Postural control in children with sensory processing disorder

In order to meet the environmental demands in an effective way, a child must be able to assume and maintain stable positions, move without losing balance and have adequate postural control to support movements of hands and legs. This becomes essential for a child to be competitive and successful at his/her performance areas such as play, home and school.

Postural deficits that are often associated with vestibular and proprioceptive dysfunction include a group of components as follows.

1. Low tone in extensor muscles

2. Poor postural stability

3. Poor co-contraction

4. Poor equilibrium reactions

5. Poor tonic flexion in neck muscles.

Example of poor postural control: A teacher complained about child that each time the child was asked to pick up materials from bag that was placed under the chair, the child had to get up from chair, turn around, sit down to pick up  things and repeat the same procedure to get back to chair. The child lacked the postural control that was required to remain seated and retrieve the materials from the bag. This is a typical example of inadequate postural control.

Home and school behavior:

–          Finds difficulty sitting still

–          Appears clumsy

–          May be lethargic/ lazy or be slow at day to day activities

–          Looses balance and falls often

–          May seem weak due to poor proprioception

–          May seek intense vestibular input yet avoid challenging vestibular activities while on play ground with peers present

–          Drops things often from hand When children exhibit cluster of postural difficulties, they are most likely to have difficulty in processing vestibular and proprioceptive sensation.

Hence intervention should be emphasized on activities that provide enhanced vestibular and proprioceptive sensation that simultaneously challenge posture.

Those activities should address the following 4 components of posture.

–          Postural extension

–          Postural flexion

–          Postural stability

–          Balance

A. Postural extension: Activities given on prone position, i.e., child lying on tummy, gives good effort to extension position. These include,

–          Lying prone on flat swing and do activities like fixing puzzles, dropping coins etc using hands

–          Lying prone on gym ball and reach for toys overhead to allow lifting head and neck against gravity

–          Lying prone on elbows and playing with toys or blowing candles placed in front can be given for kids with low muscle tone

–          Lying prone from a higher surface such as cot or barrel/ bolster and weight bear with hands on floor will allow good co-contraction for shoulder and neck muscles and performing activities using one hand in this position will provide good opportunity for weight shifting.

–          Lying prone on a wedge with neck and arm unsupported to net a ball into a basket overhead is a highly challenging task for developing tonic extension.

–          Activities can be done lying prone on scooter board, hammock or lycra swing

B. Postural flexion: Activities given on supine position, i.e., child lying on back, where head and limbs are aimed at moving towards the abdomen gives good effort to flexion position. These include,

–          Lying supine on an inclined mattress or wedge and raising head and trunk to reach target held by the care giver

–          Lying supine with a little pillow under head and playing kicking ball

–          Lying supine on floor and propelling swing through legs

–          Sitting on a disc swing, hammock or lycra swing and picking up objects from floor

–          Hanging on trapeze to swing and cross over an obstacle

C.  Postural stability: Creating activities with postural rotation and weight shifting helps the child attain postural stability through facilitating mobility superimposed on stability.

–          Rotation can be given through activities such as rolling inside a barrel, swinging at all directions with change in body postures as in reaching for toys overhead and under swing etc

–          Weight shifting can be given using any piece of equipment that move or any activity that involves reaching at various positions such as kneeling, standing, quadruped, one leg standing, squatting, bending etc.  

D. Balance: The ultimate goal of postural control is to maintain body balance when there is a movement threat to the body or support surface. This can be achieved through reaching out from various static postures to elicit subtle equilibrium reactions and progressing to activities that can be performed by placing the child on any unstable equipment such as swing, gym ball, balance board, balance beam, bean bag, spin disc, see saw, etc. Care should be taken that activities to develop balance should progress from static to dynamic postures and should never be a threat to the child.

Tactile defensiveness is the most common sensory modulation deficit of tactile system and it is predominantly found in children with autism. Children with tactile defensiveness tend to react negatively to touch sensation that is considered otherwise non-noxious by most typical children. Most commonly it is the hyper-responsiveness to light or unexpected touch.

A child with tactile defensiveness may

• – Dislike changes in temperature such as going in or out of bathing
• – Dislike going barefoot or taking his/her shoes off
• – Pull away from light touch
• – Dislike eating messy foods with his/her hands
• – Avoid getting his/her hands in finger paint, sand, paste, clay, etc
• – Dislike having hair washed, teeth brushed or face washed
• – Prefer to touch rather than be touched
• – Seem irritated by fuzzy clothing
• – Have tendency to walk on his/her toes
• – Choose to weight bear on tip of the fingers
• – Get irritated when handled by others especially strangers
• – Resist wearing new clothes
• – Get irritated by tags on clothing
• – Prefer to stand at the end of the line to avoid contact with others
• – Prefers solitary play

Note:  Child should be observed for cluster of behaviors to be identified as having tactile defensiveness. These behaviors alone do not constitute to tactile defensiveness.  Detailed assessments using sensory profiles are important to arrive into a confirmation.

Tactile defensiveness is a problem, in large part, because of the inappropriate behaviors that accompany it. Defensiveness to touch potentially interferes with all occupations and roles. Basic self-care is affected when a child resists to food, clothes, washing hair, cutting nails, etc. Avoiding sand, refusing to walk barefoot on grass and sand affects play and aversive reactions to different textures or touch of other children disrupts class room behaviors in large which would in turn make learning difficult.

