A Review of Sensory Integration Therapy as a Treatment For Autism Elizabeth Kraljic Evelyn Agrusti Joanne Tasy Caldwell College Graduate Program In Applied Behavioral Analysis
What Is Sensory Integration? • Founder of Sensory Integration Theory: • A. Jean Ayres Ph.D, OTR, FAOTA • Credited with having first identified sensory integrative dysfunction. • Author of three major standardized tests. • Occupational therapy’s foremost leader in theory development
A. Jean Ayres • Other Accomplishments: • Educator at University of Southern California 1955-1984 • Wrote books, journal articles, and training videos • Founder of Sensory Integration International • Licensed Psychologist • Credentials • BS and MA in Occupational Therapy • Ph.D in Educational Psychology • Post-Doctoral Traineeship at UCLA Brain Research Institute
A. Jean Ayres and Theory of Sensory Integration • Systematically investigated the brains processing of sensory information • She developed a theory to explain the relationship between the behavior and brain functioning • Sensory Integration: • A Neurobiological process that organizes sensations from one’s own body and environment and makes it possible to use the body effectively within that environment.
What is Sensory Integration • The senses are the primary building blocks of the central nervous system • External senses-all five senses • Internal senses • Tactile System- sense of touch through skin • Vesticular System- balance and weight • Proprioceptive System- sensory data from tendons, muscles and joints • The three systems are interconnected but are also connected with other systems in the brain • Critical for basic survival • Allow us to experience, interpret and respond to different stimuli in the environment.
…Continued • Sensory impact nourishes the brain • Raw material for brain development and learning • Sensory stimulation produces “ brain tone” which is responsible for basic brain waves of the conscious state • They provide the input that stimulates the Reticular Activation System of the brainstem to arousal • Regulates alertness, coordination, focus, and the regulation of input and output
Multi-various sensations • Stimulated simultaneously, and must be organized quickly and accurately • Sensory Integration (S.I.) • Provides the foundation for complex learning and behavior. • All skills are complex processes based on a strong foundation of sensory integration • S.I. is information processing. • Praxis and perception are the resulting products.
Theory Of S.I. • Sensory Integration is an automatic process. • Natural outcomes include: • Motor planning • Adaptive ability to incoming sensations • When S.I. does not efficiently the process is disordered • Learning problems • Developmental lags • Behavioral or emotional issues
…Continued • The young brain is malleable • Structure and function become set with age • Formative- allows person- environment interaction to promote and enhance neuro-integrative efficiency • A deficiency in effective interaction at critical periods interferes with optimal brain development and overall brain ability • Early detection and therapeutic interaction can enhance individual opportunity for normal development
Signs of Sensory Integrative Dysfunction • Sensory Integration focus’s on three basic senses or systems: • Tactile, Vesticular, and proprioceptive • Tactile System- nerves under skin that send information to brain (light touch, pain, temperature, and pressure) • Important for perceiving environment and for protective reactions for survival • Dysfunctions: • Withdrawal from touch • Food texture avoidance • Sensitivity to types of clothing • Reaction to washing face or hair
Dysfunctions continued: • Avoiding getting hands dirty (glue, sand, mud, paint) • Using fingertips rather than full hand • Misperception of touch or pain (hypo or hyper sensitivity) • Self imposed isolation, irritability, distractibility and hyperactivity • Tactile Defensiveness: • Is a condition where individuals are extremely sensitive to light touch. • Abnormal signals to the cortex in the brain interfere with other brain processes.
Sensory Integration Dysfunction • Vestibular System • Refers to structure within the inner ear called the semi-circular canals. These structures detect movement and the position of the head. • Dysfunction-Hypersensitivity • Hypersensitive to vestibular stimulation and have fearful reactions to ordinary movement. They may have trouble learning to climb or descend stairs or hills. They may be apprehensive walking or crawling on uneven or unstable surfaces. • Dysfunction- Hypo-Reactive Vestibular System: • Actively seeks very intense sensory experiences. • Whirling, jumping, spinning
Proprioceptive System: • Components of muscles, joints, and tendons that provide the subconscious awareness of body position. • Praxis or motor planning • The ability to plan and execute different motor tasks • Dysfunction • Clumsiness,tendency to fall, lack of body position in space, odd body posturing, difficulty manipulating small objects, eating in a sloppy manner, resistance to new motor movement activities
S.I.D. Implications • Implications: • Dysfunction in the three previously mentioned systems can be manifested in many ways. • Over or under responsiveness to sensory input • Deficiencies in gross and fine motor coordination, speech/language delays and learning issues • Behaviorally, the child is frequently impulsive, easily distractible, and shows a general lack of planning. • Tendency towards difficulty in adjusting to new situations, easily frustrated, aggressive, or withdrawn
S.I.D. Resulting Problems • Attention and Regulatory: • The ability to attend to a task depends on screening out nonessential sensory information, background noises, or visual information. • Can produce distractibility, hyperactivity, or uninhibited output. • Sensory Defensiveness: • Individual has highly aroused nervous system, which prepares the body for survival. • Individual does not recognize input as non threatening
…Continued • Activity Level: • The child may appear disorganized or lacking purpose in their activity • Does not explore the environment or lacks variety in play activities • May appear clumsy or have poor balance • Behavior: • The child exhibit negative behaviors • They lack flexibility, may be explosive, or have difficulty transitioning • Sensory Modulation: • The child’s inability to regulate sensory input and maintain a situation-appropriate state.
