Articles about Sensory Integration.
By Cindy Hatch-Rasmussen, M.A., OTR/L
Children and adults with autism, as well as those with other developmental disabilities, may have a dysfunctional sensory system. Sometimes one or more senses are either over- or under-reactive to stimulation. Such sensory problems may be the underlying reason for such behaviors as rocking, spinning, and hand-flapping. Although the receptors for the senses are located in the peripheral nervous system (which includes everything but the brain and spinal cord), it is believed that the problem stems from neurological dysfunction in the central nervous system--the brain. As described by individuals with autism, sensory integration techniques, such as pressure-touch can facilitate attention and awareness, and reduce overall arousal. Temple Grandin, in her descriptive book, Emergence: Labeled Autistic, relates the distress and relief of her sensory experiences.
Sensory integration is an innate neurobiological process and refers to the integration and interpretation of sensory stimulation from the environment by the brain. In contrast, sensory integrative dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior. A general theory of sensory integration and treatment has been developed by Dr. A. Jean Ayres from studies in the neurosciences and those pertaining to physical development and neuromuscular function. This theory is presented in this paper.
Sensory integration focuses primarily on three basic senses--tactile, vestibular, and proprioceptive. Their interconnections start forming before birth and continue to develop as the person matures and interacts with his/her environment. The three senses are not only interconnected but are also connected with other systems in the brain. Although these three sensory systems are less familiar than vision and audition, they are critical to our basic survival. The inter-relationship among these three senses is complex. Basically, they allow us to experience, interpret, and respond to different stimuli in our environment. The three sensory systems will be discussed below.
Tactile System: The tactile system includes nerves under the skin's surface that send information to the brain. This information includes light touch, pain, temperature, and pressure. These play an important role in perceiving the environment as well as protective reactions for survival.
Dysfunction in the tactile system can be seen in withdrawing when being touched, refusing to eat certain 'textured' foods and/or to wear certain types of clothing, complaining about having one's hair or face washed, avoiding getting one's hands dirty (i.e., glue, sand, mud, finger-paint), and using one's finger tips rather than whole hands to manipulate objects. A dysfunctional tactile system may lead to a misperception of touch and/or pain (hyper- or hyposensitive) and may lead to self-imposed isolation, general irritability, distractibility, and hyperactivity.
Tactile defensiveness is a condition in which an individual is extremely sensitive to light touch. Theoretically, when the tactile system is immature and working improperly, abnormal neural signals are sent to the cortex in the brain which can interfere with other brain processes. This, in turn, causes the brain to be overly stimulated and may lead to excessive brain activity, which can neither be turned off nor organized. This type of over-stimulation in the brain can make it difficult for an individual to organize one's behavior and concentrate and may lead to a negative emotional response to touch sensations.
Vestibular System: The vestibular system refers to structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of the head. For example, the vestibular system tells you when your head is upright or tilted (even with your eyes closed). Dysfunction within this system may manifest itself in two different ways. Some children may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary movement activities (e.g., swings, slides, ramps, inclines). They may also have trouble learning to climb or descend stairs or hills; and they may be apprehensive walking or crawling on uneven or unstable surfaces. As a result, they seem fearful in space. In general, these children appear clumsy. On the other extreme, the child may actively seek very intense sensory experiences such as excessive body whirling, jumping, and/or spinning. This type of child demonstrates signs of a hypo-reactive vestibular system; that is, they are trying continuously to sti mulate their vestibular systems.
Proprioceptive System: The proprioceptive system refers to components of muscles, joints, and tendons that provide a person with a subconscious awareness of body position. When proprioception is functioning efficiently, an individual's body position is automatically adjusted in different situations; for example, the proprioceptive system is responsible for providing the body with the necessary signals to allow us to sit properly in a chair and to step off a curb smoothly. It also allows us to manipulate objects using fine motor movements, such as writing with a pencil, using a spoon to drink soup, and buttoning one's shirt. Some common signs of proprioceptive dysfunction are clumsiness, a tendency to fall, a lack of awareness of body position in space, odd body posturing, minimal crawling when young, difficulty manipulating small objects (buttons, snaps), eating in a sloppy manner, and resistance to new motor movement activities.
