SENSORY INTEGRATIVE DYSFUNCTION
Introduction
Sensory integration is a function of our brains that we use continuously in order to
accomplish our daily tasks. Sensory integration is the ability of the brain to take all
the information coming from all our senses - touch, movement, taste, smell, hearing and
vision - and to use this new information in combination with prior information consisting
of memories, knowledge, feelings and experiences in our brain to make a meaningful response.
This response can be an appropriate social or emotional response, solving a difficult problem,
merely using movement to avoid collision with someone in the supermarket isle, saving the food
from burning on the stove or the bath from running over. Most of the basic simpler actions
often take place without our consciously thinking about it. Our brain decides the appropriate
action and mobilises the necessary skills to accomplish what needs to be done.From this
explanation it is clear that sensory integration is one of the main tasks of the brain.
Stephens (1997) says that ... sensory integration occurs in the central nervous centre 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 activities as co-ordination, attention, arousal
levels, autonomic functioning, emotions, memory... If we remember that basic senses like movement,
touch, smell and taste are the main senses the brain uses in the early years to gather information
and learn about the surrounding world and the people in the world, we can surmise that dysfunction
in these areas must be present or starts fairly early in the baby's and toddler's life.
What is Sensory Integrative Dysfunction
Sensory Integrative Dysfunction is exactly the opposite from what is described in the previous
paragraph. Carol Stock Kranowitz, the author of the book Out-of-Sync child, remarks that the young
child never wilfully wants to behave inappropriately. Children seek approval of their emotionally
important adults like moths seek light. Children can also not help not to want to learn because their
brains compel them to seek new information and experiences and make sense from their life-world experiences.
In the same vein, young children seek social contact and want approval and social acceptance from their peers.
Yet, we all know children that seem unable to learn even though they are seemingly bright and intelligent.
They seem to continuously do the wrong thing or the inappropriate reaction that isolates them from their
caregivers and their peers.
Dr A Jean Ayres (Stephens, 1997) was an occupational therapist and academic who, after her own traumatic,
trouble filled childhood, became interested in this field. She was the first one to research and describe
the theories and frame of reference of sensory integration in the 1960s. She used several analogies to
describe the chaos in the brain when sensory integration does not take place ... 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 in Stephens, 1997).
From this description we can deduct that there are two kinds of processes at work in the brain. The
one process we can call the "input process" where the brain receives information from the senses. If
the senses, or some of the senses, provide the brain with inadequate information or even completely
wrong information, the "output" or reaction will naturally be inappropriate. The second process is the
"output" process. It may happen that the senses are providing the brain with correct information but
that the brain processes this information, for whatever reason, inadequately. In this case, the reaction
will also be incorrect. What we need to remember is that the young child, or even the older learner and
sometimes even adults, have very little control over these processes if left to themselves. To blame the
child for the incorrect response is in fact compounding the child's inability to make sense and react
appropriately. Thousands of children are labelled "naughty", "maladjusted" and "impossible". They get
labels and become the outcasts and black sheep of their small communities. We often hear about children
that are expelled from preschool. The majority of these children are victims of an inability and ignorance
on the part of the adults in the learning environment to understand Sensory Integrative Dysfunction.
Kranowitz says: Until I learned about SI Dysfunction, I could not find a pattern in these children.
The only common thread - and this troubled me most - was their sadness. Whether their modus operandi
was hostility, aggression, anger, frustration, tuning-out, whining, silliness or wildly inappropriate
gusto, they all seemed to sense that they weren't like the other kids. They didn't feel a sense of
belonging (Martin, 1999).
Developmental delays and lack of developmentally appropriate experiences
The question most people seem to ask is: "Why". If we think in general terms about brain
development, there are several phases where different aspects can adversely influence brain
development.
Pre-natal Development
New knowledge about the vulnerability of the developing brain to environmental factors suggests that
early exposure to nicotine, alcohol and drugs (in utero and in the post-natal environment) may have even
more powerful and long-lasting effects on young children than was previously suspected (Shore, 1997:44).
One of the theories about the influence of nicotine and other drugs on the developing brain is that when
a synapse is activated (as in sensory input or output) neurons release more transmitters than they need
and then re-absorb the excess at special receptor sites. The theory is that nicotine and other drugs
interfere with the re-absorbtion process by blocking the re-absorbtion receptor sites. As a result, the
neurons' "connection sites" are overflowed with leftover chemicals and may become over-stimulated (Shore,
1997:45).
