Sensory Integration

and
Chronic Schizophrenia: Past, Present and Future
Virginia J. Hixson and Arthur W. Mathews.

Abstract
This paper briefly outlines the therapy of sensory integration as developed by Dr. A. Jean Ayres, including a breakdown of the most prevalent types of dysfunction. In an extensive literature review which includes writings from 1811 through to the present day, the symptoms of schizophrenia which may be related to sensory integrative deficit are then examined. Finally, current research and treatment programs which utilize sensory integrative treatment with schizophrenics are reviewed, with emphasis on a program review conducted at Whitby Psychiatric Hospital in Ontario, 1981. Implications for future treatment and research are explored.

Basic Sensory Integration Theory

The theory of sensory integration was developed in the 1950's by Dr. A. Jean Ayres (Ayres, 1974) and was applied specifically to learning disabled children. Since then, research by Ayres and others (Silberzahn, 1975; Rider, 1978; Endler and Eimon, 1978; Larson, 1982, Ottenbacher, 1982 etc.) has led to a continuous modification and refinement of the theory. Essentially, sensory integration involves taking a sensation in, processing the information, and then connecting this to make sense of the environment. This ability develops in a predictable, genetically determined sequence, and if this is delayed or modified, sensory integrative dysfunction results. Such a dysfunction hampers a person's ability to relate to his environment, and therefore affects his ability to adapt to the changes required in effective daily living. According to Dr. Ayres. "Sensory integration, or the ability to organize sensory information for use, can be improved through controlling input to active brain mechanisms." (Ayres, 1974, p. 15). In treatment, the ontogenetically earlier systems (i.e. vestibular, tactile and proprioceptive), are given primary attention, as sensory integration aims at promoting sequential development and as they seem to have the most widespread effect on general function, (Ayres, 1974; Ayres, 1974b; Barr, 1979).

primary to sensory integration and its function so specialized, that it is generally accorded consideration separate from that given to muscle, joint and ligament proprioception (Bellhorn, 1972; Ayres, 1974; Ayres, 1974b; Barr, 1979). The role of this system is often overlooked as its functions take place largely below the level of awareness. Sensations are evident only when the system is disturbed or when the digestive tract is affected, giving rise to dizziness, vertigo, nausea, a feeling of faintness, or a 'lost in space' feeling that has been referred to as postural insecurity, or 'primal terror'. (Ayres, 1974; Weeks, 1979; Shaffer, 1979). The vestibular system is constantly receiving input from the force of gravity and allows one to detect motion (vertical, horizontal or rotary) especially acceleration and deceleration, as these affect the semicircular canals in the inner ear. The constant reception of the earth's gravitational pull helps in the development of a basic sense of security, a sense that the ground will always be where it is expected to be.

Proprioceptive Function and Praxis:

Proprioception refers to information about the body arising from muscle, joint and ligament receptors as well as those associated with bone. As with vestibular input, if the system is functioning normally, much of the information received by these receptors does not reach the level of consciousness unless attention is concentrated on it. Proprioception is critical to the motor action by which reflexes, automatic responses and planned motion occur and is therefore basic to human survival. Proprioception can be subdivided into a kinetic sense (sensation of active or passive movement, an awareness of the motion of a limb or body part) and a static sense (a sense of position). The development of proprioception serves as a base for the development of both praxis and visual perception, (Ayres and Heskett, 1972; Ayres, 19

Vestibular function:
The vestibular apparatus, strictly speaking, is part of the proprioceptive system, however its importance is so
Virginia J. Hixson, 0.T.R., 0.T.(C). Sr. Occupational therapist, Occupational Therapy Department, Whitby Psychiatric Hospital, Whitby, Ontario. Arthur W. Mathews, B.Sc. (0.T.) Occupational Therapist, Occupational Therapy Department. Whitby Psychiatric Hospital. Whitby. Ontario. FEBRUARY/FVRIER 1984

