Occupational Therapy -with an SI approach

John is attending OT (occupational therapy) two times a week right now at Casa Colina Rehabilitation Hospital.  The therapists working with him are working with a SI (Sensory Integration) approach.  To understand this a bit more, I thought I would define SPD (Sensory Processing Disorder), the treatment, and how it all affects behavior, emotions, social skills, and motor skills.


What is SPD?
First, to understand SPD, we need to look at what Sensory Processing (sometimes called Sensory Integration) is all about.  According to the Sensory Processing Foundation, sensory processing is our nervous systems way of receiving messages from the senses and turning them into appropriate motor and behavioral responses.  If you touch something that is too hot, your nervous system interprets that touch and you react accordingly, realizing it is too hot.  If you hear something that is too soft, you are able to react by turning the volume up because the nervous system interpreted the sense of hearing and sent the message that the volume was too low. 

SPD, or sensory processing disorder, is when the signals do not get interpreted correctly and therefore, responses are not organized appropriately.  The brain receives the sensory information incorrectly and inappropriate responses in behavior, emotions, motor planning, social skills, etc. 

Some people with SPD may over-react to one of their senses, while others under-react.  Some people are bothered by textures, tags on their clothing, certain foods, loud noises, bright lights, etc.  Some people with SPD have poor posture, low motor planning, low muscle tone, appear klutzy, etc.  Others crave sensations in what appears to be "overdrive", where they can't seem to get enough of a particular texture, swinging on a swing, spinning in circles, etc.

MANY PEOPLE THAT HAVE SPD GET MISDIAGNOSED FOR OTHER PROBLEMS BECAUSE THE BEHAVIORAL, EMOTIONAL, SOCIAL, MOTOR PLANNING, ETC. ARE AFFECTED AND CAN APPEAR AS SOMETHING DIFFERENT.

There have often been times throughout our journey where I have wondered if the "at risk" for autism diganosis or the PDD-NOS diagnosis for John was really just SPD.   Children on the Autistic Spectrum have Sensory Processing problems, so oftentimes, both SPD and an Autistic disorder are present.  I hit a point a long time ago where the actual label didn't matter to me anymore.  I know what John's current needs are and I'm addressing those as they come up.  About 3 months ago, it was obvious that he needed OT above all other help.

OT with an SI (sensory Integration) approach is when an occupational therapist works with the child in a "sensory rich" environment in an OT gym.  The therapist will guide the child through play activities that challenges the child in areas where he/she need improvement.   For John, they are currently working on fine motor skills (buttoning buttons, writing, hand games), motor planning (using yoga positions to challenge him to manipulate his body to match a photo and hold position without falling, using obstacle course where he crawls through tunnels, climbs over obstacles, hits a baseball, kicks a soccer ball, bounces on a trampoline, jumps in a ball pit, swings on a trapeze bar, etc), stengthening posture by having him use his upper body more (this week they had him lying on his stomach on a skateboard and had to use his hands, arms, and upper body to move the skateboard through the bases of baseball).

John has a problem with organization in his brain.  There are days where he becomes over-stimulated through  the day and can no longer organize his body, his responses, etc.  There are times you will see him slumped over in a chair---standing facing the chair, with his head in the chair--- constantly moving to get comfortable or he might appear "tired" where he wants to be carried and slumps over ones shoulder like a young infant.   He sometimes throws his head back and shakes his head so his eyes move back and forth.  These are all signs that his brain is "disorganized" and he can't appropriately focus or react to what is going on around him.    Occupational Therapy teaches him how to regulate himself when he gets that way, as well as helps him learn everyday activities through play therapy.

Where is Thumbkin?

According to The Lotus Tree Sensory Integration Center, praxis is the ability by which we figure out how to use our hands and body in skilled tasks like playing with toys, using a pencil or fork, or building a structure. 

Children with praxis problems have a hard time writing, eating with a utensil (often spilling frequently which leads to a preference to use their hands to eat), playing games like rock, paper, scissors or Where is Thumbkin, putting up fingers to show how old they are,  button a shirt, etc.

As a toddler, John would hold 2 fingers (with the opposite hand) when he wanted to show he was 2 years old.  He couldn't fold the other 3 fingers down, while still holding up the 2 to show his age.  He has ALWAYS used his hands while eating and frequently needs to be reminded to use a fork.  He has very little control of it and is considered a "messy eater".    He had problems building towers out of square blocks and during early intervention, they worked with him stacking first 4 blocks, then 5... and then up to 9.    We put a variety of sponges in the bathtub for him to squeeze and release to help him with the muscles in his hand.  The releasing is important because that is the same muscle used to let go of a block with control when it sits on top of another.   In OT, he has been working on buttoning.

More recently, we noticed he couldn't play hand games.  Last week in Kids Crew, the lesson centered around finding "fair" ways to determine who goes first when playing games.  They learned about picking a number from 1-10, eenie-meenie-minee-moe, bubble gum bubble gum, and rock, paper, scissors.  John was unable to make the "scissors" with his two fingers.

