When Sensory Sensitivity Requires Intervention: Assessment and Treatment of Sensory-Sensitive Children

[Editors’ note: This is the third in a series of articles examining the role of sensory integration in early childhood. We also draw your attention to part 1 and part 2.]

In the first article in this series (“Supporting Sensory-Sensitive Children in a Sensory-Intensive World,” Volume 29, Number 1, Spring 2017), we defined terminology pertinent to sensory issues that frequently appear in young children, in addition to exploring how sensory processing disorder (SPD) can relate to academic performance issues and conditions such as autism, ADHD, and anxiety. The second article in the series (“Classroom Solutions for Sensory Sensitive Students,” Volume 29, Number 2, Summer 2017) provided guidance on how to create a sensory-friendly classroom environment for all students, regardless of sensory profile. This final article will explore what is involved in assessing, diagnosing, and supporting a child who has a significant sensory issue.

A LENS ON SPD: WHEN TO CONSIDER ASSESSMENT

Sensory processing disorder occurs when one’s body is unable to deal successfully with the information that it receives through its senses. The manifestation of this inability can appear in many ways, but, in order for the disorder label to apply, it must occur with frequency, intensity, and/or duration. Such dysfunction generally appears through a child’s inability to either 1) read cues from his/her surrounding environment, which come as input through one or more senses, 2) consistently absorb and organize that sensory input, or 3) adjust his/her own behavior appropriately based on the effectively processed sensory input (Kranowitz, 1998).

Characteristics of SPD can appear as early as infancy, but atypical sensory processing does not automatically mean that a child will have difficulty learning or developing. When does a sensory difference become significant enough to interfere with a child’s daily functioning, including learning? Determining that answer is rarely easy.

Frequently, children with sensory processing deficiencies are first identified as having a challenge by their classroom teachers when they reach school age, as these children can have significant difficulty in the school setting, both with learning-related tasks and with appropriate behaviors and self-regulation (Miller-Kuhaneck, Henry, Glennon, & Mu, 2007; Noddings, 2012). Areas of particular challenge often include behavior problems, organizational problems, or difficulties performing fineor gross-motor activities requiring a higher level of coordination (Polotajko & Cantin, 2010). How prevalent are sensory integration (SI) difficulties in children in the United States, or, more frankly, how often does a child have enough of an SPD to warrant intervention? Estimates range from between 5 and 15% of the U.S. population for children without disabilities to as high as 40–88% of children with disabilities, according to some researchers (Ahn, Miller, Milberger & McIntosh, 2004). (In other words, if a child is diagnosed with another disability, his or her odds of having SPD are much higher.) Occupational therapist (OT) and leading SI researcher Lucy Jane Miller estimates that approximately 1 child in 20 is severely impacted by sensory issues (Wallis, 2007). Other researchers argue that having heightened sensitivity in one or more sensory areas does not necessarily qualify as a disorder, with all of the medical and financial support that diagnosis entails.

Part of the difficulty in accurately identifying prevalence numbers stems from how SPD is assessed. Multiple assessment tools are in use by OTs, and their results can be inconsistent, because accurate assessment of sensory difficulties requires not simply focusing on a child’s behaviors but also examining why the child is behaving in a particular way. In other words, observers must look at the sensory stimuli in a given environment at the time a behavior occurs (Williamson & Anzalone, 2001). Thus, diagnosis requires extensive observation of a child across multiple environments over time. Assessment can be further complicated when a child’s symptoms appear inconsistently, varying moment to moment or combining hypersensitivity in one area with hyposensitivity in another (Dobbins, Sunder & Soltys, 2007).

An OT generally begins a sensory assessment with a screening and a parent interview (Smith & Gouze, 2004). If the results of the screening warrant further evaluation, next steps may include administration of a formal SI assessment tool; observations at home, school, or a clinic; and/or interviews with or checklists filled out by teachers and other adults who work with the child. For a full-scale assessment, some OTs strongly recommend assembling a multidisciplinary team, including a pediatrician and a psychologist (Miller, 2006), in order to ensure a truly comprehensive look at the child. Next, we’ll take a closer look at several assessment tools, how they are used, and who administers them, as we learn more about the history of sensory therapy.

