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Sensory Processing Disorder: Identification and Intervention
Linda King-Thomas MHS, OTR/L Developmental Therapy Associates Durham and Cary
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Sensory Integration Sensory integration is the neurological process that organizes sensation from one’s own body and from the environment and makes it possible to use the body effectively within the environment. Ayres (1972) Sensory Integration and Learning Disorders p.11 Sensory integration is a normal brain phenomena and occurs anytime the brain receives information. And there is no perfect nervous system!! Definition: organizing sensory information for use specific theory and intervention approach that emerged from within the field of occupational therapy by Dr. A. Jean Ayres *an occupational therapist with PhD in educational psychology, *pioneer and key researcher in development of theory and practice * provided research and theory development over several decades and died in 1988. Dr. Ayres estimated that 5-10% of the children in the United States have sensory integration dysfunction -- boys 5 times more likely to have difficulties. This is only an estimate ..
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Uses of the term Sensory Integration
Theory (sensory integration theory) Diagnosis (based on an assessment) Sensory Processing Disorder (SPD) Functional pattern (normal sensory integration abilities) Remediation approach (therapy/intervention Currently SPD network is seeking signatures on a petition to add SPD diagnosis to DSM-IV SI approach provides alternative explanation for behavior Behavior is communication – has a purpose Look at behavior from a sensory perspective – helps to reframe the issues (behavior, function or disorganized learning patterns)
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Sensory Systems Vestibular (movement and gravity) Tactile (touch)
Proprioceptive (“heavy work”, input to muscles and joints) Auditory (hearing) Visual (sight) Olfactory (smell) Gustatory (taste) Our brains must be able to organize and process sensory inputs and use that input to respond appropriately to any given situation. For this to happen, we must integrate the information we receive through all our senses and from movement and gravity. The ability to learn even the simplest things and to behave appropriately in different situations depends upon these integration abilities.
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All of us, including children, are expected to be able to take in information through all channels and perform many skills independently. We often take for granted that children have automatically learned to integrate the various sensory inputs received on a daily basis. For them to do this, they must feel comfortable with where their bodies are in relation to their environment. They must feel safe in their bodies, and they need to know how to interpret different tactile inputs. But what if our brains did not discriminate, filter, prioritize, coordinate, organize, and integrate all of these sensory inputs?
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Sensory Integration Foundations for Learning and Behavior
Sensory systems foundation: tactile vestibular proprioception --- body senses olfactory, etc Environmental spatial senses Sensory Motor Development Perceptual Development Cognitive Intellect Sensory integration provides the foundation to work in collaboration with other intervention strategies such as educational models or teaching social understanding as developed by Carol Gray. Prepares the nervous system to attend and respond
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Sensory Processing Disorder
Sensory Modulation Disorder Sensory Over-Responsivity Sensory Under-Responsivity Sensory Seeking / Craving Sensory Discrimination Disorder Sensory-Based Motor Disorder Postural Disorder Dyspraxia The Interdisciplinary Council on Developmental and Learning Disorders (2005). Diagnostic manual for infancy and early childhood. Bethesda, MD: author Regulatory-Sensory Processing Disorders Work group members: Lucy J. Miller, Marie Anzalone, Sharon Cermak, Shelly Lane, Beth Osten, Serena Wieder, Stanley Greenspan
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Sensory Modulation Disorder
Difficulty modulating, discriminating and organizing sensory input Difficulty with self-regulation, in terms of arousal states, may be under or over responsive to sensory input Difficulty interacting effectively to demands of environment, relationships and tasks Difficulty adapting to challenges in daily life SMD– difficulty turning sensory messages into controlled behaviors that match the nature and intensity of sensory information
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Sensory Modulation Disorder
Sensory Over-Responsivity – quick or intense response to sensory stimuli Sensory Under-Responsivity -- slow response to sensory stimuli, requires a high intensity or increased duration of stimuli to elicit a behavioral response Sensory Seeking/Craving – actively seeking sensation often in socially unacceptable way Under responsivity – Over responsivity – sometimes called sensory defensiveness Sensory seeking/craving – can be insatiable craving for sensory experiences
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Alertness / Arousal States
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Sensory Over-Responsivity
Covers ears with loud noises Is sensitive to bright lights Fears movement or changes in position Avoids touching certain textures (grass, sand, finger paints, squishy) Does not like to get messy Has strong clothing preferences Does not like to be touched unexpectedly Has a poor tolerance to grooming Sensory defensiveness -- in one or more sensory systems hi arousal -- impulsive, over active hypervigilant -- big eyes, cautious, careful fails to learn.. -- acts fearfully -- life is dangerous, not safe rigid interactions -- creates rituals and routines to avoid sensation and to control the situation
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Sensory Over-Responsivity
Is often irritable, aggressive, impulsive, and moody Has a poor tolerance to transitions Frequently cries and is hard to console Does not like to be held or cuddled Needs help to fall asleep and stay asleep Exhibits extreme separation anxiety Has difficulty transitions to new foods Does not like the feel taste sight or smell of certain foods
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Dennis the Menace is saying, “Go ahead Joey: it’s all downhill from here!”