1974; Silberzahn, 1975; Montague. 1978; Shaffer, 1979; Resman, 1981). Without good proprioceptive information about the extent and force of larger movement. the development of praxis and correct body scheme is hampered. Ayres states: The body scheme is basic to all motor action. It is defined as the knowledge we have of the construction and spatial relationship of the different anatomical elements such as finger, legs, arms, that make up the body. It involves being able to visualize these elements in the movement and in different positional relationships... Active motion provides the individual with the knowledge of his physical self, how it is related and how it can deal with space (body scheme). Motion enables the body to learn the most about its relation to space for motion elicits the greatest number of proprioceptive impulses. (Ayres. 1974b, p. 52). Poorly developed body scheme results in what Ayres terms developmental dyspraxia. In extreme cases this may mean the inability to unconsciously plan a simple movement such as standing up or picking up an object from a table. This necessitates the employment of higher level cortical function for these low level tasks at the expense of internal energy resources and efficiency. In a review of neurophysiological experiments related to cortical and subcortical integration of sensory stimuli, Foulks (1960) found considerable evidence indicating that if one concentrates on a motion, this has a detrimental effect on the quality and accuracy of that motion. Additionally, muscles controlled by attention fatigue rapidly. It was found that more afferent impulses were received in the cortex when attention was not being directed toward a movement in execution. Thus, the neurophysiological result of dyspraxia compounds the problem. Visual skills and perception are also affected by poor proprioceptive function as inadequate information from the muscle spindles in fine occular muscles results in poor occular control. The development of visual perception is thus inaccurate and unreliable, interfering further with higher level learning.

tically early system, when balanced by the more advanced discriminative system, continues to serve a valuable function in alerting the individual to close stimuli and in preparing him (physically and emotionally) in dangerous situations. Adaptive behaviour and modern life however, require more than a general alerting and a diffuse response to danger. One must have more specific information about the environment. If the body is constantly dealing with ' touch as a warning of danger. giving necessary attention to the finer aspects of tactile stimuli becomes impossible. For effective function, the discriminative system must be able to inhibit the excitation of the protective system. Additionally however, when danger does threaten, the person must be alerted to it and be able to respond quickly. Ayres (1974; 1974b), postulates that the balance of two well functioning systems fluctuates to meet the requirements of the specific circumstances an individual finds himself in. If the person is threatened or if the system is malfunctioning, the protective system dominates. Otherwise, the discriminative system is predominant. Disorders in tactile perception may occur in either system or may be noticed as an imbalance in the two. If an imbalance exists, its most common manifestation is tactile defensiveness which is connected with fear of touch, increased motor activity, anxiety and withdrawal, (Ayres, 1972; Ayres, 1974; Ayres, 1974b; Montague, 1978). The second functional cutaneous afferent system postulated, that of discriminative touch, serves as a source of specific tactile information about the environment. Through the manipulation of objects and the tactile input involved in moving objects, the individual develops form and space perception and develops reliance upon the tactile messages his system receives. Dysfunction in the discriminative tactile system results not only in poor tactile accuracy, but also hampers the development of body scheme, motor coordination and form and space perception. Tasks which others find easy, e.g. dressing, become monumental without reliable tactile information. Self confidence and self esteem suffer.

Tactile Function:
Closely connected with praxis through factorial studies is the tactile system, (Ayres, 1966; Ayres, 1971; Geddes, 1972; Ayres, 1974b). Ayres (1974; 1974b) postulates dual functional cutaneous afferent systems (1) a protective system which responds to stimuli with movement. altertness and a high degree of affect (often negative), and (2) a discriminative system which is used in the interpretation of stimuli in a temporal and spatial sense for cognition. This duality was earlier identified by Head (1920). who named these the "protopathic" (protect) and the "epicritic" (discriminate) systems. The major purpose of the protective tactile system is to warn of potential harm and to assist in preparing the body for defense. It tends to interpret cutaneous stimuli as signs of danger and responds by eliciting the emotions and physiological changes appropriate to fight or flight and by evoking motor activity. This phylogene20

