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ISIC 2019 in Hong Kong – A Sensory Extravaganza

Just a few weeks ago Hong Kong hosted ISIC 2019 and today Ray-Anne Cook shares her wonderful experience with us.  Ray Anne is so well known in local and international SI circles for her passion and enthusiasm for all she does.  She is a long-standing and senior member of the SAISI Board since 1991, the international liason for SAISI at congresses along with Annamarie van Jaarsveld, runs a private practice in Durbanville, and I am sure you will feel her passion for the subject in her writing.

South Africa hosted the first International Sensory Integration Congress in 2018, so with much anticipation we awaited the next ISIC congress in Hong Kong to meet our colleagues/friends again.

Our excitement was dampened with news of the riots in Hong Kong but nothing was going to stop me having the privilege of being part of this international ASI® community.  The excitement grew as colleagues posted they had landed in Hong Kong, and as we walked into the lobby of the hotel  we saw and greeted one another like long lost friends eager to catch up on the latest news.

The theme of the congress was  “An International Journey of Innovation, Identification and Intervention in ASI®”.

Innovation has the wisdom and theory from Ayres Sensory Integration® supporting “play” to enhance participation and health for all children. Dr Anita Bundy expanded further in her keynote presentation on “The art of sensory integration “, that therapy is more than just a science.

Identification included the recent research and advancement to promote a comprehensive evaluation and early identification of children with SI dysfunction and Zoe Mailloux updated us on the EASI test.

Intervention in ASI® includes research on intervention adhering to the ASI Fidelity Measure. Prof Shelley Lane took us further on this topic in her keynote presentation of where ASI® is in the current conversations about sensory integration.

Over 20 countries were represented with about 200 participants, expanding and sharing about ASI® in other countries, both successes and challenges.

When there were South Africans speaking I got even more excited. My chest was bursting with pride when Dr Annamarie van Jaarsveld, Gina Rencken and Shanna Louwrens presented their papers. Go South Africa!

ISIC Hong Kong was a sensory experience of note and being a sensory seeker, I was in my element, volunteering for an experiment in Stephan Chan’s presentation on the application of real-time electro-dermal activities in sensory integration assessment. The Gala Dinner continued this experience with the food being a visual feast with amongst others the fried chicken head, and the tactile and olfactory senses with the flavours, textures and tastes of all the ethnic cuisine from Hong Kong.

To end the sensational evening: having to describe to everyone my auditory experience of listening to Sensofoam in a shooter glass!  Wow! Each ear heard a different sound!.

And the riots? Hong Kong was so organized with regular updates of where the riots were. Typical – my husband and I walked into the rioters late one night whilst trying to find our way home in this huge concrete jungle and the rioters politely let us pass!!

ISIC Hong Kong 2019 was an experience and to end it we did our sightseeing with Annamarie and her husband:  the light show, cable car trips etc – memories to treasure.

Are you joining us in the next ISIC 2020 California to celebrate Ayres 100th Birthday?

A Glimpse into the Normative Data Collection of the EASI – not so “easi”

South African therapists are so glad to be given a chance to be part of the International Normative Data Collection (INDC) for the Evaluation of Ayres’ Sensory Integration (EASI)- a test that will eventually replace the Sensory Integration and Praxis Tests (SIPT) which are currently the gold standard for evaluating sensory integration dysfunction.  However, collecting data and establishing norms and diagnostic patterns from children across the world is no mean feat and has its challenges, as Sally Fraser-Mackenzie shares with us in this week’s humourous and frank account of her experiences.  Sally we salute you for your perseverance!

The online training for learning the new Evaluation of Ayres Sensory Integration (EASI), soon to hit South Africa was excellent, what a breeze! And so interesting in terms of what they have kept and thrown out from the SIPT. It was lovely to see our old clinical observations integrated into it all as well. So here goes with the South African Normative Data Collection! And that is about where the wheels started coming off, and massive challenges meeting us.

As Normative Data Collectors, it is amazing to feel part of 72 country wide collecting this information. It really gives you a feel of the complexities of how the norms for any tests are gathered. So testing five children didn’t seem like such a gargantuan task.  As my Afrikaans isn’t very good, certainly not good enough to dive in and test 5 Afrikaans children with a new test I wasn’t very familiar with, I got allocated English children, and in doing so, a school nearby, one where my child is attending. A big government school with 35 kids per class, 2 English streams per grade, which makes 70 English children per grade.  Then I got allocated my Male/Female; Black/White/Indian/Coloured; 6yr/7yr/8yr case requirements. How hard can it be to find ONE 7 year old BLACK GIRL who is (1) willing, (2) seems neurotypical, (3) who has neurotypical siblings, (4) whose parents can manage the fairly dense information package and (5) whose parents give permission. It turned out to be a 1/70 experience!!! Yes,  I could find ONLY one per grade – just enough in each grade to limp through. How was this possible? As I discovered, the questionnaires were just too much for some parents and disappeared into the ether, despite much following up through the poor harassed teachers (by me). Some parents refused without reason – a bit of a blow, but fair enough. One teacher assured me that the chosen boy was White, but when I looked at the form, the very white blond mother had written Indian in the block, as the father is Indian. The teacher did not want to tell the boy I now couldn’t test him, especially based on race (she had already got him all excited about being tested!) and asked me nicely if I wouldn’t mind just testing him and then not entering the data (just a few hours of my time for political correctness….!!), I promised I would give him a gift to apologise and no, I was unable to do it.

Then there was the case of the teachers promising me that there is lots of space to test, but when I arrived, there was no space. You have to book the space, and even then, the “space” was a small store room with a large table and no chairs. So the initial two assessments I did, were in a corridor which was sporadically busy with classes walking through, and kids coming and having a fascinated look.

The following week, the next two were in the storeroom. At least it was quiet, but juggling all that EASI stuff and equipment was a challenge. One child was a quarter of the way through and mentioned he had done similar stuff with his OT – stop right there! Oops, teacher knew nothing about it, but it was in fact ticked by the parent and I hadn’t checked the form in that much detail. It had been years ago. Find a new kid for next week!

The final child was found by pressurising the teacher until she was sick of me, and I had no option at this time of the year, there were no male black 6yr olds in the 70 Gr 1’s who didn’t have learning issues, so I had to look at Gr R just before they turned 7. The teacher’s assistant was on maternity leave and her son was in that class. After 3 weeks of pestering, the permission form was returned so I had the go ahead.

Being fortunate to now have an entire classroom at the preschool, I arrived an hour early and set up the whole EASI, as different stations around the room. I knew that the test itself would take much less time if it was like this, and easier for the child and myself. Then I waited. The class begins at 8. The child wasn’t there….. At 8:10, the mother sent the teacher a message to say “There was a tyre accident”. Assuming that meant some sort of traffic accident, I offered without hesitation, to go and fetch the child from the townships. Luckily for me in Knysna, the townships are not that far away. I phoned the mother and she couldn’t explain directions to me, but apologised as she’d forgotten I was coming today and said “no it wasn’t a traffic accident”, but that he didn’t want to come to school. Confused but determined, I tenaciously headed into the townships to track this boy down! I drove around for some time, phoning her regularly to discuss various landmarks, water towers, churches, and asking other people I came across to speak to her and discuss where she was, which was the most successful strategy. I found them eventually, the boy was well, and it turned out that the previous day at aftercare, he had been playing on the tyres  (hence tyre accident) and a boy had kicked him in his private parts, and he hadn’t felt like coming to school. So, we drove back to school, and I conducted my 5th and final EASI successfully and smoothly.

