Sensory Sensory Processing Processing Disorder: Disorder:

Identification Identification and Intervention and Intervention

Linda King-Thomas MHS, OTR/LLinda King-Thomas MHS, OTR/L

Developmental Therapy Developmental Therapy AssociatesAssociates

Durham and CaryDurham and Cary

www.developmentaltherapy.comwww.developmentaltherapy.com

Sensory IntegrationSensory Integration

Sensory integration is the neurological Sensory integration is the neurological process that organizes sensation from process that organizes sensation from one’s own body and from the one’s own body and from the environment and makes it possible to environment and makes it possible to use the body effectively within the use the body effectively within the environment.environment. Ayres (1972) Ayres (1972) Sensory Integration and Learning Sensory Integration and Learning DisordersDisorders p.11 p.11

Uses of the term Uses of the term Sensory IntegrationSensory Integration

Theory (sensory integration theory)Theory (sensory integration theory)

Diagnosis (based on an assessment)Diagnosis (based on an assessment) Sensory Processing Disorder (SPD)Sensory Processing Disorder (SPD)

Functional pattern (normal sensory Functional pattern (normal sensory integration abilities)integration abilities)

Remediation approach Remediation approach (therapy/intervention(therapy/intervention

Sensory SystemsSensory Systems Vestibular (movement and gravity)Vestibular (movement and gravity) Tactile (touch)Tactile (touch) Proprioceptive (“heavy work”, Proprioceptive (“heavy work”,

input to muscles and joints)input to muscles and joints) Auditory (hearing)Auditory (hearing) Visual (sight)Visual (sight) Olfactory (smell)Olfactory (smell) Gustatory (taste)Gustatory (taste)

Sensory Integration Sensory Integration Foundations for Learning Foundations for Learning

and Behaviorand Behavior

Sensory Processing Sensory Processing DisorderDisorder

Sensory Modulation DisorderSensory Modulation Disorder Sensory Over-ResponsivitySensory Over-Responsivity Sensory Under-ResponsivitySensory Under-Responsivity Sensory Seeking / CravingSensory Seeking / Craving

Sensory Discrimination DisorderSensory Discrimination Disorder

Sensory-Based Motor DisorderSensory-Based Motor Disorder Postural DisorderPostural Disorder DyspraxiaDyspraxia

Sensory Modulation Sensory Modulation DisorderDisorder

Difficulty modulating, discriminating Difficulty modulating, discriminating and organizing sensory inputand organizing sensory input

Difficulty with self-regulation, in terms Difficulty with self-regulation, in terms of arousal states, may be under or over of arousal states, may be under or over responsive to sensory inputresponsive to sensory input

Difficulty interacting effectively to Difficulty interacting effectively to demands of environment, relationships demands of environment, relationships and tasksand tasks

Difficulty adapting to challenges in Difficulty adapting to challenges in daily lifedaily life

Sensory Modulation Sensory Modulation DisorderDisorder

Sensory Over-Responsivity – quick or Sensory Over-Responsivity – quick or intense response to sensory stimuliintense response to sensory stimuli

Sensory Under-Responsivity -- slow Sensory Under-Responsivity -- slow response to sensory stimuli, requires a response to sensory stimuli, requires a high intensity or increased duration of high intensity or increased duration of stimuli to elicit a behavioral response stimuli to elicit a behavioral response

Sensory Seeking/Craving – actively Sensory Seeking/Craving – actively seeking sensation often in socially seeking sensation often in socially unacceptable wayunacceptable way

Alertness / Arousal Alertness / Arousal StatesStates

Sensory Over-Sensory Over-ResponsivityResponsivity

Covers ears with loud noises Covers ears with loud noises Is sensitive to bright lightsIs sensitive to bright lights Fears movement or changes in positionFears movement or changes in position Avoids touching certain textures (grass, Avoids touching certain textures (grass,

sand, finger paints, squishy)sand, finger paints, squishy) Does not like to get messyDoes not like to get messy Has strong clothing preferencesHas strong clothing preferences Does not like to be touched Does not like to be touched

unexpectedlyunexpectedly Has a poor tolerance to groomingHas a poor tolerance to grooming

