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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
SPD are not identical,
even though there's a lot of similarity or overlap,
she replied. Children with SPD 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 (OCD). Now I was beginning to wonder whether
what a lot of us had attributed to OCD might be
this "other thing" -- sensory processing dysfunction.
By the end of the
workshop, it still seemed that there was tremendous
overlap between what the presenter was calling SPD
and my son's and husband's ADHD-TS-OCD.
As I started reading more on the
topic of sensory integration years ago, I learned that sensory issues
seemed to be discussed a lot in certain parent
groups: parents of children with ADHD, parents of
autistic children, parents of children with Tourette's Syndrome and/or OCD, and parents of children with
Fragile X Syndrome, to name but some.
In the past few years, we now have research that actually confirms parents' concerns and reports in terms of the the greater prevalence of difficulties associated with certain disorders, and the relationship between sensory processing difficulties and behavior or emotional regulation. For example:
Sensory Issues in Obsessive-Compulsive Disorder and Tourette's Syndrome
Sensory phenomena are a frequently-reported, but little understood, part of Tourette's Syndrome, and to a lesser extent, Obsessive-Compulsive Disorder. The phenomena have been described as "urges," "itches," or "premonitory urges."
Prado and her colleagues (2008) have reviewed the research on sensory phenomena in children with Tourette's Syndrome (TS), OCD, and TS+OCD. There appears to be a subgroup of children with early-onset OCD who have a significant sensory phenomenon as part of their presentation. From their study, some of the experiences below sound very much like sensory processing issues or sensory defensiveness (sensory over-responsiveness):
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Different Descriptions of Sensory Phenomena |
Tactile, visceral, and muscle-skeletal |
Uncomfortable sensations in the skin, muscles-joints, or body, which come before or along with the repetitive behaviors. The individual may have to repeat certain behaviors until experiences a sense of relief from this uncomfortable sensation. |
“Just-Right” experiences triggered by visual, auditory, or tactile sensations |
A need for objects to look a certain way or “just-right.”
A need for objects or people to sound “just-right” or have the “just-right” pitch.
A need for touching people or objects until getting a “just-right” feeling in the hands or the body |
Feeling of incompleteness/need to feel “just right” (without triggering stimuli) |
The individual may have an inner feeling and/or perception of discomfort that makes him/her do things until feeling relieved. He/she has an inner sense of not being “just-right” or feeling ”incomplete,” and he/she needs to repeat a behavior until feeling “just-right” or ”complete.” |
Urge |
No sensations of feeling, just an urge to perform the repetitive behaviors. |
Energy |
An energy that have to be released. |
Urge |
Need to perform repetitive behaviors not preceded by obsessions nor by any type of sensory phenomena. |
Hazen Reichert, et al. (2008) describe a subset of children with OCD who have a clinically significant intolerance or intrusive reexperiencing of ordinary sensory stimuli that drive compulsive behaviors. These children did not experience any intrusive thoughts that are characteristic of typical OCD. Unfortunately, although their study suggests sensory processing deficits, they did not obtain any direct measures.
To date, there has been no research that I've been able to find that examines whether individuals with TS or OCD really have any sensory processing deficits that would show up in testing when compared with normal controls, although some research has found thinning in the sensorimotor cortex of patients with TS. Thus, it is possible that the sensory phenomena described above may be related to sensory processing difficulties, but then again, they may not be. We need actual research to examine the possibility.
Sensory issues in autism spectrum disorders (ASD)
Tomchek and Dunn (2007) found that compared to normally developing 3 to 6 year-olds, 95% of children with autism spectrum disorders (ASD) displayed some level of sensory processing deficits, most notably in Underresponsive/Seeks Senation, Auditory Filtering and Tactile Senstivity. Their findings received confirmation from a study by Ashburner et al. (2008), who found that Underresponsive/Seeks Sensation and Auditory Filtering explained 47% of the variance in academic performance in a group of students with ASD who had average intelligence. Of particular significance, they found significant correlations between (1) auditory filtering and inattention to cognitive tasks, (2) tactile hypersensitivity and hyperactivity and inattention, and (3) movement sensitivity and oppositional behavior. A significant relationship between sensory processing and emotional and behavioral patterns was also reported by Baker, Lane, et al. (2008).
Sensory issues in Attention Deficit Hyperactivity Disorder
Huecker and Kinnealey (1998) reviewed available literature and conducted a retrospective chart review of 90 children with ADHD seen in OT clinics. They found (pdf) three major types of sensory processing deficits: developmental dyspraxis (68.9% of children), tactile defensiveness (82.2%), and poor anti-gravity control (81.1%). Dyspraxia is impaired motor planning or execution of skilled motor acts in the correct sequence.
Parush, Sohmer, et al. (2007) compared boys with ADHD with and without tactile defensiveness (TD) to normal controls on several measures of somatosensory functioning. Of note, boys in the ADHD+TD group exhibited significantly higher central somatosensory evoked potentials (SEP) amplitudes than did the ADHD-TD group, suggesting a central inhibitory mechanism is involved in tactile defensiveness.
Bröring, Rommelse, et al. (2008) found that girls with ADHD had higher levels of tactile defensiveness than normally developing peers or boys with ADHD; boys with ADHD and controls did not differ from each other. Siblings of ADHD had no tactile defensiveness, regardless of gender.
