What is Sensory Integration?

Sensory Integration is the neurological organization of sensory input for skill, learning and social interactions - allowing us to perform our daily occupations. This special field of research and theory is central to the profession of Occupational Therapy. Over 30 years ago, the theory was developed by Jean Ayres, PhD, OTR - a mentor to generations of therapists. Dr. Ayres, through factor analytic studies and her work with children with learning disabilities in the 70’s, linked our somatosensory system as the foundation for motor planning/praxis. She also linked the vestibular-proprioceptive systems as holding the key to bilateral integration and sequencing skills. Dr. Ayres cited neuronal connections at the level of the brainstem as her area of study and resulting focus for therapy interventions.

Since intact, efficient sensory processing leads to a child’s adaptations across changing environments, dysfunction in one or more special senses can lead to deficient motor skills, poor coordination, diminished body awareness (our body map or body scheme), immaturity of emotional regulation, avoidance or craving of specific inputs, and immature visual-perceptual skills. It is essential in occupational therapy to address the underlying sensory dysfunction before challenging the more obvious motor or perceptual delays. In Dysfunction of Sensory Integration (DSI) there is an inability to discriminate, coordinate or organize sensations adaptively.

Sensory Integration theory provides a scientific foundation for techniques that support the arousal, affect and motivation of children. With a trained clinician offering a “just right” challenge for children, the results of therapy are a child’s mastery, engagement and a new sense of well being. “When the functions of the brain are whole and balanced, the body movements are highly adaptive, learning is easy and good behavior is a natural outcome.” (Ayres 1979).

What causes DSI?

Some researchers are finding familial tendencies, suggesting a genetic origin. Other studies indicate early trauma in the neonatal period. Children born prematurely as well as infant multiple births appear to have greater incidences of Dysfunction of Sensory Integration. Studies of children who were institutionalized in infancy and deprived the natural handling and interactions of infancy are at great risk for DSI. There appears to be a range of causes as well as many unknown factors - that will be revealed to us as the studies continue.

It is important to note that in true DSI, a child demonstrates an intact central nervous system with inefficient brainstem processing. Therefore, the prognosis for change following sensory integrative therapy is very good for these children. In the presence of central nervous system damage (for example, cerebral palsy), DSI may be seen as another symptom, and prognosis is individual based on the limits of a disordered nervous system.

What are some of the symptoms of Dysfunction in Sensory Integration?

 * Poor body awareness and difficulty dressing self 

* Incoordination - especially of opposite sides of the  body   (jumping  jacks)

* Inattention secondary to poor auditory, tactile or visual processing 

 * Repetitive or diminished play strategies.

* Social isolation and emotional immaturity

* Fearful of movement or having feet off the ground

 * Tactile defensiveness or dormancy.

 * Avoiding or craving specific sensory input

 * Signs of overload/tantrums as the environment changes

 * Perceptual difficulties of copying forms or structures, related to poor midline crossing skills and decreased spatial awareness

How is the theory of Sensory Integration Expanding?

Occupational Therapy Research over the past 15 years, with resulting new Evaluation Tools has added the ecological model of Sensory Modulation Dysfunction (SMD) to the theory base of Sensory Integration (from the 1970's).

Dysfunction in Sensory Integration (DSI)

DSI results in deficiencies of discriminative functions seen in praxis, postural control, oral and ocular control -

    * Did you touch me in one or two places?

    * Was that sound from left or right direction?

    * Did I move my arm up or down?

    * How can I move my body to climb into that barrel?

    * Is there still food in my cheek?

    * How can I plan to draw that figure or rotate it in space?

    * What form is in my hand?

Sensory Modulation Dysfunction (SMD)

SMD is one’s inability to internally regulate the degree, intensity and nature of a response to sensory input in a graded and adaptive manner, disrupting skill performance, routines and social interactions. SMD manifests itself in a child’s over-reaction or under-reaction to sensory input that is disproportional to the input. It appears that the child is craving or avoiding sensory input, in accordance with her own nervous system thresholds. At times, a child may under-react to a stimulus consistently and this is referred to as “Sensory Dormancy”. Some children may always over-react to a stimulus and this is referred to as “Sensory Defensiveness”. At times, some children may exhibit reactions that swing either way - hence the term “Sensory Modulation Dysfunction”.

To better understand this area of dysfunction, consider this example: a child who is always moving and craving swinging and spinning (at levels greater than his peers), is providing additional movement input, in accordance with a vestibular system that under-registers vestibular input. Unfortunately, constant movement does not organize us, nor does it further develop an attention span for new learning. Many children demonstrating SMD may also show near age level motor skills. The dysfunction is seen in the modulation of sensory input, throughout the day, across various environments having profound effects on a child’s ability to participate in peer activities, perform daily living skills, and stay regulated at school. 