Bilateral Integration:
Another problem related to sensory integration which Ayres adresses is that of poor bilateral integration, (Ayres, 1971; Ayres, 1974; Ayres, 1974b). Often linked with vestibular disorders, the most significant characteristic of this dysfunction is a tendency to use each hand independently of the other and on its own side of the body. Since the symptoms of this problem are a tendency rather than an inability, this disorder is easily overlooked. Adequate bilateral motor function requires first of all, two acceptably coordinated extremities. Kephart (1960) suggesied that laterality (an internal awareness of the difference between the two sides of the body) must be learned by experimenting through movement with the two sides of the body and with their inter-relationship. A person with poor bilateral integration will tend to do tasks one-handedly. thereby missing this movement experience. A true hand dominance for
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tasks is not established. Ayres hypothesized that "the failure to integrate function of the two sides of the body reduces the tendency to establish one hand as the dominant hand because the non-dominant hand performs most of the motor duties on its side of the body." (Ayres, 1974b, p. 140). The ability to use the hands together becomes more important with increased age, as more complex tasks are required in daily life experiences. Again, the more affected a person is by this dysfunction, the more difficulty he will have in attempting complex motor tasks and self confidence will suffer.

Sensory Integration as Related to Schizophrenia

In his book, SCHIZOPHRENIA: SCIENCE AND PRACTICE, Shershow (1978) includes writings of many modern 'experts' on schizophrenia, e.g. Borus, Hollister, Kety, Klerman, Lidz, Snyder, etc. Regarding a definition of schizophrenia, he states: "The point, of course, is that the definition of 'schizophrenia' has varied tremendously throughout modern psychiatric history, not to mention the period prior to the modern era." (p. 4). The greatest consensus identified was that process schizophrenia, or "poor prognosis schizophrenia" was a true schizophrenia. Process schizophrenia is "characterized by a gradual decline of activity, dullness, autism, ideas of reference, thought disturbances, prolonged history of maladjustment, poor physical health, difficulties at home and in school, abnormal family relationships and somatic delusions." (Wolman, 1973, p. 339). Another definition of this category reads: "those forms of severe schizophrenic disorders in which chronic and progressive organic brain changes are considered to be the primary cause and in which prognosis is poor, as contrasted with reactive schizophrenia.'; (Stedman, 1976, p. 1259). It is the chronic or process schizophrenic with which this paper is primarily concerned.

Past:

