Stacey Szklut MS, OTR/L, presenting Session A - Enhancing Sensory Integration Perspectives for Intervention: The Art of Clinical Reasoning contributed this piece on sensory diet.

The term diet often conjures up a visual image of someone who is overweight, or elicits a visceral reaction about our own state of ‘weightiness’.  But a sensory diet is fun, natural, intuitive, and incredibly useful!  It consists of sensory based strategies used throughout the day, often unconsciously, that help us maintain a calm and organized state, encourage attention and focus, and support our ability to fall asleep and wake up without difficulty.  Although the terminology may be new to you rest assured that you already have a variety of sensory strategies in place.  

• When you wake up in the morning the strong smell and taste of that cup of coffee begins to alert you well before the caffeine hits your blood stream. 
  
• Turning out lights and climbing under a nice warm quilt encourages sleep. 
  
• The next time you are at a meeting notice the strategies people are using to stay focused and attentive. 
  
  • How many have legs or arms crossed, or are resting their chin on their hands?  These strategies provide our body with touch pressure that is calming and organizing (like a hug, massage or a warm bath). 
    
  • Who is drinking from a cup or water bottle, or eating a chewy snack?  Exercise to our mouth is one of the most powerful sensory tools.  
    
• Speaking of exercise, this is considered the panacea by sensory experts like myself.  Regardless of whether you are tired and lethargic or stressed and anxious a little exercise can help you feel more grounded and organized, even if you just stand up from your desk and stretch for a minute.

It is extremely important for children to use sensory organizers throughout the day, especially when needing to sit and focus at school. Simple strategies like crunchy snacks, water bottles and movement breaks encourage more optimal learning.  Many children we see at South Shore Therapies need stronger and more frequent sensory strategies to focus, stay calm and organized.  
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Stacey Szklut MS, OTR/L is owner and Executive Director of South Shore Therapies in Weymouth and Pembroke. Ms. Szklut is nationally known speaker and frequently contributes articles and book chapters for professional magazine and college text books.  Visit her website at www.southshoretherapies.com.

Did you know?
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1. Your breathing pattern has an impact on your nervous system.  The impact can be positive with a proper breathing pattern.  (Abdominal distension, 3-D lower rib cage expansion followed by apical filling)  With a proper breathing pattern, your exhale is longer than your inhale and this drives the autonomic nervous system into a parasympathetic state.  This then allows you to focus, stay calm and relaxed.  For children and adults alike, this state allows work to get done.    If your breathing pattern is poor (example—breath holding, using accessory muscles excessively) the ANS can be driven into a parasympathetic state with a “fight or flight” response.  This is a tough state in which to be productive.
2. Your breathing pattern has an impact on you circulation.   You know that blood flow to the tissues is important for healing.  Breathing can affect circulation via the ANS.  If the sympathetic nervous system is stimulated via your breathing pattern, the blood vessels are constricted.  If the parasympathetic nervous system is stimulated, vasodilatation of the vessels occurs increasing the blood flow to the tissues.
3. Your breathing pattern has an impact on how efficiently you use your musculoskeletal system.  The muscles of respiration have a dual purpose—respiration and postural stability.  With the contraction of the respiratory diaphragm upon inhalation, an increase in intra abdominal pressure occurs.  This action is important for several musculoskeletal relationships.  It provides passive stability to the “core” of the body allowing other muscles to be able to take a “break”.   The muscles that might need a break are the cervical muscles, the paraspinal muscles or the pelvic floor muscles.  When the diaphragm relaxes, the abdominal muscles engage and contract providing active stability.   Therefore, a proper breathing pattern is very instrumental in facilitating core stability.  In turn, core stability is needed for the production of efficient movement.  Research is bearing out that the transverse abdominus contracts before the deltoid when doing an arm movement.   An efficient breathing pattern is also being linked to pelvic floor health and in turn to bowel and bladder function. 

 
 
The workshop “Air is Good” will focus on assessing breathing patterns and strategies to improve a poor breathing pattern.  Prior to attending the workshop it would be very helpful for you to review the anatomy of the respiratory system and chest development.

​Would you see this kid as a neck issue kid? Learn how to treat these in the upcoming course at the 3rd RAIR Symposium. This young man had an undetected cranial base compression.  He was referred due to biting his lower lip most of the time and having articulation problems.  The problems were easily corrected and core issues addressed after treating his neck compression. The action picture demonstrates the child using ORAL CORE exercises for gaining head, neck, core, oral control as a team. Starting things over to get all systems in sync is most efficient.

