SENSORY PROCESSING DISORDER - INTERVENTION STRATEGIES

Environmental modifications and initial sensory strategies :

Signs of atypical sensory processing	Environmental modifications and initial intervention strategies
Proprioception : Child may: •      Grasp objects too lightly or loosely •      Be un aware of changes in the body position •      Be clumsy and break toys •      Seek activities in which he has to jump, push, hit, pull, or bump. •      Grind his or her teeth •      Chew on non-food items such as toys •      Seems weak	•      Use heavy toys to provide more proprioceptive feedback •      Perform activities that require weigh tbearing, pushing and pulling, resistance joint traction and compression. ( playdoh, moving heavy objects, tug of war, weighted vest, heavy blankets, theraputty, theraband, backpack, etc.)
Tactile discrimination/ Hyporesponsiveness : The child may :         Like exploring through touch        Place object in his/ her mouth to explore it      Prefer to go barefoot       Have difficulty with tasks that require hand   manipulation        Have difficulty with gross motor coordination tasks        Have oral motor difficulties	•      Provide activities that require localization of tactile input and discrimination •      Suggested activities : ball bath, finding objects in sand or other textures, brushes, bubbles •      Observe motor skills – see motor planning
Tactile modulation : Child may :        Dislike changes in the temperature such as going in or out of the bathtub         Dislike going barefoot or taking his/her shoes off         Pull away from light touch         Seem irritated by fuzzy clothing        Prefer to touch rather than being touched         Resist wearing new clothing       Dislike eating messy foods with his/ her hands       Dislike having hair / teeth brushed , or face   washed         Avoid getting hands in finger paint, sand, paste, clay        Get irritated by tags on clothing         Have difficulty transferring to table food         Get irritated when being handled by people other than the primary caregiver ( cries during treatment)         Weight bear on finger tips         Have a tendency to walk on his/ her toes        Cry when hair is washed, nails are clipped         Avoid using hands or weight bear on open hands	Modify your social interaction with the child:         Respect personal space         Do not impose         Allow the child to have control over the tactile input he/ she receives – expect a response         Gentle and firm intervention style – a challenge Modify the physical environment:         Avoid activities that include light touch. Provide inhibitory input such as deep pressure and proprioception        Avoid tight clothing. Wash clothing before child wears it.         Provide a sensory diet : Pressing child between two large pillows, rolling down an incline, rolling a child inside a blanket or sheet, and brushing body
Vestibular system : modulation •      Be fearful of movement, going up and down stairs, playground equipment •      Get nauseous or vomit after movement experiences such as riding in a car •      Avoids having feet off the ground or balance activities such as walking on curbs •      Dislike being moved backward in space even when trunk support is provided •      Move very carefully •      Avoids jumping off a step or other surfaces •      Appear fearful when lifted up in space or when moved in space	•      Respect the child’s fears. Do not force movements •      Give the child control over his/her movements in space •      Treat near the ground •      Provide activities that require proprioception •      You may start by providing the child with the opportunity to experience linear vertical input (sitting on a wide based platform swing placed near to the floor) •      Start with antero-posterior movement of the trunk before you move to lateral and rotational movements
Vestibular - Hyporesponse: •      Seek large amount of movement experiences such as spinning, rocking, and twirling •      Not get dizzy when other children do •      Have difficulty with balance and protective reaction •      Tend to lean on hands when performing table top activities •      Have difficulty with tasks that require maintaining a stable visual field •      Have difficulty with activities that require bilateral motor coordination such as riding a bicycle or tricycle	•      Provide opportunities for movement experiences •      Provide activities that promote extension against gravity and proximal joint stability in the neck and the shoulder girdle area. Examples include swinging in prone while propelling on the floor or by pulling a rope, working in prone on the mat, etc. •      Work on maintaining stable visual field while moving(e.g., swinging and hitting a target) •      Activities that promote bilateral motor coordination •      While on the swing, pull on rope or providing an equipment to bump on, to change direction, speed and tempo of the swing’s movements.

Other daily activities (For propriocepion and vestibular hypo) :

}  Try having your child do some activities such as reading, playing a game, or coloring, while lying on his stomach and propping himself on his elbows.

}  Encourage activities that require balance, such as cycle riding, bike riding, kicking and so on.

}   Include “bilateral” or two-sided activities, such as jumping rope, swimming, rowing, playing a musical instrument and so on.

}  Try activities that involve coordination of movement of the eyes, head and hands, such as target games, catching, throwing, ping pong, tennis, and so on.