OCCUPATIONAL THERAPISTS AND ASSESSMENT OF SENSORY INTEGRATION

Occupational therapists have been practicing sensory integration therapy (SI therapy) with children diagnosed with sensory challenges for over 30 years. This specialty originally emerged from the work of OT and developmental psychologist Dr. A. Jean Ayres. Ayres’s work in this branch of occupational therapy extended into the development of the Sensory Integration and Praxis Tests (SIPT) in the 1970s and 1980s (Ayres, 1989), a tool specifically designed to identify and diagnose SPD (Schaaf & Davies, 2010). Today, approximately 90% of American OTs who work in school settings use SI therapy when working with students who demonstrate difficulties that may be related to sensory organization (May-Benson & Koomar, 2010).

It is important to note, however, that OTs receive widely varied amounts and types of training in the area of sensory integration, depending upon when they completed their university studies, the age level on which they are focusing their practice, and their level of personal and professional interest in this area of the field (Noddings, 2012). OTs specializing in pediatrics tend to find more SI-related knowledge integrated into their university course-work and postgraduate professional development (PD) opportunities, particularly over the last 20 years, but they still must choose to seek out those PD opportunities. OTs who commit to a significant SI focus can become certified to administer the SIPT tool—a certification that can take up to a year to attain.

Even OTs who have completed SIPT certification report a tendency to utilize pieces of a variety of SI assessment tools when evaluating young patients, including components of the SIPT as well as the Sensory Profile (Dunn, 1999) and the Sensory Processing Measure (Miller-Kuhaneck, Henry, Glennon, Parham & Ecker, 2008). This piecemeal approach is in part because the complete SIPT has a total of 17 subtests, and administering it in full can quickly become expensive, especially for families who must pay for these assessments without assistance from school districts or medical insurance. Regardless of tools chosen, observations of children in a variety of environments are a cornerstone of the SI assessment process, as is checklist-based input from parents and teachers.

Two terms frequently used by OTs when speaking of SI are sensory modulation and praxis. Williamson & Anzalone (2001) define sensory modulation as a person’s ability to manage reaction to sensory sensation, including the ability to appropriately and proportionately generate responses to sensory input. Praxis, on the other hand, is a person’s ability to mentally formulate goals, plans, timing, and sequence based on the foundation of sensory input. While the SIPT is still used by OTs today to assess SI issues focused on praxis, for children between the ages of 4 and 9, additional assessment tools—including the widely used Sensory Profile (Dunn, 1999), for use with children ages 3 to 10, and the Sensory Processing Measure (Miller-Kuhaneck, Henry, Glennon, Parham & Ecker, 2008), for use with children ages 5 to 12 within a school environment—have been developed over the past 20 years to specifically assess just the sensory modulation aspect of sensory processing. The varied terminology often used to describe these three assessments is indicative of continued debate within the OT community as to the best terms to use to describe SI issues, both broadly and more narrowly, for specific subtypes (Schaaf & Davies, 2010).

DIAGNOSED:  WHAT NEXT?

If a child receives a diagnosis of SPD, parents then must decide whether they are able to commit to the time and expense of treatment with an OT. A typical program of intervention involves occupational therapy with an SI focus delivered in a one-on-one setting at least 1 to 2 times a week for at least 10 weeks, and possibly up to a year or more. In one review of 27 research studies investigating effectiveness of SI therapy, studies showing effective results generally had participants in OT 2 to 3 times a week for 6 months (May-Benson & Koomar, 2010), but with significant variability depending upon the nature and severity of the child’s sensory challenges. That variance tends to be less based on the age of the child or OT’s practice environment and more attributable to the specific needs of the child, the amount of support or reinforcement that the child receives outside of therapy, and the practice philosophy of the particular therapist (Noddings, 2012).

