SENSORY PROBLEMS AND AUTISM
Integration Dysfunction (SID, also called sensory processing
disorder) is a neurological disorder causing difficulties with processing
information from the five classic senses (vision, auditory, touch,
olfaction, and taste), the sense of movement (vestibular system),
and/or the positional sense (proprioception). For those with SID,
sensory information is sensed normally, but perceived abnormally.
This is not the same as blindness or deafness, because, unlike those
disorders, sensory information is sensed by people with SID, but
the information tends to be analyzed by the brain in an unusual
way that may cause distress or confusion.
SID can be a disorder on its own, but it can also
be a characteristic of other neurological conditions, including
Autism Spectrum Disorders, dyslexia, developmental dyspraxia, Tourette
syndrome, multiple sclerosis, and speech delays, among many others.
Unlike many other neurological problems that require validation
by a licensed psychiatrist or physician, this condition is most
often diagnosed by an occupational therapist. It is increasingly
being diagnosed by developmental pediatricians, pediatric neurologists,
and child psychologists. While it has not yet been included in the
American Psychiatric Association's Diagnostic and Statistical Manual
as a discrete diagnosis, Regulatory-Sensory Processing Disorder
is an accepted diagnosis in Stanley Greenspan’s Diagnostic Manual
for Infancy and Early Childhood and the Zero to Three’s Diagnostic
Classification. There is no known cure; however, there are many
Meaning of sensory integration
Sensory integration is the ability to take in
information through the senses of touch, movement, smell, taste,
vision, and hearing, and to combine the resulting perceptions with
prior information, memories, and knowledge already stored in the
brain, in order to derive coherent meaning from processing the stimuli.
The mid-brain and brainstem regions of the central nervous system
are early centers in the processing pathway for sensory integration.
These brain regions are involved in processes including coordination,
attention, arousal, and autonomic function. After sensory information
passes through these centers, it is then routed to brain regions
responsible for emotions, memory, and higher level cognitive functions.
Sensory Processing Disorders (SPD)
There are now 3 types of Sensory Processing Disorders,
as classified by Stanley I. Greenspan as supported by the research
of Lucy, J. Miller, Ph.D., OTR. These new terms are meant to increase
understanding between Occupational Therapists and other professionals
who frequently encournter SPD and physicians and other health professionals
who approach sensory integration from a more neurobiological vantage.
This understanding is critical as physicians are responsible for
diagnosing SPD, which is a necessary step in accessing reimbursement
(eventually from insurance companies) for professional services
to treat SPD.
Sensory Processing Disorder is being used as a
global umbrella term that includes all forms of this disorder, including
three primary diagnostic groups:
Type I- Sensory Modulation Disorder
Type II- Sensory Based Motor Disorder
Type III- Sensory Discrimination Disorder
Type I- Sensory Modulation Disorder (SMD)- Over- or under responding
to sensory stimuli or seeking sensory stimulation. This group may
include a fearful and/or anxious pattern, negative and/or stubborn
behaviors, self-absorbed behaviors that are difficult to engage
or creative or actively seeking sensation.
Type II- Sensory Based Motor Disorder (SBMD)-
Shows motor output that is disorganized as a result of incorrect
processing of sensory information.
Type III- Sensory Discrimination Disorder (SDD)-
Sensory discrimination or postural control challenges and/or dyspraxia
seen in inattentiveness, disorganization, poor school performance.
This information is adapted from research and
publications by: Lucy, J. Miller, Ph.D., OTR, Marie Anzalone, Sc.D.,
OTR, Sharon A. Cermak, Ed.D., OTR/L, Shelly J. ,Lane, Ph.D, OTR,
Beth Osten, M.S,m OTR/L, Serena Wieder, Ph.D., Stanley I. Greenspan,
Sensory modulation refers to a complex central
nervous system process by which neural messages that convey information
about the intensity, frequency, duration, complexity, and novelty
of sensory stimuli are adjusted. Behaviorally, this is manifested
in the tendency to generate responses that are appropriately graded
in relation to incoming sensations, neither underreacting nor overreacting
Sensory Modulation Problems
Sensory registration problems - This refers to
the process by which the central nervous system attends to stimuli.
