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from Fall 97 issue
All of us depend on adequate sensory integrative functioning in order to carry out daily tasks in work, play and self-maintenance. Disorders in this domain can greatly influence our ability to function, but also can be so subtle that they easily go unrecognized. Particularly in the young child it is easy to attribute behaviors and reactions to other causes ("He's stubborn, lazy, or doesn't want to do it," or "She's spoiled, shy, or headstrong.") or to consider it within the norms of the wide range of personality and developmental characteristics of young children. However, it is important to identify and address sensory integrative dysfunction to enable the child to function at his or her optimum level and to minimize disruption in family life. This article will explain ways of addressing sensory integrative problems within the context of family life and the child's normal activities.
Sensory integration, simply put, is the ability to take in information through senses (touch, movement, smell, taste, vision, and hearing), to put it together with prior information, memories, and knowledge stored in the brain, and to make a meaningful response. Sensory integration occurs in the central nervous system and is generally thought to take place in the mid-brain and brainstem levels in complex interactions of the portions of the brain responsible for such things as coordination, attention, arousal levels, autonomic functioning, emotions, memory, and higher level cognitive functions. Because of the complexity of the various areas which are dependent upon and interact with each other as well as the child's own personality and environment, it is not possible to have a single list of symptoms which identify sensory integrative dysfunction.
A. Jean Ayres, Ph.D., was an occupational therapist who first researched and described the theories and frame of reference which we now call sensory integration. In her book, Sensory Integration and the Child, Dr. Ayres makes several analogies which describe sensory integration and its dysfunction. She describes sensory information as food for the brain similar to the food which nourishes our physical bodies. Difficulty in processing and organizing sensory information causes dysfunction which can be compared to indigestion which occurs when the digestive tract malfunctions. Another analogy compares the brain to a large city with traffic consisting of the neural impulses. She states: "Good sensory processing enables all the impulses to flow easily and reach their destination quickly. Sensory integrative dysfunction is a sort of `traffic jam' in the brain. Some bits of sensory information get `tied up in traffic,' and certain parts of the brain do not get the sensory information they need to do their jobs." (Ayres, p. 51)
Various characteristics of sensory integrative dysfunction will be discussed under four categories: attention and regulatory problems, sensory defensiveness, activity patterns, and behavior.
The ability to attend to a task depends on the ability to screen out, or inhibit, nonessential sensory information, background noises, or visual information. The child with sensory integrative dysfunction may frequently respond to or register sensory information without this screening ability and is considered distractible, hyperactive, or uninhibited. These children are always "on the alert" and constantly asking about or orienting to sensory input that others ignore (refrigerator motor, heater fan, distant airplane, etc.). Other children may fail to register unique sensory input and are unresponsive to stimuli. For example, the child may not turn around or respond when her name is called. One parent said that her child was oblivious and unresponsive to a loud noise in the same room but immediately responded when he heard a piece of candy being unwrapped two rooms away.
Children with regulatory disorders often have difficulty establishing appropriate sleeping and eating patterns, are unable to calm or console themselves, and may overreact to environmental stimuli. Georgia DeGangi states that "disorders of regulation appear to be based on problems associated with sensory processing, communicative intent, state control and arousal, and modulation of emotions" (DeGAngi, 1995). The infant or child who is very irritable, difficult to soothe, emotionally labile, and hypersensitive to touch or other sensory input may have regulatory problems.
Sensory defensiveness is a sensory integrative disorder characterized by a "fight, flight, or fright" reaction to sensory information most individuals would consider harmless. Tactile defensiveness, or hyper responsiveness to touch, was identified by Dr. Ayers in the 1960's. Since that time researchers have recognized defensiveness in other sensory areas as well. The individual who has sensory defensiveness typically has a highly aroused nervous system which prepares the body for survival, but does not recognize that the input is nonthreatening. Behaviors which can be associated with tactile defensiveness are aggressiveness, avoidance, withdrawal, and intolerance of daily routines. Combing or shampooing hair, cutting fingernails, or brushing teeth can be exhausting and difficult for families of children who react defensively with acting out behaviors or tantrums. Other children may cope by being very rigid and demanding with insistence on certain textures of clothing, cutting all tags and labels out of clothing, or displaying extremely limited choices of food because of intolerance to textures. Social skills can be very limited if the child withdraws or picks fights as a result of unexpected touch.
Auditory defensiveness can occur with negative responses or fears related to sounds and noises. Some children are so fearful of sounds such as vacuum cleaners, lawn mowers, hair dryers, leaf blowers, or sirens that parents must arrange to use appliances when the child is out of earshot. Other children may show intolerance of sounds and noises by clapping their hands over their ears. One child I knew could not tolerate the sound of a flushing toilet, another covered his ears when his preschool class had music.
Visual defensiveness can occur with hypersensitivity to light or avoidance of gaze. Oral-motor defensiveness (tactile defensiveness within the mouth) can cause distress with brushing teeth and dentist visits as well as intolerance to textures or temperatures of food. Children with olfactory defensiveness (intolerance to odors) may gag or be distressed with certain smells which other persons don't notice or don't mind. One child I know could not tolerate going into a deli with his mother because the odors made him feel sick.
