applying the principles...

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Applying the Principles of Sensory

Integration to School‐Based Assessment

Session #56

OTAC

October 21, 2017

Aja Roley, MA, OTR/L

Kelly Auld‐Wright, MA, OTR/L

Introduction

Objectives

I. Identify underlying areas of sensory integrative dysfunction and how they impact school participation

II. Utilize assessment data and clinical reasoning tools to develop a hypothesis regarding a child’s particular sensory needs.

III. Develop relevant and measureable goals addressing underlying sensory processing factors.

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Objective 1• Identify underlying areas of sensory

integrative dysfunction and how they impact school participation

Sensory in School‐based practice

•90% of OTs working in school setting report using SI theory (May‐Benson & Koomar, 2010)

•Ahn, Miller & Milberger & McIntosh (2012) report high percentage of sensory processing dysfunction found in children with:

•Autism Spectrum Disorder

•Fragile X•Attention Deficit Hyperactivity Disorder (ADHD)

Sensory in School‐based Practice

• AOTA (2015)

• “Occupational therapy practitioners working in schools use evidence‐based sensory‐based interventions or a SI approach when sensory‐related issues are identified and affect a child’s ability to benefit from his or her education.” (6913410040p2).

• Intervention can include environmental accommdoations/recommendation, direct treatment or collaboration with other IEP team members.

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OT/PT Guidelines for CA Public Schools:

Includes evaluation and

treatment of sensory factors

What is Sensory Integration?

What is Sensory Integration?

Dynamic & Ecological Theory of • Brain/Behavior

Relationships

Way of understanding

behavior

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Sensory integration is the process by which:

We receive information through our senses

Organize this information

Use it to participate in everyday activities.

Sensation

Ayres Sensory Integration®?

• Originally described by Jean Ayres in 1960’s

• Theory and frame of reference that highlights:

• Tactile, proprioceptive and vestibular systems

• Explores:• Sensory perception• Sensory reactivity in each

system• Postural Ocular and Bilateral

Functions• Praxis

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Theoretical Models of SIFUNCTION

•Ayres1979, 2005•Classic Model of Sensory Integration and typical development

•Smith Roley, 2006•Analysis of Sensory Integration Functions

•Smith Roley & Spitzer, 2001•Model of SI and development relative to occupational science and therapy

DYSFUNCTION

•Bundy, Murray, & Lane, 2002; in press•Patterns of SI and praxis deficits

•Smith Roley, 2006; revised 2011 based on Mailloux, et al., 2011•Analysis of Patterns of SI Dysfunction

•Miller et al., , 2007•Sensory Processing Disorder proposed nosology

Terminology

• Sensory Perception/Discrimination• Ability to distinguish and interpret sensory inputs

• Sensory Reactivity/Modulation• Regulation of arousal and behavioral responses to sensory

input

• Sensory Processing• Receptor capability • Transmission capability • CNS detects & registers sensation

• Sensory Registration• CNS “notices” input

Terminology

•Bilateral integration & sequencing•Coordination of the two sides of body to perform synchronized and sequential movements

•Body Scheme

•Unconscious map of physical body stored in brain

•Postural‐ocular control•Motor control of body position and eye movement

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Vestibular Functioning•Spatial orientation

•Holding still•Moving against gravity•Organizing visual gaze

•Vertical alignment

•Head/neck/eye control

•Postural control

•Security with gravity

•Balance

•Disassociation of movements

•Oral motor control

•Bilateral motor coordination

•Laterality

Proprioceptive Functioning

•Sense of body position and movement

•Joint Stability

•Grading the force and direction of movement

•Timing of movement

•Internalized movement patterns

Tactile Functioning

•Body scheme

•Oral motor skills

•Spatial location of body relative to people and objects

•Hand skills

•Emotional Responses

•Attachment

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Praxis• Ideation/creativity

• Imitation

• Construction

• Sequencing

• Tool use

• Gesture to command• Unfamiliar• Familiar

• Problem Solving

• Initiating, Sequencing and Completing

• Exploration/exploitation of • Space• Body movement• Objects• People

Integration

• “The neurological process that organizes sensations from one’s body and from the environment and makes it possible to use the body effectively in the environment.”

• “Sensory integration is information processing…The brain must select, enhance, inhibit, compare and associate the sensory information in a flexible, constantly changing pattern: in other words, integrate it.”

• A. Jean Ayres, 1988

Sensory Integration and Praxis Performance Skills

•Sensations must be

perceived, organized

and interpreted

•Contributes to •Arousal, alertness and attention•Cognitive, motor and praxis skills

•Emotional regulation

•Social communication and interaction

•Organization of behavior in time and space

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Sensory Integration & Participation• Formation of identity

• Health and well being

• Occupational choices• Exploration and engagement• School participation• Play• Self care• Sleep and rest

Sensory Integrative Processes

The senses Integration of their inputs End products

Auditory (hearing)

First level Second level Third level Fourth level

Vestibular (gravity & movement)

Proprioceptive (muscles & joints)

Tactile (touch)

Visual (seeing)

Speech

Language

Eye movements

Posture

Balance

Muscle tone

Gravitational security

Sucking

Eating

Mother-infant bond

Tactile comfort

Body perception

Coordination of two sides of the body

Motor planning

Activity level

Attention span

Emotional stability

Eye-hand coordination

Visual perception

Purposeful activity

Ability to concentrate

Ability to organise

Self-esteem

Self-control

Self-confidence

Academic learning ability

Capacity for abstract thought and reasoning

Specialization of each side of the body and the brain

© WPS 1979, 2005

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Evaluating Sensory Functions

Data Driven Decision Making (DDDM) Process

1. Identify child’s strengths and participation challenges

2. Conduct a comprehensive assessment

3.Generate a hypotheses

4.Develop and scale goals

5. Identify outcome measures

6. Set the stage for intervention

7. Conduct the intervention

8.Measure outcomes and monitor progress

(C) Roseann Schaaf & Zoe Mailloux 2015

DDDM©

•Review IEP strengths and areas of needs

•Interview teacher and parent•Conduct an initial observation of the student

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Comprehensive Assessment

• Schaaf & Mailloux (2015):

• Identify child strengths and participation challenges

• Record review (medical/developmental history)

• Conduct standardized assessment (direct and/or indirect measures)

• Structured qualitative assessment (interviews, observations)

“Complete the educationally related or early intervention OT or PT assessment, which includes child observation, record review, interview, performance‐

based, and standardized/non‐standardized

testing procedures in areas of suspected disability according to specified timelines.” (p.10)

“Standardized tests, while not required by law, provide reliable and evidence‐based methods of examining discrete abilities or skills to

identify or rule out the possible factors that contribute to a child’s ability to participate in the general education curriculum.” (p.83)

http://www.bot.ca.gov/forms_pubs/otpot_guidelines_2012.pdf

Standardized tests

• Any test administered, score and interpreted in the same way for all test takers.

• Two types of standardized assessments: Direct measures and in‐direct measures

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Standardized Tests

• Direct Measures:• Performance based

Standardized Tests

• Indirect measures

• Checklists or questionnaires

• Completed by someone that knows the child

Standardized Assessment in ASI

•How are you currently assessing sensory functions in school‐aged children?

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Standardized Assessment in

SI

•Standardized tests currently available:•Sensory Profile/Sensory Processing Measures

•Indirect measures

•Can be criticized for rater bias•Focus mainly on sensory reactivity

•Comprehensive observations of Proprioception (COP)

•Criterion referenced •Observational tool

•SIPT•Gold standard•ONLY standardized direct measure of sensory perception

•Evaluation in Ayres Sensory Integration (EASI)•COMING SOON. Standardized measure of sensory perception and reactivity

Standardized Assessment in ASI

•SIPT is ONLY direct standardized measure of sensory perception but…

•Use SIPT is declining• Therapists report using non‐standardized and parent report measures of sensory integration more frequently (Burtner, McMain & Crowe, 2002).

• Sensory Profile (SP) and Sensory Processing Measure (SPM) offer insight into sensory processing but…

•More focused on sensory reactivity

•These tests are based on parent/teacher report which can introduce bias (Schoen, Miller & Sullivan, 2014).

Food for thought

•School‐based Occupational Therapy (OT) best practice guidelines in the United States (U.S.) emphasize the importance of evidence‐based practice and data‐driven services (Bissell & Cermak, 2015).

•Use of standardized assessments and routine outcome measurements are integral to this practice.

•If you do not use a standardized assessment, how do you know if your results are valid? How confident can you be in your clinical analysis?

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Why is valid standardized testing important?

How do we know if a child’s performance is typical or problematic?

Non‐Standardized Assessment in SI

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Lets Practice

•With a partner, practice administering the clinical observations.

Lets Watch

•What does typical performance look like on the clinical observations?

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Clinical/structured observations

•Tactile perception•Stereognosis•Touch localization •Sequential finger touching•How does child feel when vision occluded (do they try to peak or rely on vision to know what hands are doing?)

•How are in‐hand manipulation skills?

•How does child appear in general? (i.e. messy eater, dirty, clothing askew)


•SIPT LTS age trend


•Proprioceptive perception•Muscle tone

•Joint laxity/mobility

•Ability to co‐contract when prone over therapy ball•Seated position•Mid‐range control

•Gradation of force•Diadokinesis (loud? Slapping hands?)•Schilder’s arm extension test

•Postural control on ball•Sequential finger touching •Slow ramp movements

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•SIPT kinesthesia age trend


•Vestibular perception•PRN•Postural control on ball, swings, slides•Prone extension on ground and over ball•Balance with eyes open vs eyes closed•Bilateral skills•Schilder’s arm extension test

•Diadokinesis•Visual pursuits•Feedforward skills


•Assessing PRN•10 rotations in 20 seconds•Stop and time

•Average:9‐10 seconds +/‐ 3 (Mailloux et al., 2014)

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Clinical/Structured Observations

•SIPT PRN age trend


•Sensory reactivity •Tactile reactivity

•How does child respond to various textures?•Light touch?

•Vestibular reactivity (GI/Aversion to movement)

•How does child respond to various movement challenges?

•Will child climb play structure?

•Allow to be tipped backward into space over therapy ball?

•Allow you to put him/her on therapy ball?

•Avoid playground apparatus?


•Vestibular reactivity (under‐responsive to movement)

•Can present as high or low energy. Does the child appear to be

•Seeking movement?

•Sluggish?

•Do you see adaptive response after providing intense movement?

•PRN low?

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Group Activity

Consider the sensory problem your group is assigned.

List as many observations as you can that a child having difficulty with that sensory processing problem might have in the following areas:

‐Circle time ‐English/language arts (i.e. writing)‐Art‐Recess‐Toileting/lunch‐Physical Education

Objective 2• Utilize assessment data and clinical

reasoning tools to develop a hypothesis regarding a child’s particular sensory needs.

Generating a

Hypothesis

DDDM©

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Generating a hypothesis

Review strengths/challenges

1

Compile assessment data

2

Cluster and look for pattern

3

Sensory Integrative Dysfunction

•50 years of research

•Patterns identified through Factor Analyses using SIPT and related measures

•Factor Analyses•Ayres, 1965‐1989•Mulligan, 1998

•Mailloux et al., 2011

•VanJaarsveld et al., 2015

Between 1965 & 1989, Ayres conducted 7 Factor Analyses which revealed the following patterns

•Tactile & motor planning deficits (1965, 1966, 1969,1972,1977 & 1989)

•Visual perception/visual praxis deficits(1965, 1966, 1969,1972,1977 & 1989)

•Vestibular, postural & bilateral deficits(1965, 1966, 1969,1972,1977 & 1989)

•Tactile defensiveness & hyperactivity/distractibility (1965, 1966, 1969,1972)

•Other factors (auditory language; somatosensory perception) seen in some studies

(1969, 1972, 1977,1989)

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Mulligan (1998)found similar patterns:

N = 10,475

•Bilateral integration & sequencing

•Somatopraxis

•Visuopraxis

•Somatosensory perception

•Postural/ocular

Mailloux, Mulligan, Smith Roley et.al. 2011found similar patterns

N=273

•Visual and Somatodyspraxia

•Vestibular Bilateral Integration and Sequencing

•Tactile & Visual Discrimination

•Tactile Defensiveness and Attention

Schaaf & Mailloux, 2015

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Case Study

•Sascha

Case Study

• Discussion and group work

• Use provided assessment data and your video observations to develop a hypothesis regarding the student.

• Hypothesis:

• Child is having difficulty with (identify underlying sensory systems) impacting his ________ needed for ________.

• Example: Billy is under‐responsive to vestibular and proprioceptive input impacting his bilateral coordination for cutting tasks.

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Discussion

Objective 3• Develop relevant and measureable goals

addressing underlying sensory processing factors

IEP and Goal Writing

• Identify specific underlying sensory areas impacted in PLP.

• Choose measurable outcomes

DO:

• Writing modulation goals for attention or non‐preferred activity (OT is about engagement)

• Having multiple areas or outcomes within the same goal

AVOID

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Good Goal or Bad Goal?


Sally will demonstrate improved tactile/proprioceptive perception and body awareness as seen by her ability to maintain her personal space during circle time, given 2 verbal cues, 4/5 opportunities.

Bobby will demonstrate improved sensory modulation as seen by his ability to attend to 10 minutes of a non‐preferred activity, given 5 verbal cues, 4/5 opportunities.

Good Goal or Bad Goal

Thomas will demonstrate improved vestibular/proprioceptive perception and bilateral coordination as seen by his ability to zip and unzip his backpack, independently, 4/5 opportunities.

Jane will demonstrate improved tactile modulation as seen by her ability to complete a classroom art project, without excessive hand wiping or needing to wash her hands, given verbal encouragement, 4/5 opportunities.

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Sam will demonstrate improved praxis to complete a 3‐4 step obstacle course, given 2‐3 verbal cues and sensory strategies as needed, 4/5 opportunities.

Tina will demonstrate improved sensory modulation (i.e. under‐responsive to vestibular) as seen by her ability to engage in 10 minutes of classroom activity, without excessive sensory seeking (i.e. rocking in chair, leaving work area), given 4 verbal cues, 4/5 opportunities.

Case Study

• Based on your hypothesis, develop a PLP and goal for the student.

Discussion

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Conclusion

SI is an important part of school practice

Comprehensive assessment of SI functions is essential for understanding child’s

sensory processing problems

Developing hypotheses and writing measurable goals is important for determining

treatment efficacy

It’s OK to be wrong! Hypotheses change all the

time!

Questions?

Thank you!

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References

Ahn, R., Miller, L., Milberger, S., McIntosh, D. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58 (3), 287‐293.

AOTA (2015). Occupational Therapy for children and youth using sensory integration theory and methods in school‐based practice. American Journal of Occupational Therapy, 69 (Supplement 3), 6913410040p1‐19.

Ayres, J. (1972). Sensory Integration and Learning Disorders. Los Angeles: Western Psychological Services.

Ayres, J. (1989). Sensory Integration and Praxis Tests: SIPT manual. Los Angeles: Western Psychological Services.

Ayers, J. (2005). Sensory Integration and the Child: Understanding hidden sensory challenges. Los Angeles: Western Psychological Services.Bissel, J., Bohman, S., Mailloux, Z., Test, L. (Eds.) (2012). The Guidelines for Occupational Therapy and Physical Therapy in California Public Schools, Second Edition. California Department of Education Press: Sacramento, California.

Burtner, P. A., McMain, M. P., & Crowe, T. K. (2002). Survey of Occupational Therapy Practitioners in Southwestern Schools. Physical & occupational therapy in pediatrics, 22(1), 25‐39.

Refrences

Mailloux, Z. & Miller Kuhaneck , H. (2014). Evolution of a Theory: How Measurement Has Shaped Ayres Sensory Integration. American Journal of Occupational Therapy, 68 (5), 495‐499.

Mailloux, Z., Mulligan, S., Roley, S. S., Blanche, E., Cermak, S., Coleman, G. G., et al. (2011). Verification and clarification of patterns of sensory integrative dysfunction. American Journal of Occupational Therapy, 65, 143–151. doi:10.5014/ajot.2011.000752.

Mailloux, Z., Parham, D. & Roley, S. (2015). The Evaluation of Ayres Sensory Integration (EASI), training manual: Tactile perception tests (unpublished).

May‐Benson, T. A., & Koomar, J. A. (2010). Systematic review of the research evidence examining the efficacy of interventions using a sensory integrative approach for children. American Journal of Occupational Therapy, 64, 403–414.

Mulligan, S (1998). Patterns of sensory integration dysfunction: A confirmatory factor analysis. American Journal of Occupational Therapy, 52 (10), 819‐828. doi: 10.5014/ajot.52.10.819.

Parham, L. D., Roley, S. S., May‐Benson, T. A., Koomar, J., Brett‐Green, B., Burke, J. P., et al. (2011). Development of a f idelitymeasure for research on the effectiveness of the Ayres Sensory Integration_ intervention. American Journal of Occupational Therapy, 65, 133–142. doi: 10.5014/ajot.2011.000745.

Reed, Kathlyn (2011). The American occupational therapy association advisory opinion for the ethics commission: Outdated and obsolete tests and assessment instruments. Retrieved from https://www.aota.org/‐/media/corporate/files/practice/ethics/advisory/outdated‐and‐obsolete‐assessment‐Instruments.pdf.

References

Schaaf, R. (2015). Creating evidence for practice using data‐drive decision making. American Journal of Occupational Therapy, 69, 6902360010. http://dx.doi.org/10.5014/ajot.2015.010561.

Schaaf, R. & Mailloux, Z. (2015). Clinicians guide for implementing Ayres Sensory Integration: Promoting participation for children with autism. Bethsida, MD: AOTA Press.

Schaaf, R., Posatery, B., Cohn, E., May‐Benson, T., Schoen, S., Smith Roley, S., Lane, S., Parham, D., & Mailloux, Z. (2014). State of measurement in occupational therapy using sensory integration. American Journal of Occupational Therapy, 68 (5), e‐149‐e153.

Storch, B. & Eskow, K. (1996). Theory application by school‐based occupational therapists. American Journal of Occupational Therapy, 50 (8), 662‐668. doi: 50.5014/ajot.50.8.662.

Su, C.‐T. & Parham, D. (2014). Validity of sensory systems as distinct constructs. American Journal of Occupational Therapy, 68 (5), 546‐554.

Tomchek, S., Little, L., Dunn, W. (2015). Sensory pattern contributions to developmental performance in children with autism spectrum disorder. American Journal of Occupational Therapy, 69 (5), 1‐10.

Watling, R., Davies, P., Koenig, K., Schaaf, R. (2011). Occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. Bethseda, MD: AOTA Press.

Western Psychological Services (n.d.). The Sensory Integration and Praxis Tests (SIPT). Retrieved from http://www.wpspublish.com/store/p/2971/sensory‐integration‐and‐praxis‐test‐sipt.

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