Capstone Literature Review

Dr. Temple Grandin, livestock-handling equipment designer living, invented the Squeeze Machine for livestock slaughterhouses to apply deep pressure compression to slow the heart rate and respiration in order to reduce anxiety and stress on the animal. As discussed in her books Temple Talks(2015) and The Way I See It(2015), she is an adult working, creating, and living with autism. She has written books and has spoken about the effects of sensory sensitivities and how therapeutic activities can be beneficial. She states in The Way I See It(2015), “I have been talking and writing about sensory problems for over 20 years, and am still perplexed by many people who do not acknowledge sensory issues and the pain and discomfort they can cause. A person doesn’t have to be on the autism spectrum to be affected by sensory issues” (p.100). There are many ways senses can be affected and stressed even for those without sensory sensitivities. Therapeutic techniques and environments for those with sensory issues can also be applied to stimulate and calm the senses for those without sensitivities (VanMuers-Juergens, 2016).

According to Beil et al. (2009), Sensory Processing Disorder aka sensory integration (SI) dysfunction comes with many titles and can be difficult to diagnose toward a specific disorder:

Sensory processing problems often occur in conjunction with many different diagnostic labels. Children and adults diagnosed with the following may also have sensory problems: developmental delays, autism, Asperger’s syndrome, pervasive development disorder, ADHD (attention deficit hyperactivity disorder), learning problems, prematurity, fragile X, fetal alcohol syndrome, Tourette’s syndrome, anxiety, and many others. (p.xii)

The senses work together to help individuals understand who they are, where they are, and what is happening around them. Children are taught 5 senses growing up: Visual System (sight), Gustatory System (taste), Olfactory System (smell), Auditory System (sound), Tactile/ Somatosensory System (touch). However, they are not taught about the other three senses that effect how people interpret space and movement: Proprioceptive System (muscle/joint, where body is in space), Vestibular System (balance), Interoceptive System (state of internal organs). (Miller & Fuller, 2006) At any given moment individuals are receiving multiple sensory stimuli at a time. The senses send signals to the brain and the brain processes that information and relays a response and behavior accordingly. With SPD, the brain confuses the signals and processes them inaccurately causing the person’s inability to respond to the stimuli appropriately (Beil et al., 2009).

Grandin (2015) discusses in The Way I See Ithow difficult creating and organizing studies around sensory processing can be because the way one inputs and reacts to sensations are ever changing:

A person can be hyper-sensitive in one area (like hearing) and hypo-sensitives in another (like touch). One person can have a marked olfactory sensitivity and another might not be affected at all in that sense. Complicating matters even further, on a day-to-day basis, in the same individual, the sensory sensitivities can change, especially when the person is tired or stressed. (Grandin, The Way I See It, 2015, p.102)

Sensory sensitivities very within each person and can change from moment to moment. For example, a person can be hyper-sensitive to rain where the drops and can feel painful like pin needles on their skin and can also be hypo-sensitive where they may not feel the sensation of a mosquito bite itch. Both examples are how tactile sensitivities can vary in the same person depending on the situation.

In the 1970’s, Dr. A Jean Ayres recognized that an impaired sensory integration affected the learning and development process (Beil et al, 2009). Miller & Fuller (2006) discusses the symptoms for those with SPD can include hypersensitivity and/or hyposensitivity to sound, sight and touch, poor fine motor skills, easy distractibility, poor oral coordination, speech delays and picky eating. One’s sensory input may be out of proportion to the actual experience resulting in an over-responsive or under-responsive reaction to the situation. Some pursue sensory seeking behaviors, like rocking or spinning to receive vestibular input, sleep with a lot of heavy blankets or pillows for tactile input, or have constant verbal output to receive auditory and oral input. However, seeking input can change regularly. A sound or feeling sought after one day may be offensive the next (Miller & Fuller, 2006).

