COVER STORY

Figure 1 Sensory integration - background information

Integration
The concept of sensory integration was initiated and developed by the late Dr Jean Ayres, an occupational therapist in the USA. She describes Sensory Integration as the neurological process that organises sensation from ones own body and from the environment, and makes it possible to use the body effectively within the environment (Ayres, 1989, cited in Fisher et al, 1991). Dr Ayres was particularly interested in the way in which sensory processing and motor planning disorders interfered with activities of daily living and learning. Information that is organised and integrated comes from five senses auditory, vestibular, proprioceptive, tactile and visual. Ayres hypothesised that development of these basic sensory systems and the integration of their information on the lower subcortical and brainstem area is necessary before higher-level skills will develop normally. This integration helps us function throughout life; normally this process develops between the ages of 3 - 7 years but continues to make progress and integrate after this time. Ayres considered the years between 3 and 7 to be a crucial period for sensory integration because of the brains receptiveness to sensations and its capacity for organising them at this time. The vestibular system forms the basic relationship of a person to gravity and the physical world. This system seems to prime the rest of our nervous system to operate effectively. It is the major organiser of all other sensory channels and so is thought to contribute to the development of language, understanding and speech (Ayres, 1978, cited in Mauer, 1999, p.386). The tactile system refers to touch and the way the nervous system processes the many kinds of touch from the external environment - light touch, deep pressure, temperature and pain. This system has strong links to social, emotional and body scheme development and serves as a basis for the development of praxis, perception and cognitive functioning. The proprioceptive system develops through weight bearing and movement against gravity. This sense is critical in maturation of reflexes and it provides information from muscles, joints and ligaments of the entire body. It tells us where our body parts are in relation to each other and to space, without needing to use our sense of vision. Visual feedback is important in monitoring posture and movement; visual / proprioceptive integration is critical to the refinement of spatial concepts and body percept (Fisher & Bundy, 1989; Mathews, 1988). It helps regulate attention and gives the brain vital information about a body pattern or movement that is needed in order to repeat or correct a movement pattern. This has obvious implications for functional and speech development.

Dysfunction
When children are unable to successfully integrate information from the five senses they are said to have a sensory integration dysfunction. The sensory systems are still receiving the sensations but they are unable to interpret them. There are several types of sensory integration dysfunction. The most common are the childs inefficiency in registration, modulation and discrimination of different sensory inputs. If a child cannot register information correctly he will pay little attention to most things. When a child over responds, under responds or fluctuates in response to sensory input, they are exhibiting a sensory-modulation disorder. Attention, alertness and arousal are important for basic survival. They contribute to the ability to filter out irrelevant information, to tune into important elements in the environment, to process new information for learning, and to engage in purposeful activity. The process of sustained attention, particularly the ability to differentiate novel and familiar stimuli, has been identified as important in the development of later cognition (Bornstein & Sigman, 1986; Fagan, 1982; Rose & Wallace, 1985; Ruff, 1986 - all cited in DeGangi, 1994). Sensory discriminatory disorders are a childs reduced ability to discriminate, touch, movement or body position. Dysfunction can occur within a specific sensory system - vestibular, proprioceptive or tactile - or within a combination of systems, for example tactileproprioceptive (otherwise known as the somatosensory system). The vestibular system is the balance sense, and a dysfunction results in gravitational insecurity and resistance to movement. Children exhibiting this dysfunction also seek out abnormal amounts of vestibular stimulation such as through rocking, or they avoid certain types of movement. These tendencies interfere with normal play and functional activities. The vestibular system is also responsible for muscle coordination and modulation, with a deficit affecting the articulators, body language and other non-verbal expression. Children who have a dysfunctional tactile system are likely to have difficulties in learning fine motor skills and to display tactile defensiveness by withdrawing when someone touches them. This will have obvious effects with social bonding, both in the home and preschool environment. It is through the tactile system that a child gains a sense of security and emotional well-being. Tactile dysfunction may also result in problems in articulating sounds, developing basic concept awareness and independence skills. Proprioception is the conscious and unconscious awareness of body position and movement. It is often described as the muscle sense. The common signs of a dysfunction are clumsiness, lack of awareness of body position in space, problems manipulating small objects and learning new motor activities. Difficulties of this nature can be seen in body dyspraxia as well as oral and verbal dyspraxia.