Supplying gifts to all the children and all 5 teachers (since they were all different) was a necessary part of the process, and although very time and cost ineffective for me, it was well worth it! I’ve felt part of a bigger process and will understand and feel invested in the EASI assessment knowing that those 5 children made up the norms we will use for decades to come.

[Sally Fraser-Mackenzie has been serving on SAISI’s board for many years.  She runs a private practice in Knysna, Western Cape.]

Sensory Integration and Babies Part II

In our last blog we had a brief look at how the worlds of sensory integration and baby/toddler therapy meet.  We summarised the sensory systems involved and how occupational therapists can assist parents and infants with feeding and sleep routines.  In this blog post we look a little closer at sensory integration therapy for infants.

Sensory integration therapy for infants is made up of three different modes of therapy:

  • Counselling
  • Hands on therapy using Sensory Integration methods
  • Home programmes

It is important to remember that scheduling hands on time with tiny tots can be really challenging, especially when the parents are already struggling to achieve a calm-alert state with their baby.  For this reason, we often ask parents to come as they are, whatever the time of day, so that we can see the struggles and experience it with them.  Often an unhappy baby gives us a lot more information than a calm or sleepy one.

  1. Counselling

During counselling sessions we try to empower parents.  The objectives are to help the parents to understand the sensory contributions to the child’s behaviour, and how they can better deal with them.  This could include feeding tips, positioning, adjustments to the environment and more.

  1. Hands on SI methods

There is a time and a place for hands on therapy with the infant population.  Individualised and direct intervention is designed using Ayres Sensory Integration® (ASI®) theory and principles to remediate the identified problems.  Although the principles are the same, experience with the younger population is vital as the babies express their discomfort differently to older children.  Outcomes are similar and include modulation of sensory input, regulation of sensation and state, and improved sensory processing.  Successful adaptive responses are often subtle and reported back by the parents as the child is able to adjust better to different environmental demands once they go home.

  1. Home programmes

As with older children, home programmes form part of a sensory integration approach.  This often forms part of the counselling sessions as parents have much more time to implement the strategies than the therapist.  This includes modifications to the child’s environment to fit the child’s needs.

As with older children, sensory integration makes use of the ability of the central nervous system’s ability to change (plasticity).  For this reason, early intervention is so critical.  The earlier the intervention, the better the trajectory for later development.  When the child’s ability to process and organise sensory input improves, it allows for an adaptive response.  In the case of the infant, this sensory integration happens within the context of their normal daily activities.

Some examples of aims for infant therapy may include:

  • Achieving an optimal level of arousal and self-regulation through alerting/calming input
  • Promoting and supporting self-regulation
  • Desensitising the neurological systems to tolerate certain daily activities
  • Improving registration
  • Organising sustained attention
  • Facilitating organised and sustained activity, or
  • Eliciting an adaptive response.

The infant practice

There are not many differences in the look and setup of an infant practice.  There should be equipment and toys to stimulate each of the sensory systems, including:

  • Tactile equipment
  • Vestibular equipment
  • Age appropriate toys or household objects with appropriate affordances
  • A sensory rich and motorically challenging environment

Some toys might look specifically like they belong in a nursery.  A baby slide could fit indoors, and a rocking horse provides wonderful opportunities for movement.  A safe and quiet space for little ones to escape to is also a great idea.  Tactile opportunities abound with a variety of mats and different balls in ball pits as you need less space, or perhaps even various smaller rooms, in which to work.

In summary, infant sensory integration therapy stems from the same theory and work of Jean Ayres, however, a careful eye for differences, and a very important relationship with the parents, will guide therapy practice.  It is wonderful to find a mentor with years of experience to guide you, as sound theory can then be backed up with subtle observations and a little intuition, to ensure the baby and parents cope better with the demands of various environmental challenges.

[This article was written by Karen Powell, adapted from information from Meg Faure’s Infant Sensory Integration Training (ISIT) – 2019.  Karen works primarily with infants and toddlers in private practice and is currently serving on SAISI’s board.]

Sensory Integration and Babies Part I

This week, the World Association of Infant Mental Health (WA-IMH) is hosting a Week of Celebrating Babies.  Infant Mental Health is a new phrase to many – so what does it mean?

WA-IMH’s mission promotes education, research, and study of the effects of mental, emotional and social development during infancy on later normal and psychopathological development through international and interdisciplinary cooperation, publications, affiliate associations, and through regional and biennial congresses devoted to scientific, educational, and clinical work with infants and their caregivers (www.waimh.org).

So where does sensory integration fit in to all this?

Sensory integration is the process whereby sensory information is taken in through the brain and processed, and determines output, that is, the baby’s reaction or behaviour.  In infants, the behaviour we see starts on a very basic survival level, and is supported through the child’s interaction with their primary caregiver, usually their mother.  If the mother-infant dyad is affected in some way and secure attachment is not present, then the behaviour that is observed is usually negative in one of three areas:

  • Sleep
  • Feeding
  • Self-soothing

Infants with difficulties in these areas are often referred to occupational therapists, who might be asked to help.  This assistance could be in the form of:

  • Establishing an age appropriate eat-sleep-wake cycle
  • Assisting with specific feeding difficulties
  • Teaching the mother to facilitate self-soothing
  • Promoting a variety of sensory experiences for the baby during their awake time.

So do infant mental health and sensory integration principles complement each other?

Well, yes they do!  By facilitating better sensory registration and processing in the infant, the behaviour of a previously “difficult” baby will hopefully become more manageable.  If the mother feels more in control, and that she is able to respond appropriately to her baby’s cues, she will feel empowered and closer to her baby, thus forming a better bond with her child.  The reverse is also true.  When a child presents with secure attachment to the mother, a good and safe environment is provided, the context in which the therapist can work with the mother and child on feeding, sleeping or soothing issues.

The therapist working primarily with infants focuses on two very important sensory systems:

  • The tactile system (sense of touch)
  • The vestibular system (sense of movement)

The baby’s sense of touch is vital for the development of Activities of Daily Living, including feeding, bathing and nappy changing.  The tactile system is vital in the bonding process, self-calming, emotional stability and socialisation. Skills and functions such as rolling, crawling, eating, and mouthing objects all require an intact tactile system without over- or under-responsivity. When there is dysfunction in the sense of touch, it may present as tactile or proprioceptive defensiveness, hyposensitivities (under-reactivity) or poor praxis (due to poor tactile discrimination).

The vestibular sense registers movement of the infant’s body or changes in the position of the head.  It allows for successful modulation of arousal and alertness, as well as paying attention to the environment.  Through movement and coordination the infant learns to maintain posture, integrate reflexes and integrate movements.  It is the vestibular system that provides the unconscious awareness of movements and position in space. Here we can see why children prone to allergies and middle ear infections are so often affected and have sensory integration difficulties later on.

The senses of taste, smell, hearing, vision and proprioception of course all have significant effects on the infant’s development.

In this week of celebrating babies, let’s think for a moment about the infants and toddlers in our lives.  We are often so quick to label a baby’s personality as easy-going, friendly, fussy, difficult or strong-willed.  What are often seen as personality traits might be much more physiologically based than we realise – based on the demands and reactivity of the child’s sensory systems, and within the context of the mother-infant dyad. Post a photo, send a message of support or share a quote to celebrate babies and the very special place they hold in our lives for such a short time.

