears kind of pointing similarly forward just like the eyes do. That's your best way to hear something. So, if you're stuck in a visual posture because that's the best way for you to see and not fall down, you could be missing a lot of other sensory information. 

So, I wanted to talk a little bit about optic nerve hypoplasia, septo-optic dysplasia... specific to the limbic system of the brain. And so that's why we have a drawing over this way. But then also talk about where-what vision and the tree of vision. And this information might be more related to cortical visual impairment or CVI. So for-- oh, here's the view... ideally. This view. Yeah. So, for optic nerve hypoplasia and septo-optic dysplasia, I'm often asking myself why is there such high emotion? Why is there so much difficulty controlling the body? Why does it seem like the hips are turned out? Or why is there constant self-stimulation behavior? And so, when you look at some of the brain structures that are involved in optic nerve hyperplasia and septo-optic dysplasia-- and you'll see this in, like, medical records or nurse's records. Sometimes it'll talk about things like panhypopituitarism or pituitarism. And so, what we want to know is at this very center of the brain, this limbic system part of the brain in the case of septo-optic dysplasia or SOD or ONH, it really hasn't seemed to form right. There's something called the thalamus and below that the hypothalamus. Pituitary gland has is attached to that. And then a continuous set of structures includes the amygdala and hippocampus. But mainly what you might see in ONH or SOD is hypopituitarism or panhypopituitarism. And it's these structures. Normally the hypothalamus regulates everything. It's like your autonomic nervous system. So, your temperature, your sleep-wake cycles, your hunger, your thirst, the way water is managing your body, the way sugar is broken down in your body. All those are things done by this homeostasis of the hypothalamus. But in the case of ONH or SOD, they might not be making the correct hormones for this structure to share information of the pituitary gland. And the order is that this structure knows kind of what the organs need to do. The kidneys, the heart, the breathing rate. Sends the information to the pituitary gland, which then sends it to each end organ or to other glands in the body. And so, if this isn't working right, you're going to have to take some kind of hormone support just for regular growth and development. So, I wanted to point that out in optic nerve hyperplasia and septo-optic dysplasia. And then this big structure here- the thalamus- is part of the limbic system as well. And all your sensory information just goes here first. There's some exceptions, but for the most part your vision, your hearing, your touch, your movement is going to go here first before going anywhere else in the brain. So, that's like a filter. Or some people say it's like the little brain, the anteroom. It's sort of the site before it goes to higher learning centers. Most information is done here. Most information drops away here because you only want to focus on the vision you're using and the hearing you're using and the movement you're using... in the moment. So, if you're focusing on too many things because this isn't working right, it could be that you're getting information that the rest of us really aren't even bothered with. The flashing of lights or certain sounds out in the environment. Buzzing, or things that I don't even notice if they're not being, like, kind of filtered out for you. That can be really difficult, especially with vision impairment and now, in addition, you've just got the sound environment just kind of seeming to continuously give you information that's hard to decipher. The other thing here- the hippocampus- this is your memory center. So, both short-term and long-term memory start here. But these are place memories. There are cells in here called place cells. And so, anytime I'm in a familiar environment, the cell activity here is a little bit different. If I'm in a place I'm not familiar with it's also a little bit different. And so, these cells help you know where you are, navigate the world. So, that would be true too with vision loss. It doesn't mean that these things aren't working. It just means you're working with different information. And then also thinking about the amygdala just with the high emotion sometimes with optic nerve hyperplasia or septo-optic dysplasia. There's kind of an easy, over-excitement or a nervous system response. Sometimes that's called the sympathetic response, where someone just is visibly anxious and you might see it through repeated body movements, you might hear it in voice, how loud they might be, or they might be upset and having kind of an emotional breakdown. And part of that is because their diagnoses includes all these structures. And all these structures regulate each other. And these are only some of them. These are only some of them in the limbic system. So, that's part of why we see so much emotionality around it. The corpus callosum is on top of this. And I really think if you have someone with ONH or SOD and their hips are turned outward and their trunk is turned and their neck is turned, that probably they have some involvement with this part of the brain too. Called the corpus callosum because that's the left-brain/right-brain, like, split of axons that are going to go to the opposite side of the brain and body. It's a huge fibrous... sort of brain organ. And part of it is in the limbic system too. 

