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Sensory Integration

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-neurological process that ORGANIZES SENSATION from one's own body & from the environment & makes it possible to use the body effectively within the environment -Emphasizes vestibular, proprioceptive, & tactile systems

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Sensory Integration Theory

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1) Learning is DEPENDENT on the ability to take in & process sensation from mvmt & the environment and use it to PLAN & ORGANIZE behavior 2) Individuals who have a decreased ability to process sensation also may have difficulty to produce appropriate actions, which may INTERFERE with learning & behavior 3) Enhance sensation, as part of meaningful activity that yields ADAPTIVE INTERACTION, improves the ability to PROCESS sensation, thereby enhancing learning & behavior

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Assumptions of SI Theory

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1) The CNS is PLASTIC 2) Sensory Integration develops 3) The brain functions as an INTEGRATED WHOLE -OPEN SYSTEM is capable of self-regulating, self-organizing, & changing 4) Adaptive interactions are critical to SI 5) People have an INNER DRIVE to develop SI through PARTICIPATION in sensorimotor activities

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Boundaries

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*SI is intended to explain mild to moderate problems in learning behavior (Not frank CNS damage i.e. CP) *SI implies deficits in central processing of vestibular, proprioceptive, or tactile sensation that aren't attributable to frank peripheral or CNS damage (or cognitive deficits) *Research on SI is still emerging *SI is a specialized area of practice-need advanced training

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SI: CORE ELEMENTS

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1) Provide sensory opportunities 2) Provide just-right challenges 3) Collaborate on activity choice 4) Guide self-organization 5) Support optimal arousal 6) Create play context 7) Maximize child's success 8) Ensure physical safety 9) Arrange room to engage child 10) Foster therapeutic alliance

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Overarching Principles of OT-SI

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*Environmental modification *Establishing relationships *Helping the child meet his/her own needs *Use of enhanced sensation *Selecting & adapting tasks

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Modify the environment

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Create an environment that supports behavioral organization & functional performance

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How do we modify the environment?

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*Organization *Complexity (developmental challenge) *Comfort & Safety *Opportunities for exploration *Social aspects *Physical aspects (challenge to strength, balance, sensory system organization *Music, auditory, visual, kinesthetic

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Establish a routine

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*Balance novelty & routine *Increase/decrease structure *Facilitated transitions *Help child learn expectations

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Establish Relationships

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*Design social aspects of intervention activities *Encourage interaction *Decide which interaction "style" will facilitate the child's ability to interact...challenging, nurturing, playful, supportive

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Help child become independent in meeting his sensory needs

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*Reduce cueing & supports as performance improves *Encourage child to identify sensory needs & methods to modify *Problem solve with child how to manage his sensory needs

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Help child meet his own sensory needs by:

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*Enhanced sensation (e.g. hugs, rocking) *Activity/task selection (e.g. select calming activity) *Selecting his environment (ex. ask to sit in front of class) *Structuring his own routine (ex. maybe do better in mornings to get work done) *Selecting relationships (e.g. which friends help/impede growth)

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Utilize enhanced sensation

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*Use of sensation to CHANGE AROUSAL & ATTENTION levels *Use of sensation to CHANGE MUSCLE TONE, ability to balance, coordination *Use of sensation to CHANGE SENSORY PERCEPTION (e.g. tolerance, discrimination)

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Types of Sensation used to elicit an adaptive response

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*Vestibular -linear/angular -slow/fast -resistance *Tactile -deep touch (calm) -joint compression -discrimination Notes: linear-slow-calming, angular-fast-alerting Light touch - alerting

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Use of sensation in intervention session

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-The sensation is chosen carefully -Generally used in the BEGINNING of intervention (to calm or alert), but may be used throughout

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Select & adapt tasks to achieve child's goal

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*Task must CHALLENGE THE CHILD, but also provide the supports needed for him to succeed -Just right challenge for targeted skills -Cueing & prompting *Task may need to be ADAPTED IN THE MIDDLE if it was not properly selected (and that is OK!) -tasks can be graded across multiple dimensions (e.g. visual, motor, social, cognitive demands)

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Reasons to select & adapt tasks

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*Demand for sustained attention *Level of engagement *Motivation

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Specific strategies

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*Sensory modulation problems *Sensory-based motor problems *Sensory discrimination problems

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Sensory Modulation Disorder (SMD) includes...

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-sensory overresponsivity (SOR) -sensory underresponsivity (SUR) -sensory seeking/craving (SS)

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Sensory-Based Motor Disorder (SBMD) includes...

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-dyspraxia -postural disorders

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Sensory Discrimination Disorder (SDD) includes...