If you would like to follow WA-IMH this week as they celebrate babies, have a look at their Facebook page on https://www.facebook.com/waimh.org/

[This post was written by Karen Powell, who has a special interest in sensory integration in the infant and toddler population, and is currently serving on SAISI’s board.]

References and Sources:

1. World Association of Infant Mental Health website www.waimh.org

2.  Notes adapted from Infant Sensory Integration Training with Meg Faure

Developmental Coordination Disorder and Sensory Intergration

What is Developmental Coordination Disorder (DCD)?

Developmental coordination disorder (DCD) is a neurodevelopmental condition characterised by motor coordination that is below the expectations for the child’s age.1Difficulties with motor coordination are not caused or explained by other causes such as a physical or intellectual impairment. DCD is formally recognised in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the World Health Organization (WHO).

Difficulties with motor coordination manifest in fine or gross motor problems that interfere significantly and persistently with functioning in everyday life, including learning age-appropriate self-care skills, functioning in school and ability to participate in age-appropriate play activities.1The disorder exists on its own, but can also co-occur with conditions like attention-deficit/hyperactivity disorder (ADHD).

What is the difference between DCD and Dyspraxia?

The term dyspraxia is often used to describe motor incoordination in children. In some countries like the UK and Ireland, dyspraxia and DCD are used interchangeably.2While DCD is a defined condition with specific diagnostic criteria, there is no universal consensus on what constitutes dyspraxia and how to diagnose it. Therefore, the term DCD is preferred where a child complies with the diagnostic criteria for the condition.

What are the symptoms of DCD?

Children with DCD may present with:

  • Clumsiness and/or poor coordination
  • Handwriting / printing / copying difficulties
  • Difficulty finishing academic tasks on time
  • Requiring extra effort and attention when tasks have a motor component
  • Difficulty with activities of daily living (e.g., dressing, feeding, grooming)
  • Difficulty with sports and on the playground (e.g. last to get picked for teams)
  • Difficulty learning new motor skills
  • “Awkwardness” when engaging in motor activities
  • Difficulty with, or reduced interest in, physical activities (may be a “couch potato”)

How is DCD diagnosed?

Since DCD is a medical condition, it should only be formally diagnosed by, or in collaboration with, a medical practitioner (typically a paediatrician, neurodevelopmental paediatrician, paediatric neurologist). However, due to the nature of the symptoms of DCD, other team members such as educators, physiotherapists, occupational therapists or biokineticists may be more involved in the diagnostic pathway.3

Before a diagnosis of DCD is made, care should be taken to rule out other conditions that may result in motor incoordination. It is currently recommended that a formal diagnosis of DCD should only be made around the age of six years3; however, this does not mean that intervention for motor coordination difficulties should be left until that time. Since motor incoordination is often visible early in development, seeking appropriate intervention as soon as difficulties are noticed is important. The earlier intervention is provided, the better the prognosis of the child regardless of the presence or absence of a formal diagnosis.

What causes DCD?

DCD is a very heterogeneous condition, and the causes are believed to be diverse. There is research evidence that shows differences in the brain activation patterns of children with DCD compared typically developing peers, which provides at least some confirmation of the neurodevelopmental nature of the condition.3

How does DCD relate to sensory integration?

A recent study4 identified that an estimated 88% of children with DCD also have sensory processing differences. The field of sensory integration as pioneered by Jean Ayres, also known as “Ayres Sensory Integration®” (ASI®) has a wealth of knowledge demonstrating the influence of sensory processing difficulties on motor performance. Difficulties in sensory processing that lead to problems in motor performance or ‘praxis’ is termed “sensory-based dyspraxia”. The available evidence thus suggests a large possible overlap between DCD and sensory-based dyspraxia.

Should a child with DCD receive therapy based on Ayres Sensory Integration®?

The aim of occupational therapy based on ASI® is to address participation challenges that arise as a result of sensory processing difficulties. ASI® is an effective intervention for children who have difficulties in sensory processing that leads to problems in motor coordination and participation in daily activities. When there is evidence of sensory processing difficulties in a child with DCD, occupational therapy based on ASI® should be considered as an evidence-based intervention option to address sensory processing challenges in order to improve participation in daily activities.

[This blog post was written by Elize Janse van Rensburg, who shared 6 myths about autism and sensory integration last week. She gives acknowledgement to Annamarie van Jaarsveld for her contribution to some of the content of this blog post.]

References

  1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. (5th ed.) Washington: DC: APA.
  2. Dyspraxia Foundation. (2019) https://dyspraxiafoundation.org.uk/about-dyspraxia/dyspraxia-glance/
  3. Cacola, P. & Lage, G. (2019) Developmental Coordination Disorder (DCD): An overview of the condition and research evidence. Motriz, Rio Claro, Vol. 25, No. 2, http://dx.doi.org/10.1590/S1980-6574201900020001
  4. Allen, S. & Casey, J. (2017). Developmental coordination disorders and sensory processing and integration: Incidence, associations and co-morbidities. The British Journal of Occupational Therapy. Sep;80(9):549-557. doi: 10.1177/0308022617709183.

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Six myths about Sensory Integration and Autism

With awareness of autism and appreciation of neurodiversity increasing globally, therapeutic approaches to help autistic children with those areas in which they experience participation challenges are under scrutiny now more than ever. This blog explores six myths about sensory integration and autism to create a greater understanding of the contribution that this field can make to enhance meaningful participation in daily life activities for autistic children.

  1. MYTH: All people have five senses: sight, smell, taste, touch and hearing

As human beings we have, in fact, many more senses! While the five senses of sight, smell, taste, touch and hearing are the most well-known, some of the other senses include our sense of body position (also called proprioception), or sense of movement and gravity (also called the vestibular sense) and interoception (our awareness of internal body sensations such as being hungry, needing to go to the toilet, etc.). Depending on how we count them, neuroscientists have identified more than twenty senses perceivable by the human body1. Ironically, it is often in the ‘lesser known’ senses that autistic people experience the most diversity.

  1. MYTH: Sensory integration therapy looks only at whether you are hyper/over-responsive (e.g. sensitive) or hypo/under-responsive (e.g. don’t notice) to sensory stimulation

While the notions of over- and under responsiveness is perhaps the most well-known ‘classification’ of sensory processing difficulties, especially in relation to autism, the field of sensory integration has studied many more processes involved in sensory processing. Our understanding of the complex processes involved in sensory integration constantly evolves as new research emerges, and so new classifications of sensory processing and sensory processing difficulties develop over time. In addition to difficulties with sensory responsiveness (e.g. hyper- or hypo-responsivity to sensory input), sensory integration also looks at difficulties in sensory discrimination (the ability to distinguish, identify and interpret the characteristics of sensory input received through the different sensory systems), and problems in using sensory information for action, known as praxis.

Jean Ayres defined praxis as “the basis for dealing with the physical environment in an adaptive way … dressing, eating with utensils, playing, writing, building, driving an automobile, changing the physical environment to meet a purposeful goal, and making a living”2(p. 44). Numerous studies, conducted over decades, have demonstrated the intricate link between sensory processing and praxis, and thus the ability to use sensory information in a meaningful way to interact with the environment.3

In the current diagnostic criteria for autism4, sensory processing challenges in the form of hyper- or hypo responsivity is acknowledged; however, research5,6 has demonstrated that autistic people often experience difficulties in sensory discrimination and praxis that have as pervasive an influence on their participation in daily life activities as sensory hyper- and hypo responsivity. The prevalence of sensory processing differences among autistic children is estimated between 45% and 96%.7

The take-home message: sensory integration is about much more than hyper- or hyporesponsivity, and autistic children can have challenges with any or all of the areas of sensory integration.

