Sensory Integration

Sensory integration is a specialty area of practice within the field of occupational therapy. When we think of the senses we generally think of sight, sound, smell and taste. In addition to these senses, occupational therapists are concerned with the senses of touch, movement and postural responses to the sensation of gravity and movement. Just as the eyes detect visual information and relay it to the brain for interpretation and action, other sensory receptors pick up and relay information to the brain for interpretation and purposeful response. Many of our sensory processes take play within the nervous system at an unconscious level. Cells within the skin send information about light touch, pain, temperature and pressure to the brain. Structures in the inner ear along with our eyes detect movement and changes in position of the head. The vestibular system allows us to maintain our balance while engaged in physical activity. The proprioceptive system gives us a sense of where we are in space and allows us to move our arms and legs in a guided and controlled fashion. An adequately functioning sensory system is crucial to helping us interact with others and the environment. This interaction between the senses and higher cortical functions is complex and necessary in order for a person to interpret a situation accurately and make an appropriate response. It is this organization of the senses that is termed sensory integration. Pediatric occupational therapists work with infants and young children to facilitate an adequately functioning feedback loop between the sensory systems and the brain allowing for the development of appropriate skills and self-regulation.

DIR Floortime Model
     The DIR Floortime was developed by Dr. Stanley Greenspan and Dr. Serena Weider and colleagues. The DIR model is an approach used to treat children with disorders of relating and communicating. While many people see this as a treatment approach for children on the autistic spectrum, in reality, it is an appropriate model for children with a wide range of diagnoses. One of the key components of this model is that the team approach is crucial to the child's success. This team consists of the child/parent/caregiver, pediatrician, nutritionist, mental health professional, educator, speech therapist, occupational therapist, and physical therapist, to name a few. The DIR model gives all the disciplines coming from their own perspective, a framework to talk about the child and pursuing the goals and outcomes.

The D in DIR stands for Development. This encompasses all areas of development for the child: motor, visual, sensory, cognitive and emotional etc. It also refers the the development of all the people in the child's environment as they are in their own stages of development and bring to the table their strengths and weakness regarding their ability to evaluate and provide treatment. The I in the DIR stand for individual differences this includes, biological, constitutional, temperamental, sensory processing and modulation, as well as, autonomic nervous system functioning. The R in the DIR stand for relationship. This work must be done within the context of relationships. The child's relationship to self, parents/family, school personal, therapists, peers and community. All work is done within the context of the relationship. It is through the interaction with another that deep and meaningful change will occur.

     Greenspan and Weider have outlined certain core capacities in development that must be firmly in place and integrated into a child's schemata before they can function solidly at each successive stage. In working with children with disorders in relating and communicating we always come back to assess whether or not the child is solid at each developmental level, if they are not functioning solidly at that developmental level, then we go back and work at that level to strengthen their interactions and their core capacities. The Functional Emotional Developmental Levels as outlined by Dr. Greenspan and Dr. Weider are as follows:
   I. Self-Regulation and Interest in the World
    II. Forming Relationships, Attachments and Engagement
   III. Intentional Two-Way Purposeful Communication
   IV. Development of a complex sense of self (e.g. behavioral organization and elaboration)

V. Representational capacity and elaboration of symbolic thinking
VI. Emotional thinking or the development and expression of thematic play

Level 1: Self regulation and interest in the world is related to internal regulation and harmony within the environment and another person. At this level we are very concerned with the child's and caregivers ability to process sensory information to regulate themselves individually, together and within the environment. When we speak of the sensory systems, most people are familiar with the visual, auditory, tactile/touch, olfactory, and taste. There are two other systems that occupational therapist's are particularly concerned with; the vestibular and the proprioceptive systems. The vestibular system (located in the middle and inner ear) is involved with sensations related to gravity, movement and postural control. The visual and auditory systems are closely related to the vestibular system and frequently when there are difficulties in one of the systems, the others will be affected. The proprioceptive system is located in our muscles and joint and provide feedback as to where our bodies are in space. It also provides feedback as to how much or how little force we need to use to complete a motor task.