Concurrently, he was learning "Where is Thumbkin" at his My Gym Preschool.  He needed to isolate the thumb, the pinkie, and the pointer finger at different points in the song.  At the end, the teacher showed them that if you put all 3 up together, it means "I Love You".  John struggled that day, and the next day had the problems with Rock, Paper, Scissors in Kids Crew.

All week, John has been practicing holding up each finger, singing the Thumbkin song, and attempting to play Rock, Paper, Scissors.  .... AND THERE HAS BEEN SUCCESS!!!   He's got it figured out.  He's able to do it all now and the hang loose sign (like the sticker on the back of Daddy's truck).  I'm so proud of him.  He had to work through some frustration to get there, but he did it all on his own.  Although we've been working on different aspects of praxis since we started early intervention, we concentrated more on achieving the goals that were set for him, like eating with a fork, building the blocks, etc.  He figured out his own goal this week and conquered it before he had to go back to Kids Crew.  This morning he told me, "Mom, I'm going to show my friends in kids crew that I can do it!"  He's proud too! ;)

The Vestibular Sense

Using Carol Stock Kranowitz' book, The Out-of-Sync Child as a reference, I am going to concentrate on the Vestibular Sense today.

The Vestibular System

The vestibular system sends sensory messages to our brain about balance and movement, generating muscle tone so we can move smoothly and efficiently. The receptors for vestibular sensations are hair cells in the inner ear, stimulated by gravity. It is what responds when we feel ourselves "falling"-- the response being self-protective reflexes.

Vestibular Dysfunction

Vestibular dysfunction is the inefficient processing in the brain of sensations received through the inner ear. Posture and coordination can be off. Eye movements are influenced by the vestibular system, so visual problems can occur --- inadequate gaze stability, inability to focus on moving objects, reading problems due to coordination issues with left-to-right eye movement, etc. It can contribute to difficulty processing language. Certain movements that should produce a calming effect do not for the out of sync child, causing them to be unable to calm themselves down. Difficulty moving smoothly interferes with behavior and attention.

Overresponsivity - children respond negatively to movement; causes emotional outbursts or overexcitement; can't organize sensory stimuli due to overload; some may be intolerent to any movement at all;

Gravitational Insecurity - no sense of stability; primal fear of falling - abnormal distress and anxiety about falling

Underresponsivity - this child doesn't seem to notice changes in movement; these children typically were called "easy babies"; loved curling up for long naps; later lacks any motivation to want to move; does not usually seek movement; needs extra movement just to get going, but then once started, has difficulty stopping; oblivious to the sense of falling

Seeking more - can't get enough of movement; increased tolerance for movement; enjoys vigorous activity; loves being upside-down, loves to climb - -uses everything for a ladder; loves swinging for exceptionally long times; loves twirling in circle --oftentimes seeming like they don't get dizzy; darts from one activity to another; short attention span even for things they enjoy; constantly on the go, but moves without caution or good motor coordination


Muscle Tone is the degree of tension normally present when our muscles are in the resting state. A child with a vestibular dysfunction may have low muscle tone. (this is not strength of muscles, but the state at which the muscles are at rest). Their muscles lack the energy needed to be ready to move. It takes a little bit of extra effort to just get them started.

Bilateral Coordination is a term used to describe using both sides of the body to work together. A well-regulated vestibular system helps to integrate sensory information from both sides of the body. Children by age 3 or 4 should be able to cross the mid-line, which means reaching with one hand to the other side of the body (crossing the center of one's body) -- think 'cherry-pickers' from grade school PE class (arms outstretched-twisting and bending to touch our right hand to our left foot and then back to center, reverse) or shaking hands with someone (your right hand with their right hand, crossing over your center of your body).
It's also what contributes to the ability to jump with both feet from a ledge to the ground, as opposed to just stepping off with one foot.---- or using both hands to clap.

The Vestibular Sense and John

For John, I checked 2 of the 4 listed for underresponsive in movement
and 4 of 7 in sensory seeking. I had a lot checked and a lot of question marks in the "sensory slumper with sensory-based postural disorder affecting movement of head, balance, muscle tone, and bilateral coordination".

John had lots of scattered skills throughout this section, but nothing that is definitive for me, although my gut tells me he is the sensory seeker for movement.

For example, he moves all the time and is almost always in constant movement, which would tells me that he is a sensory seeker. However, he doesn't vigorously shake his head, doesn't rock back and forth, doesn't like trampolines more than other kids (he will jump for 2 seconds and then he is done, as with everything else he does), etc. Many of the questions in the checklist were not age appropriate for me to know yet with John (like seeks out thrill rides at amusement parks).