  1. MYTH: The “brushing protocol” and bouncing on a therapy ball at specific times during the day are examples of sensory integration therapies

May I repeat…MYTH. While the mentioned interventions can be regarded as examples of sensory-based intervention they are NOT sensory integration therapy, nor Ayres Sensory Integration® as it has been trademarked to avoid confusion. Sadly, many studies performed on the effectiveness of so-called ‘sensory integration therapy’ for autistic children was conducted on interventions that did not adhere to the principles of Ayres Sensory Integration®. In response to these challenges, a fidelity measure was developed to measure the extent to which an intervention adheres to the core principles of ASI®. Making sure that interventions labelled as ‘sensory integration’ adhere to the ASI® Fidelity Measure8 is thus crucial for both researchers wishing to study the effectiveness of ASI® and for parents who seek to make informed decisions about appropriate therapeutic approaches to help their autistic child. For more information, visit our blog.

  1. MYTH: Sensory integration is a behavioural intervention that aims to reduce ‘autistic behaviours’

There are so many things wrong with this statement, but let me focus on the case in point. Ayres Sensory Integration® is NOT a behavioural intervention. That is, the intent of sensory integration is NOT to modify behaviour, or to ‘reduce autistic behaviours’ so to speak.

What is the purpose of Ayres Sensory Integration® then? ASI® aims to promote participation in daily life activities (called ‘occupations’ by occupational therapists) where participation challenges are thought to be linked to sensory processing difficulties.

Let me use an example to illustrate the difference:

Behavioural perspective: Jason is a five-year-old autistic boy. He has a lot of autistic behaviours that interferes with his functioning at school. During break times he mostly flaps his arms, rocks back and forth, and makes noises. A behavioural approach to Jason would be to find ways to reduce these ‘unwanted behaviours’ such as discouraging flapping, rocking and making noises through positive or negative reinforcement. The focus is on reducing the behaviour.

Sensory integrative perspective: Jason is a five-year old autistic boy. He does not participate in play activities at school spontaneously. He is over-responsive (sensitive) in his movement (vestibular), hearing (auditory) and touch (tactile) senses and struggles with praxis. As a result, he avoids most of the playground equipment at his preschool. He also finds being between the other children overwhelming, because break time is typically very noisy. Therefore, he tends to isolate himself during break time, and uses strategies such as flapping, rocking and making noises to try to calm his overwhelmed sensory systems and reduce his anxiety. A sensory integrative approach to Jason would be to help Jason with processing of movement, hearing and touch senses so that he would feel more comfortable to participate in play activities at school. If his system was less overwhelmed by the sensory input, he would be more likely to explore with playground equipment and participate in play alongside his  peers. By promoting praxis and encouraging play skills together with improving his sensory processing abilities, ASI® will positively influence his ability to participate in meaningful occupations such as play.

Do you see the difference? Yet, despite the fact that ASI® does not claim to be a behavioural intervention, it is often compared to behavioural interventions, for the effect thereof on behaviour, and then targetted for being ‘ineffective’ in comparison to ‘behavioural interventions’. Which brings me to the fifth myth…

  1. MYTH: There is no evidence that sensory integration works for autistic children

Indeed, this is a myth that you may encounter frequently when perusing the literature on sensory integration and autism. Even an official (luckily by now outdated) policy statement by the American Academy of Pediatrics9 declared that “…Pediatricians should recognize and communicate with families about the limited data on the use of sensory-based therapies for childhood developmental and behavioral problems.” The majority of the criticism against sensory integration in the policy statement was derived from a study10 titled “Comparison of Behavioural Intervention and Sensory-Integration Therapy in the Treatment of Challenging Behaviour”. In light of MYTH #4 above, I shall just leave this here. Or in addition, point out that the sample size of the study was four participants. Four.

The criticism of “no evidence base” unfortunately does not stop with an outdated policy statement. In a 2019 review article11, ‘sensory integration’ was classified as a “red – don’t do it” intervention for autistic children, on the grounds of no evidence supporting its effectiveness. However, despite the bold assertion, the review did not consider adherence to the core principles of ASI® (‘fidelity’), nor did it include a number of high-level, recent studies which did consider fidelity and demonstrated highly favourable outcomes.

There are many different classification systems for when an intervention is regarded as ‘evidence-based’. ASI® meets the criteria for an evidence-based intervention by different classification systems, among others the standards of the National Professional Development Center on Autism Spectrum Disorders, the Council for Exceptional Children Guidelines for Identifying Evidence-based Practices in Special Education as well as the Standards for classifying Evidence-based Practices (CEC).12

Among many other studies that investigated the effectiveness of ASI® in children with autism, two randomized controlled trials6,7 (the highest level of experimental research), studying 69 children in total, demonstrated that “the evidence is strong that ASI intervention demonstrates positive outcomes for improving individually generated goals of functioning and participation as measured by Goal Attainment Scaling for children with autism.”14

  1. MYTH: Sensory integration can solve all of an autistic child’s problems

Sensory integration IS NOT a one-size fits all approach, a quick fix, a universal solution or a behavioural intervention. It does not claim, neither does it intend, to be the best or the only solution to challenges that arise with the neurodiversity associated with autism.

BUT IT IS an evidence-based intervention to address participation challenges that result from sensory processing difficulties in autistic children. It IS an approach that puts the child first. It IS – it must be – enjoyable and fun, and tailored to the unique and individual needs of the child. If it is not, it is not ASI®.

[This article was submitted by Elize Janse van Rensburg, private practitioner, part-time lecturer at the University of the Free State and she is currently serving as vice chairperson for SAISI.]

REFERENCES

  1. See, for example, http://www.bbc.com/future/story/20141118-how-many-senses-do-you-have and https://en.wikipedia.org/wiki/Sense
  2. Ayres, A.J.,Cermak, S. (2011). Ayres Dyspraxia Monograph 25th Anniversary Edition; Pediatric Therapy Network:Torrance, CA, USA.
  3. Lane, S.J., Mailloux, Z., Schoen, S., Bundy, A., May-Benson, T., Smith Roley, S., Schaaf, R.C. (2019).Neural Foundations of Ayres Sensory Integration®. Brain Sci., Vol. 9, 153; doi:10.3390/brainsci9070153.
  4. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  5. Lane, A.E., Young, R.L., Baker, A.E.Z., Angley, M.T. (2010). Sensory Processing Subtypes in Autism: Associationwith Adaptive Behavior. J Autism Dev Disord, Vol. 40:112–122. DOI 10.1007/s10803-009-0840-2.
  6. Pfeiffer, B.A., Koenig, K., Kinnaeley, M., Sheppard, M. & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, Vol. 65:76-85.
  7. Schaaf, R.C., Benevides, T., Mailloux, Z., Faller, P., Van Hooydonk, E., Freeman, R., Hunt, J., Leiby, B., Sendecki, J., Kelly, D. (2014) An Intervention for Sensory Difficulties in Children with Autism:A Randomized Trial. J Autism Dev Disord, Vol. 44:1493–1506. DOI 10.1007/s10803-013-1983-8
  8. Parham, D., Smith Roley, S., May-Benson, T. Koomar, J., Brett-Green, B., Burke, J.P., … Schaaf, R.C. (2011). Development of a Fidelity Measure for research on effectiveness of Ayres Sensory Integration®. American Journal of Occupational Therapy, Vol. 65:133-142.
  9. American Academy of Pediatrics. (2012). Policy Statement: SensoryIntegrationTherapiesforChildrenWithDevelopmentalandBehavioralDisorders. Pediatrics, Vol. 129, No. 6. www.pediatrics.org/cgi/doi/10.1542/peds.2012-0876. doi:10.1542/peds.2012-0876
  10. Devlin, S., Healy, O., Leader, G., Hughes, B.M. (2011) Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. J AutismDevDisord. Vol. 41, no. 10:1303–1320
  11. Novak, I. &Honan, I. (2019). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Australian Occupational Therapy Journal, Vol. 66:258–273. doi: 10.1111/1440-1630.12573.
  12. Schaaf, R.C. (2015). Evidence for Ayres Sensory Integration. Congress Presentation: European Sensory Integration Congress (ESIC), Birmingham.
  13. Pfeiffer, B.A., Koenig, K., Kinnaeley, M., Sheppard, M. & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, Vol. 65:76-85.
  14. Schaaf, R.C., Dumont, R.L., Arbesman, M., May-Benson, T. (2018). Efficacy of Occupational Therapy Using Ayres Sensory Integration®: A Systematic Review. The American Journal of Occupational Therapy, 72, No. 1. 7201190010. ttps://doi.org/10.5014/ajot.2018.028431

