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Utilizing Sensory Processing Theory and Strategies in Trauma Informed Care: A General Guide for the Occupational

Therapy Practitioner

Erika Kemp, OTD, OTR/L, BCPLindy L. Weaver, PhD, MOT, OTR/L

Learning Objectives

1. Identify trauma experiences among children and youth and their impacts on mental health, occupational functioning, and sensory systems.

2. Describe the application of sensory processing theory and strategies in trauma informed care in schools or other pediatric settings.

3. Describe the potential roles of an occupational therapist within a trauma informed care setting.

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Trauma & Mental Health

Mental Health Development

Is characterized by age-related changes in cognitive, emotional, and behavioral abilities

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Mental Health Development

As children mature, successful completion of developmental tasks generally leads to a balanced development of strengths and weaknesses.

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Mental Health Development

Disruptions or difficulty transitioning through these processes can impact mental health development.

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Disruptions to Mental Health Review

Abuse Stress & Trauma Neglect Disability Health

Conditions

Genetics & Biological Factors

Social & Environme

ntal Factors

Introduction to Trauma

Dictionary Definition (relates to the experience or event)

“A deeply distressing or disturbing experience”

“ A physical injury”

Introduction to Trauma• American Psychological Association (relates to the

response to experience or event)• “An emotional response to a terrible event like

an accident, rape or natural disaster.• http://www.apa.org/topics/trauma/

• Exposure to trauma places you at a higher risk of developing very concerning mental health issues or difficulty with occupational participation & performance, but it does not guarantee it.

Examples of Trauma• Violence

• MVA

• Natural disasters

• War

• Peer victimization or bullying

• Divorce

• Extended separation or displacement from family

• Household food insecurity

• Invasive medical procedures.

• Abuse (physical, sexual, emotional)

• Neglect

• Rape and sexual assault

• Terrorism

DSM-V & Trauma

• Trauma- and stressor-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion.

• Psychological distress following exposure to a traumatic or stressful event is variable.

• In some cases, symptoms can be well understood within an anxiety- or fear-based context.

http://dsm.psychiatryonline.org.proxy.lib.ohio-state.edu/doi/full/10.1176/appi.books.9780890425596.dsm07

DSM-V & Trauma

• Many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristics are:

‒ Anhedonia and dysphoric symptoms

‒ Externalizing angry and aggressive symptoms, or

‒ Dissociative symptoms.

http://dsm.psychiatryonline.org.proxy.lib.ohio-state.edu/doi/full/10.1176/appi.books.9780890425596.dsm07

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DSM-V Trauma & Stressor Related Disorders

‒ Reactive attachment disorder‒ Disinhibited ‒ Social engagement disorder‒ Posttraumatic stress disorder (PTSD)‒ Acute stress disorder‒ Adjustment disorders

Typical Neurodevelopment

• Through neurodevelopmental experiences, pathways are made within the brain.

‒ When these pathways are formed, we no longer “think” about our responses and can focus on other new/novel input.

‒ Future experiences follow these developed pathways and allow for higher level development and function.

‒ Children depend on caregivers to help initiate these experiences.

‒ Children learn and develop through their bodies with physical experiences.

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Trauma & Early Childhood Experiences

• For most children with histories of trauma, this process did not happen in a developmentally appropriate sequence.

• Potential Reasons:‒ Pathways didn’t fully develop (scattered, erratic) ‒ There wasn’t enough myelin sheath support to

maintain the pathway. ‒ Pathways were developed inappropriately and the

path took a wrong turn.

