Sensory Integration Education

                                                   Dr. Shelly Lane                                         

                                                  Dr. Anita Bundy

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Gina Daly, SensorNet Editor, sat down for an exclusive interview with Dr. Shelly Lane and Dr. Anita Bundy following the recent release of the third edition of the core textbook “Sensory Integration Theory and Practice”. Over the years, it has been an essential textbook for therapists, educators and researchers all over the world.

It is a book that formulates the foundational learning for so many therapists studying sensory integration. This is the last edition for Shelly and Anita and they are now ready to hand over the torch to the associate editors – Shelley Mulligan and Stacey Reynolds. The third edition is dedicated to A. Jean Ayres and to those who live with sensory integrative dysfunction who continue to be our teachers.

SN: The third edition of “Sensory Integration Theory and Practice” was released at the end of 2019, what were your main aims and objectives when writing this book?

Shelly & Anita: It had been a long time since the release of the second edition in 2002 and a lot has changed within the SI context and literature since then. There was a need for the information to be updated. From 2002 until now, it wasn’t covering the material like it needed to. Since it is so often being used as a core text, it needed to pull a lot of the recent advances in research together and bring a fresh and revised approach to many topics.

SN: When did the project for the third edition begin and why?

Shelly & Anita: We knew we would have to do a third edition at some point so it started more or less immediately after we finished the second edition. We first started asking contributors and began consistently writing in 2015, with lots of planning time before that. We knew that we wanted to do many things differently for the third edition, so that was an instigator to keep moving forward with the project.

SN: What was the greatest challenge in culminating this body of work?

Shelly & Anita: One of the challenges was the length of time between editions. Writing this edition was almost like starting from scratch again. All of the chapters from the second edition, needed a considerable amount of revision. All of the topic areas had to be updated and refreshed. The authors who contributed to this edition, put forward a huge effort for this project and we are incredibly grateful to them. The mechanics of organising such a body of work was also very challenging. When you do an edited book, you really want it to sound like it has been written by those of “like minds” with a similar writing style, therefore it requires quite extensive editing. You can’t just take the chapter someone sends you and have that as the completed piece of work. Each chapter needs to flow into the other and it needs to be cohesive.

SN: You mentioned that the third edition is the last for you both, but you are passing the torch to associate editors - Shelley Mulligan and Stacey Reynolds?

Shelly & Anita: We identified in the early stages that we needed assistance with editing the chapters for the third edition, and so we brought Shelley and Stacey on board. It was clear to us from the beginning, that we wouldn’t do another edition, especially since it takes at least a decade in between editions. It’s time for other people to take it up from here.

SN: Can you explain more around the new model of SI dysfunction featured in the book? – more specifically around proprioception and why there is no link to modulation anymore?

Shelly & Anita: Part of the struggle we had is that the model tells us about poor modulation. However, we know very little about modulation of proprioception. We know clinically that people use proprioception as a modulating tool. Proprioceptive input is our “go to” when trying to regulate children but what does underresponsiveness and overresponsiveness to proprioceptive input look like? There is no research on it. It is a big hole in our knowledge base and that’s where the development of more research is required as there is an absence of information. We have our clinical wisdom that says proprioception is a modulator, but we don’t have the research evidence base to support this yet.

There are some anecdotal reports of what it might look like when proprioception is not well modulated but those reports tend to align with those children who have clear neuromotor deficits rather than sensory integrative deficits. This is an example of a new area for development and expansion for the next edition. It has highlighted a big gap in the Sensory Integration research that we need to tackle. An idea for someone who would like to do a PhD possibly.

SN: Interoception is also included within this new model. Tell us the rationale and reasoning for including this?

Shelly & Anita: The inclusion of interoception grew out of the increasing body of literature on interoceptive concerns, primarily in children with ASD, ADHD and to some extent in other children outside of those diagnoses, such as sensory modulation disorder. The interoceptive system structurally parallels the anterolateral system so it is a logical link to somatosensation. The map that we develop of our internal body through interoceptive information has to somehow integrate with the map that we develop of our external body from vestibular, proprioceptive and tactile input. Putting those two pieces together is logical. We now have a wealth of literature on the interoceptive system looking at that brain-gut link and the interoceptive-exteroceptive linkages. There was an emerging body of literature that we took advantage of which stands in stark contrast with what is available in proprioception.

