Ch 20 Sensory Integration

In occupational therapy, the term sensory integration refers to

the neural organization of sensory information for functional behavior, as well as a frame of reference with theoretic tenets, which includes specific assessments and intervention strategies.

Ayres used the term sensory integration to refer not only to intricate synaptic connections within the brain, as neuroscientists typically do, but also to neural processes as they relate to functional behavior. Hence her definition of sensory integration is the

organization of sensation for use”

However, to have an optimal effect on development, learning, and behavior, sensory input must be actively organized and used by the child to act on and respond to the environment. ____ _____, which provides a variety of sensory experiences, leads to a sense of “agency” or ownership of one’s body and motor learning

Active Movement

A child does not passively absorb whatever sensations come along, but actively selects the sensations most useful at the time and organizes them in a way that facilitates accomplishing goals. This involves brain processes of sensory integration. When these processes are going well, the child also organizes a successful, goal-directed action on the environment, which is called an

Adaptive response

Typically developing children and most children with disabilities have a drive to develop sensory integration through adaptive responses. Ayres called this ____ ___and speculated that it is generated primarily by the limbic system of the brain, a network of neural structures known to be critical in both motivation and memory

Inner drive

Ayres’ tenet that change occurs in neural synapses and circuits as adaptive responses are made is based on understanding and appreciation of the brain’s neural plasticity. Plasticity is the brain’s ability to

change, remodel, and reorganize with the outcome being a better ability to adapt to new situations (Demarin & Morović, 2014)

Neural plasticity is the ability of experience to shape the development of neural circuits, both structurally and functionally, because of cellular and molecular neural activity

most of the primary CNS processing of vestibular information occurs in the brainstem, and a great deal of somatosensory processing takes place in the thalamus. One of the basic propositions of Ayres’ theory is that, because older parts of the brain integrate and filter information before it is relayed to the cortex, increased efficiency in structures such as the brainstem and thalamus enhance

higher-order functioning

Ayres reasoned that the refinement of primitive functions, such as postural control, balance, and tactile perception, provides a sensorimotor foundation for higher-order functions, such as

intellectual and academic ability, behavioral self-regulation, and complex motor skills (e.g., those required in sports).

Inner drive leads children to search for opportunities in the environment that offer

“Just right challenge”

In this chapter, a sensory reactivity problem is synonymous with a sensory modulation problem. Modulation refers to CNS regulation of its own activity (Ayres, 1979). The term sensory modulation refers to

the tendency to generate responses that are appropriately graded in relation to incoming sensory stimuli, rather than underresponding or overresponding to them.

Hyporeactivity

unusually weak or absent response to sensory experience

ØExample: sensory registration problem: does not notice that an object or environmental feature is present

hyperreactivity, sometimes called hyperresponsiveness or sensory defensiveness (Knickerbocker, 1980; Mailloux, 2006) if the difficulties involve hyperreactivity in multiple sensory systems. This condition may occur as a general response to all types of sensory input, or it may be specific to one or a few sensory systems. The child who is hyperreactive is overwhelmed by

overwhelmed by ordinary sensory input and reacts strongly to it, often with anxiety (Pfeiffer, 2012) and activation of the sympathetic nervous system

Tactile defensiveness: easily upset by light touch sensations (e.g., from clothing, food, and people)

ØAuditory hyper-reactivity: distressed by environmental noise, loud or shrill sounds

ØMay be present in one or in multiple sensory modalities

Sensory discrimination and perception allow for refined organization and interpretation of sensory stimuli. Discrimination refers to

the brain’s ability to distinguish between different sensory stimuli, such as two points touched on the skin simultaneously.

Perception is the brain’s process of

giving meaning to sensory information, as when the complex visual stimuli from a person’s face are integrated and interpreted as a specific facial expression of emotion.

Proprioception problems

ØInaccurate perception or unaware of body position.

ØOften clumsy, awkward.

ØMay seek firm pressure, jumping or walking forcefully, and joint

compression for extra sensory feedback.

ØPraxis is usually affected

vestibular-bilateral problems to refer to this pattern which includes difficulty with

head and trunk control, vestibular-ocular functions, balance, and bilateral coordination.

Inefficient balance and equilibrium reactions, as well as poor bilateral coordination, are likely to affect competence in performing activities such as bicycle riding, roller-skating, skiing, and playing games like hopscotch. In addition, difficulty with bilateral coordination may make activities such as

cutting with scissors, buttoning a shirt, or doing jumping jacks especially challenging. Bilateral motor difficulties are sometimes associated with delays in body midline skill development, such as hand preference, spontaneous crossing of the body midline, and right-left discrimination

Praxis is the ability to

conceptualize, plan, and execute a nonhabitual motor act (Ayres, 1979). Problems with ____ are often referred to as dyspraxia or problems in motor planning.