Patterns of S.I.D. • Research identified factors that highly correlate with each other, • Patterns of sensory integration dysfunction examples: • Visual construction and praxis deficits, and Tactile discrimination and praxis • Developmental coordination disorder (fine and gross motor, balance, and coordination deficits) • Developmental regulatory disorder • Under, over, or fluctuating response to sensations
Evaluating S.I.D. • Assessment-- First step of the treatment process • Individualized- Identify the specific learning motor and behavior difficulty of a child • Tests, observations, interviews of neuromotor function and sensory modulation abilities • Standardized Tests: Ayres developed seventeen standardized tests and many non standardized observations to identify and understand the multiple patterns of S.I.D. Her tests and others are currently used to test for sensory issues.
Evaluation continued • Examples: • Sensory Integration and Praxis Tests (SIPT) for children 4-8 years and 11 months • Test for Sensory Integration (TSI) for children 3-5 years of age • Bruininks Osteretsky Test for Motor Proficiency for ages 5-15 years • Peeramid ages 6-14
Evaluating S.I.D. • Evaluation and treatment of the basic sensory integrative processes is preformed by trained SI occupational therapists and or physical therapists or speech and language pathologists • Goals • Provide the child with sensory information which helps organize the central nervous system • Assist the child in inhibiting and or modulating sensory input • Assist the child in processing a more organized response to sensory stimuli
Validation of S.I. Treatment • In 2002 occupational therapy experts defined the core principles of sensory integration as used in professional practice such as occupational therapy. • This was done to validate methods reported as sensory integration in research. • These principles are deemed essential to providing sensory integration intervention
Intervention Principles Based on Sensory Integration Theory • Qualified professional, occupational therapist, physical therapist or speech and language pathologist. • Intervention plan is family-centered, based on a complete assessment and interpretation based on the patterns of sensory integrative dysfunction, collaboration with significant people in the individual’s life, adherence to ethical and professional standards of practice.
Safe environment that includes equipment that will provide vestibular, proprioceptive and tactile sensations and opportunities for praxis. • Activities rich in sensation especially those that provide vestibular, tactile and proprioceptive sensations and opportunities for integrating that information with other sensations such as visual and auditory. • Activities that promote regulation of affect and alertness and provide the basis for attending to salient learning opportunities.
Activities that promote optimal postural control in the body, oral-motor, ocular motor areas and bilateral motor control sustaining control while holding against gravity and maintaining control while moving through space. • Activities that promote praxis including organization of activities and self in time and space. • Intervention strategies that provide the “just-right challenge”
Opportunities for the client to make adaptive responses to changing and increasingly complex environmental demands. Highlighted in Ayres Sensory Integration intervention principles is the “Somato-motor adaptive response” which means that the individual is adaptive with the whole body, moving and interacting with people and things in the 3-dimensional space. • Intrinsic motivation and drive to interact through pleasurable activities, in other words, play.
Therapist engenders an atmosphere of trust and respect through contingent interactions with the client. That is the activities are negotiated, not pre-planned, and the therapist is responsive to altering the task, interaction and environment based on the client’s responses. • The activities are their own reward and the therapist ensures the child’s success in whatever activities are attempted by altering them to meet the child’s abilities.
Guidelines for Competency in Application of S.I. Theory • Restricted to professionals qualified occupational therapists, physical therapists, speech and language pathologists • Competencies developed through post graduate continuing education, mentoring in clinical experience • Advanced training is through the same means • Certification in S.I. should include administering and interpreting the Sensory Integration and Praxis Tests (SIPT) when used in O.T.
Maintaining Competency • Applying clinical application of S.I. for a maximum of two years • Mentorship through supervision and professional guidance by a therapist certified in S.I. • Ongoing study and review of literature • Ongoing feedback from professional peers as a check and balance for best practice.
