The occupational therapists at Emerge work with children who present with a variety of needs. At the core of many developmental, social and behavioral differences lies difficulty with the processing of sensory information. As a result, many of the programs, activities and equipment at Emerge are designed to address sensory processing concerns.
First and foremost, however, we are occupational therapists, and chances are you may know very little about occupational therapy and may be wondering why your child was referred to an occupational therapist. We well recognize that we have a bit of an identity crisis with the name of our profession. And the fact that we are equipped to deal with a wide variety of special needs, making it challenging to capture the essence of occupational therapy in a line or two.
Basically occupational therapists are concerned with everyday occupational performance. So what does that mean in the world of children: facilitating their success in the occupations of childhood: play, self-help skills, and school. Which pretty much sums up how they spend their time. So when a child is struggling with some aspect of everyday life, the occupational therapist assesses the child, based on the referral concerns, to determine what foundational skills have been impacted. Then an intervention plan is developed to address those foundations (sensory, motor, social, perceptual, self-regulation, etc.), always with an eye on the ultimate goal of helping the child be more successful with the demands of everyday life: their occupations.
Many children are referred to Emerge because someone suspects that the difficulties they are experiencing may be related to how they are experiencing the world: their sensory processing or integration. Our understanding of our bodies and the world around us is based on processing information received through our senses. Throughout the day we are bombarded with sensory input, which must be organized and interpreted so that we can successfully adapt to the world around us. In addition to the more readily recognized senses of sight, hearing, smell, and taste; development is also heavily dependent on our:
• Tactile/touch pressure system
• Vestibular system (sense of balance)
• Proprioceptive system (sense of body position and movement)
Children with sensory processing differences often struggle to meet the demands of everyday life and demonstrate behaviors that may not respond to behavioral approaches. As a result these children are often challenging to parent and may struggle in school. When a child is unable to process information from the senses efficiently, they are said to have a sensory processing disorder (or sensory integration disorder). Sensory processing disorders may manifest in a variety of ways and can affect a child’s motor skills, learning, communication skills, activity level, behavior, social skills and emotional regulation.
Common Sensory Processing Difficulties:
Sensory Defensiveness: Sensory defensiveness refers to a tendency to overreact to routine sensory stimuli. We have two ways of responding to sensory input. The higher, more mature response is discrimination, which allows us to immediately interpret what the stimuli is and whether or not we need to respond to it. The more basic, survival-oriented response is a protective fight, flight, or fright reaction. Children with sensory defensiveness tend to be operating more in the survival mode, with stimuli being interpreted as threatening or annoying. Most commonly seen in relation to tactile and auditory input, but can also be seen in relation to vision, taste, or smell.
• Reacts negatively to light or unexpected touch
• Picky about clothing
• Does not like to get messy
• Reacts negatively to loud sounds and/or bright lights
• Limited diet, may gag easily
• Easily overwhelmed in large or group settings
What to do:
1. Recognize that child’s behavior is their way of coping with the environment and represents their ‘survival’ need.
2. Establish a ‘sensory diet’ incorporating deep pressure and heavy work activities throughout the day.
3. Use firm touch rather than light touch when interacting with child. No tickling.
4. Accommodate child’s preferences, but continue to encourage them to expand.
5. Avoid situations that are likely to trigger meltdowns.
6. Family should be instructed in the Wilbarger Deep Pressure and Proprioceptive Technique (DPPT), sometimes referred to as the “Brushing Program”. Because the DPPT decreases hypersensitivities, it also often helps a child modulate/regulate their emotional response to the environment and maintain a calmer, organized, less anxious and reactive state. Anyone using the DPPT must be trained and monitored by a qualified occupational therapist.
Gravitational Insecurity: Gravitational insecurity refers to discomfort with or fear of movement, particularly unexpected, and/or heights. It is felt to be related to difficulty processing vestibular and proprioceptive input. Children with gravitational insecurity are often described as “earthbound,” as they are uncomfortable with activities in which their feet are not on the ground. They often engage in limited climbing and swinging activities and are cautious on stairs. They often resist being tipped backwards for hair washing or to lie down on an examining table at the doctors.