SN: The various areas of the brain are noted along the top of the model. Do you think this will help students to make links with brain function and SI?

Shelly & Anita: Yes, it is a way of helping people to think about brain-behaviour links, but in a very basic way. The current neuroscience literature, is very strongly about neural networks. The way we have isolated the brain structures in the model is a very simplistic way to look at the neural networks and functions of the brain structures. We could have made the model so much more complex but we want people to start thinking about basic links rather than overcomplicating it.

SN: There is a chapter dedicated to the advances in sensory integration research. What were your greatest findings from devising this chapter describing the growing body of basic research?

Shelly: One of the really exciting aspects, is that the evidence base for SI is very broad and what we have been able to do collectively is to capitalise on basic science research that supports the theory of sensory integration. In some respects, it takes us full circle back to where Ayres began which was making those linkages, and hers were quite inferential. Now we are finding evidence in basic science literature that directly pertains to sensory integration theory. I think that is an area that is exploding and everyone is all of a sudden on the “sensory bandwagon” – animal and human researchers alike. That is very exciting to me.

Anita: The evidence base for sensory integration as a condition as well as an intervention is expanding. The evidence base supports the condition. We don’t generally do research into other conditions as Occupational Therapists. The evidence base for much of what we do is really about the intervention and that’s true in sensory integration as well but it is more than just about the intervention effectiveness. It is about what the neural basis for the condition is, which informs our practice and intervention.

SN: Application of sensory integration with specific populations is an exciting area of growth and progression within the field – where have you seen the greatest expansion of evidence?

Shelly & Anita: Autism continues to be the area where the greatest amount of work has been done and produced. It is also where the energy is as it has opened the inclusion of sensory concerns in autism as a diagnostic criterion and also opened doors for those studying and researching about various other conditions such as fragile X syndrome and mental health disorders to start saying – maybe it is also an essential piece to fragile X or certain some mental health disorders. People are now looking more closely at sensory processing so it really has been an impetus for other investigations.

There is also quite a bit of research being completed on ADHD, but autism remains the strongest area of research evidence within the SI field.

SN: Coaching and parental education were two big take home themes from AOTA in 2019 – there is a chapter in the book also dedicated to this. Is this an area that needs to be focussed on more by therapists in practice?

Anita: This was also included in the second edition under “ consultation”. However, coaching is the word people want to use now. We adopted the word “coaching” as it seems to be more popular at the moment, but to me it is the same concept. The origin of the word “coach” is about “transporting someone from one place to another” and that resonated with us. Families and teachers have to be involved in a child’s intervention. Having a child come to therapy once a week for a certain duration and then asking the child to be the one who translates that into their everyday life, is asking a lot of the child. If you can coach the people who are around that child and help them to understand the child then that will add to the effectiveness. Every child should be entitled to that. Should a child get direct intervention on top of that? Well…. hopefully. But if we have to choose, then it should be about coaching and consultation first.

Shelly: Sue Allen, is doing her doctoral studies on developing a parent coaching model. I also have another doctoral student who is also looking at the parent coaching component of Lucy Miller’s model, so it is an area that we are developing a knowledge base in. When both of those individuals did a literature search separately on “coaching”, neither of them discovered much information about coaching in occupational therapy. It is another one of those emerging areas that we need to capitalise on, before we lose control of it.

SN: The chapter on clinical observations includes structured and unstructured clinical observations - explain the difference and why this is an important consideration for assessment?

Shelly & Anita: We know what to expect from structured observations. We know what a child is supposed to be able to do. The outcomes of the unstructured observations are only as good as the observer. Letting the child take the lead and not telling them what to do, is very important so you can see what the child can do on their own, without direction. You won’t learn as much about something as complex as motor planning from structured observations alone.

