Occupational Therapy for. Adults

Occupational Therapy for Adults With Sensory Processing Disorder TERESA A. MAY-BENSON Many adults have sensory processing disorders that make daily activities challenging or even impossible. This personalized, intensive protocol is tailored to adults and designed for quick results. The needs of children with sensory processing problems have been identified for more than 30 years, and sensory integration intervention is commonly used with this population. 1 Although there is increased awareness of sensory integration problems in adults, practitioners are hard-pressed to locate specific information on how to treat this population. 2 In addition, adults with sensory integration problems report that it is difficult to find practitioners with expertise in this area. The purpose of this article is to describe the unique needs of adults with sensory processing problems and to present a program of intervention for this population. Adults with sensory processing problems present with the same patterns of sensory integrative dysfunction as children. They tend to seek professional intervention when they are so overwhelmed by some aspect PHOTOGRAPH COLORBLINDIMAGES / BLEND IMAGES / GETTY of defensiveness, or they are experiencing significant problems in mental health or occupational performance. For example, auditory sensitivities may interfere with the ability to work, ride public transportation, and participate in family activities. Tactile defensiveness is often related to difficulties with intimacy with a spouse or significant other and frequently affects interpersonal relations with friends, co-workers, and family. Vestibular processing problems affect the ability to drive, ride in airplanes, and engage in daily activities such as descending stairs, riding a bike, walking on uneven surfaces (e.g., when hiking), and navigating terrain such as icy sidewalks. 3 Adults with dyspraxia frequently have difficulty maintaining employment due to disorganization and problems meeting work demands, such as completing reports or projects on time and in a coherent manner. They may also have difficulty operating common office machinery such as copy machines, due to difficulties with planning, sequencing, and organizing. Adults with sensory processing problems, especially those with sensory defensiveness, often present to others as being controlling, picky, and overly sensitive. 4 They often report high levels of anxiety and depression, commonly have a history of posttraumatic stress disorder (PTSD) or trauma, 5 and may have tried years of counseling and medication before arriving at occupational therapy. Many are referred for occupational therapy services by psychologists; some seek services independently; and some request occupational therapy after they have had experience with a child with sensory processing problems. In my experience, after adults make the decision to seek services, they frequently want or need them quickly. They may have limited funds if insurance does not reimburse for services, and work commitments may dictate the need for very late afternoon or evening appointments. Some adults are uncomfortable being treated in a sensory integration clinic (because most clients are children), even if they are in a separate area. Lastly, they often want to see fast results to maintain motivation for continued therapy. ASSESSMENT Assessing adults presents many challenges. There are few standardized 15

Table 1. Assessment Battery for Adults Developmental/Sensory Histories Adult Sensory History 23 Adult Sensory Profi le 24 Adult Sensory Questionnaire 25 ADULT-SI 26 Coping Inventory Adult Version 27 Motor Skills BOT-2 28 Sensory Integration and Praxis Tests (SIPT) 29 : Postural Praxis and Oral Praxis, Standing Balance Sensory Sensory Integration and Praxis Tests (SIPT) 29 : Finger Identifi cation and Graphesthesia SCAN-A 30 Motor-Free Visual Perceptual Test, 3rd (MVPT-3) 31 Post-Rotary Nystagmus: upright and sidelying 19 Clinical Observations Muscle tone Prone extension Supine fl exion Sequential thumb fi nger Diadokokineses Oculo-motor control Gravitational insecurity Postural alignment Indicators of Sensory Integrative Dysfunction in Adults Tactile Functioning Sensitive to texture and fi t of clothing. May avoid wearing some types of clothing such as ties or pantyhose. Dislikes crowds or jostling in public places, such as lines or shopping. Becomes irritated with light or unexpected touch. May have diffi culty with intimate touch. Vestibular Functioning Diffi culties with balance, dislike of walking on uneven surfaces. Dislikes or becomes disoriented in elevators or escalators. Routinely becomes nauseous when riding in the car. Needs to ride in the front seat or be the driver. Fearful of fl ying. assessments