Manual for interventions based on ayres sensory integration

Manual for Interventions based on Ayres Sensory Integration速 Guide for Professionals For giving intervention based on theory, it is important to have structured guidelines and method, so that it can be followed consistently by everybody in the department. It is well known that Intervention based on Ayres Sensory Integration is non prescriptive. But to have consistency in intervention we are planning, this manual is developed. It includes guidelines and principles for intervening. It is not a 'cook book' for all the children. Rather, it will accommodate the variations in sensory processing status in an individual.

Hemant P Nandgaonkar

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Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

Content 1. Introduction 2. Guidelines for evaluation 3. Generating Hypothesis for intervention 4. Equipments used for intervention 5. Guidelines according to sensory processing issues 6. Fidelity Guidelines for Ayres Sensory Integration 7. Principles of Intervention 8. What to do after the treatment session is over?

APPENDIX A: Demographics APPENDIX B: Clinical observations APPENDIX C: Photographs of the activities

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9. References

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

Introduction For giving intervention based on theory, it is important to have structured guidelines and method, so that it can be followed consistently by everybody in the department. It is well known that Intervention based on Ayres Sensory Integration is non prescriptive. But to have consistency in intervention we are planning, this manual is developed. It includes guidelines and principles for intervening. It is not a 'cook book' for all the children. Rather, it will accommodate the variations in sensory processing status in an individual.

This manual guides about the following 1. Evaluation 2. How to plan the intervention?

3. How to deliver therapy?

4. What equipments and set up required for the intervention?

5. Duration of the intervention 6. What information should be given to the caregivers?

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7. How the activity analysis can be done in clinical setting?

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

EVALUATION 1. After referral for Occupational Therapy using Ayres Sensory Integration frame of reference, the child will be evaluated.

2. Initially all the demographic details will be collected.

3. The reason for referral will be noted. Caregivers will be requested to write the chief complaints. If they are able to read and write, they will be noted by the therapist.

4. Brief history will be elicited. (APPENDIX A) 5. Following instruments will be used for evaluation.

1. Clinical Observations (APPENDIX B) 2. Sensory Profile Sensory Processing measure 3. Goal Attainment Scale 4. Semi structured interview of the parents.

GENERATION OF HYPOTHESIS 1. Hypothesis will be generated for giving the intervention.

1. Whether child is tactile defensive? (Hyper responsive tactile system) 2. Whether the child is gravitational insecure? ( Hyper responsive vestibular system) 3. Whether the child is hypo responsive to vestibular input?

2. Based on the hypothesis the sensory inputs will be given and environment will be modified.

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1. For child with hyper responsive tactile or vestibular system, tactile or vestibular input will be given along with Proprioceptive input in playful context as a just-right challenge considering his present level of alertness, development. Principles and fidelity guidelines mentioned below will be followed.

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

EQUIPMENTS USED 1. Following equipments will be used 1. For giving tactile input: ball pool, different textured mats, textured blocks, brushes, shaving foam, paint, sand.

2. for giving vestibular input: platform swing, disc swing, bolster swing, scooter board, hammock, inner tube, trapeeze, barrel, trampoline, therapy ball, frog swing, lycra swing 3. for giving Proprioceptive input: ladder, ramp, mats, bean bags, heavy drums, tunnel, foam blocks of different shapes, pop tubes

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4. Other activities: toys of different complexity for the children which can be incorporated in making purposeful activities which will be fun for the child. Rings, marble

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

GUIDELINES ACCORDING TO DIFFERENT SENSORY PROCESSING ISSUES

Treat sensory modulation issues first followed by planning issues. (Sensory Based motor disorder) 

Interventions for the Child with High Threshold responses

Provide novelty, variety and varying intensity of stimuli.

More arousing stimuli: light touch, fast movement, bright lights, loud and fast music.

If the child becomes overexcited or overwhelmed, reduce the number of variables.



For the “Poor Registration" child with High Threshold/Low Activity

Move gradually to accommodate slower rate of action.

Find tasks of interest and stay with them.

Use tasks with simple steps and fewer sequences.

Reinforce learning with repetitions.

Gradually increase demands.



For the “Sensory Seeking” child with High Threshold/High Activity

Vary intensity: fast movement, interspersed with slow movement.

Expand or change tasks and vary the routine.

Add sequences to the tasks.

Encourage problem-solving Create a theme that will interest the child.

Interventions for the “Sensitive or Avoiding” Child with Low Threshold responses

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Nandgaonkar Hemant P, June 2012

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Soften stimuli

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Reduce distractions in the environment.

