Week 2: Interventions to address Sensory barriers to occupational performance

So what is sensory Integration

1. Register important sensory info. from the environment

2. Filter out irrelevant information

3. Make accurate interpretation of the information

4. Respond effectively to sensation

adaptive response

When sensations are processed efficiently, the child responds in an organized purposeful manner

When a child makes an _ that is more complex than any previously accomplished response, the brain attains a more organized state, & its capacity for further sensory integration is enhanced

General principles of Ayres SI theory

• Most individuals automatically / effectively / developmentally take in and process sensory information (from the environment, movement of their bodies, and interaction with others)

• Poor sensory processing often leads to ineffective motor and conceptual learning

• Providing enhanced and meaningful sensory experiences results in enhanced sensory processing

• By providing an optimal sensory environment and inviting active participation of the individual, both structural and functional growth occurs within the CNS

• “Just-right challenge” within a playful context facilitates SI

• SI promotes adaptive responses and occupational engagement

• We rarely works on acquiring a specific skill-rather works on the foundation necessary to build the skill

Essential concepts of the Dunn Model of sensory processing

Seekers: High Threshold/Active Self-Regulation

Avoiders: Low Threshold/Active Self-Regulation

Sensors (High Sensitivity): Low Threshold/Passive Self-Regulation

Bystanders (Low Registration): High Threshold/Passive Self-Regulation

Evaluating sensory sensitivities

It’s important to evaluate and document your client’s difficulty integrating or processing sensory information before doing sensory-based intervention (Choosing Wisely; Ten Things Patients and Providers Should Question)

Literature indicates that SI based intervention must be directly linked to assessment results (AOTA, 2018)

We learned different methods of evaluating a client’s sensory system in the Process course

Few examples?

Intervention consists of 2 phases-

Planning

Implementation

Planning

consists of 3 parts

Setting goals and objectives (should be related to occupational performance)

Type of service(s) delivery (e.g. direct, consultation, etc.)

Developing preliminary ideas about intervention

*Remember we always collaborate with the client and the caregiver

Deciding what to address first

There are no specific rules about what to address first but general guidelines

Address modulation difficulties early if appropriate

• Hyporesponsiveness

• Hyperresponsiveness

It is important to always evaluate and check if the client is making progress- ‘artful reflection’

• Constantly reassess

• Modify/change if necessary

factors to consider

• relationship with ur client

• establishing a safe environment

• providing praise and verbal feedback

• creating the just-right challenge

• structure vs. freedom

• understanding child’s volition

• open communication with the client and the family

Relationship with your client

Therapeutic use of self

Playful interactions

Creating funny situations via pretend play (e.g. rescuing farm animals)

Establishing a safe environment

Physical and emotional safety

‘Artful ability’ to promote emotional safety

Choosing tasks that minimize risk of failure (e.g. beanbag toss)

Providing praise and verbal feedback

vAlso an ‘artful’ practice

vVerbal vs. gestural, frequency, timing, etc. (e.g. Taylor)\

https://www.reddit.com/r/HumansBeingBros/comments/cd1ya7/students_give_autistic_boy_a_silent_graduation_so/?utm_source=share&utm_medium=web2x

vCreating the Just-Right Challenge

Important key to intervention

vDeciding how far to push/stretch them (e.g. scaffolding, modeling while scaffolding, etc.)

vStructure vs. Freedom

Balancing between the 2 is also an art (e.g. Jimmy)

Understanding child’s volition

Lack of motivation maybe due to-

• Task is “too difficult”

• Child is convinced that it is too difficult

• Arousal level is not in the ‘optimal band’

• The theme is too ‘babyish’

• Child can not identify to the activity (lacks meaning)

Open communication with the client and the family

Explain your clinical reasoning to the clients and the families

So they can develop strategies to learn, adapt and/or compensate across environments

Explain sensory concepts

They are used to hearing words like “lazy” or “bad”

By the time they are 6 or 7 they typically realize that they are different

Being an active participant facilitates progress

Explaining your rationale to your clients (when appropriate) opens door for collaboration

(e.g. Ava- picking and challenging herself to swing despite her fear)

Transfer skills into daily life

things to keep in mind for intervention

•Client factors

•(e.g. neurological thresholds, self-regulation strategies, modulation, discrimination, volition, influence of conditions such as CP, etc.)