Okay, so one of the repeated things that I as OT see with optic nerve hypoplasia or... septo-optic dysplasia is... maybe some big body movements, some big rocking. This is actually not uncommon with that diagnosis, especially for younger kids, for them to have one foot turned to the side and to have their body rocking back and forth in a big motion. And it can really last. So, you can have someone-- I have someone on my caseload who's a high school senior and would like to stop. She would like to stop. So, we do practice ways to stop, but for the most part she can't control it. It's under... it's not in conscious thought. And so... I've explained to her that I think what happens to her when she's up and standing is that this has become her normal. So, her normal is about having a constant motion. And it could be because she doesn't have vision, but it's something that probably started as a baby or a toddler. And it's really difficult to break as a habit. And so, I'm very careful not to say 'stop moving' or 'don't do that.' And also, really careful to explain to parents-- parents especially-- that it's not something that's in her mind for her to stop by thinking it through or thinking about it. It's something coming up from her body. So, it's not really in her conscious control. She can pull it into conscious control because she's brilliant. You can say to her or she can say to herself, 'I'm in a restaurant, I better stop rocking.' But she also can't have a conversation and enjoy her meal if she's got to keep all her focus on how not to rock in this setting. So... it's a touchy thing for parents because, obviously if you're rocking really big like this... then it makes you look different than the other people around you. But it's not something that's in conscious control. And I think that the other thing that happens with this diagnosis some, is that you can have overreactions to the environment. Maybe it's the sound environment, maybe there's too much noise for you. And so, you're kind of stuck in these patterns of, like, distress or patterns of sensory defensiveness. That commonly occurs with this diagnosis. And it's really difficult because it's-- when you're kind of stressed about sound and the world is very much a sound world as it is a vision world, you're always getting sound information. And if your brain is not teasing it out for you- what matters to you, what's relevant to you- then it's really, really exhausting because everything has an equal value. Like the teacher's voice doesn't sound any different than another voice or... noises in the hallway are equal to me than when I'm supposed to be listening to in this room. So, it's really difficult. Auditory defensiveness is. And it happens pretty often with this diagnosis, as well as tactile defensiveness and that's just the idea that you're kind of stuck in a protective mode around touch so... 'please don't touch me, please don't touch me.' And also reaching out and touching things is really difficult. It doesn't mean they can't learn. They can learn-- everybody can learn skills, in every area. But I do see a lot of, like, fear around what things will feel like through the hands or about being touched. And one of the scariest things for everybody-- sighted, everybody-- is being touched and not knowing who it is or why. So, you know, in crowded situations that happens to us too, because we're in such close proximity to each other but we can see. But I'm seeing all the times it happens to our students here and they can't see and some of them also can't talk to me and tell me about it. So, being very cautious with touch and realizing that if the person doesn't know the touch is coming, it's really jarring. It's jarring to the nervous system. 

All right. Okay, everybody. The other thing I wanted to quickly run through is where-what vision or the tree of vision and I'm thinking of CVI. But you can think of... a lot of diagnoses, actually. And you can have ONH and CVI. That's actually not all that uncommon. So, the optic nerve might be the limiting optical feature... of ONH. But for the information that does make it to the brain, what if it's not processed accurately? So, that can happen. You can definitely have both. And I have a student... who's off to college next year and she's brilliant and she has ONH and CVI. And so her... optical vision is limited by the optic nerve, light perception, some form perception. But she also has CVI. So, once the information makes it into... her visual system, a lot of time has gone by. It's called visual latency. And by the time-- she almost describes it not being worth it to try to look at people and talk to them. Not that she doesn't want to, but that when she tries to look at people and talk to them at the same time, she gets distracted by the visual feedback. So, she might literally look a bit and notice something about you, but take a little bit of time to actually recognize it. And by then everybody's moved around. And if there's more than a few people around, it's hard for her to tell who she just got this information from. So, she had her worst-case scenarios when... there's a crowd and there's a handful of people in her visual scene and it will get mixed up. Like she will literally see, you know, a feature of clothing or shoes or something on one person, but then not be able to see their upper body or head. And then if she stays put long enough, she might get their upper body or head but now everyone's moved and now-- so it's almost like so confusing that she just sort of looks down a bit in those situations and doesn't rely on her vision. 

Another picture here is just to help me talk about where-what vision or the tree of vision. And kind of the big landmarks here are-- you've got a... cerebellum back here. Of course, nothing looks like this, but this structure of the cerebellum has about half of your brain cells in it, so I'm just trying to learn how this works. Because all your stored motor patterns are there. So, you don't have to think about anything you do because you have stored motor plans here in this part of the brain that are always available. Out here, this kind of blue color would be like the cerebral cortex and it's very, very thin. It's only like six cell layers thick, but they're all sort of magical and special. And the cells from any one part of the brain in this outer layer- this outer set of layers- can reach any other part of the brain at the same time. So, that's part of why we sort of have the experience of everything happening at the same time because all these cells out here can work at the same time. 

So, when we think about where-what vision... the idea is that the brain is going to take in information-- not all of it goes to the thalamus, but that's a great first start. Some of it may go a little bit lower. But once that information-- once the thalamus decides... that this information is needed- I'm still using it- it would continue to V1 or vision processing centers in the back of the brain. And that's when it would make-- oh, sorry-- a really big split. There'll be a split both forward back towards the eye and a split up and over... the brain also back towards the eye. So, the way it works is like, if we had vision information coming in, it would go to this LGN, which is this part of the thalamus but the thalamus is really, a multisensory structure so touch is going to go in there. Hearing is going to go in there. Some body movements go in there. And the whole point of the thalamus is for everything that you're using to sort of be determined to continue higher brain centers. Everything you're not, you want to weed it out. And there's a lot of study on this topic called thalamic attention. And there's an idea that what if you have autism or you have ADHD and what if the thalamus isn't weeding out this extra visual stuff or this extra auditory stuff. And it's making its way up here to cause you more distraction, when normally you would expect it to be done. Most sensory information goes here and is done. The only thing that continues on is what we're using in the moment. The other place vision can go, though, is lower here because that's reflexes. And that's brainstem vision. And it's a whole lot of reflexes- from subtle reflexes to really big body reflexes and by reflexes, I mean every time I turn my head, my eyes follow and I do so-- oh, this might help. Your eyes obviously follow, but they also get sort of restabilized and they're supported so they're always in the middle and always pointing forward and those are cranial nerves that are doing that at the brainstem level so you don't have to do anything, your eyes are always going to point forward like binocular vision. Of course, if you have some eye muscle imbalances- strabismus, exotropia- all those things that would affect the ability of both eyes to point forward. And that's why with little babies-- I've just learned recently-- they're really trying to correct super early... eye muscle imbalance or congenital cataracts. As early as before six months. Depending on the situation because the eye is going to change so much between six months of age and 18 months of age that anything you can do to protect that vision along the way, you do. So... I've seen babies on my caseload before-- tiny babies wearing like little glasses. Cutest thing ever. And I wondered, are they seeing through the glasses? And I was kind of missing the point. In the case of that baby, she was too young to be seeing much through her glasses. But you want to keep the retina active. You want all the light coming into... the retina that you can. So, you just have to protect any vision that is imbalanced because ifÉ a muscle imbalance lasts past about 18 months to two years, it gets really harder and harder to correct. You can still have surgeries to correct the muscle imbalance. You can still do patching. It just gets harder to correct. 