Wide eyed fright response
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Sensory Under-Responsivity
Has delayed reaction time Is slow to respond to name Seems unaware of environment, wanders Has a high pain tolerance Does not sense when diaper is wet Does not feel clothing twisted on body Does not feel food on face or in mouth, or dirt on hands #2 slow take action -- has lost in space appearance #3 slow attention -- tendency to wander and not become engaged in activity or person #4 range of expression -- not aware of feelings of others #5 decreased awareness of sensation -- high tolerance for pain, not aware of toys in hand, not aware of wet chin #6 poor posture -- lay on floor, rest head on table
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Sensory Under-Responsivity
Does not seem to notice when touched Has flat affect much of the time Is hard to engage, may observe but not participate Is unaware of body sensations (temperature, hunger) Does not seem to notice noxious odors Appears slow, unmotivated, unaware,or withdrawn Seems to be ‘lost in fantasy world’
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Sensory Seeking Has a high activity level, seldom sits still
Touches everything Hangs on people/objects Smells or mouths everything Takes excessive risks that compromise personal safety Prefers foods with strong flavors Often mouths or licks non-food items Seems to have an insatiable desire for strong levels of sensation. Sensory seeking-- seeking intensity attempt to get more organized hi arousal -- very active, moving all the time affect variable disorganized motorically impulsive craves certain input -- bumping, crashing, jumping; mouthing objects, suck/ chewing (hair,clothing,straws, furniture); talk constantly; under mattress or bean bag chair, wrap up in t-shirt or bed sheet self-stimulating behavior -- twirling, spinning (vestibular), flipping fingers or toys (visual), taps, hums--vibration to head, rocks self-injurious behavior --head banging, rubbing, hitting, or biting body parts, eye poking observation when environment rich with sensory based activities SIB decreases
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Sensory Seeking Seeks out loud noise
Likes to watch bright/spinning objects Is excessively affectionate May be demanding or hard to calm Is a risk taker Intrudes on others May be kicked out of child care or expelled from preschool
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Influence on Play Skills
Avoidance of handling toys and typical play materials Withdrawal from noisy play, toys that make sounds Fearfulness of movement limits desire for exploration of the physical world Avoidance or lack of registration reduces vital developmental stimulation Withdrawal from special childhood events such as birthday parties, dressing up for Halloween and holiday parties
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Influence on Self-Care and Feeding
Avoidance and/or rejection of food textures, tastes, smells, temperature Avoidance and/or rejection of tooth brushing and bathing Avoidance and/or rejection of hair brushing, hair washing, hair cutting Avoidance and/or rejection of clothing textures and dressing process
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Influence on School Related Activities
Avoidance of classroom tools and materials Difficulty with participation in group activities which involve movement, touch or sound Difficulty staying in line Difficulty self-regulation attention in the classroom
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Influence on Social Participation
Disruption of attachment relationships due to approach/avoidance conflict Avoidance of a need to be in control, or aggression towards peers Disruption in ability to develop and maintain friendships and love relationships in adults Decreased perception of social acceptance which leads to decreased self-esteem
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Sensory-Based Motor Disorder
Postural Disorder: difficulty stabilizing the body during movement or at rest to meet demands of a motor task Dyspraxia: difficulty translating sensory information into planning and/or sequencing movement, especially new or unfamiliar Sensory Processing Disorder Poor stability in trunk Poor righting and equilibrium reactiona Poor trunk rotation Poor ocular control Sensations: vestibular, proprioceptive, visual Terminology changes to make more acceptable to DSM-IV
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Postural Disorder Fears movement due to inadequate postural control
Does not like ‘tummy time’ Has decreased muscle tone Seems weak compared to peers Loses balance easily Tires easily, has poor endurance Frequently trips and falls Appears lazy and unmotivated Has difficulty using both hands and feet at the same time (bilateral coordination)
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Dyspraxia Difficulty translating sensory information into ideas for movement, planning, organizing and/or sequencing movement, especially new and unfamiliar actions Can manifest as gross motor, fine motor and/or oral-motor problems Praxis is the neurological process by which cognition directs motor action; motor or action planning is that intermediary process which bridges ideation and motor execution with the physical world Ayres (1985)
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Dyspraxia Is clumsy Eats messily Has a disheveled appearance
