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Presentation 5: What are sensory integration (SI) and Disfunction of SI? M. Windsor, ScD, OTR/L

The assessment process

Evaluation for specific problems in sensory integration should be done as part of the comprehensive assessment of the child. Generally, occupational therapists use a "top down" approach: the first questions asked concern the child's roles and routines (what is done, what is expected to be done, what the child wants to do) and what specific problems bring the child to the occupational therapist. Previously gathered information and evaluations should be carefully read in order to understand the child as holistically as possible. These are the questions that I ask myself during the assessment process:

  • What are the problems perceived by the child and the family that bring them to an occupational therapist?
  • What information do we already have that contributes to understanding the needs of the child and family?
  • What new information is needed to clarify level of function and to select the appropriate intervention strategies? Is it reasonable and logical to think that poor sensory integration is a significant contributor to the presenting problems?
  • If I decide that I should explore the child's sensory integration functions, I then proceed to select tests and tools.

When I assess a child, I try to follow the World Health Organization (WHO) model for function. This allows me to examine different levels of function.

I usually start at the Participation Level: What is happening in the child and the family's life? How does the child behave in his or her role as a child/family member; does the child go to school/day care? Does the child have friends or belong to play/community groups? What are the child and the family's dreams and goals? What is happening that supports or constrains community participation? What needs to happen to support function and participation? This information can be gained by informal family interview; there are several standardized measures (test development follows a specific procedures; administration, scoring, and interpretation follow specific guidelines) available to professionals. I have used the Canadian Occupational Performance Measure (Canadian Occupational Therapy Publications ACE, Ottawa, Ontario) and the School Function Assessment (PsychCorp) to guide me at this level. This allows collaborative goal-setting with the child and the family. It ensures that therapy is meeting the functional needs of the child and the family: Being able to tolerate swinging in a hammock for five minutes doesn't have much "life value." Being able to ride in a car, on an elevator, etc. will make living easier, more enjoyable, and allow the child to access everyday tasks and opportunities.

After I know "where I want to go" (what are the expected outcomes from intervention), I determine the "base line" of function: knowing what the child is doing now allows me to measure change in behavior/performance/function at intervals during therapy. Therefore, I can alter strategies as needed and demonstrate the effectiveness (positive change) of treatment.

The next step is to evaluate sensory integration processes. The Sensory Integration and Praxis Tests (SIPT) (Ayres, 1989, 1991) is an instrument standardized for use with children 4 to 8.11 years old, who have relatively typical neuromotor, cognitive, and attentional abilities. There are formal training programs for its administration and interpretation. It attempts to measure component levels (simple sensory processing that are contribute to function) of the tactile, kinesthetic (awareness of body position and movement in space based upon proprioception), and vestibular systems, as well as tasks associated with visual perception and praxis (motor planning). Another example of the term "component" might be helpful: eye movements following rotation (post rotary nystagmus) measure vestibular function at a component level; ability to hold extension patterns (holding limbs straight when lying on the stomach) measures vestibular function at a task level. A list of the tests with a brief description of each is located in the digital library developed for this unit.

Obviously, the SIPT is not appropriate for many children suspected of having sensory integration problems (note age, type of child used in the standardization procedures). Therapists may also use formal and informal Clinical Observations for identifying behaviors associated with DSI. Please note Table 1. Observation of these tasks provides insight as to level of function and sensory processing necessary for successful performance. The work of Erna Imperator Blanche (Observations Based on Sensory Integration) provides a two-part video and worksheet for a nonstandardized assessment. It is available in several sources provided at the end of this unit. Parents should know that the tasks and behaviors associated with clinical observations are age-related (that means that young children may be unable to perform them) and difficult to standardize (many have attempted to do so). Used knowledgeably, they can provide important information about quality of performance, influence of sensory processing, and constraints to function.

Table1: Examples of Clinical Observations

Besides direct observation of a child's performance (performance-based assessment), use of questionnaires and histories (judgment-based assessment) are critical to diagnosing a dysfunction in sensory integration. There are two major reasons for this: (1) The SIPT does NOT evaluate sensory modulation dysfunction (e.g., Tactile Defensiveness). (2) Children perform most typically in their natural environments (home, school, etc.) rather than in the contrived clinical experiences that often use a "performance-on-command" (e.g., Hop on one foot 10 times) paradigm. The Sensory Profile (W. Dunn,), a standardized questionnaire with several age levels, is used by many therapists. My personal choice for such a tool is the Evaluation of Sensory Processing (ESP) by L. Diane Parham. The research edition is available to therapists in text Sensory Integration Theory and Practice (Bundy, Lane, & Murray).

I often use clinical observations of performance made during standardized tests such as the Bruininks-Oseretsky Test of Motor Proficiency, the Peabody Motor Scales Revised, the Movement ABC, and the Beery Test of Visual Motor Integration. These observations should support parent reports, other standardized and nonstandardized measurements, and observed functional behavior.

I would like close the assessment and evaluation section with the following thoughts. In my view, a dysfunction means there is a negative impact on function: the presence of certain behaviors associated with DSI are not meaningful to me unless they interfere with activity and participation AND unless I think that I can change them. Assessment is an important part of intervention: it tells me where I was, what I am doing (I may have modify), where I would like to go, and if I got there. The purpose of this information is to assist the family and child to be knowledgeable consumers. It is the knowledge and opinions of the writer and is not meant to replace direct service from an occupational therapist.

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