Sensory Integration: Theory, Disorders, Interventions Presented by: Alma Martinez, MOT, OTR Valerie Villarreal, OTS Maggie Flores, COTA

Sensory Integration (SI) Dr. Jean Ayres -1963 Is the ability of a person to take in a variety of sensory input, process and understand it, and use it.

What Are The Senses? Vestibular- movement Tactile- touch Proprioception- where are your body parts? Visual- seeing Auditory- hearing Taste Smell

How Is Information Processed? Main sensory systems Tactile Proprioception Vestibular Transmitters of information from environment to the brain

Why Sensory Integration? Increases interaction with others Develops necessary skills Organization

Sensory Integration Theory Automatic process Natural outcomes occur Learning problems Developmental lags Behavior issues

How is SI Used? Understanding the WHOLE environment Learning Understanding what is going on around us Regulation

Neurobiologically Based Concepts Neural Plasticity Central Nervous System Organization Adaptive Response Sensory Nourishment

Development Process of SI Detection or registration of sensation Modulation of sensation Sensory discrimination Higher sensory integrative skills Targeted occupations

INPUT SENSORY INTEGRATION OUTPUT Senses CNS Result

Sensory Processing Disorder (SPD) “Problems in directing, regulating, interpreting, and responding to sensory input.” (Miller, Anzalone, Lane, Cermak, Osten, 2007) Can influence child’s response to: Environment People Tasks/activities *Note: Some of us may have sensory processing challenges, but it is considered a Sensory Processing Disorder when the problem is severe enough to interfere with daily routines or roles.

Impacts On Every day Life Activities of Daily Living (ADLs) Social Participation Education/Work Play/Leisure Rest and Sleep

Ten Fundamental Facts About SPD Sensory Processing Disorder is a complex disorder of the brain that affects developing children and adults. Parent surveys, clinical assessments, and laboratory protocols exist to identify children with SPD. At least one in twenty people in the general population may be affected by SPD. In children who are gifted and those with ADHD, Autism, and fragile X syndrome, the prevalence of SPD is much higher than in the general population. Studies have found a significant difference between the physiology of children with SPD and children who are typically developing. Studies have found a significant difference between the physiology of children with SPD and children with ADHD. Sensory Processing Disorder has unique sensory symptoms that are not explained by other known disorders. Heredity may be one cause of the disorder. Laboratory studies suggest that the sympathetic and parasympathetic nervous systems are not functioning typically in children with SPD. Preliminary research data support decades of anecdotal evidence that occupational therapy is an effective intervention for treating the symptoms of SPD. from Sensational Kids: Hope and Help for Children With Sensory Processing Disorder (SPD) p. 249-250 by Lucy Jane Miller, PhD, OTR

SPD Subtypes Sensory Modulation Disorder Sensory over-responsivity Too much information coming in Sensory under-responsivity Information comes in but not responsive to it Sensory seeking or craving ‘Needing’ more information

Sensory Over-Responsivity Brain has too LOW of a threshold Tactile Difficulty with getting hair cuts Avoidance of touching certain textures Vestibular Disoriented after bending down Anxious when feet leave the ground Avoids rapid or rotating movements Visual Difficulty tolerating bright lights

Sensory Over-Responsivity Proprioception Difficulty being hugged Difficulty with people moving your body Auditory Fearful of sounds Distracted by certain noises Frequently cover ears Oral “Picky” eater Difficulty brushing teeth

Sensory Under-responsivity Brain has too HIGH of a threshold Tactile Difficulty noticing touch Dress inappropriately for weather Vestibular Does not get dizzy Enjoys being upside down or sideways “Thrill seeker” Visual Often miss what is right in front of them

Sensory Under-responsivity Proprioception Poor body awareness Floppy or poor posture Auditory Listens to loud music or TV Talks to self during a task (out loud) Oral May be able to eat anything

Sensory Seeking/Craving Seeks arousal of nervous system (inappropriately) Tactile Enjoy “bear” hugs Crave touch of textures Vestibular Jumping Enjoy spinning in circles, being upside down

Sensory Seeking/Craving Proprioception Loves crashing or bumping into objects Craves highly physical activities Auditory Speaks louder than necessary Needs to listen to music to concentrate Oral Puts anything in mouth (searching for oral input)

SPD Subtypes Sensory Discrimination Disorder Visual (eye) Auditory (ear) Tactile (touch) Vestibular (movement) Proprioception (muscle) Taste/smell (mouth/nose)

