Sensory Integration Education

Maria Protopapadaki is a paediatric occupational therapist having over 14 years clinical experience. She graduated with honours from the Department of Occupational Therapy, at the Technological Educational Institute of Athens, School of Health Sciences. She is NDT/Bobath certified (2007) and she started working in rehabilitation centers with children with cerebral palsy and other neurological disorders. In 2008, she was trained in Sensory Integration theory and practice by the “Pediatric Institute” in Greece. She was also certified in Greece in the training program in Sensory Integration (2011) by “Syn – Ergasia Therapeutic Intervention” in collaboration with the University of Southern California & Western Psychological Services. Over the last 4 years she has been working in the city of Kalamata, Messinia. She is the owner of two paediatric therapy clinics "erdo" and of a green care farm. The word erdo, unknown even for the Greeks, is the ancient root of the Greek word “ergo” meaning occupation (I do, act, manage, or execute).

Maria grew up in Crete, an island of Greece and she remembers with nostalgia the countless hours she spent every day in her family's orchard. When her mother was losing her, she knew where to find her … she was hidden under a tangerine tree, enjoying its juicy fruit and singing endlessly. Ever since she was trained in Sensory Integration, she has been trying to introduce a little bit of "nature" in her clinic therapies in every way. Her colleagues in Athens gave her the nickname “Beetroot Therapist” when she had the idea of doing face painting with the children in a group activity using the broth of a boiled beetroot. But as many attempts as she made, it appeared as though that wasn’t enough for her. The solution came when she left the capital and moved permanently with her family to the countryside, believing deeply that her children deserved to grow up and learn in nature. So one day, she was inspired by her farm and thought, instead of trying to bring the “nature” into the clinic, why not bring the clinic to nature? And this is how the project of sensory integration on a farm began to work… Her motto? The dirtier the feet, the happier the heart!

Introduction

In June 2018, a farm was set up in Kalamata, in Southern Greece, to serve the child’s need to have direct contact with nature. A need not met successfully over the past years due to urbanization, affecting the quality of life. The therapeutic intervention of “Sensory Integration on a Green Care Farm” consisted of a combination of rich natural sensory “equipment” offered by the farm (natural light, soilearth, trees, vegetable garden, flower-fruit scents, nature sounds, farm animals) along with special sensory equipment (e.g. sensory swings) to fully implement the basic principles of Ayres Sensory Integration Therapy.

Background

Green care is a concept not restricted to the use of animals, but also includes plants, gardens, forests, and the landscape. “Green Care” refers to structured therapy or treatment programs that take place in natural surroundings and recognize the instinctive connection between nature and health. “Green Care” is a range of activities that promotes physical and mental health and well-being through contact with nature. It utilises farms, gardens and other outdoor spaces as a therapeutic intervention for vulnerable adults and children (J. Sempik et al, 2010).

The first study about “Green Care” was published in the UK in 1979, focusing on the requirements of horticultural training programs for people with mental health disabilities (Spurgeon et al, 1979). Since the end of the 20th century and the beginning of the 21st century, there has been an increase in the number of scientific studies focused on green care throughout Europe (Garcia-Llorente et al, 2018). In 2007, a cost action called “COST Action 866 Green Care in Agriculture” was created as one of the first attempts to increase scientific knowledge of green care. Once of the main limitations one of the main limitations of green care has been the lack of evidence about the effectiveness of its various practices (J. Sempik, 2010). Health care professionals and organizations began to approach farmers to offer all kinds of services to people with mental health difficulties, intellectual disabilities, older adults, children, those with substance abuse issues and people experiencing long term unemployment. Today, care farms can be considered examples of innovative community-based service providers that can improve people’s quality of life (J. Hassink et al, 2010). The perceived benefits of care farms are improved physical, mental and social wellbeing. The mental health benefits consist of improved self-esteem and well-being, and an improved disposition (R. Hine et al, 2008). Green Care includes the following therapeutic approaches; Social and therapeutic horticulture, Animal Assisted Therapy (AAT), Facilitated environmental conservation, Care Farming, Nature arts and crafts, Green Exercise therapy, Ecotherapy and Wilderness therapy.

From the above approaches of green care, the term of care farming best represents the intervention that takes place in our farm. Care farming is the use of farming practices for the aim of providing or promoting healing, mental health, social, or educational care services (Berget et al, 2010). The approach presented is the Sensory Integration Intervention on a Green Care Farm.

Aim of the study

This study aimed to investigate whether contact with nature (in particular, green care farm adapted to SI equipment) contributed to improving children’s sensory processing and, therefore, their life’s quality. The balance between performance areas leads to quality of life. Therefore, research questions arise concerning the potential improvement in activities of daily living, productive activities and play activities. 