This usually involves an orienting response. Sensory registration
problems are characterized by failure to notice stimuli that ordinarily
are salient to most people.
Sensory defensiveness - A condition characterized by overresponsivity
in one or more systems.
Gravitational insecurity - A sensory modulation condition in which
there is a tendency to react negatively and fearfully to movement
experiences, particularly those involving a change in head position
and movement backward or upward through space. (Case-Smith, (2005)
Hyposensitivities and hypersensitivities
Sensory integration disorders vary between individuals
in their characteristics and intensity. Some people are so mildly
afflicted, the disorder is barely noticeable, while others are so
impaired they have trouble with daily functioning.
Children can be born hypersensitive or hyposensitive
to varying degrees and may have trouble in one sensory modality,
a few, or all of them. Hypersensitivity is also known as sensory
defensiveness. Examples of hypersensitivity include feeling pain
from clothing rubbing against skin, an inability to tolerate normal
lighting in a room, a dislike of being touched (especially light
touch) and discomfort when one looks directly into the eyes of another
Hyposensitivity is characterized by an unusually
high tolerance for environmental stimuli. A child with hyposensitivity
might appear restless and seek sensory stimulation.
In treating sensory dysfunctions, a "just
right" challenge is used: giving the child just the right amount
of challenge to motivate him and stimulate changes in the way the
system processes sensory information but not so much as to make
him shut down or go into sensory overload. The "just right"
challenge is absent if the activity and the child's perception of
activity do not match. In addition, deep pressure is often calming
for children who have sensory dysfunctions. It is recommended that
therapists use a variety of tactile materials, a quiet, subdued
voice, and slow, linear movements, tailoring the approach to the
child's unique sensory needs.
While occupational therapy sessions focus on increasing
a child's ability to tolerate a variety of sensory experiences,
both the activities and environment should be assessed for a "just
right" fit with the child. Overwhelming environmental stimuli
such as flickering fluorescent lighting and bothersome clothing
tags should be eliminated whenever possible to increase the child's
comfort and ability to engage productively. Meanwhile, the occupational
therapist and parents should jointly create a "sensory diet,"
a term coined by occupational therapist A. Jean Ayres. The sensory
diet is a schedule of daily activities that gives the child the
sensory fuel his body needs to get into an organized state and stay
there. According to SI theory, rather than just relying on individual
treatment sessions, ensuring that a carefully designed program of
sensory input throughout the day is implemented at home and at school
can create profound, lasting changes in the child's nervous system.
Parents can help their child by realizing that
play is an important part of their child's development. Therapy
involves working with an occupational therapist and the child will
engage in activities that provide vestibular, proprioceptive and
tactile stimulation. Therapy is individualized to meet the child's
specific needs for development. Emphasis is put on automatic sensory
processes in the course of a goal-directed activity. The children
are engaged in therapy as play which may include activities such
as: finger painting, using Play-Doh type modeling clay, swinging,
playing in bins of rice or water, climbing, etc.
Relation to other disorders
Autism spectrum disorders
Unusual responses to sensory stimuli are more
common and prominent in autistic children, though there is no good
evidence that sensory symptoms differentiate autism from other developmental
Some argue that sensory related disorders may
be misdiagnosed as Attention-Deficit/Hyperactivity Disorder (ADHD)
but they can coexist, as well as emotional problems, aggressiveness
and speech-related disorders such as apraxia. Sensory processing,
they argue, is foundational, like the roots of a tree, and gives
rise to a myriad of behaviors and symptoms such as hyperactivity
and speech delay. For example, a child with an under-responsive
vestibular system may need extra input to his "motion sensor"
in order to achieve a state of quiet alertness; to get this input,
the child might fidget or run around, appearing ostensibly to be
hyperactive, when in fact, he suffers from a sensory related disorder
Sensory Integration Therapy
The main form of sensory integration therapy is
a type of occupational therapy that places a child in a room specifically
designed to stimulate and challenge all of the senses. During the
session, the therapist works closely with the child to provide a
level of sensory stimulation that the child can cope with, and encourage
movement within the room. Sensory integration therapy is driven
by four main principles:
Just Right Challenge (the child must be able to
successfully meet the challenges that are presented through playful
Adaptive Response (the child adapts his behavior with new and useful
strategies in response to the challenges presented)
Active Engagement (the child will want to participate because the
activities are fun)
Child Directed (the child's preferences are used to initiate therapeutic
experiences within the session).
