What is Sensory Integration?
Sensory integration allows us to optimize on a daily basis our individual occupational performance and participation. Sensory integration is the process by which our brain receives, processes, modulates, organizes and makes sense of all the sensory information that we experience.
Sensory integration involves the information from our senses being sent to our brain where it interprets the information received, compares it against other information coming in as well as the information stored in our memory from past experiences. The brain then uses all of this information to help us respond to our environment. Well-regulated and appropriately functioning sensory systems contribute to important outcomes in social-emotional, physical and motor, communication, self-care, cognitive, and adaptive skills development and maintenance. Efficient sensory integration or sensory processing is important and allows us to do the things we need to do in our everyday life such as getting dressed, eating, socialising, learning and working.
For most people the development of sensory integration occurs when we are young and is part of our normal development: occurring when we do things like roll, crawl, walk and play. In some individuals, their sensory integration or sensory processing may be less well developed.
Who was the pioneer of Sensory Integration Theory and Practice?
Our understanding of sensory integration was initially developed in the late 1960s and 1970s by Jean Ayres, an Occupational Therapist and Psychologist with an understanding of neuroscience, working in the United States of America. Jean Ayres was interested in explaining how difficulties with receiving and processing sensory information from one’s body and environment could relate to difficulties at school or using one’s body to engage in everyday life.
Jean Ayres defined sensory integration as: ‘The neurological process that organises sensation from one’s own body and from the environment and makes it possible to use the body effectively with the environment’ (1972)
Jean Ayres developed a theory about what happens when sensory integration does not develop well, she developed a way of assessing these difficulties and a way of treating them. She carried out research to further develop and understand sensory integration and she treated many children with sensory integration difficulties. Her work provided Occupational Therapists with a neuroscience-based approach to address sensory integration concerns. Additional approaches emerging from Ayres’ theory have also been developed and aim to support sensory functions.
Jean Ayres was particularly interested in the interaction between and development of the vestibular system, proprioception, touch, vision and hearing. She saw these as important in supporting our ability to use our body, concentrate, develop self-esteem and confidence as well as self-control and academic skills. Today we are continuing to see the link between poorly developed senses and these abilities in our practice.
Sensory Integration Problems
Work by Parham and Mailloux (2015) has identified four categories of sensory integration problems in the following areas
1. Sensory Modulation
2. Sensory discrimination and perception
3. Vestibular bilateral function
What is meant by Problems with Sensory Modulation?
The brain either over or under responds to sensory information. We can all have these reactions from time to time but for some individuals the degree to which the brain responds or doesn’t respond impacts significantly on their daily life and function, and may also impact on the lives of their family and/or those ones around them. The individual may become distressed and/or miss out on things that are happening to them or near them. The individual may become anxious, fearful, angry and/or frustrated.
Individuals with modulation problems may develop coping strategies to assist them with difficult situations or sensory input e.g. cutting tags out of clothing, turning socks inside out so as to not feel and be bothered by the seams, removing their clothes or avoiding wearing particular clothing, not washing, flapping their hands, rocking, avoiding or withdrawing from certain environments or social situations. If an individual displays any of these types of behaviours it would be important to establish whether these behaviours might be due to poor modulation.
It has been found that individuals can be over responsive or under responsive in all the different senses, and that they may be over responsive in one and under responsive in another. For some they can be over responsive and under responsive within the same sense. Responsiveness can be dependent on a situation, an example being a stressful situation can make us more and sometimes less aware of sensation.
It is important to remember that everyone’s responses are unique to them.
What is meant by Sensory Discrimination and Perceptual Problems?
Sensory discrimination and perception refers to the process of the brain making sense of the sensory information it receives and interpreting subtle differences.
When an individual struggles to interpret subtle differences in sensation it is receiving (e.g. proprioception or touch) it may cause them to seem clumsy, they may use too much or too little force when doing things or they may have difficulties doing up buttons if they can’t feel two different points of touch close together.
Where there are problems with visual perception an individual may struggle to find objects in cluttered or busy environments, or to find a word on a page.
As part of a standardised assessment an Occupational Therapist trained in Sensory Integration could look at this area.
Vestibular-Bilateral Functional Problems – What does this mean?
Our vestibular sense picks up information about our direction of movement from receptors in the canals of our inner ear and sends it to the brain. The brain then interprets where and how we are moving, and our head/body position, and this information helps us plan our movements and maintain our balance.