•Environmental factors

•(physical, social, cultural contexts etc.)

•Task factors

•(demands placed on the client)

•Strategies to help child participate in meaningful & age-appropriate occupations

•(Direct and/or Indirect services)

=>

•Strategies to help child participate in meaningful & age-appropriate occupations

•(Direct and/or Indirect services)

Intervention ideas using SP quadrant scores

seeking/seeker

Less than other  (-/- -)	Intervention	More than others  (+/++)	Intervention
Does not seek input	Provide variety or intensity (e.g. providing variety of art supplies)	Seeks and enjoys input	Provide more opportunities (e.g. using rocking chair while doing HW)

Intervention ideas using SP quadrant scores

sensitivity/sensor

Less than other (-/- -)	Intervention	More than others (+/++)	Intervention
Less detection	Increase awareness of changes in sensory experiences (e.g. point out “see how this tastes different..”	More detection	Provide more structured sensory experience (e.g. toys on waist-high shelf to avoid bending down to reach”

Intervention ideas using SP quadrant scores

avoiding/avoider

Less than other (-/- -)	Intervention	More than others (+/++)	Intervention
Less likely to withdraw from a stimuli	Provide organized input (e.g. turn down the TV during meal time)	Bothered by input	Make less input available (e.g. encourage “quiet time”)

Intervention ideas using SP quadrant scores

registration/bystander

Less than other (-/- -)	Intervention	More than others (+/++)	Intervention
Notices more	Provide more familiarity (e.g. having predictable routine)	Notices less/miss more than others	Provide more intensity (e.g. using heavy blankets to sleep)

Provide enhanced sensation

•Activities that provide enhanced sensation to provide input &/or counterbalance poorly processed input

•Remember to use caution and upgrade sensory input gradually

•Constantly observe your client’s reaction

•Follow up with parents re: the child’s behavior after your session

Providing enhanced vestibular input

Vestibular input is one of the most powerful tools used to address SI challenges

Vestibular system is a specialized proprioceptor-provides info. about position & movement of head

Vestibular and Proprioception are considered the “unifier” in terms of integrating coordination of all other sensory systems

Otolith organs detect linear movement (up/down, side to side, etc.)

Semicircular canals detect angular movements

General guidelines for Vestibular input

vImportant to maintain a ‘just-right’ arousal state while challenging movts

vBe the agent that controls speed, direction & rhythmicity of vestibular input (e.g.- type of swing)

vSlow, rhythmic and linear movts tend to be calming and inhibitory VS. rotary movts that tend to be excitatory

vFind the balance between surprise & predictability

vGrade the degree of predictability & be mindful of the amount of surprise

vProne position thought to be more effective to activate otoliths and semicircular canal compared to sitting upright on a swing

vIf this is the case, what position would you recommend for a child with gravitational insecurity?

vDifferent positions facilitate stimulation of all vestibular receptors

vVestibular stimulation has an effect on the central nervous system for several hours

vThe more stimulation you provide, greater the length of effect

Specific Intervention Strategies for Gravitational Insecurity

Do not force movements

Give child control over movement in space

Work near the ground

Maintain feet on the floor

Allow child to see where they are going

Fear of moving backward in space

Start with linear vertical movements before rotational movements

Allow opportunities to fall from short distance on the floor followed by deep pressure or heavy work activities

Provide a positive experience and positive attitude

Specific Intervention Strategies for Hypo-responsiveness to movement

Provide variety of experiences for movement (think variety!)