Another dimension of proprioception is praxis or motor planning. This is the ability to plan and execute different motor tasks. In order for this system to work properly, it must rely on obtaining accurate information from the sensory systems and then organizing and interpreting this information efficiently and effectively.
Implications: In general, dysfunction within these three systems manifests itself in many ways. A child may be over- or under-responsive to sensory input; activity level may be either unusually high or unusually low; a child may be in constant motion or fatigue easily. In addition, some children may fluctuate between these extremes. Gross and/or fine motor coordination problems are also common when these three systems are dysfunctional and may result in speech/language delays and in academic under-achievement. Behaviorally, the child may become impulsive, easily distractible, and show a general lack of planning. Some children may also have difficulty adjusting to new situations and may react with frustration, aggression, or withdrawal.
Evaluation and treatment of basic sensory integrative processes is performed by occupational therapists and/or physical therapists. The therapist's general goals are: (1) to provide the child with sensory information which helps organize the central nervous system, (2) to assist the child in inhibiting and/or modulating sensory information, and (3) to assist the child in processing a more organized response to sensory stimuli.
Interview with Carol Kranowitz, author of Out-of-Sync Child, on sensory integration dysfunction
By Allison Martin
Carol Kranowitz is the author of the Out-of-Sync Child, the popular book on sensory integration dysfunction written for parents. In this book, Carol Kranowitz provides explanations, examples and treatment strategies for different types of sensory integration issues in children - including oversensitivity and undersensitivity to touch, taste, smell, sound, or sight, and/or to movement sensations, unusual activity levels, and problems with motor coordination.
How did you come to be interested in Sensory Integration Dysfunction?
Carol Stock Kranowitz: I wondered why some of my preschool students were not "doin' what comes naturally." They were bright and healthy, yet they responded in unusual ways to classmates, teachers, and ordinary nursery school activities. Some children avoided altogether the experiences that their schoolmates enjoyed, while others dove into activities without an ounce of precaution.
Were these out-of-sync kids behaving inappropriately on purpose? Of course not! No child seeks disapproval of his significant olders. Every child wants to learn; every child wants to play and have friends. Something else was going on that made it so difficult for them to succeed in their occupation of childhood.
Until I learned about Sensory Integration dysfunction, I could not find a pattern in these children. The only common thread - and this is what troubled me the most - was their sadness. Whether their modus operandi was hostility, aggression, anger, frustration, tuning-out, whining, silliness, or wildly inappropriate gusto, they all seemed to sense that they weren't like the other kids. They didn't feel a sense of belonging.
There had to be an explanation, and I had to find it.
What do you find to be the most common sensory problems among children?
Carol Stock Kranowitz: Children with Sensory Integration dysfunction exhibit unusual responses to touch and movement experiences.
If they are oversensitive to touch sensations (tactile defensiveness), they will avoid touching and being touched and will shy away from messy play, physical contact with others, pets, certain textures of fabric, many foods, bumpy sock seams, etc. On the other hand, if they are under-responsive to touch sensations, they'll crave touching and being touched. These children will be fingerpainting their arms, stuffing their mouths with too much food, shouting indoors, turning up the volume and bumping and crashing into people and furniture.
If children are oversensitive or defensive to movement experiences, their feet will never leave the ground. They will shun playground equipment and object to riding in the car or elevator. They may refuse to be picked up. Or, if they are under-responsive, they may crave intense movement, and seem always to be in upside-down positions, swinging on the tire swing for long periods, and on-the-go constantly -- jumping, bouncing, rocking and swaying.
It is important to note that many children are over-reactive to sensations, covering their ears when a truck rattles by, or pinching their nostrils to avoid smelling an old banana. And many children are undersensitive, perhaps liking spicy pizza and fireworks more than others do. We wouldn't necessarily say that these kids have Sensory Integration dysfunction. It is unusual reactions to touch and movement that suggest Sensory Integration dysfunction.
If parents suspect that their child may have sensory integration dysfunction or sensory difficulties, what do you suggest they do?
Carol Stock Kranowitz:
• Be a detective! Keep notes on your child's atypical behavior. Does his reaction to a sensory stimulus occur with frequency, intensity and duration? For instance, does the child have a heck of a time calming down after getting a splinter or being knocked down?