Shore (1997:23) also explains that Rakic and his colleagues at Yale University have found that the
developing cortex (outside folded layer - centre of higher thinking skills of the brain) is vulnerable
to external influence virtually from conception. As the foetus' brain develops, different types of brain
cells are placed in the appropriate places in the brain by sliding up ladder-like structures, the glial
fibres. Influences like a virus infection, alcohol consumption, poor nutrition or use of drugs at a sensitive
time could result in brain cells landing in "wrong" places. The brain destroys most of these cells but
those that survive may cause neurological disorders like autism or schizophrenia at worse, or lesser
neurological problems. This damage can happen as early as 14 to 30 days into conception. At this stage,
many prospective mothers are not even aware of the fact that they may be pregnant.
Post-natal influences
The influence of the environment on early brain development has been extensively discussed in various
articles in Kleuterklanke / Learning Years (see article in this edition). The influence of negligence or
poor emotional support for the child through a variety of factors can all play a role in the development
of the brain. Maternal post-natal depression, if it lasts longer than 6 months, can have devastating effects
on the developing brain. A factor that could also have serious implications for babies' and toddlers' emotional
development is the practice of instability and change in caretakers of the young child. Parents often place
their child, become dissatisfied and move the baby to another daymother or crèche. It has happened that babies
have been placed in 5 different care centres in so many months. This practice can cause permanent damage to
the child's feeling of trust and ability to function within the socio-emotional environment.
Accidents, serious illnesses, deprivation, molestation, and all the other bad things that continuously happen
to children can all damage brain development and cause neurological disorders, not to mention the accompanying
emotional and social scarring.
Lack of developmentally appropriate experiences
The importance of early interaction with the environment and people in the environment plays an extremely
important role in the development of the different areas where the sensory information is processed. Babies,
toddlers and young children use mainly movement, touching, tasting and smelling as a way to explore the world.
The combination of the use of these senses in a variety of experiences, and the language used by emotionally
important adults in the baby's and toddler's world, ensure that these experiences become part of the permanent
structure of the brain. Without adequate opportunity to use all of these senses and to repeat these experiences
many times, the processing areas of the brain will not be developed enough.
It is not sufficient to expose babies and toddlers to simple experiences. There must be progression of
experiences and opportunities for the brain to learn. These opportunities must also be accompanied by adult
language to help the brain make the connection between the experience and the appropriate language. It is
also important in this regard to remember that there are times when babies and toddlers are more ready to
do and learn new things. Take for instance the simple routine action of adding a variety of textures and
tastes to a toddlers diet. If you wait too long you have just as many problems than introducing it too soon.
It is not just a simple aspect of feeding. The brain has to register, experience and repeat a new experience
with texture and taste and this must become part of the sensory input that will one day play a role in sensory
integration. Movement is extremely important for sensory integration. The foundation for sensory integration
is laid in the years between birth and two-and-a-half years old. The sensory integration, according to Gallahue
(1989), really becomes a reality from 4 years old. Of course, this does not mean that we can identify children
with sensory integration problems only from 4 years old, but it is from this age that the child is able to use
all the senses to make a meaningful decision; whether this decision is to kick a ball or to draw a picture or
play in the fantasy corner, or later in life to cross a busy street after judging correctly the speed and
distance of oncoming traffic.
Looking at this very brief overview of factors that can influence the developing brain, we must bear in mind
that as far as the brain is concerned there is always two sides to development. These two aspects of brain
development have become an ongoing argument for many years, namely the balance between nurture and nature,
between what is more important, the genetic potential of the brain or the environmental influences on the brain.
A loving, interesting, supportive environment can do much to ameliorate debilitating factors in the pre-natal
phase. It is also interesting to see that when we come to activities to help children integrate sensory information,
many of these activities are normal activities you would expect to find in an enriched environment for any child.
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Characteristics of Sensory Integrative Dysfunction
How do we assess a child and decide that this child has Sensory Integrative Dysfunction? We must
also remember that the spectrum of characteristics stretches from very slight to very severe problems.
However, when the behaviour of children seem constantly to be out of character, where it seems as if
children are constantly pitching themselves against everything and everyone else, we need to consider
the possibility of SI Dysfunction.
Kranowitz (Martin, 1999) says that one of the most obvious problems associated with children with SI
Dysfunction is that they exhibit unusual responses to touch and movement experiences.
- Children who are over-sensitive to touch sensations (tactile defensiveness) will avoid touching
and being touched and are unwilling to participate in messy play. They shy away from contact with others,
avoid pets, certain textures, many types of food, seams in their socks and certain clothing.