The Purpose and Power of Play: Part II

Today we look at the theory of play in the second of a two-part blog post written by Stefanie Kruger, an ASI-certified therapist, long-standing board member of SAISI and lecturer.

At the end of last term, we went grocery shopping to buy a few things for the weekend, when my kids saw the shelf with toys. Usually I would walk straight past it, but we all had a happy holiday feeling and we paused to take a look. The Rubix cubes caught their eye, and they pleaded to buy it with their pocket money which made my OT-mommy-heart proud.

They could not wait until we got home to open it, and before I knew it, they had managed to rip off the packaging and started mixing and turning the blocks. It probably took them less than 3 minutes to go from extreme happiness about their new toy, to getting red in the face with frustration wanting to throw it out the window. It seemed that it was much harder to fix the blocks and to sort all the colours than what they had imagined. Although we try at home to provide a balance between all sorts of fun and games, it seemed that my kids found it extremely difficult to stay calm enough to accept that this was a completely new toy and that they had no previous experience with it, perhaps maybe only previously watching someone else solving it without struggling. There was no instant gratification and there was no undo button as on an electronic device. This of course then lead to my OT knowledge flying out the window, and my mommy-heart feeling all kinds of mixed emotions, being stuck between my options of how to respond to this situation.

Definition and key aspects of play

Play can be defined as “any spontaneous or organized activity that provides enjoyment, entertainment, amusement or diversion”. Play can also be seen as “doing things for the fun of it” and as a result of play, children learn and grow. Play is considered to be intrinsically driven, is often pretend in nature, and focuses on the process instead of the outcome.1Play is a complex phenomenon which wears many faces. To play optimally, players must act effectively and efficiently on the environment. Neumann (1971) proposed three criteria for play: that it is relatively intrinsically motivated, that it is relatively intrinsically controlled, and that play is relatively free of some of the constraints of objective reality. Playfulness, on the other hand, is a style, or approach to daily events and should not be confused with actual play. 2

Pretend play creates the opportunity for children to impose meaning on what they are playing through key cognitive skills such as the ability to use an object as something else; attributing properties to the object; making references to absent objects; using a story in play; and sustained symbolic thinking, such as thinking in another reality. 3Pretend play often creates the reality of “as-if” which can be played alone, or in a group whereby children share an alternative reality, acting as though they are different people in another place and time. Pretend play can be linked to emotional regulation, creativity, problem solving, and cognition; narratives and language; and social understanding. Children with deficits in pretend play may present with difficulty with social engagement, language, and self-regulation,leading to problems at kindergarten and school3.

Imitation, as a critical mechanism of play behaviour, is a primary learning process in child development. Imitation evolves from simple to increasingly complex levels of behaviour. Imitation can be defined as a vicarious learning process whereby intricate response patterns can be acquired by observing the performance of appropriate and significant models.When children elaborate imaginatively upon concrete observed events or models within the context of play, they are exposed to opportunities for acquiring planning skills, learn to delay gratification and regulate impulsivity, and in general engage in activities that facilitate appropriate and adaptive behaviour 4

An adaptive response is defined as an appropriate action in which the individual responds successfully to some environmental demand. Adaptive responses require good sensory integration. Adaptive behaviours can be observed in motor or action-orientated responses such as improved balance or better postural control. Adaptive responses may also be observed in more organised reactions (e.g. better sleep-wake cycles, and better regulated heart-rates) or on an emotional level (e.g. dealing with transitions, or feeling comfortable in the absence of the primary care-giver). Adaptive responses can be observed best when children are actively engaging in meaningful activities. 5

Imitation and mirror neurons

We are all familiar with the expression “putting yourself in someone else’s shoes”. This implies the ability to imagine yourself in the situation or circumstances of another person, to understand or empathize with their perspective, opinion, or point of view. However, there is now scientific evidence that the ability to put yourself in someone else’s shoes has significant neurological origins and implications.

Current literature emphasizes that when an action is executed actively and when an action is passively observed, the same brain regions are triggered by so-called mirror neurons, a recently discovered set of neurons in the frontal cortex. In imitating someone else, one must convert an action plan originating from the other’s perspective into one’s own. These neurons show activity in relation both to specific actions performed by self and matching actions performed by others, providing a potential bridge between minds.

The discovery of mirror neurons offers a potential neural mechanism for the imitation of actions as well as other aspects of understanding social behaviours and emotional responses in others. In childhood, mirror neurons may be the key element to facilitating the early imitation of actions, the development of language, executive function and the many components of understanding the beliefs of others and theory of mind which contribute to the development of empathy. 6,7,8

Dr Ayres recognised imitation as a strong indicator of the development of praxis. 9,10. Praxis is defined as the ability to conceptualise an idea of knowing what to do, formulating a strategy of the order of steps (e.g. where to start and what is next) and then following through on a motor level by executing the plan on a motor level i.e. doing it.11

Therefore, in order for children to optimally facilitate praxis, language skills and the development of empathy, it is critical that children should be exposed to imaginative play situations where they can learn about themselves and others. During play children do not only learn about how to discover and do new things on a motor level, but also start learning about and understanding the emotional experiences of others, especially their own impact on the environment and their friends.

Play and sensory integration

Dr Jean Ayres defined sensory integration as the organisation of sensory input for use.11A child’s brain is in need of a variety of sensory experiences which is considered “food for the brain”. Sensations therefor provide knowledge to direct the body and mind. A child develops sensory integration by interacting with many things in the world. Sensory integration occurs in moving, talking and playing, and is the “groundwork for reading, writing and good behaviour”. When a child’s brain has capacity for sufficient sensory integration, the child’s responses to the environment can be efficient, creative and satisfying. The human brain is designed to enjoy things that promote development. We therefor naturally seek sensations that help organise our brain. This is one of the reasons (besides e.g. the need to connect and form meaningful emotional attachments) why children love to be picked up, rocked, hugged, and why they love to run, jump and play on playgrounds and on the beach. They want to move because the sensations of movement nourish their brains. 11

“Fun is the child’s word for sensory integration” – Dr AJ Ayres

Occupational therapists trained in using Ayres Sensory Integration (ASI) as a child-directed approach for intervention have the unique ability to tailor activities to the “just-right challenge”, establishing a therapist-child collaboration, ensuring success, creating a context of play, and fostering a therapeutic alliance.12 Using this play-based approach, the therapist promotes working towards a trusting relationship. By expanding on the ideas that the child initiates, the therapist can engage the child as an active partner. Therapists often infuse imaginative play and creative play themes so that the child loses track of time and effort, and becomes engaged in challenging activities that might not otherwise be possible.13

Meeting children on their level

Over 40 years ago, child psychiatrist Dr. Stanley Greenspan recognized the importance of meeting children on their level—developmentally, physically and emotionally—in order to maximize communicating, interacting, and learning14.