So, the other thing about this type of vision is that it's life-saving vision. So, this is true for every sense-- every sense's first job is to keep you alive and the second job is to tell you what's happening. So, every sense will have like a reflexive part to it. So, this is vision's reflexive part so if I throw something through space and it's unexpected to you, you would do this. You would automatically throw your arms up, turn away, protect your face and eyes, and all of that is coming from this brainstem reflexive vision area called the superior colliculus. Something that I think happens with... us because we can see here for myself because I can see is, that I might hear something unexpected or a loud noise. And if it's really loud enough or unexpected enough, your body-- everybody's body-- would do the same thing. It would orient to the sound, so it'd point you to the sound so that you can look. If it's around the corner and out of your visual field you'll still have to figure out what happened. If you could look and see what it is- oh, the door slammed or that fell down- then immediately you turn off the startle. So, the startle was turned on by the noise. But as soon as I saw that I'm not in danger, I'm safe... I turn the startle off. And so, if you can't see, and a lot of the time you don't know what it was or how far away it was-- I think people are kind of getting, like, startled without the relief of like, 'I'm not in danger in this situation.' So, if we take our... vision to the LGN-- and remember all our senses are going here and it's going to filter out the thalamus, anything we don't need. What we're using is going to keep going. So, it's going to go to the occipital lobe back here. And that's kind of Vision Stop One. And then it's going to have a huge split. So, some of the information is going to go up and over. And it's moving through the motor centers of the brain towards the frontal lobe. So, that information is called 'where vision' and we'll describe it a little better. But this is your motor planning centers. And so, for something as simple as like pointing to what I want to point at, I have to have vision coming to this area of the brain. So, this is movement that's ready to go, but it is waiting on visual information. There's about 30 spots in the brain. Once they're starting to be like optic radiations, there's about 30 spots it's going to go in the brain. So, that's a lot of places... that vision will go. The other visual field is your... 'what vision.' They also have a title of 'what vision is the ventral stream.' And 'where vision is the dorsal stream.' But what vision is going to move from V1 back towards the... eye in the front of the brain because it's got to go to the language centers because this is object identification, facial recognition. All this is central vision and it's got to go through these parts of the brain to tell you who's out there and what's out there. So, I see a friend, I know them, or I might see someone I don't know. I categorize that differently. But we're constantly labeling our vision environment only it's subconscious. So, windows, doors, lights, chairs are kind of this constant update of what's right around us in our visual field that's unconscious to us unless we think about it. And that's because visual information goes through this area and it tells us what's out there. And who's out there, which is a little more specialized. Facial recognition is a little more specialized. But... information comes in here, makes its way to the occipital lobe. Most of it is what vision, so most of it is cone cell vision, central vision. The rest of it is going to be part of this where system and this where system is very much about protection. This is about safety. The where system is unconscious. Unless you're bringing something into conscious thought, but it's always evaluating how to get out of a situation. So, this part of your brain is always looking for doors and windows and ways out in case you're in trouble. So, that's a safety thing that vision is able to do easily, that without vision, obviously, you wouldn't have that comfort of knowing how to just get out of this building if I needed to. And it's a brainstem level thing. It's unconscious. You're constantly evaluating your own safety in any situation. The other senses do this, too. So, when you kind of have a feel of this for a vision, hearing has its own version of this as well. And touch. Meaning the first... kind of the first job is safety. The first job is to keep you safe. And so, the first job with hearing-- it actually hits a little lower towards the brainstem-- is... 'is that meant for me and am I safe?' Like, 'what is that sound out there? Is it relevant to me and how close is it and am I safe?'. 

We have some emergency considerations for optic nerve hypoplasia and septo-optic dysplasia, in that they-- these students might take an emergency medication. So, if you're on their school team, you would need to know if they carry an emergency medication. This might be an emergency dose of cortisone. Because cortisone and adrenaline-- you need both to manage stress. And you actually need both to turn on the body's fight-flight response in case of an emergency or an illness or a high fever. So, these students might carry an emergency medication with them, a dose of cortisone. And so, you want to know if you're on their team what students carry this medication. Also, with ONH and septo-optic dysplasia, there seems to be a lack of ability to regulate body temperature. And so, in the summer months, it can be really dangerous because students will be visibly hot but not aware that they're hot. And they might even drop and sit on the ground and it's 100 degrees or hotter. And so, there's a lack of internal body temperature regulation that is consistent with optic nerve hypoplasia, septo-optic dysplasia. And it's consistent with pituitary and hypopituitary problems. So, you know, here at school we've had situations where students will be outside longer than we'd like. So, we're bringing them water, wet towels, yoga mats, anything to get them off the sidewalk. Anything we can do to get them up and moving again if they've sat down outside, which does happen. I think sometimes students actually sit down because they're overwhelmed. May-- regardless of the temperature or what's happening. Sometimes it looks to me like students are in a shutdown mode. And one of the things that this book-- Mona Delahooke does, as well as Dr. Porges does-- is he talks to us about these states of the nervous system and one of them is this shutdown mode or dorsal-vagal state, where someone is just kind of-- literally they might be on the ground, they might be hiding their face, they might be laying down. They've just sort of checked out. They're not really interacting anymore. And so that is a very primal state. And that's a... a state of 'I just can't take anymore. I can't anymore in this moment.' And so, there's sort of a complete shutdown. 

