Tricia SimonPrincipal Speech and Language Therapist

ABMU Health BoardNovember 2009

What is sensory integration Which client groups often have difficulty

with this skill Which professionals may be involved What might intervention look like – case

examples

Sensory integration is the neurological process that organises sensation from one’s own body and from the environment and makes it possible to use the body effectively within the environment. Sensory integration is information processing. The brain must select, enhance, inhibit, compare and associate the sensory information in a flexible, constantly changing pattern, in other words the brain must integrate it.

Physical clumsiness Difficulty learning new movements Activity level unusually high or low Poor body awareness Inappropriate response to touch,

movements, sights or sounds Poor self esteem Social and/or emotional difficulties

Pervasive Developmental Disorder (including Autism and Aspergers Syndrome)

Attention Deficit Hyperactivity Disorder (A.D.H.D./A.D.D,)

Learning Disorders ( i.e. specific learning difficulties e.g. dyslexia)

Developmental Disabilities Fragile X Syndrome Developmental Coordination Disorder [DCD]

(including Dyspraxia)

Often Occupational Therapists

Speech and Language Therapist

Physiotherapist

The focus or goal of intervention may change depending on the professional background.

Profiles and direct assessment of visual auditory tactile olfactory gustatory vestibular - movement proprioception – body position

Levels of self regulation

1. Autonomic regulation Biological regulation e.g. sleep, digestion, temperature.

2. Modulation Regulation of arousal levels in response to stimuli

3. Sensory discriminationInterpret and organise information

4. Executive functionModulate, interpret and organise response

Seek out excessive amounts of one type of stimulation

Avoid specific sensations May be agitated, constantly on the go Or quiet, withdrawn, self abusive, sleep a lot

May fail to register or recognise stimulus and ignore what is happening

May respond with alarm as they don’t fully understand what is happening

Sensory difficulties may result in client operating only in survival mode

Survival response may be: Freeze, defiance, aggression Or avoidance, compliance, dissociation

Mental state cognition Area of brain

calm abstract Neocortex

aroused Concrete, rigid Subcortex

alarmed Emotional Limbic

fear reactive Midbrain

terror Reflex only brainstem

Calm, alert and attentive

Hypo: Under responsive or high thresholdHow do they alert themselves e.g. spinning, chew

Hyper excited or defensive

Shut out stimuli through to shut downResponse to stress: freeze, fight, flight, fright, vigilance?How do they self calm? E.g. head bang, deep pressure

Assessment leads to a profile of the amount, type and duration of sensory stimulus the person can cope with

Aim to facilitate a controlled regulated response to all sensory stimuli through the just right combination of alerting and calming stimuli

ALD – work at first two levels of regulation and modulation to achieve a calm alert state to allow learning and relating to others.

Control volume of stimuli in the environment Education for carers e.g. tactile defensive,

not rejecting touch/affection. Aim to sensitise parents and carers to the

individual’s behaviours and help them become aware of and modify their interactional styles according to the individual’s cues.

Therapist support carers to carry out intervention (rather than carry out the intervention themselves)

Calming/nurturing Alerting/Challenging

Taste/smell Sweet, vanilla, salt Sour, citrus, spice, bitter

Oral texture

Suck, blow, bite, crunch Chew, lick

temp Cool to moderate extreme

tactile deep pressure Light/unexpected touch

movement Stretch and resistance (hang, pull, push, crawl, carry heavy load), bounce

Linear move e.g. swingRotary move e.g. spin

auditory Vibration, rhythm music Speech sounds

Observe what the individual seeks.Aim for the individual to remain regulated during all stimuli.Initially therapist/carer acts as regulator by structuring environment.

Eadaoin Bhreathnach: OT and counsellor

Uses theories of Sensory integration Attachment classification

Use of therapeutic space from both sensory processing and attachment perspectives.

Observed behaviour may be due to sensory or emotional difficulties.

Different types of insecure attachment have different sensory profiles e.g.

Avoidant child likely to be tactile defensive, may use freeze/compulsive compliance

anxious child likely to be aggressive during fast movement and unstable surfaces.

Sensory difficulties may result in attachment difficulties in LD e.g. tactile defensiveness.

