Sensory Integration and Sensory Processing Disorders
                               
Overview of Sensory Integration

Sensory Integration, or sensory processing, is the ability to take in information through our senses (touch, movement, smell, taste, vision and hearing), put it together with prior information, memories, and knowledge stored in the brain, and respond without over or under reacting.  The process of sensory integration begins in utero and occurs throughout the lifespan.  Our brain is continuously taking in sensory information from the environment and our body, deciding what to do with the information, and then sending messages to our body to respond.  An example of sensory integration would be when reading a book when there is a lawn being mowed nearby, our brain recognizes what the sound is and therefore, that the lawnmower is not a threat.  We are able to “tune out” the sound and continue reading.  If the mower hits a rock, making a sound that we are unfamiliar with, we immediately respond by checking to make sure there is no danger.  If a person has a problem with the process of sensory integration they may be unable to tune out the sound of the lawnmower in order to read their book.  They might overreact to the unfamiliar sound of the lawnmower hitting a rock or may not hear it at all.  Thus, the brain has difficulty sorting out and making sense of sensory input coming in from the environment, therefore affecting the ability to respond appropriately.

The Process of Sensory Integration

At nine weeks in utero the fetus is already sensing touch and movement.   By birth the brain and nervous system are developed enough so that all the senses are working and sensory integration is constantly occurring.  Sensory information about sights, sounds, smells, taste, touch, and movement is continuously entering the body through the eyes, ears, nose, tongue, skin, and joints.  This information is then sent to the brain, where the brain tries to make sense of it by comparing it to past experiences.  If the brain recognizes the sensory input it automatically knows how to tell the body to respond.  If the sensory information is new, the brain typically needs more information to know how to respond and so seeks out the source, such as a sound or a texture, until the brain has figured out how to tell the body to react.  In infancy we begin learning to interpret the information received through our senses so that over time we are able to perform an increasing number of skills automatically. 

Throughout the lifespan there are things that help us relax, concentrate, or just feel good.  For example, parents use swaddling and rocking to help calm a fussy infant and babies learn to suck their thumb or a pacifier to self-soothe.  As we grow and our bodies mature, we learn which things help us feel more calm or improve concentration in various situations and often do them without even thinking about it, such as chewing gum, working out, drinking coffee, doodling, taking a warm bath, listening to music, etc. 

The typical child has an inner motivation to seek out sensory activities and to conquer challenges.  This drive encourages the child to participate actively in experiences that enhance sensory integration.  With every experience the brain is building a store of information so that it knows how to tell the body to respond to the environment automatically in a variety of situations.  Over time, we also learn, without being told, what information is important to pay attention to and what can be ignored.   In the normally developing child, sensory integration occurs when the child participates in everyday activities comfortably.   For this to occur, the child must also have a good sense of where their body is in relation to the environment in order to feel safe moving or being touched. 

There are many children who are unable to sort out and cope with the information they receive from their senses, touch and movement as well as the eyes, ears, mouth and nose.  The information is disorganized and the child’s performance is then affected.  As Jean Ayres, the founder of the theory of sensory integration, states, “disorganization of processing is like a rush hour traffic jam.”

Sensory Processing Disorder

The term Sensory Processing Disorder is becoming more widely used to refer to problems occurring during the sensory integration process.  It refers to difficulty with sensory processing as it relates to the ability to move the body, maintain attention, as well as react and behave appropriately in all situations.  There may be weaknesses in one or more sensory systems, such as touch, movement, or body awareness, impacting the ability to accurately interpret the sensory information coming into the body and brain and then perform motor tasks in response.  A child may also have difficulty screening out input from their body and/or the environment, impacting their ability to adequately focus and pay attention, resulting in problems with behavior and internal organization.

Signs of Sensory Processing Disorder

Children with a sensory processing disorder can have either a hyper (over-reactive) or hypo (under-reactive) response to sensory input, or can demonstrate a combination of both depending on the situation.  The following are common behavioral characteristics of children with a hyper responsiveness or a hypo responsiveness to sensory stimulation.

Touch:
The hyper responsive child may be very sensitive to touch and have difficulty with:

• Grooming tasks: nails cut, tooth brushing, hair washed or cut, bathing, face washed
• Dressing: dislike of tags, socks, baggy clothes, tight clothes, shoes
• Playing: avoids messy or gooey substances
• Socially: have difficulty sitting close to others, tending to push or hit

The hypo responsive child may also not feel touch adequately and may:

• Have a tendency to hold things too tightly and break things or use too much pressure
• Stomp feet when walking
• Close doors with too much pressure
• Bite and chew on objects
• Bump into furniture and objects in the environment
• Demonstrate clumsiness in their motor skills (running, jumping, handling objects, writing, etc.)