Defensiveness in the vestibular area can result in intolerance to movement or unstable surfaces with fearfulness, avoidance, or motion sickness. The child may be afraid to go down steps or to ride an escalator. One child I knew not only would not step up a few inches on my floor mat, but refused to step up a curb, even holding his mother's hand. Each time they came to a curb, the mother either had to carry him or allow him to get on his hands and knees to crawl over the curb. Another child was so sensitive to motion in the car that her family always had to take the back roads avoiding the expressways (rather difficult in an urban area!).
Young children are, by nature, active. We expect the toddler to be "into things" and the preschooler to be curious, to explore and to play vigorously. We don't expect the young child to have a very long attention span. Characteristics which indicate problems in one child may be perfectly normal in a younger child. Here are some warning signals related to activity levels:
1. The child is disorganized and lacks purpose in his or her activity. This is the child who goes through the room like a tornado. Even though the child may appear to be interested in a toy or object initially, once he gets it he may throw it aside, dump it out of the container, or immediately be distracted by something else. Another characteristic is that the child lacks exploration or manipulation; he may dump objects out of a container or off a shelf without stopping to manipulate, visually examine, or play creatively with them. On the playground the child may run around a lot but does not organize his activity to climb, swing, or explore equipment.
2. The child does not move around or explore the environment. This is the "good" baby or toddler who is content to stay in one place and does not make many demands on his or her caretakers. This child may be content to watch things in his environment although he is physically able to move around and interact. The older child may use good verbal skills to engage the adult in conversation as a way of avoiding manipulating with his hands or actively engaging in activity.
3. The child lacks variety in play activities. Some children become very repetitive or stereotypic in playing with toys. Everything may be flung aside, tapped on a surface, or brought to the mouth. Another child may prefer only visual activities (TV, videos, looking at books) while avoiding visual-motor or manipulative toys (coloring, drawing, clay, construction toys.) Other children may learn one way to interact with a toy or playground equipment without adding variations, creative play, or generalizing to other similar objects. For example, the child may line up toy cars but does not pretend they are going places or experiment with rolling them down an incline.
4. The child appears clumsy, trips easily, has poor balance. The child may experience an excessive number of bumps, bruises, stitches, or broken bones. Sometimes this child seems always to be in a hurry and impulsive, does not "look where he is going." Other children may always be bumping their heads because they lack protective responses and do not "catch themselves" when they begin to fall.
5. The child has difficulty calming himself after exciting physical activity or after becoming upset. After this child "loses it" he cannot be consoled. Tantrums may last for hours, or the child may become so excited after vigorous play that he continues high activity levels long after the event. Some children regularly escalate their activity levels during the day without experiencing "down time" or being able to engage in quiet activity. Dinner time becomes chaotic and the child has extreme difficulty falling asleep at bedtime.
6. The child seeks excessive amounts of vigorous sensory input. Many children like to jump, swing, and spin; but when this is excessive, it may be problematic. The child may spin himself on playground equipment or twirl around a room for prolonged periods without experiencing dizziness. Another child may continually throw himself on the floor, deliberately hurl himself against people and things, or jump excessively.
Sensory integrative dysfunction can adversely affect many areas of a child's development, including emotional and social. Many children become discouraged or develop poor self-concept, especially if they become aware of differences in their function and those of their peers. If a young child has difficulty with motor skills and play activities, it may be hard for him to make friends or to be part of a group. Sensory defensiveness can cause aggressive behaviors or cause the child to be a loner.
Sometimes behavior problems are the first indications that the child may have sensory integrative dysfunction. The child may lack flexibility, be explosive, or have difficulty with transitions such as leaving one place to go to another. The child may show extreme irritability or crying which may seem unexplainable until it is discovered that he is fearful of certain sounds, overwhelmed by visual stimuli, or is intolerant to wrinkles in his socks. Sometimes children are so rigid in their behaviors that families go to extremes to accommodate them in order to maintain peace. The mother who follows the child around with a spoonful of food, begging him to eat, or the parents who allow the child to sleep in their bed because he won't go to sleep otherwise, may be taking care of the short-term problems of getting the child to eat or to sleep without addressing underlying problems.
This article has been an overview of some of the ways sensory integrative problems manifest themselves. Any particular child may show only a few of the characteristics described and some characteristics could be caused by something other than sensory integrative dysfunction. Parents and professionals are advised to look at the pattern of behaviors and the "big picture" of how the problems interfere with the child's function in his or her play, physical and emotional development, and ability to develop independence. Any child who is suspected of having a sensory integrative disorder should be evaluated by a professional (usually an occupational or a physical therapist) who has had additional training in sensory integration evaluation and treatment. Sensory integration "certification" means that the individual has had more than one hundred continuing education hours in theory, test mechanics, and interpretation of test results from the Sensory Integration and Praxis Tests (SIPT). Although such certification assures additional training in this specialty area, there are many licensed professionals who are very competent in the specialty who are not certified.
Ayers, a. Jean. Sensory Integration and the Child. Los Angeles: Western Psychological Services. 1994.
DeGangi, Georgia A. et al. Infant/Toddler Symptom Checklist: A Screening Tool for Parents. Tucson, AR: Therapy Skill Builders, 1995. (1-800-0763-2306)
Trott, Maryann Colby et al. SenseAbilities: Understanding Sensory Integration. Tucson, AR: Therapy Skill Builders, 1993.
Linda Stephens is an occupational therapist in private practice in Atlanta, Georgia. She specializes in sensory integration and has worked with children for thirty years. Her private practice, Atlanta Children's Therapy, Inc., is located in Atlanta, Georgia.
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from Fall 97 issue
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Last Revision: January 6, 2005