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Sensory Integration

 

 

 

"You can think of sensations as 'food for the brain'; they provide the knowledge needed to direct the body and mind."

Q

What are sensory integrative (also called 'sensory processing') disorders?

  
   Sensory integrative/processing disorders are a set of conditions caused by an insufficient ability of the central nervous system to take in, register, modulate, perceive, and/or combine sensory experiences (input) from the environment around us.  It starts with the most basic senses in the "sensory food chain", and moves upward.  The senses affected include any or all of:
 

  • Vestibular:  our sense of movement, the pull of earth's gravity, and position in space; the first sensory organ to be completed during pre-natal development
  • Tactile:  our sense of touch, not just from the hands, but from all over the body, including the inside of the mouth
  • Proprioception:  our internal sense from joints and muscles; the basis of muscle memory
  • Auditory:  not just "hearing", but perception of different sound wave frequencies, perceiving the correct bits and pieces of sound that make up words, and organizing them in the correct sequence.  For example, perceiving the word "caterpiller" instead of "callerpitter."
  • Visual: not simply "seeing", but perceiving brightness of light, spatial orientation, form, vertical vs. horizontal, color, shape, direction, etc.
  • Olfactory & Gustatory:  our sense of smells, odors, and tastes, but also our perception of the intensity of them.  Under-reactive individuals seek excessive salt, sweetness, or hot spice, while overly-reactive people may tolerate only very bland, or just a handful of different flavors in their "repertoire" of foods.
     

     In SI/P disorders, the person affected is not "blind" to sensory input.  Rather, the neural messages become disorganized as they travel up towards the higher brain centers.  The messages may also become overly-amplified or diminished, and are hence un-usable.  Sensory inputs are the building blocks of learning and relating to our environment and the people in it. Therefore, it is no surprise that SI/SP disorders are usually associated with other learning, perceptual, movement coordination, or emotional problems.

Q

What is sensory integration? How does it relate to a child's development?


Sensory integration refers to the brain's ability to take in, process, and organize sensory input from the seven senses, but also to combine (integrate) them together.  This is how we perceive our environment and the people and physical objects in it, how we relate our body to them, as well as how they relate to each other.  We are all sensory processors!  Some examples to think about:
 

  • Learning and remembering which direction to run during a ball game
  • Finding something in your bookbag, purse, or pocket without having to look with your eyes
  • Perceiving a piece of fruit by color, shape, texture, weight, smell & taste.
  • Using our proprioceptive (position sense) processing and memory to hold a pen or pencil correctly, and press down just the right amount on the paper.
  • Visually perceiving shapes, letters, and numbers; then using proprioception combined with vision to plan the execution of the intricate movements required to write them.
  • Using our vestibular (movement/ balance sense) spatial sense and visual perception to walking through the mall and not run into people...knowing "how far away" things are.
  • Using vestibular (movement/balance sense) and visual spatial senses, integrated with proprioception to drive a car,  navigate around your city or area, maintain the car on the road and turn accurately; using a map correctly.
  • Don't know what praxis/motor planning is? Ever try to learn to drive a car with stick-shift and a clutch?  That is praxis in action!
  • Being able to accept being touched appropriately, not feeling "ticklish"; wearing a variety of clothing without feeling it is too tight, too itchy, or painful.
     

Sensory processing and the ability to organize sensations also affect our emotions and feelings!  Reflect on your emotions as you think of experiencing the following sensations:
 

  • A comforting touch...versus a painful shot...versus being tickled
  • An exciting roller coaster ride...versus slow rocking on the front porch
  • The smell of your favorite dish cooking in the kitchen...versus the odor of gas in your home
  • A loud, sudden alarm ringing...versus the sound of a loved one's voice
  • The taste of something yukky...versus Mom's warm cookies and milk
  • Sleeping in a cold room with lots of quilts piled on...versus standing in the rain with a flat tire

Link to list of useful videos

Q

Is there more than one type of S.I. disorder?


