Sensory Integration for HALD SIG

1. Sensory Integrationfor HALD SIG Tricia Simon Principal Speech and Language Therapist ABMU Health Board November 2009

2. An introduction • 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

3. Sensory integration – Ayres 1989 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.

4. Some signs of sensory processing disorder • 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

5. Common disorders that coexist with sensory integration 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)

6. Which professionals are involved? • Often Occupational Therapists • Speech and Language Therapist • Physiotherapist The focus or goal of intervention may change depending on the professional background.

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

9. Sensory integration – difficulties observed • 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amounts of one type of stimulation • Avoid specific sensations • May be agitated, constantly on the go • Or quiet, withdrawn, self abusive, sleep a lot • May fail to register or recognise stimulus and ignore what is happening • May respond with alarm as they don’t fully understand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

10. Response to threat/stress Sensory difficulties may result in client operating only in survival mode Survival response may be: • Freeze, defiance, aggression • Or avoidance, compliance, dissociation

11. Levels of arousal profile Hyper excited or defensive Shut out stimuli through to shut down Response to stress: freeze, fight, flight, fright, vigilance? How do they self calm? E.g. head bang, deep pressure Calm, alert and attentive Hypo: Under responsive or high threshold How do they alert themselves e.g. spinning, chew

12. Intervention • 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.

13. Aims of intervention • 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)

14. Sensory regulating strategiesOetter 1991 Observe what the individual seeks. Aim for the individual to remain regulated during all stimuli. Initially therapist/carer acts as regulator by structuring environment.

15. Sensory Attachment Intervention Eadaoin Bhreathnach: OT and counsellor Uses theories of • Sensory integration • Attachment classification Use of therapeutic space from both sensory processing and attachment perspectives.

16. Attachment and sensory integration 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.

17. Using theory to form a hypothesis and test it out Question: Why is the client doing a behaviour Potential 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

18. Follow client’s lead • 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

19. Case example 1 John • 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

21. Levels of arousal profile Hyper excited or defensive Shut out stimuli through to shut down Response to stress: freeze, fight, flight, fright, vigilance? How do they self calm? E.g. head bang, deep pressure Calm, alert and attentive Hypo: Under responsive or high threshold How do they alert themselves e.g. spinning, chew

22. John: Hyperexcited/defensive • 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?

23. How does John self calm? • Tapping head • Tshirt pressure • Foetal position – pressure on joints • Chew • Suck • Retreats into self

24. Intervention for John 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

25. Case example 2: Paul • 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.

27. Intervention 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

28. Case example 3 – Jane • 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

29. Levels of arousal for Jane Signs of hyperexcitation Fight – hits self Flight – increased agitation Fear – when carer moves away increased SIB What calms – hitting self on head, hitting foot on wheelchair Calm alert state 1:1 on holiday Nurturing type activities (massage, cuddles, food) Being outside Water hoist

30. Sensory attachment issues for Jane • 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 – attachment Give staff strategies to support calm state and evidence the need for 1:1

31. Summary – questions to ask • 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

32. Further information • Sensory integration network UK and Ireland www.sensoryintegration.org.uk