Sensory Processing: Differences Between Clinical and School Occupational Therapy Occupational Therapy in the Clinic: When parents are concerned about a child's development in the areas of sensory processing and/or motor skills, physicians will often refer them to a private clinic for their child to be evaluated by an occupational therapist. The occupational therapist may conduct a variety of different tests, including parent questionnaires or surveys, to determine if a child is having difficulty processing sensory information or having difficulty with fine motor, gross motor, or self-help skills. These clinicians base their recommendations on how the child performed in their clinic, as well as information from parents on the child's functioning at home and their impressions of how the child is doing in school. Occupational Therapy in the Schools: In the school setting, when a child is recommended for special education services, a multidisciplinary team evaluation is performed. The occupational therapist may be one member of this multidisciplinary team, which also includes several other professionals, such as a psychologist, a nurse, a special educator, the classroom teacher, vision and/or hearing specialists, a speech pathologist, a social worker, and a physical therapist. The special education evaluation strives to provide a comprehensive, multidimensional assessment. The student's performance may be observed over a period of time within the school environment. The team of school professionals looks at the student's functioning in several areas of development, including: Cognitive development (thinking abilities) Educational achievement (ability to learn) Social functioning and mental health Language development Physical development Pertinent medical information from the child's physician Vision and hearing Gross and fine motor skills Sensory processing Within the course of this assessment, the school OT observes the child performing academically-related tasks in the school setting. In addition, the OT interviews the classroom teacher(s) to determine if any difficulties that the student is experiencing are related to problems with fine and gross motor skills, self-help skills, and/or sensory issues. Although a student may achieve low scores during a standardized assessment in an OT clinic setting, this does not always directly relate to how a child is able to perform in the school setting. Therefore, while a school occupational therapist will certainly take a private clinical OT assessment into account, this information must be balanced with observation of the student's performance in the school setting, engaging in educationally-related tasks, as well as the findings of the other multidisciplinary team members. After consulting with the multidisciplinary team, the school OT may come to one of several conclusions, such as: Conditions other than sensory processing problems are affecting the child's functioning Sensory processing may be a factor, but other interventions may be more effective and should be tried first Sensory processing may be one of many issues to address Sensory processing is a primary issue requiring intervention Differences in a Child's Behavior between Home and School Environments Some children display different patterns of behavior in different situations. For example, children who need a lot of ongoing stimulation may actually perform better at school where there are lots of structured activities going on throughout the day, and where they can see other students setting positive examples by sitting, listening and completing their work. In this case, sensory strategies could be beneficial in the home environment, but would not be needed in the school environment. On the other hand, some children may have much more difficulty controlling their behavior at school, particularly if busy environments easily distract them, or if they demonstrate over-sensitivities to touch, noise, or visual stimulation. In this situation, they might benefit from using some sensory strategies in the educational setting, although this would not be necessary at home. Other conditions that might be confused with (or may overlap) sensory processing difficulties: The reason that a special education assessment can be very beneficial is that there are many conditions that might be confused with (or overlap) sensory processing difficulties. A multidisciplinary team is often able to assist in the identification of some of these conditions, which are described below. ADD and/or ADHD: Medical research indicates that 70-80% of individuals with this diagnosis benefit from a combination of medication and behavioral support. Therefore, if it is suspected that a child has this diagnosis after a multidisciplinary assessment is completed, the primary intervention should be for the parents to work with their physician and/or mental health professional to determine how to help the child. Sensory strategies could be beneficial, but should not be the primary or only intervention. Although individuals with ADD or ADHD sometimes have great difficulty with handwriting, this often improves when medication helps the child to slow down and become more attentive and organized. Mental health conditions (such as obsessive compulsive disorder, bipolar disorder, anxiety disorder, oppositional defiant disorder, etc.): If long-standing difficulties of an extreme and intense nature significantly interfere with a child's functioning, a referral to a physician and/or mental health professional is indicated to rule out the mental health conditions described above. These conditions often respond very quickly to the appropriate medications and/or emotional-behavioral supports. Neurological conditions (i.e. cerebral palsy, muscular dystrophy, tuberous sclerosis, tremors, seizure disorders, etc.): In these