• Ask yourself the "WH" questions, i.e., When did it happen? Where? Who was involved? What happened or what was said? How did your child respond? After taking notes for a while, you may be able to see the pattern and find the answer to the trickier question of "Why did it happen?"
• Find an occupational therapist certified to provide Sensory Integration treatment. (Only about 20% of occupational therapists are.) For a list of certified therapists, contact Sensory Integration International
Have you learned more about sensory integration dysfunction since you wrote the book that you would like to share with parents?
Carol Stock Kranowitz: Yes, I'm learning more about the distinction between two broad kinds of Sensory Integration dysfunction. One kind is a problem with regulation, or modulation, of sensory stimuli. When children are hyper-responsive (over-responsive) to sensations, they will be "sensory defensive" -- on alert and ever vigilant to protect themselves from real or imagined hazards in a scary and confusing world. When chidren are hypo-responsive (under-responsive) to sensations, they are not defensive enough and are more likely to have trouble protecting themselves.
The second broad kind of sensory integration dysfunction is one in which the child has difficulty processing sensory information. (This child may or may not have a modulation problem described above.) The child's central nervous system is inefficient at integrating, interpreting, analyzing, associating, and generally making use of sensory information. For example, the teacher will say, "Get out your pencil," and the child will get out the ruler. Although he has handled pencils many times, each time is the first time. The result of a processing problem is dyspraxia. Dyspraxia is the inability to carry out a sequence of actions that are necessary to do something the child wants to do, such as get on a bike, or climb a ladder, or answer a question.
By Dwayne Pickels
TRIBUNE-REVIEW
Monday, March 29, 2004
In a therapy room filled with toys, tools of the trade, 3 1/2-year-old Ben bounced on a ball and grinned at his mother, Jodi Yanan.
Kelly Meeder, licensed assistant occupational therapist, was amazed.
"I am so proud of you today," Meeder said. "Ben, this is a banner day for you."
Before he began treatment, Ben did not like his feet to leave the ground.
"Swinging was an issue," said Yanan, of Ardara, North Huntingdon Township.
Ben, who is autistic, has also been diagnosed with sensory integration dysfunction. His therapy includes weekly visits to the Allegheny Valley Institute for the Development of Learning in New Kensington.
Sensory integration is simply the organization of the senses allowing one to accurately interpret a situation and respond appropriately. If it does not develop normally, sensory integration is disordered, causing a bit of a "traffic jam" in the brain. Learning, development or behavior problems may occur.
Sensory dysfunction can affect all of the senses, and may or may not accompany autism. Children or adolescents may find certain sounds -- the noise of fire alarms, the buzz from overhead fluorescent lights -- unbearable. They may resist physical affection. Intolerance of certain food textures may limit what they will eat. Their play may be rigid, rather than spontaneous. Some children may be unusually active, while others may express little interest in activity.
They may play roughly with peers, possibly because they cannot accurately judge where their own bodies are in relation to others. They may hum constantly, in an effort to block out other noises and help them organize their thoughts. They may rock or spin or jump.
Things most of us take for granted -- brushing our teeth, getting our hair cut, stepping up onto curbs, ignoring annoying clothing tags -- may overwhelm them.
At what point should parents seek help? "When you sit back and realize your entire day is planned around (anticipating) your child's needs," said Susie Oresic, coordinator of occupational therapy at Children's Hospital of Pittsburgh.
With older children, she said, academic problems might be a symptom. If other potential culprits -- hearing impairment, low intelligence, vision problems -- have been ruled out, the problem might be organizing information.
Oresic believes more children are being diagnosed with the disorder largely because physicians are getting better at diagnosing it.
"We're not lumping them into (the category of) mental retardation," she said.
An evaluation can test children's visual perception, eye-hand coordination and motor planning.
"It's a very hard diagnosis to explain to parents," Oresic said. "There is no blood work, no 'aha' moment, but at least they know they are not alone."
EARLY INTERVENTION
According to the nonprofit Sensory Integration International, as many as 30 percent of school-age children have a learning disability. The majority are likely to have sensory integration problems, according to some research.
