PEDs: Sensory

Sensory Integration

Self Regulation: The individual's influence over their own thought processes, emotional stress, emotional states, motivation, and patterns of behavior

Self regulation is the process of: selecting, monitoring, and evaluating the effectiveness of cognitive strategies

Aid clients in demonstrating self-regulation

Sensory Integration Defined

Sensory integration: the neural organization of sensory information for functional behavior, as well as a frame of reference with theoretic tenets.
- Includes: specific assessments and intervention strategies
- Encompasses synaptic connections within the brain and neural processes as they relate to functional behavior.

Jean Ayres: OT and psychologist
- trademarked as Ayres Sensory Integration (ASI)

Our Senses

Auditory: The sense of hearing. Provides us the ability to receive sounds.
- Functional before birth (cochlea by ~19–23 wks); newborns prefer familiar stories/melodies heard in utero; further differentiation continues in early months.
Vision: The sense of seeing. Provides us the ability to identify and understand what we see.
- Structurally developing prenatally with light perception mid-gestation; functional but least mature at birth; rapid refinement across late gestation and first months.
Gustatory: The sense of taste. Allows us to react and perceive what we are tasting.
- Structures and taste buds form prenatally; functional at birth with taste differentiation by day 3–6.
Vestibular: The sense that refers to balance. Allows us to respond to changes in head positon and the body’s movement through space.
- Functional prenatally (17–21 wks) and keeps refining postnatally with movement against gravity and learned postural responses.

Olfactory: The sense that refers to smell. Allows us to response to smell and respond to it.
- Structures in place prenatally; fetus learns maternal odors; functional at birth with adult-like neural responses to new smells.
Tactile: The system that perceives touch, pressure, vibration, movement, temperature and pain through the skin.
- Earliest to mature; most mature at birth (perioral sensitivity by 7.5 wks; temp discrimination by late 3rd trimester).
Proprioception: Provides us unconscious awareness of body position. Allows us to know where each body part is and how it is moving.
Interoception: Sensing internal signals from your body.\

Sensory Processing Foundations

For sensory information to be used functionally, it must be registered within the CNS.
- When to pay attention to a stimulus and when to ignore it.
- Occurs automatically and efficiently.
Discrimination: the brain's ability to distinguish between different sensory stimuli.
Perception: The brain’s process to give meaning to sensory information.

Neurobiology Concepts

Sensory input is necessary for optimal brain function.
We are constantly taking in sensory information, brain malfunctions if it is deprived of it.
Our brains require adequate sensory experiences during critical periods of development.
- This causes brain connections to form
Too much stimulation or distressing and painful stimuli can generate stress
Sensory stimuli that is actively organized and used by the child to act on and respond to the environment has the optimal effect on development.

Sensory Integration and Adaptive Response

Children actively select sensations that are most useful in any given moment. They take this information and then organize them in a way that facilitates them accomplishing goals.
- Sensory integration utilized.
Adaptive response: when one is able to organize a successful, goal-directed action on the environment.
- Occurs when a challenge presented in the environment is successfully met.
Adaptive responses drive development forward

Neural Plasticity and Environmental Enrichment

Plasticity: the brain’s ability to change, remodel, and reorganize with the outcome being a better ability to adapt to change, remodel, and reorganize. The outcome is a better ability to adapt to new situations.
Neural Plasticity: the ability of experience to shape the development of neural circuits, both structurally and functionally, because of cellular and molecular neural activity.
Interesting and novel environments lead to development of neural circuits
Neural Plasticity is most likely to occur in childhood, however some changes may occur throughout the lifespan.
Plasticity makes it possible for adaptive responses to increase the efficiency of sensory integration at a neuronal level.

When do problems in sensory integration occur?

For some, differences in sensory integration function create challenges in daily life.
- May cause difficulties throughout daily occupation
Children may become frustrated when experiencing difficulties with tasks that seem ordinary and easy for others.
Many with SI difficulties avoid/reject simple sensory or motor challenges
- Respond with refusals/tantrums when pushed for participation in these tasks.
SI difficulties may occur without a comorbid dx OR in conjunction with other dx.

