Occupational Therapy and Sensory Integration for Visual Impairment

Originally presented on September 20, 2021

by Dr. Vidya Pingale, MS, PhD, OTR/L

Sensory Integration therapy is an integral part of occupational therapy that is often practiced in the pediatric population, especially among youth with visual impairment. Not only is this type of therapy fun for children, it has a significant impact on emotional adjustment, personal-social skills, language, and daily routine tasks. Join Dr. Vidya Pingale for a discussion about the impact of visual impairment on sensory integration, treatment strategies, and techniques to incorporate at home.

Transcript

Vidya

Hearing sense, our taste or gustatory sense, and our smell or olfactory senses, these are the basic senses that most people know about. There are two hidden senses. One of them is proprioception which is more about what our body or what our joints and muscles are doing at any point in time. Vestibular sense is about the movement sense and it gives us information about if we are moving, we are spinning, we are walking slowly or we are running. So, that’s about vestibular sense.

So, we need all of the senses to actually make sense of the world that is around us. And we use that information to interact with the world around us, especially vestibular proprioceptive senses give information about our body and what our body is doing within that environment, and how it will interact with the environment and after the interaction, what needs to be done in order to produce better movement, or produce better skills.

So, the sensory integration in a nutshell is about the ability of our brain to organize all the information that comes through all the senses that I just mentioned, make an accurate and clear picture about our body and the world around us so that you can negotiate our day-to-day activities and interact with the world in a secure and safe manner.

Sensations are the building blocks. Sensations are the language the brain understands. If you don’t have senses, either interpreted correctly, or due to another reason it’s not reaching the brain, our brain is not going to be able to form an accurate representation of the world around us or even about your own body. As a result, your interaction with the surrounding environment is going to be affected or impacted.

When we hear a sound, somebody is calling your name, you know it’s your friend, or somebody else just based on the discriminative qualities of the sound. It allows us to know the difference between an apple versus a rock and what to do with them based on what interpretation you make about these objects. It also tells us when to duck or extend your arms to catch when you see something coming your way. This is all possible because the brain is able to make that interpretation about the senses that are constantly bombarding our brain.

So, there is something called sensory deprivation. And some children who do not receive enough tools or sensations during their early days of life in infancy, or when they are our babies, it actually has long-lasting effects on the skills that they acquire- the development, motor, cognitive, social, emotional, all of the developmental areas as such.

So, this is just a diagram of what sensory integration is about. It’s about integration of all the senses, and using it purposefully in goal-directed activity. It’s not just the motor activity, or it’s not just the movement that I’m talking about, but also it helps us regulate emotions. It regulates our activity level, we all need a certain degree of movement, a certain degree of sensory stimuli in order to stay awake and alert. When you don’t receive that kind of stimuli, you’re not motivated to interact with the environment. That is essential, especially for babies. It is very essential because through exploration, babies grow, they understand what they are capable of and what their environment is about, the boundaries of their environment, how their bodies are, their interaction, how their movement brings about the changes. Those are the building blocks of developing gross motor skills, fine motor skills, concept formation, and other social emotional skills.

This is the diagram that talks about how important the sensory integration or interpretation of sensations is. As you can see, olfactory, visual and all of the basic sensations are the foundation of this pyramid. They are based on which your postural securitydevelops, your awareness of two sides of the body develops, which is essential for bilateral coordination, ability to plan motor movements develops, ability to screen input, and development of body schema, which is more about what your body’s boundaries are, how long your hands are, what your body is doing and the spatial relationship from the objects within the surroundings. Those again, are the foundation for eye-hand coordination, visual motor skills, postural adjustments, eventually contribute to academic learning.

So, sensory integration is necessary and it happens all the time at an unconscious level. It is always happening in the background. Usually when we talk about sensory integration, there’s some degree of sensory input going through the brain and it gets screened out and interpreted and organized at a brainstem level. It’s one of the parts of the brain where sensory integration actually occurs. With individuals with visual impairment, some of the things that I’m going to talk about in the next couple of slides are actually relevant to individuals who have significant visual loss and/or visual impairment that is impacting their interaction with the environment.

Because any of the other physiological or neurological issues to sensory systems, or when visual stimuli doesn’t reach the brain, it does have some similar impact that sensory integrative function would have. Attachment is one of the areas which is crucial for our social emotional development. It’s unique – babies need to develop secure attachment with their parents. It is also a building block for communication and social interactions. The way the secure attachment develops is by looking at the parent, what they’re doing, if they’re smiling- usually babies try to imitate their parents behaviors, and there is that reciprocal back and forth, a parent sees the baby smiling, so parents actually show more encouragement, and that’s the foundation for that secure attachment.

