Tourette Syndrome Plus - Conditions - Sensory Integration Overview

	Site Map	Conditions	Education
	Behavior	Miscellaneous	Home

Information Section: Conditions
Condition: Sensory Integration
Article: Overview of Sensory Integration
Source: Leslie E. Packer, PhD
This File Last Updated: December 2004

Article Page 1 of 1

PREFACE

In the course of normal development, the brain integrates and organizes sensory input from the environment. The sensory inputs consist of sound, sight, touch, movement, body awareness, and the pull of gravity. These sensory integrative experiences form the building blocks for children's more complex learning as they mature. But what happens if the normal sensory integration processes that occur with maturation are delayed or disordered? What happens then?

When I attended a workshop on sensory integration therapy years ago and the presenter started describing the symptoms, I had to ask her how what she was describing was different from Attention Deficit Hyperactivity Disorder (ADHD), because some of the core symptoms for sensory integration dysfunction being describing included impulsivity, hyperactivity, distractibility, and fine motor problems.

ADHD and sensory integration dysfunction (SID) are not identical, even though there's a lot of similarity or overlap, she replied. Children with SID might be unusually sensitive or over-responsive to touch or certain kinds of sensory experiences, and they might be extremely uncomfortable with certain types of fabrics, she explained. Well, my son had those problems, too -- I used to have to cut all the tags out of the back of his shirts, he still is uncomfortable stand wearing shirts with button holes, and we totally gave up on him wearing socks for over five years because he had to keep pulling them up and the seams drove him crazy. And my husband still has sensory issues about clothing and won't wear certain fabrics because he "can't stand" how they feel against his skin. But I thought that was part of their Tourette's Syndrome and Obsessive-Compulsive Disorder. Now I was beginning to wonder whether what a lot of us had attributed to OCD might be this "other thing" -- Sensory Integration Disorder.

By the end of the workshop, it still seemed that there was tremendous overlap between what the presenter was calling SID and my son's and husband's ADHD-TS-OCD. Perhaps the only differentiating symptom I could see had to do with posture and balance, and I knew that my husband didn't have those problems -- heck, he's the guy who walks on beams and roofs at construction sites and fire scenes with no problem.

As I read more on the topic, I learned that sensory integration problems seem to be discussed a lot in certain parent groups: parents of children with ADHD, parents of autistic children, and parents of children with Fragile X Syndrome, to name but some. But I also found out that there are no clearly agreed-upon diagnostic criteria, and that "Sensory Integration Disorder" is not recognized as a distinct disorder in either of the major diagnostic reference books (the ICD-10 and the DSM-IV-TR).

If you are parenting a child who has a veritable alphabet soup of diagnoses, you may be as puzzled as I was about sensory integration dysfunction and its symptoms. The following material is meant as an overview only and a summary of what I've read or learned elsewhere.

OVERVIEW

Dr. A. Jean Ayres is generally credited with developing both a theory of sensory integration dysfunction and therapeutic interventions for children suffering from it. Of particular importance here, her work emphasizes the importance of three of the senses: tactile, vestibular, and proprioceptive:

The tactile (touch) system provides information on light touch, pain, temperature, and pressure. If a child suffers from dysfunction in the tactile system, he may experience light touch or a gentle hug as intense or aversive, he may find certain kinds of fabrics or clothing irritating, may refuse to eat foods of a particular texture, and may avoid touching or handling certain kinds of objects. We say that a child is "tactile defensive" when he or she is extremely sensitive to light touch. When touched, it is as if the brain is flooded with an overload of sensory input that it cannot process, and the child's response may be disorganized and emotional. How often do we attempt to gently refocus a distracted child with a light touch on the shoulder? How often have we seen a child who seems to be having an exaggerated pain response to something that we know was "just minor?" Perhaps we think that the child is just a "drama queen" or attempting to get our attention, but if the child is tactile defensive, it may be that they are really perceiving the sensory input differently than we do.

The vestibular system involves structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of your head. If you were to close your eyes for a moment and tilt your head, you would know that your head is tilted even without having the visual input because your vestibular system provides that information. If a child's vestibular system doesn't develop or integrate normally, she may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary childhood activities such as swinging on swings, going down slides, etc. She may also experience difficulty walking on or negotiating nonlevel surfaces such as hills or stairs. Children with this kind of hypersensitive vestibular system often appear clumsy, but not all clumsy children have hypersensitive vestibular systems, and not all children with vestibular dysfunction are hypersensitive. Some are under- or hyposensitive. Children with hyposensitive vestibular systems often engage in what appears to be sensation-seeking behaviors. They may whirl around like a dervish, jump, and/or spin.

The proprioceptive system provides feedback from your muscles, joints, and tendons that enables you to know your body's position in space. If there is a disturbance in the proprioceptive system, the child may be clumsy, fall, seem to maintain abnormal body postures, have difficulty manipulating small objects, and and may resist trying different movements. If you've ever watched a student's grip on a writing instrument and noticed how abnormally tight the grip was, you may have been seeing an indication of this kind of problem (although there might be other explanations for the problem).

When we talk about sensory integration dysfunction, we are talking about some disturbance in the child's ability to process sensory input. It could be a disturbance in just one of the sensory systems, or it could involve two or more systems.

Signs of Sensory Integration Dysfunction

Signs of sensory itegration dysfunction in children may include:

Overly sensitive to touch, movement, sights

Inability to habituate to sounds and fear with unexpected noises

Easily distracted

Holding hands over ears in complex environment

Avoids tastes, smells, or textures normally tolerated by children that age

Activity level that is unusually high or unusually low

Impulsive, lacking in self-control

Inability to unwind or calm self

Poor self-concept

Social and/or emotional problems

Physical clumsiness or apparent carelessness

Hesitation going up or down stairs

Difficulty making transitions from one situation to another

Holding on to walls, furniture, people, or objects, even in familiar settings

Delays in speech, language, or motor skills

Delays in academic achievement

Seeks out movement activities, but poor endurance and tires quickly

ARE ALL SENSORY ISSUES INDICATIVE OF SID?