He appears at times to be uncoordinated, but can clap, cross the mid-line, open doorknobs, is already potty trained (poor bladder control is one checkbox), and loves structured activities (hard time with structure was another check box) -- he actually loves the structure.

So, to sum it up, there seems to be an issue here for John, but I can't pin point it myself. I'll have to see what the OT evaluation shows.

Sensory Integration Disorder

Through an Occupation Therapy screening, I have learned John needs an evaluation for Sensory Integration. Sensory integration is an innate neurobiological process and refers to the integration and interpretation of sensory stimulation from the environment by the brain. In contrast, sensory integrative dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior

I was told to read a book called, "The Out-of-Sync Child" by Carol Stock Kranowitz. I can't put it down. Right now, I'm about 150 pages into the book. I feel like I am reading a book that was written about my son.

The book has checklists that parents can use to determine if their child has a Sensory Integration dysfunction and what kind it may be. I have learned that John is a Sensory Seeker. He craves movement, loves being upside down, bumps into couches for sensory stimulation, loves spinning, oftentimes not getting dizzy, can't get enough of tactile stimulation (through the hands), etc.

John has always wanted his hands in my armpits. He would put them there when trying to fall asleep, when I'd carry him in the grocery store, standing in church---everywhere and any time. I thought it was weird and annoying, but didn't think much more of it. He touches to a point of annoyance, even when the touch isn't wanted. He always has his hands on my face or trying to put them in my mouth. If I'm talking to other people and my attention is diverted away from him, he often grabs at the collars of my shirt, trying to put his hands down the front of my blouse or up the sleeves.

John is always mouthing/teething objects. He doesn't put play dough or glue in his mouth, but he does chew on shirt collars, toys, blocks, bottles, the car seatbelt ---anything that can be chewed on. His shirt is often wet and if he can't find anything else, his fingers go in his mouth. He never was a thumb sucker and his pacifier was given up at 6 months old. But, he has always chewed on toys and clothes.

He loves his teeth brushed. He has always been obsessed with toothbrushes and helping my husband and I brush our teeth. We used to joke that he was going to be a dentist. Recently, we bought him an electric toothbrush, which has helped him with his poor muscle tone in his mouth.

Low muscle tone is one of John's problems. I never realized this, as I always thought of him as strong. But, muscle tone is not a measure of strength. It is the amount of tension our muscles have at rest. Normal muscle tone would reflect muscles that are "ready to move" or react when we need them to. Low muscle tone means that they are more at rest than they should be.

John's low muscle tone in his mouth accounts for his speech delay and inability to make his mouth move in certain ways to make certain sounds. It makes it difficult to blow bubbles. Ways of increasing muscle tone of the mouth includes sucking a milkshake through a straw, blowing bubbles, etc.

Low muscle tone would also account for the inability to stack blocks. Stacking blocks in a high tower requires the hand to 'release' the block. The muscle used to release is different than the muscle used to grasp. Ways of increasing muscle tone of the hands is to squeeze a wet sponge and release it. Different size sponges increase the level of difficulty of squeezing to help build the squeeze and release muscles.

John loves tactile sensations. Many kids do, but children who are sensory seekers can't get enough of it. The brain doesn't recognize that it has received enough stimulation because the nervous system is "out of whack". These kind of children want "more more more". The opposite, but still sensory dysfunctional on the other extreme, would be the child who can't stand touch, who withdraws from it (or any other sense for that matter --- covers ears during fireworks, high pitch noises, doesn't like crowds). Each sense has sensory seekers and avoiders, as well as those that don't show one way or another. A "normal" sensory integration child would be able to adapt to the environment as different senses pick up different things. It's what tells us that there is danger or fun in what is around us. Kids with this dysfunction don't know how to interpret this sensory information and it throws their whole day off.

For John, he needs "more more more". His brain is using its energy inefficiently, which accounts for his lack of attention. Everything is full force and outside the level his brain should function at. Calming him down is difficult. When he sleeps, he's not at full rest. He inefficiently does everything around him.

I tested this theory, doing a sensory activity for the tactile sense. I put both my kids in a bathtub with shaving cream. I told them we were going to finger paint in shaving cream. I squirted it all over the bathtub and let them at it. Katie rubbed her hands and arms in it for a few minutes and then washed it off, proceeding to draw letters and pictures around the tub. John, on the other hand, took huge clumps of it, clapped it together, watched it fly around the bathroom and giggled. He then sat in the tub and put his feet up on the sides, rubbing them in the shaving cream, giggling. After that, he stood up and grabbed a bunch and began lathering himself in it. He rubbed it on his stomach and then continued to put more and more on. He then slapped it and watched it float and fly off his body. Once it was gone, he wanted more. I obliged and it started all over again. When it was all over, he transitioned fine to the next activity, but talked about the 'shvn crm' all night long. Now, every time he sees the bathtub, he wants the 'shvn crm'. I'm just happy he's saying "shvn crm"!