When the baby cannot see clearly or is not able to see at all, it becomes an issue because he cannot imitate what parents are doing, be it making raspberries or making silly faces, so that interaction does impact a baby’s ability to respond and consequently parents do not see babies respond, and as a result, they decrease their interaction with the child and the development of secure attachment could also get impaired in some of the children with visual impairment.

As I said earlier, environmental exploration is essential. Exploratory play is extremely important for the growth, motor development, your social development, your emotional development, cognitive development, concept formation for your language development, environmental exploration is important. When babies, because of visual impairment, are not able to see what’s within their environment, they may not have tried to interact with the environment, they may not see something, they might hear something so, they might turn and look at it, try to reach out and go towards that particular stimuli. But visual stimulus is one of the main stimuli at that age, where that actually facilitates that drive to interact with the environment.

So consequently, because of visual impairment or lack of clarity of vision babies may not interact with the environment. And because of that, or they might show actually some of the developmental delays. It’s not necessarily because their motor system is not maturing enough. When babies are born, all of these systems are intact, that you need that in that interactive factor, with environments, with the people in order to mature the systems, and use these already prepared systems to develop skills. So in order for skill development, the fine motor, gross motor, or language and communication, you start at repeated movements as a baby, just kicking, or smiling, making raspberries and eventually, through experimentation and exploration, these kids develop skills that are more matured and refined.

One of the things that you might actually see with some of the kids with visual impairment at an early age, is stiffness of neck muscles, especially in children who have nystagmus, or lazy eye, or strabismus or even a visual impairment, because of some other conditions, which actually they tend to tilt their head, in order to get clearer and more stable visual representation of the environment. Since they all rely on certain groups of muscles, it could lead to something called torticollis. It is often seen with children with some of the developmental delays or even the babies, you’ll see some of these things early on at the tender age of one or one and a half.

Again, the other aspect of it is posture and balance. Children with visual impairment sometimes also have posture and balance related issues, partly because we do rely on visual systems to understand the visual system does contribute to our posture and balance. But there is also a proprioceptive system which gives us information about the muscles and vestibular system, which gives us information about the movement and all of those contribute to maintaining appropriate postures and balance.

When children, early on, do not get enough stimulation through different movements, these systems don’t develop well, or they develop with delays. As a result, children may have some of the difficulties in postural and balance related issues. Then again, gross motor development, because of lack of significant interaction with the environment, experimentation with movement itself will impact gross motor development as well as visual development.

One of the things to remember here is, not everybody is necessarily going to have some of these issues. It depends on the severity of the visual impairment, exposure to some of these, how you compensated for these. So, vision is only one system, right? The brain actually does take the drive to interact, the drive to grow is always there no matter what. Sometimes children will compensate by responding more to auditory stimuli or to tactile stimuli or touch, and as a parent, you have to remember to use these to engage when you’re interacting with the child to promote their development.

Again, gross motor development or motor development in general, it’s not necessarily all of the children, regardless of their visual, the level of their visual impairment, they will develop all of the gross motor milestones or they might be delayed, but they do tend to develop them. As I said earlier, the drive to interact is always there so eventually that will take over and lead to gross motor development. They might need additional support and that’s where therapy services and other professional services come into the picture. 

Some of the strategies as a parent that could be used to promote development is actually support the interactions within the environment using cause and effect toys- you press a bell and it makes a noise. Actually, enhancing the sensory stimuli that goes into the body or the brain, through auditory and tactile feedback could be used on a larger scale, if there is severe degree of visual impairment. You want to support exploration if there is a severe degree of visual impairment, the child is not going to show that level of motivation to explore and interact. So, as a parent or as a professional, you want to support exploration through tactile and auditory media as much as possible.

One of the things that happens is with the delayed milestones and the strength, because those movements do not get done as often and as quickly in some of the children, you want to promote muscle tone, you want to promote the balance and postural control to exercise, so some of the things that you could do is tummy time. It is one of the routines, not just for the visually impaired, but we recommend tummy time for all of the babies these days because it does help you to develop that muscle system that actually supports you standing upright and sitting with good posture.

You want to encourage play as much as possible. Schedule some time to go back and forth with it. If the child is using verbal interactions, do encourage those as much as possible to auditory feedback. What we continue to do, or we stop doing depends on the feedback that we receive from people around us. If you encourage some of the behaviors such as verbal feedback that you’re going to go give is auditory – so verbal directions with praise and touch, hugs and cuddles. So, positive feedback, through either touch or with your voice, can be used to promote interaction and play and develop that secure attachment with the babies.

