Multi-Sensory Environment – A Protocol for Individuals with Autism

Introduction:
When building a dedicated MSE room it is important to control the outside and external influences or variables upon the individual. Variables such as noise levels, light intensities, privacy and even room temperature can be controlled. This is important because it sets the stage for comfort and allows the individual the opportunity to control the amount, intensity, degree, and frequency of sensation from multisensory equipment that they seek, and a practitioner has identified they require. Why? Because the more variables they can control the more they will experience/learn and benefit from an understanding of their internal dynamic process. There is no linear cause and effect relationship, no recipe for everyone. What there is however is an opportunity for a very individualized process to take place that motivates rewards and empowers a person to make positive changes for her/his self through some significant connections. These associations or relationships are dynamic and often an unconscious process that when self-identified can be useful in making healthful and positive behavioral change. Such as when this light appears, with these colors, and this music, I feel good, calm. (Therefore, when I am excited, I can use xxx color and xxx music to make me feel calm.)pleasure principle*2 through stimulation of the primary senses and serves as the primary reinforcement in a dedicated space with an awesome variety of equipment. Jackson and Hackenberg wrote in 1996 in the Journal of the Experimental Analysis of Behavior that “Modern Operant chambers have stimuli, including lights, sounds, music, figures, and drawings.” A Multi-Sensory Environment can offer the same stimuli including figures and drawings through the use of different projected images. If “figures” are defined as the human form, one can interpret this as the practitioner in the room. A well designed Multi-Sensory Environment can deliver the same reinforcements and can be controlled to change and shape behavior just as in as any Operant chamber. I believe this can be an ideal choice for treatment of those with Autism and other Developmental Disabilities.

Autism*3 is marked by: Qualitative impairments in Social Interaction, Qualitative impairments in communication and Restricted repetitive & stereotyped patterns of behavior, interests and activities. Descriptive features include: Odd responses to sensory stimuli for example: Oversensitivity to sounds, Oversensitivity to being touched, Exaggerated reactions to lights or odors and High thresholds for pain. The Multi-Sensory Environment serves to combine behavioral approaches with control of the sensory stimulation for the individual with Autism. The environment as a whole will have the first impact on the individual and that the individual will have to adapt to; so the first emphasis must be on making the individual want to be there. To accomplish this, the room must be designed to have the equipment be turned on and off individually, such as with wall switches. This is in addition to on/off switches on the equipment itself. The room must be turned on in a slow consistent sequential order each time that individual enters the room. It should only have enough equipment turned on to be useful to the individual and not too much to be over-stimulating or under-stimulating. To accomplish this equipment must be linked to controls that will allow for changes in duration and frequency and be operable by both the practitioner and the individual; thus allowing for a closed and open loop for variability. (This variability is also necessary to generate neuronal plasticity*4) The open and closed loop link to the practitioner allows the practitioner to ultimately control the entire environment to allow for the contingencies the environment will eventually offer the individual. Setting up the environment to do this requires interfacing control devices that allow for changes in duration. This will allow the practitioner to shape behavior through the environment, not by personally putting demands on the individual. Ultimately it is the multi-sensory environment that will lead to self-discovery for the individual, much the way “play” teaches normal children. The individual with Autism that has Sensory Processing Disorders*5 can control the initial amount (intensity, frequency and duration) of sensory input allowing the practitioner to observe which sensory system is approached and which is avoided by the individual as they explore specific equipment. One can consider this an assessment period. It is also the period in which the individual learns to perceive the environment as comfortable, fun, and predictable. This includes the practitioner who will get assigned a positive association with the environment and experience. However, this will be contingent upon the practitioner following the initial rules of engagement.

The key to these rules is consistency, consistency and more…you got it, Consistency!