Vestibular Function:
In 1811, (reprinted in 1977) Cox published case studies describing the effect of his use of a special swing (vestibular sensory input) on the treatment of the mentally ill. Although many of his patients resisted its application and it was sometimes seen by the patient as a punishment, Dr. Cox states: ...after a very few circumvolutions a degree of change was observed, both as to the appearance of the features and the mind: the former expressed apprehension, while the ideas, though confused, did not seem to crowd so rapidly... surrounding objects though they must have appeared indistinct and confused from the gyration, attracted the attention, and became the subject of conversation... on suspending the motion, both mind and body in a few seconds resumed their former morbid peculiarities ...I could detail other cases where considerable relief was procured by swinging..." (Cox, 1977, p. 3, 4).
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For decades the involvement of the vestibular system in schizophrenia has been under examination. Studies comparing nystagmus responses, (vestibular-occular reflex, an indirect measure of vestibular function) of schizophrenics with those of the normal population were undertaken as early as 1940 (Angyal and Blackman, 1940), and have shown this population as having a marked deviation from the normal reaction e.g., decreased duration, decreased number of beats, greater dysrhythmia (Schilder, 1933; Angyal, 1940; Freeman and Rodnick, 1942; Leach, 1960). With the advent of electronystagmography a small number of studies, (Rosenblum and Friedhoff. 1961; Levy, Holzman and Proctor, 1965) have shown no significant difference of nystagmus response between schizophrenic and normal populations. This may be due to the type of schizophrenia included in the studies or medication effects, neither of which were clearly report-ed. Other studies using electronystagmography continue to show differences, notably Colbert who, when studying nystagmus responses in schizophrenic children, found an average duration of zero. Most of these subjects found the experience pleasurable and none showed any sign of dizzines or nausea. Similar results were found with caloric stimulation (Douglas, 1982). Numerous reports suggest that there is some connection between nystagmus and schizophrenia. Scientific methodology has consistently linked psychosis in both children and adults with disorders in the vestibular system (Angyal, 1940; Freeman, 1942; Ayres, 1972; Montague, 1978; Weeks, 1979; Rider, 1979). Postural reflex development and muscle tone, largely vestibular traits, have been identified as irregular in many schizophrenic people. Silver and Gabriel (1964) found residual primitive postural responses and decreased muscle tone in 30 out of 39 boys diagnosed as schizophrenic. Endler and Eimon (1978), found comparable results in a study with adult schizophrenic patients. In more recent times, a cross-cultural study of tetraataxiametric (four point weight bearing) patterns of static balance in adults, by Kohen-Raz and Hiriartborde (1979), found that the sub-group of subjects who were emotionally disturbed but neurologically normal was characterized by a significantly more pronounced posterior weight displacement relative to that of the remaining subjects in France, suggesting differences in posture and balance in that group. All other groups studied across four nations showed no appreciable difference. Schilder (1933) considered the vestibular system to be the primary organizer of sensory information and saw it as having a direct link with emotions through the limbic system. Anatomically this is supported (Barr, 1979; Dimond, 1980; Douglas, 1982). Ornitz (1933) hypothesized that the schizophrenic person limits his motion to avoid perceptual distortions which can be induced in a disordered system by motion and suggests that vestibular disturbances and disturbances of the perception of one's own body are related. Hubbard, in his study of skyjackers who exhibited schizoprenia post-skyjack concludes: Essentially, the skyjacker appeared to be driven to commit his extraordinary crime by a combination of 21

an intense sense of unreality and clear suicidal intent. Substantial evidence has been accumulated to the effect that the skyjacker developed an inordinate awareness of his personal inability to maintain a stable physical equilibrium. vertically as well as both on a literal and on an angular axis. His psychic disequilibrium appears to have clear associative patterns with his physical disequilibrium... equilibratory defects create great difficulties in achieving psychic homeostasis intrapersonally and interpersonally'. (Hubbard, 1971, p. 230).

Proprioceptive Function and Praxis

In 1972, Gellhorn related proprioception with emotion in a cause/effect relationship, stating that proprioceptive discharges contribute to the physiological processes underlying the emotions in two ways: (1) By setting the hypothalamic balance determined by the posture of the body the total quantity of impulses from the proprio-impulses arriving in the posterior hypothalamus per unit of time serve as a regulator. (2) By facial expression input from contraction patterns leads to afferent impulses via the hypothalamic-cortical system which interact with the tactile impulses of the expression in the cortex. In 1940, Angyal related many of the hallucinations common in certain types of schizophrenia to a proprioceptive and tactile base. These are often included in clinical descriptions of the schizophrenic. "The general behaviour appears odd in many ways: mannerisms, grimaces, purposeless acts, stereotyped motions, impulsive gestures are observed." (Angyal, 1940, p. 616). At times motion is reported to be exaggerated, at times to be severely limited. Both can be explained through application of sensory integrative theory. Excessive, exaggerated or stereotyped motion may increase both vestibular and proprioceptive input. Severely limiting motion can be indicative of postural insecurity or tactile defensiveness in an adult.

rity and differentiation of the self." (1978, p. 71). He continues. The failure to differentiate clearly between self and non-self which is so characteristic of schizophrenic patients, is. as Piaget has described, a normal characteristic of the young child. It represents the egocentricity of the `sensori-motof period and to some degree the 'preoperational' state of cognitive development... Overcoming this initial egocentricity' is vital to human development for many reasons but especially' for cognitive development because no true category formation can occur unless the self can be excluded from a grouping or category. nor can object constancy be achieved. (Lidz, 1978, p. 81). The tactile system forms the literal boundary between the self and non-self, and as such appears vital to the establishment of individual identity and ego strength.