With optic nerve hypoplasia and septo-optic dysplasia, you could have... students who are taking daily medication. So, it could be adrenal support or cortisone or growth hormone or thyroid hormone. And other endocrine support medications because the pituitary gland and the hypothalamus are not working normally. This is not always the case. It's more likely the case was septo-optic dysplasia. Sometimes you can have optic nerve hypoplasia and not have any of these symptoms. Sometimes it's in the optic nerve and it's not back further in the brain. However, here on my caseload, almost everyone I see does have an emergency medication and take some medication support for optic nerve hypoplasia and septo-optic dysplasia. If the corpus callosum is involved-- so that's a big brain structure. It's like a band of... axons between the left and the right brain and it connects the right brain with the left brain and there's all kinds of crossing in the brain. But for motor functions and for vision functions and sensory functions--  this is one of those locations where those brain fibers cross. And there's a part of it in optic nerve hypoplasia and septo-optic dysplasia that doesn't seem to form quite right. And so, it seems like this causes a difficulty between the left brain and right brain integration. And sometimes in the more extreme... cases, I see people's postures-- standing or sitting really being quiet, turned to one side and their arms and limbs maybe even close to this. This might be, like... if I were standing, this might be a rocking position. But even sitting. You get kind of a bit of a big whole-body movement that has a little bit of turning. I think that's... probably related to the corpus callosum, which is about keeping the right brain and the left brain integrated and moving together and in the same way. So, it's harder to have midline control or to have precise movement if a lot of your whole-body posture and movements are kind of engaged in these repeated behaviors. So, sometimes that seems to be that the left brain and the right brain aren't really integrated that well. The other way you can see it is you can try some simple exercises about crossing the midline and if they're hard that kind of is another cue to you that it might be hard to reach across midline. It might be hard to reach across the body. And if that's the case, it's also harder to have precise fine motor skills and things that happen right in the center of the body. 

With optic nerve hypoplasia and septo-optic dysplasia, the limbic system information is relevant where we're talking about behavior. And it seems like the students can easily get overwhelmed, upset, and maybe even stay upset longer than you might expect. It might take them a long time to come back down from feeling upset. Which makes sense if they have these limbic system reactions but don't naturally make the adrenaline and the cortisone to deal with daily stress or to deal with emergency stress. So, we might need to support them more. They might have more emotions related to the limbic system functions. 

There can be some sensory processing imbalances. So, there might be tactile defensiveness, for example. Tactile defensiveness is the idea that... how I feel things through my skin could be aversive to me or difficult for me to tolerate. It might be through the hands and fingers. It might be anywhere on the skin. So, if you have someone or if I have someone on my caseload... who is tactilely sensitive and maybe they are Braille readers... and they are doing specific things with their hands and I want to help. I have to realize that my touching them is a big input to them. So, if I'm going to touch someone, I want to be careful about what verbal cues I might be using. I don't want to overload someone with my touch and my verbal instruction, so I want to be very careful with how I'm touching. I think we're really good at that here at the blind school by asking permission before we touch. But sometimes I forget. The scariest thing to the brain in terms of the touch system is being touched and not knowing who's touching you or why you're being touched. That's a very scary and uneasy feeling for the brain. So, when you're working with someone-- so I'm kind of picturing a table working, working beside someone, I might be thinking about the hands. Maybe we're shoe tying, maybe we're trying initials. But the body- the entire skin system- is activated. So, I might be working on the hands, but I'm also trying to remember now and I've learned that, 'Oh, the entire skin system, the brainstem is very active because I'm touching another person.' So, anytime you're touching another person, the brainstem is like 'alert, alert, alert. Is it safe? Is it safe? Is it safe?' And so, I'm trying to be really careful about how I touch, about being sure to let someone know before I touch. And also, just have the idea in my mind about how much of a feeling of safety is required for someone to relax and let you do some hand-under-hand or hand-over-hand if it's right for the kid. But just realizing that my touch, even though I might be on the hands mainly, is really activating the entire body the same. And it's a big brainstem input for another person to be touching you. 