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

Create plans and expectations so the child knows what to expect.

Offer choices that allow the child to determine the program.

Change gradually, adding variety slowly.

Calming stimuli: deep pressure; slow, rhythmical repetitive stimuli, movement with resistance.

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Balance sympathetic over-activity by facilitating parasympathetic activity

Proprioception/Heavy Work Breathing Attention to task/flow Identify and reduce stimuli that cause stress response

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Interventions for motor planning issues

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Work from stationary activities and gradually add dynamic elements



Bilateral movements then unilateral movements.



Repetition (for learning and reinforcement) with added changes to challenge

It is important to relate the activities to function in different domains, ADL, Work/School, Play, and the social skills needed to support these occupations Also it is necessary to incorporate Ideation, Planning, Postural control activities and behavioural organization during the session.

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

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

FIDELITY GUIDELINES 1. Following fidelity guidelines will be followed. This means that each session will use a standardised method of delivering Ayres Sensory Integration i.

1. Provide sensory opportunities - The therapist presents the child with 2 of 3 types of sensory opportunities—tactile, vestibular, and Proprioceptive—to support the development of self-regulation, sensory awareness, or movement in space.

2. Provide just-right challenges - The therapist suggests or supports an increase in complexity of challenge when the child responds successfully.

These challenges are primarily tailored to the child’s postural, ocular, or oral control; sensory modulation and discrimination; or praxis developmental level.

3. Collaborate on activity choice - The therapist negotiates activity choices with the child, allowing the child to choose equipment, materials, or specific aspects of an activity. Activity choices and sequences are not determined solely by the therapist.

4. Guide self-organization - The therapist supports and presents challenges to the child’s ability to conceptualize and plan novel motor tasks and to organize his or her own behaviour in time and space.

5. Support optimal arousal - The therapist helps the child to attain and maintain appropriate levels of alertness and an affective state that supports engagement in activities.

6. Create play context - The therapist creates a setting that supports play as a way to fully engage the child in the intervention.

7. Maximize child’s success - The therapist presents or facilitates challenges that focus on sensory modulation or discrimination; postural, ocular, or oral control; or praxis in which the child can be successful in making an adaptive response to challenge.

Nandgaonkar Hemant P, June 2012

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9. Arrange room to engage child - The therapist supports and challenges postural control, ocular control, or bilateral development. At least 1 of these types of challenges is intentionally offered: postural challenges, resistive whole-body challenges, ocular–motor challenges, bilateral

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8. Ensure physical safety - The therapist anticipates physical hazards and attempts to ensure that the child is physically safe through manipulation of protective and therapeutic equipment and the therapist’s physical proximity and actions. An existing safe room is important, as is the therapist’s attention to the child’s abilities and potential dangers.

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

challenges, oral challenges, and projected action sequences. Challenges praxis and organization of behaviour. The therapist supports and presents challenges to the child’s ability to conceptualize and plan novel motor tasks and to organize his or her own behaviour in time and space.

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10. Foster therapeutic alliance - The therapist promotes and establishes a connection with the child that conveys a sense of working together toward one or more goals in a mutually enjoyable partnership. Therapist and child relationship goes beyond pleasantries and feedback on performance such as praise or instruction.

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

PRINCIPLES OF INTERVENTION 2. Following principle will be followed 1. Intervention will delivered by a qualified professional – occupational therapist.

2. The intervention plan will be family centered and based on a complete evaluation and interpretation of the patterns of sensory integrative dysfunction in collaboration with significant persons in the client’s life and with adherence to ethical and professional standards of practice.

3. Therapy will take place in a safe environment that includes equipment that will provide vestibular, proprioceptive, and tactile sensations and opportunities for praxis.

4. Activities will be rich in sensation (especially vestibular, tactile, and Proprioceptive sensation), and offer opportunities for integrating that information with other sensations, such as visual and auditory.

5. Activities will promote regulation of affect and alertness and provide the basis for attending to salient learning opportunities.

6. Activities will promote optimal postural control in the body, oral-motor, ocular-motor areas, and bilateral motor control, including maintaining control while moving through space and adjusting posture in response to changes in the centre of gravity.

7. Activities will promote praxis, including organization of activities and self in time and space.

8. Intervention strategies will provide the “just-right challenge.”

9. Opportunities exist for the client to make adaptive responses to changing and increasingly complex environmental demands. Highlighted in Ayres Sensory Integration intervention principles is the “somatomotor adaptive response,” which means that the person is adaptive with the whole body, moving and interacting with people and things in the three-dimensional space.

