Sensory Integration Education

Virginia Spielmann is a British born and British trained Occupational Therapist (Oxford Brookes University) living in Denver, Colorado. Virginia has lived and worked in the United Kingdom with the Oxford Radcliffe Hospitals Trust; Kenya as part of the non-profit Family Impact Africa; and Hong Kong where she was a founding therapist, owner and Clinical Director of SPOT Interdisciplinary Children’s Center. 

Virginia has advanced training in Ayres Sensory Integration and is a member of the ICDL (The Interdisciplinary Council on Development and Learning) Clinical Consultants Board and an Expert Provider and Trainer in DIR/Floortime. She is at the candidacy stage of her PhD in Infant and Early Childhood Development with an Emphasis on Infant Mental Health (Fielding Graduate University).

In August 2017, Virginia joined the team at the STAR Institute for Sensory Processing as Dr. Lucy Jane Miller’s apprentice. Shortly after this she was a co-author and key contributor to the STAR Frame of Reference as formalized in Kramer, Hinojosa and Howe (published in 2019). In September 2018, Virginia became the Executive Director of the STAR Institute. Virginia has transformed her ISIC 2019 presentation into a feature article for SensorNet. It focuses on the thought provoking topic of the Interplay of Regulation, Relationships, and Sensory Processing.

Whenever we begin to dive into the mechanisms of human development, it is helpful to ensure we remain focused on the bigger picture - the core philosophy of the work that we do. The paradigm that we operate from as allied health professionals provides a lens through which we view the world, our clients, and ourselves, and provides context for our clinical reasoning and reflective practice.  

From the perspective of the occupational therapist, we want our clients to flourish through the experience of fulfilling and balanced occupational roles. Wilcock summarized the occupational perspective of health as “doing, being, becoming and belonging” – a multidimensional definition that highlights ‘doing’ as only one aspect of our work. During childhood, perhaps more than any other period of life, meaningful occupation is both a means and an end. During childhood we are son/daughter/ sibling, important members of a family unit, participants in a learning community, perhaps a religious community etc. In all this we are also growing, maturing, and becoming adults. Childhood is a process – one involving daily growth, play, learning and relationship and at the same time, a work in progress aiming for long term self-actualization. This means the allied health professional team is predominantly interested in play, family participation and, later, classroom participation. Although this really means they are in the business of developing: effective emotion regulation; enjoyment of other people and perspective taking; fine motor and gross motor skills; attention to tasks; increasingly coordinated and refined motor actions; mastery of routines; planning and sequencing for novel tasks; positive and harmonious social relationships; self-management for time sensitive demands; selfcare; and joyful participation in family activities and roles. As our clients mature this translates to engaging in occupational roles they value, such as care of self and others, engagement with people and objects, and participation in social contexts.

Ultimately, we do all this with the primary aim of seeing our clients flourish as they realize and express their true authentic selves. This concept of flourishing, or psychological well-being, is nicely summarized as “autonomy, competence, interest in learning, goal orientation, sense of purpose, resilience, social engagement, caring and altruism” by Huppert (2009).

The end goal of sensory integration therapy, then, is more than a mere absence of dysfunctional sensory processing and integration, it is psychological well-being or ‘flourishing’. “Sensory Processing is a means to an end and the end is quality of life.” (Miller, 2015). This is the work of the sensory integration therapist.

 Ayres herself always kept the bigger picture in mind; indeed, Ayres pioneered a kind of detective work that now characterizes the work of the sensory integration therapist – looking beyond observable behaviors to brain-based processing. This drive to look under the surface of behaviors and instead ask why children are struggling founded a field that is thriving now more than ever.

Ayres was also aware that sensory integration meant more than enhancing motor development alone. “What is rocking and being cuddled other than tactile and vestibular stimulation plus an interpersonal relationship? Are not the neural traces for the sensory and the social aspects of the experience laid down as one in the brain? Are not many of a child’s important emotional experiences in the first five years of life closely associated on an experiential and therefore neurological basis with their sensorimotor equivalents?” (Ayres, 1972, p266).

It is astonishing to think that the field of neuroscience only formally emerged in the late 20th century. Indeed, Ayres, in her way, was a participant in this paradigm shift. Interestingly the field of Infant Mental Health emerged around the same time and as these fields and those of psychology, sociology, anthropology, biology and linguistics have converged in their understanding of human development and experience the field of interpersonal neurobiology has emerged. It is in this context and with this ‘new knowledge’ that sensory integration therapy (SIT) is now situated.

This holistic view of wellness demands a holistic view of the human body and brain. One system working together consisting of multiple sub-systems that all interact and support one another. As students of component parts of the system (sensory systems) the areas we focus on exist in a broader milieu, consisting of multiple systems within which there are innumerable transactions, multidirectional relationships and influences that occur each second.

Accordingly, it is beneficial to integrate theory regarding three principle domains of human development. These foundational domains are relationships, regulation and sensory integration. These domains, or systems, interact with one another bidirectionally and changes in one will impact all three systems. One outcome of our work then is ‘integration’ of the physiological, neurobiological and affective systems of relationship, regulation and sensory integration and processing as demonstrated in figure 1.