You want to encourage gross motor movements and abilities as much as possible. You could use strengthening exercises on a day-to-day basis, vibrating pillows or pens to wake up their body, weighted pencils for older populations, cushion grips for pencils, sitting and standing by themselves when they are at toddler age or age of one. Walking on uneven surfaces and on different textures could be used to promote balance as well as stimulate your vestibular system.

You want to carry a baby in a sling with their back securely attached against you securely placed against your chest. So that even if they are not moving, or they don’t have that drive or motivation to move they are getting that vestibular stimulus, which is going to support their balance and postural control when they grow up, and consequently motor activities. You want to encourage them walking, running or even interacting with other objects in the environment that is a little difficult. So, any activities that actually involve the body like tumble play, somersaults and again, you’re going to have to think about if there are other comorbid conditions when you’re doing some of these activities.

Push and pull, tug of war and those kinds of activities could be used to give them that sensory input of proprioceptive input, vestibular input or even tactile, as well as auditory input. Running is also a good activity. One of the ways that you would encourage learning, again, it’s a different stimulus that you get when you’re running, either running together hand in hand or, for the older population running together, at the end of the rope, it also gives you the sense of freedom and you are capable of doing that, it instills confidence or self-worth.

So, either asking a playmate or sibling to run with the child, you have to make sure that wherever you’re doing that particular activity, you want to keep it safe – so clutter free and there is enough room for them to interact in that particular area. Any questions so far? All right.

Host

We have one question that came in. Can we try to restore the senses in the child when they did not get this during infancy? And how old is too old to try therapy?

Vidya

So, it depends upon the condition – if you’re talking about visual impairment, depending upon what the underlying condition is, some of these illnesses or disorders are progressive. So, a child might be born with intact vision, or very slight or minor issues with the vision and this condition progresses as the child ages. So, in those children, you’re not going to have as much of an issue when it comes to developing that secure attachment or gross motor development or postural control, or tonal issues, because if they are moving, they’re using their body. That should stimulate the sensations as it is. But then children who have severe visual impairment, you do want to start early on and it is never too late according to me. Anytime you include sensory input, your brain is plastic because your brain is capable of learning. If you give it the correct amount of input and correct methods of learning, it will absorb and develop, and you will see changes in the skill level. I hope I answered that. Go ahead.

Host

And then we just have one more. This question says My child is born with one eye, sighted, but one eye blind. Are there any development challenges or disorders associated with this type of monocular condition?

Speaker

So specifically, you will see preference towards one side of the body. So, interacting with one part of the environment. You do want to encourage them to compensate by turning the head or turning your body to look at you. So yes, strengthening one part of the body or neglecting the other part of the body are some of the things you might actually see. I don’t know how old your child is, but if you’re doing the tummy time, you want to make sure that you are actually stimulating on both sides of the body. So, your neck muscles are stretching out or your hand muscles are stretching out.

Those muscles need to be stretched out because lifting your neck up is a primary movement, and after that, then you stretch your arms and that helps you to roll over. So they might actually prefer rolling only on the one side. So, you want to stimulate- if you’re playing, you want to approach from the other side of the body so that they are actually interacting with the other side of the body where the vision is impaired as well.

I’m gonna move on to the sensory processing disorders or our sensory processing issues, which is more of the sensory integrative dysfunction that we talk about. The difference between sensory processing disorders or sensory integrative dysfunction is that the sensations are intact, but the interpretation gets kind of mushed over and because of that, individuals or kids who have sensory processing disorder tend to misinterpret the world around them and what their body is doing. As a result, you’ll see a range of manifestations for these kids.

If this particular sensory processing disorder is also present, in addition to visual impairment, then you have to actually address both of those issues. Because if you’re going to have visual impairment, and if your sensory processing disorder is impacting other systems or interpretation of systems overall, you want to make sure actually that the systems are working correctly, because you want to compensate with either the tactile or auditory systems, and if those are also impaired, then it could be quite challenging.

