SENSORY INTEGRATION SCREENING QUESTIONNAIRE TACTILE SENSATION

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1 Mike Brazelton, M.D. Healthy Habits Pediatrics SENSORY INTEGRATION SCREENING QUESTIONNAIRE Object to being touched? Dislike being cuddled? Seem irritable when held? Prefer to touch rather than be touched? TACTILE SENSATION React negatively to the feel of new clothes? Dislike having hair and/or face washed? Avoid certain texture of food? Isolate self from other children? Frequently bump and push other children? (By accident, not intentionally) Seem overly sensitive to sound? Miss some sounds? Seem confused about the direction of sounds? Like to make loud noises? Have a diagnosed hearing loss? Explore the environment with smell? AUDITORY SENSATION OLFACTORY SENSATION Discriminate odors? React defensively to smells? Ignore noxious odors? Have a diagnosed visual defect? Have difficulty eye tracking? VISUAL SENSATION

2 Make reversals when copying? Have difficulty discriminating colors, shapes? Appear sensitive to light? Resist having vision occluded? Become excited when confronted with a variety of visual stimuli? Act as though all food tastes the same? GUSTATORY SENSATION Explore by tasting? Dislike foods of a certain texture? Dislike being tossed in the air? VESTIBULAR SENSATION Seemed fearful in space (going up and down stairs, riding see saw, etc)? Appear clumsy, often bumping into things and/or falling down? Prefer fast moving, spinning rides? Avoid balance activities? Seem stronger than normal? Frequently grasp objects too tightly? Have a week to grasp? Tire easily? Seem accident prone? Eat in a sloppy manner? Have difficulty with pencil activities? Have difficulty dressing and/or fastening clothes? Does not have a consistent hand dominance? Neglect one side of the body, or seem unaware of it? MUSCLE TONE COORDINATION REFLEX INTEGRATION AND DEVELOPMENT Was the child's slow to reach the usual developmental milestones? Was a child irritable in infancy, particularly when held?

3 Does the child have difficulty isolating head movements? Does the child lack adequate protective reactions when falling Sensory Processing Disorder Checklist Below is a list of other behaviors exhibited by children with SID/DSI: Loves to spin, swing and jump this will seem to calm them down after several minutes. Complains of how clothing feels, does not like tags left in their clothing and have to have their socks on just so, or a certain kind of sock. Picky eaters get stuck on one certain food and is basically impossible to get them to eat anything else. Oversensitivity to smells. Or undersensitivity may sniff people, objects, food. Oversensitivity to sounds will frequently cover ears. Or undersensivity. May have an exceptionally high pain tolerance May tire easily Unusually high or low activity level Resists new situations Problems with muscle tone, coordination, motor planning Can be very impulsive or distractible. Persistently walks on toes to avoid sensory input from the bottom of the feet. This can also be a sign of cerebral palsy if the child is unable to bring their feet down flat when asked or trying. These are just a few of the symptoms that children with SID/DSI can exibit. Many of the symptoms listed in the following categories are common to that particular age group. Where more than a few symptoms are found in a child, we recommend you talk to your doctor for a professional experienced with treating Sensory Processing Disorder. Infant/ Toddler Checklist: My infant/toddler has problems eating. My infant/toddler refused to go to anyone but me. My infant/toddler has trouble falling asleep or staying asleep My infant/toddler is extremely irritable when I dress him/her; seems uncomfortable in clothes. My infant/toddler rarely plays with toys, especially those requiring dexterity. My infant/toddler has difficulty shifting focus from one object/activity to another. My infant/toddler does not notice pain or is slow to respond when hurt. My infant/toddler resists cuddling, arches back away from the person holding him. My infant/toddler cannot calm self by sucking on a pacifier, looking at toys, or listening to my voice. My infant/toddler has a "floppy" body, bumps into things and has poor balance. My infant/toddler does little or no babbling, vocalizing. My infant/toddler is easily startled. My infant/toddler is extremely active and is constantly moving body/limbs or runs endlessly.

4 My infant/toddler seems to be delayed in crawling, standing, walking or running. Pre School Checklist: My child has difficulty being toilet trained. My child is overly sensitive to stimulation, overreacts to or does not like touch, noise, smells, etc. My child is unaware of being touched/bumped unless done with extreme force/intensity. My child has difficulty learning and/or avoids performing fine motor tasks such as using crayons and fasteners on clothing. My child seems unsure how to move his/her body in space, is clumsy and awkward. My child has difficulty learning new motor tasks. My child is in constant motion. My child gets in everyone else's space and/or touches everything around him. My child has difficulty making friends (overly aggressive or passive/ withdrawn). My child is intense, demanding or hard to calm and has difficulty with transitions. My child has sudden mood changes and temper tantrums that are unexpected. My child seems weak, slumps when sitting/standing; prefers sedentary activities. It is hard to understand my child's speech. My child does not seem to understand verbal instructions. School Age: My child is overly sensitive to stimulation, overreacts to or does not like touch, noise, smells, etc. My child is easily distracted in the classroom, often out of his/her seat, fidgety. My child is easily overwhelmed at the playground, during recess and in class. My child is slow to perform tasks. My child has difficulty performing or avoids fine motor tasks such as handwriting. My child appears clumsy and stumbles often, slouches in chair. My child craves rough housing, tackling/wrestling games. My child is slow to learn new activities. My child is in constant motion. My child has difficulty learning new motor tasks and prefers sedentary activities. My child has difficulty making friends (overly aggressive or passive/ withdrawn). My child ïgets stuck' on tasks and has difficulty changing to another task. My child confuses similar sounding words, misinterprets questions or requests. My child has difficulty reading, especially aloud. My child stumbles over words; speech lacks fluency, and rhythm is hesitant. Adolescent/Adult: I am over sensitive to environmental stimulation: I do not like being touched. I avoid visually stimulating environments and/or I am sensitive to sounds. I often feel lethargic and slow in starting my day. I often begin new tasks simultaneously and leave many of them uncompleted. I use an inappropriate amount of force when handling objects. I often bump into things or develop bruises that I cannot recall. I have difficulty learning new motor tasks, or sequencing steps of a task.

5 I need physical activities to help me maintain my focus throughout the day. I have difficulty staying focused at work and in meetings. I misinterpret questions and requests, requiring more clarification than usual. I have difficulty reading, especially aloud. My speech lacks fluency, I stumble over words. I must read material several times to absorb the content. I have trouble forming thoughts and ideas in oral presentations.