Al sh'loshah d'varim haolam omed: Al haTorah, v'al ha-avodah, v'al g'milut chasadim. The world depends on three things: on Torah, on worship and on loving deeds. - Pirkei Avot 1:2
This year each issue of Vshinantam will be on a different topic in the area of special needs and written by our consultant, Shana Erenberg, Ph.D. Shana received her doctorate from Northwestern University. For 20 years, she served as the founding director of the Keshet Sunday School for students with disabilities in Northbrook, IL and is currently the Chairman of the Department of Education at Hebrew Theological College in Chicago. She also has a private practice and serves as a consultant.
It is my passionate belief that all Jewish children are entitled to a Jewish education, regardless of need or ability. It is their birthright and our obligation.
Vshinantam is organized around the three pillars of Torah, Avodah, and Gmilut Chasadim. In the Torah section you will find an overview of the topic, in Avodah, applications for your classroom, and in Gmilut Chasadim additional resources.
In the first issue of 5765, we examined the characteristics of Attention Deficit Hyperactivity Disorder, as well as teaching tips to help these students be successful. In this and subsequent issues, we will look as disorders that are easily mistaken for ADHD. The goal of this series is to raise awareness and understanding of these disorders so that remediation and interventions can be appropriate and meaningful and every child can achieve to his or her fullest potential.
What is Sensory Integration?
Sensory integration (SI) is the neurological process of organizing the information we get about the world around us through our five senses: touch, taste, smell, hearing and vision. It is the ability of the nervous system to receive, filter, organize, process and use motor and sensory information from the environment and to disregard unnecessary stimuli. Sensory integration allows you to focus attention and ignore distractions, so that you can listen to someone speaking despite other noises. It allows you to plan and execute fine and gross motor movements in response to environmental stimuli, so that you can write a letter, ride a bicycle or serve a tennis ball. Sensory integration also establishes the foundation for complex learning and behavior.
As input comes into the brain through one or more of the sensory systems, it is processed and integrated so that appropriate responses can be formulated and executed. Usually, this process is seamless and instantaneous. For example, we reach for a cup of coffee on the table, and our brains connect the visual input of seeing the cup to the complex motor demands of directing our hand to the cup, determining the amount of pressure needed to grasp and lift the cup, raising the cup to the mouth and drinking. We are able to accomplish this seemingly simple task through the fluid and automatic integration of our sensory and motor systems. Our brains and bodies are intricately intertwined to respond to constantly changing environmental stimuli.
In addition to receiving and processing external stimuli through the five senses, the brain organizes and processes internal information through the neurological vestibular and proprioceptive systems. The vestibular system involves a series of responses in the inner ear to movement and gravity. This system controls balance, muscle tone, and eye movements. The vestibular system provides regulatory information about movement, speed, orientation and direction. It is also linked to ocularmotor skills, or eye movements, and emotions. The proprioceptive system receives and responds to input from muscles and joints. This system transmits specific information about ones position in the environment, and allows for coordinated motor planning and movement. The interaction of the vestibular, proprioceptive, and sensory systems forms the basis of sensory integration. The smooth interactions of these systems enable us to carry out activities of daily living efficiently.
Sensory integration is a naturally developing process for most children, maturing through the course of typical childhood activities. Sensory integration is facilitated through a childs exploration and interaction with the environment. Motor activities such as touching, running, jumping and climbing promote the development of sensory integration. The organization of behavior, learning and performance and the development of higher level thinking skills are the result of the process, as is the ability to respond to incoming sensations. For some children, however, sensory integration does not develop efficiently. When the sensory integration process is affected, a number of problems in learning, development, attention or behavior may occur.
Sensory Integration Dysfunction
Sensory integration dysfunction is complex neurological disorder that causes difficulty in processing, adapting and responding to sensory input and impacts on the childs ability to act on the environment in a meaningful way. Sensory integration deficits can exist in isolation or can co-occur with learning disabilities, attention deficit disorder, autistic spectrum disorders and other special needs. They may range from very mild and barely noticeable to severe. Sensory integration deficits can cause a variety of problems with attention, behavior and learning, as well as balance, coordination and self-esteem. Some children with sensory integration dysfunction may exhibit behaviors that are sensory seeking, which can be easily confused with hyperactivity. Conversely, some children may exhibit sensory avoidance behaviors, in which they are reluctant or refuse to participate in an activity.Some children with sensory integration dysfunction may also exhibit dyspraxia, a severe motor planning problem. Sensory integration dysfunction may affect twelve to seventeen percent of children and causes them to be out of sync emotionally, socially, and behaviorally (Kranowitz).
Sensory integration dysfunction can be manifest through a variety of symptoms that impact on the childs ability to function in school and at home. The following is a brief overview of the affected areas and characteristics of children with sensory integration dysfunction. Note that these symptoms rarely occur in isolation. Rather, children with sensory integration dysfunction usually present with a combination of complex symptoms.
