Lucy Jane Miller, Ph.D., OTR Associate Professor of Rehabilitation Medicine and Pediatrics

1. Sensory Integration Dysfunction in Individuals with Cognitive Disabilitiesfor theColeman Institute WorkshopAspen, COOctober 2001 Lucy Jane Miller, Ph.D., OTR Associate Professor of Rehabilitation Medicine and Pediatrics University of Colorado Health Sciences Center Director of STAR Center at The Children’s Hospital, Denver, CO lucymiller@frii.com

2. Jan Ingebritson Jane Koomar Shelly Lane Mark Laudenslager Zoe Mailloux Shanley Mangeot Kathy McBride Kent McBride Jude McGrath-Clarke Danny McIntosh Laura Meyer Debbie Moulton Andrea Nyhoff Todd Ognibene Acknowledgements It Takes a Village!! • Roiann Ahn • Grace Baranek • Judy Benzel-Martin • Teresa May Benson • Erna Blanche • Julie Bonnell • Pam Buckley • Anita Bundy • Janice Burke • Sharon Cermak • Kelly Church • Ellen Cohn • Wendy Coster • Patti Davies • Winnie Dunn • Pat Fodor • Kate Glover • Linda Greco-Sanders • Kathy Green • Becky Greer • Ed Goldson • Marshall Haith • Randi Hagerman • Barb Hanft • Brian Hinaman

3. It Takes a BIG Village!! • Catherine Spence • Clare Summers • Vivian Shyu • Tracy Stackhouse • Peter Teale • Julie Tourigny • Sharen Trunnell • Jeff Walker • Lisa Waterford • Julie Wilbarger • www.SInetwork.org • Diane Parham • Bruce Pennington • Nicki Pine • Chip Reichardt • Marty Reite • Gilana Rivkin • Don Rojas • Sally Rogers • Roseann Schaaf • Mary Schneider • Robin Seger • Janelle Sheeder • Jodie Simon • Susanne Smith Roley

4. What is Sensory Integration Dysfunction (DSI)? • Is the treatment of DSI effective? • Is DSI a valid syndrome? • What are the underlying mechanisms of DSI?

5. Introduction: Definitions and Terminology

6. Importance of distinguishing terms for: Neuro-physiologic Processes Sensory Integration Functions Sensory Integration Dysfunction (DSI)

7. Neuro-physiologicProcesses vs. Behavioral Manifestations • processes: are not observed because they occur at the cellular or nervous system level and • behavioral manifestations of these processes, can be observed in sensory integration functional and dysfunctional patterns

8. The minimum intensity of stimulus at periphery necessary to produce excitation or inhibition. Peripheral Sensory Threshold

9. Leads to transmission of the electrical or chemical signal. Central Sensory Threshold

10. Exists at periphery at receptor level, at the level of the action potential, and at each central synapse. Sensory Threshold

11. Intra-Sensory Integration Central process in which sensory input from a single sensory system converges on a cluster(s) of neurons, together affecting the activity of the neuron on which they synapse.

12. Central process in which cluster(s) of neurons receive input from more than one sensory system. Inter-Sensory Integration

13. A Model to Explain Sensory Integration Terminology Sensory Processing

14. Sensory Detection Awareness of sensation is the conscious realization or unconscious awareness of sensation

15. Sensation Modulation Function The capacity to regulate and organize the degree, intensity, and nature of responses to sensory input in a graded and adaptive manner. McIntosh, Miller, Shyu, & Hagerman, 1999

16. Discrimination of Sensation The ability to discern the qualities, similarities, and differences among sensory stimuli, including differentiation of the temporal or spatial qualities of sensory input. Miller and Lane, 2000

17. What does the term “Sensory Integration Dysfunction” mean?

18. Sensory Integration Dysfunction Atypical processing of sensory stimuli that is severe enough to produce significant difficulties in functional aspects of daily routines and activities.