Sensory Discrimination Disorder Examples Proprioception Constant slamming of doors Pushing too hard (to increase awareness) Tactile Need to use eyes when searching for object in backpack or purse Taste/smell Difficulty distinguishing between flavors or scents Vestibular Frequently falls out of chairs

SPD Subtypes Sensory Based Motor Disorder Dyspraxia Difficulty motor planning Postural disorder Poor cocontraction Muscle tone (Low) Equilibrium and posture Immature reflexive abilities Bilateral Integration

Examples of Dyspraxia Proprioception Poor gross motor skills Poor motor control and body awareness during dressing Vision Navigating through crowded hallways Poor gross motor skills Running jumping Poor fine motor skills Zipping Buttoning Problems in figuring out how to do movements Dressing Complex dance steps

Examples of Postural Disorders Low muscle tone ‘slumped’ in chair Leans on things Poor balance Often trips or bumps into objects Difficulty with riding a bike or jumping Poor stability Sits in awkward positions Head and eye stability Difficulty when reaching for objects Use of two sides of body not stabilizing paper to write

How Do You Feel About… Cold shower Wool clothing Panty hose Sweatpants The feel of Jell-O in your mouth The sound of birds Bright colored walls in the bedroom The smell of perfume Elevators Roller Coasters

Support Groups Moms Connect About Autism-MoCAA http://www.momsconnectaboutautism.com Sensory Planet Social Network http://www.sensoryplanet.com/home.php SPD Parent SHARE http://www.spdparentshare.com

References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Doman and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-645. Baranek, G., Foster, L. & Berkson, G. (1997) Tactile defensiveness & stereotyped behaviors. Am J. of Occupational Therapy, 51, 91-95 Bundy, A., Lane, S., Murray, E. (2002). Sensory integration theory & practice. Philadelphia: F.A. Davis Company. Dunn, W., Myles, B. & Orr, S. (2002). Sensory processing associated with Asperger syndrome: A preliminary investigation. AJOT, 56, 97-102. Kimball, J. (1999). Sensory integrative frame of reference. In Kramer, P. & Hinojosa, J. Frames of Reference for Pediatric Occupational Therapy. Baltimore: Williams & Wilkins. Kranowitz, C. (2004). The out-of-sync child: Recognizing and coping with sensory processing disorder 2nd ed. New York: Berkley. Miller, L. Anzalone, M., Lane, S., Cermak, S. & Osten, E. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. Am J of OT, 61, (2), 135-140. Henry, D. A, Kane-Wineland, M., & Swindeman, S. (2007). Tools for Tots: Sensory Strategies for Toddlers and Preschoolers 2007. http://spdlife.org http://www.spdfoundation.net/facts.html http://autism.org.uk http://sensoryprocessingdisorder.com

Review of challenges/characteristics….. Slow Processing - Difficulty shifting attention Inattentive, Difficult to arouse Does not like change or transitions - Rigid – Demands routine

Difficulty with, or seeks out, certain types of foods/textures Smells all food before eating - smells objects Unable to sit with anyone behind them in class Difficulty attending from the back of the room Explosive emotions or lack of emotions or incongruent emotional responses

Aggression to self or others Compulsive Behaviors Difficulty with clothing, type of clothing, and change of clothing

Perseveration on topic or activity - Fixation on sensory stimuli Clumsy, awkward, difficulty in sports Over or Under-reaction to pain Unsure of group situations, cautious, or a loner 2

Work Sheet Which is your student/child? Identify the sensory type (or types) that you observe to be true of your student or child

So What Can We Do? The "Sensory Diet"

The “Sensory Diet” includes…. PROVIDING SENSORY EXPERIENCES A combination of sensory experiences needed by a person to adaptively interact with the environment (“make it through the day”). MAKING ENVIRONMENTAL MODIFICATIONS Modification and organization of the environment in order to decrease stress on a fragile sensory system.

Those with sensory processing challenges May not be able to filter and focus May attempt to adjust in a maladaptive way (Ex: Escalation of Mood, Shutting Down) Will require a “sensory diet” enriched with unique sensations and experiences

Creating The Sensory D.I.E.T. D …..Do an Informal Assessment I …..Individualize E …..Environmental Supports T …..The Power Senses

Do an Informal Assessment Assess the Environment and the Individual’s response to a variety of sensory experiences Seeker? Active Avoider? Under-Responder? Overwhelmed

Individualize the Sensory Diet What has worked for one person may not work at all for someone else!