The other things that can happen with tactile defensiveness is it can be really difficult to brush teeth, to tolerate bathing and showering. All these things that require water and lots of texture can be really hard for kids who have tactile defensiveness. So, they might be very slow to learn to brush teeth. It might be difficult for them. They might have eating difficulties that are related to oral tactile sensitivities and how food feels like in the mouth and how things are crunchy or what texture they are. All of this might be very important to someone with ONH or septo-optic dysplasia or tactile sensitivities. And it's really difficult and takes a long time to sort of build skills over what we might think of as oral tactile defensiveness or tactile defensiveness. And I'm trying to be careful with my language so I'm not meaning to say that someone is emotionally defensive. I'm just meaning to say that it looks like their skin or their touch responses are overreactive or oversensitive. I don't want to label someone, so I'm trying to be careful about how I describe it. There are some... writers who say maybe we should be calling it tactile selectivity or tactile sensitivity would be a little better than defensiveness. So, we want to be careful with our language. But if you're tactile-defensive, then it's really hard to let another person touch and guide you. The same is true for listening- for auditory defensiveness. If you're auditory-defensive, it can be really hard to listen to speech. It can be hard to listen to your teacher's speech. It can be hard to make sense of what is being told to you because you're getting signals that are about the entire sound world. And just your teacher's voice is part of this entire sound world. And so, there's kind of... in tactile defensiveness and auditory defensiveness, there's kind of a-- just a version of blocking out, a resistance to tolerating sensory information. And it's really hard to get a whole picture, right? If you have a vision impairment but you're also struggling with what it feels like to feel things through your skin or what it feels like to you to hear things, it can be hard to get a whole picture of what's happening around you. In addition to tactile defensiveness and auditory defensiveness, I see some gravitational insecurity or fear of movement, which makes sense with vision impairment. But sometimes with optic nerve hypoplasia or septo-optic dysplasia, it's a little bigger than that. So, I see some students have a real fear of movement-- and by a fear movement, I mean it's hard to get up and down from a chair. It's hard to get up and down... even from the table at times because I think especially for sitting, I think there's not a real clear feeling for when the body is going to be fully in the chair. I think there are some things about weight-shifting that are scary if you have this gravitational insecurity and so simple movements are alarming and anxiety-provoking. Because you don't have a real good sense of 'how far down is down?' Or 'how far up is up?' So, I think there seems to be some-- especially in transitional movements which impact things like toileting, things that you need to do over and over-- are scary because you don't have an easy way to move without feeling scared in the motion. And so there can be some defensiveness just about movement alone. And so sometimes you might see someone refusing to get up or maybe being stuck actually in sitting or sitting on the ground. So, there could be a piece that's about movement sensation and movement processing... with optic nerve hypoplasia and septo-optic dysplasia. And actually, with any developmental diagnosis, you could have these multiple factors. You could have-- If vision is present. What is the vision environment like? How are they using their vision? If they have intact hearing do they also have good auditory processing? And if they have intact touch skills, is it easy for them to use their hands and their fingers and feel things through their skin? So, one of the things we want to try with tactile defensiveness-- or I want to try to touch defensiveness-- is... what activities can I do to try to push past that a little bit? So, I do a lot of things around tactile defensiveness. Like the brushing routine is just one, but using pressure and vibration. Like trying to find what tactile information is soothing. Not just to the hands, but to the whole body. So, I do vibration, pressure, weighted blankets, those sort of things for... tactile defensiveness. For auditory defensiveness, I do have some specialized headphones. I have headphones that are about blocking out some of the sound of environment, as well as headphones that are about listening to specialized music. So, those are the kind of things I try for auditory defensiveness. And a lot of, like, sound machines and select your own music. I think with... optic nerve hypoplasia, septo-optic dysplasia and other diagnosis, if people have real strong preferences in sound or in vision, I try to give them those preferences. So, if I have someone come into my room for OT and I know they have low vision and I know they have preferences for vision, I let them know right away they can make any changes they want. We can cut the lighting to 50%. We can turn off the lights and play with colored lights and toys. I just think there's not a lot of chance for a student to control the light environment or the sound environment. So, I try to make sure they know they can do that in my room. And it's really quite great. People will be really creative. For the sound environment, I have students who choose... sound machine sounds. The very favorites are like thunderstorms. And I have students who choose white noise or pink noise. So, I do try to make sure that we have a way to kind of figure out what sounds you have a preference for-- you the student. Or what visual... needs do you have-- you the student? And so, I have students who come in and right away they cut the lights to what they want the lights to be and we decide on what we're going to listen to. And we get started that way. 

So, for tactile defensiveness, I do use a ton of vibration. So, this is just an acupressure ball that vibrates. And I do use the skin brushing routine. This is just a skin brush with vibration. I don't use vibration if anyone has seizures. If they do have seizures and I want to try it, then I talk to mom and dad and the health center first. Because I don't want to add vibration in case someone has seizures and in case it could be a seizure trigger-- I've not really heard of that being the case that someone's had a seizure because of it. But I had a therapist explain to me that if we think of strobe light as... a particular intensity of light- dangerous because of their ability to... cause seizures possibly. She sort of thinks that vibration is the same. She says vibration is faster, but it's just a repeated signal into the skin. And so, if I think someone's at risk for seizures, I want to make sure I don't do anything that could be seizure... be a seizure trigger for them. So, it's always clear vibration and spinning. I don't spin anyone on a swing or spin board if I think they have seizures. There could be exceptions if mom or dad or the health center knows that they've never had a seizure related to movement then that makes me feel a little different. But vibration and... spinning I'm careful with if anyone has a seizure history. The other thing with seizures is that... it's possible to have a seizure triggered by smell. So, I'm really careful with smell. In the big picture, you don't put anything in the air and don't put anything on anyone's skin. So, you want to be careful with smell. It's possible to have a migraine or even a seizure triggered by smell. Or some people have in their seizures [unclear] that includes particular smells. So, we're very careful here with smell. Our campus is a fragrance-free campus, so we just want to be careful with smell. 

