Functional problems- Is it sensory AND behaviour, complex clinical reasoning Dee-Arn Holzl, O.T Merthyr CLDT, 20 June 2012
Aims/ content 1. Overview Sensory Integration( SI) theory, originator Jean Ayres. Diagram 1 2. Sensory AND behaviour- adolescents, adults. 3. Expansions to theory- Sensory Defensiveness, Sensory Diets, Sensory Attachment, Auditory Processing, Autistic Persons describing their sensory experiences. 4. Diagram 2. complex clinical reasoning used. 5. Two case scenarios. 6. Sensory points to consider when analysing the function of behaviour.
Terms- attempts to be consistent Sensory Integration (SI) theory is term used within OT profession but latest term for disorders is Sensory Processing Disorder (SPD) Tips to survive SI training: can be quite overwhelming, apply it in relation to specific referrals whilst reviewing references, lots of reading and reflection, look for patterns.
Who am I? Bachelor Occupational Therapy, Uni of Qld., Brisbane plus one research module, Open University. 10 years MH (acute, community, rehab, day services, intake) 15 years LD (hospital, resettlement, day services, community) Lecturer ( QIT, Brisbane, Caboolture)
Who am I? Singer, musician- look for patterns Awards for maths, science- patterns Courses Sensory Integration (3) Sensory Defensiveness (1) Therapeutic listening (2) Dyspraxia (1) TEACCH (1) Intensive Interaction (2)
1. Overview Sensory Integration In order to use our bodies in a coordinated and calm way we need to register, process and integrate the meaning of various sensations. Visual, sound, touch, moving or sustaining our body in certain positions, positioning or moving our head, taste, smell. Apply this to yourselves as you sit and listen to me in this room. What sensations within your body, the venue, the activity and which are helpful?..distracting? There are many interconnections between the different sensory systems, but the original theory focused on mainly these senses: tactile, vestibular/visual, proprioception.
What is Sensory Integration? Lindsay Hardy, S. I. Network A term used by the originator of the theory, Jean Ayres, Occupational Therapist, Psychologist, Neuroscientist. 1920-1988. SI has 3 interrelated elements of practice: A theory of normal development A means of analysing and understanding behaviours and evaluating sensory processing disorders. A specific approach to intervention.
Senses via CNS, then output Senses: Vision, Hearing, Smell, Taste, Touch, Proprioception, Vestibular. Interconnected. Via CNS: register or take notice of sensory stimuli, evaluate its significance- Will it hurt me? and What should I do?, What to ignore and what to concentrate on? What should my body and mind do about it? so Affects functional performance and learning new skills.
Diagram 1: Sensory Processing Disorders Sensory integration affects sensory modulation, sensory-based motor problems, and sensory discrimination. See handout of definitions. In LD, sensory based motor problems and sensory discrimination are hard to assess, how much is delayed development due to the LD? In LD adults, OT s start with/focus upon Sensory modulation which affects daily functioning. If dyspraxia needs, OT would refer on if can t address.
Sensory Modulation This involves looking at whether the person tends to have enduring patterns of over and/or under responsiveness to sensations which affects behaviour/functioning Sensory Under-responsivity (not noticing), Sensory Over-responsivity (defensiveness to usually several types of sensation) or Sensory Craving ( excessive seeking certain sensations) and thus preventing a calm, focused state so interferes with being able to: concentrate, interact and carry out daily functional activities in areas such as :personal care, domestic, mobility, use of community, social, productivity, leisure. See Diagram 1 and Definitions hand-outs.
Assessing sensory modulation problems No specific physiological assessment yet. Look at behavioural indicators and observed/self reported reactions to sensations within body/activities/venues. See References: Dunn and Brown; Reisman and Hanschu.
SI Therapy Parham et al, 2011 1:1 treatment with OT/Physio/SLT postgraduate trained in SI. Treatment sessions meet specific criteria: multiple sensory experiences, novelty in environment, active engagement in challenging, sensory and motor tasks. ( Sue Allen)
Fidelity paper Parnham et al, 2011 Various published papers have had methodology problems, this paper gives clearer guidance.
To be a Sensory Integration therapist Sensory Integration Network modules: 4 modules, about one per year. www.sensoryintegration.org.uk American network, good references www.sinetwork.org
2. Adolescents/adults with LD Children-If behavioural problems and/or more severe LD, unlikely to have had paediatric Therapist input. If enduring sensory issues, develop behaviours to cope with them so it becomes sensory AND behaviour. E.g. Behaviours that seek intense sensation to block out discomfort or avoidance. 13 sensory referrals I ve done, it was sensory AND behaviour.
3. Expansion of SI theory: Sensory Defensiveness Therapists looking into Over Responsiveness to sensation have identified that rarely one sensory system is involved. Usually several sensory systems involved with primary sensory symptoms, and secondary medical, behavioural factors due to chronic anxiety and frequent episodes of panic/distress. Patricia and Julia Wilbarger and Sensory Defensiveness. Wilbarger Therapressure Protocol- deep pressure massage technique using a specific brush. Originator of Sensory Diets See Reference list
Sensory Diets Sensory diets= compensatory changes to sensations within person, activities and venues PLUS add sensory activities to routines that provide a therapeutic level of sensation. Aim: calm, focused, participate Certain types of sensation help a person to be calm and focused and better able to participate in daily activities. Discriminative processing to overcome effects of faulty evaluative processing. What activities help you to achieve this? For me: swimming backstroke, massage, aromatherapy and walking up smooth inclined country lanes.