So, with sensory processing disorder, the main differences is, in spite of intact sensations, or most of the sensations are still intact, and in spite of the interpretation gets mushed together or disrupted, and as a result, the interaction that child has with the responses, emotional behavior or motor responses, that child shows in response to any demands or interaction with the parents or the people around are not mature or are not appropriate as such. So these are some of the ways that sensory processing disorders get segregated, or sensory modulation disorder, which is more of emotional regulation that we talk about. These children also have sensory-based motor disorder, and they have issues because they cannot move their body in a coordinated way or figure out how to catch a ball because they just don’t know how their body works. And sensory discrimination disorder is where children with sensory discrimination cannot understand the qualities or sensory qualities. Is it strong? Is it soft? Is it loud? Is it too light, and how to change not only the sounds that are coming from outside, but also how to modulate their sensory. Should they be holding a pencil tightly or too loose? Should you be squeezing the egg until it breaks, or should you be holding it lightly because it’s considered a fragile act. So, those are the things that you will see with sensory discrimination disorder, and I’m going to talk about it a little more. 

When it comes to over responsibility stimuli, they’re under-responsive. So we need a lot of stimuli in order to just resist or some of them actually respond by sensory seeking. These are the kids that are on the go all the time.

When it comes to motor base disorder, it’s the postural disorder, they will have difficulty maintaining appropriate posture or dyspraxia, or motor planning issues where they just can’t figure out how to move the body around in a coordinated way.

For all children with oversensitivity or responsivity, not just touch, but most of the stimuli, they react to it in a strong manner. So they refuse to touch something because they find that stimulus, or that particular stimuli, even if it’s a soft toy, or a furry toy, that every other child loves, they’re gonna find it as a negative experience. They might push away, they may not want to walk in the rain, they have a strong reaction, they might have a meltdown if there is even a marker spot on their hand. At the same time, they do seek deep pressure and hugs. They don’t like to get messy. So any activities that involve painting, shaving, cream, using glue, is usually a trigger factor and that could lead to a significant amount of crying or a very severe emotional reaction.

It doesn’t have to be very severe, but it is actually a negative reaction. You will see some kids learn to cope with some of this over-responsivity or defensiveness to certain stimuli by just avoiding it, and they will start verbalizing, “I don’t want to go there.” If they have good language skills, they’ll just come up with a brilliant excuse. These are the kids because they are always sensitive to tactile they like to wear long sleeves in the summer, or refuse to wear a jacket in winter. They’re reluctant to participate in new tasks because everything is unpredictable or the environment is unpredictable for individuals who are sensitive. They will prefer solitary play over playing with other kids. Because again, most of the kids are very unpredictable, they will be in your personal space, and it’s hard to judge what’s coming next. So, they instinctively just play by themselves.

The other aspect of it is they rationalize verbally, they have difficulty sitting in the circle time, they often have meltdowns or tantrums. For us, there are no apparent reasons. If they have verbal skills, and if you probe them, they will tell you what’s bothering them. And even a three-year-old kid will tell you what’s bothering them, and that actually is a clue to work around the environment to remove that particular stimulus that they are overly responsive to.

They might appear distracted. So we tend to filter out. Our brain is constantly bombarded by stimuli, right? With water dripping somewhere, there is a fire truck going in the back, there are kids playing around. But when we are talking or when you’re listening, or when we are learning, or you’re doing a specific activity- you are attending to that particular activity and you filter out everything else. For these children, they actually register each and every sensory stimuli. So they are hearing the clock ticking, they’re hearing the water dripping. And that leads to something called sensory overload because that’s a lot of stimuli to process all the time. And as a result, they could actually appear as distracted or inattentive, and they might also like or dislike the playground activities, there are wood chips there and other things that could be perceived as threatening or sensitive to.

They hold onto the rails while going up and down the stairs. They’re uncomfortable in elevators, if they have movement oversensitivity. They might seek continuous physical support because they are scared to let go and they don’t know how it would be without it. When they are always sensitive to some of the tastes or texture of food, they are basically picky eaters, they will eat only certain textures of food. So, most of the children who are picky eaters. It also impacts their ability to move around the food in order to make a bolus and swallow it, so that pudding or peanut butter are some of the things that they do not like to eat. Or they’ll stick with just one particular texture food so it becomes just macaroni and not soup and so on.

Again now, when it comes to auditory sensitivities, they do not like loud noises or vacuum cleaners. Sometimes even the A/C noises could bother them enough to have a meltdown. Again, it’s going to be on the spectrum as not everybody’s going to be excessively oversensitive and respond excessively. You might come across a range of it. When it comes to children who have under-responsivity, they are often unaware of touch unless they are very intense, or they’re unaware of bruises or falls. They might not cry when they fall. They are indifferent to falls or burns, have difficulty manipulating tools, they need to be moved. They need stimuli to get going. They don’t realize their pants are twisted or one is folded and one is not. They tend to be clumsy, often knock off things or bump into things because they are not aware of it. They’re generally disorganized, could appear as clumsy or awkward or uncoordinated.