Types of Sensory Integration Problems

Sensory integrative problems, sensory integrative dysfunction, sensory processing disorder
Sensory integrative differences involve the CNS
A consensus on how to categorize SI problems does not exist.
Different models exist
- 1 model depicts 2 primary SI problems (Poor sensory modulation, Poor praxis)
Sensory Processing Disorder
- Sensory modulation disorder
- Sensory based motor disorder
- Sensory discrimination disorder
Sensory reactivity: Suggests that sensory reactivity follows a continuum
Quadrant Model (Winnie Dunn): Considers potential roles in neural processes in generating behavior of responsiveness among typical developing individuals.

Four Basic Patterns of Sensory Integration Differences

Sensory Reactivity
Sensory Discrimination and Perception
Vestibular-bilateral Function
Praxis (Ability to make a motor plan)

► Sensory seeking behavior is often seen in conjunction with each of these categories of sensory integration problems.

May serve a variety of adaptive purposes for the child
Therapists must carefully analyze why seeking behaviors are occurring.
Consider this in conjunction with sensory assessment data, occupational profile, temperament, and events occurring within the child’s life.

Sensory Reactivity Problems

Sensory Reactivity: How you react to sensations

Sensory Reactivity Problem can also be referred to as Sensory Modulation Problems
Modulation: the CNS regulation of its own activity.
Sensory Modulation: the tendency to generate responses that are appropriately graded in relation to incoming sensory stimuli, rather than under responding or over responding.
Sensory reactivity is now part of the DSM-5 as part of the diagnostic criteria for ASD.

Sensory Registration Problems: HypoReactivity

Children with hyposensitivity have a lack of registration, attention or response to sensory input. These children need increased levels of sensory input to register and response to stimuli.
When a child does not notice a certain stimuli we must consider whether the underlying problem is perceptual or cognitive difficulty rather than registration, before considering an SI approach.
Hyporeactivity interferes with the child’s ability to attach meaning to an activity or situation because they are not noticing critical sensory information in relation to the objects or contexts.
Impedes play and language development.

Sensory HyperReactivity

A child who is hyperreactive is overwhelmed by sensory input and often responds to it with anxiety and activation of the sympathetic nervous system.
Common comorbidities with hyperreactivity (Anxiety, ADHD, autism, OCD)
Both anxiety and hyperactivity involve states of high arousal due to stimuli.
Three possible scenarios to explain the link between sensory hyperreactivity and anxiety disorders:
- Anxiety causes sensory hyperreactivity
- Sensory hyperactivity causes anxiety
- These two conditions are associated through a common risk factor (like heightened amygdala activity)

Problems with Sensory Reactivity

Type of Issue	Description	Observations	Impact on Participation
Limited Sensory Registration	Often does not notice or register relevant environmental stimuli	Often oblivious to touch, pain, smell, movement, sight and sound. Is not aware that the stimulus is present. May not notice physical injury. Potential for self-injurious behavior	Participation may be severely limited by lack of awareness of people, objects, or sensations.
Tactile Defensiveness - Make sure they can see you approach before touch -Use firm pressure because it is easier to process	Hyperreactivity to ordinary touch sensations Light touch stimuli are aversive, esp. in the very sensitivity body areas such as face, abdomen, and palmar surfaces of the upper and lower extremities. Self applied input is tolerated better than that applied by another person. Tactile stimuli worse if the child can not see the source.	Responds to irritation and discomfort to light touch stimuli. Emotional response to stimuli often causes anxiety, distractibility, restlessness, anger, having a tantrum, aggression, fear, and distress. Most feel comfortable with deep touch stimuli and may feel relief and calmness when applied	Participation is often limited in self care activities. Participation in classroom & play activities is often limited. May avoid/become upset activities that require proximity to others. Behavior is often misinterpreted as rejecting, demanding or aggressive
Gravitational Insecurity	Hyperreactivity to vestibular sensations involving linear movement. Particularly sensations from the pull of gravity and from vertical movement through space.	Fear during whole body movement activities. Moves slowly and carefully Avoids/refuses to use stairs, escalators, elevators, playground equipment, etc (uneven and unpredictable) Overwhelmed by changes in head position or movements. Fear or heights May resist lifting off of the ground. Avoids tilting head in different planes.	Participation in community activities may be limited. Community mobility may be limited and stressful Participation with peers in games, sports, bike riding, may be limited and stressful. Exploration of the environment may be limited.
Auditory/Visual/ Olfactory and Gustatory Defensiveness	Hyperactivity to sounds, sights, tastes and smells	Distress to discomfort with loud sounds, bright lights, strong smells, or tastes, excessive stimuli	Limited or no participation in events such as birthday parties, fairs/festivals, Participation in classrooms and cafeterias very stressful due to sights/sounds/smells Mealtime participation may be limited by smells and tastes or food, especially if food is not familiar.