As we delve deeper into the sensory system and the body's physiological ability to self-regulate we are very concerned with the Autonomic Nervous System (ANS). The ANS has two parts, the Sympathetic Nervous System (SNS) and the Parasympathetic Nervous System (PNS). The SNS is responsible to alerting and action and the PNS is responsible for our bodies ability to rest and digest. It used to be thought that all of this happens automatically and indeed for the most part it does. We have learned in recent years that we can exert some control over the ANS by calming our breathing, heart rate and level of arousal through meditation, yoga, tai chi and relaxation techniques. We have also learned through scientific research that some individuals naturally have increased vagal or sympathetic tone, leaving them at risk for emotional disorders.

Level II: Forming Relationships, Attachments and Engagement: At this level the key hallmark is the bonding between caregiver and child by both parties ability to be in a calm and regulated state individually and together. At this stage the child and parent become absorbed in one another, that importance of the other, the infant gurgles and coos at the sound or appearance of mommy and daddy and nothing else matters. This craving and need for the all important mommy and daddy sets the stage for further development of cognitive, language and motor development. This love between child and caregiver has a profound affect on the child's motivation to learn new tasks. Mom walks in, baby's face lights up, mom talks, baby coos and perhaps lifts her head up to better see, mom picks up baby etc. It is through this developmental phase that children learn to care and trust and co-regulate.

Level III: Intentional Two-Way Purposeful Communication: Intentional two-way communication involves opening and closing circles of communication, preverbal, gestural and verbal. Here the hallmark is that continuation of the back and forth dialogue between the caregiver and child that is often referred to as opening and closing circles. This communication is through simple gestures, touch, back and forth signaling non-verbal and verbal and becomes more and more complex as both the child and caregiver mature into this new and wonderful relationship. This sets the foundation for friendships later.

Level IV: Shared Social Problem Solving: Shared social problem solving continues the flow of opening and closing circles of continuous communication. Cause and effect is included into the drama in many sequences and chains of events. Baby crawls over to mom on the floor folding laundry. Mom encourages the baby over by playing peek a boo with the laundry. Baby spots the booster seat next to mom and climbs in to play, but baby gets stuck. Here the baby begins to get frustrated because she is stuck and wants to play but can't move her body. How can mom keep the play going and find just the right challenge while encouraging her baby turn her body around in her chair. Indeed, what is the just right challenge to keep the back and forth going? Here not only are the baby and mommy learning to solve the problem, but they are learning in a co-regulated state. The child is learning where and how their little body moves and fits in space. The parent's ability to help the child solve the problem, not necessarily get them out of the booster seat, is very important to the child learning to problem solve and motor plan. The initial game of peek a boo may shift to a very important game of in and out!

Level V: Creating Symbols and Ideas Creating symbols and ideas is related to the development of pretend play, attaching emotional content to that play and the expression of feeling states. At this level the child begins to be able to express their feelings, in addition to exploring them from pretend play. Representational play is one of the early hallmarks at this level and later toward the end of this level symbolic play emerges. Representational play is using an object for what it is intended and symbolic play is using an object that may have some similarities to its intended pretend use. Grand-mom is visiting with her three pronged walker. One child uses it as a cane and walks like an old person. Yet another child picks it up and pretends she is a rock star singing into her microphone.

Level VI: Building Bridges Between Ideas: Logical Thinking: At this level we continue to deepen and broaden the development of symbolic thinking and playing to opening and closing many circles of communication through play, gestures and dialogue. The drama becomes much more complex and flexible enough to incorporate new ideas and peers. Again, the child is able to attach feeling states to the play but can now state why. "I am mad because I want my dolly and I don't want to share her with you." She and a friend may even be able to come up with a solution that would make both of them happy. Along with that is the ability to set aside the play in order to come to dinner, because the child knows she can return to the drama at a later time and place.