     Yes!  This is important, because poorly trained therapists often present SI disorders as simply issues of sensory reactivity.  This is an erroneous perception!
As mentioned above, there are four major sub-types of sensory processing disorder:
 

  • Sensory modulation dysfunction
  • Developmental dyspraxia
  • Postural-Bilateral Integration dysfunction
  • Generalized dysfunction (impairments in all areas)
     

     This set of problems first began to be identified in the 1960's by Dr. A. Jean Ayres, an occupational therapist and pediatric neuropsychologist at the University of Southern California. Ayres initially noticed that people with primary motor disorders also had significant visual-spatial, tactile, and vestibular perceptual impairments.  Later, she identified the movement disorders of apraxia (or developmental dyspraxia) in children, as well as postural-bilateral integration dysfunction. She also identified patterns of over-reactivity or under-reactivity to sensory experiences that we now call sensory modulation dysfunction.
 

     Sensory Modulation Dysfunction:  Just as you can control the volume on your radio or television from very faint, to quite loud, the brain has built-in systems that automatically "decide" how much sensory information they will allow to enter.  This ability helps us to "filter" sensations, putting more emphasis on those that are important at the moment, while damping down those that are not---a process called "inhibition."  However, children with SMD are not effective sensory modulators.  Their brains may interpret a tickling feather as painful, a conversational tone of voice as "too loud"; or a little bit of movement as "making me dizzy."  The smell or taste of many foods may actually make them become nauseous and vomit!  (Not much fun in the school cafeteria!)

     At other times, the opposite can happen.  The child may seem sluggish, unaware of sensory stimuli, such as someone calling them.  A bad fall that causes a bruise doesn't make them cry; or they can spin in circles repeatedly and not feel dizzy.  They may even seem to crave certain sensory experiences, like engaging in a lot of falling-and-crashing play.


    Developmental Dyspraxia is a type of coordination disorder where the child is unable to mentally visualize and "figure out", or plan, new or skilled movements.  (People usually say the child is "clumsy.")  These movements might involve large muscle actions, like learning how to roller skate or do a cartwheel; or fine hand/finger skills for handwriting or using tools like scissors, or eating utensils.

   Children with milder impairment have a "mental picture" of what they wish to do (called ideation), but cannot execute the body positions and action sequences to accomplish it.  More severely impaired children do not have a mental image of the possibilities of a given object.  Gibson & Gibson called these object cues of what-to-do-with-this-object, "affordances."   Children with severe dyspraxia do not recognize affordances.

   Even more significantly, Ayres found that these dyspraxic children showed an underlying pattern of impairment in the detection, organization, and discrimination of sensory information from the skin (tactile), joints and muscles (proprioception), and/or vestibular system (inner ear "equilibrium").  Her hypothesis for successful intervention was to treat the underlying sensory processing issues---not an educational process to teach the child how to execute specific movements.
       

    In Postural-Bilateral Integration & Sequencing problems, children show

  • immature developmental reflexes and core muscle patterns,
  • poor ability to use the two sides of the body together,
  • poor trunk rotation and a tendency not to cross the body midline, and
  • poor lateral dominance development.


    They frequently also have

  • poor conjugate eye movements, and
  • confusion about space, distances, and directionality.
  • unusual fear/discomfort in certain positions (on tummy, moving backwards, going down stairs, riding on parent's shoulders.)
     

    This is the child who switches hands to write or draw on different sides of the page; confuses "b" and "d", or "m" and "w"; has difficulty with skills requiring alternating limb movements, such as riding a bike, roller skating, or two-handed skills like buttoning a shirt.

Q

Why is sensory integration disorder not listed in the ICD-9 diagnostic manual? My physician is unable to find it.


      Most of the individual components of SPD can be identified within the ICD-9, but there is not yet a set of listings that encompass the family of sensory processing/integration disorders.  (However, there is a procedural code for sensory integration treatment in the CPT manual.)

      However, there is currently a Sensory Processing Disorders Study Group comprised of some of the nation's top neuroscientists, occupational therapy researchers, neuropsychologists, and pediatric psychiatrists, who have gathered pertinent research, are writing terms and definitions, and are now submitting these documents to the AMA committee for inclusion in both the ICD-9 or 10 AND the Diagnostic and Statistical Manual (used in mental health.)  Top genetic researchers at Harvard and other institutions have identified the gene likely responsible for sensory over-reactivity.  This monumental effort shows signs of potential success, and will be a major breakthrough for children with SI disorders!

