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CPD Update: Neurodevelopmental Soft Signs: Implications for Sensory Processing and Praxis Assessment—Part One

An interesting read, this AOTA CE Article links sensory integration and processing difficulties and higher functions linked to occupation and participation. 
A table in the article links types of neurodevelopmental soft signs (NSS) in Occupational Therapy evaluation and underlying brain areas implicated in the literature, commenting that
“Integrating clinical observations of NSS with advanced brain-based research expands our understanding of the sensorimotor scaffolding that leads to higher functions of behavior organization, communication, and cognition.”
To access/buy a copy you can find out more here:
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Celebrating International Women’s Day 2019

This international women’s day, ASI wise are remembering and celebrating Dr. A. Jean Ayres a neuroscientist, educational psychologist and occupational therapist who pioneered the concepts of sensory integration and its impact on human learning and development. She wrote books, papers and research articles, mentored therapists and offered pioneering therapy to children, inspiring therapists over the globe to take her work and research, develop, teach and use it to support countless children and adults across their lifespans to live their best possible lives.

Here’s to all the amazing therapists inspired by one woman’s revolutionary insight!

International womens day 2019

 

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Choosing Wisely ® and ASI – a fantastic initiative from AOTA – it got me thinking about why people think sensory is easy and just anyone can do it.

Just like a parent can decide a child has a cold and needs Calpol, a sensory rich home environment can help support development. However just like a child may need a Dr, Dentist or other specialist if they have a more serious illness, what some people need is specialist intervention.

Sensory Integration therapy requires years of training, first just to become a therapist and then the advanced training needed to accurately assess, develop a personalised intervention plan and then carry out the intervention. We might all know when tonsils need removing, but few of us would do it at home. Telling someone about how tonsils get removed or how sensory integration happens is very different to actually doing it, and doing it safely and so that the outcome is as expected. Sensory integration therapy is not just about swinging on a swing or bouncing on a ball – it is about so much more. And is definitely not about just about wearing headphones and having a bouncy cushion.

The superb article from AOTA’s CHOOSING WISELY programme – see link below – got me thinking. I get weekly emails from people offering to treat other people’s children without training, offering Sensory Profile assessments by mail from a questionnaire when they are not even a therapist.

Share this blog and have interesting discussions with clients, colleagues and line managers. As relevant here in UK and Ireland as in US. This really confirms what we teach in our modules and promote as an organisation; including the best standardised norm referenced tool currently at our disposal – the SIPT. No or limited assessment waters down efficacy. Standardised assessment (when possible) structured clinical observations and thorough clinical reasoning using a clear process are imperative. Data driven decision making.

https://www.aota.org/AboutAOTA/Membership/Tools/Periodicals/choosing-wisely-sensory.aspx

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Messy Play 1 – What is messy play and how can it help?

Submitted by guest blogger, Ruth OT

It’s the summer holidays for most schools in England, including my kid’s schools. I’m well known for my love of messy/ tactile play, and summer holidays and messy play are made to go together.

First of all, can I just say that messy play is not just about the sensory input, it’s not a “sensory session”, it’s certainly not a substitute for “sensory integration therapy”?

All play is sensory.

All activity is sensory.

Messy play is a about normal development and learning through a playful activity using tactile experiences and experimentation. It should be fun, it can be intensely therapeutic, and it can form a part of sensory integration therapy session, but overuse of the word “sensory” for activities like this weakens the power of true sensory integration therapy.

Second of all, can I just say that messy play is not a substitute for natural tactile experiences? Messy play is not a substitute for muddy walks, tree climbing, animal handling and other important life and learning experiences. It can scaffold and enable those activities for children who find these experiences difficult to tolerate, but there’s nothing like nature and the great outdoors for kids’ sensory skills.

Here are some of the reasons I love messy play…

It teaches basic cookery skills, but nobody has to actually eat the product

Through making recipes, you can practice opening packages, pouring, measuring, stirring (and holding the bowl still at the same time) and following a recipe. But you don’t have to worry about food hygiene, if the child drops it on the floor, picks their nose, spits, or anything els. You don’t have to pretend it’s delicious. But there is still a tangible result.

It teaches flexibility of thinking and problem solving

So many times I say to kids “OK, that doesn’t look like it does on my picture, what did we do wrong?”, followed by “OK, let’s try that then!”. It’s amazing to watch our children move from “it’s gone wrong, bin it” to experimenting to try and improve the outcome. When I hear “it’s too runny, add more flour” I smile, I count this as a breakthrough parenting moment.