[34:21] are exactly the opposite. They want everything that is out there. They want to touch the wall. They want to touch the toy. They want to hug you, they want to put everything in their mouth, they might crave running, or spinning. They will also fall, but it is intentional to seek the stimuli so they actually bump into things on purpose. They are the kids who will rush into a bunch of kids and often get in trouble for that matter.

These are the kids that are constantly moving, shaking their head constantly, crave intense jumping, sometimes, your heartbeat skips because they are always close to falling or getting hurt, they can go on the roller coaster rides or merry-go-round or swing for hours without getting dizzy, and so on.

Children with partial control issues also have something called body awareness issues. Because, as you know, vestibular proprioceptive stimuli and along with visual stimuli does contribute to our interpretation about what our body image is or what our body is and how far are you from the door? How far are you from the table? How far are you from the TV, and so on.

So, these children tend to have body awareness issues. Because of that, they might exhibit some of the bumping and falling and tripping, but as professional occupational therapists, we tend to separate or kind of differentiate between what the cause is. Is it body awareness? Or is it over response or under responsivity or is it because of something else.

They do have decreased movement balance, as well as, they tend to slouch in the chair, leaning too much on the table, somebody needs to tell them constantly to hold their head up, or they need to sit upright.

Children with dyspraxia have all of the coordination issues from gross motor and fine motor delays, they don’t crawl as a baby, they have delayed milestones, they need to observe other kids several times before participating in activities. Sometimes they do need hand-over-hand assistance and so on.

Children with [36:45] disorder tend to have difficulty creating movement, they might throw too hard or too soft, that will interfere with play. They tend to hold either too tight or too loose, or they often break objects that require simple manipulation because they cannot tell how forceful they need to be. Their movements are uncoordinated. They look to others before responding, look to other people responding and they’re unable to pay attention or understand and remember instructions, especially issues related to the auditory system or voice related system.

Generally speaking, because their world is so unpredictable, with children with sensory processing issues or even visual impairment, the feedback usually comes from visually or your body needs to integrate what you did and how that worked out. Were you successful in that particular movement? Were you successful in that particular interaction? That feedback helps us do better next time, or do it the same way because you were successful and help us refine these movements or these interactions. Because of either sensory processing issues or visual impairment, when you don’t get that appropriate feedback, it impacts not only the motor movements and motor growth, but then you’re not sure about what you’re doing, and you don’t have the confidence, “am I gonna do it right”? “Is somebody going to yell at me”? “Am I going to fall”? “If I touch that, is it going to bother me”, and so on. As a result, they do have emotional issues and sometimes they look like these are behavioral issues.

They might be pushy, they might come across as unmotivated or controlling. They might come across as stubborn and rigid or emotionally insecure, they may have poor social skills, or sometimes they appear, especially with sensory seeking kids, they seek so much sensation that their peer or their playmate might think “oh, he’s hitting me” but he may not be hitting, he’s just seeking a strong hug or something like that. So, that’s where the emotional issues or behavioral issues come from, it’s because they are unsure about themselves and what they do.

So, I think what that’s based on is when you are confronting sensory processing issues, the visual system is not sending enough stimulus to the brain, so that system is taken out of the picture. Regardless of what you do, our brain actually relies on a couple of systems, usually visual, auditory and tactile are the three exploratory senses that help us determine, that actually work together to give you an appropriate or accurate picture about the world around you. If you hear a big sound, and our auditory system is the first one that actually leads to orientation response, you’re gonna look at it. But then it was just a book that fell down because you saw it and you don’t need to run to the door. Worse is when you hear a big bang or big noise and you see, there is fire.  That actually means that we need to run to the door for whatever reason.

Same goes with understanding the difference between a fake fruit versus the real fruit. How many times have you walked these days and some of the plastic flowers or fruits are so real looking that you sometimes need to touch them in order to figure out if it’s real or not. Is this flower real or not, because when you see it, it looks real, but then another system kicks in to make sure it is real. So, you rely on three systems or four systems if you bring in the taste and the olfactory, or smell you rely on those to actually make a judgement about any object as such. And that concept formation and your motor development kind of goes hand in hand. That does play a role in forming concept.

So, when your visual system is not working the way it should because of visual impairment, and then the other systems should be taking over to provide the feedback and stimulus that your brain craves or needs. Then because of over sensitivity or under or over responsivity or under responsivity or sensory discrimination issues, those systems are also impacted, then you have to really work around to figure out how you’re going to provide the feedback that you need to provide.