Nandgaonkar Hemant P, June 2012

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11. The therapist will engender an atmosphere of trust and respect through contingent interactions with the client. The activities will be negotiated, not preplanned, and the therapist will be responsive to altering the task, interaction, and environment based on the client’s responses.

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10. Intrinsic motivation and drive will be used to interact through pleasurable activities; in other words, play.

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

12. The activities will be their own reward, and the therapist will ensure the

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client’s success in whatever activities are attempted by altering the activities to meet the client’s abilities.

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

WHAT AFTER THERAPY SESSION? 1. After completion of the therapy session the caregivers will be briefed about the session. They will be informed about both kinds of behaviour i.e. Positive and negative 2. After that they will be given list of activities to be done at home to meets child's sensory needs.

3. Also child as well as the parents will be taught to monitor child's alertness level.

Also strategies will be given for self regulation of alertness level.

4. They will be given phone number for contacting, if need arises.

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5. After the session is over they will be given the next appointment.

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

APPENDIX A FAMILY INFORMATION Child’s name: ____________________________________________________________ Birth date: __/___/____Age:___ years____ months Phone number:____________________ Parent’s name: ___________________________________________________________ Address: ________________________________________________________________ Email: __________________________________________________________________ With whom does child live most of the time? □ Biological parents

□ Mother

□ Father □ Adaptive parents (adapted at what age……...)

□ Step-parents

□ Mother

□ Father □ Siblings (number……………………………)

□ Grandparents

□ Other (specify)

REFERRING INFORMATION Who referred this child for an evaluation? ____________________________________________ Reason for referral: ______________________________________________________________ ______________________________________________________________________________ What are you primary concerns/goals regarding your child? ______________________________ ______________________________________________________________________________ When did you first have those concerns?

_____________________________________________

______________________________________________________________________________ What do you see as your child's strengths? ____________________________________________ ______________________________________________________________________________

In one sentence, how would you describe your child? ___________________________________ ______________________________________________________________________________ Do you have any additional information that will help to better understand your child? _________

□ Left

□ Both

Current school placement:_________________________________________________________

Nandgaonkar Hemant P, June 2012

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□ Right

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Hand preference:

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______________________________________________________________________________ SCHOOL HISTORY

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

Present grade:______ Have any grades been repeated? □ No □Yes(if yes, specify____________) is your child in a special class or receiving any support services(specify)?

___________________

______________________________________________________________________________

What does the teacher say about your child? __________________________________________ ______________________________________________________________________________

MEDICAL HISTORY Any difficulties during pregnancy or delivery?

□ No

□ Yes (if yes, specify______________

______________________________________________________________________________ Length of pregnancy:____________________ Length of labor: ___________________________ Birth was:

□ Normal □ Caesarian

□ Breach

□ Twins or more

Birth weight:_________ Did baby require assistance in starting to breathe □ Yes □ NO Remarks: ______________________________________________________________________ ______________________________________________________________________________ Were there any complications/problems in early infancy? □ NO □Yes (If yes, specify _________ ______________________________________________________________________________ Were there any feeding difficulties in early infancy? □NO □ Yes (if yes, specify _____________ ______________________________________________________________________________

Who is your child's present physician? _______________________________________________ ______________________________________________________________________________ Does your child have a diagnosis? □ NO □ Yes(If yes, specify___________________________) Diagnosed by whom? ________________________ Date: □ 15

Does your child have now or in the past had: (check all that apply) Significant health problems (specify:_________________________________

□ Hospitalization (specify: ___________________________________________

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□ Respiratory, lung, or bronchial difficulties (specify: _____________________

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□ Surgery (specify: _________________________________________________

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

□ Cardiac problems (specify:_________________________________________ □ Seizures (when and how often: _____________________________________ □ Allergies (specify: ________________________________________________ □ Ear infections (specify:_____________________________________________ Is your child currently on any medications? □ NO □ Yes(If yes, please give a list & state reasons) _______________________________________________________________________

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Previously tried medications: ______________________________________________________ ______________________________________________________________________________ Does your child use any specialized equipment? □ NO □ Yes (If yes, specify_________________ ______________________________________________________________________________ Has your child had a hearing evaluation? □ NO By whom:________________

Date: _________________________

Has your child had a vision evaluation?

