OVERVIEW OF SENSORY INTEGRATION

PREFACE

Sensory integration is a maturational process that occurs developmentally. In most cases, and with normal exposure to environmental stimuli and activities, the child's brain integrates information from the senses. But what happens if the normal sensory integration processes that occur with maturation are delayed or disordered? What would the signs or symptoms be?

When I attended a workshop on sensory integration therapy years ago and the presenter started describing the symptoms, I had to ask her how what she was describing was different from Attention Deficit Hyperactivity Disorder (ADHD), because some of the core symptoms for sensory integration dysfunction being describing included impulsivity, hyperactivity, distractibility, and fine motor problems.

ADHD and sensory integration dysfunction (SID) are not identical, even though there's a lot of similarity or overlap, she replied. Children with SID might be unusually sensitive or over-responsive to touch or certain kinds of sensory experiences, and they might be extremely uncomfortable with certain types of fabrics, she explained. Well, my son had those problems, too -- I used to have to cut all the tags out of the back of his shirts, he still is uncomfortable stand wearing shirts with button holes, and we totally gave up on him wearing socks for over five years because he had to keep pulling them up and the seams drove him crazy. But  I thought that was part of his Tourette's Syndrome and Obsessive-Compulsive Disorder. Now I was beginning to wonder whether what a lot of us had attributed to OCD might be this "other thing" -- Sensory Integration Disorder.

By the end of the workshop, it still seemed that there was tremendous overlap between what the presenter was calling SID and my son's ADHD-TS-OCD. Perhaps the only differentiating symptom I could see had to do with posture and balance.

As I read more on the topic, I learned that sensory integration problems seem to be discussed a lot in certain parent groups: parents of children with ADHD, parents of autistic children, and parents of children with Fragile X Syndrome, to name but some. But I also found out that there are no clearly agreed-upon diagnostic criteria, and that "Sensory Integration Disorder" is not recognized as a distinct disorder in either of the major diagnostic reference books (the ICD-10 and the DSM-IV-TR).

If you are teaching a child who has a veritable alphabet soup of diagnoses, you may be as puzzled as I was about sensory integration dysfunction and its symptoms. The following material is meant as an overview only and a summary of what I've read or learned elsewhere.

OVERVIEW

Dr. A. Jean Ayres is generally credited with developing both a theory of sensory integration dysfunction and therapeutic interventions for children suffering from it. Of particular importance here, her work emphasizes the importance of three of the senses: tactile, vestibular, and proprioceptive:

The tactile (touch) system provides information on light touch, pain, temperature, and pressure. If a child suffers from dysfunction in the tactile system, he may experience light touch or a gentle hug as intense or aversive, he may find certain kinds of fabrics or clothing irritating, may refuse to eat foods of a particular texture, and may avoid touching or handling certain kinds of objects. We say that a child is "tactile defensive" when he or she is extremely sensitive to light touch. When touched, it is as if the brain is flooded with an overload of sensory input that it cannot process, and the child's response may be disorganized and emotional. How often do we attempt to gently refocus a distracted child with a light touch on the shoulder?  How often have we seen a child who seems to be having an exaggerated pain response to something that we know was "just minor?" Perhaps we think that the child is just a "drama queen" or attempting to get our attention, but if the child is tactile defensive, it may be that they are really perceiving the sensory input differently than we do.

The vestibular system involves structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of your head. If you were to close your eyes for a moment and tilt your head, you would know that your head is tilted even without having the visual input because your vestibular system provides that information. If a child's vestibular system doesn't develop or integrate normally, she may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary childhood activities such as swinging on swings, going down slides, etc. She may also experience difficulty walking on or negotiating nonlevel surfaces such as hills or stairs. Children with this kind of hypersensitive vestibular system often appear clumsy. But not all children with vestibular dysfunction are hypersensitive. Some are under- or hyposensitive. Children with hyposensitive vestibular systems often engage in what appears to be sensation-seeking behaviors. They may whirl around like a dervish, jump, and/or spin.

The proprioceptive system provides feedback from your muscles, joints, and tendons and enables you to know your body's position in space. If there is a disturbance in the proprioceptive system, the child may be clumsy, fall, seem to maintain abnormal body postures, have difficulty manipulating small objects, and and may resist trying different movements.  If you've ever watched a student's grip on a writing instrument and noticed how abnormally tight the grip was, you may have been seeing an indication of this kind of problem.

When we talk about sensory integration dysfunction, we are talking about some disturbance in the child's ability to process sensory input. It could be a disturbance in just one of the sensory systems, or it could involve two or more systems.

SIGNS OF SENSORY INTEGRATION DYSFUNCTION

Signs of sensory itegration dysfunction in children may include:

• Overly sensitive to touch, movement, sights
• Inability to habituate to sounds and fear with unexpected noises
• Easily distracted
• Holding hands over ears in complex environment
• Avoids tastes, smells, or textures normally tolerated by children that age
• Activity level that is unusually high or unusually low
• Impulsive, lacking in self-control
• Inability to unwind or calm self
• Poor self-concept
• Social and/or emotional problems
• Physical clumsiness or apparent carelessness
• Hesitation going up or down stairs
• Difficulty making transitions from one situation to another
• Holding on to walls, furniture, people, or objects, even in familiar settings
• Delays in speech, language, or motor skills
• Delays in academic achievement
• Seeks out movement activities, but poor endurance and tires quickly

COMMENTS

While this brief overview has focused on three systems (tactile, vestibular, and proprioceptive), teachers should keep in mind that the child can have sensory defensiveness in any of the sensory systems. Thus, for example, some children will find certain sounds intolerable (such as the bell signalling change of periods, or noises in the hallway), while other children may find particular smells or tastes intolerable. Any kind of sensory defensiveness can make it difficult for the child to function normally in a school setting or to engage in normal social activities with peers.

If a student appears significantly impaired by sensory-related issues, the school-based occupational therapist should be asked to assess the student. Interventions designed to promote normalization of sensory integration appear to be most effective when provided early in life or in the elementary school-age years.

In terms of research investigating specific classroom interventions, one intervention that seems to have some usefulness is the use of weighed vests for young school children with autism or ADHD. A survey of professional school-based occupational therapists found that weighted vests were reported to increase attention span, staying on task, and staying in the child's seat.

Finally, and is the case with so many other diagnoses, "Sensory Integration Disorder" seems to have become the "diagnosis du jour" in some circles. One national support organization for children with Tourette's Syndrome has published a number of articles by their education "expert" that gives parents a whole list of symptoms and encourages them to insist that the school evaluate the child for SID if the child has any of those symptoms. To date, however, there has been absolutely no research to demonstrate that Tourette's Syndrome is, by itself, associated with sensory integration dysfunction. Tourette's Syndrome is definitely associated with sensory issues in the sense that many people with Tourette's report sensory prodromes or before releasing their tics, but that is not necessarily the same thing as a sensory integration dysfunction.

Let the student's behavior guide you. If the student seems to have significant trouble handling parts of the normal school routine -- if the hallways are "too loud and noisy" for them to handle, if they can't tolerate listening to the school band or music because it's "too loud," if they can't work with classroom materials because they feel "too yucky," if they can't tolerate certain smells or visual stimuli without getting emotional or engaging in avoidance behavior, if they seem to avoid normal childhood play activities that involve balance, if they have a very restrictive diet because of intolerance of certain tastes or textures -- then consider a referral to the occupational therapist. If the parents report that they have to cut the tags off of the child's clothes at home, well, there might be a sensory integration problem there, but it doesn't mean it's significantly interfering with their academic, social, or emotional functioning.