Considerations for the Sensory Diet UNDER-RESPONDER Increase the use of visual supports and routines. Structure the environment. Time to respond Careful encouragement to try new experiences SEEKER Provide sensory experiences frequently & proactively May need to limit excitatory experiences Considerations for the Sensory Diet ACTIVE AVOIDER Modify the environment to reduce the need to escape Gentle introduction to new experiences OVERWHELMED Control the environment Limit stimulation Limit change but prepare for changes when they need to occur.

Environmental Supports Organization Predictable, Structured, Consistent Environment Task or Curriculum Visual Supports Escape Environments

Proactively Schedule Sensory Activities Use the Power Senses throughout the day in order to help a person alert, attend, act, and react At times, additional activities or input may be needed based on the behaviors observed

Proprioceptive System The Power Senses Tactile System Proprioceptive System Vestibular System

The Power Senses Vestibular Movement Proprioception Input through joints and muscles Tactile Deep Pressure Touch

The Power Senses Tactile System

Protective Two Tactile Systems Discriminative

Pertains to the sense of touch Helps provide a basis for body image Tactile System Pertains to the sense of touch Alerts to danger Gives body boundaries Helps provide a basis for body image

Protective System Activates “Fight, Fright, or Flight” Born with this system- “Primal” Stimulated by light touch, pain, temperature Processed through the emotional, excitatory portion of the limbic system  NOT a cognitive response

Discriminative : Pressure Touch Deep touch/pressure, and vibration Activates Parasympathetic System Calms and organizes Allows for more cognitive response Helps us learn and think

Dysfunction of the Tactile System Distractibility Hyperactivity Over/Under Sensitivity Hyper-vigilant Inappropriate pain sensation Avoids getting hands dirty Difficulties with clothing/textures Avoids whole hand Disorganized when touched Intolerant of wearing glasses/hearing aide Difficulty with Social Space

Tactile Defensiveness is when… - Sensitive to light touch Touch causes difficulty organizing behavior and concentration Touch causes negative emotional responses Can become aggressive, if feeling threatened or stressed

Interventions for Tactile Defensiveness Brushing Protocols Wilbarger Protocol PRR Brushing over arms, legs, back with a soft brush , followed by joint compressions Caution A brushing protocol should only be implemented after an assessment and training by a qualified professional

Why Focus on The Power Senses?

Sensory Bucket Three Power Senses will provide: more input To“fill the sensory bucket” quickly use the Power Senses Three Power Senses will provide: more input more quickly to make changes that are more rapid Sensory Bucket Based on Work of Bonnie Hanshu www.sensoryprocessing.com

Environmental Supports Access to an escape/private area Caution with placement. Student may want to sit where no one is behind him Some feel secure with boundaries that keep others at a distance….. Others need space in order to make a “quick escape”

Quiet Sensory Area

Heavy Blankets, Pillows, Tactile supports Heavy Blankets, Pillows, Lap Pads Pencil Grips Fidget Items

Choose carefully….. Or Under-Responsive ....but need this to avoid Seeker may want this..... ....but need this to avoid getting too "high"... Avoider Overwhelmed Under-Responsive Or

Other Tactile Supports Consider the type of clothing and the way it fits Tight? Loose? Fabric? Swimming/Water Play Body Sock Remove tags from clothing

Body Sock

People Supports: What Others Can Do Avoid unnecessary touch and Ask Permission Avoid touching face to gain attention Move slowly and provide “Waiting Time”- up to 10 seconds When touch is necessary, use Deep Pressure Touch

Proprioceptive System The Power Senses Proprioceptive System

Proprioceptive System Muscles, joints, and tendons provide a person with a subconscious awareness of body position via the feedback from receptors in the muscles, tendons and joints.

Proprioceptive System Motor Planning Awareness of body in time and space without constant visually monitoring

Dysfunction of Proprioceptive System Clumsiness, a tendency to fall Lacks awareness of body position/odd posture Difficulty with small objects (buttons/ snap) Disorganized….. Materials & Thoughts Poor or resistance to handwriting Eats in a sloppy manner Resists new motor movement activities

Activities that provide proprioceptive input Joint compression or extension “Heavy work” activities The larger the joint, the more proprioceptive input

Examples of “Heavy Work” Passive Joint Compressions Jumping/Trampoline (floor may be better..) Stacking Chairs Weight Lifting “Bungee Cord” on Chairs Chewing Gum “Pretzel Hugs”

Fine Motor Supports “Hand-prep” exercise Limit Handwriting Requirements Alternatives to handwriting Keyboarding Software Set of notes Grips Velcro on Shoes Alternatives & Accommodations Options in Word and PowerPoint Sensory Breaks between tough fine motor activities

ALL will need environmental supports Organizational Supports Visual Supports Color coding Timers/Watches Written directions Written rule reminders Under-Responders will need clear and noticeable supports

Stay on schedule Pace language Use Concrete Language Use Wait Time What Can Others Do Stay on schedule Pace language Use Concrete Language Use Wait Time

The Power Senses Vestibular System

Vestibular System The vestibular system refers to the structures within the inner ear (the semi-circular canals) These structures detect movement and changes in the position of the head.