Present

Tactile Function:
A second neurological system central to sensory integration is the tactile system. Referring to this, Montague wrote: "Although touch is not itself emotion, its sensory elements induce those neural, glandular, muscular and mental changes which, in combination, we call emotion..." He further states that contact (touch) seeking is the foundation upon which all subsequent behaviour develops (Montague, 1978, p. 103). Lacombe refers to the ego as being the perception of the bodily self "...and w-hat one feels and knows of the body is the skin." (in Montague, 1978. p. 88). In describing schizophrenia, Weiner (1958) related tactile failure to estrangement, uninvolvement, lack of identity, detachment, emotional shallowness and indifference. "Another basic characteristic of schizophrenic patients." states Lidz. "is their tenuous self boundaries (sometimes termed 'ego boundaries'). which lead to confusions between what arises within the self and what is outside it and to deficiencies in maintaining the integ22

As mentioned in the review of basic sensory integrative theory included earlier, factorial studies have linked visual-motor problems with dysfunction in the more basic tactile and vestibular sensory modalities, (Ayres, 1964; Ayres, 1966; Geddes, 1972; Ayres, 1974; Montague, 1978). Kenny and Rohn, (1979) found that adolescents who attempted suicide showed a significantly higher incidence of visual-motor problems during psychological testing than did a comparable group of normal adolescents. Their findings suggested that unrecognized learning disabilities might be an additional stress in life which could increase susceptibility to suicide. The importance of early sensory stimulation to development was shown by Melzack. (1962) who demonstrated that even mild deprivation of patterned visual stimuli during early maturation of dogs resulted in greater difficulty in perceptual discrimination and in the ability to utilize the discrimination in a new learning situation. In adult humans sensory deprivation has resulted in emotional, perceptual, and other behavioural deterioration. There is repeated reference to lack of organizing, structuring and relating of the self to objects and objects to objects, (Solomon, 1961; Silver and Gabriel, 1964; Gellhorn, 1972; Montague, 1979; Hubbard, 1971; Resman. 1981). In a study of mice with vestibular defects, Douglas (1982) found that there was a marked increase in vestibular self stimulation, antisocial behaviour, agressive behaviour, and a decrease in nuturing and parenting skills. Such studies show results which appear similar to the clinical picture of the person with sensory integrative dysfunction and to that of schizophrenia. Ornitz (1973) suggested that faulty modulation or inadequate homeostatic regulation of sensory input, (i.e. sensory integrative dysfunction), may result in severe emotional stress and may be the mechanism that produces hallucinations in schizophrenia. Lerner (1968) generated and confirmed a hypothesis that in a sample of schizophrenic patients there is a correspondence in developmental level between cognitive-perceptual functioning and social effectiveness and that the level of
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cognitive-perceptual functioning is predictable from the level of social effectiveness. The preceeding authors have connected dysfunction in the sensory systems primarily targeted in sensory integrative treatment, or their integration as being highly involved with emotions, emotional disturbance and more directly with schizophrenia.