The equipment chosen by the individual becomes the primary reinforcement (motivator) that will be interfaced with control devices and utilized to help shape the behavior after the individual is empowered, and perceives the environment as both safe and predictable. How long this takes depends on frequency of visits and Consistency. The importance of this is to reduce stress and anxiety associated with the inability to adapt to the natural environment and all of the demands in the natural environment including traditional Therapy and School. The natural environment initiates more demands then an MSE/Snoezelen room upon the individual. It requires the individual to process multiple channels of information comprised of both the conscious process such as cognitive demands such as those made by people, places, and activities and so on; and unconscious process demands; those environmental factors that impact internal functions of the brain and body put on an individual by the ever dynamic changing environment. Primarily the internal unconscious process responds to the natural environment with automatic functions such as “tuning-out” background noises or shifting in a seat as the body prevents itself from “pins and needles” or “sweating” when it is too warm. These functions are not on a conscious level. We don’t think about it: our bodies just react to changing messages from our senses about our environments. This dedicated space must offer not only the primary stimulation of the senses but also limit the interference of the natural environment on the unconscious process. By design and control of the MSE the practitioner assists the individual with autism with managing the unconscious process of sensory information. The design must afford uninterrupted quiet, control of gradual dimming of lighting to black darkness, control of comfortable temperatures, good acoustics and enough space to allow for areas of self isolation/privacy and openness for movement by the individual. It must also have a designated control center for the operation of the room. What equipment is selected for an MSE will depend on its ability to be controlled and interfaced with both the individual in question and the practitioner. An additional requirement is to reduce demands by assuring that the practitioner remains initially quiet/silent without giving directions or putting stress or demands on the individual. (This requires a mind set change as most professionals and paraprofessionals are taught through their training that “they” must “do” and “produce” consequently we over talk and over instruct giving too many directions especially verbally.) If the practitioner becomes neutral in this environment they are perceived as non-threatening. If we take a hint from normal development in vitro the environment is doing the “speaking”. The developing embryo interacts within the womb and all that it has to offer as a sensory environment; for example: warm fluid, tactile surfaces, vibration, sound, resistance and even light. The practitioner must perceive themselves as an instrument of the environment to be interacted with/and by choice of the individual. The practitioner needs to recede and blend into the background and let the environment do the talking first. I go as far as wearing all black clothing so I am not a distracter from the process.

Since a primary deficit in Autism is the lack of social engagement the MSE can be utilized to elicit this basic skill. The MSE allows for non-verbal communication through the primary senses taking the format of being explored first and used by the individual for pure pleasure. They simply must be allowed to experience the process and communicate with the environment. They must through their choice be able to initiate touching, seeing, moving, hearing and smelling in this controlled environment without being “told” to.

The protocol for people with Autism using the Multi-Sensory Environment/Snoezelen
Room requires:

  1. At least one piece of equipment be awe inspiring and produce The Pleasure Response. (It brings a smile, or approach reaction immediately without hesitation)
  2. Be predictable and safe to set the stage for decreasing stress, anxiety.
  3. Not producing a fear response; fright, flight or fight sympathetic nervous system chemistry
  4. Being initially demand free and choice driven by the individual.
  5. Being conscious and respectful of the required physical space for the individual.
  6. Provide enough choices and control to empower the individual.
  7. Have enough variety of equipment to provide all types of primary sensations to illicit and access their sensory diet*7 and to act as motivators to the individual with Autism. (visual, auditory, tactile, vibration and some voluntary/active movement particularly
    of the head and neck )
  8. Having equipment that can be interfaced with control devices and have variables for manipulating the environment (controlled by the practitioner but operated by the
    individual)
  9. Have enough equipment accessories to provide power sensations to the body through the proprioceptive/kinsesthetic and deep pressure touch systems.
  10. Have just enough change so the person’s sensory/nervous system does not habituate for too long to the sensation (static vs. dynamic change).
  11. A projector with accessories that will influence head and neck movement in all planes and can be operated by the practitioner [with sufficient abstract visual effects to provide for a continuum of movement, speed perception to change brain arousal*].
  12. A variety of instrumental music and a system that can play at least three different selections as seamlessly as possible.
  13. Use of only positive to neutral supports by the practitioner.
  14. A practitioner that will not make quick judgments and confuse their sensory diet needs with the individuals’.
  15. Rules of Engagement for the practitioner:
    1. Set the stage prior to entering the room, tell the individual what to expect and tell them it is “OK to have fun and play or not it’s up to you”.
    2. Remove shoes (both yours and theirs if they cannot do it themselves) This signals a change is about to happen.
    3. Escort the individual into the MSE into the center of the room (which is off and regular lighting is on) Do not tell them to “sit down” or instruct them in any way.
    4. Step back and slowly start the room sequence protocol.
    5. Remain silent and speak only when spoken to; use non-verbal communication as much as possible and if you must speak use a quiet whisper.
    6. You may need to give an individual “permission” to do something, as many of these individuals have been conditioned to not touch things.
    7. Blend into the background and get below their eye level.
    8. Continue the above room sequence and observe the individuals’ sensory diet, identify the equipment piece that can be used as the motivator.
    9. Identify the relaxation process in the individual, look for signs of deep breathes, loss of muscle tension, yawns, changes in speed of locomotion/movement and calm etc.
    10. Identify the individuals non-verbal communication for enjoyment and its level(intensity) and/or frequency depending on the sensation they are receiving.
    11. During this period of adjustment by the individual use the projector and tempo of the music to match the general arousal level and change it to calming.
    12. Once the individual feels safe and exhibits signs of relaxation on a continuous bases prepare the room to offer small contingencies for the individual to adapt to.
    • Interface a control device such as a powerlink and switch into the
      identified piece of equipment that is the motivator.
    • Set the delayed time to go off after ten or fifteen minutes ( the timed delay should be varied after the first initiation of this step)
    • Start the room sequence as usual and step back.
    • When the piece of equipment goes off be positioned near the individual, still say nothing, wait for their response.
    • In most cases the individual will seek you out to “solve the problem” by communicating they want it on by engaging you in some fashion; establishing eye contact, taking your hand, and pointing are examples. You just hit pay dirt and the beginning of a long and trusted relationship can develop…become a play partner and build upon the success.
    • Keep setting up the environment to offer contingencies that now place you between individual and reward, develop the relationship.
    • Continue to make available new sensory diet activities.
  16. Perhaps the best thing to observe in these individuals is the emotional change that occurs as they smile and develop a sense of self over time. I know of no greater high then to see
    the quality of life that emerges. It really is true; that people will not remember what you say; they will not remember what you do; but they will always remember how you made them feel!

    Definitions:

    *1 Skinner Box:
    A Skinner Box is an Operant chamber and can deliver:
    • A primary reinforcement – unconditioned stimulus (food or pleasure )
    • A conditioned reinforcement (Token)
    • It is often sound-proof and light-proof to avoid distracting stimuli.

    *2 The Pleasure Principle: S. Freud… we go towards pleasure and avoid pain.

    *3 Autism is marked by: Qualitative impairments in Social Interaction, Qualitative impairments in communication and Restricted repetitive & stereotyped patterns of behavior, interests and activities. Descriptive features include: Odd responses to sensory stimuli for example: Oversensitivity to sounds, Oversensitivity to being touched, Exaggerated reactions to lights or odors and High thresholds for pain. Source: DSM- IV – TR,

    *4 Neuronal plasticity: the nervous systems ability to create new synapses

    *5 Sensory Processing Disorders: the nervous systems inability to control sensory information

    *6 Brain Arousal: Donald W. Pfaff, PhD, Rockefeller University; in a continuum of low to high, would be
    defined as: more Motorically active, more alert to Sensory stimuli of all sorts, more reactive Emotionally;
    Other states of arousal will influence one another; dampening or increasing the other state on top of the
    generalized arousal state causing an emergence of one focus

    *7Sensory Diet: the multi-sensory experiences that one prefers to seek on a daily basis to satisfy one’s need for sensory produces self-regulation, produces organization , The diet provides an optimal combination of sensations at the appropriate intensity for the individual, P.Wilbarger.
    A “sensory diet” is our attempt to modify stressors and control arousal levels and it is unique to each of us;
    it is based on both internal unconscious processes and on developing ongoing life experiences a cognitive process that leads to personal preferences… both the sensory diet and personal preferences combine to establish motivation.