The syndrome affects far more boys than girls, although no reason has been determined.
Those are the children Rebecca Moyes hoped to reach when she opened the institute last June. It offers therapeutic services for a variety of childhood learning disabilities.
The institute is sponsoring a workshop April 2 at Futules' Harmar House, 1321 Freeport Road, Cheswick, for parents, educators and professionals, to address working with children with sensory dysfunction in the school and home.
Occupational therapist Ronna Hockbein recalled how Ben used to hide under a table and run from her when she provided in-home therapy.
These days, Yanan said, tantrums are almost a thing of the past. "He is so much calmer," she said.
Ben was flagged early by a pediatrician, his mother said. When his speech was not developing at 12 months, the doctor recommended therapy. At his 2-year-old checkup, sensory issues were discussed. Ben was seen by a development specialist, diagnosed and began occupational therapy.
Ben likes the feel of different textures -- mud, water, shaving cream -- on his skin. But certain food textures, including meat, can bother him. And he dreads getting his hair cut.
He and John Green Jr., 5, who also has autism and sensory dysfunction, have both benefited from a dietary change. Some autistic children seem to interact better with their peers and families when they follow a gluten- and casein-free diet.
John, said his mother, Marla Green, of Lower Burrell, is easily "set off" by certain noises, like vacuum cleaners and loud vehicles.
He also finds haircuts traumatic. "It takes him 15 to 20 minutes to calm down afterward," his mother said. "It takes him to the brink."
He has had some problems with fine-motor issues. But he is learning life skills, she said, and is better at dressing himself and holding a pencil.
"He's more focused," she added.
Marla Green is preparing a booklet to help her son's teachers when he begins kindergarten next year. "For John to succeed," she said, "his team needs to be on the same page."
He attends a typical preschool program. "We are hoping he can hold his own," his mother said. "If not, we will by all means get him a
(classroom aide)."
CHANGING BEHAVIOR
Earlier, Hockbein had applied shaving cream to John's legs and feet, as part of touch therapy. He and Ben took turns lying across and rolling around on a huge inflatable pillow. Ben slapped the pillow to show Hockbein he wanted to be lifted onto it.
"He normally doesn't like this," she said.
Working with Meeder, he identified animals on a wooden puzzle, and imitated the sounds they make.
"More animals," he told Meeder.
Ben, who sometimes fears strangers, turned to a visitor and instructed, "Away."
Meeder and Hockbein both have children with sensory dysfunction. Meeder recalls shopping trips lasting for hours, as her son traced the letters on license plates of cars in the parking lot.
"As a parent," Meeder said, "you educate your pediatrician, your therapists."
Moyes, a former teacher, added, "We really feel that parents and educators and professionals need training in this field."
Teachers can learn what sounds or activities can agitate children in their classrooms. Sometimes allowing "movement breaks," or letting children leave class before or after the halls become crowded, can make for a smoother school day.
Hockbein's son could glance at a clock and know when a school bell was about to ring, and raise a hood to cover his ears.
One of Meeder's son's teachers stuffed newspaper into an intercom system, to muffle the noise and reduce static.
Some children have eye-hand coordination problems, or trouble with perception of movement.
Their brains can perceive an action, "but they can't execute the movement," Meeder said.
With some kids, the smell of a shampoo, exhaust fumes or cleaning fluids can aggravate them.
Others have trouble with transitions, simply coming inside from outside, or putting a coat on or off.
Parents have to become detectives, Hockbein said, and determine the roots of certain behavior. "These behaviors always seem random, but they are never random," she said.
With early intervention, a child's prognosis can be good.
"Every single child has his own recommendation that will work for him," said Oresic. "It's definitely very individualized."