We often forget that children are not little adults, and that we have to get onto their level and into their worlds to fully comprehend their perspectives and experiences.

“You can learn more about a person in an hour of play than from a lifetime of conversation” – Plato.

Play vs entertainment

The Oxford dictionary defines the concept of entertainment as the “action of providing or being provided with amusement or enjoyment”, or as “an event, performance, or activity designed to entertain others”. When considering the above-mentioned definitions, it is evident that entertainment is provided by someone else, and that the person being entertained is the passive receiver of some form of amusement. As parents, we should refrain from entertaining our children to the point where they can no longer find the fun for themselves, or make up games without a directive adult or other play-mate. It is good for children to not have anything structured to do. It provides the opportunity to form ideas of their own and try out their plans without interference, even though they might not succeed at first. Although we all need some quiet time to relax, we should also be careful not to use the television or other electronic device as an easy alternative to playing indoors. There are many other games that children can play indoors. Examples may include hide-and-seek, creative arts and crafts activities, board games, dress-up games, indoor sport activities, baking and reading.

Setting up the environment to support play:

The environment plays a crucial role that can impact a child’s play behaviour, both in therapy sessions as well as at home. When we want to facility play, the following have to be considered9,12:

  • Appropriate peers, toys and materials that are likely to trigger a child’s interest;
  • An agreement between adults and children that they are free to choose from the above available materials and peers;
  • Adult behaviour that is minimally intrusive or directive;
  • A friendly atmosphere where children can feel and comfortable to explore and engage; and
  • Choosing a time that reduces the likelihood of the children feeling hungry, tired, ill or other types of bodily stress.

Activity ideas

Sensory-motor play-based activities may help families to enjoy weekends and holidays to the fullest. With the summer holidays in mind, here are some fun activity ideas to promote play while on holiday, whether you are away or at home13,15:

  • Jumping on a trampoline
  • Roller skates / blades
  • Bicycle, tricycle, or scooter games
  • Jumping or climbing in and out of inner tubes
  • Running and climbing activities such as on jungle gyms or playground equipment
  • Playing in sandboxes or on the beach with buckets and spades, or burying their body parts under the sand
  • Swimming
  • Horse riding
  • Drawing with chalk on the driveway or paving
  • Making a fort or a house with cardboard boxes and blankets
  • Pulling each other on towels, or in boxes
  • Going down sandy or grassy hills in or on a cardboard box
  • Various ball games e.g. soccer, volley ball, tennis, table-tennis, mini-golf, swing ball
  • Hop-scotch
  • Rock-climbing
  • Going camping (real or pretend)
  • Baking
  • Playing shopping and dress-up games
  • Having a music show
  • Pillow fights
  • Squeeze or walk on bubble wrap
  • Paint
  • Use toilet rolls, empty boxes and other empty containers to build things
  • Swinging, making roly-polys
  • Go down super-tubes
  • Create and complete obstacle courses
  • Hiking with a backpack
  • Boardgames e.g. chess, scrabble, Monopoly, Pictionary, hangman
  • Keeping a holiday diary (writing and drawing pictures)

 

Children may also be involved in and assist with household chores:

  • Writing the shopping list
  • Pushing the trolley
  • Looking for the items on the shelves
  • Unpacking and sorting the groceries
  • Assist with cooking, planning the menu and setting the table
  • Sweep, vacuum, mop, dust, empty the rubbish bin
  • Packing and unpacking the dishwasher
  • Washing the car and/or dog
  • Mowing the lawn, raking leaves
  • Gardening
  • Wrapping gifts, writing cards

 

Conclusion

So, to get back to the Rubix cube dilemma, needless to say we had to take a break for a while. When everyone was feeling better, we had a look on the internet for “how to solve a rubix cube” videos.

Luckily, we also live in an era where information is at our fingertips which were not available in the “old days” when we were growing up. Thankfully, their loving father enjoys solving these kinds of puzzles. Before the weekend was over, both Rubix cubes were solved, and my children could practice simpler patterns and experienced small victories of solving one colour.

It should however be noted that when they became frustrated with not being able to solve the Rubix cube instantly in the car, it was a trigger or outlet for sensations and emotions that built up during the course of the day. It was in fact the “end-of-the-school-day-meltdown” at lunch . On their last day of school, they had to be there at 6am for a special event with a radio station. There was lots of excitement, loud music and various sweet things to eat. Then when the morning show event of the day was in full swing, the sun was hot and reached upper 20°C temperatures before noon. This background context provided some insight as to why my children were not ready (mentally and otherwise) to deal with the challenges their new toy posed. It was not a good time to try and solve a difficult puzzle after a busy and hot morning. It is critical for us as parents to remember that children should be in the right state of mind and in the right place to be open to new challenges, play nicely and have fun. Choose the right place and time when children are not tired, hungry, sick or overstimulated from other events for optimal play to take place.

Play is not a distraction from important work, play IS the important work of children with many benefits. There is a critical impact on their overall development when the possibilities of play are absent or limited. Let’s slow down in our daily routines, and allow children to play and have fun like we used to, so they can build memories, skills and meaningful relationships. And of course, remember the sunscreen.

References:

  1. Parham D, Fazio L. Play in occupational therapyfor children. Mosby; 1997.
  2. Bundy AC, Lane S, Murray EA, Fisher AG. Sensory integration : Theory and practice. 2nd ed. ed. Philadelphia :: F.A. Davis; 2002.
  3. Roberts T, Stagnitti K, Brown T, Bhopti A. Relationship between sensory processing and pretend play in typically developing children. American Journal of Occupational Therapy. 2018; 72(1):7201195050p1-p8.
  4. deRenne-Stephan C. Imitation: A mechanism of play behavior. American Journal of Occupational Therapy. 1980; 34(2):95-102.
  5. Roley SS, Blanche EI, Schaaf RC. Understanding the nature of sensory integration with diverse populations: Pro-Ed; 2001.
  6. Williams JH, Whiten A, Suddendorf T, Perrett DI. Imitation, mirror neurons and autism. Neuroscience & Biobehavioral Reviews. 2001; 25(4):287-95.
  7. Williams JH, Waiter GD, Gilchrist A, Perrett DI, Murray AD, Whiten A. Neural mechanisms of imitation and ‘mirror neuron’functioning in autistic spectrum disorder. Neuropsychologia. 2006; 44(4):610-21.
  8. Dapretto M, Davies MS, Pfeifer JH, Scott AA, Sigman M, Bookheimer SY, et al. Understanding emotions in others: Mirror neuron dysfunction in children with autism spectrum disorders. Nature neuroscience. 2006; 9(1):28.
  9. Ayres AJ. Sensory integration and learning disorders: Western Psychological Services; 1972.
  10. Ayres AJ. Sensory integration and praxis tests (sipt). Los Angeles: Western Psychological Services. 1989.
  11. Ayres AJ, Robbins J. Sensory integration and the child: Understanding hidden sensory challenges: Western Psychological Services; 2005.
  12. Schaaf RC, Mailloux Z. Clinician’s guide for implementing ayres sensory integration: Promoting participation for children with autism. Bethesda, md.: American occupational therapy association. linda. linneanet. fi/F. 2015.
  13. Schaaf RC, Roley SS. Sensory integration: Applying clinical reasoning to practice with diverse populations: PRO-ED, Incorporated; 2006.
  14. Greenspan SI, Lieberman AF. A clinical approach to attachment. Clinical implications of attachment. 1988:387-424.
  15. Haldy M. Making it easy: Sensorimotor activities at home and school: Psychological Corporation; 1995.