    Some Science Trends and References:

    Location. Location, Location
    Researchers discover that learning suffers if brain transcript isn’t transported far out to end of neurons
    July 10, 2008 Children’s Neurobiological Solutions Foundation, Internet Source: Georgetown University
    Medical Center

    Eric M Marrow et al., Science July 2008 Vol.321 pg 218-223
    Identifying Autism Loci and Genes by Tracing Recent Shared Ancestry
    Michael Brecht and Dietmar Schmitz

    Rules of Plasticity
    Neuroscience, Perspectives, Science Vol.319 Jan.2008
    “Ongoing sensory experiences may improve performance through a signaling mechanism that
    strengthens synapses beyond their initial potential”

    The Brain That Changes Itself: stories of personal triumph from the frontiers of brain science, Norman
    Doidge, M.D. 2007

    Einat Adar, Arnon Lotem and Anat Barnea
    The effect of social environment on singing behavior in the zebra finch (Taeniopygia guttata) and its implication for neuronal recruitment,
    Behavioral Brain Research Volume 187, Issue 1, 11 February 2008, Pages 178-184, Department of Zoology, Tel-Aviv University, Ramat-Aviv, Tel-Aviv 61391, Israel Department of Natural and Life Sciences, P.O. Box 808, 108 Ravutski Street, The Open University of Israel, Raanana 43107, Israel [supports the hypothesis that increased neuronal recruitment in birds exposed to a complex social environment correlates with processing and storing of auditory input, and not with song produced by the bird. (auditory output)]

    Brain Arousal and Information Theory: Neural and Genetic Mechanisms, Donald Pfaff, Harvard University Press, 2006

    PRINCIPLES of HORMONE/BEHAVIOR RELATIONS, Donald W. Pfaff, M. Ian Phillips, Robert T. Rubin, Elsevier Academic Press, 2004

    Scott M. Monroe
    Modern Approaches to Conceptualizing and Measuring Human Life Stress
    Annual Review of Clinical Psychology Vol. 4: 33-52 Volume April 2008

    John H Reynolds, Mapping the Microcircuitry of Attention pp861 – 862 nature neuroscience aug08 doi:10.1038/nn0808-861 A study uses electrophysiological recordings from primary visual cortex of the monkey to demonstrate that the effects of attention are modulated by task difficulty and that two different neuronal populations mediate this effect.

    Jason P. Mitchell (2008) Contributions of Functional Neuroimaging to the Study of Social Cognition,
    Current Directions in Psychological Science 17 (2), 142–146 doi:10.1111/j.1467-8721.2008.00564.x
    Adele Diamond1and Dima Amso2(2008)Contributions of Neuroscience to Our Understanding of Cognitive Development , Current Directions in Psychological Science 1,Department of Psychiatry, University of British Columbia, and Department of Child and Adolescent Psychiatry, BC Children’s
    Hospital, Vancouver, Canada; and 2Sackler Institute for Developmental Psychobiology, Weill Medical
    College of Cornell University

    Megan Gunnar and Karina Quevedo,
    The Neurobiology of Stress and Development, Annual Review of Clinical Psychology
    Vol. 58: 145-173 Volume January 2007

    Sonia J. Lupien, Alexandra Fiocco, Nathalie Wan, Francoise Maheu, Catherine Lord, Tania Scramek and
    Mai Thanh Tu
    Stress Hormones and Human Memory Function Across the Life Span, Psychoneuroendocrinology , Volume 30, Issue 3, April 2005