- This over-sensitivity may also extend to visual and auditory sensitivity. We get children that
cannot handle normal everyday sounds like hair driers, vacuum cleaners, certain music and normal preschool
sounds. I once had a little boy that crept under the table as soon as we started music. Thirty years ago the
term SI Dysfunction did not even exist and we decided that this child's home environment was lacking in some
way - a viewpoint many preschool teachers still adhere to.
- Over-sensitive children are often defensive of movement experiences. They are earthbound and find it
difficult to jump, climb stairs or play on the outside equipment. For instance, they defend themselves
against an oncoming ball. In severe cases, they get hysterical in lifts or on moving escalators. There are
reported cases where children refuse to climb in a car because they experience overwhelming fear of movement.
- Certain children may also be under-responsive to touch; they seem to crave touching and will rub
themselves against the teacher, rub her dress between their fingers or bury their noses in food to smell.
They will spend a long time exploring different textures. Sometimes this under-responsiveness to sensations
will extend to sound and these children will turn the music on to a deafening pitch or experiment with
instruments without listening to rhythm or words. It almost seems as if they play the instruments in a
trance becoming mesmerized with the noise.
- Under-responsive children will often finger-paint the floor, their arms and their clothes. While this
is acceptable, exploratory behaviour from a two year old, it is definitely "out-of-sync" for older children.
- Under-responsive children seem to be oblivious of danger and unable to protect themselves.
In categorising these symptoms, we use the categories of Stephens (1997).
Attention and regulatory problems
To be able to give attention anyone of us need to focus on the relevant sensory information and screen
out any irrelevant information. A child learning to read initially needs to be able to focus on one word,
hen one sentence and eventually one paragraph. You cannot read if you are not able to screen out all the
other letters and words on a page. In the same way we listen to the sounds we want to listen to. Many of
us have the ability to exclude all other sensory information and concentrate on relevant information only.
This is an essential ability. If your brain cannot give attention and regulate the attention in such a way
that important information is separated from unimportant information, it would mean that something as
unimportant as a car passing in the street, or a dog barking outside or the refrigerator running, would
have the same intensity and importance as the adult telling a story. What we have in fact is a myriad of
sensory experiences knocking on the same door, with the same urgency, clamouring to enter into the brain's
consciousness all at the same time. Stephens (1997) says: ... These children are always 'on the alert' and
constantly asking about or orienting to sensory input that others ignore ... Other children may fail to
register unique sensory input and are unresponsive to stimuli.
Children with regulatory disorders often have difficulty establishing appropriate sleeping and eating patterns,
are unable to console themselves and may over-react to environmental stimuli. Parents often report that children
will be inconsolable and will scream and sob for hours for a relatively minor reason.
Shore (1997:23) also explains that Rakic and his colleagues at Yale University have found that the
developing cortex (outside folded layer - centre of higher thinking skills of the brain) is vulnerable
to external influence virtually from conception. As the foetus' brain develops, different types of brain
cells are placed in the appropriate places in the brain by sliding up ladder-like structures, the glial
fibres. Influences like a virus infection, alcohol consumption, poor nutrition or use of drugs at a sensitive
time could result in brain cells landing in "wrong" places. The brain destroys most of these cells but
those that survive may cause neurological disorders like autism or schizophrenia at worse, or lesser
neurological problems. This damage can happen as early as 14 to 30 days into conception. At this stage,
many prospective mothers are not even aware of the fact that they may be pregnant.
Sensory defensiveness
Sensory defensiveness is a Sensory Integrative Disorder characterised by a "fight, flight or fright"
reaction to sensory information (Stephens, 1997). The difference between the defensive reaction of a
child with SI Dysfunction and that of most other individuals, is that the sensory input is considered
harmless. Consider the stress and energy a child with sensory defensiveness is constantly producing
because the nervous system does not have the ability to recognise input as non-threatening. High levels
of adrenaline, which in itself also triggers the secretion of the stress hormone dopamine in the brain
that further inhibits normal brain function, always accompany a high level of "fight, fright or flight"
reaction. The result is a highly aroused nervous system and because danger is presumed to the child, the
child reacts with a very human emotion namely aggression to protect him- or herself from the perceived
danger. This can be extremely stressful for families and for preschool centres. Normal activities like
shampooing hair, combing hair, brushing teeth, flushing the toilet, just to mention a few, could turn
into a major battle zone. Imagine a child that acts ferociously and aggressively if he or she is accidentally
touched. These children's social skills are indeed seriously hampered by their sensory dysfunction. It is
interesting to note that it seems that some of these defence mechanisms persist into adulthood if not
sufficiently addressed in the preschool years.