The TARGET is a comprehensive format for collecting and organizing assessment data from tests, observations, histories and questionnaires.  This format helps the therapist see the relationships between original concerns and underlying causes, prioritize areas that need addressing in treatment and plan the sequence of treatment. Goals can then be generated together and progress tracked together.  The TARGET is composed of 4 pages, each of which is a category of like areas of function. They are titled:

• Page 1 is Modulation
• Page 2 is Postural Development and Outcomes
• Page 3 is Learning how to Learn and Remember 
• Page 4 is Integrated Brain Activity, Emergent Processes and End Products.
  

The following case demonstrates issues and concerns on all 4 pages and reflects the assessment and treatment planning outcomes.

Case Example
E is a 6.9 year old beautiful little girl with a smile on her face most of the time.  Her history includes an unremarkable pregnancy and delivery at term.  There were no major issues other than difficulty attaching to and remaining attached to the breast.  This was reportedly difficult until she weaned herself at 8 months and switched to a sippee cup. No particular problems were noted until her preschool teachers told the parents they had some concerns about her language organization and some speech concerns.  They also noted her motor skills were a bit awkward and she avoided the slide, climber and swings on the playground.  Peer interaction was minimal (her preference was to play or sit in class by herself) but all thought that was because of her speech and language issues.
By the first grade these concerns remained and an OT consult was recommended which was followed by assessment and recommendation for a treatment intensive.  A speech and language evaluation was also recommended and she began receiving services about the same time an OT intensive was scheduled.  

This blog was contributed by Nancy Lawton-Shirley, OTR/L who will be teaching the two-day Session H. CranioSacral Applications in Pediatrics. Nancy owns Points of Stillness, which offers occupational therapy at Healing Waters Health Center in Hudson, WI.

1. Be sure your child has physical activity after school. Time outside is ideal. Free time to just play can really recharge a child's brain from a day of structure. Self-directed play is a great way to work the creativity parts of the brain!
2. Have snacks available during study time. Things to chew, suck and crunch actually help the brain to pay attention, focus and learn.
3. Do memory tasks while a child does rhythmic movement, i.e. sitting on a ball and bouncing or jumping up and down while they spell a word or learn math. Rhythm lays down memory faster!
4. Try watching the MeMoves DVD! Have the family do one set of the exercises on the DVD. It very quickly calms everyone down, and gets the brain ready to learn. This is good for preschool- through high school-aged children!
5. Some children need absolute quiet to concentrate. Other children really benefit from playing music with a consistent beat. Ideas:Baroque for Modulation, Sacred Earth Drums, Calming Rhythms.

And remember your child has been working hard all day!

This contribution is from 3rd Symposium speaker Shelley Mannell, PT, from her recent blog at HeartSpace Physical Therapy. 



When I first became a pediatric PT we talked about primitive postural reflexes as part of the development of postural control.  We certainly didn't have all the answers and there were many different perspectives, so these were lively conversations with lots of good clinical problem solving. But references to primitive reflexes had mostly disappeared from the discourse on postural control until fairly recently.  

We used to think of development as a hierarchical process. But as our understanding of how the brain works has improved, we now understand it as a complex, dynamic, multi-systems process. So rather than primitive reflexes, I prefer to use the term developmental reflexes - stereotypical movement patterns triggered in response to a sensory stimulus representing our first developmental experiences with registering and responding to our position in space. Babies experience extension and flexion of their body (Moro), their relationship to the support surface (TLR), differentiation of left and right sides of their body (ATNR) as well as the dissociation of their upper body from their lower body (STNR) – all with reference to their head position.  As such, they lay down the early sensory and motor neurological wiring which supports the development of mature postural control.  And even when mature postural control is present, if the system is stressed or damaged, these patterns reappear to help out with stability.  One has only to watch me try to ski a beginner's hill to view a classic ATNR! 

 

Regardless of their usefulness, many clinicians and the literature 1-3 tend to agree that their continued presence in everyday activities is an indicator of postural control difficulty. We also understand that they can interfere with functional skill development.  This leads us to the next question - how might we address them in treatment?

My preference is to work from the inside out in building a clinically relevant understanding of the sensorimotor development of postural control. Early postural control is characterized by developmental reflexes, while mature postural control is characterized by both anticipatory and reactive components. Recent research has yielded some exciting information regarding the organization of central stability, alignment, pressures, recruitment of inner core muscles and activation of outer core muscle groups in different client populations.  We can leverage this new information in treatment of children with sensory and motor challenges, as we build and blend these developmental reflexes into more mature postural control, which ultimately serves to support complex motor, perceptual and emotional regulation skills. 