What to do:
1. Support child, emotionally and physically, introducing new motor demands gradually.
2. Fade physical support for an activity as child becomes more comfortable.
3. Use a sensory diet incorporating heavy work activities.
4. Start with slow linear swinging, as child will tolerate.
5. Provide opportunities to explore movement that are safe (eg without a lot of children in area).
Sensory Registration: Children with poor sensory registration are not successfully processing information from their environment in order to interact appropriately with the world. Children with poor sensory registration may respond by either going with the poor registration or by working against it.
Children who go with the poor registration can be described as having a low arousal level.
• tend to be passive
• often demonstrate a flat affect
• low energy level
• muscle tone maybe low
• seem self-absorbed
In contrast the child who is working against his poor sensory registration is a sensory seeker.
• very active
• love to crash, jump, climb, etc
• often are impulsive
• poor safety awareness
• sometimes poor awareness of pain and/or temperature
It is not uncommon for some children to fluctuate between the two extremes, but they have difficulty attaining/maintaining a ‘just right’ level of focus and attention (see modulation section).
What to do: These children benefit from lots of proprioceptive (heavy work) input. Use lots of whole body movements, activating arms and legs. Have an area both inside and outside the house for ‘heavy work’. Be proactive. Provide heavy work early in the day and at regular periods throughout the day.
• Crash pillows (sew or use twin duvet covers – stuff with large foam pieces: The Mill Outlet in Raleigh); couch cushions; bean bag chairs: for child to climb over, under, jump onto
• Cardboard boxes
o Make obstacle courses
o Fill with books and push
o Sit inside and have parent push/pull
• Fisher Price bounce and spin zebra (under 3 years), hoppitty ball, mini trampoline
• Small tunnel (Oriental Trading company has inexpensive one) to crawl through
• Fill up empty liter soda bottles with colored water to carry around, pull in wagon, push in wheelbarrow, etc.
• Play wrestling with parent
• Sucking/Blowing/Chewing activities
o Fill bowl 1/3 full with water and a little dish soap. Have child blow bubbles using a long, curly straw.
o Drink thick liquids through a straw.
o Whistles (see PFOT.com).
o Chewing gum, fruit leather, beef jerky.
Passive, low arousal child: 1. Change activities often 2. Use a variety of materials, textures, sound and colors 3. Change position frequently 4. Do activities in standing 5. Encourage physical activity Active, sensory seeker child: 1. Incorporate daily physical activity, preferably outside 2. Encourage ‘heavy work’ that is not overly stimulating (pulling a heavy wagon, moving furniture, pushing a heavy box) 3. Alternate quiet activities with more vigorous ones 4. A crash area with large pillows may be helpful 5. Use toys that require some force; large pop beads, hammering bench 6. May benefit from pressure or weighted vest – check with occupational therapist
Dyspraxia: Praxis or motor planning refers to the ability to conceive, organize and execute skills in a refined, efficient manner allowing the generalization of learned actions to new situations. It is dependant on adequate sensory (tactile, vestibular, and proprioceptive) feedback and the establishment of a good body schema (awareness of one’s own body) and spatial maps (awareness of the physical world. There are three processes involved in motor planning: ideation, planning and execution. Ideation is the ability to conceptualize an action and come up with ideas for activities. It is the intent to do something. The second component of praxis is the ability to plan or program actions. This means knowing how to go about doing what one wants to do by developing strategies, organizing behavior, and ordering ideas over space and time. Part of the planning process is the ability to rely on knowledge from past experiences as well as information from your body and the environment in the moment of action. This allows you to anticipate the likely results of your plan and adjust it accordingly so that you are successful. The third component of praxis is actually executing or carrying out the plan. Deficits in any one component of motor planning can seriously impact a person’s ability to sequence not only fine and gross motor skills, but also their ability to sequence ideas, behavior and social interactions.
Praxis is the basis for interacting effectively with the physical world and allows us to be successful with the demands of life. A child has to motor plan to learn new skills such as dressing, riding a bike, negotiating a plan of play with a peer, or preparing a snack.
What to do:
1. Break tasks down into smaller steps to help child learn more challenging activities.
2. Provide a wide variety of sensorimotor activities to help child develop a better awareness of their body and how they move (climbing, obstacle courses, playing in sand and water). The Out of Sync Child Has Fun is a good resource.
3. Encourage child to plan out what is needed for a particular activity. Don’t anticipate their needs.