Increase opportunity for movement (e.g. sit on a ball while coloring)

Work on maintaining a stable visual field while moving. E.g. swinging and hitting a target or rotate on a large ball to reach for a toy and then fixating on the OT’s face when stopped

Provide activities that promote B motor coordination

Specific Intervention Strategies for Laterality & B coordination

Do activities that require symmetrical patterns: pumping the swing, Pulling on a trapeze with both UE, propelling a scooter, catching/throwing a ball, etc.

Do activities that facilitate use of alternating patterns: pulling on a rope hand over hand, animal walks, wheelbarrow walk, swinging in prone while propelling on the floor using UE or pulling up a rope to retrieve something

Use rhythmic songs or clapping games during movement activities

Specific Intervention Strategies for Postural Control

Provide activities that require maintaining a stable visual field while moving

Consider the type of input being provided in relationship to the postural mechanism being facilitated

Linear movement affects extension against gravity

Rotary movement affects ocular motor control

Consider activities that facilitate improving overall balance & postural control (e.g. walking on unstable surface)

Providing enhanced proprioceptive input

Typically input to the proprioceptive system occurs at the same time that input is provided to the tactile system and the vestibular system

Muscle spindles/joints detect resistance & are primary receptors of proprioception

*Typically anytime we provide/facilitate movement with resistance we are providing proprioception

Input to this system typically has an inhibitory effect on the reticular activating system

•General guidelines for providing enhanced proprioceptive input

•The effect of input is thought to be temporary and the effects appear to be the most powerful when the input is being delivered

•Our system seems to habituate to this input quickly so staggered input with breaks may be more beneficial than prolonged input

•So what does it mean? (e.g. weighted vest)

Specific Intervention Strategies for Modulation

Provide opportunities for large amounts of proprioception to regulate level of arousal & organization of behavior

E.g. use inner tubes in games like “bumper cars” or rolling inside a stack of inner tubes and “crashing” into a large pillow; push-pull games: tug of war or combine with movt. (push OT on a scooter)

Increase attention to task & facilitate purposeful interactions with the environment (make sure child is active)

Pair prop. with behavioral responses (organization of behavior)

Specific Intervention Strategies for Discrimination

Improve ability to discriminate force & direction

E.g. high-fives (just-right vs. soft)

Improve body awareness

E.g. When in wt. bearing facilitate weight shifts by moving the child lightly to activate muscles

Provide opportunities to participate in activities with variety of experience such as push, pull, lift different sized objects/equipment during play

Pair prop. with targeted motor activity (adaptive response)

providing enhanced tactile input

•General guidelines for providing touch

•Allow client to guide touch

•Let the client see where touch is going to happen (avoid surprises)

•Deep pressure typically recommended to decrease tactile defensiveness

•

•Do not need to provide enhanced tactile input to the entire body

•Tactile sensation more tolerable when applied in the direction of hair growth

•Respect child’s reaction/feedback

•Be intentional about where to provide tactile input

•Start at the back of the hands and forearms

•Allow child to guide input to more sensitive areas such as face, feet, thighs, etc.

•Tactile input can influence the nervous system for about 30 minutes

•Monitor every time you provide with enhanced tactile input

•May respond differently to the same input on 2 different days

Specific Intervention Strategies for Tactile Modulation

Start with vestibular & prop. input, continue with deep pressure & then end with touch if tolerated

Provide inhibitory input such as deep pressure & proprioception (e.g. taco escape, wrestling)

Avoid unexpected and light touch

Try using surfaces vs. hand (hands change pressure while surfaces are constant)

Give child a sense of control over the play

Give options (touch w/ finger vs. tool)

Reduce sensory overload: lower voice, use of natural light, work in smaller space (e.g. coloring inside a tire tube)

Specific Intervention Strategies for Tactile Discrimination

Use variety! (e.g. if using brush- paint brushes & scrub brushes)

Cover equipment with interesting textures (e.g. towels, carpet, lycra sheet)

Present activities that provide rich tactile input (e.g. finding items in a ball pit)

When inside a container of balls- encourage change in position of the child via active movement

Provide activities that encourage discrimination such as objects inside bin full of rice or beans

Encourage localization of tactile input (e.g. stickers on arms & legs)

Play games with different textures (puzzles, play-doh, silly putty, etc.)