Sensory Discrimination and Perception Problems

Sensory discrimination and perception allow for refined organization and interpretation of sensory stimuli.
Sensory integrative disorders involve inefficient/inaccurate organization of sensory stimulation. (the difficulty differentiating one type of stimuli from another.)
Reactivity problems often coexist with perceptual problems.
- It is understandable that children may have difficulty with perception given their limited experience with sensations.
Discrimination/perception problems can occur within any sensory system

Problems with Sensory Perception

Type of Issue	Description	Observations	Impact on Participation
Tactile Perception	Difficulty interpreting the location	Difficulty localizing precisely where an object has brushed them. Difficulty with stereognosis to manipulate an object that is out of sight (fine motor coordination is impacted). May be seen along with problems with visual perception and motor planning.	Hinders participation in play activities that require precise hand/finger movements. Difficulty participating in classroom and self-care activities that require precise hand and finger movements. Participation may be stressful and may require visual compensation for activities.
Proprioceptive Perception	Difficulty interpreting body position and the position and movement of the muscles and joints.	Appears clumsy and awkward. Relies on visual guidance of movement or on cognitive strategies. Uses too much or too little force during activities (i.e. handwriting). May seek excessive proprioceptive input (pushing/pulling). Misjudges personal space and force.	Participation at school or in play with peers may be compromised by behaviors that get them into trouble, perceived as intentionally disruptive. Participation in movement and sports activities may be hindered.
Visual Perception	Difficulty interpreting features of visual stimuli such as shape, size, direction, and figure ground relationships. Despite adequate visual acuity.	Difficulty with visual Perception, visual-spatial, visual construction, and/or visual-motor tasks. May impact motor functions such as grasp, balance, and locomotion.	Participation in play activities may be limited (i.e. puzzles). Participation in academic tasks may be impacted (i.e. handwriting).
Auditory Perception	Difficulty discrimination and interpreting sounds, but hearing is not impaired.	Difficulty locating where sound is coming from. Difficulty following Directions. Difficulty understanding conversation. Difficulty focusing on sounds or words when background noise is present	Participation in social play may be impacted due to communication deficits. Participation in sports, games, & music or dance activities may be impacted by inability to rapidly/ accurately interpret auditory info. Participation in activities at home and school may be compromised by difficulty understanding auditory info.

Vestibular-Bilateral Problems

Vestibular-bilateral problems Indicates motor outcomes of vestibular processing and can also be called:
- Postural and bilateral integration disorder
- Vestibular-bilateral integration Disorder (VBI)
- Bilateral Integration and Sequencing (BIS) pattern
- Vestibular Bilateral Integration and Sequencing (VBIS) pattern
Difficulty with head and trunk control, vestibular-ocular functions, balance, bilateral coordination.
Sensory reactivity can occur with this pattern.
May impact activities such as riding a bike, roller-skating, skiing, playing games like hop-scotch, cutting with scissors, buttoning a shirt, jumping jacks, etc.
Can sometimes be indicated by delays in body midline skill development (i.e. establishing hand dominancy).
Reasons for referral are typically clumsiness, incoordination, difficulty with team sports, slumping or slouching when sitting, and attention difficulties.

Problems with Bilateral Integration and Sequencing (BIS)

Type of issue

Description

Observations

Impact on participation

Problems with Vestibular

Bilateral Integration

Inefficient processing of vestibular sensory

information needed for postural and ocular control, bilateral coordination, midline integration, optimal muscle tone for readiness to move, and balance.

Jerky/disorganized eye tracking movements.

