Life Experiences of a Child with Challenges in Sensory Processing and Integration: A Case Study

Children have occupations they need to perform in order to learn, grow, and develop. Challenges in processing and integrating sensory information can impair their capacities . for occupational participation and engagement. Sensory integration interventions have been promoted as able to help children improve their abilities to use sensory information for function as well as provide strategies for self-regulation. Much of the research on the efficacy of sensory integration interventions is experimental and descriptive, and largely inconsistent. Qualitative methodologies have not been widely used to examine the approach or to investigate the first-person experiences of the children who participate in sensory integration interventions. This phenomenological qualitative research study investigated ~he life experiences of a child with challenges in sensory processing and integration who had received sensory-based occupational therapy intervention. The themes identified were freaking out and I engage. The perspectives acquired can help influence the clinical reasoning of occupational therapists and expand the research base of sensory integration interventions. -SENSORY PROCESSING LIFE EXPERIENCES Life Experiences of a Child with Challenges in Sensory Processing and Integration: A Case Study 4 The role of occupational therapy is to promote "the health and participation of people, organizations, and populations through engagement in occupation" (American Occupational Therapy Association [AOTA], 2008, p. 625). Participation is simply performing an activity, while engagement requires motivation and choice (AOTA, 2008). Both participation and engagement in the occupations of children can provide the foundation for learning, growth, and development. Lane (2012) stated that "children are not little adults; they are impressionable beings who experience and learn" (p. 4 ). In order for children to successfully experience and learn, as well as participate and engage in occupations, they need to process, organize, and respond to sensation arising from the body and the environment. This process is called sensory integration and it is the foundation for the development of selfawareness, learning, and behavior (Ayres, 1972). The theory of sensory integration, as conceptualized by Ayres (1972), is the "neurological process that organizes sensation from one's own body and from the environment and makes it possible to use the body effectively within the environment" (p. 11). Ayres' theory was developed in accordance with the neuroscience research of her day and revqlved around the phenomenon of neuroplasticity, or the brain's ability to change its structure and function in response to experience (Parham & Mailloux, 201 0). A typically developing person is able to process and organize sensory information from both the body and the environment in order to create an accurate body scheme and SENSORY PROCESSING LIFE EXPERIENCES judge the body's orientation in space. This information allows the individual to respond to sensory experiences in an appropriate manner and adapt his or her responses to novel experiences as necessary. The brain collects and draws upon these experiences and responses for the performance of everyday childhood occupations such as selfcare, education, play, leisure, and social participation. Any time the response to a sensory experience is more complex than its predecessor, organization of the brain is improved and the "capacity for further sensory integration is enhanced" (Parham & Mailloux, 2010, p. 327). 5 Dysfunction in processing, organizing, and integrating sensory information for use may manifest as poor gross and fine motor skills, language skills, cognition, and emotional regulation which in turn affect academic performance, occupational engagement, and participation in family and social life (Parham & Mailloux, 201 0; Watling, Koenig, Davies, & Schaaf, 2011). It is estimated that 5% to 15o/o of American kindergarteners (Ahn, Miller, Milberger, & Macintosh, 2004), 40o/o to 80°/o of children with developmental disabilities (Baranek et al., 2002), and 30°/o to 1 OOo/o of children diagnosed with autism spectrum disorder (Dawson & Watling, 2000; Tomchek & Dunn, 2007) have these types of challenges in processing and integrating sensory information. Many intervention strategies can be implemented when addressing these deficits; sensory integration being one of the most utilized approaches (Blanche & Blanche Kiefer, 2007). Occupational therapy research on the effectiveness of sensory integration interventions is mixed; nevertheless, caregivers have expressed appreciation for the changes in abilities, activities, and self-worth sensory integration interventions bring to their children (Cohn, 2001 b). Expanding the research base on SENSORY PROCESSING LIFE EXPERIENCES 6 sensory integration interventions is an important step in increasing the knowledge and understanding of the effects of this treatment approach. Most of the existing research on sensory integration interventions utilized experimental or descriptive methodologies. Qualitative research methodologies have