 

The Purpose and Power of Play : Part I

“Play is often talked about as if it were a relief from serious learning. But for children play is serious learning. Play is really the work of childhood” – Fred Rogers

From the “old days” to our current times a.k.a “van toeka tot nou”

Our children often ask us how things were in the “old days”. And much to their surprise, there were no cell phones, internet, wifi, Xbox and tablets when we were growing up. We grew up in a time where we could ride our bikes in the neighbourhood, or roller skate to our friends’ houses, and swim until it got dark. We made mud-cakes and had pretend tea parties, or built forts and had a pretend war against a fierce enemy. We camouflaged ourselves with charcoal stripes on our cheeks and leaves in our hair. We wore uniforms that we created from scrap pieces of material from our mothers’ sewing cupboards. It is true that times have changed and that we should not compare the way our children are brought up with the way things were in the “old days”. The needs of children have stayed the same, but they are somehow expected to walk, talk, read, behave and perform as soon as possible, even before they are neurologically or emotionally ready. In fact, everything has sped up in this modern day and age, even for us as parents.

Which toys to buy for children at the different ages and stages to best stimulate their development is a question that we regularly ask ourselves (and others) probably even from before they are born. Baby and toy stores are literally packed to the ceiling with boxes containing colourful and often noisy battery-operated toys. The shopping experience is potentially a sensory disaster in itself. With excellent marketing strategies and packaging, we are somehow convinced that THIS is the toy we should get, even if it does not completely fit within our budget, and often against our better judgement. How often have we witnessed that children (even parents) end up playing with the bubble wrap, or playing with the ribbons and other pieces of packaging instead of playing with the gift itself? Toys can be so simply, and children really don’t need much, yet it seems that some children do not really attach value to too many toys, and there is a tendency to replace rather than repair broken things.

The purpose of this post is to reflect on play as a critical component of development in childhood, and to provide some guidelines to keep it simple, go back to basics and to assist with the selection of activities that facilitate play in children, especially with the summer holidays around the corner.

“Play is the work of childhood” – Jean Piaget

Play is a natural part of a child’s typical daily routine, like sleeping, eating, getting dressed, learning, and social interactions.1Through play, children learn to communicate, grow, and build the necessary skills to function in society. Participating in play is a fundamental part of growth and development throughout life. Sensory, motor, communication and social interaction skills need to be integrated for a child to be a successful play-mate. If a child has sensorimotor, emotional, or social deficits, his or her ability to play maybe compromised. 2 It is through play that children learn about themselves and about the world around them.3

Childhood is divided into the following stages: early childhood (0-2 years), middle childhood (2 – 6 years) and late childhood (6 – 11 years). 4 Each stage has its own developmental characteristics that we should “allow” as parents and therapists. We should try and encourage mindfulness when playing, so that children can be present in the here-and-now, without pressure to hurry-up and grow up. Children have to explore what their bodies can do, and later learn about the different things that objects can do, and how to use toys in different ways.

This process of exploring different possible uses contributes to their ability to form ideas about what to do with things, expand their play repertoire, and how to solve problems as well as connecting the actions with the appropriate language to attach meaning to their experiences.5,6 As parents and as therapists we have often heard about how “bored” children can get, but the question we should ask ourselves, is whether they are truly bored, or whether they do not know how or what to play.

During the different stages of childhood and having the opportunity to play freely, the foundation is laid for future learning, including their interaction with the environment and others. As Robert Fulghum wrote in “All I really need to know I learnt in kindergarten”7:

  1. Share everything.
  2. Play fair.
  3. Don’t hit people.
  4. Put things back where you found them.
  5. Clean up your own mess.
  6. Don’t take things that aren’t yours.
  7. Say you’re SORRY when you HURT somebody.
  8. Wash your hands before you eat.
  9. Flush.
  10. Warm cookies and cold milk are good for you.
  11. Live a balanced life – learn some and drink some and draw some and paint some and sing and dance and play and work everyday some.
  12. Take a nap every afternoon.
  13. When you go out into the world, watch out for traffic, hold hands, and stick together.
  14. Be aware of wonder. Remember the little seed in the Styrofoam cup: The roots go down and the plant goes up and nobody really knows how or why, but we are all like that.
  15. Goldfish and hamster and white mice and even the little seed in the Styrofoam cup – they all die. So do we.
  16. And then remember the Dick-and-Jane books and the first word you learned – the biggest word of all – LOOK.

Nature’s playground

During an informal social gathering at school, one of the fathers mentioned that his child spent a lot of time on his iPad. The father wanted to encourage his son to spend less time on the electronic device and hence sent him to go and play outside. After a while he was getting worried about his child’s whereabouts, and noticed how he just took the iPad and kept on playing the game outside the house. Although it was funny in that moment how his son interpreted his suggestion, it is also a reflection of what our children sometimes consider as “playing outside”.

In South Africa we are fortunate that our weather allows us to spend a lot of time outdoors. We should explore nature’s playground more often, and allow our children some freedom to engage with what nature provides on the best outdoor playground, and to take healthy risks within reason and without compromising their safety: trees, sticks, rocks, water, mud, leaves, and whatever treasures they can discover. With the festive season on the horizon, we should also consider the needs of our children when choosing restaurants or venues for family gatherings, where they are not expected to be on their best behaviour despite loud music, lots of people in their personal space, unhealthy eating or excessive heat. It is always a good idea to choose a venue where there is an outside space or play area for the children to move freely without hurting themselves or at risk of breaking things.

As parents we want to make sure our children have the same opportunities as others and in the process are at risk of getting caught in the trap of structuring their days too much with a tight schedule of extramural activities. We therefore have to ensure that there is a balance for our children so that they have time to play in their busy schedules during the week and to rest so that they can enjoy life. Even into adulthood, we have to find a work-life balance so that we can be present in our children’s lives as well as our own.

Next week we will look a little deeper into the theory of play and how Dr Jean Ayres worked it into the theory of Sensory Integration.

References:

  1. Occupational therapy practice framework: Domain and process (3rd edition). American Journal of Occupational Therapy. 2017; 68(Supplement_1):S1-S48.
  2. Jankovich M, Mullen J, Rinear E, Tanta K, Deitz J. Revised knox preschool play scale: Interrater agreement and construct validity. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2008; 62(2):221-7.
  3. Case-Smith J. Occupational therapy for children. 5th ed. ed. St. Louis :: Elsevier Mosby; 2005.
  4. Kielhofner G. A model of human occupation : Theory and application. 3rd ed. ed. Baltimore, MD :: Lippincott Williams & Wilkins; 2002.
  5. May-Benson TA, Friel S. The relationship between narrative language skills and ideational praxis in children. American Journal of Occupational Therapy. 2017; 71(4_Supplement_1):7111505135p1.
  6. May-Benson TA, Blanche E, Schaaf R. A theoretical model of ideation. Understanding the nature of sensory integration with diverse populations. 2001:163-81.
  7. Fulghum R, Elders H. All i really need to know i learned in kindergarten. TECHNOS QUARTERLY. 2002; 11(4):32-.ties at home and school: Psychological Corporation; 1995.