Any problems with our vestibular sense can result in poor balance and difficulties with coordinating two sides (bilateral motor co-ordination) of the body. There can be many reasons for having balance and coordination problems but an Occupational Therapist trained in Sensory Integration will be able to identify whether the difficulties are a result of problems with the vestibular system.
Praxis Problems – What does this mean?
Praxis is how our brain plans for and carries out movements or activities that are new to us or that we have not done before. For example when a child begins to learn to ride a bike or an adult starts to learn to drive a car, praxis is essential for success and mastery of the new skill.
Dyspraxia or motor planning problems are terms used to refer to if an individual has praxis problems.
Not all praxis problems are a result of sensory integration.
Ayres identified two types of dyspraxia associated with underlying sensory issues. They are:
- Somatodyspraxia – where person has problems with praxis as well as problems with processing touch and proprioceptive senses
- Visuodyspraxia – where person has a problem with praxis and visual processing
Some people have been found to have both types of dyspraxia, while others have one or the other.
People with dyspraxia may present as clumsy or awkward with their movements.
Why Sensory Integration Assessment and Therapy?
Sensory integration and modulation disorders often lead people to have extreme over reactions to what others consider mild stimuli, or to completely shut down and disengage. Differences in interpretation of stimuli can impact motor skills and coordination, further limiting engagement and participation.
What a Sensory Integration Session Might Look Like?
A huge thank you to the family who consented to this collage of photos being used so other families may get some understanding of what a Sensory Integrative Therapy session might look like. These photos were screen shot from video footage taken as part of my studies and certification in Sensory Integration/SIPT (Sensory Integration and Praxis Tests).
SENSORY INTEGRATION AND SENSORY PROCESSING DISORDERS MAY PRESENT ACROSS THE LIFESPAN
Occupational Therapists can come across individuals of all ages with sensory integration and/or sensory modulation disorders. Across the main age groups the following issues may arise and require follow up from an Occupational Therapist trained in Sensory Integration.
Infants and toddlers at risk of developmental problems or those with a known disability or that are presenting with difficulties with modulation of the sensory input which may be making daily life a challenge e.g. in areas of sleep, emotional regulation, soothing, feeding, bathing, dressing, being moved or touched, and/or impacting on infant or toddler’s ability to reach out and engage with others, explore and experience freely and with pleasure play options at home and in the community.
Pre-school and school aged children with identified developmental problems, disabilities along with children who may have no diagnosis but appear to be struggling to keep up with their peers in the areas of play, being with other children and making friends, emotional regulation, independence in self care, attention, learning, general coordination and organization of self, work space and materials.
Adolescents and young adults with sensory integration or modulation issues such as a fear of movement, sensitivity to touch, poor motor planning or praxis issues and decreased awareness of their body position in space, may find these difficulties interfering with
- learning to drive
- choosing a suitable vocation
- engaging in leisure activities
- developing independence
- establishing a romantic relationship with another person
Adults of all ages who have never been identified with a sensory integration or processing disorder may present with difficulties with
- interpersonal relationships
- vocational skills
- engagement in healthy leisure activities
- quality of life
Without intervention, issues in sensory integration continue into adulthood and have been reported to impact work performance, relationships, and general functional abilities (Kinnealey, Koenig, & Smith, 2011).
SIGNS OF SENSORY INTEGRATION OR SENSORY PROCESSING DISORDER
The following are important to keep in mind
- not all children with a learning, developmental or behavioral problem have an underlying sensory integration disorder
- we all have our own unique sensory tolerances and preferences – what we like and don’t like
- our sensory preferences can change throughout our day
- as our sensory systems become more and more integrated, we learn how to pay attention to what is relevant sensory information and block out that which is not, and in doing so adapt our behaviors appropriately
Individuals with sensory integration disorder by not processing adequately sensory information, may display some of the following behaviors which can impact on independence in daily activities and routines, the foundations for learning and emotional well-being.