for this age group, and many adults find standardized assessments threatening and very challenging. The evaluation may be more of a consultation or interview with the client than a formal assessment. Consequently, it is essential to obtain a comprehensive clinical history. During the interview the therapist should determine the type and nature of the client s sensory integration and motor problems and how those difficulties are affecting participation and occupations, as well as the client s social-emotional state. A developmental history and sensory questionnaire are vital tools for obtaining comprehensive information. Standardized tests are selected based on referring problems, but the therapist will typically evaluate for praxis problems; tactile, proprioceptive, and vestibular discrimination difficulties; visual perceptual problems; auditory processing problems; and oculo-motor and postural control problems. Standardized assessments with age-appropriate normative data are the first choice (see Table 1); however, a lack of appropriate assessments for this age group may make it necessary to use some tools in nonstandardized ways. Observations during testing and client report of the experience of testing may ultimately be more useful than actual test scores. Adults may score within average limits on standardized tests but express extreme difficulty completing the task. INTERVENTION Interventions for adults frequently emphasize home programming and sensory diet activities for managing the sensory defensiveness issues. Although helpful in managing day-to-day events, these interventions do not usually create permanent changes in functioning. While consultation and home activities may be the only alternatives for some due to financial or time constraints, neuro-physiological changes in the nervous system are possible in adults 6 and direct service is needed to make lasting changes in these individuals. Intervention is most effective if it can be started with an intensive period of treatment during which the individual can observe significant changes in sensory processing over a several-week period. Consequently, an intervention protocol that is an eclectic mix of sensory and motor-based interventions and provides Auditory Functioning Sensitive to loud sounds. Irritated by sounds not usually bothersome to others, such as pencils or pens scratching, lights buzzing, or candy wrappers rustling. Motor Functioning Diffi culty driving, parking, shifting gears, or entering a freeway with an automobile. Difficulty managing common home and office machinery (copy machine, etc.). Self-perception of being clumsy or awkward with daily or gross motor activities. a framework for intervention for adults has been developed. This program is based on sensory integration principles and techniques commonly used with children and developed over 20 years of working with adults with sensory processing problems. Intensive sensory integration intervention was strongly advocated for use with children by Ayres, 7 so clients are typically seen five times per week for 3 weeks, with some clients maintaining this frequency for more than 4 or 5 weeks. This intensive program, which consists of both home and clinic activities, typically results in notable changes. Throughout the program, therapists need to use good clinical judgment in monitoring the client s responses to these intensive sensory experiences, adjust activities accordingly, and provide organizing activities as needed. Home Activities Two types of home activities are provided: sensory diet and remedial. Sensory diet activities allow the person to function throughout the day, and are introduced in the first evaluation session. General sensory diet strategies of heavy work and deep pressure are introduced (e.g., use of stretchy ropes/thera-band, wall push-ups, weighted blankets, pillow squishes) to provide organizing sensory inputs that decrease arousal and sensory defensiveness, which may allow the individual to 16 JUNE 15, 2009 WWW.AOTA.ORG

begin to function better on a day-to-day basis. Environmental modifications and suggestions for modifying routines are provided (e.g., use of music or headphones to decrease sound sensitivity, use of sea bands or ice for vestibular oversensitivity) to further facilitate daily functioning in a variety of contexts. Remedial activities, designed to promote changes to the nervous system and address the underlying sensory problems, are modified from the following clinical activities and are provided throughout the intervention program as needed. Clinical Activities The clinical component is based on the principles of occupational therapy practitioners using sensory integration intervention. First and foremost is the need to establish a therapeutic alliance