For hyper responsiveness

}  Adding weight ( for example, wrist or ankle weights or a backpack filled with bags of beans or rice) can help a child feel more secured when climbing or moving

}  If your child is fearful when walking up stairs, try holding him at the hips and applying gentle pressure. This may help him to feel more secured than when holding his hands.

}  Allow increased time for your child to explore and attempt activities that seems scary

For motor planning:

}  Play games like “ follow the leader “ help child to be able to plan actions based on watching and copying your/peer actions.

}  Encourage games that involve simple verbal directions to plan actions such as “Simon says” to help a child to plan actions without visual cues.

}  Ask child to help in activities like cleaning and arranging rooms, arranging items, unpacking, packing, wrapping a gift etc.

Video Modelling and autism

Video modelling is defined as, "the occurrence of a behavior by an observer that is similar to the behavior shown by a model on a videotape". 

Modelling is regarded as one of the basic learning processes and it is also treated in the science of applied behavior analysis as a procedure for teaching new behaviors and improving already acquired ones. Modelling can be defined as a procedure whereby a sample of a given behavior is presented to an individual and then the behavior of that individual is assessed to determine if he or she engages in a similar behavior. Video is regarded as a novel and expanding technological medium for positive behavioral support. It has considerable potential as an effective and socially acceptable form of support, mainly because it is widely used by typically developing children and adults for leisure, educational and business activities.

In the area of autism, video modelling has concentrated on teaching a variety of different skills and video technology was used for a retrospective analysis for the identification of early symptoms such as sensory-motor and social behaviors, communication and attention in infants who subsequently were diagnosed as having autism.

Advantages of video modelling in Autism

·        Video models can present a variety of different behaviors in realistic contexts  

·        Video may be a useful medium for learners who cannot take
advantage of print materials or of complex language repertoires  

·        Video can efficiently display various examples of stimulus and
response situations, taking advantage of the observed attentional skills of children with autism to graphical presentations.   

·        A video modelling procedure can lead to new intervention strategies in such a way that individuals with autism could control their severe behavior problems

·        Video modelling promotes discrimination training for the target
children or their families, by including error models. In this way, not only does training in the correct responses take place, but it is also relatively easy to show which responses are to be avoided. The video medium provides new opportunities for addressing the generalization deficits displayed by children with autism.  

·        Video modelling serves as an efficient cost-effective tool in the
treatment of individuals with autism.  

Instructions and Guidelines for using Video Modelling procedures

Below is an overview of the general instructions and guidelines that were taken into consideration.  

·        After a task analysis, each component of a specific task should be videotaped. The number of sequences to be shown needs to be gauged for a particular child experimentally.

·        Preferably one model should be used. Simple behaviors demonstrated by the model should be about 30–40 seconds maximum.

·        At the initial stages, the setting viewed in the videotape should be the same as the setting in which the child will demonstrate the imitative behavior. Thereafter, different settings could be used.

·        The treatment provider has to be sure that the videotape shows a
close-up of the action he or she wants the child to imitate.

·        The child should be allowed to watch each video clip at least once.

·        The child has to be allowed to have at least two or three minutes to demonstrate the modelled behavior. Whether or not the child has imitated the videotaped behavior, the treatment provider could occasionally provide him or her with praise or a small piece of food for behaving well unless disruptive or challenging behaviors are in place.

·        The child should watch the same modelled sequence again if he or
she fails to imitate the behaviors; this should be done at least three
times.

·        The treatment provider must keep data for every trial and let the
child have at least three successful trials before he or she moves to the next video clip.

·        Programming for maintenance and generalization of the imitative behavior must take place across settings, stimuli, people and time.

NOTE: In our clinical experience we have used video modelling to teach tooth brushing, colour concepts, using communicative sentences like "no", "give me",  etc and we have seen  tremendous and quicker improvements in kids with autism in learning these concepts.  

Dyspraxia and the oral motor system

          "Apraxia" comes from the Greek word "praxis," which means action. Apraxia or Dyspraxia is defined as difficulty in motor planning of movement to achieve a predetermined idea or purpose, despite having the desire and the physical ability to perform the movements.  It is believed to be an immaturity of parts of the motor cortex (area of the brain) that prevents messages (ideas) from being properly transmitted to the body, which may affect any or all areas of development. It is inconsistent, and affects each child in different ways, at different stages of development and varies in severity.

Praxis is a largely cortical process that is highly dependent on subcortical processes such as sensory discrimination, body scheme/body awareness, and the ability to produce feed forward responses.  Praxis involves four major components.

 (a) Ideation - the ability to conceptualize and identify a motor goal and some idea of how to achieve the goal;

 (b) Motor planning - the ability to plan and organize a series of intentional motor actions in response to environmental demands;

(c) Motor coordination/execution - the ability to perform motor responses with precision;

(d) Feedback - the ability to recognize and respond to the motor act and its consequences.