For a long time, we've known that children and adults with Tourette's Syndrome (TS) have what are often referred to as "sensory premonitory urges" that precede their tics. In describing tics, Dr. James Leckman has said, "Like habits, tics often arise from a heightened and selective sensitivity to cues from within the body or from the outside world." Dr. Leckman goes on to say that for many patients with TS, tics are a response to unwanted sensory urges that besiege the individual's conscious awareness and that are experienced physically and mentally as irresistible urges that can only be relieved by releasing the tics. Sensory prodromes have also been reported in patients with Obsessive-Compulsive Disorder (OCD).

But do the types of internal events described by TS and OCD patients indicate sensory integration dysfunction? To date, there has been ro direct research on this question, and I think it might be premature to conclude that children with TS or OCD have sensory integration problems because they have heightened sensitivity.

SENSORY INTEGRATION DYSFUNCTION AND SPECFIC CONDITIONS

As noted earlier, some conditions seem to be more linked to sensory integration disturbances than other conditions. But even in conditions where the "common knowledge" is that sensory integration problems are often associated, there has been a lack of controlled research to demonstrate the efficacy of therapeutic interventions. In their review of the literature on sensory integration problems in autism, Dawson and Watling (2000) summarized their findings and conclusions this way:

"Evidence is reviewed on the prevalence of sensory and motor abnormalities in autism and the effectiveness of three interventions designed to address such abnormalities--sensory integration therapy, traditional occupational therapy, and auditory integration training.... Four objective outcome studies of sensory integration therapy were identified. These were of such small scale that no firm conclusions regarding efficacy could be made. No empirical studies of traditional occupational therapy in autism were found. Five studies of auditory integration training were found. Results of these studies provided no, or at best equivocal, support for the use of auditory integration training in autism."

Since I first incorporated sensory integration as a topic on this web site, I have continued to look for relevant research. To date, there continues to be controversy over the effectiveness of this modality. That said, a number of parents have reported that their children benefitted by sensory integration exercises and techniques. In terms of research investigating specific classroom interventions, one intervention that seems to have some reported usefulness is the use of weighed vests for some young school children with autism or ADHD. A survey of professional school-based occupational therapists found that weighted vests were reported to increase attention span, staying on task, and staying in the child's seat. It is important to note that those were survey responses, however, and no actual objective data were provided to assess or support the therapists' impressions or reports.

GENERAL COMMENTS

While this brief overview has focused on three systems (tactile, vestibular, and proprioceptive), teachers should keep in mind that the child can have sensory defensiveness in any of the sensory systems. For example, some children will find certain sounds intolerable (such as the bell signalling change of periods, or noises in the hallway), while other children may find particular smells or tastes intolerable. Any kind of sensory defensiveness can make it difficult for the child to function normally in a school setting or to engage in normal social activities with peers.

If a child appears significantly impaired by sensory-related issues, parents may wish to arrange for an assessment by a qualified occupational therapist. If sensory-related issues are affecting school functioning, parents may wish to ask the school district to arrange for a school-based OT evaluation, keeping in mind that the scope and purpose of a school-based OT assessment are generally somewhat different than an OT assessment arranged for privately.

As is often my advice, let your child's behavior guide you. If your child seems to have significant trouble handling what should be "normal" parts of their childhood -- if they avoid situations that their peers would enjoy, if they avoid too many foods or textures, if they avoid playground equipment out of fear, if they seem to experience normal voice volumes as "too loud" -- then you may want to consider an OT assessment.

SCHOOL-BASED INTERVENTIONS

Elsewhere on this site, you can find a fact sheet from the AOTA about what Occupational Therapy can do as a related service for students with disabilities. One of the issues that has come up in the last few years is the issue of having school-based occupational therapists provide "sensory integration therapy" as a related service. First, it is important to keep in mind that there is no uniformly agreed-upon diagnostic category called "sensory integration disorder." Second, there is no unequivocal demonstration of efficacy of "sensory integration therapy" as an intervention. Although occupational therapists routinely incorporate assessment of some sensory integrative functions in their evaluations, and activities that promote sensory integration, they understandably focus on those aspects of functioning that have educational impact. In a 2000 "frequently asked questions" handout, the AOTA published the following, which is important for parents to understand, so I am quoting their question and entire response below:

I Have Asked The District To Provide Sensory Integration Therapy for My Child. The School OT Seems Unwilling to Do This. What Can I Do?
Sensory integration is one frame of reference or perspective which might be used in the occupational therapy intervention process. The service or therapy that school districts are mandated to deliver is occupational therapy.

In the schools, the focus of OT is on the child's ability to function in the educational environment.

As long as the child's educational needs are being appropriately met, the school-based OT is operating within his/her scope of practice and training.

Each occupational therapist, using professional judgment, evaluation data, and expected outcomes, selects a particular frame of reference which will guide the intervention. You are encouraged to discuss your concerns with the school therapist to help you understand the reasoning used to guide the intervention.

If your child is doing well in school but has sensory issues, that does not mean that school-based OT is necessary as a related service. It only becomes necessary and appropriate when the child is unable to benefit from their special education program without the service.

Information Section: Conditions
Condition: Sensory Integration
Article: Overview of Sensory Integration
Source: Leslie E. Packer, PhD
This File Last Updated: December 2004

Article Page 1 of 1

	Site Map	Conditions	Education
	Behavior	Miscellaneous	Home