And that’s where sensory processing or sensory integrative intervention or sensory-based interventions come into the picture. When it comes to addressing, you do want to address sensory processing issues early on. We have seen and there is enough literature and studies out there that show that sensory processing issues actually can occur concurrently with a variety of childhood disorders, including autism spectrum disorder, children with Down syndrome, Williams syndrome, and many others. Depending on the condition you’re looking at, 5-40% of the population does show underlying sensory processing issues.

You want to acknowledge if you have a younger child and you see some of these things that I just mentioned, you do want to take a deeper look at it, you want to acknowledge those issues. It’s easier when you have an older sibling, versus if it’s your first child and then you have to really rely on people around you to get the understanding about how your child is doing. For sensory processing issues, you do want to consult the occupational therapist so that they can screen or evaluate based on the manifestations or symptoms that you tell them in order to identify if it is sensory processing issues, or it is something else that needs to be addressed. One of the things that you do want to keep in mind.

Each child will be different and respond differently to the sensation, you have to be sensitive to the child’s reactions. They’re not doing it because they want to do it or they actually are inconsistent in their reaction. Today they might be fine wearing that particular shirt and the next day it is like you’re putting a shirt of thorns on them. It’s inconsistencies come from their processing issues and not because of the behavior. We tend to say that there is no behavior until the age of 3 1/2 because they are just responding to the bodily needs and their emotional needs. They’re not necessarily manipulating anything to call it a behavior.

You want to understand the sensory demands of activities, of any activity for children who have just visual impairment or children who have both together. Sensory Processing has that. If a child is over responsive to some of the tactile stimuli you want to address that by either giving long-handled brushes, cutting the tags, be sensitive when you’re taking them for haircut, maybe they’re sensitive to the temperature of the scissors or the hair that falls down and so on.

You want to be a step ahead of the meltdown or behavior that’s gonna erupt. That’s how, as a parent, you’re going to be prepared. Look for cues from a child for sensory preferences. If the child likes to jump around, maybe you want to develop an activity that will give him that particular stimuli for that appropriate activity. Make sure to use a timer so that they’re not doing it all the time. You’re doing it as part of a play, or part of a dance, or something like that. Use the trampoline at home if they crave that particular movement stimuli.

If they are oversensitive to auditory stimuli, maybe you want to structure their study area where there is no interference from other sounds as much as possible. Sometimes it’s impossible to actually do that, but you want to try and minimize sound or maybe turn off the TV or put the phones on vibration mode and so on.

One of the ways that you’re going to address sensory processing issues or in providing sensory stimuli is through some of the sensory interventions. But one of the ways is to actually provide opportunities for sensory play. And when we talk about play, it should be fun. It shouldn’t be demanding. Let the child decide what’s appropriate and what is not appropriate. Therapy is where you actually push a child to do a little bit more every day. But play, from a parent’s perspective, should be fun. It shouldn’t be too demanding, and it needs to end on a positive note. So providing opportunities to interact with some of the textures that they are not really comfortable with, or the sounds that they’re not comfortable with, is through the play environment. Definitely provide a safe and supportive environment. If they don’t want to do it, don’t trick them into touching this or doing that. That does not usually go well. You want to encourage and not force. You have to go slowly and systematically as much as possible when you’re interacting with them or helping them actually interact with an unpleasant stimuli. 

Sensory integrative therapy is used for children with visual impairment, and also with children with sensory processing issues. What sensory integrative therapy focuses on first is helping children assimilate and make a coherent picture of managing all of the stimulus that comes into the brain. It’s not just one stimulus or two stimuli, it works with swinging. If you are thinking about sensory integrative therapy, you want to go to somebody who is certified and has training in sensory integration therapy. They know the principles of sensory integration therapy and how to challenge the child to take more sensory input and build on it, or build on that sensory input and some of the skills that we talked about, be it motor skills, or social, emotional maturity and so on.

Sensory diets are another area where you actually develop a specific activity diet. So, it could be a combination of bouncing on a ball, bear hugs, or body brushing is one of the modalities, body brushing or scrubbing the body with a rough blanket, are some of the activities that are part of sensory diets and you actually do that two or three times a day or sometimes four times a day depending upon what the child needs. A therapist usually will help you identify those specific activities that help the child regulate his emotions, calm himself down and respond to sensations in a positive manner. The other aspect is, and you might have seen it around, weighted vest or compression vest. They both serve to give that deep-pressure compression. It actually helps with the body awareness also helps with attentiveness and reducing sensory seeking behaviors. You cannot just leave it on from morning to evening. You need to wear it and take it off. Because generally speaking, when you wear something, your body gets used to it and then that stimulus wears off. So, that’s why it needs to be on an on-and-off schedule in order for the weighted vest to be effective.