Uses toys the same way over and over Is rigid in play/routines Frustrates easily Has trouble maneuvering around obstacles Breaks things unintentionally Characteristics of dyspraxia Poor integration of somatosensory input Poor analysis of task requirements Poor problem solving abilities Difficulty uisng appropriate perceptual cues Difficulty learning new motor skills Poor anticipation and preparation Difficulty using feedback Needs more practice and repetition
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Dyspraxia Has difficulty following directions for activities that require more than one step Has trouble learning new skills Is disorganized Prefers ‘fantasy games’ over physical games Prefers sedentary activities Has delays in speech and/or motor skills ranging from mild to severe
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Complex bilateral tasks
scoop sand unwrap candy
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Influence on Play Skills
Difficulty with playground activities Difficulty with manipulative and construction toys Difficulty with the sequence and rules of play Difficulty with timing and sequencing of body parts in sports and motor activities Directional confusion leads to poor spatial organization with team sports. Poor ideation leads to decreased play possibilities Modified from information presented by Susan Stallings-Sahler at a 1999 NCOTA fall workshop Prefer fantasy game to “doing”, elaborate story very simple actions In general: prefer simple play; familiar play 1) Accident prone, trip and fall, difficulty plan body in relation to swings and ropes 2) Many break toys due to poor grading of actions
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Influence on Self-Care and Feeding
Slow in managing dressing fasteners and shoe tying Difficulty in mastering the spatial organization of clothing Problems managing tools for self-care (hairbrush, washcloth, utensils) Difficulty with food wrappers Messy eater Disorganization with personal belongings
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Zippers Understanding the direction and force of the pulling action
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Organization of behavior for getting a drink of water
Open lid screw off lid Manipulate the faucet for water
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Influence on School Related Activities
Poor and/or slow handwriting and drawing skills Difficulty using classroom tools and materials effectively (scissors, glue bottle) Disorganization of work space (desk, locker) Difficulty learning new skills through imitation
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Awkward tool use; difficulty placing the scissors in his hand
Once scissors oriented properly in the hand; Craig could cut on the line!!
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Influence on Social Participation
Social rejection by peers during games due to poor motor skills Withdrawal from social situations due to poor self-esteem Difficulty discerning social and physical boundaries; poor social judgment Disorganized peer interactions due to poor ability to read non-verbal cues Tendency to be rigid and controlling Tendency to play alone Play class “clown” as a strategy of avoidance
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Intervention Education/awareness
reframe behavior (view) from a new perspective Individual therapy using a sensory integrative approach Consultation model for home and school Develop new strategies – sensory diet
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Research Roberts, J. E., King-Thomas, L., & Boccia, M. L. (2007). Behavioral indexes of the efficacy of sensory integration therapy. AJOT, 61, Single subject ABAB design: subject diagnosed with sensory modulation disorder and delayed communication skills Behavioral data collected by preschool teachers who were blind to the timing of sensory integration therapy Improvements in behavioral regulation noted: increased engagement & decreased aggression, less need for intense teacher direction, decreased mouthing objects
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Research Miller, L. J., Coll, J. R., & Schoen, S. A. (2007). A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. AJOT, 61, Twenty-four children assigned to 1 of 3 treatment groups: OT-SI, Activity Protocol, and No Treatment Significant changes noted in OT-SI group on GAS (goal attainment scaling), attention, Cognitive/Social composite of Leiter-R parent rating
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Sensory Diet The daily intake of sensory and motor experiences needed by a person to adaptively interact with the environment Sensory and motor experiences help maintain optimal arousal and attention for learning Sensory diet formula: intensity, frequency, duration, rhythm of input is varied to achieve optimal performance You’ve probably figures out, without too much thought, what helps you relax, concentrate, or just feel good in various situations. You probably use different strategies depending on the context and the circumstances. *Maybe music keeps you energized when working but is distracting during tasks that require focused attention. *Maybe you chew gum or crunch crackers or carrots to stay alert. *Maybe you run in the mornings to energize your day, or maybe in the evening to relieve stress. *Maybe you drink caffinated drinks early to charge your system, or drink hot drinks in the evening to unwind. Most of us develop preferences because certain types of sensory input (this includes activities, sounds, textures, foods) have helped us respond appropriately in any given situation.