Within occupational therapy practice, praxis represents performance skills and forms the foundation for developing performance patterns and occupations.

Oral Motor System

The primary oral motor mechanism is the suck/swallow/breath (SSB) synchrony. This involves the rhythmical, coordinated pattern of sucking, swallowing and breathing. An intact synchrony of SSB is critical to many elements of sensorimotor and cognitive development including speech and language development, postural control, feeding/eating behavior, eye/hand coordination, and sense of well being. Even a subtle disruption in any element of the SSB may have a far-reaching impact on development and function. The SSB synchrony often functions as an organizer for neuromotor behavior and can be used effectively in treatment to bring about more integrated behavior. Bite, crunch, chew, lick, suck, seal, vacuum, swallow, blowing and vocalization are ways to activate the SSB synergy. Suck, blow, bite, crunch, chew and lick are major components of oral motor activity, which can be incorporated into meals, snacks, and play activities. Use of these along with taste, temperature, texture, size and form will help improve SSB synergy and therefore influence sensorimotor and cognitive functioning.

Praxis related to oral motor system

Oral Dyspraxia - children are unable to reproduce mouth movements. Examples of this are the inability to put their tongue up to the roof of their mouth. A child with oral dyspraxia may not be able to perform these movements, even though they do this unconsciously.  Questioning for following movements in child may help to identify oral praxis problems in children.

·       Smile

·       Make jaw and lip movements that correspond to saying “aa”, “ee”, “oo”, “ae”, or “oh”.

·       Kiss, or make a kiss face

·       Stick out their tongue

·       Try to touch their tongue to their nose

·       Lick honey off from their upper, side, or lower lip

·       Imitate making a funny face

·       Blow out candles or blow bubbles

·       Bite their lips

·       Show various emotions in facial expressions

Verbal Dyspraxia - children have difficulty pronouncing sounds or saying words. Many words just do not sound right regardless of how hard they try to produce the sound or word correctly.In ideomotor apraxia, the execution of simple and complex, meaningful and meaningless movements with the orofacial musculature and/or with the limbs is impaired in distinct ways. The parapraxic distortions of movements occur when the movement is required out of context. The recognition of movements and gestures is intact. Ideomotor apraxia manifests itself as oral apraxia, bilateral limb apraxia, or unilateral limb apraxia. In ideational apraxia, in contrast, there is a disturbance in the conceptual organization of complex actions requiring the use of various objects. The syndrome is observed in the spontaneous behavior of the patients. There are indications that these patients are also impaired in the recognition of actions.

Oral Defensiveness – is an avoidance of certain textures of food and activities using the mouth in general (such as tooth brushing). Each child differs in the types or textures or activities they find offensive. Some common behaviors a child with Oral Defensiveness may exhibit:

·       Resist brushing his teeth or going to the dentist.

·       Be a picky eater and preferring only certain textures, dislike foods with unpredictable lumps, disliking sticky foods such as rice, jelly, banana, etc.

·       Refuse to eat hold or cold foods.

Activities to develop oral praxis

Few specific activities to develop the integrated and controlled movement of Jaw, lips and tongue along with those activities listed below to develop oral motor integration would help to develop good oral praxis which will in turn help in successful development of speech and oral skills.

Jaw Control  

·       Opening mouth wide to accommodate and hold balls of lemon size

·       Pull along strings by teeth from semi close boxes to develop clenching of Jaw as in saying “eee”

·       Holding and transferring straws or tubes in mouth with hands at the back to develop controlled jaw protrusion

Tongue control

·       Let the child put the tongue out of the mouth to lick honey or pickle.

·       Apply honey on ice cream stick and hold vertically to allow child to lick it from top to down and bottom to top.

·       Apply sweetened lipstick around the lips for licking.

·       Ask child to move beads from left to right and vice versa in a “U” shaped string

·       Stick magic pops or chewy candies at different area inside the mouth and let the child remove them out using tongue.

·       Draw different figures using ketch up or Jam on plate and let the child lick them in the same pattern

Lip control

·       Teach to purse lips by using straw or tube which is pulled unexpectedly when the child holds on it.

·       Teach upper and lower lip approximation in the same way as mentioned in lip pursing by using an ice cream stick placed horizontally between the lips.

·       Video model funny oral movements as in animal or vehicle sounds.

·       Incorporate other blowing activities as mentioned below.