Methods

Study Design: 

Case study

Instruments: 

- Structured clinical observations based on Sensory Integration Theory (Blanche, 2002)

- Sensory Processing Measure (SPM) Home Form (L. Parham & C. Ecker, 2007)

- Goal Attainment Scaling (GAS) (L. Turner-Stokes, 2009)

Data Collection:

January 2017, January 2018, September 2018, June 2019

Sample:

1 child, diagnosed with Sensory Processing Disorder (SPD), 7 yrs old. He started the occupational therapy sessions at the age of 4 years & 10 months. However, the same intervention has been applied to 15 children in total aged 4 - 9 years old with the same characteristics.

Intervention:

The OT intervention was based on Ayres Sensory Integration.

The intervention was based on the transfer of the environment from the clinic to the farm at the same time and day for June, July, September, October and some days of November. This intervention program involved children aged 4 - 9 years old, who were diagnosed with a variety of disorders, but all having sensory integration difficulties in common.

Physical Environment (adapted based on the Part 3 Items Measuring Process Elements of the ASI Fidelity Measure):

- Natural sensory “equipment”: Natural light, fresh air, soilearth, trees, vegetable garden, flower-fruit scents, nature sounds, farm animals.

- SI equipment: Platform swing, square platform, hammock, therapy ball, scooter, inner tube, ropes for pulling, visual targets.

- Tailored SI equipment: olive trees for climbing equipment, potatoes/ oranges/ pumpkins for weighted objects, tree house for quiet space, square hay bale for balance equipment, sacks stuffed with sawdust for pillows, the hood of the immobilized tractor for vibration, inground trampoline, rags, tactile elements (grass, pond, hay, bran).

Therapeutic strategies involved in practice of ASI intervention (Fidelity Measure, 2011) tailored to the Green Care Farm: 

Therapeutic strategies easily applicable on the farm, for example:

- The therapist easily presents to the child at least 2 or 3 types of sensory opportunities— tactile, vestibular, and proprioceptive—to support the development of self-regulation, sensory awareness, or movement in space. For example, tactile input is available everywhere on the farm.

- On the farm there are plenty of opportunities for postural, ocular motor or bilateral control and praxis challenges as the child can plan abundant novel motor tasks.

- Activity choice. All human beings seek contact with nature and when the therapist combines this knowledge with an environment that supports play there is a greater chance of full involvement of the child in intervention.

- Successful activities with the just - right challenge. The intervention on the farm comfortably offers the therapist the opportunity to increase or decrease the complexity of the challenge for successful activities through which the child is satisfied and feels important, e.g. feeding the hen can be a successful activity through which the child gets tactile input from contact with the bran, proprioceptive input as it holds the heavy basket with food.

- Fully engaging the child in the intervention. The child is allowed to choose the desired activity among many options with varying degrees of challenge. Simple tasks such as watering the grass to more challenging tasks such as tree climbing.

- The calm and positive energy offered by contact with nature creates the appropriate conditions for the development of the therapeutic alliance and working together sense.

Results

The results of the Goal Attainment Scaling (GAS) study, are presented below. The data collection was performed 4 times, as mentioned above. The requirements of each goal, gradually increased depending on the child’s functional level in each period. Noteworthy are the GAS - record sheets with SMART goals (table 1 & 2) which were supplemented in September 2018 and in the latest assessment made in June 2019. The Baseline GAS score was 33.6 and the Outcome GAS T – Score is 66.6 which means much better than expected. The change in GAS score is 32.

Τhe first results of the first Sensory Processing Measure (SPM) Home form (which was provided when the child started the OT sessions in January 2017), show strengths in visual processing but significant difficulties in other sensory systems, including touch & hearing. It also found poor body awareness, balance and planning ideas. He had definite dysfunction in social participation. Additionally, Blanche’s structured clinical observations (which were carried out when he started the OT sessions, in January 2017) revealed difficulties in vestibular and proprioceptive processing and tactile and proprioceptive processing.

Conclusion 

According to our study, it seems that a balanced combination of intervention both in the equipped Sensory Integration Clinic and in the natural environment of the farm (structured with basic S.I. equipment) works more effectively, thus improving the child’s life quality. The Green Care Farm provides opportunities for different and new occupational roles for the child e.g farm animal caregiver, gardener, nature explorer, group member, and a student learning about nature. The Green Care Farm is a safe starting point for assuming meaningful occupational roles in daily living.

It appears that, the intervention on the green care farm supports children’s occupational performance and participation in everyday living activities. 

Table 1. SMART Goals/ Daily Living Activities

Goal Attainment Scaling

Table 2. SMART Goals/ Play activities

* Costas is a pseudonym for the child in this case study.