Sensory Processing Disorder: Identification and Intervention

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

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

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

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)

6. Sensory Integration Foundations for Learning and Behavior

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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, 555-562 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, 228-238. 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

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

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

41. Movement • Unstable surfaces: therapy ball, air pillow, air cushion • Games and calisthenics • Jumping, swinging, • Rocking, rolling, • Bouncing, • Marching, dancing

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

43. Deep Pressure Touch • Weighted vest, weighted blanket • Firm hugs, massage • Lycra exercise shorts or tights under clothing • Games: • rough house play • tactile sandwich

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

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

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

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

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