Sensory Over-Sensory Over-ResponsivityResponsivity

Is often irritable, aggressive, impulsive, Is often irritable, aggressive, impulsive, and moodyand moody

Has a poor tolerance to transitionsHas a poor tolerance to transitions Frequently cries and is hard to consoleFrequently cries and is hard to console Does not like to be held or cuddledDoes not like to be held or cuddled Needs help to fall asleep and stay asleepNeeds help to fall asleep and stay asleep Exhibits extreme separation anxietyExhibits extreme separation anxiety Has difficulty transitions to new foodsHas difficulty transitions to new foods

Sensory Under-Sensory Under-Responsivity Responsivity

Has delayed reaction time Has delayed reaction time Is slow to respond to nameIs slow to respond to name Seems unaware of environment, Seems unaware of environment,

wanderswanders Has a high pain toleranceHas a high pain tolerance Does not sense when diaper is wetDoes not sense when diaper is wet Does not feel clothing twisted on bodyDoes not feel clothing twisted on body Does not feel food on face or in Does not feel food on face or in

mouth, or dirt on handsmouth, or dirt on hands

Sensory Under-Sensory Under-ResponsivityResponsivity

Does not seem to notice when touchedDoes not seem to notice when touched Has flat affect much of the timeHas flat affect much of the time Is hard to engage, may observe but not participateIs hard to engage, may observe but not participate Is unaware of body sensations (temperature, Is unaware of body sensations (temperature,

hunger)hunger) Does not seem to notice noxious odorsDoes not seem to notice noxious odors Appears slow, unmotivated, unaware,or withdrawnAppears slow, unmotivated, unaware,or withdrawn Seems to be ‘lost in fantasy world’Seems to be ‘lost in fantasy world’

Sensory Seeking Sensory Seeking

Has a high activity level, seldom sits Has a high activity level, seldom sits stillstill

Touches everythingTouches everything Hangs on people/objectsHangs on people/objects Smells or mouths everythingSmells or mouths everything Takes excessive risks that compromise Takes excessive risks that compromise

personal safetypersonal safety Prefers foods with strong flavorsPrefers foods with strong flavors Often mouths or licks non-food itemsOften mouths or licks non-food items

Sensory SeekingSensory Seeking

Seeks out loud noiseSeeks out loud noise Likes to watch bright/spinning Likes to watch bright/spinning

objectsobjects Is excessively affectionateIs excessively affectionate May be demanding or hard to calmMay be demanding or hard to calm Is a risk takerIs a risk taker Intrudes on othersIntrudes on others May be kicked out of child care or May be kicked out of child care or

expelled from preschoolexpelled from preschool

Influence on Play SkillsInfluence on Play Skills

Avoidance of handling toys and typical play Avoidance of handling toys and typical play materialsmaterials

Withdrawal from noisy play, toys that make Withdrawal from noisy play, toys that make soundssounds

Fearfulness of movement limits desire for Fearfulness of movement limits desire for exploration of the physical worldexploration of the physical world

Avoidance or lack of registration reduces vital Avoidance or lack of registration reduces vital developmental stimulationdevelopmental stimulation

Withdrawal from special childhood events such Withdrawal from special childhood events such as birthday parties, dressing up for Halloween as birthday parties, dressing up for Halloween and holiday partiesand holiday parties

Influence on Self-Care and Influence on Self-Care and FeedingFeeding

Avoidance and/or rejection of food Avoidance and/or rejection of food textures, tastes, smells, temperaturetextures, tastes, smells, temperature

Avoidance and/or rejection of tooth Avoidance and/or rejection of tooth brushing and bathingbrushing and bathing