with the client. The client must feel both emotionally and physically safe to take on the challenge of intervention. As the therapist presents sensory opportunities to address tactile and vestibular problems, the adult may be threatened by the challenging stimuli; thus, it is vital that the client be fully invested in participating in the activities and control which activities are engaged in and for how long. The therapist must assure that activities are always at the just-right level to support intrinsic motivation for participation. Adults may push themselves to do too much in an attempt to prove to themselves and the therapist that they can accomplish a given activity, sometimes resulting in unpleasant sensory overstimulation. Similarly, the therapist must assure that the activity is achievable. It is often embarrassing for adults to be unable to do child-like activities such as throwing or catching beanbags or balancing on a swing. As the therapist presents increasing postural, ocular, and motor challenges, he or she must constantly be aware of facilitating and maintaining the client s appropriate level of arousal through activity suggestions and direction. Clients know what their nervous system can handle on any given day and must be able to decide what activities to do and when. The therapist must go slowly and be a careful observer of the impact of the sensory stimuli, especially when dealing with clients with a trauma background because they may experience flashbacks or panic attacks. Each therapy session is individualized by following the client s lead as to what is needed. In general, sessions consist of four stages: (a) preparatory activities to promote overall functioning, help center the client, and establish a functional arousal level; (b) sensory activities targeted toward a particular areas of difficulty (e.g., tactile, auditory, vestibular); (c) integrating activities, to provide multisensory experiences and elicit adaptive responses at a just-right challenge with later activities involving increased praxis demands; and (d) organizing wrap-up activities, often involving deep-touch pressure or heavy work to facilitate self-regulation and arousal, decrease defensiveness, and integrate the sensory inputs provided. Traditional sensory integration treatment activities are used throughout the program; however, adults often prefer structured P-4144 17

activities so those from a variety of other programs (e.g., Learning Breakthrough or Ball-A-Vis-X) are also used. The following are some typically used activities. Preparatory Activities Cranio-sacral therapy and myofascial release therapy may be used for self-regulation, arousal, and increased postural mobility. A session may start with 10 to 20 minutes of work to organize the client and establish a functional arousal state. 8 Deep-touch pressure may be used alone using a weighted blanket or heavy crash pad, or may be coupled with cranio-sacral therapy. Sensory Activities Sound therapy programs may be used for auditory processing and sensitivity problems. The program may be explored in the clinic for tolerance and evidence of change, and then a home program may be implemented. Several common programs are available. 9 11 Wilbarger Therapressure Protocol, or some variation, is used when appropriate to address tactile defensiveness and as a means of providing organizing deeptouch pressure. 12 Beanbag tapping firmly along the extremities to provide deep touch is a good alternative for adults who do not like the deep pressure provided with a brush. 13,14 Heavy-weight Thera-Band or stretchy ropes made from bicycle inner tube tires pulled with the arms or against the feet is an effective means of providing organizing proprioceptive input. Beans and rice bins for finding small hidden objects is a good activity for decreasing tactile sensitivity. Astronaut training program provides intense vestibular input to all semi-circular canals through rotation on a large spinning board and promotes equalization of vestibular processing across the canals. 15,16 It is always followed with integrative oculo-motor and functional movement activities in order to use and integrate the input provided. Adults may need to progress one spin at a time and use organizing inputs like a weighted blanket while engaged in the activity. FOR MORE INFORMATION New! Sensory Integration: A Compendium of Leading Scholarship By C. Royeen and A. Luebben, 2009, Bethesda, MD: AOTA Press. ($55 for members, $79 for nonmembers. To order, call toll free 877-404- AOTA or shop online at http://store.aota.org. Order #1248-MI.) AOTA Fact Sheet: Addressing Sensory Integration Throughout the Lifespan Through Occupational Therapy By J. Bissell, R. Watling, C. Summers, J. Dostal, & S. Bodison, 2009. Available at