[This blog post was written for SAISI’s blog by Stefanie Kruger, a long-serving SAISI board member, ASI-certified therapist and lecturer.  Look out for Part II next week.]

What is Sensory Integration Treatment?

Now that we have some background and understanding of Sensory Integration, we explore treatment options in this week’s post.

Sensory Integration Treatment

Occupational therapists trained in Ayres Sensory Integration (ASI®) use purposeful activities, specialized equipment and sound clinical reasoning to create opportunities for enhanced sensory integration in therapy. Therapeutic activities are designed to provide the child with opportunities to master challenges during participation in activities and demands presented by the environment. In doing so, the therapist aims to effect change in the naturally malleable nervous system of the young child towards more effective sensory processing. The younger the child, the more plastic the brain i.e. it has the ability to form new neural pathways and reroute information where necessary.

Once the child is processing and organising sensory information more effectively, he/she will find it easier to interact positively with his/her peers, play creatively and achieve success in all of his/her occupational performance areas at home and at school.

ASI® intervention can only be provided by therapists with post-graduate training in ASI® and is characterised by certain unique features, namely (Schaaf & Mailloux 2015):

  • Therapy will always take place within the context of play.
  • The therapist will establish a therapeutic alliance with the child and collaborate with the child in activity choices.
  • The therapist will create challenges that are just-right for the child, and always ensure success.
  • The therapist will make use of specialised equipment and always ensure a safe environment within which the child can engage.
  • Activities will be rich in sensory inputs, with a particular emphasis on tactile (touch), vestibular (movement) and proprioceptive (body position) processing.
  • Depending on the child’s unique sensory integrative difficulties or dysfunctions, activities will challenge modulation of sensory input, the ability to discriminate the spatial and temporal characteristics of sensory input, postural and ocular control, integrating the two sides of the body, planning and coordination of new motor actions (praxis) and organisation of behaviour.
  • Therapy will always include collaboration with parents/caregivers, educators and other multi-disciplinary team members.

Sensory integration and the realities of the South African context

A reality in SA is that about two thirds of the population will not be able to afford sensory integration services, a service that will make a difference to foundational functional academic skills such as, amongst others, reading and writing. SAISI is involved in or supporting various actions and endeavours to address these inequalities.

Financial support is provided to research within this field through research funding. SAISI also supports the development of “Back to Urth” playgrounds that are designed to provide especially tactile (touch), vestibular(movement) and proprioceptive (body position) sensory experiences that support sensory integration and thus function and allow children from marginalised communities access to play equipment which will provide them with the sensory rich experiences which support development (Van Jaarsveld A, 2015). Main sections of the playgrounds are constructed with a low-cost, eco-friendly building methods which makes it a sustainable solution for communities lacking in resources and infrastructure.

[This piece was initially written for the SAISI promotional pamphlet and adapted by Karen Powell]

References:

Schaaf, R.C. & Mailloux, Z. 2015. Implementing Ayres Sensory Integration®. 2015. AOTA Press: Bethesda.

Van Jaarsveld, A. 2015. The realities of SI assessment and intervention in 3rd world countries. Presentation at European Sensory Integration Congress, Birmingham, UK.

 

SAISI Contact Details:

P.O.Box 14510 Hatfield Pretoria South Africa 0028

Tel: 012 3625457

Fax: 0866523658

Email: saisi@uitweb.co.za

Website: www.instsi.co.za

Identifying Sensory Integration Difficulties

Last week we had a look at what Sensory Integration is, and what Sensory Integration problems are on a neurological level.  In this post we examine how they present in the child, at home or in the classroom, and how they are identified by occupational therapists.  It may seem like a lot of new terminology, but as you read on you will see examples and perhaps recognise these signs in some children you know.

What do Sensory Integration difficuties look like?

Difficulties with sensory reactivity can present as over- or under-responsivity to sensory input and modulating sensory information. A child with a well-modulated nervous system adapts effectively to changes in the environment and is able to maintain a level of arousal and attention appropriate to the task at hand. The child is able to block out irrelevant information, attend to relevant information and respond appropriately and adaptively. This enables the child to engage in a meaningful manner in activities of daily life.

A child who is over-responsive to sensations experience difficulties with filtering sensory inputs and may experience sensory inputs more intensely than most other children. Over-responsiveness may lead to a fight, flight or freeze response to non-threatening stimuli.
A child who is under-responsive to sensations may not respond, or show a less intense response, to normal sensory stimuli. These children may appear to “miss” sensory information from their bodies or the environment.

Difficulties with sensory perception result in difficulties in identifying, discriminating and interpreting sensations.

Children who struggle with discriminating the spatial and temporal characteristics of sensory input will have problems with tasks such as knowing how hard to press on their pencil, finding an object in a bag without looking, adapting the body during balance activities or learning the spatial orientation of numbers and letters.

Postural and ocular control and bilateral integration difficulties will be noticeable in the performance of daily tasks.

Children may struggle with postural and ocular control, which may present as a slouched posture during table-top activities, problems with making postural adaptations while moving during sporting activities, or struggling to maintain visual contact with a moving object such as an approaching ball.
They may also experience challenges with integrating the two sides of the body. This may lead to difficulties with bilateral tasks such as throwing and catching a ball, cutting, dressing and motor sequences like skipping and galloping.

Difficulties with praxis will be noticeable in the child’s physical interactions with objects, people and the environment.

Children can experience challenges regarding visual- and visual-motor planning, tactile perception and difficulties with imitating, planning and/or sequencing motor actions.
Challenges may also occur in the planning and coordination of new motor actions (this function is known as “praxis”). Children who struggle with praxis may appear clumsy, and uncoordinated, may be hesitant to engage in new motor activities, or may appear as though they do not know what to do with or how to use objects in the environment.

How are Sensory Integration problems identified?

To make a diagnosis of sensory integrative dysfunction, there needs to be evidence of a deficit in processing of vestibular(movement), proprioceptive (body position) or tactile (touch)sensory inputs.

An occupational therapist trained in Ayres Sensory Integration(ASI®) will utilise various standardised and non-standardised assessments to collect information regarding the child’s ability to process sensory information. Currently, the Sensory Integration and Praxis Tests (SIPT) are the international golden standard for testing sensory integrative functions. In addition other tests, checklists and clinical observations are used in conjunction with collateral information from parents/caregivers and educators are used to assist in identifying sensory integrative dysfunctions. Based on the assessment information, the occupational therapist will develop a hypothesis regarding the underlying sensory integrative difficulties or dysfunctions that contribute to the child’s problems/challenges in activities of daily life.

Assessment in ASI® is an on-going process. Continuous assessment and observation during therapy as well as continued interaction with parents/caregivers and educators are of the utmost importance to guide intervention towards optimally supporting the child.

[This piece was initially written for the SAISI promotional pamphlet and adapted by Karen Powell]

SAISI Contact Details:

P.O.Box 14510 Hatfield Pretoria South Africa 0028

Tel: 012 3625457

Fax: 0866523658

Email: saisi@uitweb.co.za

Website: www.instsi.co.za