- ATTENTION – Attention is a complex behavior that requires the integration of several areas of the brain. The first component of attention is “registration”, our initial awareness of a change in sensory stimuli. The second component of attention is “orienting”, an increase in our level of alertness. The final component is involves “effort” or exploration of the stimulus. For example, our effort might be to listen to or watch the stimulus.
- BILATERAL INTEGRATION – refers to the ability to use the two sides of the body together in a coordinated manner.
Examples of bilateral tasks include: running, skipping and jumping with both feet together.
- COORDINATION -Includes both motor control and praxis (motor planning). Motor control is the ability to move with precision and smooth quality.
- FINE MOTOR CONTROL -involves development of manipulation skills in the hands to eventually allow for efficient and precise manipulation of objects. Sensory motor skills must be well developed for this to occur, including postural control, sensory modulation and praxis.
- MUSCLE TONE – This refers to the tension in a muscle. Muscle tone should be high enough to hold a position against
gravity, yet low enough to move a body joint through its full range of motion. Abnormal muscle tone would be either
extreme tension or lack of tension in a muscle.
- POSTURAL CONTROL – refers to the ability to sustain the necessary background posture to efficiently carry out a skilled task, such as reading or handwriting. The ability to stabilize the trunk and neck underlies the ability to develop efficient eye and hand movements.
- PRAXIS – This is the medical term used to describe motor planning. It is defined by Dr. A. Jean Ayres as “The ability of the brain to conceive of, organize and carry out a sequence of unfamiliar actions. Inadequate praxis, Apraxia, is often a symptom of inadequate sensory processing. Long term problems noted in children with apraxia, include: clumsiness, difficulty performing motor tasks at age level, difficulty following directions and imitating movement. A child with apraxia may need extra practice and instruction to learn a new motor task. Once he learns something, he may refuse to try it another way and appear “stubborn”.
- PRIMITIVE REFLEXES- There are movement reflexes that each baby is born with. These “primitive” reflexes assist the infant in successfully progressing through various stages of movement so they may learn to roll, crawl, sit and walk, etc. As a child matures, these the child is able to move without the need of these reflexes and they become more integrated and do not predominate or direct movement patterns. Sometimes a reflex continues to direct or dominant movement after an age where it is normally integrated. We would consider this an abnormal reflex pattern.
- PROPRIOCEPTION – This is information that the brain receives from our muscles and joints to make us aware of body position and body movement. Proprioceptive makes a strong contribution to praxis, to the child’s ability to grade movement and to postural control.
- SELF REGULATION – refers to the ability to attain, maintain and change your level of arousal appropriately for a task or Arousal is considered a state of the nervous system and describes how alert someone feels. To attend, concentrate and perform tasks according to situational demands, the nervous system must be in an optimal state of arousal (or alertness) for the particular task. Adults use a variety of subtle sensory techniques to maintain their arousal level.
- SENSORY INTEGRATION – “is the organization of sensations for use. Our senses give us information about the physical conditions of our body and the environment around us. Sensations for into the brain like streams flowing into a lake.”
….”The brain must organize all of these sensations if a person is to move and learn and behave normally.”(Dr. A. Jean Ayres, Sensory Integration and the Child, Western Psychological Services, 1981, pg.5.)
- SENSORY MODULATION – is the ability to regulate our responses in a manner proportional to the sensory stimuli. There are children who have an increased level of arousal and seem to be over responsive to sensory input. This is described as sensory defensiveness. Children at the other end of the spectrum have a decreased level of arousal and seem to be under responsive to sensory input. This is referred to as sensory dormancy. Both extremes of modulation may be seen in one child to the same type of stimuli, but generally, one extreme tends to dominate. Both, cause the child to have difficulty with allocation of attention and interfere with the development of sensory processing skills.
- TACTILE – This refers to our sense of touch. The sense of touch is a child’s first way to learn about the external world. It is a critical sense to developing relationships with primary care givers and to giving comfort. The sense of touch plays a very important role in the child’s development of body awareness and is critical in the development of praxis (motor planning).
- VESTIBULAR – This is the sense that allows us to recognize how we are moving in relationship to gravity. Receptors in our ears sense if we are upright, upside down, moving sideways, spinning, etc. As a result of this sensory input, we make adjustments to posture and to our eye movements. Vestibular sensation has a strong impact not only on posture and eye movements, but also on: balance, coordination of the two body sides, and emotional control. Accurate vestibular processing is essential for the development of praxis.