Figure 1. The Interplay of Regulation, Relationships and Sensory Integration

The fourth trimester is a term that refers to the first three months of life outside the womb and highlights the tremendous changes that take place in this time. Humans give birth to helpless babies and in part this is because the brain finishes growing and forming in relation to the environment within which it exists. Context, experience and environment interact with genetic predisposition to shape the human brain. Brain architecture is dependent on environment and the parent-infant relationship is the first major environmental influence on this process.

Relationship

As infants emerge into the world in the first months and years of life they rely on attuned, consistent caregiving to build a map of themselves and their world. At this stage there is no self and other and the infant is embedded in these caregiver relationships and reliant on them for healthy development. As the infant communicates in anyway – intentionally or not – through behavior and gestures, the caregiver responds contingently, identifies the cause or event and soothes or provides as appropriate. For example, when an infant exhibits a startle response as a result of gut motility, the caregiver notices as the infant’s eyes widen, the pupils dilate and the arms and fingers extend. The caregiver labels the event and soothes the infant “Don’t worry that’s just your tummy you’ll be ok” and comforts the infant as they experience these new interoceptive sensations. These ‘serve and return’ interactions are critical for the development of sense of self, communication, social connectedness, regulation and sensory processing and integration at the very least.

These caregiver-infant relationships are more than just conversations, there is a brain-to-brain connection within the dyad that has been explored and documented since the mid-1980s. This connection is responsible for a large part of the development of self-regulation which is the ability to be calm and alert and available in response to the world and our own bodies. Furthermore, this crucial interbrain connection, much like wi-fi, can experiences interruptions to service.

Disordered sensory processing, a common cause of these connectivity challenges, can result in the wi-fi signal being inconsistent, scrambled, adding extra data that is confusing or being cut off altogether. In these situations, the disordered sensory processing experiences of the infant create a developmental experience that is contrary to what is needed and a further stressor on the developing child.

Regulation

Regulation refers to how we shift and maintain states according to the demands of the environment. In a balanced sympathetic/parasympathetic nervous system ‘regulation’ toggles between unconscious and conscious as we shift between states of arousal, according to internal and external context-dependent demands. Regulation refers to more than just sensory modulation, although sensory modulation is a common contributor to challenges with regulation. Other spheres that may contribute to challenges with regulation include emotional, physical, interoceptive, social, cognitive, attention and language and are depicted in figure 2.

Figure 2. Factors that influence regulation

We learn to regulate through being regulated by our caregivers, the experience of feeling safe and calm in the care of our parents is critical for establishing balanced para-sympathetic and sympathetic nervous system functioning.

Furthermore, through relationship we learn how to recover from stress, or dysregulation, and return to a calm, alert and available state. We learn that social connection aids recovery, and we often learn other strategies this way too as our attuned caregiver establishes what type of linear acceleration we find most soothing, which sounds help us to be alert and available and what lighting we need in order to fall asleep. The sensory processing aspects of regulation are inseparable from the relational and affective aspects and, when healthy, offer tremendous support to the developmental process.

Tronick (2007) tells us that in the first year of life there are as many as 15,536,000 micro second-by-second exchanges of an adult and the awake infant. These necessary exchanges wire brains for the development of self-regulation. In the infant with disordered sensory integration and processing multitudes of these opportunities are missed potentially resulting in cascading, cumulative, developmental trauma and dysfunctional regulatory capacity.

Sensory Integration and Processing

Sensation should support emotional and neurological development. Plastic sensory systems are online but not mature at birth and considerable modification takes place postnatally, primarily in the context of the caregiver-infant relationship. Neonates are socially connected, emotionally immature creatures that require external regulation from a caregiver as they make sense of their self in the world.

Sensory integration and processing refers to how we use what we sense to make sense of the world around us, it is critical for psychological well-being and the foundation for building our sense of who we are. We use information from each sensory system to get a complete picture of where we are in the world. This is how we feel, and it is embedded in every aspect of the human experience. Every event is a sensory event first and it is impossible to separate sensation from affect in the life of the young child.

Clinical Implications

Supporting development in these three domains requires an inter-disciplinary team (including mental health) with a robust understanding of the neural mechanisms of sensory integration and processing. Supporting the family system and child’s immediate team is critical, and this means involving parents in treatment sessions, teaching parents sensory problem solving skills, and educating classroom teachers and communities about the transformative potential of sensory health and wellness.

In many cases sensory processing differences do not need to be disabling and environmental modifications, accommodations and changes in the expectations of the caregiving team can dramatically improve quality of life and potential for meaningful participation.

In treatment sessions the best way to support integration and nurture development across these three domains is through the power of play. Fun, process-based, sessions that are dynamic and optimize the just-right-challenge in such a way that the child and caregiver are experiencing success and growth are the ideal.

"When the therapist is doing her job effectively and the child is organizing his nervous system, it looks as if the child is merely playing" - Ayres, 1979