Therapy
Ayres suggested that the end product of sensory integrative therapy is the ability to communicate through language (1979, cited in Mauer, 1999, p. 387). Sensory integration treatment itself should directly improve speech and language skills without specifically targeting language abilities. The goal of sensory integration treatment is to produce mature, spontaneous adaptive responses to sensations in a meaningful, selfdirected activity within a controlled sensory environment. 4
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

Therapists who adopt this treatment technique use various pieces of equipment to provide appropriate sensory input. To provide vestibular input, suspended equipment such as platform, booster and sling swings, scooter boards and climbing apparatus is used. Tactile stimulation can be acquired by use of textured mitts, carpet squares and large inflatable therapy balls rolled across the body. Employing weighted blankets, trampolines and pushing, lifting and carrying heavy items can provide proprioceptive input.

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Figure 2 Session example

Session 8

Each child undresses to t-shirt and shorts to develop independence in self-care, and enable the therapist to provide proprioceptive and tactile stimuli to legs, feet, arms and hands as required. Each child chooses a coloured shape to wear on their t-shirt, and sits on the corresponding shape on a large therapy mat (focusing point for beginning of each new activity).

9.30 - 9.40 Warm-up gross motor activity

Children take turns on trampoline, to get proprioceptive input and enhance their alert state. Some children require a weighted bear hug vest, or are involved in other sensory stimuli to achieve their optimum state of alertness.

An integrated approach in every sense

IF YOU ARE INTERESTED IN BOTTOM-UP APPROACHES MULTIDISCIPLINARY WORKING EARLY INTERVENTION
Donna and Geraldine

9.40-9.50 Blow football

Using thick straws and polystyrene balls (developing oral-motor control and interpersonal skills such as turntaking, respect of each childs spatial area).

9.50-10.00 Hello song

Incorporating gross motor actions, motor planning, animal and vehicle sounds.

10.00 -10.25 Combined speech and language / occupational therapy activity

Introduce body parts, then play the mannequin game. Child lies in prone position on scooter-board and retrieves body parts: in the ball pool (developing tactile, proprioceptive and perceptual skills) on the ramp (developing sensory and motor-planning skills) under a large weighted therapy mat (developing proprioceptive, tactile and spatial awareness) and places body parts on mannequin.

Do slings, scooter boards and climbing apparatus have a role in speech and language therapy? Donna McCollum and occupational therapist colleague Geraldine Teague share the outcomes of their joint sensory integrative group therapy for preschool children with specific language impairment.

10.25 -10.40 Break / Independence training

Therapist chooses a helper to carry juice and biscuits on tray, and pour juice. Use straws. Followed by free-play with multisensory balls.

10.40 -11.10 Combined speech and language / occupational therapy activity

Musical chairs. When music stops, sits on the chair with the body part that corresponds to their chosen item of clothing eg. head-hat (developing classification and spatial awareness skills). Children put on socks, shoes and trousers.

11.10 -11.20 Story time

Children are more attentive and responsive to stories after receiving the appropriate sensory diet facilitated by the therapists during the previous activities.

11.20 -11.30 Individual / group parental discussion time

Outline progress made, and activities for home-practice.

n July 2001 both the Homefirst Community Trust paediatric occupational therapy and speech and language therapy departments in Magherafelt moved into the new Oaktree Therapy Centre. The rooms were purpose-built for group intervention and up-to-date technology was incorporated; for example, video linking allowing the parents to view their childrens sessions as well as giving the therapists an opportunity to tape the therapy sessions. A specialist speech and language therapist and occupational therapist, we are both trained in sensory integration techniques (figure 1). The building design meant we could establish this kind of group as a main form of service delivery for preschool children with a specific language impairment. Planning of the building included the structures necessary to accommodate the suspended equipment, and funding was given for other specialist sensory integration equipment including swings, ramps, trampolines and scooters. To evaluate the inter-disciplinary sensory integrative group therapy approach with these children, we considered two aspects of the service. Firstly, we noted formal improvements in the childs communication skills and, secondly,

parental satisfaction with the joint therapy approach and the resources available. We assessed 30 preschool children. Sixteen were suitable for a joint model of intervention as they presented with both a specific language impairment and also had sensory integration dysfunction. Three groups of five to six children received group therapy of two sessions per week, each lasting approximately two hours over a course of seven weeks. Although a pure sensory integrative approach was not adopted, there was a strong sensory integration basis to the model of service delivery (see session plan in figure 2). We also visited each childs playgroup / nursery school to encourage an integrated approach to the childs development. At the end of the seven-week block, we invited parents to the therapy centre for a progress meeting. Future therapy intervention was also discussed and we asked parents to complete a confidential questionnaire on the service. We gave each child an (approximately) threemonth consolidation block before being reviewed by both disciplines to monitor progress. We reassessed the children on certain aspects of their performance and speech and language skills, to allow pre- and post-therapy outcomes measures to be compared.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