- VISUAL MOTOR SKILLS – refers to the development of smooth and efficient eye movements to allow for tracking of objects, focusing on specific targets and shifting gaze from one object to another.
- VISUAL PERCEPTION – refers to the brain’s ability to interpret and make sense of visual images seen by the eyes.
Approaches to Development
- SENSORY INTEGRATION (SI):
It is the neurological process of organizing information which we get from our body and the world around us for use in daily life. It takes place in the central nervous system, which consists of countless neurons, a spinal cord, and at the “head” –a brain.
HOW DOES SENSORY INTEGRATION DEVELOP???
During the first few years, a child learns to sense his body and the space around him. He also enjoys to challenge Gravitational forces, and develops simple to complex sensory motor skills, which are goal directed. He also learns meaning of different sounds, language and body skills for expression of his thoughts and ideas. He starts interacting with human and physical environment.
Integrates sensations(Proprioception, Vestibular, Tactile, Auditory and visual)from the external environment and interceptors inorder to develop healthy body and sensory motor skills. These become the building blocks for adaptive and academic skills necessary for higher learning, psychosocial behaviour and emotional development in school and outside.
SENSORY INTEGRATION DYSFUNCTION
1.Sensory modulation disorder:
- a) Hyper responsiveness to a particular sensation
- b) Hypo responsiveness to a particular sensation
- 2. Sensory processing disorder:
- a) Motor planning disorder- Apraxia
3.Sensory discrimination disorder:
- a) Poor ability to discriminate touch, movement, force or position of body in space.
- b) Problems in spatial orientation, position in space, poor body scheme.
4.Postural ocular movement disorder
BEHAVIOUR PROBLEMS ASSOCIATED WITH SENSORY INTEGRATION DYSFUNCTION
- Problems with muscle tone and motor coordination.
- Problems with motor planning
- Lack of a definite hand preference by the age of 4 or 5
- Poor eye-hand coordination
- Resistance to novel situations
- Difficulty making transitions from one situation to another.
- High level of frustration
- Self-regulation programs
- Academic problems
- Social problems
- Emotional problems
- Auditory-language problems
- Speech or articulation problems
- Vision problems
- Eating problems
- Digestion and Elimination problems
- Problems with Sleep regulation
- NEURO DEVELOPMENTAL TECHNIQUE (NDT):
NDT is a sensorimotor approach widely used by occupational therapist in the treatment of CNS disorders which result in abnormal posture and movements.
This treatment modality is used for varied patients with various dysfunctions like those with neuromuscular disorders, immature CNS disorder (premature infants) and other developmental delay.
NDT is used for paediatric rehabilitation point of view.NDT can be simply defined as progressing the child through his developmental stages with facilitation of normal movements and inhibition of abnormal movements.
Main principles of NDT which forms basic of treatment plan are given by DR.BERTA BOBATH (1943).
- Normal development and interplay between stability and mobility.
- Effect of postural reflexes on sensory motor sensory feedback.
- Movement components and the ability to dissociate movements
- Sequential development takes place in three planes: vertical, horizontal and diagonal.
Since the baby is conceived in womb, a complex task of CNS formation begins. Even when baby is in womb, some movements, some response is given to surrounding. If these are appropriate, healthy maturation of CNS occurs. These movements are happening at reflex level. Many such reflexes are present at birth and with development keeps on integrating in CNS only to result in more mature and voluntary movements. Any block in this process at any level leads to abnormal development.
So NDT focuses on specific handling techniques as well as adaptive equipments to achieve inhibition of abnormal pattern and facilitation of normal patterns.
Tone normalization: These techniques are designed to normalize tone and obtain postural alignment throughout entire body and to prepare upper extremity and lower extremity for weight bearing , weight shifting and function.
NDT helps child to enhance the quality of motor performance, teach new movement skills in preparation for greater performance and prevent disability resulting from abnormal motor pattern. Gross motor skills such as locomotion ( rolling, crawling, walking). Oral motor skills such as feeding techniques, speech, head and trunk control, fine motor skills such as reach, grasp, manipulation and release. All are developed and refined using NDT technique.
All ADL tasks like self care( feeding, dressing , toileting, bathing, grooming, play) if carried out with NDT techniques more functional goals are achieved .
Many disorder’s make use of Adaptive Devices mandatory for the child such as C.P chair, wheelchair, adaptive equipments like modified utensils, home environment etc. If NDT techniques are known to caregivers or are supervised by a known therapist progression of physical disability because of faulty environment is avoided.