Poor Balance Trouble assuming and maintaining extensor position while prone. Frequent slouching or difficulty staying in an upright seated position for more than a few minutes at a time. Movement appears slightly floppy. Poor bilateral coordination. Difficulty with postural control during shifts in body midline. Frequent tripping/falling Hesitance or avoidance of reaching across the body for an object. Hesitance or difficulty leaning forward or sideways to grasp an object out of reach

Difficulty participating in sports/dance/play due to poor balance.

Social participation is secondarily impacted.

Loss of place when looking up at the classroom board and then back down at a worksheet. Limited participation in activities that require remaining seated for an extended period of time. Trouble participating in activities that require coordination of both sides of the body such as pedaling a bicycle or tying shoes.

Praxis Problems

Praxis: the ability to conceptualize, plan, and execute a non-habitual motor act.
Problems with this often referred to as: Dyspraxia (Problems with motor planning)
Throughout studies, a consistent relationship between tactile perception and praxis can be seen.
Praxis needs may manifest in different forms, not all SI in nature.
- Somatopraxis: the aspect of praxis that IS sensory integrative in origin and grounded in somatosensory processing.
- Somatodyspraxia: a sensory integrative deficit that involves poor praxis and impaired tactile and proprioceptive processing.
- VisuoPraxis: the relationship between visual perception and visually directed praxis.
- Visuadyspraxia: patterns in visual perception and visually directed praxis are areas of difficulty.
Some children with dyspraxia have difficulty with ideation
This is difficulty generating ideas of what to do in a novel situation or conceiving play possibilities with novel toys.

Type of Issue

Description

Observations

Impact on participation

Poor Praxis

Difficulty coming up with an idea for how to move in a new way. Difficulty planning and performing new sequences of movements to achieve a new goal.

Difficulty learning new motor skills. Lack of ideas about new ways to use an object or toy. Difficulty learning to dress self. Difficulty putting on new type of clothing. Imitates what others are doing, rather than imitating a new activity. Poor timing or sequencing of actions. Trouble manipulating objects, drawing, or building

Limited participation in sports. Limited participation in games that require moving in new ways. Limited participation in activities that require construction. Difficulty developing independence

in self-care skills. Difficulty participating in arts activities that require new ways of moving or manipulating objects. Limited social participation due to difficulty joining others in activities.

Sensory Seeking Behavior

Some children appear to seek intense sensory stimuli.
Sensory seeking used to be considered a modulation disorder, however as new research emerges we now know it can be caused for a variety of reasons.

Generate additional sensory input to compensate for inadequate discrimination of perception in one or more sensory systems.
Regulate general arousal level.
Modulate hyper- or hypo- reactivity in other sensory systems
May be an expression of temperament and not related to sensory integration problems.
May serve to dampen hyperreactivity in another sensory system
Sensory seeking may serve as an adaptive function
Generating additional sensory input to compensate for weak processing of 1 or more sensory systems.
Children who have difficulty with praxis may appear to have sensory-seeking behaviors.
Occupational therapists need to remember that people of all ages have individualized preferences for certain sensory experiences. If no other indicators of sensory integration difficulty are present, then the sensation seeking behavior is LIKELY an expression of temperament and personal preferences and not a manifestation of sensory integration problems. If so, an SI approach would not be appropriate.

Examples of Sensory Seeking Behavior

A child seeks strong proprioceptive input in the form of active resistance of muscles, deep touch pressure simulation, or strong joint compressions and traction (i.e. stomping instead of walking, jumping forcefully, intentionally falling/bumping into objects).
The occupational therapist may hypothesize that the child is not aware of positions of

body parts without intense proprioceptive information.

A child has signs of poor tactile perception and is observed to touch things and

people excessively. This behavior might be a way to compensate for inadequate

tactile information by increasing the flow of tactile sensations into the CNS to

enhance interpretation of touch sensations during object manipulation and social

contacts.

Specific Sensory Techniques

Treating using specific sensory techniques does not fall within Ayres SI interventions.
Specific Sensory Techniques: interventions that involve applications of specific types of sensory stimuli that are controlled and delivered in a predetermined manner, usually according to a prescribed schedule, protocol, or sequence.
Generally involved the passive application of sensory stimuli.
Sometimes referred to as a sensory diet.