Avoidance and/or rejection of hair Avoidance and/or rejection of hair brushing, hair washing, hair cuttingbrushing, hair washing, hair cutting

Avoidance and/or rejection of Avoidance and/or rejection of clothing textures and dressing clothing textures and dressing processprocess

Influence on School Related Influence on School Related ActivitiesActivities

Avoidance of classroom tools and Avoidance of classroom tools and materialsmaterials

Difficulty with participation in group Difficulty with participation in group activities which involve movement, activities which involve movement, touch or soundtouch or sound

Difficulty staying in lineDifficulty staying in line Difficulty self-regulation attention in Difficulty self-regulation attention in

the classroomthe classroom

Influence on Social Influence on Social ParticipationParticipation

Disruption of attachment relationships Disruption of attachment relationships due to approach/avoidance conflictdue to approach/avoidance conflict

Avoidance of a need to be in control, or Avoidance of a need to be in control, or aggression towards peersaggression towards peers

Disruption in ability to develop and Disruption in ability to develop and maintain friendships and love maintain friendships and love relationships in adultsrelationships in adults

Decreased perception of social Decreased perception of social acceptance which leads to decreased self-acceptance which leads to decreased self-esteem esteem

Sensory-Based Motor Sensory-Based Motor DisorderDisorder

Postural Disorder: difficulty stabilizing the body during Postural Disorder: difficulty stabilizing the body during movement or at rest to meet demands of a motor taskmovement or at rest to meet demands of a motor task

Dyspraxia: difficulty translating sensory information Dyspraxia: difficulty translating sensory information into planning and/or sequencing movement, especially into planning and/or sequencing movement, especially new or unfamiliarnew or unfamiliar

Postural DisorderPostural Disorder Fears movement due to inadequate Fears movement due to inadequate

postural controlpostural control Does not like ‘tummy time’Does not like ‘tummy time’ Has decreased muscle toneHas decreased muscle tone Seems weak compared to peersSeems weak compared to peers Loses balance easilyLoses balance easily Tires easily, has poor enduranceTires easily, has poor endurance Frequently trips and fallsFrequently trips and falls Appears lazy and unmotivatedAppears lazy and unmotivated Has difficulty using both hands and feet Has difficulty using both hands and feet

at the same time (bilateral coordination)at the same time (bilateral coordination)

DyspraxiaDyspraxia

Difficulty translating sensory Difficulty translating sensory information into ideas for movement, information into ideas for movement, planning, organizing and/or planning, organizing and/or sequencing movement, especially sequencing movement, especially new and unfamiliar actionsnew and unfamiliar actions

Can manifest as gross motor, fine Can manifest as gross motor, fine motor and/or oral-motor problemsmotor and/or oral-motor problems

DyspraxiaDyspraxia

Is clumsyIs clumsy Eats messilyEats messily Has a disheveled appearanceHas a disheveled appearance Uses toys the same way over and overUses toys the same way over and over Is rigid in play/routinesIs rigid in play/routines Frustrates easilyFrustrates easily Has trouble maneuvering around Has trouble maneuvering around

obstaclesobstacles Breaks things unintentionally Breaks things unintentionally

DyspraxiaDyspraxia

Has difficulty following directions for Has difficulty following directions for activities that require more than one stepactivities that require more than one step

Has trouble learning new skillsHas trouble learning new skills Is disorganizedIs disorganized Prefers ‘fantasy games’ over physical Prefers ‘fantasy games’ over physical

gamesgames Prefers sedentary activitiesPrefers sedentary activities Has delays in speech and/or motor skills Has delays in speech and/or motor skills

ranging from mild to severeranging from mild to severe

Influence on Play Skills Influence on Play Skills

Difficulty with playground activitiesDifficulty with playground activities Difficulty with manipulative and construction Difficulty with manipulative and construction

toystoys Difficulty with the sequence and rules of playDifficulty with the sequence and rules of play Difficulty with timing and sequencing of Difficulty with timing and sequencing of

body parts in sports and motor activitiesbody parts in sports and motor activities Directional confusion leads to poor spatial Directional confusion leads to poor spatial

organization with team sports.organization with team sports. Poor ideation leads to decreased play Poor ideation leads to decreased play

possibilitiespossibilities

Influence on Self-Care and Influence on Self-Care and FeedingFeeding

Slow in managing dressing fasteners and Slow in managing dressing fasteners and shoe tyingshoe tying