To understand NDT more meaningfully let us go through normal child development.
Any child develops first head control posture, the next development would be turning and rolling involving a lot of movements in order to achieve the next development stage. Then to this equilibrium component is also added. This became necessary to maintain sitting position. From sitting position the infant has to move to creeping and then creeping to quadruped and then to crawling. Then comes static standing, kneeling and finally walking, then more difficult motor patterns like standing on one leg, hopping, skipping, and running are learnt & mastered.
This was just a glance through child development for gross motor activities. Many other development for a child go through such series of achievements like hand control, eye movements, speech etc which are not given amount of weightage they deserve in the development.
For any therapist dealing with NDT therapist has to concentrate mainly on following issues.
- Developing the child in aspects which have been missed during development.
- Practicing age appropriate patterns which stress on mastering previous stages of development.
- To prepare for next stage of development.
While using NDT, occupational therapist treats not just one or two limbs but the whole individual, not only by inhibition of wrong movement, but also by facilitation of right movements.
NDT deals differently for hypotonic & hypertonic child.
For both hypotonic &hypertonic abnormal tone affects midline orientation leading to difficulty in performing bilateral skills. Low Ms tone infants have poor ability to do eye tracking leading to visual perceptual problems resulting in difficulty for visual motor task like tying shoelaces, writing, coloring etc. Hand function like grasp, grip, and nature motor patterns for object manipulation faces difficulty. For those children with high Ms tone there are high chances of development of contractures, determinates, tightness to a extent to cause faulty postures, decreased thoracic space leading to less lung capacity for respiration inability to use upper extremity and lower extremity for any functional use. Range of motion at any joints may get compromised.
Handling technique varies for each child according to his clinical pictures (tone, age, developmental stage, nutritional status, prognosis, functional involvement). Parent education, quality home program is the key for successful rehabilitation using NDT.
- SOCIAL SKILL TRAINING (SST):
One of the most significant problems for people on the autism spectrum is difficulty in social interaction. This difficulty is, of course, made more significant by problems with speech and language. But autism also seems to create problems with “mind reading” — that is, with knowing what another person might be thinking. Most people can observe others and guess, through a combination of tone and body language, what’s “really” going on. In general, without help and training, autistic people can’t.
Without knowing why, a person on the autism spectrum can hurt feelings, ask inappropriate questions, act oddly or generally open themselves up to hostility, teasing, bullying and isolation.
social skills therapy may consist of group activities (usually games and conversation) with autistic and typically developing peers. Groups are overseen by occupational therapists and may be held in the different environment where there is a need of social skills starting from sensory integration room to open garden and then integrate the group in market, malls, hospitals, and venues away from home in which the group gets the knowledge of those environments by interacting with other people( every opportunities are created to improve the social skills) .
Children are grouped by age and ability, and may make use of specific social skills curricula as developed by social skills therapy
In theory, social skills therapy will provide people on the autism spectrum with the ability to converse, share, play and work with typical peers. In an ideal world, such therapy will allow people on the autism spectrum to become almost indistinguishable from their typical peers.
In fact, social skills therapy tends to be offered no more than an hour or two a week — and while it may provide autistic learners with specific skills and techniques (“look at a person’s face when you’re conversing,” for example) it’s unlikely to make an autistic person appear typical. A program most likely to have such an impact would be very intensive — unlike the vast majority of existing social skills programs.
- responding to other people.
- expressing ideas to peers.
- waiting for a response from peers.
- negotiating deals.
- taking turns.
- knowing when to persist or let go of an idea.
- interpreting facial expressions and voices.
- understanding the rules of the game.
- expressing various apprppriate expression.
- understanding sharing and concept of give and take.
- EARLY INTERVENTION:
“Early Intervention” commonly called E.I has different meanings depending on context in which it is used.
It is a comprehensive, coordinated, community based system for developmentally vulnerable or delayed young children from birth to 3 years.
For any medical disorder, disease or any illness, there is a time period from onset till intervention. It is very easy to understand that this interval is directly proportional to ease, well being or cure. Therefore earlier the intervention, degree of damage reduces and quality of cure increases.
E.I is a job of multidisciplinary team for a neonate in NICU with involvement of Doctor, Nurses, and Occupational Therapist. Later as child grows, appropriate involvement of other team members at appropriate time of development becomes mandatory like Speech Therapist, Special Education, and Psychologist etc.