Sensory issues in Social Anxiety Disorder (Social Phobia)
Sensory processing sensitivity may also contribute to Social Anxiety Disorder (social phobia). Hofmann and Bitran (2007) found that sensitivity was highly correlated with harm avoidance and agoraphobic avoidance; patients wtih a generalized subtype of social anxiety disorder reported higher levels of sensory-processing sensitivity than individuals with a non-generalized subtype. Their higher sensitivty may help explain the development of greater avoidance.
Sensory issues and "rage attacks"
Cheng and Boggett-Carsjens (2005) suggest that children who have what I call "rage attacks" should be screened for sensory processing deficits that might contribute to dysregulated mood and increased risk of explosive outbursts.
Sensory issues, sleep problems, and behavior
Of particular interest to me, a study by Shochat et al. (2009) looked at the relationship between sensory hypersensitivity, sleep, and behavior in normal school children. Not surprisingly, they found a significant relationship among all three measures, but the relationship between sleep and behavior decreased when controlling for sensory processing. In other words, some of what many of us may have thought was the impact of sleep problems on behavior may be mediated by sensory processing difficulties that interfere with sleep. Tactile sensitivity was a significant predictor for sleep problems, while sensation seeking and tactile sensitivity were significant and moderately strong predictors for behavior.
The more data that accumulates, the more it seems clear that many children and teens with neurological disorders should be screened for sensory processing deficits if they are having behavioral problems.
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THERAPY AND SCHOOL-BASED INTERVENTIONS
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There is little doubt that occupational therapy has something to offer in terms of techniques that may help children normalize their sensory processing and improve behavior or academics, but which techniques actually work? Research on the effectiveness of different types of interventions has not yet produced many clear answers.
One of the more controversial issues involved whether "sensory integration therapy" is effective. Research attempting to validate its effectiveness produced equivocal results, due, in part, to design limitations. Some of the problems in evaluating research on its effectiveness are evident in a 2001 review by Hender and a 2004 policy statement about auditory integration training published by the American Speech-Language-Hearing Association. A review by Mulligan (2003), however, found that 4 out of 5 studies investigating the effectiveness of occupational therapy with a sensory integration approach reported “significant gains on outcome measures after intervention.”
The most significant improvements were for gross and fine motor outcome measures. While those aspects of functioning are important, what we are looking for is evidence that the child is better able to tolerate normal sensory experiences, or improves in behavior or academic functioning.
One other reason that it is difficult to answer the question of "does sensory integration therapy" work, is because "sensory integration therapy" is not a manualized modality that can be strictly applied and replicated. It is, instead, a conceptual approach to working with children that is synonymous with "occupational therapy" in current usage. Lucy Miller (2003) provides an informative explanation of what questions we need to ask and why it is so difficult to find answers. In her article, she acknowledges that the question, "Is sensory-based OT an effective intervention?" could not be answered (at that time) by available empirical evidence.
What we can, and should be able to answer through adequately controlled research, however, is determine whether specific elements or techniques are of benefit. Before we spend our time, money, insurance benefits, and hope, shouldn't we know whether there's any likelihood of effectiveness?
One classroom intervention that seems to have
some reported usefulness is the use of weighted
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. In a recent review of the use weighted vests, Stephenson and Carter (2009) reviewed the available studies and concluded that that "... on balance, indications are that weighted vests are ineffective. There may be an arguable case for continued research on this intervention but weighted vests cannot be recommended for clinical application at this point." Their review reminds us, once again, that we need objective data from designs that are adequately controlled.
While weighted vests produced equivocal results in terms of effectiveness, a small study on using therapy balls instead of chairs for students with ADHD indicated that it might be effective. Using an ABAB design with 3 students with ADHD, Schilling, Washington, et al.(2003) found improved in-seat behavior and writing legibility during the therapy ball phases. Schilling and Schwartz (2004) conducted the same experiment on young children with Autism Spectrum Disorder. As with the ADHD students, students with ASD showed substantial improved in engagement and in-seat behavior when participants were seated on therapy balls. In both studies, teachers and students expressed preference for the therapy balls. in light of demonstrated effectiveness in these small, but controlled, studies, the use of therapy balls as alternatives to regular seating warrants further exploration in school settings. One of the questions that needs to be addressed is what happens if the therapy balls are used over extended periods -- do any benefits wear off or continue?
Many parents are already familiar with other types of strategies, such as the use of fidgets that allow children to decrease stress and channel excess energy into socially acceptable behaviors. Fidgets may help a student concentrate better.
Other programs, such as Astronaut Training (for vestibular, auditory, and visual systems), and the "How Does Your Engine Run?" program are based on sensory processing and arousal. Another approach that may be used as part of programming is a sensory diet -- a planned and individualized set
of activities throughout the day to control the sensory input the child receives. Allowing the child to chew gum or something crunchy may be part of a sensory diet, depending on the student's needs. Once again, however, although these techniques are in use, there is little controlled research to demonstrate their effectiveness by typical scientific and clinical standards.
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Information
Section: Conditions
Condition:
Sensory
Integration
Article: Overview of
Sensory Integration
Source: Leslie E. Packer,
PhD
This File Last Updated:
February 2009
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Article
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of 2
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