Activity levels
All children are active. It is the hallmark of childhood. Especially toddlers seem to be forever
running to explore and discover something interesting. However, warning signs that seem to flash with
children that could be suffering from SI Dysfunction, could be the following:
- Children are easily labelled as being hyperactive. Most children could be very active but
their activity is purposeful. They accomplish something through their activity. A child with SI
Dysfunction is disorganised and lacks purpose in his or her activity. Stephens (1997) says that
this child will go through a room like a tornado. Interest in a toy or an activity is short-lived.
It also seems that these children find it difficult to explore and discover through their activity.
Exploration and discovery is the main purpose of children's playing.
- This child as a baby did not move around to explore the environment. Stephens describes these
children as "good" babies or toddlers who are content to stay in one place and watch from a distance
though the toddler is perfectly capable of moving and reaching out. The older child may use good verbal
skills in communicating with adults in order to avoid manipulating the environment. This is probably one
of the first clues we can pick up quite early if the child has a problem with sensory input. All babies
and toddlers use their bodies to explore. The brain compels the child to move around and explore because
the brain needs the input to strengthen synapses and establish new synapses. This early phase is the key
to establishing good sensory integration later on.
- Because exploration and discovery is a way and means to develop a knowledge base of the surrounding
world, these children have a one-dimensional approach to play activities. They lack variety and creativity
and play may become repetitive (because it is safe) or stereotypic. Some children prefer visual activities
like TV and videos. These activities hide the fact that the child has a problem and in a way exacerbates
the problem because it makes the opportunity for sensory learning over a wide spectrum less, while providing
the child with verbal skills which make the child appear as precocious.
- The child appears clumsy, falls easily and bumps into furniture. The child appears to be impulsive
and does not look where he or she is going. Other children may always have bumps on their heads because
they do not know how to protect themselves when they fall.
- These children easily get over-excited and have difficulty to calm themselves after an exciting
physical activity or being upset. Tantrums may last for hours. Many of these children seem to be "on a high"
right through the day. Lunch, dinner and sleep time becomes a battle zone. Some of these children find it
extremely difficult to "switch off" and to fall asleep.
- Some children seek excessive amounts of vigorous sensory input. They run around, jump, swing and spin
without pause and without care for themselves and other people. They seem to be unable to control themselves.
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Behaviour
It is almost inevitable that these children would exhibit behavioural problems. The lack of
socio-emotional skills and also opportunities to acquire these skills, has already been mentioned.
Children who are aggressive or on the other hand reluctant to participate in the normal exploration
and discovery activities with their peers usually withdraw, doing the limited range of things that
they do not find threatening. These children are normal in their desire to be part of a group and be
accepted. They lack, however, the insight to know why they are rejected and feel isolated. Many of
these children lack flexibility, find transitions from one activity to another in the daily programme
difficult and have a low tolerance for frustration threshold. Some of these children can be so rigid
in their behaviour and demands that families go to extremes for sake of peace. This makes it difficult
for families to see the bigger long-term picture of the child's future ability to be accepted in society.
Using the Preschool curriculum to help children with Sensory Integrative Dysfunction
Helping these children is a complex process. The most important step is to observe the child carefully
over a period of time. Kranowitz (Martin, 1999) says that careful detailed notes must be kept. Look at the
child's reaction to sensory stimulus out of the perspective of what is reasonable. What are the frequency,
intensity and duration of the reaction? Determine when the reaction occurred. Where? Who was involved and
what was the child's reaction? Kranowitz as well as Stephens feel strongly that should parents or the preschool
suspect SI Dysfunction, help should be sought from professionals with knowledge and experience of Sensory
Integration Dysfunction. More information of the Sensory Integration International Association, 1602 Cabrillo
Ave, Torrance, CA USA 90501-2812 can be found on the following websites: www.comeunity.com or seeking on the
keyword Sensory Integration.
Therapy and activities
We must realise that there is a difference between that which could be accomplished in the preschool
programme and the therapy that would be the task of a professional physiotherapist or occupational therapist.