By whom: ________________

□ YES

□ NO □ YES

Date: __________________________

Has your child had a psychological evaluation? □ NO By whom: _________________

□ YES

Date: __________________________

Has your child had a neurological evaluation? □

NO

□ YES

By whom: __________________ Date: _________________________

DEVELOPMENTAL HISTORY LIST THE AGE AT WHICH YOUR CHILD ACCOMPLISHED EACH ACTIVITY (Indicate "not yet", if they have not yet accomplished it)

Roll over both ways………………

Reaching for objects……………………………………...

Sitting alone………………………

Finger feeding……………………………………………

Creeping on all 4's ………………..

Eating with spoon………………………………………...

Pulling to stand……………………

Drawing a circle………………………………………….

Walking……………………………

Cutting with scissors……………………………………...

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Riding bike ……………………………………………...

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Head Control……………………..

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MOTOR

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

Jumping……………………………

Using knife for cutting …………………………………...

Hopping on one-foot…………………………

Does your child have difficulty learning new motor skills? □ NO

□ YES

(If yes, specify: ________________________________________________________________)

LANGUAGE Said first word……………………… Pointing to simple pictures……………………………….

Combined words……………………

Following one step commands…………………………

Spoke sentences…………………….

Following several-step commands………………………..

Looking when called………………… Looks in direction that others point……………………...

SELF HELP Dressing……………………………….

Bathing independently………………….…………….

Put on shirt independently…………….

Combing hair………………………………………......

Button independently………………… Toilet trained…………………………………………...

Zips independently……………………

Bowel…………………………………………………….

Snaps independently…………………..

Bladder…………………………………………………

Dress self independently………………

Toileting independently………………………………..

Grooming………………………………. Ties shoes……………………………………………….

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Describe a typical day for your child from waking till bedtime including whether it is difficult for your child to get to a sleep at night and stay asleep. (Use back of page if necessary.)

Nandgaonkar Hemant P, June 2012

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

APPENDIX B CLINICAL OBSERVATIONS OF NEUROMOTOR PERFORMANCE Name: ________________ Test Date: ________________ Birth Date: _____________________ Age:______________ Poor Sensory Modulation 1. GRAVITATIONAL INSECURITY - Normal reaction to change in body position + Fear reaction out of proportion to actual danger 2. AVERSIVE RESPONSE TO MOVEMENT - No evidence of aversive responses + Feelings of discomfort (nausea, vomiting, vertigo, dizziness) to movement 3. TACTILE DEFENSIVENESS - Tolerates variety of tactile stimuli + Overreacts or aversion to tactile stimuli 4. AVOIDANCE OF SENSORY EXPERIENCES - Seeks new & challenging experiences + Avoids unfamiliar activities or sensory stimuli 5. HYPERRESPONSIVE TO SMELL - No evidence of aversive responses + Overreacts or aversive response to smell 6. HYPERRESPONSIVE TO SOUND - No evidence of aversive responses + Overreacts or aversion to noise 7. DISTRACTIBILITY

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- No evidence of unusual tendency to attend to irrelevant stimuli

- Level of motor & verbal activity appropriate to situation

Nandgaonkar Hemant P, June 2012

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8. LEVEL OF ACTIVITY

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+ Attends to irrelevant stimuli; difficulty attending task

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

+ Unusually high levels of activity or difficulty transitioning from active to quite activities DIFFICULTY WITH POSTURE 1. PRONE EXTENSION - Extends body against gravity easily for 20-30 sec + Difficulty extending body against gravity 2. PROXIMAL STABILITY IN QUADRUPED - Stabilize scapulae, back, elbows during weight bearing + Lordosis, hyper extends or locks elbows or scapulae wing 3. EXTENSOR MUSCLE TONE - No evidence of low tone + Lordosis & hyper extended knees in standing, “mushy” muscles when palpated 4. EQUILIBRIUM - Makes postural adjustments of uphill limbs & maintains head or upper trunk upright + Does not maintain head/upper trunk upright or make postural adjustments of uphill libs to maintain balance 5. NECK FLEXION IN SUPINE - Flexes neck & no head lag when assuming supine flexion + Head lag (leads with chin) when assuming supine position 6. POSTURAL ADJUSTMENT - Appropriate postural adjustments to support limb movements + Exaggerated, awkward, inappropriate or diminished postural adjustments

POOR BILATERAL INTEGRATION AND SEQUENCING (BIS) 1. MIXED HAND PREFERENCE - Consistently uses the same hand for given task 19

+ Sometimes uses right & sometimes uses left hand to perform the same task (or history of doing so)

+ Avoids crossing midline

Nandgaonkar Hemant P, June 2012

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- Spontaneously crosses midline of body