It can be really helpful to use non-specific language, I love seeing that look and a laugh when I say ‘you need a good amount of this’ or ‘give it a squirt of that’. I say we’re working on estimating.

It teaches art, creativity and scientific experimentation

We’ve made beach scenes out of shaving foam and cornflour gloop, farms from rice and silly string and just beautiful visual effects from any range of strange concoctions. I love that moment of “what happens if I mix this with that?”. So long as you’ve checked what you’re using properly, to make sure it’s safe, the worst that will happen is a sticky mess.

Beware of borax as a substitute in cheap homemade slime recipes!

It teaches communication

It can be a great motivator that isn’t food-based; practising choice-making, turn-taking and asking for help is really easy with a tin of shaving foam and some dry pasta. You can follow a recipe, practising reading and maths. Make visual recipes pictures of the scoops of flour and oil, with laminated recipes so the child can tick off each step they do – wiping clean at the end. Get older kids to research their own recipes on the internet and print them off ready for the session.

It teaches motor skills and tactile discrimination

Opening packets, pouring to a measure and sprinkling need I go on? And then squeezing, pressing, rolling, stretching and cutting. It’s amazing for fine motor skill development. You can hide things in a messy play tray or a ball of playdough for the child to find and choose the perfect texture. 

It exposes the child or young person to new sensations

You will make lots of smells with microwaveable soap kits, you will spill liquids, you will touch textures and the outcome is often unpredictable.

It can help with food aversions

Food-based textures and odours can become familiar through messy play. Exploration of food and food-like substances in a calm, fun activity without the pressure and anxiety of being pushed to eat can help to break down anxiety responses to foods, meals and eating.

It’s fun

Or at least, you should make sure it is. 

So, with all of that in mind, Over the next few days, I’ll give you 6 of my favourite recipes, one for each week of the English summer holidays. There are loads of recipes out there, I have a whole book of slime recipes (yes, really) but these ones are tried and tested and hopefully varied.

Hope you have fun trying them out…

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Assessment tools are just that – tools in our toolbox!

We should use and value our specialist skills – promoting our profession – information from one assessment tool is not a comprehensive assessment. We should act with integrity and only practice what we are skilled in and trained to do. This can and must include postgraduate training and we should value this investment in our own skills to deliver a great service to our clients. I felt ashamed of my own profession today, and here is why.

selective focus photography of three disney princesses figurines on brown surface

Today I chatted with a parent I was introduced to on social media. They had paid almost more money than I earn in 2 days in private practice for a 10-page report written after the parent returned a completed Sensory Profile to a therapist via the mail. Then after a 45-minute meeting where the child played on the floor while the therapist interviewed the Mum, the report and recommendations were written.

On the back of this report, the child who lives far away from the assessing therapist is now about to undertake:

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  1. Balance exercises every morning which the Mum was training to do over the internet. These include standing on one leg eyes open and eyes closed, and, hopping eyes open and eyes closed along a line.
  2. A brushing programme; which Mum will be soon be trained to do over the internet – this needs to be done every morning and every night.
  3. Using a sensory diet sheet and the child will follow 5 activities off this sheet each day with her TA at break-time while her friends are out on the playground.
  4. Using a wobble cushion at lunch to facilitate eating new foods.
  5. An after-school calming plan – spinning on a wheelie board and jumping on a trampoline for 10 mins.

The final recommendation was getting sensory therapy from a ‘Sensory OT’ if these things didn’t work. I am apparently one of the closest ‘sensory therapists’, so I got a call. The therapy has not worked. Where do I start? What is a ‘Sensory OT’? Am I one of these?

I have to be professional. So I started with educating the parent about our profession and how we practice.

Screen Shot 2018-07-03 at 08.41.10Then I told her about Jean A Ayres and about Ayres’ Sensory Integration and Practitioner Education including the ICEASI. I had to dispel some myths she’d been sold that sensory diets are not related to Ayres’ Sensory Integration – exploring the history of the theory’s development, explaining how the theory should be used to inform assessment and clinical reasoning even when we can only provide advice and strategies – but that these should still be individualised following a comprehensive assessment.

Screen-Shot-2018-07-03-at-08.16.50.pngThe approach used and charged for is not what I recognise and not what encompasses best practice – best practice in occupational therapy, wherever we work, involves using assessment tools; some standardised and with norms or some just structured questionnaires that collect and collate our clinical observations. Then we listen and hear the client’s voice/story via their narrative and then using this to confirm our clinical observations. Then using the best possible evidence we should work alongside clients to develop goals and set a way to measure if what we then do makes a difference – improving participation in daily life.