Question: Why is the client doing a behaviourPotential answers Can’t tolerate the sensation – hyperexited or

defensive reaction Not enough sensory information (high threshold

or under responsive) – sensory seeking Cognition/ stage of development; difficulties with

perception and misinterpretation. Past ‘trauma’ or negative experience Communication Emotional/attachment e.g attract attention

Start where is comfortable in terms of physical space and sensory stimulation – don’t trigger a self stimulatory/ SIB reaction or survival mode

Tune in Work at their pace Stop before triggering threshold for stimuli –

ensure a positive experience

Parallels with Intensive Interaction approach

Withdraws (‘sleeps’) at day service – in foetal position in wheelchair with t-shirt

over his head Moves away when touched

Emerges to accept food and drink only Foster carers – chews bedding/mattress at

home

Levels of self regulation; John

1. Autonomic regulation - physiologicalRubella stress patternChest infection ?gastric issues

2. Modulation Avoidant Hypervigilant? Tactile defensitveDisengages tone postureSelf soothes – taps his head

3. Sensory discrimination - interpretPostural control very goodFollows instructions around food, active withdrawal at other

times

4. Executive functionOrganise around food and posture

Calm, alert and attentive

Hypo: Under responsive or high thresholdHow do they alert themselves e.g. spinning, chew

Hyper excited or defensive

Shut out stimuli through to shut downResponse to stress: freeze, fight, flight, fright, vigilance?How do they self calm? E.g. head bang, deep pressure

Cut out/shut down – foetal position, under bedclothes/t-shirt, eyes closed

Stress reactions Freeze – foetal position Fight – SIB banging head, destroying mattress Flight – move away Fright – scream

Tactile defensiveness – Is he defensive to the sensation or emotional avoidance/control?

Tapping head Tshirt pressure Foetal position – pressure on joints Chew Suck Retreats into self

Aim to engage in positive experience – tune in and mirror what he seeks

Aim for calm alert state so need to use calming interventions

Sucking Bite –melt foods Chewing Movement (car, rocker) Deep pressure – careful in case control issues Rhythm of SIB or tapping

Autistic Hyperexcited signs – smile, bounce up and

down, hands in mouth can then escalate to agitation (pacing, rocking), aggression, and not registering pain.

Triggered by pub, football match – important for relationship with Dad.

Levels of self regulation; Paul

1. Autonomic regulation – lots of physiological issuesLow tone, epilepsy, cleft palate, hayfever, eczema, allergies,

tunnel vision, middle ear problems, high sugar intake, high urine output

2. Modulation Low tone – difficulty regulating muscle controlSeeking proprioception (jumping)Tactile defensive – either emotional or postural challenge not

sensory

3. Sensory discrimination - interpretAuditory processing problems, body scheme problemsDelayed processing with food, cognition Gravitational insecure (won’t tilt head)

4. Executive functionProblems planning movement – uses reflex fight/flight

Regulate during family activities by Reducing noise (ear coverings?), therapeutic

listening to reduce defensiveness. Provide calming stimuli –lots of

proprioception (pull, push, lift, hold) e.g. chewing dried fruit/ carrot/ apple, suck on water bottle, trampoline, squeeze ball, walk hills

Primary need is to address health and physiological difficulties e.g. tunnel vision

Lots of input for challenging/self injurious behaviour but no solutions found to date

Often sleeps at day service (staff report this as a good day)

Noisy at home Difficult to engage and interact with

Signs of hyperexcitationFight – hits selfFlight – increased agitationFear – when carer moves away increased SIBWhat calms – hitting self on head, hitting foot on wheelchair

Calm alert state1:1 on holidayNurturing type activities (massage, cuddles, food)Being outsideWaterhoist

Sleep – is this shut down/escape from sensory overload at day service?

Tactile defensiveness – trigger for SIB Vestibular – postural insecurity and needs lots

of proprioception (deep pressure) but without being worried about balance

Auditory – can’t cope with sudden sounds Fear reaction when staff move away –

attachmentGive staff strategies to support calm state and evidence the need for 1:1

What is the person’s past experience and learning?

What patterns is the person following – emotion or sensory based, or is there another reason for their actions e.g. communication, cognition/ developmental level.

What will help e.g. environment, activities/sensations

Sensory integration network UK and Ireland

www.sensoryintegration.org.uk