The OT conundrum: Is it sensory or behavioral? And what can be done about it anyway?
Heather Bernert, Volume 28 • Issue 8 • August 2023, pp. 29–30 08/01/2023SHARE
You may have been to an individualized educational plan (IEP) meeting where talk turns to the child having sensory concerns—instead of just behavioral concerns—and the table of experts on the child’s team turns to you to weigh in. How do you know if a child has sensory concerns, and if that’s what is fueling the negative behaviors? Even if the sensory concerns can somehow be definitively discerned from purely behavioral challenges, how do you, as the sensory “expert” on the team, effectively treat the child in the school setting? Further complicating the discourse is that, for many parents, an underlying nervous system condition (such as dysregulation) can be a lot more palatable than a behavioral issue. It lands differently to the parent to hear that a child is doing something out of their control as opposed to listening to a discussion about negative “willful” manipulation. The latter may lead to them seeing the discussion as an attack on their parenting style or feeling that they’re being judged; thus, pushback may occur before any interventions are considered. In my experience, it can be very difficult to differentiate one condition from the other. Sure, there are assessments. I usually utilize the Sensory Profile School Companion™ 2 (Dunn, 2014). But even if the child scores in the “definite difference” area (two standard deviations from the mean), as the occupational therapy practitioner (OTP) you might still be left wondering how best to treat the student. One of the challenges I have encountered is that the school environment is a poor substitute for the sensory integration clinic. None of my schools, for instance, have suspended equipment and swings that a sensory integration clinic can provide—and which are especially effective for achieving modulated vestibular input. Vestibular input (followed up with some good proprioceptive/heavy work) is particularly important in terms of achieving enhanced self-regulation, and without this component, noticeable, positive changes in the neural pathways can take a long time or be non-existent. Therefore, the order in which the stimuli is presented is important, and an OTR trained in sensory integration theory can be especially helpful for planning this. Another big challenge is the time that is necessary for this kind of intervention. Occupational therapy in the school realm does not include a lot of time needed to administer a customized “sensory diet.” A sensory diet is a group of activities that are specifically scheduled into a child’s day to assist with attention, arousal, and adaptive responses. Ideally, this diet should be provided on a proactive, rather than reactive, basis. This could mean about 10 minutes of concentrated sensory input every couple of hours. Unless a child has a personal care assistant, it might be next to impossible for a teacher to carry it out properly with all the other demands on their time. On top of this, will it really work? Is it an effective tool under these constraints? Through my own anecdotal evidence, based on the children’s cases that I weigh in on... I’m not sure. It depends on the child for sure, and there needs to be “buy in” as well as a well-trained, well-intentioned team surrounding the child. Significant neural changes most realistically happen during an extended period, with no prescribed end point. It can be very time intensive and costly on an outpatient basis, yet maybe this is necessary to see the desired outcome. Perhaps we should be advocating for a two-pronged approach in schools; sensory strategies (see Figure 1) and behavioral strategies to facilitate the change that we desire. In Specially Designed Instruction (SDI) (Council for Exceptional Children, n.d.), for instance, listing potential sensory strategies (movement breaks, dynamic seat cushions, resistive bands on chair legs, etc.) as well as behavioral strategies (positive reinforcement, token economy, self-rating behavioral chart, etc.) would provide a more balanced approach. Keep in mind that if one goes with the two-pronged approach, the approaches should not be implemented at the same time. If tried at the same time, if a change is noted (positive or negative), it will be difficult to determine which intervention was the most valuable. Also, when proposing sensory-based trials (for a month perhaps), introducing one modality at a time will help you see the most valuable nervous system response. For instance, start with the dynamic seat cushion for 1 or 2 weeks and ask for feedback from people who interact daily with the student. If there is no change (or a negative change in attention/behavior), suggest another idea and follow this pattern. Figure 1. The Most Impactful and Teacher Friendly School-Based Sensory Strategies (in my opinion) Primary grades
Wearing a weighted backpack
Adding resistive bands to chair legs
Wrapping the child as a burrito in a bedsheet on the floor
Making an enclosed “fort” (can be done with classroom table, bedsheet, and pillows)
Having access to a straw cup at desk
Using a class-wide wall for push ups
Having school-based, pre-vocational “chores,” that approximate work and keep the students' dignity intact. Examples:
Stacking and unstacking cafeteria chairs
Washing cafeteria tables and windows
Wearing a heavy backpack while going to the water fountain to fill up a water bottle (a straw cup is preferable)
Organizing locker daily (heavy books)
Bringing books to the library
Working in the office (e.g., 3-hole punching, stapling, opening and closing binder rings)
Folding large towels and blankets (while on all fours on the floor)
Cooking activities (especially involving mixing resistive dough) and hand washing dishes
This process can potentially be arduous, but there isn’t necessarily a tangible way of determining the effectiveness of the strategies otherwise. Sensory strategies are not a “one-size-fits-all” protocol; they are highly individualized. Having an open-minded, collaborative team is critical when discussing sensory-based interventions in the classroom.
Council for Exceptional Children (n.d.). Specially designed instruction. https://exceptionalchildren.org/topics/specially-designed-instruction
Dunn, W. (2014). Sensory Profile School Companion™ 2. Pearson. https://kitrin.com/wp-content/uploads/2021/02/School-sensory-profile.pdf
Heather Bernert, MS, OTR/L, is an Occupational Therapist who has been working with children for more than 20 years in the preschool, elementary, and secondary education realms. She also worked in a sensory integration clinic early in her career as both a student and a staff therapist. While there, she was trained in DIRFloortime. She is currently contracted in the third-largest school district in Pennsylvania. She has a BA from the University of Delaware and has received her MS from Temple University. She has expertise in working with children with varying disabilities, including those on the autism spectrum.