ASI WISE RCOT 2018 Poster ASI Beyond ChildhoodOur recent poster at Royal College of OT Conference in Belfast shows the 2015 Schaaf and Mailloux data-driven decision-making process.

This is not a process restricted to Ayres’ Sensory Integration, but one that should guide best practice in any area of clinical practice; judicious collection of data through assessment to inform clinical reasoning that will allow the setting on individualised, personal goals to inform intervention planning and implementation – with careful measurement of outcomes alongside reflective practice.

This is our profession – working with people in partnership, alongside them in conversation and while using assessment tools in the assessment is expected, we choose tools specific to the person, the referral reason using our clinical reasoning. This is our expertise and what makes our jobs a profession.

The Sensory Profile, like all assessments, is meant to only guide and inform clinical reasoning. Otherwise, we could just hire number crunching computer programs that use algorithms to assess plan intervention and write reports instead of OT’s.

[This blog was written a while ago, with some details changed to protect the family, but at their request and with their permission. It was written just after my father in law fell and then sadly did not recover. I was very sad anyway, but after this conversation, I was really very very sad and I waited to make sure I still felt as concerned and as sad after some time had passed.]

 

 

 

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Occupational Therapy and Trauma 3: A Tool for considering the physical environment in children’s residential homes to address sensory processing issues in trauma-affected children

This article by Clinical Psychologists Christopher Robinson and Alicia Madeleine Brown in the Scottish Journal of Residential Child Care includes a lovely environmental checklist (adapted from Simpson 2009) used in considering the physical environment in three children’s residential homes.

Abstract: Sensory processing issues are generally considered to be clinically significant in children who have suffered abuse and trauma and much has been written about the possible neurological correlates of such sensitivities (De Bellis and Thomas, 2003; van der Kolk, 2014). Comparatively little focus has been given to the functional aspects of these sensitivities, and particularly how these might interact, in context, with a child’s underlying neurological vulnerabilities. In this respect, the environment surrounding the child is a neglected area of significant, perhaps critical, importance. In terms of potential hypersensitivity to environmental stimuli, children with Autistic Spectrum Conditions (ASC), although with different aetiological correlates to trauma affected children, are known to face profound environmental challenges. Children with ASCs have received a wealth of attention in the literature with regard to these sensory challenges, whereas, in contrast, trauma affected children have received very little direct attention at all. It is the aim of this paper to focus on the environmental aspects of sensory processing in trauma affected children, specifically in relation to the physical environment of children’s residential homes.

from the Scottish Journal of Residential Child Care 2016 – Vol.15, No.1 Scottish Journal of Residential Child Care ISSN 1478 – 1840 6

Read the full article free here.

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A Weekend of Learning at Abbot’s Lea School, Liverpool – Using Sensory Strategies for Mental Health and wellbeing Weekend Workshop

The ASI Wise lecture team have been at Abbot’s Lea School in Liverpool this weekend with a fantastic group of committed and enthusiastic occupational therapists, speech and language therapists and teachers exploring the use of sensory strategies and Ayres’ Sensory Integration therapy to support children, young people and adults mental and wellbeing health.

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Experiential learning opportunities, embedded into the course, help participants to understand their own sensory systems and to experience the challenges that the people they are working with face on a daily basis.

 

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With a mixture of classroom-based and hands-on practical learning, participants explored how to use the spaces and environment available in both school and clinic to support regulation and praxis. The workshop provided an opportunity to hear about the theory and practice of Ayres’ Sensory Integration, it’s application supporting those with autism, ADHD and dyspraxia,  with up to date research and evidence supporting practice.

To find out more about our courses and learning here

 

 

We are so grateful to Abbot’s Lea School who have allowed us to use such a beautiful spacious venue. The three lovely well-lit rooms allowed us to create a pop-up sensory clinic, where participants had space to move about; extra room to break into groups supporting learning and the sharing of ideas. The school staff and local therapist volunteer support team have been incredibly welcoming and supportive, helping the workshop to run smoothly. As a bonus, the sun has shone all weekend which has allowed us to use the outdoor spaces, we have spotted a few daffodils and blossom trees around the city – it feels like spring is on its way.

Thank you to our volunteer therapists who helped to make the weekend such a success.

 

 

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Sensory Ladders

The first Sensory Ladders were made in 2001 for adults with sensory integration difficulties receiving help with mental health difficulties in Cornwall. Influenced by the paediatric Alert Program, they offered therapists a way to combine Dialectical Behaviour Therapy and Ayres’ Sensory Integration, addressing the development of the person’s self-awareness in collaboration with ward staff on an acute psychiatric inpatient unit.