Difficulty in mastering the spatial Difficulty in mastering the spatial organization of clothingorganization of clothing

Problems managing tools for self-care Problems managing tools for self-care (hairbrush, washcloth, utensils)(hairbrush, washcloth, utensils)

Difficulty with food wrappersDifficulty with food wrappers Messy eaterMessy eater Disorganization with personal belongingsDisorganization with personal belongings

Influence on School Related Influence on School Related ActivitiesActivities

Poor and/or slow handwriting and Poor and/or slow handwriting and drawing skillsdrawing skills

Difficulty using classroom tools and Difficulty using classroom tools and materials effectively (scissors, glue materials effectively (scissors, glue bottle)bottle)

Disorganization of work space (desk, Disorganization of work space (desk, locker)locker)

Difficulty learning new skills through Difficulty learning new skills through imitation imitation

Influence on Social Influence on Social ParticipationParticipation

Social rejection by peers during games Social rejection by peers during games due to poor motor skillsdue to poor motor skills

Withdrawal from social situations due to Withdrawal from social situations due to poor self-esteempoor self-esteem

Difficulty discerning social and physical Difficulty discerning social and physical boundaries; poor social judgmentboundaries; poor social judgment

Disorganized peer interactions due to Disorganized peer interactions due to poor ability to read non-verbal cuespoor ability to read non-verbal cues

Tendency to be rigid and controllingTendency to be rigid and controlling

InterventionIntervention

Education/awarenessEducation/awareness reframe behavior (view) from a new reframe behavior (view) from a new

perspectiveperspective

Individual therapy using a sensory Individual therapy using a sensory integrative approachintegrative approach

Consultation model for home and schoolConsultation model for home and school Develop new strategies – sensory dietDevelop new strategies – sensory diet

ResearchResearch Roberts, J. E., King-Thomas, L., & Boccia, M. L. Roberts, J. E., King-Thomas, L., & Boccia, M. L.

(2007). Behavioral indexes of the efficacy of sensory (2007). Behavioral indexes of the efficacy of sensory integration therapy. integration therapy. AJOTAJOT, 61, 555-562, 61, 555-562

Single subject ABAB design: subject diagnosed with Single subject ABAB design: subject diagnosed with sensory modulation disorder and delayed sensory modulation disorder and delayed communication skillscommunication skills

Behavioral data collected by preschool teachers who Behavioral data collected by preschool teachers who were blind to the timing of sensory integration were blind to the timing of sensory integration therapytherapy

Improvements in behavioral regulation noted: Improvements in behavioral regulation noted: increased engagement & decreased aggression, increased engagement & decreased aggression, less need for intense teacher direction, decreased less need for intense teacher direction, decreased mouthing objectsmouthing objects

Research Research Miller, L. J., Coll, J. R., & Schoen, S. A. (2007). A Miller, L. J., Coll, J. R., & Schoen, S. A. (2007). A

randomized controlled pilot study of the randomized controlled pilot study of the effectiveness of occupational therapy for children effectiveness of occupational therapy for children with sensory modulation disorder. with sensory modulation disorder. AJOTAJOT, 61, , 61, 228-238.228-238.