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Thirty one children were offered appointments for assessment (figure 3) with one failure to attend. Sixteen were identified as suitable for this joint group therapy and were involved in this type of therapy provision (52 per cent). Fifteen were subsequently used for the outcome measures project. One child was not included as he was referred back to community speech and language therapy after the group as he no longer presented with a specific language impairment.
Figure 3 Children referred for assessment
Children not presenting with a sensory integration dysfunction

NUMBER OF WORDS

We assessed understanding of basic concepts (figure 6) using the Basic Concepts Sub Test of the Celf-Preschool (Wiig et al, 2000). Twelve children (80 per cent) improved, with a range from 10 - 50 standard scores.
Figure 6 Change in understanding of basic concepts

Figure 9 Change in greatest length of utterance

Post-group

7 6 5 4 3 2 1 0 1 2 3 4 5 6

Pre-group

180 160 140 120 100 80 60 40 20 0

Post-group Pre-group

7 8 9 10 11 12 13 14 15 SUBJECTS

STANDARD SCORE

52%

45%

Children who did not attend for assessment Children presenting with a specific language impairment and a sensory integration dysfunction

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 SUBJECTS

3%

STANDARD SCORE

The mean age of children starting the group was 3;9, range 3;3-4;2. The ratio of male to female children was 5:3. Children were assessed before they started the group therapy intervention and then approximately six months later. We assessed attention levels (figure 4) using Cooper et al (1978). Childrens attention and listening skills can be profiled using the four levels identified. Within each level there are three different stages of development. Thirteen of the children (86.6 per cent) moved up one level, one child moved up two levels and one child stayed at level 3.
Figure 4 Change in attention levels
12 LEVELS OF ATTENTION 9 6 3 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 SUBJECTS
Post-group Pre-group

The childs range of expressive vocabulary was assessed using the Labels Sub Test of the CelfPreschool (Wiig et al, 2000) (figure 7). Twelve children (80 per cent) improved, with the increase ranging between 10 and 60 standard scores.
Figure 7 Change in naming of vocabulary

160 140 120 100 80 60 40 20 0

Post-group Pre-group

Fourteen of the sixteen parent / carer questionnaires were completed (87.5 per cent). Results show that: - 14 (100 per cent) rated the facility their child received therapy in as excellent. - 11 (78.6 per cent) rated the joint service in terms of the assessment procedure as excellent, three (21.4 per cent) as very good. - 9 (64.3 per cent) rated the amount of therapy as excellent, four (28.6 per cent) as very good, and one (7.1 per cent) as good. - 11 (78.6 per cent) rated the quality of therapy received as excellent, three (21.4 per cent) as very good. - 7 (50 per cent) felt their child had made excellent progress in speech and language and occupational therapy since the beginning of their treatment, six (42.9 per cent) very good progress, and one parent (7.1 per cent) some progress.

Improvement
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
SUBJECTS

We charted the childrens phonological impairments using the six different levels ranging from very severe (0) to age appropriate speech (5) (adapted from Enderby & John, 1997) (figure 8). Fourteen children (93.3 per cent) improved, while the other child had no phonological impairment from the outset.
Figure 8 Change in phonology

This project was designed to evaluate the use of sensory integration principles in a joint occupational and speech and language therapy group for preschool children with specific language impairment. The two main goals were to compare pre- and post- treatment results and to evaluate parental satisfaction with

SEVERITY OF IMPAIRMENT

We assessed understanding of vocabulary using the British Picture Vocabulary Scale (Dunn et al, 1997) (figure 5). All the childrens standard scores increased, ranging from an increase of 2 to 33.
Figure 5 Change in understanding of vocabulary