We're all under responsibility. So, this is someone who. It's like using a really heavy touch and kind of touching everything. And they'll touch each other, or they'll touch other people or their touch themselves a whole lot. So, we think maybe they're not getting enough information through the skin. And so that's kind of why they just keep going, just trying to get input into the skin. So that's, seeking behavior, tactile seeking behavior. And these kids often like, play to rough their rough with their peers or rough with their toys. They might not know how much force they're using through their hands and fingers. So that's kind of a combined tactile thing in a pressure proprioception thing. So, I have a student on my caseload now who's the best. But really everything he does is big and heavy with his hands. And I think that's because that's how he feels things through his hands. He just feels he's more abrupt movements. I don't think he feels a more subtle movement through his hands. And so, I think that's kind of why he grabs things. So, with such force at times. And, you know, it's easy for him to break things unintentionally because he's playing with him, but it's honestly playing really, really rough. But I don't think he feels like the difference between, rough grasp and a soft grasp. We give him a lot of language about soft and careful, and he's super, super kind, so he's doing his best. But it looks to me like his first impulse is just kind of this. And so also what? Tactile under responsivity. You can see someone, frequently mouthing. They might frequently put things in their, in their mouth, hold things in their mouth. Aural, tactile seeking. But you might also see someone who bites themselves or pinches themselves or scratches, picks up sores and things on their skin. And they might have a really high pain tolerance. So, like, I have someone on my caseload now, when he bites his own hand, he sort of turns his hand and bites it this way. This finger is very scarred and very much a scar tissue finger, and often is a little bit wet, like it doesn't always dry all the way. So, there's always, some skin sensitivity here. And that's just from very frequent biting. The other thing that I'll see is that students don't have the tolerance for Band-Aids or something on their skin, or if they have their own skin or injury or mosquito bite, they might scratch and scratch and pick at that. And they don't seem to feel, the irritation or the pain you might expect. So, this student, this under responsive, tactile student is touching things too rough playing with things too hard, grasping other people too firmly, and probably not feeling those nuances, not aware that they're doing it with too much force and difficulty with tactile processing causes difficulty in gross and fine motor control. Again, too much or too little pressure. They might be using too much or too little force, and they have difficulty differentiating between types of touch. 

With alternate defensiveness or extreme sensitivity to sound. They could be, covering their ears, but it could be that they have distress related to specific sounds. They might be very afraid of certain environmental sounds. Lawn mowers and weed eaters are a big one. Toilets flushing, especially toilets flushing unexpectedly, like the automatic flushing toilets and dryers. All these things can be scary. Sounds like they're kind of big sensory events too, but they're also scary sounds. And so, I've seen kids have like, really fearful reactions to going to the restroom, all because of the different sensory things that might happen in the restroom, to the point that we've adapted some routines so that students can use, a bathroom. And we've disabled the automatic flush, and we've made sure that there's not, any scary sounds in there, like the hand dryers or the, paper towel dispensers. Kind of. So, a student doesn't have to go through all these sensory things just during the restroom routine. So, it can be really disruptive. It can be really disruptive. I've met I've noticed, you know, my case I was initially was just holding it throughout the day because she was so uncomfortable with all the things happening in the different bathrooms. Now we have that fixed. But, yeah. So, you might not know that until someone tells you or a parent tells you. So, these students might, I think, already said this. They might be kind of loud students, or they might be seeking sound and making sound. So, they might be tapping. They might be making like a constant sound can be bothersome to other students. They might be vocalizing a lot. Humming. Are making their own noises even though they're concentrating and working. And so, they, they just might be making noises that then impact the other students. Depending on someone's auditory preferences, they might prefer a quiet room, you know, of a student who mostly wants a quiet room because his classroom is so loud and excitable that when he comes into my room, he does 50% lights and a quiet room and we might put on a background noise, either some classical music or some nature sounds. And he just talks about feeling like he's in a place where he can think. And I think for him, honestly, I do think he has low vision, and I think he's pretty jarred when there's loud noises in the room. He's really, really kind and really, really polite. So, he sort of just doesn't really say much. And then when you get in conversation, you kind of find out, oh, that sound that the student keeps making is really difficult for him. Or when another student is upset and yelling, for some reason that's really difficult for him. So, he is internalizing some of this stuff that I don't think I would know if he weren't able to come into the room, make sure we can be quiet, he can choose a sound setting, and then he can talk to me a bit about auditory and other issues in his classroom.

So, for vision and low vision I always follow the recommendations of the vision specialist and vision instructors. I have found with students who have low vision that I will carry a bag and I have quite a few light toys in my bag. And so, for the most part, if I just turn something on and just go into the room with some of my lights flashing-- I have two kiddos that that's enough for them to come and play with me. We literally call it light and sound toys. But that's easy. And it's a see-through bag. And so... someone with vision might really be drawn to your colored light toys or to your other light toys. The other thing I do is I have things that vibrate and I have things that make noise and I'll put them in my bag and turn them on. And then the whole bag's vibrating a little bit and just be kind of beside them until they hear it and then they'll feel it, play with it, and come with me. So, I've sort of put together a big see-through bag of toys. These are the kind of toys that I play with most and take with me. I generally bring students to a therapy room and I have a bike, so I pick them up on a bike. We have our toys ready to go, and we go to an OT mat room. And it's great. It really works. The other thing I do is, like, I might save something, like, this is a super-favorite toy for one of these little guys. And I might kind of hide this one and save it for the bike ride back at the end. If he has trouble, like, ready to leave the room, it can be hard to leave the room if he has very favorite toy. So, I try to save something that I know he's going to want to play with. He loves light switches, like, the kind at the doors and the walls and so he plays with this one in kind of the same way, just like a light switch. 