Application
King, (1974) began reporting on the symptoms of sensory integrative dysfunction which she noted in chronic schizophrenic patients and since then attention has been focused on the implications this holds for occupational therapy treatment with this difficult population. The underlying theoretical concepts for her use of a sensory integrative approach with this population are based on the premises that: 1. Schizophrenics often show poor ability to move automatically (motor plan). This is shown in psychomotor retardation, perseverative behaviours, and disruption of speech patterns. Motor planning is related to all of the primary sensory systems considered by Ayres. (Ayres, 1974, 1974b, 1971). 2. Schizophrenia has often been associated with postural-vestibular difficulties such as excessive primitive postural reflex patterns, unstable posture, and postural insecurity (Ornitz, 1970; Montague, 1978; Douglas, 1982). 3. The vestibular system is in continuous contact with the limbic system, thus having a potentially strong effect on the emotions (Schilder, 1933; Barr, 1979; Dimond, 1980; Douglas, 1982). 4. Vestibular and tactile input have a strong effect on basic arousal levels, even affecting physiological signs such as blood pressure, heart rate, and respiration (Ayres, 1974; Barr, 1979; Montague, 1978). Recent studies with adult schizophrenics have shown sensory integration treatment as effective in promoting verbalization, gait and posture, body scheme and on a short term, decreasing overt psychotic behaviour. Most of these studies were short, with treatment being given for an average of six weeks. None of these studies were designed with a control group to control for the possible biasing of the Hawthorne effect, and all were done with less than ten subjects participating, (King, 1976; Levine, 1977; Rider, 1978; Leville, 1981). At the present time, several facilities in Ontario are considering establishing a sensory integration program for their chronic schizophrenic population. One such program is found at Whitby Psychiatric Hospital (WPH). WPH is a large facility, serving urban and rural areas and both an acute and chronic psychiatric population. The sensory integration program is an outgrowth of the occupational therapy assessment unit, organized in 1977. By 1978 it was operating as a separate speciality area. Currently the program is comprised of three treatment groups, indiv idual treatment sessions and assessment, which utilize the Bruininks-Oseretsky Test of Motor Proficiency, the Purdue Perceptual Motor Survey, the Southern California Sensory Integration Test, the
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Southern California Postrotary Nystagmus Test, and clinical observations as suggested by Dr. Ayres. (1974). In the fall of 1981 a review of the sensory integration program participants was undertaken in which results from pre and post treatment assessments (BruininksOseretsky and Purdue), were analyzed and compared with similar testing of non-treated patients with an eleven month interval between pre- and post- testings. The results of this analysis highlighted a number of significant trends. In particular, the treatment group consistently improved on the two measures utilized while the non-treated group had instances of decreased or stagnated function. This improvement in the treatment group approached statistical significance in the fine motor function composite and the battery composite of the Bruininks-Oseretsky test and in all three sections of the Purdue battery. In comparing the two groups after the eleven month time span, (between initial and post-test), the treatment group had improved more than the non-treatment group to a degree which approached statistical significance on four measures; the Bruininks- Oseretsky gross motor composite, upper limb co-ordination measure and battery composite, and the Purdue perceptual-motor match task. It is felt that with a larger group size, and the resultant smaller standard deviation, statistical significance would be achieved on these measures.

Future:
Many indicators point to the possibility of a sensory integrative basis for chronic schizophrenia, ranging from literature published in 1811 to more recent works. Due to the subjective nature and multitude of confounds associated with many of these indicators, the immediate future holds primarily the promise of increased structured research aimed at developing a more definitive statement regarding the nature of chronic schizophrenia and its relationship to sensory integration. The application of sensory integrative theory to chronic schizophrenia offers a possible explanation for variabilities observed in this confusing diagnostic category. Differing symptomatology may be related to dysfunction in different sensory systems or in the way they interact. It is possible that the difference between reactive and chronic schizophrenia is related to the strength with which the basis of sensory integrative function has been formed. With stress, a stronger system may collapse and then re-integrate, whereas a weaker system may be unable to do so, and deteriorate further. In the longterm, if the connection postulated is supported through research, two major benefits will be accrued. Firstly, this will serve as the foundation for the development of a non-invasive treatment modality for a most difficult clientele, and secondly, this may aid in the development of preventative strategies. With the early recognition of sensory integrative difficulties and a greater knowledge of the implications this holds for the individual it may be possible, through early intervention, to decrease the incidence of process schizophrenia in future generations. 23