the potential to provide relevant data on par with experimental, outcomes, and descriptive research (Tomlin & Borgetto, 2011). Additionally, much of the existing qualitative literature surrounding sensory integration interventions for children focuses on parental and familial perceptions (Cohn, 2001a; Cohn, 2001 b; Cohn, Miller, & Tickle-Degnen, 2000) while the perceptions of the children themselves are unknown. Background The field of occupational therapy is concerned with an individual's ability to engage in occupations and participate in everyday life. Occupational engagement requires an individual to make choices and to be motivated to perform. Engagement includes "carrying out activities meaningful and purposeful to the individual person" (AOTA, 2008, p. 660). Participation is defined by the World Health Organization (2001) as "involvement in a life situation" (p. 1 0), and is the natural outcome of performing an activity (AOTA, 2008). For children, occupational engagement and participation provide the foundation and the building blocks for learning, growth, and development. When engagement and participation are disrupted, so are these outcomes. Participation and engagement. Kids want and need to do the everyday "kid things" (Lane, 2012, p. 3) that contribute to learning, growth, and development. Learning and systems theorists have proposed a sequential developmental process whereby the everyday kid things contribute to the maturation of the central nervous system (CNS) SENSORY PROCESSING LIFE EXPERIENCES 7 and result in learning (Case-Smith, Law, Missiuna, Pollock, & Stewart, 2010). They believe that a child must interact with his or her environment in order to grow in "knowledge, skills, and occupations through experience that leads to a permanent change in behavior and performance" (Case-Smith et al., 2010, p. 30). Burgman (2012) believes that everyday kid things also contribute to a sense of agency, which she describes as the "ability to self-determine engagement with and response to life experiences" (p. 11 ). Engagement suggests a "commitment made to performance" (AOTA, 2008, p. 660), rather than simply performing an activity. However, simply performing an activity, or participating, may provide a child with the experience necessary to determine whether or not an activity elicits enough meaning and/or purpose for the child to make that commitment to performance. The ability and desire to participate and engage in occupations that are wanted and needed contributes to the development of identity and competence, and supports health and participation (AOTA, 2008). Childhood roles of family member, friend, student, and player (Posatery Burke, Schaaf, & Lomba Hall, 2098) typically provide plenty of occupational opportunities for participation and ~ngagement. Areas of occupation. The American Occupational Therapy Association (AOTA, 2008) has offered multiple definitions for the term "occupation" (pp. 628-629), all of which encompass the concept of daily engagement in purposeful or meaningful activities. Occupational therapists recognize that participating and engaging in occupations can help to organize daily life and promote overall health (AOTA, 2008). Eight areas of occupation have been identified, five of which are of primary concern to SENSORY PROCESSING LIFE EXPERIENCES cllildren: activities of daily living, instrumental activities of daily living, education, play, leisure, and social participation (AOTA, 2008). 8 Activities of daily living (ADLs) are fundamental self-care activities (AOTA, 2008) and essential occupations within the maturation process (Shepherd, 2010). Active participation in ADLs such as bathing, dressing, and grooming can help a child to progress in the development of physical skills and problem-solving skills (Shepherd, 2()1 0). Learning and mastering ADLs can cultivate self-esteem, self-reliance, selfdetermination, autonomy, and pride (Shepherd, 201 0). Responsibility for establishing habits and routines for ADL performance that is socially acceptable increases over time and becomes necessary for engagement in other occupations and community living (Shepherd, 201 0). · Instrumental activities of daily living (IADLs) are homeor community-based activities that take place beyond the self, such as meal preparation and cleanup, care of pets or others, and community mobility (AOTA, 2008). Natural opportunities for participating and engaging in IADLs exist within the home and community for children as young as three years (e.g. assisting in caring for pets, meal preparatiqn and cleanup, and shopping); however, the autonomy developed in adolescence seems to motivate the development of the more complex IADLs in preparation for independent community living (Loukas& Dunn, 2010). Participation and engagement in IADLs at any age or ability level can "promote self-determination, self-sufficiency, health, and social participation" (Loukas & Dunn, 2010, p. 518). Education encompasses both formal and informal activities necessary for learning (AOTA, 2008). Children in formal educational settings (schools) can be SENSORY PROCESSING LIFE EXPERIENCES expected to participate and engage in academic and nonacademic activities that help them develop performance skills such as sensory/perceptual, motor, cognitive, and social (Bazyk & Case-Smith, 201 0). These skills can help support participation and engagement in other occupations throughout the lifespan. 