By David Noonan
Who is the sensory-sensitive child? Let's consider "Tom." When he walks into my music class, he doesn't want to be hugged or touched. Some days, he looks anxious as he makes the transition from the hall into my classroom. When I hand Tom an instrument, it often takes him a little extra time to take it from me and then figure out how to play it. If I give him more than two instruments to choose from, he becomes overwhelmed and can't make a decision. When Tom hears loud recorded or live music, he puts his hands over his ears as if he is in pain and he often blinks when the lights are too bright. He doesn't like to dance when he has to learn steps and often gets extremely frustrated when learning new movement sequences. One day, he became so frustrated during a dance activity that he "melted down," and it took a long time to calm him. Tom often complains that the tag in the back of his shirt is "itchy." He doesn't like to put his coat on in the winter and has a hard time tying his shoes. If the room is too hot or cold, he finds it difficult to focus on any musical tasks. Some days he has a lot of energy and is in constant motion. Other days he seems bored and unmotivated.
Tom scored very high on Gordon's Primary Measures of Musical Aptitude, and his IQ is within one standard deviation above the norm. He is extremely articulate. When he plays a musical instrument, he does so with enormous sensitivity, demonstrating capabilities well beyond his peers. When he moves, his motions are beautiful, thoughtful, and flowing. Tom has the potential to be a great musician. Who is Tom, and what separates him from other children? Tom has been diagnosed with Sensory Integrative Dysfunction. I do not use that term, preferring to use the term sensory challenged or sensory sensitive. The word "dysfunction" carries a heavy negative impact.
Tom is hypothetical, but for this article he typifies the characteristics of children who have sensory challenges. What defines sensory integration challenges? Our brains continually process incoming sensory input--sight, sound, touch, and smell. In addition to the more obvious senses, the brain also processes information from the vestibular system, which is located in the inner ear and processes movement and balance. Proprioception is still another sense, defined by how the muscles and joints interact in relationship to gravity. Children with sensory integration challenges have a difficult time processing everyday sensory input. The "wiring and firing" activity in the brain is such that sensations from a "normal" environment cannot be organized neurologically, and the child does not feel safe or comfortable in his or her world. Instead of their senses giving them the security they need to interact in the world, the information perceived through the senses is often inconsistent and unreliable, which leaves the child feeling insecure or frightened (Koomar, Szklut, and Cermak 1988). Often sensory issues are at the core of other disorders such as autism, attention deficit disorder, and learning disabilities. The primary purpose of this article is to assist the reader in recognizing sensory sensitivity in children and adapting the classroom environment so that the spark of music can remain alive and be nurtured. Knowledge leads to understanding, and understanding a child's behavior leads toward compassion. Understanding and compassion can result in the child's success as opposed to low self-esteem. Successfully adapting the classroom can also prevent teacher frustration, making the classroom environment more positive for both students and teachers.
Some children with sensory challenges are hypersensitive and, as a result, have an acute awareness of their environment. This challenge can also be their greatest gift. A child with a hypersensitive auditory system may score extremely well on a musical aptitude test and have great potential to be a wonderful musician, but become overwhelmed by too much auditory input. A logical adaptation is for the teacher to be aware of the volume of the live or recorded music. If you anticipate the classroom becoming too noisy, make prior arrangements with the child and give him or her a subtle, nonverbal cue to help him or her anticipate the dynamic level or arrange for the child to let you know when he or she needs to leave the environment in order to self-regulate. Hypersensitive children are often adversely affected by bright lights and poorly regulated temperatures. To adapt, cut some of the fluorescent lights and bring in floor lamps. A hypersensitive child who is too hot may fall apart simply because of the temperature. Be constantly aware of temperature extremes, and have a plan for dealing with them.
Other children with sensory challenges are undersensitive to sound, and as a result, their nervous systems may crave auditory input to remain organized. Allow these children to play a contrabass xylophone bar or other large instrument that vibrates fully. Chances are that if they are undersensitive in one area, they may be undersensitive in another. Therefore, the vibrations may allow the child to feel more secure with the incoming sensory input. For undersensitive children, it is often helpful to use consistent eye contact paired with animated facial expressions and voice. Children who present undersensitivity challenges often need a lot of input from their environment. For example, a quickly paced lesson paired with plenty of opportunities to experience many skills--moving, playing instruments, singing, and so forth--will allow the child the necessary sensory input within a structured setting. Lack of an appropriate level of stimulation may lead the child to create the necessary stimulation, which is often disruptive behavior.