www.aota.org. AOTA Fact Sheet: Frequently Asked Questions About Ayres Sensory Integration By S. Bodison, R. Watling, H. M. Kuhanek, & D. Henry, 2008. Available at www.aota.org Living Sensationally: Understanding Your Senses By W. Dunn, 2008. Philadelphia: Jessica Kingsley Publishers. ($23.95 for members, $34 for nonmembers. To order, call toll free 877-404- AOTA or shop online at http://store.aota.org. Order #1428-MI) AOTA CE Article: Understanding Ayres Sensory Integration By S. Smith Roley, Z. Mailloux, H. Miller-Kuhaneck, & T. Glennon, 2007. (Earn.1 AOTA CEU [1 NBCOT PDU/1 contact hour]. $24.75 for members, $35 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org. Order #CEA0907-MI) AOTA CE Article: The Use of Clinical Observations To Evaluate Proprioceptive and Vestibular Functions By E. I. Blanche & G. Reinoso, 1998. (Earn.1 AOTA CEU [1 NBCOT PDU/1 contact hour]. $29.95 for members, $41 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org. Order #CEA0908-MI) Slow linear movement with the swing hung low to the ground is helpful for adults who are gravitationally insecure or fearful of movement. Exploring uneven surfaces by walking across unstable surfaces such as mattress flooring, through large pillow crash pads, etc., is helpful for increasing comfort with uneven terrain. BOSU Ball activities promote vestibular function when the client stands, bounces, or balances on the uneven surface of this half therapy ball while doing eye hand coordination activities. 17 Moving the head out of upright may begin after the adult has some comfort with movement. Activities such as falling slowly in a controlled way off a swing into a large pile of pillows or leaning over to pick up items off the floor are a good start. Working in prone extension while on a glider swing may be challenging as well. 18,19 Integrative and Praxis Activities The infinity walk provides intense but gentle vestibular input and involves walking in a figure 8 while maintaining a visual fix on a central target. Various oculo-motor and praxis challenges can be incorporated. 20 The Flow is a flexible water-filled tube with handles that provides proprioceptive input during a variety of activities that promote visual-vestibular integration and praxis (www. pdppro.com). Ball-A-Vis-X ball activities promote oculomotor control and integration of visual and auditory sensory inputs. 21 The Learning Breakthrough Program combines visual and vestibular activities to improve oculo-motor control, balance, projected action sequences, timing, and spatial awareness. 22 Developmental activities using simple whole body movements is a good place to start. Log rolling across the floor or following a line may be difficult to coordinate and may challenge those sensitive to movement. Crawling through pillows provides heavy work, trunk rotation, and bilateral coordination and may be combined with a visual activity. These activities emphasize development of early motor movement patterns, which often are lacking in these individuals. Pumping and riding on swings can be a good praxis activity to maintain balance and develop bilateral skills. Incorporating visual targets and projected action demands can increase the complexity. Balance board activities using an 8-footlong by 12-inch-wide board covered in carpet can provide a wide range of praxis challenges. Place the board on large beanbags on the floor for a simple balance challenge, then place it over two inner tubes as a bridge for a more complex activity. Hang the board between two suspended inner tubes for a swinging, unstable bridge, or use in various positions as a ramp. CONCLUSION The activities presented here are not the only ones that can be used with 18 JUNE 15, 2009 WWW.AOTA.ORG

To discuss this article, go to www.otconnections.org. Click on Forums, Public Forums, then OT Practice Magazine discussion. adults with sensory processing problems, but they have been found effective. With this program adults have reported positive outcomes, including a general decrease in defensiveness to auditory input, touch, and movement, and improved mental health through decreased stress and anxiety and improved interpersonal relations. Anecdotally, functional changes have been reported in improved safety and comfort with driving, improved ability to ride a bicycle and hike with the family, improved intimacy with a significant other, ability to fly in airplanes with minimal discomfort, and increased food choices and improved nutrition. References 1. Bundy, A. C., Lane, S. J., & Murray, E. A. (2002). Sensory integration: Theory and practice (2nd ed.). Philadelphia: F. A. Davis. 2. Heller, S. (2002). Too loud, too bright, too fast, too tight: What to do if you are sensory defensive in an overstimulating world. New York: Harper Collins. 