1. Poor Vestibular Processing
Children (and adults) who have weakness in the vestibular system may have problems with balance, muscle tone and bilateral integration (using both left and right sides of the body together). Vestibular processing may be under-responsive, or over-responsive. When the vestibular system is under-responsive, children may
seem floppy and slouch
seek vestibular stimulation through excessive movement such as spinning, rocking or swinging
be delayed in developing hand dominance and display right-left confusion
appear clumsy and have difficulty maintaining balance
have problems with organization, handwriting\ and fine motor activities that require spatial accuracy
display increased activity levels, are risk takers and have a poor sense of danger
Children with over-responsivevestibular systems may
find the environment unpredictable and frightening because cannot trust their own sense of balance to provide stability
scream when picked up, fear heights, experience motion sickness and may be disoriented after bending over
have difficulty with oculomotor skills, the fluid coordination of eye movements, and therefore make frequent visual errors in reading, such as skipping lines, losing their place and omitting words
display strong emotions that are seemingly inconsistent with a given situation, having a low tolerance for frustration
2. Weak Proprioception
Children with weak proprioception are not able to use the feedback from their joints and muscles to plan and execute motor movements and responses. These children have a lost in space quality; they cannot adequately judge their body positions and movements relative to the environment. They may
be prone to bumping into things such as doors, walls, lockers, and desks
overload their desks with a disorganized array of books and supplies, leaving little if any room for work
have stiff, poorly coordinated movements resulting in an awkward gait, as well as problems with running, skipping, hopping or jumping
have difficulty with organized sports and bicycle riding due to problems in gross motor coordination
have difficulty maintaining a seated position at their desk in the classroom, shifting around in their chairs and falling off
lean with one hand to support their body on the chair when writing, rather than using that hand to stabilize their paper
have problems with organization, illustrated by messy lockers and rooms
have trouble finding something, even if the item is in relatively clear view
have difficulty dressing and undressing
frequently place objects such as pencils and toys in their mouths and chew their clothing. hold a pencil too tightly and assert too much pressure when writing, resulting in torn papers, broken pencils, and a poor quality of writing
3. Attention and Regulatory Problems
The ability to activate, focus and maintain attention depends on the intact arousal and filtering systems in the brain. In order to attend to a particular task, one must ignore irrelevant stimuli and distractions. Children with sensory integration dysfunction often have difficulty sustaining and modulating attention. You may observe that they
are easily distractible, impulsive, disinhibited or hyperactive. Therefore, these children are often misdiagnosed with attention deficit disorder.
seem to require intense, continuous movement, sometimes contorting themselves into pretzel-like positions in their seats or on the floor or rolling around restlessly while other students sit attentively
have difficulty modulating their responses because they respond to sensory input without screening interference
are easily overstimulated
sometimes seek excessive amounts of sensory stimulation and then are unable to adequately process the information
may overreact to auditory stimulation and are easily disturbed by extraneous sounds, such as classroom chatter or lunchroom noises
exhibit strong, seemingly unprovoked emotional reactions, with periods of irritability or crying,
are prone to behavioral melt-downs and have difficulty subsequently calming themselves, lack emotional flexibility, are explosive, or have difficulty with transitions
4. Sensory Defensiveness
Individuals with sensory integration dysfunction often have difficulty tolerating sensory input. It is as if their sensory reaction systems have been set on high; stimuli that are tolerable to others are intolerable to them. For example, most children will ignore the clanging of silverware in a crowded, noisy lunchroom. Children who have an auditory defensiveness will find the noise almost painful and will try to avoid the situation altogether.
Tactile defensiveness refers to hypersensitivity to tactile input and is often mistaken for ADHD. Children with tactile defensiveness may
be bothered by the tags in their shirts, itchy clothes, tight cuffs or the seams on their socks. In fact, these children tend to wear the uniform of the tactilely defensive: loose-fitting, soft t-shirts, sweat pants or soft, well-washed khakis (no jeans), socks turned inside-out, slip-on or Velcro shoes (no laces).
resist touching things that are messy or sticky, such as paste, glue, or finger-paint
dislike crowds due to bumping and jostling. As a result, they might shy away from group activities
have difficulty sitting still on a rug for circle time
resist grooming, face washing, or brushing teeth, as the facial area is particularly sensitive. In fact, a trip to the dentist or barber can be extremely challenging.
be extremely fussy about textures and foods
be fidgety and squirmy due to their level of discomfort
Children with sensory defensiveness may also be hyposensitive to stimuli. In this case, the sensory system under-reacts to sensory input. The hyposensitive child may
appear tired and lethargic
get hurt and not realize it do to a lower sensitivity to pain
drop something and not realize it
have difficulty discriminating objects through touch
have poor body awareness
Academic and Behavioral Concerns
Children with sensory integration deficits face a wide range of behavioral and academic challenges. The environment is an unpredictable and frightening place for children who cannot use sensory feedback to guide them. The ever-present threat of overly or unpleasantly stimulating experiences contributes to the anxiety and distress these children feel. The inability to filter out extraneous stimuli creates an environment in which it is difficult to sustain attention. Specific challenges include: learning to read, writing, tasks that require visual perception and spatial organization, low self-esteem and social problems. Children with sensory integration deficits may appear lazy, bored, or unmotivated.