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-Marti Smith, OTR/L

Trauma & Neurodevelopment

7 6 5 4 3 2 1 0

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-Marti Smith, OTR/L

• Trauma can cause disruptions in:

• Cognitive Development

• Sensory Development & Processing

• Social, Emotional, and behavioral development

Trauma & Neurodevelopment

• Traumatic experiences often involves many of the senses & cognitive processes

‒ Sight, hearing, smell, physical pain‒ Emotions, speech and thought

• Thus, it is stored in multiple regions throughout your brain.

https://www.psychologytoday.com/blog/the-time-cure/201211/your-brain-trauma

Impact of Trauma on Cognition

• Hyper-arousal

• Hyper-vigilance

• Nightmares

• Pervasive thoughts

• Fears

• Distorted/catastrophic thinking

• Self-blame

• Shame

• Poor body image

• Decreased attention, memory, orientation (due to the above and also due to re-experiencing)

• Decreased emotional regulation

• Impaired executive function

• Difficulty envisioning future

• Poor problem solving & decreased frustration tolerance

• Decreased self-awareness

https://www.psychologytoday.com/blog/the-time-cure/201211/your-brain-trauma

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Behavioral and Emotional Responses

• When over stimulated, the most primitive protective part of the brain is tapped.

• Over time, this response becomes habit/behavior and learned.

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Behavioral and Emotional Responses• Anxiety

• Fear

• Depression & withdrawal

• Isolation

• Decreased self-esteem & self-efficacy

• Substance use & abuse and other self-harm

• Irritability

• Anger

• Aggression

• Decreased emotional connections

Occupational Responses

• Individuals may start adjusting their routines around the dark memories and the emotions they evoke.

‒ Avoid socializing

‒ Difficulty completing daily tasks

‒ Diminished motivation for ADLs due to shame, low self-esteem, feeling of violation

‒ Difficulty being in public

‒ Disturbed sleep and fatigue

‒ Difficulty with trust and forming/maintaining relationships

‒ Find simple tasks frustrating or have difficulty problem solving through them to complete

‒ Work may be difficult

Trauma Informed Approach

• According to SAMHSA’s concept of a trauma-informed approach, “A program, organization, or system that is trauma-informed:

‒ Realizes the widespread impact of trauma and understands potential paths for recovery;

‒ Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

‒ Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

‒ Seeks to actively resist re-traumatization."https://www.samhsa.gov/nctic/trauma-interventions

Trauma Specific Interventions

• Trauma-specific intervention programs generally recognize the following:

‒ The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery

‒ The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety

‒ The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

https://www.samhsa.gov/nctic/trauma-interventions

Using Trauma Approaches in OT6 Principles

1. Safety

2. Trustworthiness and Transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice and choice

6. Cultural, Historical, and Gender Issueshttps://www.samhsa.gov/nctic/trauma-interventions

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Using Trauma Approaches in OT

• Take a non-pathological view:‒ Respect the person as a human being who is and has

experienced pain

• Occupational Profile‒ Build trust‒ Collaborate & Empower‒ Identify personal, relevant issues

• Many OT approaches fit well into TIC‒ Professional identity; holistic‒ Intentional Relationships‒ Sensory‒ MOHO

https://www.samhsa.gov/nctic/trauma-interventions

Trauma Care & Occupational Therapy

• OT use meaningful activities to promote physical and mental health

and well-being.

• OT focus on participation in education, play and leisure, social

activities, ADL, IADL, sleep and rest, and work.

• Task analysis is used to identify factors (e.g., motor, social–

emotional, cognitive, sensory) that may limit successful participation

across various settings, such as school, home, and community.

Trauma Care & Occupational Therapy• OT may target:

‒ Promoting social participation

‒ ADL completion

‒ Building self-esteem & self-efficacy in occupations

‒ Return to work or employment assistance

‒ School management

‒ Time management

‒ Community involvement

‒ Creating habits & routines

‒ Sleep hygiene

✲ Provide trauma-informed sensorimotor arousal regulation interventions in collaboration with mental health professionals

✲ Teach children mindfulness strategies to reduce stress and to cope with overwhelming emotions.