The need to start with the person where they are at, before introducing learning about new ways of being, including the development of new skills, made it necessary for the Sensory Ladder to remain a very individualised and personalised journey within a close safe therapeutic relationship.

Both Ayres’ Sensory Integration(ASI) and Dialectical Behaviour Therapy(DBT) share a common understanding that development and change can only occur within a safe environment. The DBT idea of balancing safety and challenge reverberates strongly with Ayres’ concept of the ‘just right challenge’.

Creating a Sensory Ladder is about creating opportunities for an adult or child to learn to become aware of themselves in a new way – to explore and discover new things about mind, body and brain. It allows the therapist and person to do “curious wondering” together, and for the person to try new things – creating and promoting active but informed risk-taking; testing how we might feel and experience something when we do it differently; new ways of being – new ways of responding.

Making and using a Sensory Ladder is about the journey together within a safe therapeutic relationship. It’s about getting to see and know someone in a very different way, getting underneath the skin of behaviours that are perhaps being described by others as tricky or challenging.

The Sensory Ladder facilitates the reframing of behaviour that are a result of sensory integration challenges, providing the first step of acceptance of the behaviour necessary before strategies and therapy support development and change to happen.

To see more Sensory Ladders, visit our Sensory Ladder FB Page

Pokemon Sensory Ladder copy

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Ayres’ Sensory Integration and the great outdoors

The “just right challenge: for this plucky young lady. She clearly likes the sensory input these activities are providing to her body and brain. These are exactly the outdoor sensory system challenging opportunities afforded by climbing trees and jumping streams that  Jean Ayres’ wanted to recreate in her therapy spaces. For those of us lucky enough to live in rural areas and near great parks and other outdoor spaces, do we think about these natural spaces and resources enough.

I will be sharing this with every family I work with for Easter half term when it is a great time to start to once again out and about, now the snow has gone.

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The “just right challenge” is not just about equipment and activity, it’s about our therapeutic use of self – as OT’s doing ASI we need to be shapeshifting chameleons.

The skillful therapist is like a chameleon – able to shapeshift and turn their hand to any and all presentations; artfully engaging with, weaving and drawing out magical cooperation; making it fun. The art of both assessment and therapy are to make sure whatever we do, it is the “just right challenge”. Whether it’s just the right way of being to connect to a child, preparing a room for the initial visit with a swing or ball pool that’s likely to entice play and engagement, aiming for the “just right challenge” is essential.

Doing parent training in a school recently reminded me again how important it is that we ensure what we do is the “just right challenge” for parents and teachers too. While we are very good at simplifying what we do to make it understandable and accessible for all, sometimes parents need to trust us because we have knowledge and skills beyond what they can read in books and on social media sites.

The “just right challenge” is critical to the therapeutic relationship; too much or too little challenge and too much or too little safety, and we don’t create the right brain chemistry for engagement and participation. Remember last time you were frightened and scared, in an interview – How was your performance, were you able to be who you usually are?

This includes making sure we choose the right assessment tools and therapy activities, the therapist ensuring the ‘just right challenge’  – not too tricky, but also not too easy.

I explained the Sensory Integration and Praxis Test, Clinical Observations and the Sensory Processing Measure to a group of parents, and why we won’t always use the same test for each child, because each child is unique.

Critically, not every child can be assessed with a standardised norm-referenced test like the SIPT or Movement ABC, some assessment can only happen in a different way – with equipment and games, through play – play and assessment served up with artful skill so that the assessment can happen unnoticed by the child.

I was reading a report written by another OT, and her artful use of self to get a thorough clear assessment in a situation just like this. It reminded me about what is special about being an OT. We are trained to problem solve and think outside the box  – perfectly placed to creatively choose from the many tools we have in our toolboxes and mix and match them to each person’s unique needs.

Each child is so unique and different – some are clearly children with obvious sensory integration patterns that link to their Autism, just like the research predicts. Some children have had trauma, some have genetic differences, and their patterns are more complex, needing different lenses, and a skillful combination of assessment and therapy approaches. Others need us to wear different hats, combining what we know – Neurodevelopmental Therapy interwoven with Ayres’ Sensory Integration or ASI woven with just the right amount of attachment theory, or just a cognitive behavioural approach coupled with backward chaining to learn a new skill. Skilled experienced therapists know the “just right” combination.

 

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