These new conversations have raised more questions and I'm excited once again by discussions that are filled with new research, clinical observations and problem solving.  Please join me for a 2-day adventure as we explore the theory, practical applications and treatment strategies regarding developmental reflexes in Function From the Inside Out: Sensory and Motor Processing for Postural Control as part of the RAIR Symposium in Bloomington MN Feb 26-27, 2016.   


1.     Sohn M, Ahn Y, Lee S. Assessment of primitive reflexes in high-risk newborns.  J Clin Med Res. 2011; 3(6): 285-90.

2.     Tribucci AT, Penedo-Leme S, Funayama CAR.  Postural adjustment as a sign of attention in 7-month-old infants.  Brain Dev. 2009; 31: 300-6.

3.    Konicoarova J, Bob P.  Asymmetric tonic neck reflex and symptoms of attention deficit and hyperactivity disorder in children.  Int J Neurosci. 2013;  DOI: 10.3109/00207454.2013.801471.

 

photo credit leader.pubs.asha.org

You think you understand what the "sensory diet" concept is - really?  Take some time to explore the neuroscience and clinical reasoning that ensures your practice is up to date!

Sensory Diets are commonly utilized by pediatric occupational therapists, including school based therapists, early interventionists, and  general pediatric clinicians.  Most typically, the sensory diet is selected to address a concern related to difficulties in sensory modulation.  The concept of a "sensory diet" (as originated by Patricia Wilbarger) is often included in treatment plans, IEP's, etc.  However, the power of a sensory diet is only as strong as the underlying clinical reasoning.  Unfortunately, many therapists use "sensory tools" without a strong underlying theory base or without grounding the intervention in sound neuroscience principals.  As such, many sensory diets are limited in their impact and this leads families and school teams to not adhere to the prescribed intent, intensity, or scope of the full sensory diet. This can result  in the plan being abandoned or losing its intended focus or purpose.     

This one day course will sharpen your clinical reasoning skills and allow you to harness the power of the sensory diet concept. The course will focus on neurologically based principals that drive the selection and timing of the inputs utilized in the sensory diet.  The course will also bring contemporary issues related to relationship based intervention into the context of the sensory diet concept.   The course helps each clinician to use the sensory diet concept to enhance outcomes and ensure best practice!  


This blog post was contributed by Tracy Murnan Stackhouse, presenter of Session K.

Paul Stadler, MS, OTR/L, NDT wrote this blog on his sessions B. THE IMPACT OF PRIMITIVE REFLEXES ON DEVELOPMENT, SENSORY PROCESSING, AND ACADEMIC ACHIEVEMENT and F. THE INPP DEVELOPMENTAL TEST AND SCHOOL BASED PROGRAM. For more information on these sessions, visit Mr Sadler's blog from last year: A Perspective on Reflex Integration

I am very much looking forward to joining again the Richter Air Symposium on Therapeutic Applications for Pediatrics to present  “The Impact of Primitive Reflexes on Development, Sensory Processing, and Academic Achievement” and “The INPP Developmental Test and School Based Program”. 

Past participants have described these courses as highly informative, lending a fresh perspective on many issues that pediatric therapists face with younger children.  It took until 2008, for a scientist to discover the gene that acts as the trigger mechanism for cell differentiation, the next major step in development after fertilization.  The unraveling of the complexity of childhood development has long been on its way, but we continue to see an emergence of new ideas that tackle delays and difficulties in this.  These courses will engage participants in this direction.  The INPP Developmental Test and School Based Program not only provides the theory and research, but will guide participants through a regimented evaluation and treatment program for groups of children who experience many issues we encounter in the classroom.  As school systems adopt more of a group based provision for services for children across related services, this program further enhances the opportunity for success with children within this complex developmental framework.

Judy Michels Jelm, MS, CCC-SLP expanded on why she's excited for session C2.


I am thrilled to be presenting two courses at the Richter AIR Symposium 2015. One course Part II: “My 25 Favorite Oral-Motor Treatment Techniques”, is an interactive course.   Actually, this course could be entitled “”My Favorite……..Techniques and even more” since there will be a time for sharing between participants and myself.  We will discuss, for example, how to manipulate and change oral-motor techniques based a trial exploration and experience.  Since my experiences take into account a wide range of treatment options over multiple decades, I have become a multi-experienced thinker and practitioner. 