What happens when a sensory-sensitive child has a meltdown in your classroom? In this situation, the child's nervous system gets overwhelmed and cannot organize any more input. The central nervous system must find a middle ground (Koomar, Stultz, and Cermak 1988). At that point, the child needs an opportunity to self-regulate or modulate his or her behavior. If meltdowns occur consistently in your classroom, explore the environment for causes. What happens before music class?
A typical setup for failure would be a child with sensory challenges who comes to music after physical education. This schedule would provide too much stimulation the period before and not enough time to make a transition into a potentially stimulating musical environment. Perhaps the child's schedule needs to be changed. If the schedule cannot be changed, how could you ease the transition? Here are several suggestions for extreme cases. Allow a young child to bring in a squeeze toy that doesn't make any noise. The repetitive movement of a squeeze toy may help stimulate the vestibular system and as a result help the child to better organize sensory input. I have a hammock swing in my classroom where children who have sensory challenges are allowed to go when they need to self-regulate. Again, the swinging motion stimulates the vestibular system in the same way that the squeeze toy does. You may see a child lying on the floor in an attempt to self-regulate. The pressure of their body against the floor can provide the brain with the necessary stimulation it needs at the time. The deep pressure of the floor against the body can be very calming and reassuring for an overstimulated child. Perhaps the child even needs to lie on the floor in a tent structure to help dampen visual input at that moment. In extreme cases, headphones may be necessary to eliminate auditory stimuli. When a tantrum occurs, it is important that the teacher remain calm and not get into a power struggle with the child. The child simply needs a safe container in which he or she can calm down (Aron 2002).
An extreme expression of frustration (e.g., meltdown) may also occur when children with sensory challenges are learning new steps to a dance or are engaged in any physical task that requires movement sequencing. This may be a sequence as simple as picking up an instrument and playing it. In this case, motor planning challenges are the culprit. Motor planning is the ability of the brain to organize and sequence a series of motor tasks. The child's brain simply cannot organize your plan for teaching. The resulting behaviors may appear to be disruptive and uncooperative, but they are simply adaptive--being silly, refusing to participate, or having a tantrum. When teaching sequential movement, regardless of the grade level, it is critical to employ adaptive teaching techniques. Use an icon for each sequence you teach. Present the teaching sequence in simple sentences rather than compound or complex sentences. Teach one idea at a time, and closely monitor the child's reactions. Be prepared to intervene before an escalation of disruptive behaviors occurs.
Some of the adaptations mentioned above are intrusive and could cause conflicts with other children in the class who want a toy or to swing. How do you deal with this? With younger children, I am comfortable explaining to the class that Tom sometimes gets upset and needs some extra help. I am quick to give Tom feedback regarding his own ability to self-regulate. For example, "I saw that when you picked up your squeeze toy, you began to calm down." I have seen children in a class of four-year-olds who would bring a squeeze toy to a child who was upset. This is the ideal situation: everyone is aware, compassionate, and able to offer assistance. For older children, this scenario may not work. Once self-consciousness becomes an issue, more subtle adaptations may need to be used.
Once you recognize that you have a child in your classroom with sensory challenges, you need to seek professional help. Please do not implement any of the adaptations suggested above without the support of other professionals. I highly recommend requesting the services of an occupational therapist who is trained in sensory integration, as well as consulting with the school psychologist or counselor. Working with a team will give you the support you need to develop creative solutions to a potentially frustrating situation. The results are rewarding and can often bring new depth to music teaching.
Historically, I would imagine that many of our greatest musicians presented a profile similar to Tom's. I often wonder how many children with sensory challenges who have extraordinary musical talent go undiscovered because of their "out-of-the-box" behaviors. Providing a classroom where a child with sensory challenges can thrive and continually discover the artist within is a great gift. Next time a "Tom" walks into your classroom, open your heart, embrace him, and perhaps eventually Tom the glowing musician will walk out.
References
??? Aron, E. 2002. The highly sensitive child: Helping our children thrive when the world overwhelms them. New York, NY: Broadway Books
??? Koomar, J., S. Szklut, and S. Cermak. 1988. Making sense of sensory integration (cassette recording). Boulder, CO: Belle Curve Records, Inc.
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By Liz Rose
Liz Rose is associate professor of music education and music therapy, Appalachian State University, Boone, North Carolina.