Children with lower sensitivity (hyposensitivity) may be exposed
to strong sensations such as stroking with a brush, vibrations or
rubbing. Play may involve a range of materials to stimulate the
senses such as play dough or finger painting.
Children with heightened sensitivity (hypersensitivity)
may be exposed to peaceful activities including quiet music and
gentle rocking in a softly lit room. Treats and rewards may be used
to encourage children to tolerate activities they would normally
While occupational therapists using a sensory
integration frame of reference work on increasing a child's ability
to tolerate and integrate sensory input, other OTs may focus on
environmental accommodations that parents and school staff can use
to enhance the child's function at home, school, and in the community
(Biel and Peske, 2005). These may include selecting soft, tag-free
clothing, avoiding fluorescent lighting, and providing ear plugs
for "emergency" use (such as for fire drills).Some occupational
therapists also treat adults with this condition.
Alternative views on Sensory Integration Dysfunction
Not everybody agrees with the notion that hypersensitive
senses is necessarily a disorder. However, sensory integration dysfunction,
sometimes called sensory processing disorder, is only diagnosed
when the sensory behavior interferes significantly with learning,
playing, and activities of daily living (ADL). Sensory issues can
be on a spectrum. Being annoyed and distracted by the sound of a
noisy ventilation system or the scratchiness of a sweater is considered
to be a typical sensory response. However, when a child is so strongly
affected by background noise or tactile sensations that he totally
withdraws, becomes hyperactive and impulsive, or lashes out as part
of a primitive fight-or-flight response, the child's sensory issues
are severe enough to warrant intervention.
In addition to experiencing hypersensitivity,
a person can experience hyposensitivity (undersensitivity to sensory
stimuli). One example of this is insensitivity to pain. A child
with sensory integration dysfunction may giggle when given an injection
or not even blink when receiving a second-degree burn.
There is no proof for the idea that hypersensitivity
would necessarily be a result of sensory integration issues. However,
there is anecdotal evidence that sensory integration therapy results
in more typical sensory responses and sensory processing. For example,
Grandin has claimed that the deep pressure created by a cattle
squeeze machine she used in her youth resulted in her being able
to tolerate the affectionate hugs and touches she craved. Additionally,
over 130 articles on sensory integration have been published in
peer-reviewed (mostly occupational therapy) journals. The difficulties
of designing double-blind research studies of sensory integration
dysfunction have been addressed by Temple Grandin and others. More
research is needed.
It is possible Sensory Integration Dysfunction
can be misdiagnosed, just as with any other disability. Some experts
claim that occupational therapists and other professionals incorrectly
apply this label to individuals with attention difficulties or who
simply don't put forth any effort during assessments. For example,
a student who fails to repeat what has been said in class (due to
boredom or distraction) might be referred for evaluation for sensory
integration dysfunction (although many, many school teachers, therapists,
and administrators are unfamiliar with sensory integration dysfunction
or don't believe in it, this sometimes happens. The student might
then be evaluated by an occupational therapist to determine why
he is having difficulty focusing and attending, and perhaps also
evaluated by an audiologist or a speech-language pathologist for
auditory processing issues or language processing issues. As part
of the auditory evaluation, the student may be asked to listen to
signals coming from either side of a pair of headphones and identify
where they are coming from. If the student is bored or distracted,
or confused by the oral directions given, the test may be inconclusive
and may not isolate what the problem is. The assessor must consider
sensory and language factors in evaluating the student's performance
on the test. Diagnoses based on single tests are unreliable, and
integrated assessment utilizing multiple sources of information
is the preferred means of diagnosis.