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2. CROSSING THE MIDLINE

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

3. RIGHT-LEFT CONFUSION - Correctly identifies right & left or knows but cannot label correctly + Confuses right & left 4. PROJECTED ACTION SEQUENCES & BILATERAL MOTOR SKILLS a. CATCHING A BOUNCED BALL - Able to catch bounced ball when force or direction varies + Difficulty catching bounced ball when force or direction varies b. HOPPING/JUMPING IN SERIES OF CIRCLES - Able to jump in a series with both feet together, without stopping + Cannot jump with feet together, breaks task apart into jumps, difficulty terminating series c. SKIPPING - Skips in a fluid, reciprocal manner + Unable to skip; breaks into step-hop pattern d. JUMPING JACKS - Able to simultaneously open & close arms & legs & jump in smooth series + Moves arms or legs segmentally while jumping or difficulty performing a series of jumps e. SYMMETRICAL STRIDE JUMPING - Simultaneously swings ipsilateral arm and leg forward and backward while performing a series of jumps + Unable to move ipsilateral arm and leg simultaneously, segment jumps, unable to perform a series of jumps f. RECIPROCAL STRIDE JUMPING - Simultaneously swings contra lateral arm and leg forward and backward while performing a series of jumps + Unable to move contra lateral arm & leg simultaneously, segments jumps, unable to perform a series of jumps 20

g. STEPPING OVER A MOVING OBJECT

Comments:

Nandgaonkar Hemant P, June 2012

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+ Object hits client with attempt to step over moving object

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- Able to plan and execute movement over moving object without object hitting client

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

SOMATODYSPRAXIA 1. SUPINE FLEXION - Able to assume & maintain body in total flexion easily 20-30 sec + Unable to assume or maintain position 2. SEQUENTIAL FINGER TOUCHING - Able to oppose thumb to each finger bilaterally in smooth sequence + Unable to touch thumb to fingers in smooth sequence, visual monitoring required 3. IN-HAND MANIPULATION - Able to manipulate objects within hand + Must use two hands or place object on table to manipulate objects 4. DIADOKOKINESIA - Pronation or supination in continuous bilateral sequence + Segmented movements, poor bilateral coordination

Other Clinical Observations That May Suggest CNS Immaturity Or Be Common In Individuals With Sensory Integrative Dysfunction

1. ASSOCIATED MOVEMENTS - No evidence of extraneous movements or overflow when performing developmentally appropriate tasks; some overflow when performing difficult tasks + Excessive extraneous movements or overflow when performing developmentally appropriate tasks 2. FINGER TO NOSE - Alternately and accurately touches nose with finger + Diminished accuracy touching nose; over- or undershoots 3. SLOW (RAMP) MOVEMENTS 21

- Able to flex and extend elbows in smooth, bilateral, symmetrical pattern

- Extends downhill limb when balance is lost; supports weight on “weight-bearing” limb

Nandgaonkar Hemant P, June 2012

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4. PROTECTIVE EXTENSION OR SUPPORT REACTIONS

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+ Moves arms segmentally or unable to move both arms simultaneously

Pediatric Unit, Occupational Therapy School and centre, Seth GS Medical College, KEM Hospital, Parel, Mumbai

+ Delayed extension of downhill limbs when balance is lost; difficulty shifting weight onto “weightbearing” limbs

VISUALLY CONTROLLED EYE MOVEMENTS

1. TRACKING - Able to easily follow small objects with eyes + Loses object; eyes not well coordinated; tires easily 2. CONVERGENCE OR DIVERGENCE - Able to easily follow small objects with eyes + Eyes not well coordinated; tires easily 3. QUICK LOCALIZATION - Able to easily follow small object with eyes + Eyes not well coordinated; tires easily - Indicates evidence of difficulty or dysfunction + Indicates NO evidence of difficulty or dysfunction

References

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i Parham, L. D., Roley, S. S., May-Benson, T. A., Koomar, J., Brett-Green, B., Burke, J. P., et al. (2011).

Development of a fidelity 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

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1. Sensory Integration and child, Jean Ayres 2. Pediatric Occupational Therapy, 6th Edition, Editor: Jane Case Smith, Chapter: Sensory Integration 3. Frames of Reference for Pediatric Occupational Therapy, Kramer 4. Sensory Integration for the diverse population, Susan Smith Roley, Rosan Schaff 5. Sensory Integration: Theory and Practice, Anita Bundy

Nandgaonkar Hemant P, June 2012