Early intervention program or treatment is individualized treatment protocol which takes into consideration the individual, his culture, his specific environmental characteristic and family.
Early intervention techniques are based on evidence based scientific research which states that E.I can prove to be both remedial and preventive.
E.I is based on neurophysiologic principles, developmental study, and social norms or belief.
E.I emphasizes on
- Early Brain Plasticity: that is for a brain which is growing, there is increased myelination of pathways and nuclei in nervous system and rapid proliferation of synaptic connections. And this is the basic stage and critical time for adaptive learning to result in mature brain of adult.
- Importance of Early experience: Final wiring of the brain occurs after birth and is governed by early experience. Environmental experiences cause neurons to be activated leading to formation of persistent or dominant pathway.
- Critical period for experience: Specific graded environmental stimulation is needed to promote normal brain development during pregnancy to early childhood when rapid brain development occurs. The connections of brain are most sensitive and vulnerable to environmental experiences during this critical period.
- Importance of environment: Human development is a transactional process between the child and his contexts or environment. Development is a continuous dynamic interaction of child and his experience with family and environmental facilitation. Caregiver’s response shapes child’s personality e.g infant with disabilities or poor sensory modulation create problem for parents to which if parents don’t adjust as per child’s development both suffer.
- Interrelatedness of behavior across development areas : All areas of development like cognitive, language, motor, perceptual, emotional are interdependent with each one facilitating other one. Any failure to respond to any particular sensation leads to primary deficits which in turn cause secondary deficits which leads to tertiary one and the chain continues giving a handicapped picture of potentially sound brain. Any form of low tone, motor planning deficits sensory processing deficits etc limits person’s ability to adapt, explore and learn.
- I prevents admission of a child in special schools. It maximizes the potential for future independent living skills even for that matter earning his livelihood.
Independent functioning of young children, according to their developmental age, is achieved through assessment and intervention efforts in areas of motor control, sensory modulation, adaptive coping, sensorimotor development, social emotional development, daily living skills and play.
To understand concept of critical period , it is important for parents to know chronological age and developmental age. Any difference in these two age’s is considered deviation from normal.
To explain this concept in further details let’s take a hypothetical situation of a child 6 months old(chronological age) showing 2 months old (developmental age) picture and another child 4 years old(chronological age) showing 2 years old(developmental age) picture. Now here the first child has to be worked upon for only 4 months whereas second child has to be worked upon for 2 years lag. For first child at 6 months only motor social and basic cognition is expected but for second child the expectation increases to age appropriate higher level physical development, cognitive development, social skills, academic skills, speech and communication skills so more the gap more difficult will be achieving age appropriate standards.
So it is mandatory to send or refer the child for early intervention in critical time period. An experienced pediatrician can cause miracle in a child’s life by diagnosing him on time and referring for early intervention
Occupational therapy works not only on infants but also on parents, and also on environment. Since it is a skill of Occupational Therapist to create a familial climate conducive to prevent or minimize developmental delays and promote harmonious growth and development.
Thus it can be concluded that “A stitch in time saves nine”. No treatment modality can compensate for loss in critical time of Intervention.
- PLAY & COMMUNICATION:
- ORAL MOTOR THERAPY:
Wrongly used by most speech therapists, oral-motor therapy uses a variety of exercises to develop awareness, strength, coordination and mobility of the oral muscles. For example it may be used to improve muscle tone of the face or to reduce tongue thrust (the protrusion of the tongue from the mouth).
Oral-motor therapy is often used as a component of feeding therapy. In this case an experienced therapist will be able to determine why a child is having difficulty in a particular area and will create an oral-motor-feeding plan individualized for the child.
There is no current research to support the use of oral-motor therapy to treat speech disorders. Unfortunately, despite that fact, research shows that 8 out of 10 speech therapists use oral-motor when attempting to treat speech disorders.
A case in which I would use oral-motor therapy to “help” speech clarity is when saliva is collecting in the mouth and causing slushy-speech. However this is not a “speech” disorder. The root cause of this is a “swallowing” disorder leading to problems with speech clarity. That distinction is important.
Oral-motor therapy can be very helpful or it can be a waste of time. It depends on how and for what it is being used.
If a speech language pathologist is recommending oral-motor therapy for your child it is important to understand why and to be involved as much as possible. If not you are at risk of wasting time and money.
- BEHAVIORAL MANAGEMENT:
- FUNCTIONAL TRAINING: