20Q: Understanding Sensory Integration and Processing

From the Desk of Ann Kummer

“Sensory integration” is a term that is used to describe the processes in the brain that allow us to integrate, organize, and respond to information that we receive from our senses (e.g., sight, hearing, smell, taste, touch, and proprioception). Sensory integration and processing is foundational to human development, normal function, engagement, and relationships. A sensory processing disorder is when the sensory information that the individual perceives results in abnormal responses. Some defects in the sensory systems, particularly in the areas of auditory perception and proprioception, can affect speech development. Therefore, it is important for speech-language pathologists (SLPs) to learn about theories of normal sensory function and sensory integration dysfunction in order to improve our support of occupational therapists and enhance our own therapeutic practices in working with affected individuals.

Although this is such an important topic for SLPs, most SLPs have little to no training in this area. Therefore, I am particularly excited about this article. Common questions about sensory integration and processing will be answered by Virginia Spielmann, a well-known and respected occupational therapist who specializes in the area, and Carrie Dishlip, an SLP who has advanced training in this area.

Virginia Spielmann is Executive Director of STAR Institute for Sensory Processing Disorder. She serves as the Clinical Consultant for the Interdisciplinary Council on Development and Learning. Virginia was trained in occupational therapy at Oxford Brookes University in England. She completed her Masters in Occupational Therapy in the USA and is wrapping up her PhD in Infant and Early Childhood Development with an emphasis on mental health at Fielding Graduate University in Santa Barbara. Virginia is a well-traveled speaker, coach, and educator on topics including sensory integration and processing, DIR/Floortime, child development, and infant mental health. She has conducted trainings around the world and leads workshops at international conferences.

Carrie Dishlip received her Master of Science degree in Speech-Language Pathology from the University of Arizona in 2004. She has worked with clients with disordered sensory integration and processing in home, school, and clinical settings. Carrie has taken the University of Southern California Advanced Training in Sensory Integrative Dysfunction and the STAR Institute for Sensory Processing Mentorship level 1 trainings. She has led professional and parent workshops on communication development, social skills, and sensory integration and processing.

In this article, the authors will discuss how to recognize the role of sensory integration and processing in development. They will also talk about common patterns of sensory integration and processing dysfunction and their effect on communication skills. Most importantly, they will describe the roles an SLP may have in supporting a client with sensory integration and processing challenges.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q:  Understanding Sensory Integration and Processing

Virginia Spielmann

Carrie Dishlip

1. We are continually processing sensation from multiple sensory systems. Sensory stimuli occur both in the environment (externally) and inside our bodies (internally); our nervous system registers the data and then our brain and body produce a response (e.g. motor, behavior, emotion, etc). The neurological processes of sensory integration are an intractable part of human functioning. As with any aspect of neurophysiology, sensory integration and processing has tremendous potential to support development or can be catastrophic if disordered/dysfunctional. What does the term sensory integration and processing refer to?

Sensory integration and processing refers to how the brain and body use sensation to make sense of the world. It refers to the mechanisms of how we feel and how that guides our actions. Sensory integration and processing is fundamental to human development and function in every domain throughout the entire lifespan.

Although it is not a linear process, sensory integration comprises the following steps. These steps take place somewhat sequentially and yet almost instantaneously at the same time:

• Registration/detection and cataloging of stimuli
• Modulation/filtering
• Discrimination/perception
• Multi-sensory synthesis/integration
• Planning to action? Sequencing?
• Response production/execution

Sensory integration and processing is the active process of selecting and organizing sensations in a way that facilitates accomplishing goals. The term Sensory Integration and Processing is the preferred term in the American Occupational Therapy Association (AOTA). There has been some controversy around terminology in the field and this guideline/recommendation from AOTA aims to resolve that.

2. So what is the history behind sensory integration and processing and what’s the deal with terminology?

In the 1950s an Occupational Therapist (and later Psychologist) named Dr. A. Jean Ayres first began exploring the subject of proprioception. Over time her research, deeply rooted in neuroscience, uncovered interactions between multiple sensory systems and their impact on childhood learning and behavior. Dr. Ayres pioneered the development of the theory of sensory integration that supports assessment and intervention. Dr. Ayres’ treatment approach specifically targets the integration of body sensations (tactile, proprioceptive, and vestibular experiences) through play-based, child-led sessions held in specialized treatment gyms with dynamic multi-sensory equipment. This therapy approach is called Ayres Sensory Integration (ASI) or Sensory Integration Therapy (SIT), it is also part of the STAR Frame of Reference.  Ayres Sensory Integration was recognized as an evidence-based practice for children on the autistic spectrum in 2020 the same year that would have been Dr. Ayres 100th birthday.

There are multiple models of functional and dysfunctional sensory integration and processing.

Models of typical sensory integration include:

• Model of Sensory Integration and Typical Development, Ayres (1979, 2005)
• Dunn’s Model of Sensory Modulation (a model on the behavior - sensory threshold relationship using a four quadrant model), Dunn (1997)
• Analysis of Sensory Integration Functions, Smith Roley (2006)
• Model of Sensory Integration and Development (relative to occupational science and therapy), Smith Roley & Spitzer (2001)

Models of dysfunctional sensory integration and processing include:

• Patterns of Sensory Integration and Praxis Deficits, Bundy, Murray, & Lane (2002, 2019)
• Nosology of Sensory Processing Disorder, Miller et al. (2007)
• Analysis of Patterns of Sensory Integration Dysfunction, Smith Roley (2006)

It is important to delineate terminology related to the theory, the assessment, the disorder, and the intervention. Agreement exists about the theory. Some assessments use the term sensory integration others use sensory processing.

Sensory integration theory has also been confused with the field of multisensory integration. Clinicians working with adults/children with challenges in sensory integration and processing can only observe behavior that is reflective of these challenges while in neuroscience, the term ‘multisensory integration’ is used to refer to the consolidation of sensory data from more than one sensory system at the neurophysiologic cellular level.

Dr. Lucy Jane Miller et al. proposed a change in terminology from sensory integration dysfunction to sensory processing disorder (SPD) for several reasons. This proposal was designed to provide clarity across research disciplines and fields and support the effort to get SPD recognized as a discrete diagnostic category in the DSM-V. While this bid to get SPD recognized as a stand-alone diagnosis has not yet been successful it was partially incorporated into the diagnostic criteria for autism which has had many positive outcomes (see Kilroy, Aziz-Zadeh & Cermak, 2019 for more information).

Despite all this, the main thing is still the main thing - in order to engage with others, organize our oral motor system to chew and swallow food and drink, develop gestures, body language and verbal communication, and establish organized adaptive behaviors we must be able to make sense of what we sense from our bodies and the world around us. Sensory integration and processing is foundational to human development in every domain.

3. Why is it important for SLPs to understand sensory integration and processing?
Sensory integration and processing is important to SLPs because of the way people take in, process, and interpret and integrate. Sensation impacts the way they develop, learn, communicate, and interact with the world. From conception onwards, every event is ‘sensory’ first and, multiple sensory systems converge in order to generate a mental image of self and world.  This, combined with memory and cognitive processing creates the ‘whole picture’ a person has of the world.

Capacity for sensory integration and processing has a significant impact on engagement, interaction, and other foundational tools for communication. In order to effectively build and expand communication, it is important for SLPs to understand the fundamentals of sensory processing and integration and how to use sensation to support all developmental processes related to language and learning.

Assume that an infant is born into a calm, consistent, and well-attuned family. To bond with her caregivers, she must sense them, sense her own body, and have a sense of being safe/needs being met? She must be able to interpret touch and smell in a way that communicates connection, responsive caregiving, and fulfillment of basic needs. She must be able to sense that she was soothed by the provisions of her caregivers in response to her crying (perhaps she was hungry). She must be able to interpret basic visual stimuli in a way that helps her interpret the world, caregivers, cause and effect, and all the patterns therein including the most basic first stages of serve and return interactions.

Sensations tell us about our internal state and the external world. Through sensation we learn to feel safe, move, impact the world, engage in self-care, form relationships and so much more. Sensory integration and processing is incredibly complex and involves innumerable sensory receptors sending information to multiple regions of the brain where stimuli are integrated, interpreted, and processed. This information then produces a response, behavior, or action plan that supports interaction with others.

In summary, we need to sense the world and our bodies within the world, in order to make sense of who we are (i.e. to have a sense of self). At the very earliest stages of development, this is mostly simple cause and effect (eg., "I do something and the world changes"). However, to understand this most fundamental part of human development, we rely on intact sensory integration and processing.

4. What are the ‘eight sensory systems’ and what does that really mean?
Each sensory system (or domain) first serves to keep us safe and alive and then has multiple other purposes. It is critical to remember that the word system refers to “a set of things working together as parts of a mechanism or an interconnecting network” and not a unitary construct. This list is not exhaustive:

1. Smell - the olfactory system is hard-wired to threat detection (is the house on fire?), attachment processes, memory, and flavor appreciation.
2. Taste - the gustatory system is hard-wired to threat detection (is this food safe?), attachment processes, comfort and regulation, and feeding/eating.
3. Touch - the cutaneous system includes tactile data (including affective or pleasant touch), thermal, pain, and itchy (pruritic) data.
4. Sight - the visual system helps detect threats (is that a snake? No it’s a rope), form relationships, determine shape, location of self and self-movement, as well as forming a foundation for understanding self in time.
5. Sound - auditory processing is first about safety, second about attunement and attachment, it tells us about space and time, and it codes and decodes communication via language, as well as giving us valuable information about movement.
6. Position - proprioceptive processing from the mechanoreceptors in the tendons, ligaments, muscles and deepest layers of the skin tell us where our body is without looking.
7. Motion sensing - the vestibular system senses motion, speed, where your head is in relation to the ground (gravity) and supports spatial awareness.
8. Internal sensations - the complex interoceptive system/domain recognizes sensations within the body. These can be concrete signals like, “It is time to eat” or “I need to use the bathroom” or more subtle signals that might indicate worry or frustration. Internal receptors strongly linked to emotions.

The reason it is important to belabor the point about safety is that disordered sensory processing can craft a perception of a world at war with the individual. Any of the subtypes listed below (over- and under-responsivity, praxis and postural challenges) can create this sense of being at odds with the environment. There can be a genuine experience of being bombarded by the environment and even our own bodies at all times. This easily creates cycles of trauma because children and adults with disordered sensory processing often have highly sensitive threat detection and their responses to these perceived dangers are regularly perceived as ‘misbehavior’. When ‘behavior’ is dealt with as the primary problem, a negative cycle is created that puts the nervous system in conflict with itself and causes further developmental trauma and sometimes catastrophe.

It is all more profoundly important and more deeply complex than we have ever known and research from fields of neuroscience and psychology are proving this more and more.

5. What is disordered or dysfunctional sensory integration and processing? Is it a formal diagnosis?
All humans are sensory beings therefore there is a lot of variation in sensory integration and processing. While some people may relish in the smell of freshly turned dirt, others may wrinkle their nose and move away. Sensory “variations” are as individual as fingerprints and can be impacted by more than just sensory processing such as by positive or negative memories or environmental cues. Most people have a story of some food that they ate before once becoming ill, that they no longer can tolerate the taste/smell/sight of. If that food is present on the buffet table at a party we might not participate in that part of the event, we might not be able to sit at the same table as someone eating that dish. For some people, sensory experiences elicit that response frequently simply because of the way their nervous systems stored the experience of that integrate and process sensation. When this occurs and/or when there are challenges in too many of the sensory systems at once, we can see a significant impact on development, psychological wellbeing, and participation in daily activities.

A more formal definition is: disordered sensory processing is a neurophysiologic condition in which sensory input either from the environment or from one’s body is poorly detected, modulated, or interpreted and/or to which do not support planning and organizing behavior/participation. Pioneering occupational therapist and psychologist Dr. A. Jean Ayres, likened disordered sensory processing to a neurological “traffic jam” that prevents certain parts of the brain from receiving the information needed to interpret sensory information correctly and act in accordance with that information. Those with disordered sensory processing perceive and/or respond to sensory information differently than most other people. Unlike people who have impaired sight or hearing, those with Sensory Processing Disorder do detect the sensory information; however, the sensory information gets “mixed up” in their brain and therefore the responses are inappropriate in the context in which they find themselves. See questions 9, 10, and 11 below for more information.

Disordered sensory processing can mean that an individual is unable a) to feel safe in the world, b) to make sense of the world, c) organize a response to the demands of the world, d) accurately interpret the overtures of caregivers, e) evaluate the impact that they have on the world. These challenges interfere with development of attachment, development of self, sense of agency, and the foundational skills for communication. If wanting to communicate, and believing that you can change the world you are in are the building blocks for development of communication then disordered sensory integration disrupts this process. Sometimes it is hard for an individual to identify what is causing them to feel “not right”. Instead of saying, “I don’t like the tag in this shirt,” the painful and caustic sensation might lead to a tantrum that seems unrelated to the situation. Communication can be disrupted at every level due to disordered sensory integration and processing.

Research continues to emerge supporting the presence of SPD without a comorbid diagnosis. There are several papers now demonstrating neurological and genetic differences in individuals with disordered sensory processing who do not qualify for any other diagnosis (for more information read: https://www.universityofcalifornia.edu/news/unbearable-sensation-being). At present the area most researched is sensory over-responsivity but research is ongoing into all of the domains of sensory processing, and further support for the formal diagnosis is anticipated.

6. What is the prevalence of sensory integration and processing challenges and what are the most common co-occurring conditions in which disordered sensory integration and processing is a common factor?
While there has been some variability in the research, partially due to the diagnostic criterion used, the prevalence of disordered sensory integration and processing is between 5-16% in the non-clinical population (i.e. individuals who do not meet the criterion for another diagnosis) (Ben-Sasson et al., 2009; Ahn et al., 2004, Latest research findings, n.d.). In individuals who meet the criterion for Autism Disorder, the prevalence is 75-95%. The DSM V includes “Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment such as adverse response to specific sounds or textures (hyper), apparent indifference to pain/temperature (hypo), excessive smelling or touching of objects (unusual interests), visual fascination with lights or movement (American Psychiatric Association, 2013). Many autistic advocates have described their sensory integration and processing differences as foundational to how they interact with their environment and others. Attention Deficit Hyperactivity Disorder and disordered sensory integration and processing can often result in similar behavioral patterns though the neurological basis of the two disorders is different. The prevalence of sensory integration and processing challenges for individuals with a diagnosis of ADHD is around 40% (Ben-Sasson et. al., 2017). Thorough evaluations for sensory integration and processing and for ADHD can support treatment priorities and determine the best supports for an individual with both sensory and attention-based challenges. In the gifted population, prevalence is as high as 30% (Jarrard, 2008). The differences between a person’s high cognitive capacities and even average or low average processing skills can lead to functional challenges and frustration. Those with more significant sensory integration and processing challenges can have difficulty demonstrating their cognitive strengths/capacities due to regulation and arousal difficulties. Other commonly co-occurring diagnoses include: anxiety, depression, PTSD, intellectual disability, and learning disabilities. It is important to consider sensory integration and processing differences with all clients, no matter their diagnosis, but some populations may be more likely to present with these differences along with their speech and language challenges.

7. What does disordered sensory processing look like?
For each individual, the manifestation of sensory integration and processing challenges will be quite different. This depends on which sensory systems or integrative functions are impacted and the severity of the impact. In a mild form, auditory over-responsivity might cause a person to plug their ears in community settings or remove themselves from a location with too much sound. In more significant forms, the responses may result in parasympathetic nervous system disruption and a fight/flight/freeze behavioral reaction. These keep the individual from having an appropriate adaptive response and over time can cause trauma. Everyday settings could cause significant reactions.

Disordered sensory processing doesn’t always have to be disabling either, environmental accommodations can be the difference between equitable participation and an inability to function within a given setting.

Ultimately disordered sensory processing has been shown to manifest in ways that are often interpreted as ‘bad behavior’, anxiety, being self-absorbed, disorganized, lazy and more (Spielmann & Miller, 2020). There is no ‘one’ presentation for disordered sensory integration and processing. We do know that it is impossible to outline one behavioral manifestation of differences in sensory integration and processing. There are commonly identified clusters of behaviors and these are described in the various models of dysfunction outlined above and the nosology summary below. It is important to keep in mind however that disordered sensory integration and processing has been identified in populations across the lifespan including prison populations, eating disorder clinics and more. It is complicated, pervasive and critical, and more research needs to be done.

In the questions below we will outline common presentations of disordered sensory integration and processing from Dr. Lucy Jane Miller’s nosology of 2007.

8. What is a Sensory Modulation Disorder?
A person with a Sensory Modulation Disorder has difficulty regulating their responses to sensory stimuli. There are three primary subtypes of modulation disorders: Sensory Over-Responsive, Sensory Under-Responsive, and Sensory Craving. With an over-responsive subtype, people typically have a predisposition to respond too much, too soon, or for too long to sensory stimuli most people find quite tolerable. This might mean that a sound that one person finds mildly annoying, may send an over-responsive individual into a fight/flight/freeze response. For the under-responsive subtype, people may have a predisposition to be unaware of sensory stimuli, to have a delay before responding, muted responses, or less intense responses compared to their peers. For example, a client who seems “checked out” or “self-absorbed” may become more alert or attuned when participating in an intense swinging game or when louder music and movement activity is presented at the beginning of the session. The craving subtype is less researched and less common. The observation is that this subtype occurs when a person is driven to obtain sensory stimulation, but getting the stimulation results in disorganization and does not satisfy the drive for more. This can lead to highly increased arousal and poor ability to control one’s behavior and participation in other activities. It is common for people to present with mixed modulation subtypes across the eight sensory systems. Individuals can be over-responsive in their auditory or olfactory systems but under-responsive in the proprioceptive and vestibular systems. This can lead to challenges in multi-sensory environments like the classroom or the cafeteria.

Clinically, we see some unique language patterns in the modulation population, especially when dysregulated. Most typically there is a change in the quality or quantity of language used. When dysregulated some children start to speak rapidly and become less fluent. Others stop talking or greatly diminish their verbal communication. Sometimes people are unable to filter out or habituate to sensation leading to distractibility, which can then impact sustained listening and conversational skills. This population often tests well on standardized language evaluations (typically done in a small room with limited sensory input), but then cannot use their language efficiently in multi-sensory environments.

9. What are Sensory Based Motor Disorders?
A person with a Sensory Based Motor Disorder has difficulty with posture, balance, motor coordination, and the performance of skilled, non-habitual and/or habitual motor tasks. The two subtypes of Sensory Motor Disorders include postural disorder and dyspraxia. Postural disorder is associated with impaired perception of body position (proprioception) and orientation in space (vestibular) resulting in immature movement patterns and poorly developed automatic motor control. Thus, people appear weak and/or to have poor endurance. Dyspraxia is described as having difficulty thinking of, planning and/or executing skilled movements especially novel movement patterns. Many speech-language pathologists refer to this as body praxis. The underlying patterns (i.e. challenges with planning and sequencing) are the same as the challenges in verbal and/or oral praxis though dyspraxia usually is associated with full-body movements. Developmental Coordination Disorder (DCD) is sometimes used synonymously with dyspraxia though DCD does not incorporate the cognitive components of dyspraxia (e.g. non-movement parts of planning and sequencing). You may see references to both in the literature, though often DCD is used in research studies given that it is a formal diagnosis in the DSM-V.

Clinically we see different speech and language patterns in individuals with postural disorder and/or dyspraxia. With postural challenges, many people have difficulty maintaining a static upright position which can impact sustained attention and listening skills. This can impact their participation in structured language tasks. This population is often best served in a very supportive chair or in less traditional/non-table top seating. Challenges with endurance are significant for those with postural disorder and breath support and articulation precision may diminish throughout the day (or even throughout the session). This may impact the time of day, or time within the session, that’s best to work on speech production goals. The planning, sequencing, and execution challenges that characterize dyspraxia can have a direct impact on narrative language skills. The ability to organize and move through space impacts success with sequencing a story or understanding how to use transition words effectively. Difficulty moving through space can impact the acquisition of ‘action’ words and those with more significant praxis challenges often have trouble “walking and talking” at the same time (i.e. maintaining language while navigating through space). This can make it hard to keep up or participate actively in social language and pretend play activities. Sometimes the desire to control the play, in order to stay an active participant, impacts pragmatic language skills with peers.

10. What is Sensory Discrimination Disorder? How is it different from modulation?
With a Sensory Discrimination Disorder, people often have difficulty interpreting the qualities of objects, places, people, or other environments because individuals can’t differentiate elements of the sensory information they are experiencing. This can be seen in just one sensory system or in all eight systems at once. Speech-language pathologists are most familiar with auditory discrimination challenges such as understanding speech in noisy environments or difficulty differentiating between similar sounding words. Similar challenges can be seen across the visual, tactile, gustatory, olfactory, proprioceptive, vestibular, and interoceptive systems as well. While the body takes in the sensations, if it does not interpret these signals effectively it is hard to create an appropriate response. Sometimes people with SDD will allow their body to take in too much of a sensation then it will suddenly become overwhelming when it is registered. Others will have difficulty understanding subtle differences in sensation.

Based on clinical observations some language patterns seen in children with discrimination challenges include: misunderstanding similar sounding words, specific adjective or adverb confusion, they can be slower to acquire emotional labels especially for more subtle emotional states due to visual or interoceptive discrimination challenges, and / or they may have more difficulty interpreting non-verbal gestures and understanding the effect of others.

11. What areas of speech and language development are obviously impacted by disordered sensory processing?
Possibly the most fundamental is the concept of regulation. It is foundational to other speech and language functions and may be disrupted as a result of any of the subtypes listed above. Arousal regulation refers to our ability to maintain an optimal performance level and how alert we are in order to sustain our attention and complete tasks as the environment demands. This foundational skill impacts the ability to communicate effectively and efficiently and is often disrupted by any of the SPD subtype manifestations. Self-regulation is our ability to achieve, sustain, and change our arousal level to meet the changing demands of the task or situation.  As a child matures they develop strategies they find will help them to maintain attention, and some are not always appropriate/effective if there are regulatory issues. With adequate self-regulation, the child will be able to develop and refine strategies unconsciously. When a person presents with disordered sensory integration and processing their ability to maintain baseline regulation is often disrupted as well. This is often referred to as dysregulation. When attempting to target speech and language goals, it is important that the client is in a regulated state and this can sometimes be achieved by meeting their sensory and movement needs within the session.

a) Breath control - While breath control can be impacted by a number of factors, one significant challenge comes from core stability.  People with postural disorder have diminished core stability. This directly impacts one’s ability to generate, regulate, and maintain trunk pressure and manage those pressures in the thoracic and abdominal cavities. The diaphragm serves as both a postural and respiratory muscle. With compromised postural control, the coordination and control of the diaphragm is often compromised. This will directly impact sustained breath control and can indirectly impact all higher-level skills especially feeding development. Postural supports should always be considered within speech and language intervention, but especially for speech production and feeding interventions.

b) Oral motor and feeding development - Feeding is one of the only activities in which we coordinate use of all eight sensory systems. Therefore, if someone has difficulties within any of their sensory systems, it can impact feeding either from a sensory standpoint or from a mechanical standpoint. For example, if someone has over-responsivity challenges, they can be hesitant to try new foods of single or mixed textures due to the appearance, smell, texture, or taste of the food. Or perhaps, those with discrimination challenges might not use enough force when chewing or may lose track of where the bolus is in the mouth. Individuals with sensory-motor challenges may have difficulty with motor planning of how to move the food within the mouth with their tongue or figuring out how to chew the food well enough for safe swallowing.

c) Articulation - Articulatory precision requires control of the respiratory system, the larynx and vocal folds, and each of the articulators (i.e. the hard and soft palate, the mandible or jaw, the teeth, the tongue, the lips, and the cheeks). Those with disordered sensory processing and integration, especially with discrimination disorders impacting the tactile and proprioceptive systems, may have difficulty positioning the articulators correctly. It may be more challenging for them to respond to verbal only cues, and they may need additional visual and/or tactile feedback in order to improve articulatory accuracy.

d) Apraxia and dyspraxia - The terminology of apraxia and dyspraxia have resulted in some confusion in research domains both in the fields of speech and occupational therapy. The diagnosis of Developmental Coordination Disorder is a formal diagnosis often used for children with praxis challenges. While this doesn’t encompass all aspects of dyspraxia (i.e. challenges with the planning of sequences) DCD has more research literature and many therapists use the terms interchangeably. New research has shown that the co-occurrence of children with suspected Childhood Apraxia of Speech and Developmental Coordination Disorder could be as high at 49% - versus a 9% prevalence for DCD in the general population (Duchow et. al, 2019). While this research was done on a small sample there are indications that there is a higher percentage of individuals with suspected CAS who also have full body praxis challenges. As mentioned above language challenges can be associated with dyspraxia, and if motor speech is also affected, overall communication can be quite impacted.

e) Sequencing - Difficulty sequencing, as is a part of the definition of dyspraxia, can result in communication challenges, especially for receptive and narrative language development. At a more basic language level, it can be difficult to plan and therefore execute multi-step directions. Some children might shut down at the initiation stage for directions while others may miss the order of tasks or directives. Individuals may also have difficulty understanding time/sequence concepts and using these when retelling or generating a story. Their narratives may seem immature for their overall language development and lack critical story elements that connect events together due to planning and sequencing challenges.

12. What are the best ways to evaluate disordered sensory processing?
Occupational therapists are most often the profession with the strongest background and training in the assessment of sensory integration and processing and working with an OT trained in this specialism is considered best practice. An evaluation should incorporate parent/teacher interviews, use of questionnaires/report measures in different environments, standardized evaluations, and qualitative observations of play and movement in a new environment.

Parent and teacher report measures are best used as screening tools in the broader context of a holistic assessment because, while standardized scoring is available for many of these tools, so much of the measure relies on the perception of the adult completing the test. What if this is a parent with their own disordered sensory processing? Or a teacher who is highly unsympathetic? So much needs to be considered. However, if you are not able to access an occupational therapist trained in sensory integration then a report measure is a good place to start. Whatever happens, an evaluation always needs to link back to function and participation and not just be about sensory integration for the sake of sensory integration.

See below for further education offerings that increase a speech-language pathologist’s ability to understand individual differences in sensory integration and processing and their impact on development, behavior, and communication.

Further reading on available assessments can be found here: https://www.aota.org/Publications-News/SISQuarterly/Sensory-Integration/8-16-measure-assess.aspx.

13. What is the difference between Sensory Integration Therapy (SIT or Ayres SI) and sensory stimulation/protocols?

It’s more than you think! Most therapists have heard of sensory-based activities and protocols - including sensory diets. These activities include stimulation of one or more senses and are often done in a prescriptive manner (i.e. at 9:00 wheelbarrow walks down the hallway, 10:00 tactile brushing, and joint compression, etc). While the sensations can be beneficial and organizing for a client, they tend to be imposed rather than client-led and omit the dynamic clinically-based reasoning process that is an important part of Sensory Integration Therapy (SIT). The principles of SIT require the therapist to engage the individual in client-led, sensory-based activities that provide a “just right challenge” which result in a higher-level adaptive response. As each client’s sensory profile and sensory needs are different, the activities for each client must be equally individualized. The initiation by the client adds a level of intrinsic meaning into the activity that is lacking in imposed/protocol-based sensory stimulation. The clinician then helps support, adapt, and guide the activity so that the client moves towards the goals of the sessions (i.e., helping the individual achieve improved social interactions, increased participation in daily life activities and routines, etc). For an SLP, the goals and therefore the adaptive response might lead to increased attention or engagement, improved participation, more organized behavioral responses, increased communicative intent, or improved receptive or expressive language skills. All of which are targeted within dynamic and meaningful interactions. 

14. What could happen in therapy if I don’t consider the downsides of an individual’s sensory integration and processing challenges?

Given how important sensation, perception, and processing are to all aspects of development, to regulation, and thus to all higher-level skill development, not considering the impact of sensory integration and processing can have a negative impact on the therapeutic process. It can leave the therapist “managing behaviors” in a person who is unavailable for organized learning. If a client is continuously exposed to a negative sensation experience she/he will have difficulty establishing trust with those who are “causing” the exposure. This can disrupt the relationship between therapist and client and halt the progress on goals. Additionally, intervention can take longer and skill-building can be less meaningful if the experience does not consider the child’s own awareness of the world and their ability to move within it. This can result in splinter skills or skills that can be used in one setting but do not generalize across settings. Recognizing each client as a “sensory being” and understanding how her/his individual sensory profile impacts interactions with the world, can allow a therapist to address communication goals in a way that is the most meaningful and personalized to the client.

15. What does the treatment effectiveness research say?
Treatment effectiveness research has accelerated over the past 10 years. There is now sufficient evidence to support Ayres Sensory Integration as an evidence-based practice. The article by Schoen et al., 2019 subjected the evidence to the criteria set forth by the Council for Exceptional Children Standards for an Evidence-Based Practice in Special Education. They found ASI met the criteria and was determined to be an evidence-based practice for children with autism, age 4-12 years.  Additionally, ASI was recognized as an evidence-based practice by the National Clearinghouse on Autism Evidence & Practice (NCAEP). (See: https://ncaep.fpg.unc.edu/sites/ncaep.fpg.unc.edu/files/imce/documents/EBP Report 2020.pdf.)

Evidence for the effectiveness of the STAR Frame of Reference is just emerging. One study was a retrospective chart review and the other is a multiple baseline single-subject design. Both studies suggest this sensory-based approach that incorporates the principles of ASI is also effective (Schoen, Miller & Flanagan, 2018, Schoen, Miller, Camarata & Valdez, 2019, Schoen et al., 2020).

16. I have an OT report on Sensory Integration and Processing and it’s confusing, what should I look for?
A good report should link sensory integration and processing differences/findings to the presenting problem and reasons for referral. However, we know that sometimes you may need to dig a little deeper to understand what a report of sensory integration dysfunction means in terms of everyday functioning. There is a guide to the language you might find in a report and what it means on the spdstar.org website. (See: Sensory Integration and Processing Jargon Guide at https://www.spdstar.org/basic/resources-tips-downloadable-flyers)

There are two types of significant data in a report: the standardized assessment data and the qualitative data from interviews and observations. Both types of information are valuable. A helpful guide for interpreting standardized data can be found on the spdstar.org website. (See: Bell Curve Interpretation at https://www.spdstar.org/basic/resources-tips-downloadable-flyers)

These should be followed by an interpretation of what that means with regards to function.

17. If my goal is language development, how do I collaborate or consult with an OT to support my client with sensory processing and integration challenges?
There are many ways that a speech-language pathologist can support a client with sensory integration and processing challenges in collaboration with an OT colleague. The first step is to refer for an occupational therapy evaluation if you suspect sensory integration and processing challenges that are impacting development. Often the speech-language pathologist is the first therapist to work with a family. SLPs can help parents to understand the role of sensory processing and integration and to understand what a thorough evaluation can do to support their child’s overall development. Establish a relationship with an OT that understands disordered sensory processing and integration and can be a resource for your clients. Similarly, educate the OTs on the team to understand the very dynamic range of developmental goals that can be supported by speech and language services. This may lead to referrals for their clients that need support with joint attention, play, feeding, and social communication in addition to the more traditional areas of language comprehension, language expression, and speech production.