I have learned that the power of tool manipulation has become my best friend when learning techniques.   The oral-motor system is a complex system but these complexities will allow you, the participant to open your mind to a vast amount of techniques you might not have considered in the past.  I will share with you and my hope is you will share too.

Part I:  Syncing Oral Motor/Sensory Assessments to Meet Goal Areas will give you a basis for Part II. What assessments do you use?  Does that assessment give you information needed for your treatment session?

The following is an excerpt from Sensory Diet Concept for use with Individuals with Smith-Magenis Syndrome (SMS) and Use of the Sensory Diet Template, by Tracy Murnan Stackhouse (speaker for Session D: The Power of the Sensory Diet Concept). The article in its entirety can be found here.



A sensory diet is a treatment strategy used within the framework of occupational therapy to address two particular problems: sensory defensiveness and difficulties maintaining appropriate states of arousal. Sensory defensiveness is the tendency to respond in a negative or avoidant manner to sensory input; even normal sensations such as the feeling of clothing on the skin, water at bathtime or lights in a gymnasium can be sources of negative overstimulation. When this presents in a pattern of over-responsivity coupled with behavioral response of avoidance or agitation, it is called sensory defensiveness.

Arousal difficulties refer to the tendency of a person’s nervous system to maintain an optimum level of activation for the context/task at hand; if it is time to sleep, optimal arousal is low to match the sleep state.  Alternatively, if the task is a college lecture, then arousal should be alert and focused without a lot of body activity, in contrast to the alert, focused and active body used during a sporting activity. Because individuals with SMS often struggle with meeting their sensory needs and with poor arousal modulation, the sensory diet approach is ideally suited to address these particular needs.

The concept of the sensory diet was originated by Patricia Wilbarger, MA, OTR. It is an occupational therapy intervention strategy which consists of a carefully planned program of specific sensory-motor activities that is scheduled according to each child's individual needs (Wilbarger & Wilbarger, 2002). It also takes into consideration each family’s schedule, preferences, and resources.

A sensory diet can help maintain an age-appropriate level of attention for optimal function as well as be used to reduce sensory defensiveness. Like a diet designed to meet an individual's nutritional needs, a sensory diet consists of specific elements designed to meet the child's sensory integration needs. The sensory diet is based on the notion that controlled sensory input can affect one's functional abilities. Martin (1991) states in Principles of Neuroscience:

 “Sensory systems are not only our means for perceiving the external world, but are also essential to maintaining arousal, forming our body image and regulating movement.”

A Sensory Diet can be used in 2 primary ways:
–  To Decrease/Treat Sensory Defensiveness
–  To Maintain an Optimal State of Arousal across Time

The OT devising the sensory diet should be certain to focus or parse the focus of the sensory diet to meet the individual goals. 

Wilbarger & Wilbarger's (2000) comprehensive approach to treating sensory defensiveness includes education and awareness, a sensory diet, and other professional treatment techniques. One such technique is called either the “Wilbarger Protocol” or “Therapressure” technique, which uses deep pressure to certain parts of the body, followed a series of joint compressions that provide the sensory input of proprioception. Proprioception refers to sensory input that activates muscle and joint receptors, providing information to the brain about those muscles and joints (what are they doing, how are they moving). Most important from an arousal standpoint, proprioceptive input releases chemicals in the brain that foster organized modulation or arousal functions.

The Wilbargers also suggest a specific protocol, called the Wilbarger Oral Tactile Technique, which addresses oral sensory defensiveness. Oral sensory defensiveness manifests in aversive, negative responses to oral sensations and is usually seen in feeding and speech-related behavioral concerns. Either Therapressure or the Oral Tactile Technique are used in combination with an overall sensory diet. The sensory diet provides the structure which coordinates sensory motor activity into the life routine of the individual for whom it is designed. It is critical that these protocols not be used in isolation and that the overall program be initiated and monitored by an appropriately trained occupational therapist.

A sensory diet is best designed by the family and therapist together. The therapist utilizes direct treatment time to learn the individual child’s “formula” for attaining and maintaining appropriate sensory reactivity and arousal modulation. The therapist takes this information, and together with what she or he knows about the family’s schedule and resources, designs a schedule of sensory supports that comprises the sensory diet.

Note: The complete article includes such topics as:

• Creating Powerful and Precise Sensory Diets
  
• Typical elements of a sensory diet
  
• Sensory diet activities
  
• Individualizing a sensory diet
  
• How to structure a sensory diet
  
• Suggested routines for SMS
  
• Sensory diet data sheets and templates