conditions, the "northbound" messages to the brain may be processed adequately, but the "southbound" messages going to the muscles get scrambled and the motor pathways misfire; ultimately medication, motor strategies, and/or compensatory skills are more effective than sensory processing strategies in helping students. Learning Disabilities: In the IDEA legislation, a learning disability is defined as "a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, speak, read, write, spell or do mathematical calculations". A school's multidisciplinary team uses many different criterion and testing instruments to determine if a learning disability exists. If this is found to be the primary area of concern, educational intervention is deemed to be the most appropriate avenue of support. It is possible that sensory processing issues may coexist, and that sensory strategies could be helpful, but educational approaches should receive the primary effort. Developmental Disabilities (such as Down syndrome, limited cognitive functioning, etc.): Sensory processing difficulties may coexist with these conditions, but are not the primary cause of the functional difficulties. Sensory strategies may be useful, if incorporated into the daily routine. Autism, PDD and other related disorders: Sensory processing difficulties often coexist with these conditions. Intervention to improve sensory processing and sensory strategies are often very important and can certainly be useful, but not in isolation. Research indicates that the most effective programs utilize a number of different strategies, including programming to improve communication and social skills, behavioral programming, skills training, visual strategies, etc. Occupational Therapy Assessment for Sensory Processing Difficulties When a student has known or suspected sensory processing difficulties, an OT in the clinic may utilize standard evaluations designed to evaluate sensory processing. Although the OTs at TBA often use standardized testing to evaluate physical or fine motor concerns, we may use a combination of standardized assessment in the form of a questionnaire and informal methods to assess sensory processing, gathering information in any of the following ways: Reviewing previous student study reports, special education records, occupational therapy evaluations and/or interventions Observing the student perform a variety of activities in the classroom Interviewing teachers and parents, which may include their completion of the Sensorimotor History Questionnaire for Elementary/School-Aged Children or the Sensory Processing Measure or the Sensory Profile Questionnaire (the latter is normed and standardized for use with children) Differences in Intervention Strategies between the Clinical and the School OT When sensory processing difficulties are identified by a clinic-based OT, further clinical intervention may be recommended (often referred to as "sensory integration therapy"), or strategies for the home and/or school environment may be provided. If sensory processing difficulties are determined to be a primary issue by a school OT, he/she will provide education and consultation to the child's teacher and educational team. This may include providing an inservice on "How Does Your Engine Run" or on sensory processing disorder to the educational team, parents and other students in the classroom, recommending strategies that can be implemented on a daily basis to help a child maintain a calm, alert state for learning. Below are some examples of the kinds of activities that may be recommended: Scheduling short movement breaks throughout the day Using "move and sit" cushions to provide more subtle and acceptable forms of movement Allowing students to drink from an exercise water bottle for oral input, which can help with focusing Offering a "fidget item" that the child can manipulate to reduce restlessness Developing a quiet, calming space in the classroom that the student can use as a retreat when overstimulated Using a weighted vest or lap weight In some cases, sensory processing difficulties may impact motor control and motor performance at school. For instance, poor body awareness may lead to difficulty handling materials or performing academic tasks. In these situations, direct services from an OT to provide skills training for functional activities (dressing, eating, or handwriting, etc.) may be warranted. The role of the OT is to help students meet their sensory needs within their typical classroom routine, so that they can benefit from the educational setting. Parents may choose to pursue using their medical insurance to see if they can obtain additional OT services from private clinics or home health agencies for the following reasons: To help their child to function more appropriately in the home environment To provide supplemental services to further increase sensory processing and physical functioning OTs in will offer the names of clinical and home health occupational therapists to parents who are interested in pursuing these additional services, and will also attempt to coordinate treatment with the clinical or home health therapist, as appropriate. Sometimes clinical OTs may recommend a strategy known as "brushing", or the "Wilbarger Protocol", that must be applied to the child every 90 minutes for a period of 46 weeks or longer. This can sometimes be carried over successfully in the preschool setting, and sometimes in a special needs classroom, but it can be greatly disruptive when children spend most of their day in the general education setting. In these cases, it is recommended that the parent avoid starting an ongoing brushing program, or "Wilbarger Protocol," during the school year. The parents could implement such a program over a summer vacation, with support and consultation from a clinical or home health OT.