Maintaining Competency • Essential Knowledge for Occupational Therapist’s using Sensory Integration • Sensory Integration Theory • Assessment of Sensory Integration and Praxis • Interpretation of Assessment Data for Intervention Planning • Occupational Therapy Intervention using Sensory Integration Strategies.
Part II: TREATMENTS & SPECIFIC BEHAVIORS
3 Keys to Treatment Frequency 2. Duration 3. Intensity
Sensory Diet • Is a specifically designed plan of biochemical and neurological input to promote and facilitate function
Biochemical • Consists of two components • 1. Sleep • 2. Nutrition
Neurological Consists of 3 things: • 1. Vestibular • 2. Proprioceptive • 3. Tactile • Auditory • Visual
Vestibular System • The sensory system that responds to changes in head position and to body movement through space. • It coordinates movements of the head, body, and eyes • The receptors are in the inner ear
Vestibular Activities* • Hokey Pokey with “big” movements • Head, Shoulders, Knees and Toes • Dancing (with head and trunk movement) • Sit ‘n’ Spin • Rolling • Rocking Chair
Proprioceptive System • Unconscious awareness of sensation coming through the muscles, joints, and tendons that tells you what position you are in
Proprioceptive Activities • Stair climbing and/or sliding • Playing tug of war • Pulling or Pushing • Big Ball activities • Being squished between pillows • Scooter activities • Hitting a punching bag
Tactile System • The sensory system that receives sensations of pressure, vibration, movement, pain, and temperature through connections in the skin • This system helps to tell the difference between threatening and non-threatenting sensations
Tactile Activities • Finger painting • Making things with foam soap • Clay/Play-Doh/Putty • Walking on the grass with no shoes • “swim” and “dry off” with towel • Texture adventure bins • Lotions • Glue projects
Sensory Seeking Behaviors Running, Spinning, or other movements Provides vestibular and proprioceptive stimulation Treatments to try: Movement games like tag or relay races Bouncing on large therapy balls Rocking chair Jumping
More Sensory Seeking Behaviors • Pinching, Squeezing, or Grabbing • A students hand may be extremely sensitive compared to other body parts and sensory input in the palm may help to override the painful response to a light touch • Treatments to try: • Deep pressure massages • Hand massages or pressing hands together • Wristbands that provide pressure • Vibration toys
More Sensory Seeking Behaviors • Flapping • This movement of the body’s joints and muscles provides proprioceptive sensation to the muscles and joints in the wrists, arms, and shoulders. (could signal sensory overload) • Treatments to try: • Wheelbarrow walks • Push-ups • Jumps with hands being held • Fidget toy
More Sensory Seeking Behaviors • Pica (mouthing or eating non-food substances) • Provides strong tactile and proprioceptive input for a child who is not registering the sensation. It could also transmit vibration to the jaw which can stimulate the vestibular system • Treatments to try: • Vibrating toys for the mouth • Crunchy foods throughout the day • Listerine to be swabbed inside the child’s mouth* • *with parental permission
Sensory Avoidant Behaviors • Takes off clothing • Clue to the fact that the clothing’s touch is uncomfortable to the child’s skin • Treatments to try: • Calming techniques • Soft fabrics • Washing new clothes several times before use • Allow child to choose their clothes
More Sensory Avoidant Behaviors • Avoids eye contact • Peripheral vision could be less stressful or processing visual and auditory input could be difficult, looking away allows the child to process the auditory input better • Treatments to try: • Look into a mirror and gradually increase to someone’s eyes • Teach a child body positions that indicate listening • Using quiet hands
More Sensory Avoidant Behaviors • Avoids handling sensory material • This is a common sign of tactile defensiveness because the hands have a lot of touch receptors. Also, the temperature and wetness affect the child’s tolerance. • Treatments to try: • Deep pressure touching • Weighted lap bag or vest • Massaging hands before the sensitive material is handled
Calming Techniques • These are especially helpful for children with sensory defensiveness. • They help to relax the nervous system • They can reduce exaggerated responses to sensory input • Techniques: • Help with heavy work • Ripping paper • Joint compression • Lap “snake” • Lavender, vanilla, or banana scents • Reduced noise or light levels • Sucking through a straw • Bear hugs
Organizing Techniques • Can help a child who is either over or under reactive become more focused and attentive • Techniques: • Hard candy • Catching/throwing heavy balls • Pulling apart toys (Legos, etc) • Adding rhythm to the activity
Altering Techniques • Help a child who is under reactive to sensory input • Need to be closely monitored • Techniques: • Jump up & down (10x) • The Airplane Activity (hand out) • Fast swinging • Quick unpredictable movements • Running games • Loud, fast music