Twenty-four children assigned to 1 of 3 treatment Twenty-four children assigned to 1 of 3 treatment groups: OT-SI, Activity Protocol, and No groups: OT-SI, Activity Protocol, and No TreatmentTreatment

Significant changes noted in OT-SI group on GAS Significant changes noted in OT-SI group on GAS (goal attainment scaling), attention, (goal attainment scaling), attention, Cognitive/Social composite of Leiter-R parent Cognitive/Social composite of Leiter-R parent ratingrating

Sensory DietSensory Diet

The daily intake of sensory and motor The daily intake of sensory and motor experiences needed by a person to experiences needed by a person to adaptively interact with the adaptively interact with the environmentenvironment

Sensory and motor experiences help Sensory and motor experiences help maintain optimal arousal and attention maintain optimal arousal and attention for learning for learning

Sensory diet formula: intensity, Sensory diet formula: intensity, frequency, duration, rhythm of input is frequency, duration, rhythm of input is varied to achieve optimal performancevaried to achieve optimal performance

Sensory Diet ActivitiesSensory Diet Activities

Specific to the individual based on Specific to the individual based on assessmentassessment

Planned throughout the day to help Planned throughout the day to help maintain optimal level of organizationmaintain optimal level of organization

Most powerful and long lasting include: Most powerful and long lasting include: movement, heavy work, deep touch movement, heavy work, deep touch pressurepressure

Sensation can have calming or alerting Sensation can have calming or alerting effecteffect

Sensory Diet Activities Sensory Diet Activities

Structure activities in a playful, non-Structure activities in a playful, non-threatening mannerthreatening manner

Closely monitor for an adaptive Closely monitor for an adaptive response -- more organized behaviorresponse -- more organized behavior

More sensation in not always better More sensation in not always better --observe for signs which might --observe for signs which might indicate an overstressed nervous indicate an overstressed nervous systemsystem

MovementMovement

Unstable surfaces: therapy ball, Unstable surfaces: therapy ball, air pillow, air pillow, air cushionair cushion

Games and calisthenicsGames and calisthenics Jumping, swinging, Jumping, swinging, Rocking, rolling, Rocking, rolling, Bouncing, Bouncing, Marching, dancingMarching, dancing

Heavy WorkHeavy Work

Carrying heavy objectsCarrying heavy objects Wheelbarrow walk, animal walksWheelbarrow walk, animal walks BackpackBackpack Digging in a gardenDigging in a garden Working out on weight machinesWorking out on weight machines Pulling friend in a wagonPulling friend in a wagon Pushing heavy grocery cartPushing heavy grocery cart SportsSports

Deep Pressure TouchDeep Pressure Touch

Weighted vest, Weighted vest, weighted blanketweighted blanket

Firm hugs, Firm hugs, massagemassage

Lycra exercise Lycra exercise shorts or tights shorts or tights under clothing under clothing

Games: Games: rough house playrough house play tactile sandwichtactile sandwich

Oral MotorOral Motor

Suck: long straw or thick liquids; Suck: long straw or thick liquids; sour, sweet, spicy hot candysour, sweet, spicy hot candy

Blow: whistles; bubblesBlow: whistles; bubbles

Chew and crunch: gum, popcorn, Chew and crunch: gum, popcorn, dried fruit, bagel, pretzels; chewy dried fruit, bagel, pretzels; chewy tube, straws tube, straws

Womb SpacesWomb Spaces

Under a table or deskUnder a table or desk Tent or sleeping bagTent or sleeping bag Inside a closet or other small space Inside a closet or other small space

(box)(box) Pillow in a corner of the roomPillow in a corner of the room Creating small space feeling with Creating small space feeling with

furniture positionfurniture position

TactileTactile Hand toys to fidget: koosh balls, Hand toys to fidget: koosh balls,

silly putty, bendable figures, small silly putty, bendable figures, small stuffed animals, pieces of soft fabricstuffed animals, pieces of soft fabric

Extra toweling after the bathExtra toweling after the bath Tactile fine motor activities Tactile fine motor activities

kneading bread kneading bread sand playsand play bean playbean play finger paintingfinger painting

