Clinical reasoning guide imperator blanche (2003)

A. Four questions that guide the assessment process:

1. The individual sensory systems.
2. How they process input
3. How the sensory systems interact
4. So what? The relationship to functional performance or the
reason for referral.
B. What
1.
2.
3.
4.

sensory systems influence the childs performance

Tactile system
Vestibular system
Proprioceptive system
Visual/auditory/gustatory

C. How does the child process input over time?

1. Signs of poor registration, delayed responses and/or hypo
responsiveness
2. Signs of poor modulation and hyper responsiveness
3. Signs of poor discrimination
D. How do the sensory systems interact?
E. So what???
1. What are the functional deficits presented by the child
2. What are the strategies the child used to cope in the
environment
3. What is the relationship between sensory processing and
functional performance or the reason for referral

SnehRERC
Advanced Sensory Integration Workshop January 2014

Clinical reasoning using a sensory integration frame of reference

I.

Designing intervention

Interpretation: following the evaluation, the therapist synthesizes the

evaluation data to form the impression regarding the specific nature of
sensory integrative dysfunction and verifies impression with the client.
Planning: using the interpreted evaluation data, the therapist generates a
plan that will capitalize the childs strengths and interests and build capacities
and performance skills.
Intervention: adjusts the sensory demands of the environment, uses
environment affordances, and provides the appropriate scaffolding so that the
child can be successful in making adaptive responses.

Sensory integration disorders a proposed model

Sensory systems
Detection
/registration/
sensitivity

Vestibular
Hypo response
Postural/
Oculomotor/
Bis

Discrimination

Hyper
response

Proprioceptive
Hypo response
(may affect
modulation
and motor
planning)

Tactile
Dyspraxia

Dyspraxia

Hyper
response
Gi

Increased
response

Tactile
defensiveness

SnehRERC
Advanced Sensory Integration Workshop January 2014

Other systems

Modulation
disorder
Documents impression of sensory processing of information from each of the
sensory systems considering the following questions:
(put a check or minus in each box accordingly)
a. Does the child detect the stimuli?
b. Does the child tolerate and accommodate to the intensity of the stimuli?
(modulation)
c. Does the child decode useful information from the stimuli? (discrimination)

Visu
al

Vestibul
ar

Propriocepti
on

Tactil
e

Auditor
y

Olfacto
ry
/gustat
or

Interocepti
on
(informatio
n from
internal
organs and
systems)

Registration
Modulation
Discriminati
on

4) Using the evaluation data, consider the primary interrelationships between

sensations and decide which sensations to use and focus on during intervention.
a. What sensations is the child using to learn about their
environment? (good discrimination)
b. Is the child seeking sensation from that system in their play?
c. What sensory information is the child not discriminating well?
d. Is the child avoiding that sensation in their daily routine?
Hyporeponsive?
Hyperresponsive?
e. What are the primary functions of the systems that do not work
well?
f. What sensation that works well can also contribute to those
functions?
What activities will use those sensations and reinforce the
processing of weaker sensory systems?
g. What activities can use the sensory systems that work well and
address the identified functional challenges?

SnehRERC
Advanced Sensory Integration Workshop January 2014

5) Consider the following with regard to motor skills

a. Neuromotor issues
b. Muscle tone
Flexion
Extension
c. Postural control
d. Oral motor skills
e. Hand skills
f. Ocular motor skills
g. Bilateral motor skills
h. Ability to perform projected action sequences
6) Consider the following with regard to praxis
A. Creativity
B. Ideation
C. Construction
2-dimensional
3-dimensional
d. Sequencing
e. Use of language to sequence and follow directions
f. Motor planning
Oral
Postural
Ocular
Visual motor
g. Organizing patterns and routines
h. Organizing future events
7.
Consider the external and internal factors that contribute to sensory
modulation and the childs ability to sustain an optimal state of alertness and
learning.
A. What is interfering with the childs ability to cope and recover from
events within their day?
B. What can be changed to improve to insure the childs ability to sustain
an optimal range of arousal?
C. How can i modify the sensory qualities and difficulty of the task to
improve the childs ability to cope and engage?
D. How can i modify the nature of the childs human relationships to
improve the childs ability to cope and engage?

SnehRERC
Advanced Sensory Integration Workshop January 2014

E. What can i modify about the environment to improve the childs ability
to cope and engage?
F. What are the rules of the culture that can be modified in order to
improve the childs ability to cope and engage?

Analyze qualities of the external human and environment factors (activity,

relationships, environment and culture) and how they impact the internal factors
(emotion, attention and sensory processing)
Activity

Relationships

Environment

Culture

Emotion
Reactivity to
sensation
Attention

8) Taking the information into account from the above tables, consider the
external (environmental) factors that can be used to enhance sensory
processing, skill, and [raxis
This information is used to formulate the action plan taking into consideration
the interpretation of assessment data and principles of sensory integration
theory.
1. Activity-based consideration
2. Therapist-child relationship consideration
3. environmental considerations
4. Cultural considerations

1. Therapeutic activities
1. What are the sensory features of the activities
2. What are the motor demands of the activities
3. How many steps or parts is there of the activity
4. What is the sequencing demand of the activity
5. What is the speed of the activity
6. Does the activity require holding still or moving while performing
2. Therapist-child interactions
Determine the amount of scaffolding (therapist assistance) that is needed
1. Determine what the child is capable of doing
2. Determine what interferes with the childs successful engagement
3. Provide the child with the necessary support to achieve their goal
4. Structure the environment in a way that entices the child to explore
and play

SnehRERC
Advanced Sensory Integration Workshop January 2014

5. Grade the level of challenge within each activity to allow the child to
make adaptive responses to age appropriate challenges.
3. Determine the environmental affordances (things in the environment that
are enticing and available for the child to explore and manipulate.
1. Determine what sensations,objevts, ideas, and people interest the child
2. Consider the sensory features of the overall environment
3. Consider the sensory value of individual pieces of equipment and
potential uses
Consider the various cultural rules and expectations in which the child functions.
1. What are the rules and expectations at home?
2. What are the rules and expectations at school?
3. What are the rules and expectations of the community and extra-curricular
programs?
4. What can be modified to improve the childs ability to participate?

SnehRERC
Advanced Sensory Integration Workshop January 2014