Over responsive to sensations: Individual may become overwhelmed by everyday sensory experiences and display
- irritability or withdrawal when touched
- being bothered by tags or seams in clothing
- dislike of brushing teeth, brushing hair or having their face washed
- avoid putting hands in sand, finger paint or glue
- not liking having finger or toe nails cut
- avoid going barefoot when walking on surfaces such as sand or grass or for a younger child dislike crawling on these surfaces
- avoidance of certain textures of clothing
- frequently suffer with car sickness
- appear fearful of movement experiences that are typically found in a playground or when riding on an escalator or elevator
- dislike crowded/noisy places such as shopping malls, restaurants or birthday parties
- prefer to be at the end of the line at school
- dislike swings or rides at a show
- an exaggerated fear of falling or heights
- react to motion or change of head position with signs of distress
- seem afraid of walking on a raised surface such as a step as if it seems too high
- avoid games that involve unpredictable movements of other children, especially those that may impact balance and control
- seem bothered by bright lights
- become distressed in a busy visual environment
- be frightened by sounds that do not usually cause distress in other children such as a vacuum cleaner or a hair dryer
- respond negatively to loud sounds by running away or placing hands over ears
- avoid certain textures or temperatures of foods
- gag at the thought of an unappealing food
- show distress at smells that other children do not notice
Under responsive to sensations: Due to an individual’s inability to adequately register sensory information, he/she may
- seek more intense sensory experiences such as spinning, crashing, bumping
- excessively touch objects or others
- not be able to tell what something is just by touching it – may need to see the object
- not feel or notice pain as much as others
- be messy when eating
- not get dizzy, even after many minutes of spinning, and may love fast moving equipment
- walk into objects as if they were not there
- enjoy watching objects spin
- like to turn light switches on and off repeatedly
- appear not to hear certain sounds
- lick, smell or mouth non-food objects excessively
Problems maintaining a calm-alert state: an individual who has problems maintaining the ‘just right’ level of arousal for the demands of the task and that moment, may present with
- an activity level that is unusually high or low and may experience severe fluctuations between the two throughout the day
- being slow to rise and/or have difficulty falling asleep or settling
- waking frequently in the middle of the night
- problems maintaining attention in the classroom or while doing homework
- decreased self control
Poor Body Awareness: refers to the inability to know where the body is in space and how the body moves through space. An individual with problems in this area may
- tend to lean on objects or people
- bump into things or other children
- grasp objects too hard or too soft
- chew on toys, clothes or other objects
- break things from pressing or pushing too hard on them
- jump a lot
- misjudge how high or low to move body parts when sitting down or stepping over objects
Gravitational insecurity: Gravitational insecurity is an unusual fear response to movements and/or height that is not typically threatening to other children of the same age (Ayres, 2005). This may be seen when the individual
- becomes anxious when feet are off the ground
- has an exaggerated fear of falling
- reacts negatively to changes in head position, particularly when the head is inverted forward or backwards
- does not enjoy playgrounds or riding toys as much as other children
- avoids stepping or jumping down from a higher surface to a lower surface
- is afraid of losing his or her balance
- avoids climbing activities
- feels insecure in wide open spaces
Praxis or motor planning difficulties: Praxis results from good sensory integration of sensations from our skin, muscles and joints and inner ear, and provides us with a ‘map’ of what is required to efficiently accomplish an activity or task. Where there are challenges with praxis you may see the individual has
- trouble getting started on or ending activities
- difficulty learning new tasks
- difficulty manipulating tools or toys
- difficulty using utensils for eating and writing
- problems coordinating the two sides of the body which impacts on ball skills and the ability to do well in sport
- inability to imitate someone else’s body movements such as those in ‘Simon Says’, waving bye-bye, and blowing kisses
- problems with eating or speech/language development
- difficulty building a structure with blocks or lego from a picture or a structure that someone else has built
- seems to do things inefficiently
- difficulty following directions
- tendency to avoid unfamiliar tasks preferring to play the same games over and over
- limited ideation or ideas for play
Poor organizational skills: Refers to the inability to plan, gather materials, sequence multiple steps, execute and efficiently complete a task. This may be seen in the individual
- having difficulty sitting still
- being impulsive and not appearing to have a plan of action to accomplish a task
- having difficulty with multiple step directions and sequencing the steps involved
- having difficulty adjusting to new situations or environments