Movement:  
The hyper responsive child may be sensitive to movement and demonstrate:

• Cautiousness or fearfulness when their feet leave the ground, such as on stairs or a curb
• A dislike of having their head upside down or out of a neutral position
• Motion sickness in cars or on carnival rides
• A dislike playground equipment
• A preference for more sedentary play options (board games, TV, video games, reading, drawing)
• Poor muscle tone and stability; frequently appear tired; need to lean on things

The hypo responsive child may not get enough movement and demonstrate:

• A constant need for movement and activity
• A need to seek out jumping, twirling, spinning, rolling, swinging activities
• Inattention and distractibility
• Risk taking during play and with playground equipment (i.e. jumping from high structures, swinging high and fast, etc.)

Eyes:
The hyper responsive child may be sensitive to visual input and demonstrate:

• A sensitivity to bright sunlight or changes in light intensity
• A dislike of flickering or flashing lights
• Frustration with a busy visual environment such as when shopping in a busy store
• Frustration with puzzles and trying to find an object in a confusing background

The hypo responsive child may seek out visual stimulation:

• Seek out visual input such as flickering lights, lava lamps, fish tanks, etc.
• Need continuous stimulation to stay on task

Ears:  
The hyper responsive child may be sensitive to sound:

• Sensitive to loud or unexpected noise, and react emotionally or aggressively
• Dislike alarms or sirens
• Easily distracted by others around him
• Bothered by common household sounds
• Have a tendency to make sounds just for the sake of it

The hypo responsive child may also seek out noise:

• Seek out making loud sounds with objects
• Make sounds just for the sake of it

Mouth:
The hyper responsive child may be quite sensitive to anything he puts in his mouth:

• May be a picky eater and have very restricted food preferences
• May not have mouthed toys and objects as an infant
• Prefer bland and soft foods

The hypo responsive child may seek out a lot of oral stimulation:

• May mouth objects continually
• Chew on objects and clothing often
• Seek out spicy, salty and chewy foods
• Over stuff the mouth

Sensory Regulation

As part of the sensory integration process, it is necessary to be able to know, without being told, what information in the environment or our bodies is important to pay attention to and what can be ignored and screened out.  This is referred to as sensory regulation.  Sensory regulation is the ability of the nervous system to take in sensory information and organize it, allowing us to screen out unimportant information and help us to focus on that which is important

What is a well modulated system? A well modulated nervous system adapts to changes in the environment, allows us to remain focused on a task, block out unimportant information, pay attention to relevant stimulation, and doesn’t over or under react to a situation.  For example, if our brain and body are proficient at sensory regulation we are able to ignore the background sound of a lawnmower in order to read a book without feeling confused or agitated. 

Poor sensory regulation occurs when the brain has a problem letting in or screening out the necessary information from the body and the environment.  This usually causes a response to sensory input that is over-reactive if the brain is letting in too much information or under-reactive if the brain isn’t letting in enough information.   Good sensory regulation requires us to be at an appropriate level of arousal, or attention and focus, so that we can respond to sensory stimulation with appropriate behavior responses without over or under-reacting.  Children who demonstrate poor sensory regulation are also often operating at a level of arousal that is too high or too low and thus tend to have problems with behavior and attention.

• High Arousal Level:   A child with a high arousal level may be in constant motion, active, or impulsive, resulting in difficulty remaining focused on the task at hand.  They may also be emotionally over-reactive to situations.  These children are often easily distracted and have difficulty paying attention.
• Low Arousal Level:  This child may appear tired, inactive, or bored, and difficult to please.  They are unaware that their body requires input to reach their optimal performance level, and tend to prefer more sedentary play options

Praxis / Dyspraxia
  
Sensory processing allows the body to move and interact with the world.   The typical child is able to easily learn new and more complex motor skills from infancy, moving from such skills as waving, then crawling, to tying shoes, writing, hitting/kicking a ball, and eventually more complex sports.  The ability to organize, plan and perform such motor actions is referred to as praxis.  Praxis occurs when we first learn a new motor task and we have to think about how to do it.  Eventually the task becomes automatic and occurs without even thinking.   An example of praxis in early childhood is seen with playing games such as “Patty-Cake,” learning actions to songs, buttoning, writing the alphabet, as well as with learning to play sports and musical instruments.  Poor sensory processing can disrupt this ability to plan and perform motor actions.  Dyspraxia is the difficulty with performing motor activities and may involve problems with one or more of the following foundation skills:

• The ability to come up with an idea of what to do; instead the dyspraxic child tends to wander
• Body awareness; the dyspraxic child tends to bump into things, trip, or fall
• Grading the movement, knowing how much pressure to use; the dyspraxic child often uses too much force or not enough
• Timing/sequencing of motor actions; the dyspraxic child is frequently clumsy
• Learning from previous experience; the dyspraxic child is often unable to remember how to do something

A dyspraxic child may also demonstrate:

• A tendency to play the same game or activity over and over,
• An inability to create new or different ways to play with toys and instead do the same thing over and over again;  a lack of creativity
• A tendency to copy what others are doing, a “copy cat”
• An avoidance of motor activities, preferring more sedentary/passive play options
• Seeking out activities that provide jumping, climbing, or crashing 

A child’s difficulty with motor skills, or dyspraxia, may also impact their behavior, causing them to compensate with either becoming silly, overactive, or avoiding motor activities. 

Evaluation

Sensory Integration and Praxis Test (SIPT)
Sensory Integration and Praxis Test (SIPT)is the gold standard for evaluating suspected sensory and/or motor concerns.  It measures aspects of sensory processing and praxis (the ability to form an idea, plan the action and execute it) as well as processing challenges which may be contributing to difficulties in learning or behavior. The SIPT measures visual, tactile, and kinesthetic perception as well as motor performance (imitating postures, following verbal directions, oral motor, tracing and copying forms). A child's performance on each of these tests is compared with the average performance of other children in his or her age group. In addition to these tests, clinical observations are made of muscle tone, postural responses, coordination and hand skill development.  Results provide insight with regards to the underlying deficits contributing to motor delays, which allows for treatment to focus on the causes rather than treat only the symptoms.  It is composed of 17 brief tests and provides standardized scores.  It is appropriate for children 4 years to 8.11 years, but is given to children up to 13 years.  Administration takes approximately 2 hours and for younger children it is suggested that it be done over 2 one hour sessions.  The evaluation must be given by OT who is SIPT certified.  Kimberlee Wing has been certified in SI testing for the past 30 years.

Other assessments of sensory processing disorder include the Sensory Profile, the Sensory Processing Measure, and clinical observations.  It is important to obtain an understanding of the child in his home and academic environments as not all children exhibit the same behavior in both.  Therefore, as part of the evaluation process, parents and teachers may be asked to fill out a questionnaire on the child’s behavior in order to get the full “picture” of the child’s specific sensory processing strengths and weaknesses.

Treatment Approaches

The treatment approach for children with sensory processing and/or motor disorders (dyspraxia) is to use fun, everyday activities and games which are motivating for the child.  The activities focus on the use of motor activities while at the same time giving input to the senses of touch, movement and proprioception (stimulation to joints, tendons, and muscles that lets us know where our body is in relation to objects in the environment). 

The treatment approach and activities used are based on testing results and an awareness of the child’s strengths and weaknesses.   Through an evaluation process and parent feedback, the therapist identifies  the child’s processing abilities, arousal level, sensitivities to sensory input and/or seeking of sensory input, behavior, attention and organization.  Once the child’s sensory processing strengths and weaknesses have been identified and areas of behavior/attention concerns have been determined a treatment approach is developed and implemented.  The treatment approach will include exploring various strategies of adding or removing sensory input along with using specific organizational strategies to find out what works best for the child.  A “sensory diet” is often developed, specific to each child’s needs.  This may involve “waking up” their system at certain times of the day, or “calming down” their system in order to bring them to an appropriate arousal level for better sensory processing. 

A treatment session typically begins with motor activities which use the whole body and allow children to challenge themselves as they develop more confidence and awareness of their body during activities.  This may involve swinging, jumping, climbing, creeping, sliding, crashing into mattresses, etc.  The therapist continually observes the child’s reactions to the activities and their ability to do them, often modifying the activity as necessary in order to keep the child motivated and having fun as well as to avoid frustration and anxiety.  The games become more interactive as the child begins to challenge himself, working toward higher levels of motor development and functional skills.

Following the use of large motor activities, as described above, the therapist and child work on more refined motor performance and organization skills.  This may include handwriting programs, fine motor skills, such as puzzles, cutting, or buttoning, and organizational skills, social skills and improved behavioral responses.

Resources

Articles

• “Sensory Treatment Yields Promising Results for Children with Autism”
• “A Sensitive Subject: Sensing the benefits of sensory integration therapy”
• “Sensation Frustration: Sensory integration therapy helps troubled kids”
• “Sensory Integration Disorder: A primer for providers”

Books

• The Out of Sync Child – Carol Stock Kranowtiz
• The Out of Sync Child Has Fun – Carol Stock Kranowitz
• Raising a Sensory Smart Child – Lindsey Biel and Nancy Peske
• Sensational Kids: Hope and Help for Children with Sensory Processing Disorder – Lucy Jane Miller