Structured observations can tell you about eye tracking, prone extension, and supine flexion but not much about problem solving which is an important part of the child’s overall functioning.

SN: In this book, we see a lot more weaving of SI with other approaches such as the CO-OP. Tell us more about this and why it has been included.

Shelly & Anita: The lens that you look through, allows you to see what that lens focuses on. If you take a coop or SI approach, you may look at the child differently, but it is still the same child. Some of the impetus for encouraging therapists to combine approaches, has to do with helping children to meet their participation goals more quickly. You can still work using an SI approach, which according to the theory changes the way the brain is processing information which is a great long term goal. 

However, the child needs to have some targeted achievements along the way. This allows families to see that therapy is having an effect. We don’t have enough evidence for any one method for it to be the “go to” all the time.

SN: Anita, one of your main areas of interest is play. You speak in the book about the artful therapist being a good playmate. Can you expand on what this means?

Anita: Creating a playful transaction is inherent to the art of therapy and it is inherent to sensory integration therapy. That is part of the reason as to why some of the evidence base wasn’t very strong for a long time - people wanted to take away the art. They wanted to say sensory integration is “spinning children” and “putting them on swings”. We lost some of the art.  

In terms of play, people don’t play a lot on their own. Therapy is a situation where you have a therapist and a child. If you are going to create play, then the therapist has to play as well. The therapist has to be a good playmate for the child. The therapist is of course wearing multiple hats at the same time, as they are not only a good playmate. You have to be very skilled to be able to do that. If you want to create a playful situation while also working on goals, you’re not going to be able to completely just play. The more artful the therapist is, the better the playmate they are. If the therapist is not playing then the child is very sensitive to that.

SN: A Complicated Question which ends the book - Is Sensory Integration Effective? In your opinion where is the current evidence base at and where does it need to go? 

Anita: We need to do more Randomised Control Trial’s (RCT’s) but not everyone is in a position to be able to conduct an RCT. Therapists in the clinic are probably not ever going to be doing RCT’s. However, evidence comes in lots of different levels and in various guises. We have to ask ourselves – who is creating the evidence? Working with a particular child, devising goals, achieving those goals and documenting the outcomes is also classed as evidence. That’s what practitioners are doing and should be doing. There is going to be a different group of people doing RCT’s.

Shelly: RCT’s are not the be all and end all. They don’t necessarily reflect real life intervention. The current popular topic is “translational science” which is moving beyond the RCT. It involves taking your model of sensory integration therapy and sourcing various clinics who will implement the protocol. That is where we need to move to next. 

However, it is important to say that it is not going to work for all children. As a therapist, you are making a hypothesis that SI is going to work. You still have to be prepared to change your approach or add to your approach - if it isn’t suitable. It won’t ever be a one size fits all approach.

SN: What projects and areas of research are you currently focusing on?

Anita: I am working with EASI data which will be a long term project. Also the “Sidney playground project.” I am also involved with the "Sidney playground project" which centres around bringing sensory integration to all children. This project translates sensory integration into a whole population approach. It also considers the re-framing of risk and focuses on helping people to realise that children have to take manageable risks. We just finished a study with a masters student, who gave a "tolerance to risk in play" questionnaire to parents and then gave the children a virtual reality task where they had to cross the road. We found really good correlations between tolerance for risk in play and the children’s ability to do the task of safely crossing the road in a virtual situation. This is an area that will continue to be of interest to me for some time.

Shelly: I am currently involved in research with a colleague in Australia which is about fathers and their involvement with children in terms of supporting play and playfulness. I am involved in four different small projects around that topic. I am also doing some research on an intensive month-long intervention camp to capture the changes in children pre and post intervention and also exploring the changes in the practice of therapists pre and post intervention. 

There is a lab being built at Colorado state University which Anita and I will both use. I would like to address parent involvement in therapy and covering that within a clinical environment. This would allow parents to try out various activities with their children in a safe environment. That is work to come once the lab is built.

A sincere thank you to Shelly and Anita for their time for this in-depth interview. We look forward to seeing and connecting with them both again at AOTA and ISIC this year.