- being easily frustrated
- being distractible and having difficulty maintaining attention
- having decreased frustration tolerance
- finding transitions and change difficult
- having the need to be ‘in control’ and presenting as inflexible
Visual Perceptual problems: may occur when an individual finds it hard to organize and mentally manipulate visual stimuli in their brain, to be able to discriminate parts from whole, to see an object imbedded with other objects, to understand the objects position in space and to recognize objects that are partially hidden. Problems in this area may present as
- having difficulty with puzzles or building with blocks
- getting lost easily
- having trouble recognizing similarities and differences in patterns or designs
- having a hard time finding something in a drawer or picking a face out of a crowd
- having difficulty aligning fasteners on clothing or putting shoes on the correct foot
- attending to ‘parts’ of a project but has trouble seeing the ‘whole or big picture’
- difficulty with organizational skills in the classroom such as where to place completed work, location of the pencil sharpener, copying assignments off of the board
Delays in academic achievement: In young preschool aged children, these can be seen in combination with other sensory signs such as over or under responsivity to touch or movement. In older, school aged children, there may be academic difficulties despite normal to high intelligence. These may include
- difficulties transitioning
- unable to follow classroom routines
- fidgeting or appearing lethargic and/or uninterested when sitting and listening
- poor organization of classroom materials
- difficulty copying from the board
- presses too hard or too light with pencil
- written tasks are not easily read or well presented or organized
- lining up numbers during a written maths exercise might be a challenge
- problems with reading across the page and maintaining their place on the text
Poor self-esteem: An individual’s sense of self, pride and success can be impacted on by inefficient sensory processing or integration. An individual with poor self-esteem may
- be feeling bad about themself but they may not understand why
- appear lazy, bored or unmotivated
- look for ways to avoid tasks that are difficult or embarrassing such as homework
- be considered troublesome or stubborn
If a child has a sensory integration disorder, it is not likely that they will ‘grow out of it’. The child may learn ‘splinter skills’ that assists in compensating for poor sensory processing, however, this only covers up the problem. The individual then expends much more effort and energy than they should, leaving less energy for other things.
Sensory integration disorder is a condition that is not easily recognizable or identifiable but it can have a significant impact on an individual’s ability to perform well in their daily occupational roles and lead a healthy and happy life. Where a problem is difficult to see or understand, those involved, the parents and/or child, may begin to blame themselves which may result in further tension and anxiety, poor self-esteem and feelings of hopelessness.
There are 8 senses: 5 which are quite familiar to most of us i.e. sight, hearing, smell, touch and taste. There are 3 other senses less known about which are also important to our daily well-being. They include proprioception, vestibular and interoception.
Proprioception: Our muscles and joints have tiny sensory receptors that tell our brain where our body parts are. When you put a spoon to your mouth, you don’t need to look at the spoon to see where it is or feel for your mouth to know where to place the spoon; you know where your hand is in relation to your mouth. It is largely your proprioceptive receptors giving you this information. Your brain then uses this proprioceptive information to plan movements so that you can coordinate your body.
Vestibular: In our inner ear we have small, fluid filled canals, the fluid in these canals moves every time we move our head. Receptors in these canals pick up the direction of movement and send this information on to our brain. So we know if we are moving forwards, backwards, side to side, tilting our head, turning round or moving up and down.
Once again, our brain uses this information to plan for movements and help us maintain our balance.
Interoception: this is a fairly new area for discussion in sensory integration; interoception is how our body tells our brain what is going on inside our body, when we are hungry or feel full, when our heart is beating fast or when we have that sensation of butterflies in the stomach.
SENSORY INTEGRATION – SENSORY PROCESSING RESOURCES
Sensory Integration Network (UK & Ireland)
Sensory Integration Global Network (SIGN)
AOTA The American Occupational Therapy Association Inc. Fact Sheet 2015 ‘Addressing Sensory Integration and Sensory Processing Disorders Across the Lifespan: The Role of Occupational Therapy’
‘Sensory Integration and the Child’ by A. Jean Ayres, Ph.D. WPS (1985)
‘Sensory Integration and the Child: 25th Anniversary Edition’ by A. Jean Ayres, Ph.D. WPS (2005)
‘Sensory Integration: Theory and Practice’ by Anita C. Bundy, Shelly J. Lane, Anne G. Fisher, Elizabeth A. Murray, F.A. Davis Company (2002)
‘Sensational Kids: Hope and Help for Children with Sensory Processing Disorder (SPD)’ by Lucy Jane Miller, Ph.D, OTR (2014)
‘The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder’ by Carol Kranowitz, M.A. (2006)