9 Play is one of the primary occupations of childhood (Knox, 201 0; Parham, 2008; Watl.ing et al., 2011) and often occurs throughout the majority of a child's day. AOTA (2008) categorizes play and leisure as separate occupations; however, for children play and leisure often seem to be quite similar: active engagement in spontaneous, enjoyable, amusing, intrinsically motivating, nonobligatory activities of choice (AOTA, 2008; Parham, 2008). Participation and engagement in play and leisure are natural opportunities for children to develop cognitive and physical skills (Parham, 2008), learn about the environment (Knox, 201 0), and become proficient in interacting with it (Knox, 2008). "Occupational roles change across the lifespan" (Parham, 2008, p. 21), and the skills gained in childhood through play are likely to support participation and engagement in increasingly challenging occupations later in life. Social participation involves utilizing patterns of behavior expected within community, family, and peer/friend contexts (AOTA, 2008). In Western cultures, school is an additional social context for children (Olson, 2010). Many friendships originate from the peer interaction and social acceptance that occurs in these contexts, and can encourage emotional security, positive self-esteem, and social support (Olson, 201 0) as well as foster resilience (Burgman, 2012). "Friendship can support adaptive social processing skills including perspective taking and the development of social skills important for interacting in many social environments" (Olson, 2010, p. 312). Friendship, SENSORY PROCESSING LIFE EXPERIENCES therefore, may lead to successful participation and engagement in activities with other individuals, community members or organizations, obligatory or chosen roles, and intimate relationships (AOTA, 2008). The influence of sensation. 10 Sensation as a foundation for learning, growth, and development. For some children, engagement and participation in these areas of occupation are hindered by challenges in processing and integrating sensory information. Introduced by A. Jean Ayres more than 40 years ago, the theory of sensory integration focuses on "the organization of sensation for use" (Ayres, 1979, p. 5) and was intended to "explain the relationship between deficits in interpreting sensation from the body and the environment and difficulties with academic or motor learning" (Bundy & Murray, 1991, p. 3). Occupational therapists use this theory to help understand hov" a child's learning, growth, and development are impacted by the sensations experienced in everyday life, and to plan intervention and predict change (Bundy & Murray, 1991). The sensory integration theory delineates the role of sensation in supporting growth and achievement of typical developmental milestones in children. Sensory information comes from seven distinct systems: visual, gustatory, olfactory, auditory, tactile, vestibular, and proprioceptive. Sensory information travels through each of these systems to diffuse areas of the central nervous system, where it affects the functions and structures that are active in processing and integrating sensory information. Sensory. input is used in a variety of ways, including but not limited to an individual's ability to modulate his or her response to a stimulus based on its intensity and duration, discriminate among temporal and spatial characteristics of a stimulus, control ocular SENSORY PROCESSING LIFE EXPERIENCES 11 movements, maintain antigravity positions and balance, use both sides of the body together, sequence an activity, and conceptualize, plan, and perform motor actions (Anzalone & Lane, 2012; Schaaf et al., 201 0). All of these functions serve as building blocks for the development of advanced and complex skills needed as a child grows. Two of the primary concepts Ayres developed her theory around are neuroplasticity and the adaptive response. Neuroplasticity is the ability of the brain to alter its structure and function in response to experiences (Parham & Mailloux, 201 0). As a child engages in activities and participates in daily life, input is received through the sensory systems. As that input is processed and integrated it affects the nervous system structures and functions involved in the processing. Each experience a child has builds on previous experiences, which in turn promotes dendritic branching, creates new synaptic connections, and increases brain tissue mass (Parham & Mailloux, 201 0). All of this neural activity interacts to help the child develop a repertoire of appropriate and effective responses for a wide variety of sensory information (Parham & Mailloux, 2010) .. The adaptive response described by Ayres is a reflection of the individual's ability to respond to an environmental situation in an appropriate manner (Ayres, 1979). Throughout the day, sensations from the environment and the child's body are received by the nervous system where they are organized and processed, and where a response