Some of the situations for individuals with visual impairment, or even those who have issues with the body awareness, having that secure boundary, or tactile feedback, it does help to stay seated during some of the activities. Sensory boxes, which have tons of fidget toys or different textures, beans and stuff like that, is another way to provide some of the tactile stimuli that could help them calm down or focus better.

Host

I just want to let you know we have about five minutes till 9:30, and there are a couple of questions in the queue. So, I’m not rushing you.

Vidya

These are some of the strategies for over responsivity. I already talked about it- help them identify verbally, encourage them to participate using comfort toys, if the brushes and stuff like the blanket. It is their security, they’re attached to it, so let them carry it over, and don’t abruptly take it away. Once they are secure enough, they will take it away.

I’m just going to go through the slides, so in case you want to look at it, you could look at it later because it’s getting recorded. Strategies for children with body awareness. I already mentioned some of them for sensory seeking behaviors. Chewing gum, timers with a weighted vest also work really well, sensory diets work well. Sensory integrative therapy definitely works in all of these areas. These are some of the resources for sensory processing issues you could go to. The Spiral Foundation has tons of information for parents as well as for professionals. All right, I’m gonna stop here and we’ll take questions.

Host

Okay, I’ll read off a couple that are in the queue right now in the chat. So, the first one is how does this manifest in children with cortical visual impairment?

Vidya

So, with cortical visual impairment, you will see some of these issues, depending upon the severity of it, they are going to come as insecure children, they will be reluctant to participate or interact in the environment, they may have developmental delays as well, and as a result, participation in the rest of the activities will be impacted. So, you do want to encourage them.

Some of the things that I mentioned earlier for individuals – you do want to substitute, if there are significant visual issues, you want to substitute it with tactile stimuli, hand-over-hand movement, or using tactile modeling to teach some of these movements could be helpful. And some of these are used in special schools, some of these techniques are used to teach them be it [53:30], standing on a balance beam, basically, the child puts a hand on your extremity and feels the movement and then they do it.

As a parent or as an instructor, you’re going to give them precise feedback about what they’re doing, and what is happening out there, and then respond to that. So, some of the issues you will see overlap between some of the sensory processing issues and individuals who have cortical visual impairment as well. The way you’re going to address it is going to be a little bit different. You’re not going to just do the sensory processing therapy, you want to also address the visual impairment component and start substituting with other feedback as much as possible, versus if it’s just sensory processing, then we don’t necessarily substitute it with the other stimuli- you try to give them all of the stimuli at the same time. I hope I answered that question.

Host

And then, the next one is how can we differentiate between over-responsivity in low vision, children versus ADHD? And then how can you differentiate between over-responsivities?

Vidya

So, there are specific assessments for sensory processing issues. We tend to use some of those. Some of those you will find from your school district, or even if you go to some of those websites that I listed at the end of the PowerPoint, they have informal questionnaires, and that will tell you if is it a sensory issue, or is it visual?

If it’s just because of sensory processing issues, you will see some day-to-day variation, or hour-to-hour variation, versus a child with visual impairment is going to show that behavior at a consistent level. That’s something that you actually want to take a look at. So a child with over-responsivity might be fine with a shirt today, but may not be fine the next hour. Sometimes he is in the best mood, but then another day, depending upon how much sensory stimuli he has received, or how overwhelmed he is, or if he received a good night’s sleep or not, he’s gonna be literally off the wall the next day.

So, you’ll see a lot of behavioral variation with sensory processing issues, because, depending upon what it is, their responses will change, versus with just pure visual impairment, you do want to take the assessments or informal assessment as much as possible, you do want to contact the professional if you are in doubt, the earlier the intervention, the better it is. So, if you have any doubts, you want to actually start either with your pediatrician and talk to them, or reach out to any of the therapists. So, you want to actually put it into the professionals hands to determine what it is.

