Applying the Principles of Sensory Integration to School Based Assessment

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. 1

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) 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. Sensory in School based Practice 2

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 3

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 4

Theoretical Models of SI FUNCTION 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 5

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 6

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 7

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) Speech Vestibular (gravity & movement) Eye movements Language Ability to concentrate Proprioceptive (muscles & joints) Tactile (touch) Posture Balance Muscle tone Gravitational security Sucking Eating Mother-infant bond 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 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 Tactile comfort Visual (seeing) First level Second level Third level Fourth level WPS 1979, 2005 8

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 Review IEP strengths and areas of needs Interview teacher and parent Conduct an initial observation of the student DDDM 9

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, performancebased, 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 10

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? 11

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? 12

Why is valid standardized testing important? How do we know if a child s performance is typical or problematic? Non Standardized Assessment in SI 13

Lets Practice With a partner, practice administering the clinical observations. What does typical performance look like on the clinical observations? Lets Watch 14

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 Clinical/structured observations Clinical/structured observations 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 15

SIPT kinesthesia age trend Clinical/structured observations Clinical/structured observations 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 Clinical/structured observations Assessing PRN 10 rotations in 20 seconds Stop and time Average:9 10 seconds +/ 3 (Mailloux et al., 2014) 16

SIPT PRN age trend Clinical/Structured Observations Clinical/Structured Observations 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? Clinical/Structured Observations 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? 17

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 18

Generating a hypothesis 1 2 3 Review strengths/challenges Compile assessment data Cluster and look for pattern 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) 19

Mulligan (1998) found similar patterns: N = 10,475 Bilateral integration & sequencing Somatopraxis Visuopraxis Somatosensory perception Postural/ocular Mailloux, Mulligan, Smith Roley et.al. 2011 found similar patterns N=273 Visual and Somatodyspraxia Vestibular Bilateral Integration and Sequencing Tactile & Visual Discrimination Tactile Defensiveness and Attention Schaaf & Mailloux, 2015 20

Case Study Sascha Discussion and group work Use provided assessment data and your video observations to develop a hypothesis regarding the student. Case Study 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. 21

Discussion Objective 3 Develop relevant and measureable goals addressing underlying sensory processing factors DO: Identify specific underlying sensory areas impacted in PLP. Choose measurable outcomes AVOID Writing modulation goals for attention or non preferred activity (OT is about engagement) Having multiple areas or outcomes within the same goal IEP and Goal Writing 22

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. Good Goal or Bad Goal 23

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. Good Goal or Bad Goal? Case Study Based on your hypothesis, develop a PLP and goal for the student. Discussion 24

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! Conclusion Questions? Thank you! 25

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 idelity measure 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. 26