Sensory based motor disorder- Praxis

Refers to motor disorders that have their bases in poor sensory processing

From an SI perspective-

Poor praxis is due to poor ability to organize the plan necessary for purposeful behavior

Inability to process & integrate sensory info. (input) = poor foundation for motor planning (output)

Sensory systems essential for Praxis (internal)

Tactile Discrimination

Understanding the boundaries of the body

Refined information about where & how the body is moving relative to people & objects in the environment

Ongoing feedback during actions

Vestibular-Proprioception

Sensation of force & direction of movements; sense of weight, size, force of the body at rest & during movement

Sensory systems essential for Praxis (External)

Visual System

Surveying affordances in the environment

Interpreting space in which action will take place

Precise feedback during skilled actions

Auditory System

Spatial awareness

Sequential order of actions through self-talk

Understanding & following novel directions

Intervention activities for Practic disorders

Interventions to increase motor planning

Activities that facilitate feedback-dependent actions vs. feedforward vs. combination of both

Activities that promote Bilateral Integration

Activities that promote Ideation

Activities that promote Initiation & Execution

Activities that facilitate feedback-dependent vs. feedforward-dependent actions

Feedback-dependent tasks are the easiest

Perform motor-skills using feedback gained from actions (e.g. catching/throwing a ball)

Feedforward-dependent tasks get more challenging (anticipate all the variables)

Also known as Projected Action Sequences

During intervention planning, promote complex adaptive responses as appropriate

Tasks where child & target are both static (easiest)  child & target are both moving (complex)

E.g. Santa’s helper delivering packages to different houses (think size of the target, size of the “package”, speed, timing, force, etc.)

Activities that promote Bilateral Integration

Activities that facilitate use of both sides of the body in a skillful manner

Promote activities that facilitate working in midline, crossing midline, symm. vs. asymm. movts

Many skills that promote bilateral coordination also involve projected action sequence

Activities that promote Ideation

Think of activities that promote active exploration & interaction with objects & environment

Facilitate thinking around-

What an object can do & what can be done with it?

What are some specific actions the child can do to “achieve a goal”?

What actions are appropriate for which objects?

How are they going to sequence the steps to accomplish the goal?

Intervention activities for Practic disorders

Activities that promote Initiation & Execution

Encourage participation in new tasks vs. practicing task that the child has mastered

Use simple verbal mnemonics such as “ready…set…go” or “1..2..3” to initiate action

Use of familiar objects or equipment in novel ways (e.g. pushing a bolster)

Generalization of newly learned action (e.g. jumping on pillow vs. innertube)

Consultation on modification

Individuals with SI difficulties benefit from modification of task, environment and other external factors such as routines

OT’s role as consultant to family members, teachers and other professionals

Focus on changing client and task and environmental factors

Advocate for the child

Indirect intervention (consultation) should be an integral part of a comprehensive OT service addressing SI differences

E.gs- parent education on different sensory concepts, Sensory Diet, home program, making appropriate recommendations to change task or environmental factors

Using strategies and techniques learned to promote collaboration

E.gs- Reinforcement, Modeling, coaching, Direct teaching

So what do I do?

Questions you should ask yourself

What area does this target?

Is there evidence for this type of activity?

How does my client respond to this particular input?

Discontinuing intervention

It depends!

6 months to 3-4 years (ideally as long as the child benefits!)

Occupational participation

Participate in daily tasks with minimal to no difficulties

Interference to participation caused by poor sensory integration or processing has been minimized or eliminated

No hard and fast rule

It depends on lot of factors

E.g. insurance coverage, reached a plateau, your gut feeling, outside resources, etc.