According to Elysa Marco, who treats affected children in her cognitive and behavioral neurology clinic stated in the article, Breakthrough Study Reveals Biological Basis for Sensory Processing Disorders in Kidsstates:

Most people don’t know how to support these kids because they don’t fall into a traditional clinical group… Sometimes they are called the ‘out of sync’ kids. Their language is good, but they seem to have trouble with just about everything else, especially emotional regulation and distraction. In the real world, they’re just less able to process information efficiently, and they get left out and bullied. (UC San Francisco)

Using therapeutic activities and a SIT diet, those with SPD receive stimuli to the senses that help regulate how the brain processes sensations. By receiving sensory input at regular intervals throughout the day, it provides the nervous system stimulation to organize what the senses are absorbing (Miller & Fuller, 2006). The input calms the nervous system and allows the body to stay controlled. According to Beil et al.(2009), “calming sensory activities such as deep pressure under a heavy mat or slow swinging may reduce sensory scrambling and help information to get through to the brain” (p.xii). Occupational Therapist, Karyl VanMuers-Juergens (2016), discussed in an interview how deep compression has the same effect on those without SPD. Serotonin released from the deep compression will create a sense of calm and aid relaxation (VanMuers-Juergens, 2016).

Grandin (2015) writes, “The absence of clinical research does not mean sensory therapies are not viable for children to adults. It simply means research has not been done to date” (Grandin, The Way I See It, 2015, p.103). Chan, Thompson, Chau, Tam, Chiu, & Lo’s (2010) article,The effects of multisensory therapy on behaviour of adult clients with developmental disabilities, states, “Multisensory therapy aims to induce leisure, enjoymentand relaxation in people who have a learning disabilitythrough enhancing their sensation and emotions” (p.109). The systematic review study did show that involvement in multi-sensory environments did improve positive behavior even though there was little scientific evidence completed to show an improvement in challenging behavior or reduce self-stimulating behavior. However, MSE have been proven to induce a relaxation effect in people with developmental disabilities. A 2006 study referenced in Chan’s systematic reviewdid demonstrate that the use of MSE did reduce the incidents of challenging behavior on days following the MSE therapy sessions (Chan et al., 2010).

Devin et al. (2010) study shows that according to applied behavior analysis the function of the behavior needs to be automatically ^[1]reinforcing for sensory therapy to be an optimal course of treatment. The data presented in this study showed that the behavioral intervention was more effective than the sensory integration therapy on the participants in the study, even though a functional behavior assessment was not conducted. If a functional assessment was completed and indicated that the function of the behavior was automatically reinforcing, the sensory therapy may have been more effective than the behavioral intervention. Kaplan, Clopton, Kaplan, Messbauer, & Mcpherson’s (2006) research, Snoezelen multi-sensory environments: Task engagement and generalization, shows that treatment was effective in two of the three participants. Both saw a reduction of behaviors post session engagement and in daily frequency on days following occupational therapy sessions. Grandin’s (2015) writing confirms that in situations like these studies, it is essential to continue exploratory research into why sensory therapy works for some and not for others. She suggests follow up research between the responder and the non-responders before dismissing sensory therapy altogether.

^[1]“The reinforcement is inherent in the response itself (ie. Thumb sucking, twirling hair, masturbation, or rocking back and forth may produce a reinforcing sensation for the client). (Mayer, p.694)

Ann Hamilton is an artist that explores the notion of sensory awareness of the viewer/participant in her installation space. She transforms environments to encompass a feeling/emotion form the viewer. Her works use our range of our eight senses to tell the story of the work and to heighten the users experience. Hamilton uses materials, light, smell, sound to drive the feeling of the space. The emotion the viewer feels is just as much part of the art as the work itself within the space. She uses the viewers senses to enhance the meaning of the art, much like multi-sensory spaces. The space itself evokes a reaction of the user. MSE’s house a variety of tools to engage with to help stimulate and regulate one’s senses. Similar to the research of Ziegler (2015), material, lighting, and sound is examined and researched to create the most effective space to help regulate the senses. The article, Multi-Sensory Design as a Health Resource: Customizable, Individualized, and Stress-Regulating Spaces,explores multisensory design, concept of atmosphere, individualization and control theory, and design-parameters as active components. MSE design can use aspects of light, color, sound, acoustics, and smell, in healthcare design to reduce anxiety and stress. By studying space design and how design effects the psychology of the user, interior designers and architects can more effectively create spaces for patients and healthcare workers to reduce stress, “given attention to environmental factors and design, medications can be reduced, particularly for conditions such as depression and pain” (Ziegler, 2015, p.9).

Ziegler (2015) also discusses the effectiveness of lighting design and the ability for controlling the lighting individuality to adjust for color and intensity helps reduce stress in a similar way artist James Turrell works directly with light and space to allow the viewer to immerse oneself within, “the physical presence of light made manifest in sensory form.” (Turrell) He transforms a space by using light. He sets the tone and mood for the viewer by guiding the visual experience. He executes space and light as a sensory experience. Turrell transforms the space through the use of color to enhance the viewers perception and emotional state within the environment.