Activities to Develop Oral Motor Integration

 Licking – Have the child lick stickers and place them in a book. They may also lick lollipops and Popsicles, or place sour drops or other foods on the child’s lips and have them lick it off. Licking helps on developing the tongue musculature.

 Sucking Activities – These work on developing the tongue, check, jaw, and lip musculature. They also facilitate concentration and help the child to do transition between activities.

1. Straw – Use straws for drinking liquids. There are a variety of straws that can be used which make it easier or more difficult for the child, such as using thick and thin straws to suck over thin and thick liquids. Using two straws together can also be done to make it more of a challenge for the child.

2. Washcloth Soaked in Juice – A washcloth may be soaked in a sour juice for the child to suck on.

3. Suck Foods Off Finger – The child can also suck foods off of his finger, such as peanut butter, honey, melted chocolates, etc.

4. Sucking In – Children may suck in on a piece of balloon, bubble gum over the lips, sucking on a lollipop, nipple, pacifier, or finger and creating a loud pop as it is pulled out.

5. Chew and suck – Sugar cane and drum stick can be given to initially chew well to bring out the juice and then suck to take the juice in.

Blowing Activities – These help develop the tongue, cheek, jaw and lip musculature; respiratory control (oral, pharyngeal, upper chest, and diaphragm); it opens up the rib cage;

1. Blowing Bubbles – The child may blow bubbles into a bathtub or sink with a few drops of liquid detergent in it r use a bubble dart.

2. with a straw or tubing: blowing cotton balls, crinkled up tissue paper, ping-pong balls, or other small and lightweight object to a given target.

3. Blow through a straw into a thick substance, such as milk shakes, porridge etc for increased resistance.

4. Blow Toys – Have the child play with toys such as whistles, party blowers, other musical instruments like flute, mouth organs, etc.

5. Blow up balloons.

Bite/Crunch/Chew – These activities are used for developing jaw and neck stability as well as upper thoracic stability. It also decreases oral defensiveness, hyperactive gage, and tongue thrust, jaw protrusion and retraction, and teeth grinding. In addition, it facilitates concentration. Crunchy foods are very alerting and chewy foods are organizing.

1. Chewy Foods – Such as dried fruit; jelly, and chewing gum.

2. Chewing Activities – Have child chew on objects such as a pacifier or teething ring, dog toys, tubing, etc.

3. Crunchy Foods – Such as chips, cookies, Pop corns, candies, frozen peas, corn nuts, Chocó sticks, wafers etc.

Tactile Experiences – Have the child experience a variety of textures, temperatures, and sensations. The following are types of foods that are alerting: cold foods (frozen fruit, ice, frozen teething rings, frozen toothbrush soaked in juice), Pop Rocks candy, sour drops (also encourages puckering), and hot tastes such as fireballs.  Chew-on toothbrush, water pick, electric toothbrush, etc., are also great tactile experiences.

Feeding and Oral Motor Skill development in typical children and management in children with developmental disabilities

Feeding is the first essential function which everyone is concerned about in all new born and young children. Infants and toddlers who are at the risk for developmental difficulties or who have been diagnosed with abnormalities, however, may also have dysfunction in their feeding abilities. This problem can include  poor intake, excessive time needed to feed, unusual feeding characteristics (e.g., abnormal oral-motor patterns or inappropriate progression of feeding skills), and physiological compromises associated with feeding.

Feeding  provides an opportunity for early bonding, and its success strengthens maternal confidence.  Conversely, feeding dysfunction can erode maternal confidence, causing stress that can alter the mother child relationship and interference with bonding.

Occupational therapist working in early intervention programs have the knowledge and skill to make unique contributions to the treatment and management of feeding dysfunction in infants and young children, particularly within the context of the family unit. A background in neuromotor control, in the medical aspects of disease and disability, and in general, child development must be combined with a solid foundation in human interaction and behaviour to effectively manage feeding problems in the population.

Anatomical maturation:

          With growth, changes occur in the size and anatomic relationship of the oral, pharyngeal, and laryngeal structures. These changes are rapid during the first 12-18 months of life, then progress slows  throughout the remainder of childhood period. As the infant matures, the oral cavity enlarges and elongates, and the fatty tissue diminishes. Postural stability, through muscular contraction and the development of more rigid connective tissue, develops to provide the stability for the highly specialized movements of the lips, cheeks, tongue, and jaw, which are involved in the chewing or in sipping from cup.

          As the infant grows, the oral cavity enlarges and there is a downward elongation of the pharyngeal region. The larger oral cavity allows greater mobility of the lips, tongue, and cheeks, which allows the emergence of a wider variety of oral and speech skills. As the pharynx elongates, the hyoid must develop greater mobility to achieve continued protection of the airway. This occurs around 4-6 months of age.