When available, it can be supportive to many clients to provide co-treatment or joint treatment sessions. This can allow the SLP to focus on maximizing communicative intent while the OT leads movement and other sensory informed strategies that maintain regulation and attention. Watch the type of activities that the child and the OT explore to see where language expression or even speech production can be targeted. Help the OT understand the pacing and use of language as a regulation tool and to understand the child’s subtler communication attempts. This can allow the child to express her/his intent as independently as possible. Consider working in a dynamic space, like the sensory gym or a playground, to see how your client communicates in a more natural environment. This often provides insight into social communication as well.

If co-treatment is unavailable look into collaborating with an OT through peer mentorship. If the client has a treating OT, speaking with them about the client’s sensory profile and other sensory informed strategies can be beneficial. With caregiver permission, consider reviewing video clips from both therapists to try to better understand the role of communication delays and sensory processing and integration challenges in overall development. The OT can often provide ideas of how you can add sensory-rich experiences into the therapeutic process to improve regulation and engagement. The SLP can support the OT to understand how and what the client is communicating across settings, or to offer suggestions of how to carry over communication goals within movement and play. Even if the client is not yet receiving occupational therapy, reviewing your observations and/or video clips with an OT can help you better understand your client’s sensory profile and how to use sensory informed strategies to improve progress on communication goals.

18. Are there simple sensory informed strategies I can use as an SLP that will improve my outcomes?

Sensory informed strategies are individualized to a client’s sensory integration and processing challenges; however, there are some easy considerations that can be incorporated into any speech and language session. Some types of sensations tend to be calming, like slow, linear swinging, rocking, dry tactile, and deep pressure such as squeezes or joint compression. Other sensations tend to be alerting like jumping, spinning, wet tactile, or light touch like tickles. If your child is not able to participate in therapeutic activities effectively, consider that they might need to be calmed/alerted to be in the “just right” state for engagement. Remember it is not about “doing” the sensation to the client but providing access for the child to lead the interaction to support what his/her body needs. Consider positional adaptations as well. Many children are not well supported from a postural perspective when seated in a desk chair. Consider if there are other seating options that might provide more support, such as a footrest, or increased input, like a rocking chair, when doing tabletop work. Explore other positions like lying prone on the floor or bouncing on a ball chair while completing activities. Changing positions between each activity, even in a small space, can allow for increased attention and focus even with small changes in the sensory environment. Where possible insert movement and sensation into therapy activities. Rather than asking a child to label using actions or prepositions, explore a Simon Says type game where the child has to follow directions and/or give verbal directions. Try hiding articulation cards in a bin with dry rice or beans, or add them into an obstacle course. Carry over language goals into meaningful play activities and explore a variety of sensory-rich environments to ensure that the client understands how to use their communication skills across settings. 

19. What suggestions should I give to parents of children with disordered sensory processing and language delay?

It is important for parents to understand how their child’s sensory system works so that they can use meaningful sensory experiences to support language expansion. Sensations can be supportive but they can also be distracting and disruptive to focused attention. As a therapist, you can identify environments that allow the child to engage more effectively without causing distress (e.g. can the play space for a child with sensitivities to sound be relocated away from the noisy HVAC vent). You can also help identify which sensations help support their child’s attention and regulation. If a child resists working on sight words via flashcards, would he be more engaged if you wrote the words in shaving cream or another tactile medium? For children that need more movement in order to focus, help parents come up with jumping/crashing games that they can add phonological awareness or question responses into. Rather than just memorizing flashcards, help parents understand that words are more meaningful when paired with whole-body actions and suggest ways they can address preposition or descriptor goals through movement play. Balance movement with language demands especially for a child who has dyspraxia.

It is also important to help parents find a supportive occupational therapist who can more specifically identify sensory processing and integration challenges and make recommendations that will support progress in all areas of development.

20. How do I learn more? What next steps can I take to become sensory informed in my practice?

There are resources available at many levels to learn more about sensory integration and processing. Several introductory level books provide information on disordered sensory integration and processing and how different sensory profiles can impact development including:

• Sensory Integration and The Child: 25^thAnniversary Edition by Dr. A. Jean Ayres
• Sensational Kids: Hope and Help for Children with Sensory Processing Disorder (SPD) by Dr. Lucy Jane Miller
• No Longer A SECRET: Unique Common Sense Strategies for Children with Sensory or Motor Challenges by Dr. Doreit Bialer and Dr. Lucy Jane Miller
• The Out of Sync Child series by Carol Stock Kranowitz

Look for webinars and live talks that focus on the foundations of sensory integration and processing challenges available from the SPIRAL Foundation, the STAR Institute, and Sensory Integration Education. These cover introductions to disordered sensory integration and processing and considerations for intervention or application across settings.

Additional intensive training and certifications are available to speech-language pathologists who want to learn more about the theoretical bases of sensory integration and processing challenges, improve clinical reasoning with regard to these challenges, and explore frameworks of these challenges within practice across settings.