Freyja Sewell (2014) is a designer that has created sensory concentration spaces (images d and e) for the participant to immerse themselves in a space free from daily distractions. The pod uses soft wool felt that is tactilely inviting and has a small opening that can be closed to prevent outside light and the person can focus on only the light, sound, touch and smells within the pod. This environment is used to facilitate the heightening sensations of one’s own body within space. The LED lighting hidden within the ceiling can be controlled by the user in the pod to set the color mood. Though this space is smaller than the MSE discussed in the paper, the concept of being immersed within a space to provide the body with sensory feedback is similar (Sewell, 2014).

Elliot & Maier’s (2007) article, Color and Psychological Functioning,reviews color theory and the meaning behind psychological perception. Color associations are presumed to effect behavior. Color theory has long subscribed to the notion that long wavelength colors (warm colors) are arousing, and short wavelength colors (cool colors) are calming, though no extent of research has examined the effect of hue while lightness and chroma were controlled. This article examines that color association has meaning based on learned association and a biological disposition to respond to certain colors in certain situations (reference image f. from Designer’s Color Manual, p.49). Though the colors tested were red, grey, and green, color perception in the united states was addressed. Red was determined to evoke avoidance motivation and undermine intellectual performance without conscious awareness or intention. The Designer’s Color Manualby Tom Fraser and Adam Banks (2004) explained Goethe’s Theory of Colorspublished in 1810. Unlike Newton’s color theory based on the physics of light and color, Goethe approached color through observations of human perception, “exploring simultaneous contrast, afterimaging, the color of shadows, and the effect of illumination on objects, as well as considering how colors can relate to emotional states” (p.48).

Studies by Henner Ertel, referenced in Colorby Paul Zelanski and Mary Pat Fisher (1999), examine the physiological effects of color theory in interior design finding that bright, warm hues are being used more in school due to their effects on school children contributing a more active and mentally alert state. Cool dull hues tend to sedate. According to Zelanski & Fisher (1999), “the interior design colors with the most positive intellectual effects in Ertel’s study were yellow, yellow-green, orange, and light blue. Surrounded by these colors, children’s IQ scores rose up to 12 points” (p.37). Score fell in black, white, and brown environments. Another study by Harry Wohlfarth and Catherine Sam, also referenced in Colorby Zelanski & Fisher (1999), explored interior color theory on a group of severe developmentally and behaviorally challenged eight-year olds. Their classroom was altered from having bright orange carpet, and orange, yellow, and white walls with white fluorescent-lighting to a room with blue and brown walls with full spectrum fluorescent-lighting. The aggressive behavior dramatically decreases and lowered blood pressure rates. When returned to the previous design, the behavior reappeared and blood pressure rose. This study was also conducted on blind children with similar effects:

Suggesting that we are affected by color energies in ways that transcend seeing. One hypothesis is that neurotransmitters in the eye transmit information about light to the brain even in the absence of sight, and that this information releases a hormone in the hypothalamus that has numerous effects on our moods, mental clarity, and energy level. In what Wohlfarth calls the science on “color Psychodynamics,” colors that seem to increase blood pressure and pulse and respiration rates are in order of increasing effect, red, orange, and yellow. Those decreasing these physiological measures are green (minimal), blue (medium effect), and black (maximum effect). (Zelanski, 1999, p.37)

Color theory is an important concept and study relating to MSE. MSE use color lighting to evoke the perception of a calming or a stimulating environment. Installation spaces created by Yayoi Kusama, Do-ho Suh, James Turrell, and Olafur Eliasson use the immersive effect of color, space, use of light and the way they were able to transform the space in entirety from what it was. Eliasson states regarding his work, “The experience of being in the monochrome space of course varies with people, but the most obvious impact of the yellow light is that the perception in obviously acquired: The representational filter is brought to our awareness and with that our ability to see ourselves in different light” (Eliasson). The use of certain colors creates an immersive environment that is stimulative but can also be calming to the viewer depending on the light and their perception of that light. That sensation can be therapeutic to those with and without special needs. MSE spaces house a variety of engagement tools to help stimulate and regulate one’s senses. Material, lighting, and sound are used to create the most effective space to help enhance the senses. A careful planning of the space environmental design, the lighting color and LED sensory tools will need to be considered to help the overall results for the participant in each space.

Designing spaces for those with autism and sensory needs may differ from the needs of those with dementia. The use of MSE proves effective for both forms of treatment, however, the spaces for dementia individuals would need to incorporate different tools and technological design. The study by Bauer et al. (2015) An evaluation of Snoezelen® compared to ‘common best practice’ for allaying the symptoms of wandering and restlessness among residents with dementia in aged care facilities Multi-sensory environments were compared to “common best practice” treatments for dementia related behaviors such as, wondering and restlessness, shows that there was significant reduction in behavioral symptoms between pre and post behavioral interventions for both forms (MSE and Common Best Practice^[1]) of treatment. Environmental design for dementia care - towards more meaningful experiences through designby Ludden, Rompay, Niedderer, & Tournier (2019)discusses how environmental design is effective in supporting people with dementia and contribute to their well-being. Implementing user-centered design through the use of technology and environmental psychology can optimize environments to create novel solutions for challenges those with dementia face on a day-to-day basis. This article discusses product design that has proven to encourage engagement and connectedness through sensory stimulation. Ludden et al. (2019) created virtual nature experiences to help enhance social engagements among patients and an experience handrail to reduce wondering and provide a meaningful sensory experience. The virtual nature experience is a virtual reality that is set up to give patients the feeling of interaction with nature, where in turn they experience related emotions such as excitement, a sense of adventure, or awe:

Kaplan and Kaplan’s [30] attention restoration (ART) theory offers an explanation for why nature is wholesome. Specifically, the idea here is that nature is restorative (and therefore calming and relaxing) because it presents an infinite richness of stimuli (e.g., small leaves rustling in the wind, clouds passing by), but at the same time appeals to people’s attention mechanism in an effortless manner (it does not take cognitive effort to behold clouds rolling by). (Ludden et al., 2019, p.13)

Nature is linked to positive emotion and affects which can broaden one’s focus, engagement, and connection to others. The experience handrail was created to encourage intentional wayfinding instead of wandering. Handrails with various colors, textures, and sounds were designed to correspond with existing scenes along a walking path of the facility. For each scene created, distinguishable features were incorporated in the environment design fitting materials, textures, and sounds when appropriate to correspond with the space.This resulted in 6 categories of multisensory handrails: the sewing room, kitchen, cinema, living room, garden, and farm. Ludden et al.(2019) provides examples such as, “the handrail guiding residents towards the sewing room is covered in several fabrics sewed together, whereas the handrail near the farm comprises a tactile cover resembling grass” (p.13). This demonstrates how design and technology can be fused to address the need for social interaction through fun and relaxation, which, is often overlooked in assistive technology and environmental tools.

Feng, Dey, & Lindeman (2016) suggest, multi-sensory feedback can improve the experience and performance of a user in a virtual environment. The researchers used tactile cues from design space, movement wind, footstep vibration and directional wind, and footstep sound to investigate interaction and interaction with each other in a space. Feng et al.(2016) states, “Multi-sensory feedback has been proven to increase immersion in Virtual Environments (VEs), and it has great potential to be effective in many other aspects [28]” (p.95). They found that stimulated tactile cues on real world situations had positive effects in a virtual environment. With the article by Ludden et al. (2019), both studies can work together to inform design decisions regarding tactile sensory cues and sensory stimulation in a virtual reality multi-sensory experience to help people with dementia. The articles mentioned in this paragraph, demonstrate the need for effective design in the therapeutic environment. Spaces designed to engage and stimulate can enhance cognitive functioning and help the user to experience the immediate moment.

^[1]“interventions including psychosocial strategies such; as speaking with the resident to determine the cause of their behavior; diversion and distraction activities; engagement of the resident in meaningful and appropriate pastimes; rest; one-on-one social interactions, and pain assessment and management.32 Care staff used their knowledge of the resident and clinical judgment to determine which strategies to use on a case by case basis” (Bauer et al. 2015, p.463).

This project is a reflection on how Multi-Sensory Environments and their design helps people with ASD, SPD, Dementia, and other psychological complexes. It has explained what Sensory Processing Disorder and Autism Spectrum Disorder are and how Sensory Integration Therapy can be useful. As Temple Grandin (2015) pointed out, there are researchers that are quick to dispel Sensory Integration as an effective form of therapy due to its lack of research. The article by Devin et al. (2010) presented data that showed that behavioral intervention was more effective than sensory integration therapy, however, they had not established the function of behavior prior to the study. If a functional assessment had been conducted, it could have indicated that the function of the behavior was not automatically reinforcing and therefore, sensory integration therapy would not be an effective form of treatment. If the functional behavioral assessment had indicated that the behavior was automatically/sensory reinforcing the sensory therapy may have been more effective than the behavioral intervention. Also, in the research provided by Kaplan et al. (2006) it explained that treatment was effective in two of the three participantsand the study by Chan et al. (2010) concluded that multi-sensory environments did improve positive behavior. Sensory integration therapy has been shown to be effective in some cases rendering a functional behavioral assessment a vital role in sensory integration therapy research.

Designers and artists have been using sensorial experiences and physiological effects in their work to transform how people feel when immersed within their created environments. Artists like Turrell, Hamilton, and Eliasson transform spaces through the use of color, light, sound, smell, and textures to enhance the viewers perception and emotional state within the environmentin order for the space itself to evoke a reaction from the user. This is similar in the way Multi-Sensory Environments use of color, light, sound, smell, and textures to stimulate and calmone’s mind and body. MSE spaces need to be delicately planned to create a balance of stimulation and tranquility. They also need to be versatile to individual needs of the users and consider an individual’s sensory input experience could result in an over-responsive or under-responsive reaction to the situation. As Miller & Fuller (2006) discusses, seeking input can change regularly, therefore, an individual’s experience may change each time they are in the environment, they may pursue vestibular input like rocking or spinning or tactile input through deep compression. As referenced by Zelanski & Fisher (1999), and Fraser & Banks (2004), each space and lighting design will need to consider the color Psychodynamicsof the user. The space will need to be adaptive to reflect how they feel within the space allowing the user to change the lighting with the use of LED lights to reflect how they feel within the space. If the user is seeking active stimulation reds, oranges, and yellows (long wavelength colors)may be the best to increase blood pressure and pulse and respiration rates. If the user is seeking calming stimulation blues, greens, and purples (short wavelength colors) would be the decrease blood pressure and pulse and respiration rates.

When considering the versatility of the MSE spaces, it is also imperative to consider what types of spaces would be more effective for those with dementia. The spaces should include virtual reality environments that stimulate tactile cues on real world situations which has proven that using tactile sensory cues and sensory stimulation have positive effects to help people with dementia.Bauer et al. (2015) also discussed that in many situations staff delivering the intervention may not always be trained properly, therefore, the treatment was not as effective. Having properly trained staff is important to the assessment, monitoring, and implementation of the therapy for appropriate implementation and results.

As this project progresses, this paper serves as a foundation to support a proposed business plan to create a space that houses Multi-Sensory Environments for individuals with sensory processing needs. The business will serve as a location for at-home applied behavioral analysis therapists, occupational therapists, and art therapists to conduct therapeutic sessions outside of the patients’ home environment. It will allow therapists access to tools that typical homes cannot install due to space and finances and will in turn provide a location for more effective therapy sessions. This research serves as description of the industry, space/product design, and the target market for the business. A study conducted by Karlsson & Honig (2009) investigates “data from six companies and their environments, over five years, using several forms of data collection such as interviews, observations, and archival data” (p.27), regarding the creation and implementation of a business plan when starting a business. The findings show that those who wrote business plans did not end up using them or revising them as the business venture was set in motion.

According to Karlsson & Honig (2009), the goal of a business plan is to show the legitimacy of the business to investors and other firms. It discusses that while universities promote business plans for entrepreneur studies the most successful businesses did not have one during the startup phase. This article helps me determine what areas of a business plan to target going further in research. A current startup plan to preplan the process of beginning the company might help the overall preparation, whereas, a long-term plan is impossible to predict and rarely implemented. However, a business plan may help when applying for a loan to show the financial institution the plan of business growth and financial growth plan and emulate legitimacy of the proposed plan. This project will continue in development through the execution of an executive summary of the business proposed, as well as, market strategies, a competitive analysis, and a start-up operations plan. It will continue in the development of present and future possibilities within the market, what strategies can put it at a disadvantage and distinct advantage, and the overall desires for client and therapist use.