General goals of therapy include systematically working to improve the child’s social behaviors, sensory responsiveness, motor skills, and participation in meaningful activities or “occupations” (Miller, Coll & Schoen, 2007). Therapeutic activities should be controlled and sought by the child in the therapy session, with the OT providing an appropriate level of challenge to keep the child’s processing skills advancing. Sessions are structured to be more play-based, increasing the child’s intrinsic motivation, rather than based on cognitive behavioral strategies or repeated drill. The child must want to explore and learn from the environment in these one-on-one sessions (Kranowitz, 1998).

Over time and with frequent reinforcement, a child can demonstrate growth in a range of areas and behaviors as a result of a successful course of therapy; for example, a child experiencing numerous hypersensitivities might show improvements in motor planning, more participation in activities with peers, more flexibility in eating a variety of foods, and/or less fear related to gross-motor activities (Schaaf & Nightlinger, 2007). The parent may or may not be involved in the sessions with the child and the therapist or may observe the sessions. In addition, the parent receives training from the OT on how to apply concepts related to the therapy in daily-life settings, including home or school. Ideally, the therapist and parent will also have regular, ongoing consultation with the child’s teacher(s) and other care providers, as appropriate, in order to provide the child with consistent, daily reinforcement of the techniques introduced through therapy.

TABLE 1

SENSORY-RELATED TECHNIQUES RECOMMENDED BY OTs FOR USE IN GENERAL EDUCATION ENVIRONMENTS

TABLE 2

SENSORY-RELATED TECHNIQUES RECOMMENDED BY OTs FOR USE  WITH SENSORY-SENSITIVE STUDENTS

HOW OTs BELIEVE SI-RELATED TECHNIQUES CAN HELP TEACHERS

As Montessorians, one of our primary goals is helping children learn to self-regulate so that they can direct their own learning. Similarly, OTs work through therapy to promote children’s self-regulation, whether in the classroom or in other areas of daily life. In an interview study of pediatric OTs with established SI-focused practices (Noddings, 2012), the OTs offered their views on which sensory-based tools would be most helpful to implement into today’s general education environments to support all students, including those with sensory challenges. Table 1 offers a look at their top five choices, ranked by the number of OTs who described and selected the technique as valuable.

OTs want teachers to understand that SI really exists and that it is treatable—and it’s partially created by changes in our society (less physical labor, less movement), as children are being asked to sit longer. Teachers need help in recognizing appropriate referrals for OTs, beyond handwriting. Additionally, the OTs identified sensory-based classroom techniques for use specifically with sensory-sensitive students. While the OTs acknowledged that these techniques are more specialized than those in Table 1, they were also emphatic that general education teachers should know these techniques so they feel empowered to meet the needs of an ever-broadening array of learners. Their top five choices are shown in Table 2.

If these techniques are utilized consistently, OTs believe student behaviors and performance can improve in many concrete, measurable areas, ranging from general attention, focus, and behavior to self-calming, quality of academic work, fine-motor skills (including handwriting), and memory retention. These benefits will be available to all students, regardless of sensory need. But OTs also emphasize the importance of consistent, ongoing communication between therapists, parents, and teachers of children who are receiving SI therapy, in order to maximize the benefit of therapy and provide reinforcement of therapy techniques across a child’s daily environments.

CONCLUDING THOUGHTS

After defining terminology related to sensory processing, exploring tools to use in classrooms to promote general sensory development, and considering when additional interventions may be needed to support young learners with sensory challenges, it is my hope that you have gained a greater understanding of this often-misunderstood area of child development. As the OT community continues its work to gain broader medical and educational support for treatment of sensory disorders, each of us, as teachers, educational leaders, and parents, must be open to the possibility of sensory issues as a lens on children’s behaviors. When teachers show students that they want to help them with their challenges, the resulting positive, supportive environment promotes trust between teacher and student and helps to keep the joy of learning alive in each and every child. For an educator, there is no greater goal.