1. Sensory Processing Disorder: Identification and Intervention
Linda King-Thomas MHS, OTR/L
Developmental Therapy Associates
Durham and Cary

2. 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 ..

3. 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)

4. 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.

5. 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?

6. 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

7. 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

8. 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

9. 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

10. Alertness / Arousal States

11. 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

12. 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

13. Dennis the Menace is saying, “Go ahead Joey: it’s all downhill from here!”
Wide eyed fright response

14. 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

15. 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’

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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)

25. 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

26. 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

27. Complex bilateral tasks
scoop sand
unwrap candy

28. 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

29. 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

30. Zippers
Understanding the direction and force of the pulling action

31. Organization of behavior for getting a drink of water
Open lid screw off lid
Manipulate the faucet for water

32. 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

33. Awkward tool use; difficulty placing the scissors in his hand
Once scissors oriented properly in the hand; Craig could cut on the line!!

34. 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

35. 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

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

46. 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

47. 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

48. 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

49. 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

50. 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:

51. 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.

52. 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.

53. Resources catalogs Abilitations 1-800-850-8602 www.abilitations.com
Fun and Function
Sensory Critters
Southpaw Products
Therapy Skill Builders

54. Resources on the web Sensory Processing Disorder Foundation
SI Focus magazine
Developmental Therapy Associates