Similarly, a child may be mistakenly labeled "ADHD"
or "ADD" because impulsivity has been observed, when actually
this impulsivity is limited to sensory seeking or avoiding. A child
might regularly jump out of his seat in class despite multiple warnings
and threats because his poor proprioception (body awareness) causes
him to fall out of his seat, and his anxiety over this potential
problem causes him to avoid sitting whenever possible. If the same
child is able to remain seated after being given an inflatable bumpy
cushion to sit on (which gives him more sensory input), or, is able
to remain seated at home or in a particular classroom but not in
his main classroom, it is a sign that more evaluation is needed
to determine the cause of his impulsivity. Children with FAS (Fetal
Alcohol Syndrome) display many sensory integration problems.
And while the diagnosis of sensory integration
dysfunction is accepted widely among occupational therapists and
also educators, these professionals have been criticized for overextending
a model that attempts to explain emotional and behavioral problems
that could be caused by other conditions. Children who receive the
diagnosis of sensory integration dysfunction should also be observed
for signs of anxiety problems, ADHD, food intolerances, and behavioral
disorders, as well as for autism. Genetic problems such as Fragile
X syndrome should be looked into as well. Sensory integration dysfunction
is not considered to be on the autism spectrum, and a child can
receive a diagnosis of sensory integration dysfunction without any
comorbid conditions. However, because comorbid conditions are common
with sensory integration issues, it is important to investigate
whether the child has other conditions as well which make him or
her reactive, "touchy", or unpredictable, and manifest
in a manner similar to that characterized by occupational therapists
as sensory integration dysfunction. The theory of SI points out
that children learn through their senses. If a child seems to have
difficulty processing sensory information, it makes sense to observe
whether he or she is developmentally on track (in terms of social
skills, fine motor skills, gross motor skills, language, etc.)
While the physical methods employed by occupational
therapists as treatment for SID are often palliative (they make
the child feel better--much as a nice massage or physical contact
would make anyone feel better), it is important that children diagnosed
with sensory integration dysfunction be observed closely so that
any other conditions will not be overlooked. Moreover, SI therapy
is not "one size fits all." According to SI theory, children
with sensory integration issues have their own unique set of sensory
responses that need to be addressed. What is calming and focusing
for one child may be overstimulating for another, and vice versa.
The child's unique set of sensory responses must be considered when
designing a sensory diet.
Some adults identify themselves as having sensory
integration dysfunction; that is, they report that their hypersensitivity,
hyposensitivity, and related sensory processing issues, such as
poor self-regulation, continue to cause significant interference
in their daily lives at home, at work, and at school.
Alternatively, there is evidence to suggest that
some gifted children also have an increased tendency toward hypersensitivity
(e.g., finding all shirt tags unbearable), which may be correlated
with their greater intellectual proclivity toward perceiving the
world in unconventional ways.
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2 Lysy, K. Z., and M. M. Piechowski. (1983). "Personal Growth:
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3 Piechowski, M. M. (1986). "The Concept of Developmental Potential."
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4 Piechowski, M. M., and N. B. Miller. (1995). "Assessing Developmental
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Case-Smith, Jane. (2005) Occupational Therapy for Children. 5th
Edn. Elsevier Mosby: St. Louis, MO. ISBN 032302873X
Biel, Lindsey and Peske, Nancy. (2005) Raising A Sensory Smart Child.
Penguin: New York. ISBN 014303488X, website: http://www.sensorysmarts.com
Heller, Sharon, Ph.D., 2003. "Too Loud, Too Bright, Too Fast,
Too Tight: What to do if you are sensory defensive in an overstimulating
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