There is a 50% comorbidity of a child exhibiting DSI and ADHD according to Dr. Lucy Miller. The difference seen in children with just ADHD upon receiving a novel sensory input is that the child with ADHD will soon habituate to the stimulus (and not continue to over- react). A child with DSI will show atypical responses the entire time, when receiving a novel stimulus. Also, a child with ADHD craves novelty in play, showing adequate (but impulsive)  motor skills to complete new play tasks. For a child with DSI, novelty can be overwhelming, as poor sensory modulation interferes with higher level praxis (precise planning). This is why we usually see children with DSI playing with the same familiar toys or showing limited play interest. Important SI therapy can help remediate this limited skill repertoire in children.

Therapy strategies for children with SMD include methods that may enhance neurochemical summation (at a synaptic level) transmitting sensory input in a more efficient manner- to perception areas of the cortex. This is a premise of the pressure-brushing program used by many OT’s during therapy to reduce tactile defensiveness. Also, presenting ongoing, graded sensory input during child centered therapy and at home via a “Sensory Diet”, enhances the growth of neural synapses that may be diminished due to deprivation or other conditions of the nervous system (such as prematurity or Down syndrome).

Sensory diet items like the use of a weighted vest, backpack or small ankle weights help a child who feels the need to move more than others. The weightedness helps a child understand his speed and direction of movement, finally registering the intensity of movement. Another adaptation used for children who feel sensory overload in busy settings is a pressure band or vest. The use of pressure is very organizing- offering ongoing deep pressure and warmth to bring a sense of calm to the nervous system.

The Art of Therapy~

Sensory Integrative therapy is child centered, usually presented in a novel environment that challenges a child to address his motoric and processing difficulties by offering graded sensory input and continual “just right” challenges. As skill increases, the therapist can guide the child to try to climb a bit higher, plan out a new way to swing or drop off into a pillow, receive heavy-work, to enhance regulation and integration of the senses. Therapists with special training in the testing and interpretation of DSI are listed on the website of Sensory Integration International (SII). http://home.earthlink.net/~sensoryint/.

Using a “Sensory Diet”: Tools for Parents and Professionals~

This metaphor was first used by an occupational therapist who understood the need of a disregulated nervous system to be “fed” individualized, organizing input on a regular basis to promote self-regulation.

Sensory diets are designed by OT’s for children with DSI to be implemented at home, school and other environments to support a child’s successful self-regulation and engagement in a range of activities. This therapy intervention is designed specifically for each child, and utilized in all settings the child participates.

Components of a sensory diet may include any or all of the following listed below. 

* Therapeutic Listening: Therapeutic Listening is an important integrative tool in occupational therapy.

*Interactive Metronome program as a short term addition to a sensory diet.

 * Heavy Work! followed by soothing fine motor play. 

 * Recipes for Play: Visit this section to enjoy creative recipes for sensory play and support your child with tactile needs.

 * Rhythmic and heavy work at the mouth, to include blowing, sipping, crunching, brushing, biting or sucking.

 * Adapted equipment to include: weighted vests, pressure bands or pressure vests, weighted stuffed animals and lap pads, ankle and wrist weights, weighted wagons and bikes, weighted backpacks, body pillows, vibration pillows and toys. Many items can be designed by your therapist based on your child's individual needs and interests.

*Calming scents work best to promote rest (vanilla) and can be placed in a tent or quiet space to encourage relaxation. Placing a drop of lavender oil at the top of the bed sheet may help a child settle for sleep.

*Exciting scents help wake up the nervous system for times when attention is needed- getting dressed in the morning, reading at home or starting up homework. Lemon and peppermint scents placed near a work station can help bring an alert state to a child. Select a scent based on the child's individual preferences.

*Yoga postures and yoga breathing bring inner awareness and also slow down our physiology. Studies reveal the presence of alpha brain waves post yoga class- the quiet alert state, a place that many of our children can not reach on their own. There are many yoga cards, CD's and books available for parents to bring the practice of yoga to your children.

*A quiet space, made special for your child to include soft pillows and a favorite cuddle toy or book. This space serves as a retreat from noisy times at home or even daycare. If loud sounds are an issue, some families offer noise reducing headphones to their children who are sound sensitive. For the school age child, having a desk or table space at the back of a classroom, facing a wall is a simple adaptation to giving a student a visual/auditory break- and a great place to finish assignments when feeling out of sync. Sensory diet "tools" can be accessed at this space with more privacy for the child.

* Finally, talk to your child's doctor or nutritionist to explore the importance of having omega oils in your diet, especially to start out a child's day for school. Too many of our children eat carb rich breakfasts without protein, and the amino acid's of proteins are needed to block excess Serotonin (contributing to a sleepy brain)- and enhance Dopamine and Norepinephrine for focus.

Marget Wincent, OTR/L

Director

OT Outcomes