When it comes to children with ADHD and over sensitivity. There is a high degree of overlap between ADHD related symptoms and sensory processing. So quite a few children – I think around 40% of children with ADHD also have concurrent sensory processing issues. Again, the profile will tell you. Usually with sensory processing issues – there are other motor issues also present and there is something called inattentive part, inattentive ADHD and there is attention deficit, there is no hyperactive part in it. And especially when there is no hyperactive part in it, then you tend to think that it is not sensory related. When there is hyperactivity involved, you want to rule out sensory processing if it is one of the contributing factors. It’s usually done by therapists. We want to look at it, do the specific evaluation and see how they are following directions. What is bothering them? How are they responding to various stimuli? Are there specific assessments that we tend to use? That will help us rule out if it’s just related to ADHD or if there is some sensory component to it?

Host

And is it possible for children to have both under responsive and over responsive symptoms?

Vidya

That’s where that sensory modulation comes into the picture where they move through the cycles of up and down. And yes, it’s possible to have all five of them, they might have sensory modulation disorder, they might also have postural issues. So, it’s not one over the other, they generally tend to have a couple of things going on together. The rule of thumb that we go by is if your sensory system – Nobody has a perfect sensory system, there are certain things that bother us, depending upon how stressed you are, how overwhelmed you are. So, it happens to each and every one of them. How much does it interfere with their play? How much does it interfere with their eating, dressing, sitting, going to school or interacting with a peer or playing with a peer?

So, those are the indicators that we want to look at. And if it’s significant enough, or if it’s affecting multiple areas, or more than two areas, or one area, then you do want to think about looking into sensory processing issues. When children are over responsive, when children get too overwhelmed, then actually the brain shuts down and at that point they appear under responsive. I was actually working with one of my clients, a very sweet child and I do not see any behavioral issues that rarely come across. But when he gets excited because he is meeting somebody or he’s going to a favorite place, he gets excited. He gets so excited that he actually becomes hyper. Otherwise, he’s a very well-rounded person. He has some over sensitivities. But what happens when he gets so overwhelmed that he starts registering whatever is coming in, until he snaps. I don’t want to say snap, but until his sensory arousal level comes back to the optimal level, or where it should be, he would look like he’s either under responsive or he is overly hyper. So, the variation might still be there. It is possible. There might be responsivity to tactile stimuli versus under responsive to auditory stimuli. So, you’ll see those patterns, and there are assessments that we use to actually determine what systems and how they are responding to sensory stimuli.

Host

How can we best support a child with vision impairment who has emotional or behavioral issues, because she is unsure of her behavior?

Vidya

The best way to support them is actually giving that secure and safe environment, a lot of encouragement, a lot of positive feedback, you want to support them. We feel good about ourselves as to what we do and what we achieve. So, you do want to engage them and teach them different skills, so that you promote that confidence and self-worth, we all need that. That happens when we do stop and people say, “oh, great, you did something so good,” and stuff like that.

A secure and encouraging environment is what you want to encourage. For behavioral issues, it depends what specific behavioral issue it is, if it’s because they are scared to participate in some of the activities, then again, you want to give as much encouragement as possible. Give them the feedback to either touch or auditory as much as possible. There are some behavioral interventions or strategies like using the tokens, using reward as part of positive behavioral reinforcement. The demands are different for individuals with visual impairment or for any kind of disability. Some of the things are too easy, we think they are easy, but then some people do need to put a lot effort into it. You want to be mindful of that and respectful of that.

I think kids, no matter how young they are, they know when you are supportive. That should also address the behavioral issues as well. And I could go into specific behaviors and address it if you want, but overall that’s what we do in therapy. Providing that safe and secure environment and an encouraging environment as much as possible. Channelizing negative behavior into positive behavior. You want to actually give them attention for positive behaviors. Doing something that is productive, or showing that, okay, I’m gonna stop crying, and then we can discuss it. When you are emotionally disturbed at that particular point, when you’re upset, you cannot have a conversation with the child or even for an adult for that matter. You want to wait for them to calm down and then talk about, “what did you do”? “What was upsetting you”? “How can we figure it out or fix it”?  “What can we do to support you”?

Host

So I do want to be mindful of the time it is about 9:40. If anybody else has any questions, feel free to send an email to me and I can forward it to Vidya. I will send out the recording later this week and I will also send out the presentation that went along with it. So, again, as you’re going through it, if any questions come up, please feel free to reach out and we will get those questions answered for you. Okay, so thank you so much Vidya, that was really great. You have a lot of awesome information. You got a lot of “thumbs up,” I’m seeing.

Vidya

Thank you. I hope it was beneficial to you. If you have any questions, or specific questions, feel free to reach out to me. I’ll be happy to answer them. And it was nice meeting you all and I hope it was informative for you, as well.