PEDs II Exam II

Regulation

Regulation

Ability to adapt our neurological arousal, emotional state, motor activity, attention, and behavior to meet our own needs and the demands of the situation

Interoception System

• Our awareness of sensations originating inside of our body, such as hunger, a full bladder, feeling tired, or ill; also includes recognition of body feelings as they relate to felt emotions, such as heat from anger, heaviness from sadness, etc.

• Primarily though to relay signals about the body’s internal state

Olfactory

Sense of smell

Proprioceptive System

Unconscious awareness of sensations coming from one’s joints, muscles, tendons, and ligaments; the “position sense”. Underlies one’s ability to place body parts in a position in space

Gustatory

Sense of taste

Tactile System

Information taken into the body through the sense of touch. Can be through deep pressure receptors or light pressure receptors

Vestibular System

Comprised of structures in the inner ear that give us information about movement and the position of our head in relation to gravity

Sensory Systems

• Vision

• Hearing

• Gustatory

• Olfactory

• Tactile

• Proprioception

• Vestibular

• Interoception

How does the brain use sensory information?

• State Regulation

• Emotional Regulation

• Motor control

• To support executive functions and cognition

• Enabling communication and social interactions

• Foundation for behavior

Jean Ayers’ Contributions to Sensory Integration

• Created sensory integration (SI) theory

• Developed assessments, including the Sensory Integration and Praxis Test (SIPT) to investigate sensory processing

Jane Ayer’s definition of Sensory Integration

The neurological process that organizes sensations from the environment and makes it possible to use the body effectively in the environment

Jane Ayers’ Principles of Sensory Integration Intervention

• Purposeful activity

• Child directed and intrinsically motivated

• Incorporating use and influence of sensory experiences

• Just right Challenge

• Adaptive Response (successful response to an environmental change)

Ayers’ Sensory Integration (ADI Fidelity measure

• Developed in 2014 to ensure that SI therapy adheres closely to SI theory

• Strengthened the ability to research the effectiveness of SI interventions

What provides the foundation for all higher-level skills?

Regulation

Reticular Activating System

Responsible for mediating arousal

Arousal Continuum

We are most adaptable when we are in a “window” of midrange

Relationship between arousal and performance

• Only medium levels of arousal provide suitable conditions

• Overarousal and underarousal interfere with performance particularly in complex tasks

Sensory Events and Arousal

• Sensory events (aka sensory stimuli/experiences) impact our arousal, which influences regulatory capacities

• How each individual responds to the same sensory event varies based on their nervous system (orange line: someone able to maintain adaptable arousal, black line: person who becomes overstimulated and is in a high arousal state → more stimulation can causes a shutdown state)

Arousal Chart

Represents typical relationships between an individuals’ sensory processing and their arousal

Sensory Defensive (B)

An accumulation of sensory events throughout the day is likely to send them into “sensory overload” (aka high arousal OR “shutdown")

Sensory Non-Defensive (C)

Has sensory processing within the typical range, this person is more likely to remain regulated throughout the day.

Sensory Modulation

Process of enhancing or dampening sensory input subconsciously for the purpose of maintaining regulation/harmony of the nervous system

What is the primary purpose of sensory modulation?

Maintain regulation

Sensory Discrimination

Provides information that allows us to distinguish characteristics of sensory input

What is the primary purpose of sensory discrimination?

Skill development

High Threshold

• Aka Low registration

• Takes a lot of sensory input to register in the child’s nervous system

Passive Behavioral Response for High Threshold

• Miss (or don’t notice) available sensory input

• Spacey, clumsy

• Under-responsive or slow to response

• Able to focus in distracting environments

• Flexible, comfortable in a wider range of environments

Active Behavioral Response for High Threshold

• Enjoys sensory-rich environments

• Likely to create/seek sensation

• Trouble tolerating low stimulus environments (easily bored)

Low Threshold

• Aka sensory sensitive

• Just a small amount of sensory input may trigger a response from child

Passive Behavioral Response for Low Threshold

• Highly aware of surroundings

• Distractible by sensory input

• Notice things other people don’t notice

• Easily respond to sensory stimuli

Active Behavioral Response for Low Threshold

• Overwhelmed by sensory rich environments

• Intentional withdrawal or blocking of sensation (attempt to minimize sensation)

• Prefer structured supportive environments (with more predictable sensory stimuli)

To understand how a child’s sensory processing is impacting their ability to interact with their environment, we must become __________ ____________.

Careful observers

Characteristics of being “tipped toward” safety

• Regulation → engagement

• Engaged

• Adaptable

• Fun/creative

Characteristics of being “tipped toward” protection

Fight, flight, fright, fawn

How can you promote “felt safety” and help with sensory modulation?