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-Visual -Auditory -Tactile -Vestibular -Proprioception -Taste/smell

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Note on ASD

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*SMD problems very common in kids with ASD -kids withASD can also have problems with praxis *Diagnostic criteria for ASK now include sensory features under restricted & repetitive patterns of behavior, interests, or activities

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From DSM V

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-Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g. apparent indifference to pain/temp, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)

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Intervention Strategies for Hypersensitivity (hyperreactivity)

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*vestibular input can be CALMING if SLOW LINEAR MOTION or SLOW ROCKING *Use REPETITIVE STIMULI, applied rhythmically *Use a BEAN BAG under desk or table *Use a TENT

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Strategies for children who are sensory avoiding

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*Provide assists help child with transitions -Use VISUAL cues (pictures) -Combines with VERBAL cues -Provide a TRANSITION OBJECT *Develop strategies to help children PREPARE for sensory inputs known to be AVERSIVE *GRADE SENSORY ACTIVITIES from most accepted to most offensive *Allow child to have BREAKS, include REWARDS

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Gravitational Insecurity

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*Overresponsiveness of VESTIBULAR system *Fear of changes in HEAD POSITION or disturbances to the base of support *Extraordinarily FEARFUL of movement

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Intervention for Gravitational Insecurity

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FIRST: Proprioception & linear vestibular input -being crawling on a stable surface (e.g. up & down ramp, add pillows) -Sit on tilt board or trampoline -Sit on ball with feet on ground -Sit on swing low to ground *Child must ACTIVELY PARTICIPATE *Focus on ESTABLISHING TRUST FIRST - child must HAVE CONTROL of the activity *They FEAR MOVING BACKWARDS IN SPACE, avoid initially *Grade activities slowly increasing difficulty *Emphasize FLEXION (The bolster horse swing can reinforce flexion when the child hugs it) *Move to a more challenging (faster, unpredictable) vestibular input

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Strategies for children with hyposensitivity/poor registration

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*Goal is to IMPROVE BODY AWARENESS and ABILITY TO DISCRIMINATE sensory inputs *Provide fast, rapid mvmt, spinning (Playground time is important) *Provide extreme, deep pressure (under mat, in stockinet tube) *Use activities that are heavy work (help move desks, chairs) *Set up corner for sensory input (trampoline, rocking chair, therapy balls) *Give chewy or crunchy foods

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SBD: Dyspraxia

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Problems in: -Conceptualizing: Ideation -Planning & programming -Executing the action (not usually) Can also include difficulties in: -Bilateral integration -Crossing the midline -Projected action sequences

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Strategies for ideation problems:

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-allow EXPLORATION of equipment/objects -select objects that are FAMILIAR FIRST -Show child the POSSIBILITIES FOR ACTION on an object

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Strategies to help with motor planning:

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-Physical guidance ex. help up scissors in hand -Modeling ex. step by step

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Strategies for bilateral integration problems:

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-Symmetrical is easier than alternating -Focus on arms, then legs, then both (J.Jacks) -1st use action that requires a SINGLE BILATERAL ACTION (catching ball) -Next, use SHORT SEQUENCES of BILATERAL ACTIONS (ex. buttoning) -Then, use LONGER SEQUENCES (ex. obstacle course)

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Activities for Crossing the Midline

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-Throwing beanbags, kicking balls -Twister -Chalkboard activities -Gross motor play (ball play, target play)

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Activities for projected action sequences

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-Throwing or batting while moving on swing: able to aim at a moving target while moving -Catch a ball while swinging -Shoot at a target with squirt gun while swinging -Feed fish, throw bean bags, into inner tube -Hopscotch

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Postural Disorders

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-Underdeveloped vestibular system -Low tone in extensor mm -Poor postural stability -Poor equilibrium reactions -Cannot maintain prone extension -Poor tonic flexion of neck

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Intervention for Postural Disorders

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-Activities to develop extension in prone -In prone on ball, on bolster -In prone on scooter board, swing -Activities to develop flexion -Frog swing -Maintaining extension against resistance -Combine flexion & extension (rolling in barrel, net swing - pick up bean bags, climb rope on scooter board) -Select activities that require lateral flexion & rotation (developing equilibrium reaction, use tilt board & balls)

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Sensory discrimination problems (SDD)

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-generally seen with poor motor planning -many children who have decreased sensory discrimination crave enhanced sensation

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Decreased proprioceptive discrimination

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-have difficulty moving accurately -do not grade force well -poor body scheme -may have poor balance

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Intervention for poor proprioceptive discrimination

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-use the body's weight to provide proprioceptive input (trampoline, scooter boards) -also yoga

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Intervention for poor tactile discrimination

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-Deep pressure throughout body -Brushing or massage -Use a toy that vibrates -Hands in highly textured substance (rice)

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Transfer/generalize OT-SI

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*Playground activities *Swinging *Sources of movement in classroom *Swimming

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Sensory-based interventions (sensory modalities)

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*Use CAUTION: many of these interventions have little or no evidence/guidelines for use *Anecdotal evidence suggests they may be helpful as part of comprehensive OT evaluation *You should: do you own research on the intervention, collect data on their effectiveness with your patients, & discontinue use if changes are not seen

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Alert Program

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*AKA "how does your engine run?" *Teaches children strategies to regulate their own sensory systems *Be aware: not EVB, not Ayres-SI

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Summary

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-Specific problems need to be identified & become the focus of intervention -All therapy involves: establishing TRUST, ENGAGING the child in meaningful activities, DESIGNING the JUST RIGHT challenge with task support -Intervention includes: EXTENDING the activity to increase the challenge & practice, transitional activities to HELP the child PRACTICE & GENERALIZE the skill, incorporating ways to BUILD child's SELF ESTEEM -Sensory based strategies may be helpful, but use caution due to lack of evidence for most

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