Myania Moses OTR is a facilitator at the ICDL Summer Institute for Professionals.

For more information on the DIR/ Floortime Model refer to the ICDL website at: www.icdl.com

The following books are highly recommended:

The Child With Special Needs, by Dr. Stanley Greenspan and Dr. Serena Weider

Engaging Autism, by Dr. Stanley Greenspan and Dr. Serena Weider

ICDL Diagnostic Manual, ICDL Press, Bethesda, MD

Handwriting Without Tears was developed by an occupational therapist, Jan Olsen. It is an easy, methodical and simple way to teach the art and skill of handwriting. It has become something of a national craze with school systems buying into the program and teaching methods. We love Handwriting Without Tears and primarily use this approach to teach handwriting in our clinic. This should not be confused with the importance of the developmental hand and visual skills that are part of the treatment plan in getting children ready to write and and further developing precision and visual motor skills while learning to write. There is a program at every level from getting ready to write, printing and cursive writing. This program uses a multi-sensory approach to teaching writing skills, including music, kinesthetic awareness and practice. Each level consists of a student work and practice book and a teacher's manual filled with tips and techniques.

Feurstein's Mediated Learning and Instrumental Enrichment
Dr. Reuven Feurstein, is a psychologist who trained with psychologist, Jean Piaget. Piaget believed that we were born with innate and set cognitive skills. Unlike Piaget, Reuvenstein believed that intelligence was not set, but was modifiable. Feurstein's early work in the 1950's set out to disprove currently held concepts regarding cognition. He defined the executive skills that led to the concept of Structured Cognitive Modifiability. He organized skills into the input, elaboration and output level. He developed specific tools to mediate core cognitive deficits. Rather than teaching the materials or tools, mediators are present to ask questions to help the child/children solve the problem and develop the skills needed to solve the problem. Mediation helps to form and shape a child's perception. In order for mediated learning to occur, reciprocity must exist. The child must find the experience fun and be willing to collaborate. Through this experience the child develops fundamental concepts that enable subsequent cognitive development. Using the individual tools systematic, persistent and structured conditions for the engagement of the child in problem solving are created. We identify, isolate and practice the application of necessary concepts and efficient cognitive behavior. We mediate effectively and no more than necessary. Feurstein's Instrumental Enrichment program consists of two levels; Standard and Basic. The Standard Program is for 4th graders through High School students. The Basic Program is for pre schoolers through early elementary age children.

As occupational therapist's we see many children, who, due to sensory sensitivities and regulation disorders, have difficulties with executive skills at the input, elaboration and output level. Many of the children we treat are having difficulties with peer relations, reading their own and others signals, as well as, learning to read and write. In addition to the above, we are concerned with the development of motor planning skills; the ability to ideate, plan and the execute a response to environmental demands. The Feurstein approach is wonderful because it gives us another tool for helping the children we treat become more regulated within themselves and in their environment, developing and internalizing a sense of self and other, controlling impulsivity, improving focus and a need to think and plan before acting. Further, it gives us a philosophy and strategies for becoming mediators and supporting children in their ability to become good problem solvers and thinkers.

In the Summer of 2007 Myania Moses was fortunate to go for two weeks of training in the MLE/FLE program. She has been using it this past year with individual clients, a group of 7-8 year old boys and through the therapeutic preschool group at Columbia Baptist Preschool in Falls Church. Myania will be using the Basic Program in Summer camp and throughout the school year in the clinic. Please check this website toward the end of July for a list of Fall offerings.

For a list of the instruments at the Standard and Basic Levels as well as more information on MLE/FLE contact the International Renewal Institute at:
www.iriinc.us/index.htm

A recommended book for parents and educators is: Mediated Learning in and out of the Classroom, By Reuven Feurstein