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Sensory Diet Activities
Specific to the individual based on assessment Planned throughout the day to help maintain optimal level of organization Most powerful and long lasting include: movement, heavy work, deep touch pressure Sensation can have calming or alerting effect Calming and alerting effect: for example: light tough is alerting -- spider web on face in dark room deep pressure is calming -- a big hug fast, arrhythmic movement is alerting -- wild ride at the amusement park slow, rhythmic rocking is calming rocking chair on the porch
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Sensory Diet Activities
Structure activities in a playful, non-threatening manner Closely monitor for an adaptive response -- more organized behavior More sensation in not always better --observe for signs which might indicate an overstressed nervous system Stressed NS -- changes in breathing, skin color and other sympathetic NS signs
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Movement Unstable surfaces: therapy ball, air pillow, air cushion
Games and calisthenics Jumping, swinging, Rocking, rolling, Bouncing, Marching, dancing Games: Catch the wiggles jump and turn jumping jacks trampoline jump Activity: hammock swing playground equipment
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Heavy Work Carrying heavy objects Wheelbarrow walk, animal walks
Backpack Digging in a garden Working out on weight machines Pulling friend in a wagon Pushing heavy grocery cart Sports Carrying heavy objects: weighted stuffed animals milk jug filled with stones put away groceries errands in school or neighborhood carrying books, canned food Sports: running wrestling
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Deep Pressure Touch Weighted vest, weighted blanket Firm hugs, massage
Lycra exercise shorts or tights under clothing Games: rough house play tactile sandwich Deep pressure touch is calming and organizing Games: “hot dog” in a blanket wrestling or rough house swaddled in blankets under the mattress or big pillows
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Oral Motor Suck: long straw or thick liquids; sour, sweet, spicy hot candy Blow: whistles; bubbles Chew and crunch: gum, popcorn, dried fruit, bagel, pretzels; chewy tube, straws Suck: long straw, thin cocktail straw sports bottles thick liquids: milkshake, applesauce, pudding, yogurt Blow: variety of whistles, some easy to blow some more difficult (stronger respiration) Chew: cinnamon gum -- spicy more alerting
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Womb Spaces Under a table or desk Tent or sleeping bag
Inside a closet or other small space (box) Pillow in a corner of the room Creating small space feeling with furniture position Womb spaces are small spaces and tend to be organizing by reducing environmental sensations. Tend to be dark and quiet --- calming
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Tactile Hand toys to fidget: koosh balls, silly putty, bendable figures, small stuffed animals, pieces of soft fabric Extra toweling after the bath Tactile fine motor activities kneading bread sand play bean play finger painting
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Tactile Strategies Temperature: cool is alerting, warm is calming
Clothing preferences: long sleeve, short sleeve, cut out tags, sport socks (no seams) Bed clothes: flannel sheets, heavy blanket, light sheet Light touch (tickling): alerting Temperature: cool wash cloth on face (wake up) warm bath at night to calm and relax cool shower in the morning-wake up Light touch alerting -- tickling may even be perceived as painful or uncomfortable each system individual: light back scratch slow strokes up and down way of alerting in the morning others: enjoy this back scratch before bed, find it calming Do not force a child to play in gooey, slimy hand activities: May find it uncomfortable
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Auditory Strategies Soft music-- Mozart, fast music -- driving beat
Ear muffs, headphones White noise machine, water fountain, soft background music Voice quality -- high or low pitch Calming: soft quiet rhythmic sounds, predictable harmony, chanting mid-range to low pitch, even voice Alerting: arrhythmic discordant music, driving beat loud, unusual sounds anticipation in voice high pitch or sudden sounds
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Visual Strategies Soft dim lights
Natural light, avoid fluorescent light Muted colors and plain walls Bright lights Movement in peripheral visual field Lots of color Calming: Alerting:
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Resources Books Heller, S. (2002). Too Loud, Too Bright, Too Fast, Too Tight. New York: HarperCollins Publishers. Henry, D., Kane-Wineland, M., Swindeman, S., (2007). Tools for Tots: Sensory Strategies for Toddlers and Preschoolers. Glendale, AZ: Henry OT Services. Isbell, C. & Isbell, R. (2007). Sensory Integration A Guide for Preschool Teachers. Beltsville, MD: Gryphon House.
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Resources Books Kranowitz, C. (2005). The Out-of-Sync Child. New York: Penguin Group. Miller, L. J. (2006). Sensational Kids. New York: Penguin Group. Williams, M. S., Shellengerger, S. (2001). Take Five! Staying Alert at Home and School. Albuquerque, NM: TherapyWorks, Inc. Yack, E., Aquilla, P. & Sutton, S. (2002). Building Bridges through Sensory Integration. Las Vegas: Sensory Resources.
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Resources catalogs Abilitations 1-800-850-8602 www.abilitations.com
Fun and Function Sensory Critters Southpaw Products Therapy Skill Builders
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Resources on the web Sensory Processing Disorder Foundation
SI Focus magazine Developmental Therapy Associates
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