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Angyal, A., & Blackman, N. Vestibular reactivity- in schizophrenia. Archives of Neurological Psychiarry. 1940, 44. 611-620. Arieti. S. Schizophrenia - trier aspcts in S. Arieti (ed.). American handbook of psychiatry. New York: Basic Books. Inc. 1959. Ayres. A.J. Interrelations of perception. function. and treatment. American Journal of Occupational Therapv, 1966. 20. 288-292. Ayres, A.J. Tactile funetions: their relation to'hyperactiy e and perceptual motor behaviour. American Journal of Occupational therapy. 1969, 18. 6-11. Avres. A.J. Characteristics of types of sensory integrative dysfunction. American Journal of Occupational Therapy, 1971. 25. 329-334. Ayres. A.J. Types of sensory integrative dysfunction among disabled learners. A merican Journal of Occupational Therapy, 1972. 26. 13-18. Ayres, A.J. The development of sensory integrative theory and practice. Debuque, Iowa: Kendall/Hunt Publishing Company, 1974, (a) Ayres. A.J. Sensory integration and learning disorders. Los Angeles: Western Psychological Services, 1974. (b) Ayres, A.J.. & Heskett. W.M. Sensory integrative dysfunction in a young schizophrenic girl. Journal of Autisrn and Childhood Schizophrenia. 1972. 2. 174-181. Barr. M.L. The human nervous system - an anatomie viewpoint. (3rd ed). New York: Harper and Row, Publishers, 1979. Belmont, I. & Birch. H. Perceptual evidence of CNS dysfunction in schizophrenia. Archives of General Psychiatry, 1964, 19. 395-408. Cox, J.M. Swinging - case histories. Center-for Study of Sensory Integrative Dysfunction Newsletter, 1977, 5 (2). 7-10. Douglas, R. Vestibular contributions to higher mental processes, Los Angeles: Center for Study of sensory Inte&rative Dysfunction, 1982. Endler, P., & Eimon, M. Postural and reflex integration in schizophrenic patients. American Journal of Occupational Therapy. 1978, 32. 456-459. Foulks, F. Cortical and subcortical integration of sensory input and implications for occupational therapy, in Ayres, A.J. The development of sensory integrative theory and practice. Debuque, Iowa: Kendall/Hunt Publishing Company, 1974. Freeman, H., & Rodnick, E. Effect of rotation on postural steadiness in normal and in schizophrenic subjects. Archives of Neurological Psychiatry, 1942, 48, 47-53. Geddes, D. Factor analytic study of perceptual-motor attributes as measured by 2 test batteries. Perceptual and Motor Skills. 1972, 34. 227. Gellhorn, E. Motion and emotion - the role of proprioception in the physiology of the emotions. Psychology Review. 1964. 71. 457-472. Head, H. Studies in neurology, (v.2). London: Oxford University Press. 1920. Hubbard, D.G. Skyjacker: his flights of fantasy. New York: The Macmillan Company. 1971. Kenny, T.J., & Rohn, R. Visual-motor problems of adolescents who attempt suicide. Perceptual and Motor Skills. 1979. 48. 599-602. Kephart, N.C. The slow learner in the classroom. Columbus, Ohio: Charles E. Merrill Books Incorporated, 1960. King. L.J. Sensory integrative approach to schizophrenia. American Journal of Occupational Therapy, 1974, 28, 529-536. Kohen-Raz, R., & Hiriartborde. E. Some observations of tetra-ataximetric patterns of static balance and their relation to mental and scolastic achievements. Perceptual and Motor Skills, 1979, 48, 871890. Larson, K.A. The sensory history of developmentally delayed children with and without tactile defensiveness. A merican Journal of Occupational Therapy, 1982, 36, 590-596. Leach, W.W. Nystagmus: an integrative nueral deficit in schizophrenia. Journal of Abnormal and Social Psychology, 1960, 60. 305-309. Learner, M. Correlation of social competence and cognitive-perceptual functioning in male schizophrenics. Journal of Nervous and Mental Disease. 1968, 148. 468-490. Leveille, J. Outline of a sensory integrative approach with a chronic tactile defensive schizophrenic. British Journal of Occupational Therapy. 1981, 45, 145-148.