So, for students with low vision, I'm really trying to modify my lighting to what they need. And then I'm also kind of using light toys, colored toys... to get them to come with me often. That works pretty well. I have two students with autism. Actually, both have Goldenhar Syndrome, as well. And they both have low vision in one eye. That's kind of how that syndrome works. And they both love vision. So, both of them have a really good time just with colored lights and light toys. And they're just happy and willing to come with me to play with those toys. 

So, for vestibular processing and movement processing... so, this is whole body movement and balance and posture-- it all kind of falls under vestibular processing. And normally our movements are very much directed by our vision. So, we point our eyes and that's where we go. So, you can learn full movement. You can have full coordination without vision. It's just harder to learn because normally our movements are directed by vision. So, even something as simple as, like, picking up something from a table. This is all vision. Really where vision information... that just automatically my hand-- everything about reaching to something is visually guided for me and it's all automatic. So, anything you pick up, your hand is already making the shape of that thing because you see it and you're ready to pick it up. So, that's visually guided behavior. That's where behavior... in the vision system. And that's normally how we move our bodies as according to what we see. So, without vision you can completely learn... balance, all kinds of skills. There's no reason to think you can't learn anything. It just could be harder and take longer... than if you had vision. 

For OTs and PTs out there, just as much movement as we can get would be fantastic. So, I do a lot of swinging, jumping, spinning- with caution- riding bikes and trikes and scooters and I'm holding those up. Jumping, jumping into a crash pad. As much movement as possible is what we're trying to do every session. 

And to wrap up our senses essentially bring us all the information all the time into our body, mixes with our internal state, what we're feeling and thinking. That's the information we use to learn and to interact with each other and talk to each other. Move through the environment. This is what shapes all our interactions with each other.

>>Lynne: Okay, so Lisa, you talked a little bit about some of these behaviors caused by the sensory-seeking or sensory-avoiding... the systems. So, when you have, you know, we often hear teams say it's so distracting and... it disturbs the class when the student jumps out of their chair and starts rocking in these really big moments. Can you fix that? Can you tell them to stop and have that stop? 

>>Lisa: So, I don't think you can fix that. Certainly not by telling them to stop. Because I think what's happening is an automatic movement behavior that often is started in infancy and early childhood. So, I think some big rocking, for example, or standing and rocking. Those big movements have probably been since ages before two even... often. And so, I don't think you can stop them. You can try a movement break or try jumping or spinning or try a whole-body movement as a replacement, or to do instead, or to try and then sit back down. But you can't just say 'stop' and then they stop. Because if you say 'stop'-- and I see this in students including students who are off to college now-- if you say 'stop'... they have to put all their attention on stopping. So, they can't also listen to the conversation, take part in the classroom activities or... Their-- all their concentration is on 'don't rock' in that case. 

>>Lynne: Okay, so some of these-- some of these behaviors that kind of arise from the senses can end up in a behavior intervention plan...

>>Lisa: Ohhhh. 

>>Lynne: And so, things like shouting out. Or things like biting or scratching when there's no observable cause. How would you- coming from a sensory standpoint- kinda maybe try to talk with teams about things like that? 

>>Lisa: Well, shouting out could have a function. So, I do have someone on my caseload who's recently lost a lot of vision and is still losing vision and it seems like he's shouting out to replace vision as a distance sense. So, I think he's shouting out, 'Who's out there?' Literally. Because he used to not that long ago see who's out there. So, literally all he has to sense... is the sound of somebody. Or he has some remaining vision, but it's quite poor. Or maybe a shadow or form. And he literally is shouting 'who's there?' And in a very kind and funny way so everyone wants to answer and talk to him. But it is pretty disruptive. It's disruptive trying to travel with him. It's disruptive to the people he calls out to because some of them don't want to turn around and shout back and he doesn't really have the self-control to stop doing it. It just makes him louder and a little funnier. So, it's really disruptive... in his case. What I'm trying to do with him is I'm sometimes getting really close to him in front of him... and I will say, 'I'm so close. I'm so close. You don't even have to shout. I'm right here.' And I lower my own voice and I practice how I would talk to someone who's in a close distance from me. Because he really gets a kick out of being super loud and playful and funny. But it's hard to go down a hallway. It's hard to travel through certain parts of the building because he's literally going to be so loud that... it's disruptive. 

>>Lynne: So, you would consider that sensory-seeking behavior-- 

>>Lisa: I do! 

>>Lynne: --that he can't... control? 

>>Lisa: I think it's sensory-seeking behavior and I don't think he can control it right now honestly. We're trying in games. He's a funny person so we're trying games and other ways to kind of control it that way. But it looks to me in the moment like he needs to know who's out there. Like he sincerely needs to know who X is who made this sound over there. Even if it's far away. Even it's on another sidewalk. He really seems to need to know who that is or who that was. And I feel like in my mind right now that that's partly because he used to have that information by looking. 

>>Lynne: And for students that... the team might say is aggressive-- biting and scratching-- for what they can consider no reason... But maybe what things might you talk about the team might want to consider? 

>>Lisa: So, I have a student who is... quite self-aggressive. So, he will kind of push and hit. But most of what he does is bite himself really, really hard. Bang his head really, really hard. And I feel like he is in distress. I feel like it's a sensory response that looks tactile to me. Like he's overwhelmed. He's getting the wrong kind of input. I'm not entirely sure why he's uncomfortable. And I think he does these big things periodically... both to give himself an input that is soothing in some way, but also because I don't think he has much control over anything. And I think sometimes he takes control by self-- hitting himself, hitting his head on the floor. Some of that could be about 'where am I? I have no vision. Literally, where am I in this room, in what body position? Where's my head? Where's the rest of me. If you're kind of stuck-- he's kind of stuck. Not a real mobile person. CP. Really, really quite firm in the way he touches. I honestly think he is having a sensory reaction. I don't think there's anything about-- I mean, some of it is 'leave me alone and go away,' but it looks very sensory to me. 