Targets for intervention

•        – Increase ability to maintain optimal level of arousal in the presence of tactile (or any over arousing) input
•        – Decrease over reaction to tactile input
•        – Improve emotional and organizational skills
•        –  Help the child cope with specific environments
•        – Address fine motor skills

Intervention

          Sensory experiences can be started in each session with vestibular and proprioceptive input which will help the child calm down and feel a sense of control over the environment. It can be continued with deep pressure and gradual exposure to touch, if tolerated, can be given at the end.

Activities that provide the above mentioned sensory experiences include

•        – Swing that can be used to provide slow and rhythmic movements
•        – Hanging on to suspended equipments for proprioceptive input
•        – Enable jumping, bouncing or pulling while on swing
•        – Burrowing in large pillows and mats for deep pressure
•        – Rolling large therapy balls over child’s back or legs for providing deep pressure
•        – Activities that involve pulling or pushing heavy objects that would help in enhanced proprioceptive input
•        – Pool of balls, beads or beans where the child can submerge and move around to bet enhanced touch input (allow touch input only until it is tolerated)
•         – Playing with shaving cream, powder, lotion, paint, sand, water, glue, clay etc after providing vestibular,Proprioceptive and deep pressure input will help to decrease over reaction to touch
•         – Chewy tubes, chewy snacks blowing activities, deep breathing can be encouraged throughout the day.

Guidelines for providing the above mentioned sensory experiences

•  – Allow children to provide these inputs by themselves so that they have a control over input.
•  – It is important to experiment different types of input which would be more effective in each child. Few  children might enjoy and prefer deep pressure to heavy joint compression.
•  – Children find tactile input more tolerable of they are applied in the direction of hair growth.
•   – Proprioception is generally the most organizing type of sensation. When a child appears to be bothered by tactile sensation substituting proprioception or combining deep pressure with proprioception is often successful.

Modifying the physical and social environment

•      – Reduce sensory over load in the environment
•      – Avoid light touch
•      – Avoid tight clothing
•      – Lower voice, use natural light
•      – Respect child’s personal space
•      – Do not impose
•      – Allow the child to have a control over the sense he/she receives and expect a response

For a child to be independent and successful in his/her social environment such as home, school, peer group, etc, the child must possess social skills like communicating, sharing, waiting, turn taking, apologizing, requesting, thanking, competing, being aware of other’s needs and having age appropriate play skills. In order to develop these skills in children receiving occupational therapy at our centre, we started conducting group sessions.

Four children, two boys and girls, aged between 5 and 7 years with similar cognitive levels were taken for group therapy. All four children (referred to be in group 1) were diagnosed under autism spectrum disorders, and specifically had sensory processing issues related to bilateral integration and sequencing, and three of them had tactile defensiveness.

At the level of initial assessment, children

• Were able orient to time, place and person,
• Were able to follow simple commands
• Knew basic concepts like colours, alphabets, numbers, shapes, categories of objects, etc and were going to mainstream school.
• Were not having social skills like, greeting others without prompt, listening to others, etc
• Had problems in maintaining eye contact
• Lacked group skills like waiting, taking turns, or play with peers,
• Were not able to accept or tolerate other children’s company.

Hence group therapy was planned carrying the above mentioned problems as goals which include one activity from each of the following categories.

1. Children were asked to greet each others, parents and therapists by names with eye contact

2. Warm up activities such as jumping on trampoline, breaking soap bubbles, tapping balls/balloons ,etc were given were children were expected to stay within the given boundaries which helps to develop tolerance to touch, were asked to give chance and wait for others turn which develops sharing and waiting.

3. Activities like holding hands and jumping across rope, jumping together within hoola loop, crossing over obstacles in a line, walking together inside lycra swing, doing animal walks like crab walk, bear walk, frog jump, etc, together in a line, were given. This helps to develop skills such as doing activities together in a group, tolerating other’s touch, waiting for others to complete their task and join the group, waiting for commands and control impulsivity..

4. Activities like singing rhymes, doing action imitations, spelling words, counting numbers, reciting alphabets, were given were each child was asked to perform these tasks in turns in front of other kids and parents. This helps to develop eye contact, reduce social hesitation, and improve self confidence.

5. Activities requiring exchange of puzzles or toys among each others were given to provide opportunities for verbal communication. Concepts such as “give me”, “take it”, “thank you” and “welcome” were taught.

6. Activities like target throwing, ball catching, board games with dice, actions on commands etc were given to develop game concepts in children.

7. To teach sharing, snack time was present at the end of all sessions were each child was asked to share a piece of given snack to each other and eat once all of the get their share.

8. At last, children were taught to say “bye-bye “to each others, parents and therapists by their names.

Each of the group session would last for one hour including 7 to 8 activities from the above mentioned categories with two minutes breaks between each activity. After 8 months of group therapy children are now able to

• Greet each other without prompt
• Recognize the absence of other child
• Enjoy the presence of other kids and show emotional attachment
• Show tolerance to touch better than before
• Understand turn taking and able to wait for others turn without prompt
• Initiate activities like rhymes action imitation etc
• Verbally use “give me” , “take it”, “thank you” and “welcome” appropriately without prompt
• Point out when others did not wait or take turn appropriately
• Share and eat without prompt
• Listen and follow instruction and learn simple new games

The future goals of the group session would be to improve verbal communication, to introduce concepts of competition, winning and losing, to improve listening skills and to develop age appropriate play skills.