Children with sensory integration dysfunction are frequently misdiagnosed with attention deficit disorder due to the similarities in symptoms and behaviors. Increased levels of activity, sensory seeking behaviors, impulsivity and distractibility are easily misinterpreted as signs of an attention deficit disorder. As a result, children with sensory integration dysfunction are often put on medication for ADHD. While medication can be useful in treating ADHD, sensory integration disorders require treatment by an occupational therapist. Stimulant medication may actually worsen the symptoms of sensory integration dysfunction. As such, a differential diagnosis by a qualified professional is crucial.
Sensory Integration Dysfunction is a neurological problem that affects behavior and learning. The treatment protocols for sensory integration dysfunction stem from the pioneering work of A. Jean Ayres, PhD, OTR in the 1950s and 60s. Dr. Ayres studied the way in which sensory processing and motor planning disorders interfere with daily life function and learning and developed a therapeutic treatment program that addresses the childs underlying difficulties in processing sensation. She compared sensory integration and dysfunction to a traffic jam in a congested city. She states, Good sensory processing enables all the (neurological) impulses to flow easily and reach their destination quickly. Sensory integrative dysfunction is a sort of traffic jam in the brain. Some bits of sensory information get tied up in traffic, and certain parts of the brain do not get the sensory information they need to do their jobs (Ayres, 51).
Treatment for sensory integration deficits is most often conducted by an Occupational Therapist who specializes in this area. The approach combines vestibular, proprioceptive and tactile activities, which encourage the nervous system to process and integrate sensory input in organized and meaningful ways. The goal of treatment is to enhance the ability of the nervous system to function more efficiently. One important component of the treatment is the incorporation of an appropriate sensory diet for the child. A sensory diet includes a combination of alerting, organizing and calming techniques.
Children with sensory integration dysfunction often do not receive appropriate, early intervention. Lack of awareness regarding SI deficits and misdiagnosis can be significant impediments to proper treatment. Pediatricians often advise parents to wait and see, which delays intervention. Parents may be concerned about their child being labeled with special needs. School districts may not agree to provide occupational therapy services, and private services can be costly. Regardless of these obstacles, it is important to recognize and treat sensory integration deficits as early as possible. The window of opportunity for effective intervention is narrowby fourth grade the child may not be as responsive to treatment as a younger child. Early diagnosis and intervention are crucial in the treatment of sensory integration dysfunction.
Implications for Your Classroom
Students with sensory integration dysfunction face unique challenges in the supplementary school setting. They may come to religious school at the end of a long, overstimulating day, and may not have energy reserves left for learning. These children may be motorically and emotionally exhausted. Behaviors that were kept in check during the structure of the regular school day may be manifest in the looser environment of the supplementary school. Changes in structure and routine may contribute to the childs insecurity and feelings of lack of control. Attention problems can be a significant issue.
Tips for the Teacher
Learn about Sensory Integration Dysfunction. Ask your administration to bring in an Occupational Therapist (who is trained in SI) to speak to your teachers and parents. The greater your understanding of the disorder, the more effective your interventions will be.
Maintain regular communication with parents.
Consult with other professionals in your school, or with the individuals who work with the child in their regular school placement.
Do not automatically assume that inattentiveness, distractibility and hyperactivity are indicative of ADHD. Consider all possibilities for observed behavior. Encourage parents to speak to a professional who can assist in making a differential diagnosis.
Be sensitive to the childs behavior. Do not force him or her to participate in activities that are overly stimulating or disturbing. This will only serve to increase resistance and avoidance. Provide alternative activities that a reasonably related to the task at hand. For example, if the class is finger painting, allow the child to use a paintbrush.
Protect children from sensory stimuli they find disturbing. If they are sound sensitive, lower your voice and reduce auditory distractions. If they are light sensitive, try to use more natural light. Understand their behavior, read their non-verbal cues and respect their areas of sensitivity.
If a child is resistant to writing, limit the amount of written work required. Allow for alternative means of response, such as oral. Or write the answers on a sheet of file folder labels, which the student can select, peel, and stick onto a worksheet. Rather than eliminate writing completely, modify the task demands so that the child can complete the activity successfully.
During circle time activities, allow the child to sit on a chair or cushion. Seat the child close to you but sufficiently distant from other children to avoid bumping.
For children with under-responsive proprioception, allow them to play with shaving cream, play dough, silly putty, cornstarch mixed with water, rice and beans and finger-paints. Encouraged them to use scissors, construction toys, markers and chalk.
For children with over-responsive proprioception, provide calming activities such as low lighting, soft music, slow rocking, deep pressure, being wrapped in a blanket or relaxing on a bean bag chair. It is easier for children with over-responsive systems to tolerate firm touch, such as a shoulder massage, rather than light or moving touch, such as a tickle. Anticipated touch is usually better tolerated than unexpected touch.
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American Occupational Therapy AssociationSensory Integration Special Interest Section 4720 Montgomery Lane P. O. Box 31220 Bethesda, MD 20824-1220 (301) 652-2682