Levine, O'Connor, H.. Stacey. B. Sensory integration with chronic schizophrenics: a pilot study. Canadian Journal of Occupational Therapy. 1977, 44. 15-17. Levy. D.. Holzman. P.. & Proctor, L. Vestibular responses in schiiophrenia. Archives of General Psychiatry. 1965. 35. 972-981. Lidz. T A developmental theory. in J. Shershow. (ed.). Schizophrenia: science and practice. Cambridee: Harvard University Press. 1978. Melzack. R. Effects of early per-ceptual restriction on simple visual descrimination. Science. 1962, /37. 978-979. Montague. A. Touching: the human significance of the skin. (2nd ed.). New York: Harper and Row. Publishers. 1978. Ornitz, E.M. Disorders of perception common to early infantile autism and schizophrenia. Comprehensive Psychiatry. 1969. /0, 259-272. Ornitz, E.M. Vestibular dysfunction in schizophrenia and childhood autism. Comprehensive Psychiatry, 1970. //. 159-170. Ornitz. E.M. The modulation of sensory input and motor output in autistic children. in Child development, deviations and treatment: proceedings of the first international Kanner colloquium, Oct 31-Nov 2, 1973. New York: Plenum Publishing Company, 1973. Ottenbacher, K. Sensory integration therapy: affect or effect? A merican Journal of Occupational Therapy, 1982, 36, 571-578. Reiss, S. (ed). Abnormality: experimental and clinicat approaches. New York: MacMillan Publishing Company Ltd., 1977. Resman, M. Effect of sensory stimulation on eye contact in a profoundly retarded adult. American Journal of Occupational Therapy, 1981. 35, 15-18. Rider. B.A. Sensorimotor treatment of chronic schizophrenics. American Journal of Occupational Therapy', 1978. 32. 451-455. Rosenblum, W.R., & Friedhoff, A.J. The response of adult schizophrenics to caloric stimulation. Journal of Nervous and Mental Disorders, 1961. 133, 104-107. Schilder, P. The vestibular apparatus in neurosis and psychosis. Journal of Nervous and Mental Disorders, 1933. 78. 137-164. Shaffer, M. Primal terror - a perspective of vestibular dysfunction. Journal of Learning Disabilities, 1979, 2 (2), 30-33. Shershow, J.C. (ed). Schizophrenia - science and practice. Cambridge. Mass: Harvard University Press, 1978. Silberzahn, M. Sensory integrative function in a child guidance clinic population. American Journal of Occupational Therapy, 1975, 29, 30-34. Silver, A.A., & Gabriel, H.P. The association of schizophrenia in childhood with primitive postural responses and decreased muscle tone. Developmental Medicine and Child Neurology, 1964, 6. 495-497. Solomon, P. Sensory deprivation. Cambridge: Harvard University Press, 1961. Stedman's medical dictionary. (23rd ed.). Baltimore: The Williams and Wilkins Company, 1976. Weeks, Z. EffectS of the vestibular system on human development, part 2: effects of vestibular stimulation on mentally retarded, emotionally disturbed and learning-disabled children. American Journal of Occupational Therapy. 1979. 33. 450-457. Weiner, H. Diagnosis and symptomatology, in L. Bellak, ed. Schizophrenia, New York; Logos Press, 1958. Wolman, B.B. (ed.). Dictionary of behavioural science. Toronto: Van Nostrand Reinhold Company, 1973. A ck nowledgemen ts We would like to offer sincere thanks to all of the staff at Whitby who were of assistance to us in the preparation of this paper. in particular to the research advisory committee, Joyce Pierdon, Chief of Occupational Therapy Service, and to Marcel Vandyke, R.N. for her services in translation.

Rsum
Cet article a pour but de dfinir brivement ce qu'est l'intgration des sens telle qu'explique par le Dr. A. Jean Ayres. mettant en N, aleur les cas type les plus communs de malfonction. Par une recherche tendue de la littrature comprenant des crits de 1811 jusqu' nos jours, les symptmes de schyzophrnie qui paraissent associs la dficience de l'intgration des sens sont l'tude. En conclusion. les recherches et traitements actuels employant la mthode d'intgration des sens pour les cas de schizophrnie sont examins et mettent en valeur une revue du programme dvelopp l'Hpital Psychiatrique de Whitby en 1981. Les possibilits de traitements et recherches venir sont galement tudies.

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