Q

What codes can currently be used to identify components of SI disorder?


We suggest that physicians use the following:
a.  For general sensory processing concerns that result in behavioral problems, use 349.9 Unspecified Neurological Disorder.  Particularly important when it is desirous to avoid using a psychiatric diagnosis.
b.  For severe touch hypersensitivity:   782.0 Sensory Disturbance of the Skin:  hyperesthesia
c.  For severe hypersensitivity to smells or tastes:  781.1 Sensory Disturbance of Smell or Taste
d.  For dyspraxia or bilateral integration disorder:   781.3 Coordination Disorder
e.  For visual perceptual dysfunction:  368.10  Subjective Visual Disturbance

Q

What is the S.I. treatment approach?


    Often when they walk into our clinic area, parents are expecting an "exercise" physical treatment "no pain-no gain" environment.  That may work for adults, but not for kids!  Children are motivated by exploration and play.  Therefore, the sensory integration treatment approach entails the use of vestibular, proprioceptive, and tactile-based therapeutic activities that are combined in a playful context to motivate the child to make meaningful adaptive responses to "just-right" therapeutic challenges presented by the therapist.  Therapeutic goals are disguised by the artful therapist as play, thus obtaining the child's optimal engagement.


    In our clinic, you will see about 800 square feet of cushioned floor space with an amazing array of ropes, therapeutic suspended equipment, tunnels, crash pillows, balls and other child-oriented activities.  However, you will also see tables, chairs, and shelves filled with cognitive, perceptual, fine motor, handwriting, and self-care activities.  We also offer traditional Occupational Therapy work in these intervention areas, often in a developmental sequence which follows sensory-motor preparation.

Q

What types of changes may I expect in my child using Sensory Integration??


This of course depends on what your original concerns are.  The list includes, but is not limited to:

a.  Improvements in attention, general level of alertness.
b.  Faster processing and response to verbal requests from others.
c.  Increase in behavioral flexibility and cooperativeness, although this may take longer, and must include a home behavior management plan that works in tandem with our treatment.
d.  Better balance and coordination; less falling and accidents.
e.  Better fine motor control, increased legibility and space management of handwriting.
g.  If the child is fearful and anxious about new situations or experiences, this is reduced.  Part of this style of therapy is about risk-taking, trying new activities, and doing old things in new ways.  Over time, this generalizes to other situations outside of the clinic environment.

Q

What are some of the red flags for Sensory Integration Disorder?


Infants and toddlers
____ Problems eating or sleeping
____ Refuses to go to anyone but me
____ Irritable when being dressed; uncomfortable in clothes
____ Rarely plays with toys
____ Resists cuddling, arches away when held
____ Cannot calm self
____ Floppy or stiff body, motor delays

Pre-schoolers
____ Over-sensitive to touch, noises, smells, other people
____ Difficulty making friends
____ Difficulty dressing, eating, sleeping, and/or toilet training
____ Clumsy; poor motor skills; weak
____ In constant motion; in everyone else's face and space
____ Frequent or long temper tantrums

Grade schoolers
___ Over-sensitive to touch, noise, smells, other people
___ Easily distracted, fidgety, craves movement; aggressive
___ Easily overwhelmed
___ Difficulty with handwriting or motor activities
___ Difficulty making friends
___ Unaware of pain and/or other people

Adolescents and adults
___ Over-sensitive to touch, noise, smells, and other people
___ Poor self-esteem; afraid of failing at new tasks
___ Lethargic and slow
___ Always on the go; impulsive; distractible
___ Leaves tasks uncompleted
___ Clumsy, slow, poor motor skills or handwriting
___ Difficulty staying focused
___ Difficulty staying focused at work and in meetings

Adapted from Sensory Processing Disorder Foundation

More Red Flags

* Adapeded from Sensational Kids.