>>Lynne: Okay, well, let's talk about that. 

>>Lisa: Okay. 

>>Lynne: So, sometimes we have... people reach out to us because they have a student that's... aggressive. And so, they don't want to be hurt. And so, they don't physically interact with them. So, what would you say in a situation-- and usually these kids are the more complex learners. 

>>Lisa: Mm hmm. 

>>Lynne: So, probably with no vision, no speech. Maybe no hearing. And limited mobility. Do you think that is the most appropriate tactic to not interact with them? 

>>Lisa: No, no, no. Like, thinking of the student that I have in mind right now... I play with him. I really touch him in a really intense way. And I'm telling the teacher what I'm doing, but I'm using-- in the case of this one student, I've stopped using my hands in this position and my first touch with him is always in this position. I just want him to feel that I don't have any intention. I'm not going to grab. I'm not going to try to move him. I just want him to feel that I'm able to touch him and we can have a touch event without me having an expectation of him to get up and do something right now and he loves it. And so, I've taught his teacher-- and literally we spend a little bit of time on his back and shoulders just doing some of this. And... he doesn't have to perform in any way or do anything. All I want him to do is to enjoy touch experience. And now that we know each other, I've got... I'm pretty bold, so I'll bring something like this and it does vibrate and I'll turn it on. But I'm pretty, like, rhythmical and firm with it. He's not someone that I can be light with it. If I'm light with it, it's bothersome and he's going to move out of the way. If I'm firm with it and it's silly and it's rhythmical and I'm making noise, he's interested for a little while. So, I definitely use these things. Sometimes I move similar to the way someone is moving, so he's a real headbanger. I'm obviously not going to bang his head, but I have done 'beep beep' on his head, made a sound, made a noise, and he thinks that's hilarious because... that doesn't happen very often, you know. Someone just comes up and plays with your head, but he's going to do it anyway. And so, I'm doing some motions that kids are doing anyway. The other... one was really from... listening to Van Dijk many years ago. And he told me if I have someone doing a specific stimulation-- and in this case, it was this, I was just-- her hands were always busy because they were at her face or a little bit in her mouth. He said, 'Sit down and do it with her.' And so that's what I did. So, at first, I sat down and I did it to myself for a long time. And I borrowed one of her hands and I said, 'Yes, I have it too.' And we did that for a long time and it was hilarious. And that was my immediate in with her. And I always asked permission. 'I'm so happy to see you. Look what I'm doing. Check it out.' And she'd reach over and feel it and laugh. So, if you see someone doing a repeated behavior, if you can share in it in some way that's safe, definitely do so.  In the case of this young boy he's really, really rough. So, he can pull... your shirt. Grab your hair. And all that kind of stuff. But at the same time... he's really kind, and he really wants to play and everyone needs to be touched. And so, I find him to be so isolated in this way. So, I just figure I can go over in his space-- and sometimes that's all I do is go be in his space with my own stuff. Like, he can kind of push me away, but I don't go all the way away. Even if I'm doing my own thing. I just want him to know I didn't leave. I'm trying to stay. Even if the movement is, like, kind of jarring or... pushing me away. I'm trying to stay. Not to make him mad, but just to say, 'Oh, I want to play with you no matter what you're doing. I want to play with you, and I've got some toys and we'll be okay.' So, I do try to use people's self-stimulation behaviors as a way in... if I can. Because that's unexpected sometimes for them. They're like, 'What? Why are you doing that?' So, there's a curiosity and a leaning in and 'I want to know more.' So, I'm doing that with folks. 

>>Lynne: At some teams find it more-- easier to accept some of these sensory-seeking or sensory defensive behaviors from the more complex learners and not so much from the academic...

>>Lisa: Ohh. 

>>Lynne: ...verbal college track learners... because the expectation with those guys is they... are beyond all that stuff. 

>>Lisa: So glad you said that. So, I have... two girls in mind. One I was mislabeling the behavior myself. I was saying, 'I think there's intention behind this. I think she doesn't want to leave this class and go to the next thing. I think she's got an emotional issue.' And I sort of had in my mind like, 'Oh, she's doing this for an outcome.' And then I followed her for a couple of days during this and it wasn't that at all. It was a sound event or a touch event that triggered her every single time. And so, I told her team, I told her mom, I was like, 'I was looking at this really wrong. This is a sensory reaction. This is an environmental sensory reaction.' This is exactly what Dr. Mona Delahooke is talking about. It's not a 'I planned this because I'm not ready for PE.' Or-- it literally is a sensory response. And so, I hope I'm doing a better job now... specifically for this one student because for such a long time I thought, 'Oh, she's brilliant. She must be doing this for some reason.' I mean, she's literally brilliant. She's an actor. She's going to be great. She's going to go to college and have this great life. And so, I had in my mind- because she was so smart- that she had to have some reason. But she really didn't. When I watched her, I saw that it was a touch, a smell, or a sound every single time. And so, I took some good notes about it and sort of wrote the team, and I said, 'I've changed my perspective on this. I don't think this is intentional behavior.' So, absolutely. It's been a-- it's been a big help. This book has been a big help. 

Thank you so much for your time and feel free to contact me. My name is Lisa Ricketts. Have a great day.