3. Kinnealey, M., Oliver, B., & Wilbarger, P. (1995). A phenomenological study of sensory defensiveness in adults. American Journal of Occupational Therapy, 49, 444 451. 4. Oliver, B. (1990). The social and emotional issues of adults with sensory defensiveness. Sensory Integration Special Interest Section Newsletter, 13(3), 1 3. 5. Kinnealey, M., & Fuiek, M. (1999). The relationship between sensory defensiveness, anxiety, depression and perception of pain in adults. Occupational Therapy International, 6, 195 206. 6. Lane, S. & Schaaf, R. (2009). Critically appraised topic: Children and adolescents with sensory processing disorders/sensory integrative dysfunction. Retrieved April 29, 2009, from http://www.aota.org/ccl/si/si-1%2042946.aspx 7. Ayres, A. J. (1972). Improving academic scores through sensory integration. Journal of Learning Disabilities, 5, 338 343. 8. Upledger, J. E., & Vredevoogd, J. D. (1983). Craniosacral therapy. Seattle, WA: Eastland Press. 9. Frick, S. (2002). Therapeutic listening: An overview. In A. C.Bundy, S. J. Lane, & E. A. Murray (Eds.), Sensory integration: Theory and practice (2nd ed., pp. 358 361). Philadelphia,: F. A. Davis. 10. Frick, S., & Hacker, C. (2001). Listening with the whole body. Madison, WI: Vital Links. 11. Nwora, A. J., & Gee, B. M. (2009). A case study of a five-year-old child with pervasive developmental disorder. Occupational Therapy International, 16, 25 43. 12. Wilbarger, P., & Wilbarger, J. L. (1991). Sensory defensiveness in children aged 2 12: An intervention guide for parents and other caretakers. Denver, CO: Avanti Educational Programs. 13. Moore, K. M. (2005). The sensory connection program manual. Framingham, MA: Therapro. 14. Moore, K. M., & Henry, A. D. (2002). Treatment of adult psychiatric patients using the Wilbarger Protocol. Occupational Therapy in Mental Health, 18, 43 63. 15. Kawar, M. (2005). A sensory integration context for vision. In M. Gentile (Ed.), Functional visual behavior in children (2nd ed., pp. 87 144). Bethesda, MD: AOTA Press. 16. Kawar, M., Frick, S. M., & Frick, R. (2005). Astronaut training. Madison, WI: Vital Links. 17. BOSU Fitness LLC. (2002). BOSU Balance Trainer. Retrieved March 10, 2009, from http://www.bosupro.com 18. Herdman, S. J. (2000). Vestibular rehabilitation (2nd ed.). Philadelphia: F. A. Davis. 19. Kawar, M. (2002). Oculomotor control: An integral part of sensory integration. In A. C.Bundy, S. J. Lane, & E. A. Murray (Eds.), Sensory integration: Theory and practice (2nd ed., pp. 353 357). Philadelphia: F. A. Davis. 20. Sunbeck, D. (2002). The complete infinity walk, Book I: The Physical Self. Rochester, NY: Leonardo Foundation Press. 21. Hubert, B. (2001). Bal-A-Vis-X : Rhythmic Balance/Auditory/Vision exercises for Brain and Brain-Body Integration:Advanced Exercises. Wichita: Bal-A-Vis-X. 22. Belgau, F., & Belgau, B. V. (1982). Learning breakthrough program. Port Angeles, WA: Balametrics. 23. Koomar, J., Hurwitz, M., Kahler-Reis, R., & Szklut, S. (1996). The Adult Sensory History. Unpublished work. Watertown, MA: Occupational Therapy Associates Watertown. Available at www.otawatertown.com. 24. Brown, C., Tollefson, N., Dunn, W., Cromwell, R., & Filion, D. (2001). The Adult Sensory Profile: Measuring patterns of sensory processing. American Journal of Occupational Therapy, 55, 75 82. 25. Kinnealey, M., & Oliver, B. (2002). Adult Sensory Questionnaire. Unpublished document. 26. Kinnealey, M., & Oliver, B. (1999). Adult Defensiveness, Understanding, Learning, Teaching: Sensory Interview (ADULT-SI). Unpublished document. 27. Zeitlin, S. (1985). Coping Inventory: A measure of adaptive behavior. Bensenville, IL: Scholastic Testing Service. 28. Bruininks, R. H., & Bruininks, B. D. (2005). Bruiniks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). Minneapolis, MN: Pearson Assessment. 29. Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles: Western Psychological Services. 30. Keith, R. W. (1994). Scan-A: A screening test for auditory processing disorders. San Antonio, TX: PsychCorp. 31. Colarusso, R. P., & Hammill, D. D. (2003). Motor Free Visual Perception Test, third edition (MVPT-3). Novato, CA: Academic Therapy Publications. Teresa A. May-Benson, ScD, OTR/L, clinical director of Occupational Therapy Associates Watertown, and research director of the Spiral Foundation, is a wellknown lecturer and researcher on sensory integration. She has authored three book chapters and numerous articles on praxis, ideation, and sensory integration. She has extensive experience with children and adults with autism and a diverse clinical background, having worked in private and public school settings as well as private practice. She has been awarded the Virginia Scardinia Award of Excellence by the American Occupational Therapy Foundation. P-4143 19