When the term dyspraxia is used for children, it usually refers to

a condition characterized by difficulty with motor planning that emerges in early childhood and cannot be explained by a medical diagnosis, developmental disability, or environmental constraint.

sensory-seeking behaviors occur for diverse reasons such as to

(1) generate additional sensory input to compensate for inadequate discrimination or perception in one or more sensory systems,

(2) regulate general arousal level, or

(3) modulate hyper- or hyporeactivity in other sensory systems.

A process for occupational therapists called “data driven decision making” (DDDM), used in

intervention research examining the effectiveness of occupational therapy using a sensory integration approach, delineates steps to guide interpretation of assessment results and intervention planning

In the DDDM process, in addition to customary therapeutic goals, specific proximal and distal outcome measures for ASI intervention are identified (Schaaf & Mailloux, 2015). Proximal outcomes are

measures that assess change in the hypothesized underlying sensory integrative problems (e.g., ocular control, balance, bilateral integration, tactile defensiveness), whereas distal outcome measures assess change in the child’s participation or occupational performance.

The term ASI intervention refers to the individualized occupational therapy practice approach that Ayres developed specifically to remediate

sensory integrative problems of children (Roley et al., 2007). In this intervention, the occupational therapist presents activity challenges that are individually tailored to improve sensory integration capacities of the child. Ultimately, this intervention is designed to help a child gain competencies and confidence in performing everyday occupations at home, in play, at school, or in the community

Occupational therapy using ASI intervention capitalizes on the _____ of the child during intervention

Inner drive

Active participation is also emphasized because the brain responds differently and learns more effectively when

an individual is actively involved in a task, rather than merely receiving passive stimulation.

Suspended equipment provides

rich opportunities for engaging and challenging the vestibular system. In addition, equipment and materials are available that provide a variety of somatosensory activities, including tactile, vibratory, and proprioceptive input. Mats and large pillows are used for safety. Overall, this special environment provides the child with a safe and interesting place in which to explore his or her capabilities.

Passive tactile stimulation is not often used. Imposing tactile stimulation on a child who is tactile defensive may lead to

a state of sensitization, in which the child becomes increasingly more defensive instead of habituating to the sensation. Instead of using passive tactile stimulation, tactile stimuli are usually incorporated into the materials and surfaces that the child contacts while engaging in activities under his or her active control

Another common limitation is that the intervention provided in a study may have been called sensory integration but was not actually provided in a manner that matches the defining characteristics of ASI (Parham et al., 2007). This type of limitation is called a

fidelity problem

In intervention research, fidelity refers to the extent to which the intervention provided in a study is faithful to the key elements of the intervention approach.

Goals are often stated as objectives that target particular observed behaviors of the child. These objectives should contain

a specific description of the desired behavior, including the context of the behavior and an objective way to measure the behavior, for example, by timing how long the child can sustain an activity or with what percentage of success she can perform it after a specified number of attempts.

therapists often additionally provide interventions that immediately help a child develop

specific skills. For example, a child with poor proprioceptive feedback may need to keep up with handwriting exercises assigned in class.

Group activity programs may be provided in conjunction with individual ASI or after a period of time receiving individual ASI. These may include groups that focus on

social skills, communication, visual-motor or fine motor skills, gross motor skills or activities, or self-regulation.

The term specific sensory technique refers to

a type of intervention that is not ASI intervention because it involves application of sensory stimuli in isolation, without providing other elements required of ASI intervention, such as challenging the child’s praxis and organization of behavior, collaborating with the child in activity choice, tailoring an activity to present a just right challenge, or supporting the child’s intrinsic motivation to play

refers to interventions that involve application of specific types of sensory stimuli that are controlled and delivered in a predetermined manner, usually according to a prescribed schedule, protocol, or sequence

A sensory diet is

an intervention program that involves provision of individualized sensory experiences and activities throughout the day to support optimal functioning of the child with sensory integration challenges

Somatosensory techniques involve the controlled application of

tactile, proprioceptive, or combined tactile and proprioceptive input. Examples include massage, brushing the skin, use of a device or special garment to apply compression to the body, or having the child wear a weighted vest.

Vestibular techniques feature the use of

activities that stimulate the vestibular receptors of the inner ear (i.e., the semicircular canals and the otolith organs). Specifically, they involve the provision of rotary movement of the body through space (as in spinning around while seated on a rotating chair), linear movement of the body through space (as when swinging gently back and forth or side to side), or a combination of these types of movement.

Children and youth with sensory integration challenges will usually benefit from recommendations for sensory environmental modifications in conjunction with direct intervention. These recommendations are designed to help

cope with and manage sensory input arising from stimuli such as sound, lighting, physical contact with other people, environmental odors, and visual distractions in environments such as classrooms, playgrounds, cafeterias, auditoriums, or museums.

Cognitive interventions focus on

teaching specific strategies or procedures to the child to support successful performance or participation. These interventions differ from ASI intervention because they do not include fidelity process elements that are essential in ASI

An example of a cognitive intervention is the Alert Program for Self-Regulation, which was developed by occupational therapists Williams and Shellenberger (Williams & Shellenberger, 1994). This program applies sensory integration concepts to teach children how to self-manage their arousal levels for better participation.