19. Touch Movement Auditory Visual Taste Smell Proprioceptive (position and movement of joints) Atypical behavioral responses can occur in several sensorydomains including:

20. Decreased Social Skills & Participation in Play • Poor Self-confidence & Self Esteem • Difficulties with Daily Life Skills at Home & School • Anxiety, Poor Attention, Poor Regulation of Reactions to Others • Poor Gross, Fine or Sensory Motor Skill Development *Parham and Mailloux, 1996

21. Hypothesized Relation among DSI Patterns Dyspraxia Sensory Modulation Dysfunction Other DSI Patterns Dys SMD Other

22. Dyspraxia Difficulty in planning and performing a novel (non-habitual) motor act or series of motor actions that is severe enough to create difficulties in daily routines and activities.

23. Sensory Modulation Dysfunction (SMD) Problem in capacity to regulate and organize responses to sensory input in a graded and adaptive manner that is severe enough to create difficulties in daily routines and activities.

24. Is sensory modulation disorder a unitary construct?

25. Types of SMD • Over-sensitivity - responses to sensation are greater than those typically demonstrated by others under same circumstances • Under-sensitivity - responses to sensation are less than those typically demonstrated by others under same circumstances • Passive vs. active responses • Differences between sensory systems

27. Is InterventionEffective? Need for randomized clinical trial to compare treatment models

28. Randomized Clinical Trial

29. Is SMD a valid syndrome?

30. What is a syndrome? “A syndrome is a cluster of symptoms that reliably co-occur and identify subtypes of patients who are homogeneous.” Pennington, 1991, p. 24

31. “If a syndrome is valid, it will satisfy tests of both convergent and discriminant validity across levels of analysis.”Pennington, 1991, p. 24

32. Validating A SyndromeConverged and Divergent Evidence • Etiologies • Brain Development • Processing Abilities and Symptoms • Developmental Trajectory • Effects of Treatment

33. Childhood Developmental Disorders: Syndrome Validation SMD Depression Dyspraxia ADHD Schizophrenia FXS OCD Autism Anxiety Randy Ross, M.D.

34. What are the underlying mechanisms in DSI?

35. Can we develop a reliable laboratory paradigm to measure sensory reactivity?

36. EDR A psychophysiological measure that assesses the extent of response to stimuli by measuring changes in the electrical properties of the skin.

37. Skin becomes more electrically conductive as a result of eccrine sweat gland activity which increases EDR.

38. Eccrine sweat glands are innervated by cholinergic fibers of the SNS, thus measuring EDR provides an index of SNS activity.Andreassi, 1989; Dawson, 1995; Fowles, 1986

39. StartlingThreateningAggressiveDefensive FeelingsEmotional Events?Sensory Events?

40. Sensory Challenge Protocol Ten contiguous trials in each of five sensory systems • olfactory (wintergreen oil) • auditory (siren) • visual (strobe light) • tactile (feather on face) • vestibular (chair tilted backwards) EDR recorded after each sensation

41. EDR Variables

44. Mean Magnitude in Log10(micromhos)for FXS and TYP Miller et al., 1999

45. Proportion Responding overTrials for FXS and TYP Miller et al., 1999

46. Mean Amplitude of Mean Peak Across Modalities for Children with FX and Autism Compared to Typical Children Miller et al., 2001

47. Mean Amplitude of Mean Peak for Individuals with Fragile X Syndrome and Autism in Study 2

48. Subtests of SSP • Tactile Sensitivity • Taste/Smell Sensitivity • Seeks Sensation • Auditory Filtering • Visual/Auditory Sensation • Low Energy / Weak • Movement Sensitivity

49. Subtests of SSP • Tactile Sensitivity • Taste/Smell Sensitivity • Und-resp / Seeks Sens • Auditory Filtering • Visual/Auditory Sensation • Low Energy / Weak • Movement Sensitivity

50. Short Sensory Profile Ratings for Children with FXS and Autism Compared to Typical Children(Aut=8; FXS=25; TYP=25) - 1999