6 5 4 3
(SEE APPENDIX 3)

sensory integration treatment itself can directly improve speech and language skills without specifically targeting language abilities
this service. Findings of outcome measures indicate an 89 per cent improvement in all areas of speech and language assessed. Some of these areas, for example conceptual development, received direct intervention as part of the group treatment; others did not. It is interesting to note that both areas improved. This strongly supports the view that sensory integration treatment itself can directly improve speech and language skills without specifically targeting language abilities. This study clearly demonstrates that using sensory integration principles and adopting the two positive beliefs of early intervention and multidisciplinary working can add up to a powerful

Post-group Pre-group

120 115 110 105 100 95 90 85 80 75 70

2 1 0

Post-group Pre-group

STANDARD SCORE

1 2 3 4

5 6 7 8 9 10 11 12 13 14 15 SUBJECTS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
SUBJECTS

We informally assessed the childrens greatest length of utterance heard at the initial assessment and review (figure 9). Twelve children (80 per cent) increased in the length of utterances heard.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

COVER STORY
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method of developing a childs communication skills. An integrated treatment plan can capitalise on the ways on which sensory-motor and speechlanguage skills integrate. With an integrated approach, professionals may be better able to identify the nature of the underlying neurobehavioural dysfunction and its possible contribution to deviant or delayed communication skills (Mauer, 1999). Sixteen of the thirty children with specific language impairment in this study (53.3 per cent) were identified as having sensory integration dysfunctions. Although this is a small study it has obvious implications for future assessment and treatment of children with specific language impairment. Because speech and language acquisition depends on multiple sensory processes, it is important for speech and language therapists working in the field of specific language impairment to understand the normal sensory integration process that is required for communication. This will enable them to refer appropriate children for an in-depth assessment by a trained occupational therapist. The benefits of carrying out assessment / treatment in a joint occupational / speech and language therapy format are evident in this study. We feel that the additional fact that the speech and language therapist was also trained in sensory integration enhanced the group dynamics and team approach. As one of the parents said in their evaluation: At present only a few children are lucky enough to be able to access the group therapy sessions. I know that there are waiting lists and as a parent I feel that with expanding this service more needy children would be able to have the same advantage of both these therapies. Donna McCollum is a senior clinical specialist speech and language therapist (specific language impairment) and Geraldine Teague a head III clinical specialist occupational therapist at the Oaktree Therapy Centre, 53 Hospital Road, Magherafelt, Co. Londonderry, Northern Ireland, BT45 5EX, tel. 028 7936 5080, e-mail slt.oaktree@homefirst.n-i.nhs.uk.

Anxious? So would you be if someone else directed your day and you didnt know what to expect. Information is the key.
Four sets of symbols are available: Food, Attendance, Social & Travel.

Although this is a small study it has obvious implications for future assessment and treatment of children with specific language impairment.
DeGangi, G.A. (1994) Documenting Sensorimotor Progress, A Paediatric Therapists Guide. Therapy Skill Builders, Psychological Corporation. Dunn, L.M., Dunn, L.M., Whetton, C. & Burley, J. (1997) British Picture Vocabulary Scale: Second Edition. NFER Nelson. Enderby, P. & John, A. (1997) Therapy Outcome Measures. Singular Press. Fisher, A.G., Murray, E.A. & Bundy, A.C. (1991) Sensory integration: theory and practice. F.A. Davis Company. Mauer, D.M. (1999) Issues and application of sensory integration theory and treatment with children with language disorders. Language, Speech and Hearing Services in Schools 30: 383-392. Wiig, E.H., Secord, W. & Semel, E. (2000) CELFPreschoolUK. The Psychological Corporation.

Symbols Sets are 23 per category - Key fob is 5 - Folder is 7

School Set 100 symbols. 40

All symbols are 3.5cm x 3.5cm. Symbols arrive laminated with velcro attached.

References
Cooper, J., Moodley, M. & Reynell, J. (1978) Helping Language Development: A Developmental Programme for Children with Early Learning Handicaps. London: Edward Arnold.

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DO I TRY TO IDENTIFY PREMISES THAT CAN ACCOMMODATE MULTIDISCIPLINARY GROUPS? DO I RECOGNISE WHEN CLIENTS HAVE UNDERLYING DIFFICULTIES THAT WOULD BENEFIT FROM A JOINT THERAPY APPROACH? DO I HAVE SUFFICIENT UNDERSTANDING OF NORMALITY IN AREAS OTHER THAN SPEECH AND LANGUAGE?

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005