• By using connection and coregulation

• Relational interventions like DIR, RDI, TBRI are useful for learning the skill of connecting

For a child with low reactivity (aka low registration, aka under responsive), you would ___________ sensory input

Increase

For a chid who is in shutdown (has been bombarded by too much input), you would ___________ sensory input

Decrease

If a child who appears “low reactive” or “low registration” has a normal pain tolerance (e.g., cries/notices when they get hurt), they most likely are

Low reactive (aka low registration, aka under responsive)

If a child has a very high pain tolerance (e.g., usually doesn’t notice when they get hurt) they are most likely in a ___________ state

Shutdown

Sensory discrimination is the foundation for what functions?

• Body scheme development

• Bilateral integration and sequencing

• Postural-ocular control

• Praxis

Body scheme development

Unconscious map of physical body stored in the brain

Bilateral integration & sequencing

Coordination of the two sides of body to perform synchronized and sequential movements

Postural-ocular control

Motor control of body position and eye movement

Praxis

Ability to conceptualize and organize novel actions (have idea, plan, execute)

Specific patterns of sensory discrimination dysfunction can be examined through …..

Standardized assessments (e.g., SIPT, EASI)

Treating problems with sensory discrimination

• Assess sensory modulation and understand how it contributes to problems with discrimination

• Set up the “just right challenge”: understand what is intrinsically motivating to the child and offer opportunities for enhanced sensory exploration (don’t force it!) We want the child to enjoy the experience and feel successful

Common diagnoses of children who have challenges in sensory integrative processing

• Autism

• Children with prenatal drug exposure history

• ADHD

• People with cognitive deficits

• People with learning disabilities

• People with genetic conditions

Key words important to sensory integration therapy

• Child “buys in”

• Child-directed

• “Artful vigilance”

• “Just Right Challenge”

• Adaptive Response

• Inner Drive

• “Scaffolding”

Scaffolding

How therapist adjusts and controls task elements that are beyond child’s current skills

Patterns of Adaptation for Receptors and Stimuli

• Habituation

• Sensitization

Habituation

Typical response to repeated exposure to sensory stimuli (e.g., not noticing a tag in their shirt a few minutes after getting dressed)

Sensitization

• Repeated administration of a stimulus results in the progressive amplification of a response

• Someone has problems with sensory modulation (e.g., becoming more and more irritated by the tag in their shirt)

Features of sensory stimuli

• Frequency: how often

• Intensity: how strong

• Duration: how long

Importance and Functions of Somatosensory System

• Receptors of the self

• Gives us our boundary and informs our understanding of self vs other

• Sensory system of attachment and socialization

• Provides a lot of inhibition for the CNS

• Provides information for body scheme

• Provides detailed information for skilled use of objects and interactions with the world

• Provides information for postural and motor control

• A foundation for praxis

• Provides the valence coding, which is the basis of our emotional experience

• Provides a foundation for language and social pragmatics

Types of Somatosensory Receptors

• Exteroceptors

• Proprioceptors

• Interoceptors

Exteroceptors

• Provide information from outside of our body

• Tactile receptors

Proprioceptors

• Provide information about joint and body movements, position of the body (or body segments) in space

• Joint receptors

• Muscle and tendon receptors

Interoceptors

• Provide information from inside our body

• Sensations from internal organs

  • Mechanoreceptors, baroreceptors, chemoreceptors, thermoreceptors

• C fibers: pain, including emotional pain

Sensory modulation circuitry travels in the ______________ ___________

Anterolateral system

Sensory discrimination circuitry travels in the ________ ____________.

DCML pathway

Sensory Modulation: Somatosensory

• Circuitry that enhances and dampens sensations

• Purpose: regulation

• Travels in the Anterolateral System

• Detects:

  • valence of the stimulus

  • temperature, itch, pain, and affective touch

  • condition of our body

Sensory Discrimination: Somatosensory

• Takes in the detail of information

• Purpose: use/skill

• Travels in the Dorsal Column Medial Lemniscal system

• Detects stimulus features:

  • Quality (texture, shape, weight, etc.)

  • The location of the stimulus

  • Intensity

• Detects body position

Which sensory system is made up of exteroceptors and is responsible for our sense of touch?

Tactile System

Functions of the Tactile System

• Basis of the valence coding

• Provides earliest form of communication

• Sets the stage for bonding and social attachment

• Creates a lot of inhibition in the nervous system which can help with down regulation

• Provides us with information to create our body scheme

• Provides the basis for motor control (hand and oral motor skills)

• Activates some early, important reflexes (rooting, sucking, grabbing)

• Provides us with information about the boundary of our body, setting the stage for our sense of self

• Provides the underlying info for self/other understanding

• Provides perceptual awareness of size, shape, weight, temperature

• Provides info about the spatial location of our body relative to things in the environment

• Contributes to language and communication

• Integral to praxis

Functions of Interoception

• Basis for the affective tipping point/valancing mechanism that tips because of physical pain and/or emotional pain