The brain needs vestibular input in order to function Vestibular input provides the Strongest Sensation

Movement can change an individual’s attention, arousal and alertness in the shortest period of time The effects from vestibular input can last longer than any other input.

Hypersensitive: Active avoider and overwhelmed Fearful reactions to ordinary movement activities Apprehensive walking or crawling on uneven or unstable surfaces Seem fearful in open space Appear clumsy Want their feet on the ground! These folks need gentle experiences and support as they become more comfortable

Hypo-sensitive Under-Responders and Seekers Seeker: Actively seek and demonstrate a need for intense movement experiences (whirling, jumping, spinning, spinning objects, pacing) May includes visual stim Be aware: Seeker can become over-excited Needs monitoring “Cap-off” vigorous vestibular activity with proprioception (“heavy work” or joint compression) Under-Responder may need gentle encouragement to engage in movement activities

Activities that provide vestibular input Seeker/Avoider/Overwhelmed Linear, Calm, Slow, Controlled movement to gain attention Under-Responder Unpredictable, multi-directional, spinning (if individual requests), to alert and orient someone who is under-responsive Be very cautious imposing vestibular movement – can be very frightening

Selected Strategies Swinging Rocking Chair Sit & Spin/Dizzy Disc Therapy Balls as Chairs Moveable Cushions or Deflated Beach Balls as Chair Cushions

Selected Strategies Delivering Messages or Packages (or any job that requires walking, moving, bending, etc.) Running Track or possible a Treadmill Movement breaks placed proactively in the day

Remember…… Do NOT withhold recess/gym based on the child’s behavior or inability to complete work Movement and activity may be the input the child needs in order to maintain behavior, concentrate and learn!

Environmental Supports Firm Supportive seating Feet on floor Desk and chair that fit Railings on step Cushion for movement Space to move and pace

Creating The Sensory D.I.E.T. D …..Do an Informal Assessment I …..Individualize E …..Environmental Supports T …..The Power Senses

How can a therapist help my child? School-based therapist Part of a full evaluation or pre-referral tool Assist with program planning Educate staff and personnel Collaboration between school and clinic Clinic-based therapist Obtain observations of participation in school and home Educate the parent/caregiver Collaborate with the school therapist and school team Research

How can we help optimize the learning experience?? By knowing what type of strategies/activities to do with your child that will help the body organize and interpret sensory information to the brain.

Activities for tactile sense: Shaving cream (unscented, if possible) Playdough Theraputty Textured food Finger painting Hair gel Tactile road Playing dress-up Ball pit Blanket wrapping Pressure vest Gentle but firm massage Vibrating toys

Activities for Vestibular sense: Swings Scooter boards Wagon rides Self propelling toy cars Slides Obstacle courses Monkey bars Trampoline Rolling on mat NOTE: This must be slow and brief at first, in very secure positions.

Activities for proprioceptive sense Crash pad Crawling (can crawl through tunnel, over beanbags or pillows) Running Climbing Marching Wall push-ups Weighted garments Pressure garments Heavy work Scooter board Therapy ball Jumping on a trampoline Wheelbarrow walks

Activities for auditory sense Soft music Soft voice White noise Quiet room Up beat music Loud voice Instruments/noise makers White noise Classical music

Activities for visual sense: Soft colors Solid backgrounds Dim lights Desk lamp Uncluttered area Flash light tag Visual schedules Bright colors Bright lights

If you have any questions or concerns regarding your child development and sensory processing 1- Contact your pediatrician/primary care physician 2- Get a referral for skilled therapy services 3- Contact your therapy provider of choice

Any questions?

Alma Martinez MOT, OTR Valerie Villarreal OTS Maggie Flores, COTA You may reach us at : 6550 Springfield Ave Ste. 101 (956) 725-4555 email: fivestartherapy@yahoo.com