Tactile StrategiesTactile Strategies

Temperature: cool is alerting, warm Temperature: cool is alerting, warm is calmingis calming

Clothing preferences: long sleeve, Clothing preferences: long sleeve, short sleeve, cut out tags, sport short sleeve, cut out tags, sport socks (no seams)socks (no seams)

Bed clothes: flannel sheets, heavy Bed clothes: flannel sheets, heavy blanket, light sheetblanket, light sheet

Light touch (tickling): alertingLight touch (tickling): alerting

Auditory StrategiesAuditory Strategies

Soft music-- Mozart, fast music -- Soft music-- Mozart, fast music -- driving beatdriving beat

Ear muffs, headphonesEar muffs, headphones White noise machine, water White noise machine, water

fountain, soft background musicfountain, soft background music Voice quality -- high or low pitchVoice quality -- high or low pitch

Visual StrategiesVisual Strategies

Soft dim lightsSoft dim lights Natural light, avoid fluorescent lightNatural light, avoid fluorescent light Muted colors and plain wallsMuted colors and plain walls Bright lightsBright lights Movement in peripheral visual fieldMovement in peripheral visual field Lots of colorLots of color

Resources BooksResources Books Heller, S. (2002). Too Loud, Too Bright, Heller, S. (2002). Too Loud, Too Bright,

Too Fast, Too Tight. New York: Too Fast, Too Tight. New York: HarperCollins Publishers.HarperCollins Publishers.

Henry, D., Kane-Wineland, M., Henry, D., Kane-Wineland, M., Swindeman, S., (2007). Tools for Tots: Swindeman, S., (2007). Tools for Tots: Sensory Strategies for Toddlers and Sensory Strategies for Toddlers and Preschoolers. Glendale, AZ: Henry OT Preschoolers. Glendale, AZ: Henry OT Services.Services.

Isbell, C. & Isbell, R. (2007). Sensory Isbell, C. & Isbell, R. (2007). Sensory Integration A Guide for Preschool Integration A Guide for Preschool Teachers. Beltsville, MD: Gryphon Teachers. Beltsville, MD: Gryphon House.House.

Resources BooksResources Books Kranowitz, C. (2005). The Out-of-Sync Kranowitz, C. (2005). The Out-of-Sync

Child. New York: Penguin Group.Child. New York: Penguin Group. Miller, L. J. (2006). Sensational Kids. Miller, L. J. (2006). Sensational Kids.

New York: Penguin Group.New York: Penguin Group. Williams, M. S., Shellengerger, S. (2001). Williams, M. S., Shellengerger, S. (2001).

Take Five! Staying Alert at Home and Take Five! Staying Alert at Home and School. Albuquerque, NM: School. Albuquerque, NM: TherapyWorks, Inc.TherapyWorks, Inc.

Yack, E., Aquilla, P. & Sutton, S. (2002). Yack, E., Aquilla, P. & Sutton, S. (2002). Building Bridges through Sensory Building Bridges through Sensory Integration. Las Vegas: Sensory Integration. Las Vegas: Sensory Resources.Resources.

Resources catalogs Resources catalogs Abilitations 1-800-850-8602 Abilitations 1-800-850-8602

www.abilitations.com Fun and Function 1-800-231-6329 Fun and Function 1-800-231-6329

www.FunANDFunction.com Sensory Critters 1-866-749-2737 Sensory Critters 1-866-749-2737

www.SensoryCritters.com Southpaw Products 1-800-228-1698Southpaw Products 1-800-228-1698

www.southpawenterprises.com Therapy Skill Builders 1-800-872-Therapy Skill Builders 1-800-872-

1726 1726 www.psychcorp.com

Resources on the webResources on the web

Sensory Processing Disorder Sensory Processing Disorder FoundationFoundation www.spdfoundation.net

SI Focus magazine SI Focus magazine www.sifocus.com

Developmental Therapy AssociatesDevelopmental Therapy Associates www.developmentaltherapy.com