However, having said that, we need to remember that the task of the preschool is to help the child acquire
skills and mechanisms to become a functional member of society, whether that society is the preschool, the
primary school or the church. The most important part in looking at these children is changing our perceptions
that these children are wilfully naughty and disobedient because they are "spoiled". It is important to remember
that these children are in a constant state of feeling threatened and frightened. Their aggression should be
seen as a cry for help. The second principle we need to understand is that these children (hopefully there
will not be more than one or two per group) need to understand and accept the rules of the preschool and the
playroom like everybody else. What we need to do is to work out a strategy with the parents and the therapist
that will gradually allow the child to come to terms with the learning environment. Parents and staff in baby
and toddler centres will have to learn to include preventative measures in the baby and toddler programme to
minimise any potential problems by exposing the baby and toddler to as wide as possible a sensory programme.
Things like massaging babies can play an important role in de-sensitising touch defensive children.
Including a variety of touching, smelling and tasting activities is important. Some examples are:
- Use a NUK oral massager or a small finger brush (to brush baby's teeth) to massage the baby's, toddler's and older preschooler's gums, inside of the mouth and tongue;
- Parents as well as preschools should remember that snacks in school should include a variety of textures (soft, crunchy, rough and smooth, etc). Provide jelly, crackers, pretzels, fresh carrots, mashed potatoes, chips, etc;
- Different sort of drinks, like tea, cold water, fizzy drinks, ice water, sucking ice, etc;
- Rub the child around his mouth with cloths of different textures;
- Smear jelly powder or peanut butter around his/her mouth so that they can use their tongues;
- Use reinforcements and incentives for eating different types of food. These incentives need to be part of the activity programme and promote the objectives of the programme;
- Expose the child to different smells. Go to a dairy farm and talk about the smells. Go to the greengrocer and smell all the different smells in the shop.
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Tactile activities (we use the tactile table available from Pick'n Pay, Game and Makro. It is a round plastic bowl in a square "table" exactly the right height for toddlers from 9 months and older)
- Use instant pudding in a water bowl for babies and toddlers to play and use as finger-paint;
- Mix mealie-rice, bird seed or mealie-meal with small toys in a bowl and let the children look and play with the toys in the bowl;
- Take shaving cream and spray it on a window pane and encourage the children to make pictures;
- Put hair gel in the sturdy thick "zip lock" plastic bags. Close it and let the children play on the table with it. You can mix glitter into the hair gel;
- Allow babies and toddlers to crawl and walk barefoot on the lawn as early as possible. Plan to have surfaces with different textures in the play room;
- A water table with different toys adding soap for bubbles (a touch defensive toddler often start just by putting fingers on the bubbles to burst them). Do not add colouring in the beginning;
- Encourage parents to do baking with their children, making cookies or bread where the dough must be kneaded and rolled. Plan these types of baking activities for toddlers. It does not matter if they eat most of the dough. The objective is to encourage tactile exploration;
- While reading a story let the touch defensive child sit next to you and "brush" him/her with a brush on the back. Start with a soft brush and make it harder as you progress. Sometimes this procedure will have to be done in private since some children dislike this so much that they will kick and scream to avoid it;
- Play a game by which you mix and bake a cake on a child's back. Break the eggs, add flour, stir and beat the mixture and count how many cakes you make while the child must guess the number;
- Write with your finger on a child's back or touch and let them guess with which hand. The answer is not really important, it is the touching and the fact that it is a game;
- Make pictures with different textures like sandpaper, silky material, wool, wood, plastic carpet pieces and sand. Tell a story and take the child's hand to feel the different textures while you are telling the story;
- Add sand or mealie-meal to finger paint;
- Hide small toys in play dough and let the children look for them;
- Do these activities with all the children in your group. It is beneficial to all and prevents the tactile defensive child from feeling victimised.
Conclusion
Teachers and parents should know that in a way we must all read and increase our knowledge about factors
that make it difficult for children to progress and become what their capabilities can allow them to become.
At the Association office, we are worried about many teachers who tell us about "impossible" children, some
of whom sometimes already attend the fourth or fifth school, because neither their parents nor the teachers
know how to handle them and what to do. Most children do not have these problems that we described. Miraculously
they blossom and become shining examples of children's resilience and capabilities to extract the most out of
their life-world. Some children cannot do it on their own. We cannot make children responsible for their
inabilities, but what we need to do is to read, find information, talk to parents, look at websites and do
whatever is possible to help a child. This article was not written by a physiotherapist or an occupational
therapist, but it was written by a concerned preschool specialist - that which we all are. We can change the
future for children and parents. We can only do it if we empower ourselves with knowledge, certainly, but
also with immeasurable compassion for children. Contact your physiotherapist or the Physiotherapist Association
of South Africa for more information.
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