• Affective touch perception

• Homeostasis

  • Hunger/thirst

  • Nausea

  • Bowel and bladder

  • Heartbeat

  • Air hunger

  • Low blood sugar

• Informs us of the condition of our body including our fascia

• Gives us affective coding

• Foundation of our emotional experience

Functions of the Vestibular System

• Information taken in by receptors in our inner ear:

  • Where we are in space (in relation to gravity)

  • If we are upright, tilted, or upside down

  • How fast/slow we’re going

  • In what direction we’re traveling

  • If you are still moving, or have stopped

Which sensory system has a role is both modulation and discrimination

Vestibular system

Vestibular Modulation

• Regulates arousal, attention, autonomic (ANS), affect (emotional), and action (motor)

• Supports social functions, executive functions, cognition, and sense of self

Vestibular Discrimination

• Detail of information for purpose of use/skill

• Awareness of gravity, postural control, balance, praxis, bilateral control, cognition

If a child has trouble with vestibular modulation, they will either ______-__________ vestibular input or ______- ____________ vestibular input.

Over-register, under-register

What happens when a child has trouble with vestibular modulation and they over-register vestibular input?

They will be sensitive to movement and likely cautious

What happens when a child has trouble with vestibular modulation and they under-register vestibular input?

The child will be less sensitive to movement and be constantly in motion to get extra vestibular input to help regulate themselves

Gravitational Insecurity

• Refers to discomfort with movement that is rooted in vestibular processing challenge

• Identified by Jean Ayers

You can assess vestibular processing using what?

Sensory questionnaires (SPM-2, SP-2) or by assessing Post-Rotary Nystagmus (eye movements after spinning)

How can you treat vestibular dysfunction for sensory modulation?

• Provide connection and coregulation

• Observe ANS signs

• Address regulation

• Deep pressure touch and proprioception to provide regulation

• Engage a child’s motivation through affective engagement

• Use music or rhythm to facilitate regulation

How can you treat vestibular dysfunction for sensory discrimination?

• Keep modulation in mind at all times

• Provide opportunities for exploration with enhanced sensation

• Consider the direction of the movement (linear, rotary, oblique)

• Consider the rate and rhythmicity

• Pair vestibular movement with other sensory systems for the purposes of skill (balance or visual motor activities)

• Must address “low route” motor skills and the processing of vestibular info before targeting praxis

• Use music or rhythm to facilitate rhythmicity

How can the vestibular system be used as a strength in treatment?

• Use rhythm and movement to facilitate regulation

• Use enhanced vestibular input to elicit postural and motor control

• use enhanced movement to facilitate oculomotor control

• Use movement for engagement and fun

Signs of vestibular overload

• Flushing or becoming pale

• Change in respiration (yawning, increased breath rate)

• Lethargy

• Excitation

• Vomiting

How do you counteract vestibular overload?

• Heavy Work (pushing pulling)

• Deep pressure

• Jumping, running

• Blowing activities

• Ice cubes placed in palms of hands and then placed on back of neck and then on temples

General purpose or point of Sensory Processing/Integration intervention

• Clinical reasoning and treatment planning should happen outside of the session. Within the session, the most important thing that you can do is be present in the moment. In order to be present with the child, you may have to work on your own regulation and self-compassion

• Observe and be curious about what happens when you offer opportunities and make adjustments

• “If it works, it’s treatment. If it doesn’t, it’s assessment” Regie Boehme

How do you treat problems with sensory modulation

• Pay attention to affective valence tipping point

• Provide connection/notice whether the child can effectively use coregulation for the purpose of regulation

• Notice patterns of response relative to the situation

• Notice how regulation capacities affect sensory modulation

• Distinguish between low reactivity and shutdown. DO NOT try to desensitize or increase tolerance if the client is experiencing the activity with a negative valence

• Address physiological needs

• Address regulation with sensory strategies.

• Help family to understand their child’s sensory preferences and how they are a match for the family/occupations

• Reduce stressors

• Modify the task or environment

• Build resilience

How do you treat problems with sensory discrimination?

• Assess modulation (regulation) and it’s contribution to discrimination first

• Assess and address specific discrimination issues in the sensory systems. Offering opportunities for enhanced sensory exploration

• Tap into internal motivation

• Set up the environment to provide just right challenge

We want to offer opportunities for exploration in a _____ ________! We do not force a child to engage in activities that are uncomfortable/stressful to them

Safe context

What is important to keep in mind when treating proprioceptive dysfunction?

Postural security and heavy work

What kind of practices are important for treating interoceptive dysfunction?

Focused attention (e.g., mindfulness)

What is important to consider and keep in mind when treating vestibular dysfunction?

The direction, rate, and rhythmicity of movement

What is the most powerful tool we have to make positive change.

Therapeutic relationship