Which sensations for a sensory diet? Muscle work outs Deep pressure touch Linear movement Sensory snacks- Short acting benefits up to 20 minutes benefit: smells, chewing, sucking (straw), seated exercise routines, lying down postural core, rocking chairs, travel in a car, vibration, loofah brush rubs, fidgets, weighted products, dancing. Sensory meals-long acting benefits up to 2 hours maybe longer: swimming, walks at least 45 minutes up a smooth hill, weight lifting, pilates, yoga. Etc. Which environments: lighting, background sounds, posture/seating, smells, avoid visual clutter.
OT and Sensory Diets Daily functional issues Be a sensory detective to identify sensations within the person, activity, or venues that may be a problem. Training client/carers/mdt Make changes to routines, activities, venues to address these difficulties. ( Compensation) Personal Care: Replace tickly touch with firm, predictable set number of strokes. Add a personalised sensory diet, but needs to be strong enough effect for that individual- intensity, duration, frequency.
Then along came Eadaoin Bhreathnach( Aydeen Brannough). ebsic@yahoo.com
More expansion of SI theory: Sensory attachment An attachment counsellor and SI Consultant OT from Ireland working with traumatised children identified an emotional basis for certain sensory patterns depending upon attachment issues. 3 Types: Fear of abandonment, fear of intimacy or mixed in presence of significant carer. Her theory guides which sensory activities to use and the importance of training significant others in how to interact/relate consistently to client.
More Expansion: Auditory Processing Not just listening- cortical based, language based. Connections throughout the entire brain: brain stem( basic survival), limbic system (emotional and memory), cerebrum( thinking). Connections to various organs due to vagus nerve( Autonomic nervous system, p.81 Frick
Auditory processing Monitors surroundings Infuences arousal, attention, concentration, emotional state. If auditory problems, acknowledge interconnections, Frick says: whole brain, whole body experience, p.3 Traditional SI therapy( Tactile, Proprioception, Vestibular/Visual) usually not enough). Compensation ( headphones) not enough. Movement and sound techniques. Frick
Feedback from autistic clients (Bogdashina) Various autistic persons have written books describing their own sensory experiences and have included findings from speaking to other autistic persons. Sensory modulation described BUT also unusual sensory styles like: mono channels; IN one sensory channel and OUT another; fragmented sensation, and I currently do not think that SI theory explains all their sensory issues SO I am reading their books to better understand Autism and their definition of the sensory issues. Diagram 2. shows three overlapping circles, sometimes overlap with SI theory but may be something additional due to autism.
Diagram 2 includes expansions to original sensory integration theory Pragmatic approach- not a pure SI Therapist and don t have facilities to be one- swings/vestibular. See handout- Diagram 2. See handout- References
Types of functional issues? sensory AND behaviour Personal Care: hair washing, bathing/showering.- Tactile, invade space, interoceptors. Aggression/fear during car travel, uneven surfaces: staircases Visual/vestibular. Noisy places, sudden startling sounds- Auditory/tactile. Limited foods- textures, tastes.
5: Case 1: Profound LD, Visual/hearing impairment. Day time activities including sensory act. Sensory attachment issues: Fear of abandonment, very demanding of mother Sensory modulation issues- distressed by epilepsy and sensations within his body (cyclic behaviours), Craving intense sensation to block out discomfort e.g. (head banging) and seeking firm pressure touch- rough play, vibration; anger if routines changed( scramming) wanted predictable routines.
MDT input case 1 Team meetings with care team including family to agree consistent routines, that client has more control over. MDT included PBM advice Teaching techniques of deep pressure touch massage to mother. Offered supportive counselling to mother. Taught interaction techniques involving sensory equipment to carer team.
MDT input case 1: cont. Psychiatrist- treatment for cyclic rage, epilepsy, course of antidepressant for 6-12 months has taken edge off distress. Ongoing team meetings twice yearly, about to structure more sensory diet.
2: Autism, aggression at college placement- query suitability? Depression: Functional and sensory analysis of routines at home, college. Reframed problems: Client overloaded by sensation( lighting, talking), needing quiet time when home( self managing- with close blinds, no sound, rest in bedroom, resisted interaction). Also college special ed not challenging enough. MDT Training and advice to family, college. Alternative placement: outdoor volunteering/ interviewed outdoors with prewritten CV that client handed to manager as couldn t deal with spoken interview. In generic small literacy class. Outcomes: more suitable placement, less aggression to mother.
Adding Sensory to MDT input Many consistent routines already, if functional analysis of behaviour. Behaviour management plans Interaction guidelines- SLT OT- screens for enduring patterns to sensation within body, activities, venues PLUS observations, clinical analysis, hypothesis of which sensory modulation category/ies. Add Sensory Diet via MDT planning.
Things to consider If personal care difficult, remember it is highly tactile/in personal space, so adjust techniques to pre-warn client, use firm touch with predictable number of strokes. Give client more control/involvement. Some persons find tight hugs/firm grasps calming so PBM manoeuvres may be appealing. Consider sensations in venues: lighting, background sounds, visual clutter, seating. Which are distracting and which help concentration?
References Deearn.holzl@wales.nhs.uk Sue Allen, What is the Evidence and Why Does It Matter Powerpoint, NAS, 2011 Linda Hardy, Introduction to Sensory Integration, Powerpoint, 16/11/2011
Other references Bundy Anita, Lane, Shelly, Murray Elizabeth (2002) Sensory Integration- theory and practice. Frick and Young (2009) Listening with the Whole Body. Bogdashina, Olga (2003)Sensory Perceptual Issues in Autism and Asperger Syndrome