Options for SLPs that we recommend include:

• Mentorship I of the STAR Frame of Reference and the STAR Certification Pathway up to Level I. www.spdstar.org
• CLASI certification in Ayres Sensory Integration Therapy https://www.cl-asi.org/casi
• The USC Chan Sensory Integration Continuing Education Certificate Program (welcomes Speech and Language Therapists from recognized programs but cautions that the certificate pathway is designed with OTs in mind). https://chan.usc.edu/academics/continuing-education/sensory-integration
• The Spiral Foundation has specific webinars designed for Speech and Language Therapists, a certificate pathway and other offerings. https://thespiralfoundation.org/pecsi/
• Sensory Integration Education offers allied health professionals a Master’s of Science in Sensory Integration in partnership with Ulster University. https://www.sensoryintegration.org.uk/page-18728

There are also sensory trained speech-language pathologists who can provide mentorship and support individualized to your caseload.

The authors of this article are from STAR Institute for Sensory Processing an international non-profit whose mission is sensory health and wellness for the state, the nation, and the world. STAR Institute is a treatment, research, and education center based out of Denver, Colorado. 

References

Ahn, R, Miller, LJ, Milberger, S & McIntosh, DN. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58(3), 287-302.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Ayres, AJ (1979). Sensory Integration and the Child. Los Angeles, CA: Western Psychological Services.

Ayres, AJ & Robbins J. Pediatric Therapy Network (2005). Sensory Integration and the Child: Understanding Hidden Challenges 25th Anniversary Edition. Los Angeles, CA: Western Psychological Services.

Ben-Sasson, A, Carter, AS & Briggs Gowan, MJ (2009). Sensory over-responsivity in elementary school: prevalence and social-emotional correlates. Journal of Abnormal Child Psychology, 37,705-716.

Ben-Sasson, A, Soto, TW, Heberle, AE, Carter, AS, & Briggs-Gowen, MJ (2017). Early and Concurrent Features of ADHD and Sensory Over-Responsivity Symptom Clusters. Journal of Attention Disorders, 21(10), 835-845.

Bundy, AC, Lane, SJ & Murray, EA (2002). Sensory Integration Theory and Practice (2nd ed.). Philadelphia, PA: F.A. Davis Company.

Bundy, AC & Lane, SJ Sensory Integration Theory and Practice (3rd ed.). Philadelphia, PA: F.A. Davis Company.

Duchow, H, Lindsay, A, Roth, K, Schell, S, Allend, D & Boliek, CA (2019). The Co-Occurrence of Possible Developmental Coordination Disorder and Suspected Childhood Apraxia of Speech. Canadian Journal of Speech-Language Pathology and Audiology (CJSLPA), 43(2), 81-93.

Dunn, W (1997). The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model. Infants and young children, 9, 23-35.

Jarrard, P (2008). Sensory Issues in Gifted Children: Synthesis of the Literature (Doctoral dissertation, Rocky Mountain University of Health Professions, Provo, USA). Retrieved from https://www.spdstar.org/sites/default/files/publications/SensoryissuesinGiftedChildren.pdf

Kilroy, E, Aziz-Zadeh, L & Cermak, SA (2019). Ayres Theories of Autism and Sensory Integration Revisited: What Contemporary Neuroscience Has to Say. Brain Sciences, 9(3), 68. https://doi.org/10.3390/brainsci9030068

Latest research findings. (n.d.). Retrieved from https://www.spdstar.org/basic/latest-research-findings

Miller, LJ (2015). Sensational Kids: Hope and Help for Children with Sensory Processing Disorder (SPD) (Rev. ed.). New York, NY: Perigree Trade Paperback.

Miller, LJ, Anzalone, ME, Lane, SJ, Cermak, SA & Osten, ET (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy, 61(2), 135–142. https://doi.org/10.5014/ajot.61.2.135

Schoen, SA, Miller, LJ, and Flanagan, J (2018) A Retrospective Pre-Post Treatment Study of Occupational Therapy Intervention for Children with Sensory Processing Challenges. The Open Journal of Occupational Therapy, 6, 4.

Schoen, SA, Miller, LJ, Camarata, S & Valdez, A (2019). Use of the STAR PROCESS for children with sensory processing challenges. The Open Journal of Occupational Therapy, 7, 4, 1-17. https://doi.org/10.15453/2168-6408.1596

Schoen, SA, Lane, SJ, May-Benson, T, Smith-Roley, S, Parham, D, Mailloux, Z & Schaaf, RC (2019).  Systematic Review of Ayres Sensory Integration. Autism Research,

Smith Roley, S & Schaaf, RC (2006). Evaluating sensory integration function and dysfunction. In S. Smith Roley & R. C. Schaaf (Eds.), Sensory Integration: Applying Clinical Reasoning to Practise with Diverse Populations (pp. 15-36). TX: Harcourt Assessment, Inc.

Spielmann, V & Miller, LJ (2020). Sensory integration and processing: Impact on anxiety in autism. In S.M. Edelson, and J.B. Johnson (Eds.), Understanding and treating anxiety in autism.  London: Jessica Kingsley Press. 

Spitzer, S & Roley, SS (2001). Sensory integration revisited: A philosophy of practice. In Roley, S. S., Blanche, E. I., & Schaaf, R. C. (Eds.), Understanding the nature of sensory inte- gration with diverse populations (pp. 3–27). San Antonio, TX: Therapy Skill Builders.

Subtypes of SPD (n.d.). Retrieved from https://www.spdstar.org/basic/subtypes-of-spd.