          Infants must have split-second timing between sucking, swallowing, and breathing for safe and efficient feeding. In the sequence of feeding events, the infant takes one to two sucks and then must swallow, suppressing respiration for 0.5-1.0second. The infant then takes a breath, which is typically overlapped with sucking, and the sequence is repeated.  The coordination of breathing with swallowing during feeding continues to play an important role in spoon feeding, sipping from cup, and more matured eating skills.

          Deficits in oral-motor control are common in children with neurologic deficits and can lead to illtimed release of food into the pharynx or release of the bolus in a piecemeal fashion. If food is present in the pharynx before the swallow is triggered, there is the risk of aspiration during nonfeeding times. Children with cerebral palsy have a higher respiratory rate, less regularity to breathing, lower volume per breath, and more difficulty holding their breath than typical children. During eating, children with cerebral palsy also have difficulty in sustaining respiration and timing the integration of swallowing into the respiratory cycle. Coordination of oral skills, swallowing, and breathing remains important for children. Incoordination of these functions can lead to longer feeding times, feeding  inefficiency, physiologic compromise, aspiration, or any combination of these factors.

Sucking:

Sucking develops at 15-18 weeks of gestation.  The well-coordinated, efficient sucking needed for feeding does not generally develop until around 34 weeks of gestation. Infants who are good feeders tend to have sucking patterns that are fast and strong, as well as stable and rhythmic.

 Nutritive and non-nutritive sucking

Characteristics	Nutritive sucking	Non-nutritive sucking
Rate	One suck per second during the sucking burst	Two suck per second
Burst and pause pattern	Initial continuous sucking gradually increasing pauses toward end of feeding	Stable number of sucks per burst (4-13 sucks) and duration of pauses (3-10 seconds)
Suck-to-swallow ratio	1:1 at start of feeding 2-3:1 towards end of feeding	Multiple sucks to one swallow

Normal versus abnormal functions must be considered in the context of the following areas of performances:

1.     Neuromotor performance, including the influence of muscle tone, reflex activity, and motor control on overall posture, position, and oral-motor skills

2.     Sensory responses

3.     Swallowing ability

4.     Physiologic support for feeding

5.     Structural integrity

6.     Behaviour and interaction during feeding.

Neuromotor dysfunction can have a significant impact on the feeding posture. The characteristics of typical feeding posture include:

·        Neutral alignment of the head and neck (or slight neck flexion)

·        Midline orientation

·        Symmetric trunk position

·        Hip flexion (degree varies with the child’s age)

·        Symmetric arm position with the shoulders relaxed and forward

        The body angle during feeding depends on the level of head and trunk control present. Infants with limited head, neck, and trunk control are fed in a semireclined position. Older children who have adequate postural control are fed in an upright position.

Oral-motor control:

          The assessment of oral-motor control includes facial muscle tone, oral reflex activity, and functional oral-motor skills. Oral reflex are often evaluated for their presence or absence. It is highly important to consider their contribution or interference with feeding function.

          The child’s skill in complex activities, such as sucking or chewing, is based on the movement characteristics of each oral structures (i.e., the tongue, jaw, lips , and cheeks), as well as their coordinated function. Both the resting position and movement patterns of each structure must be evaluated. The expectations of movement vary based on developmental age and feeding activity (e.g., cup versus spoon) and are most effectively observed during the feeding time.

Atypical development and functional problems:

-         Hypertonic Muscle Tone

-         Hypotonic Muscle Tone

-         Tongue Retraction

-         Tongue Tip Elevation

-         Tongue Thrust

-         Tonic Biting

-         Jaw Thrust

-         Jaw Instability

-         Lip Retraction

-         Lip and Cheek Instability

-         Lip and Cheek Immobility

Guiding principles of treatment:

1.     Alignment: Proper alignment of the body and the head are crucial to optimal feeding performance. Abnormal alignment of body structures can influence the function of all the oral structures. For example, neck and head extension can lead to tongue retraction or thrusting during feeding.

2.     Proximal stability: Controlled extremity movement requires a stable base. The movements of the tongue and lips for feeding are distal movements, requiring stability of many proximal structures, particularly the jaw. For the mandible to be stable, head and neck stability built on trunk stability is mandatory.

3.     Appropriate movement patterns. Once proper alignment and stability have been achieved, the therapist or caregiver can facilitate appropriate oral movement patterns. Simultaneous application of inhibitory and facilitative techniques elicits the desired movement patterns.

        To achieve proper alignment, stability and appropriate movement patterns, preparation of the child using neurodevelopmental handling techniques before feeding may be beneficial.