Sensory Theories

Where Sensory Integrates with Trauma

• Use of sensory theories & strategies can help facilitate improved sensory processing or arousal management

• Sensory strategies & improved sensory awareness may help with stress and anxiety

• This will ‒ Facilitate trust and connection with caregivers‒ Promote ability to engage in occupation‒ Allow child to progress through next developmental

milestones

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Sensory Processing & Integration Review

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Our Senses

• Sensations are pieces of information that must be organized and interpreted by our minds in order for us to act on them.

• They are how we experience the world around us right now.

• Sensations are also how we remember events, places and people.

‒ Remember: trauma is often a multisensory experience and stored throughout the brain

• Sensory deprivation can be debilitating, sensory input is necessary for brain growth. (Cermak & Groza, 1998)

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Sensory Processing

• The brain is innately organized to seek out sensory

experiences that are meaningful.

• Sensory Processing/Sensory Integration

‒ “Sensory integration is the ability of the central nervous

system to organize and process input from different

sensory channels in order to make an adaptive response”

- (Ayres, 1979; Parham & Mailloux, 2001)

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Sensory Processing

• To be effective, the child must actively organize and USE

the sensory input to act on the environment, or to play

and learn.

• Problem behaviors may be a sign that processing is

impaired.

- (Parham & Mailloux, 2001)

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The Whole Process

• Five Sequential steps of Sensory Integration (J. Ayres)‒ Sensory registration, ‒ Orientation and attention, ‒ Interpretation,‒ Organization of a response, ‒ Execution of a response

• Dysfunction may occur in any of the five steps

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Sensory Integration Treatment

Ayres SI

Ayres SI Fidelity

OT Using and SI Approach

(OT-SI)

Uses principles from SI theory

Not specifically following all fidelity; & focuses on engagement in child-directed, sensory rich

experiences for adaptive sensory processing and

integration for daily activities

Single Modality

Use enhanced sensation to

improve behavior

-Focus on modulation

Weighted vests,

brushing, alternative

seating, squeezes, jumping

Combined Cognitive Behavioral &

Sensory Processing Approaches

Uses cognitive and sensorimotor strategies to support development of

self-regulation skills

Cognitive Strategies, Sensory-based tools for

managing arousal & emotion management

Sensory Diets

Sensory Integration Interventions

Sensory Based Interventions Vestibular Sense & Trauma

• A major regulator. Effects can last up to six hours

• Vestibular nerve sends information to movement and sensory areas

• Proximity to auditory (sound) nerves

• Three planes to the semicircular canals will register input differently

• Front to back and rhythmic movement is calming.

• Erratic and spinning movement is alerting.

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Proprioceptive Sense

• Often used with other types of input such as vestibular or tactile.

• The BIG calming input

• Effects can last up to four hours

• Postures of Flexion are calming

• Postures of Extension are alerting

• Often called “Heavy Work”

• This is the “Go To” type of sensory input!

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Tactile Sense & Trauma • Tactile sense is first to develop in utero.

• Skin is largest receptive organ.

• Easiest to provide regulating therapeutic input.

• Much of babies first sensory input is via the tactile system.

‒ Thus, early childhood trauma with tactile input are especially powerful

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Visual Sense & Trauma• In the first 18 months, there is an 8x synaptic density

increase while neurons seek their appropriate connections.

• Mirror neurons and social reciprocity get first input via the visual system.

• Kids with trauma background are often scanning for danger.

‒ Difficulty with focal vision and precise saccades.

‒ Difficulty looking up without moving head.

‒ Sometimes easier to fix on a target while head moves around eyes vs. asking child to track an object while head is still.

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Visual Sense & Trauma

• Some kids with trauma don’t have good eye movement

‒ If the eyes do not work together appropriately, the child will experience a lot of vestibular input simply trying to scan a room.

‒ Difficulty with visual scanning can cause a high alert level.

‒ Do the child’s eyes track together? Can he move his eyes independent of his head?

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Gustatory Sense & Trauma

• Neglect (starvation, excessive bottle feeding) may lead to nutritional deficits, oral motor dysfunction, or difficulty swallowing.

• Poor oral motor control can also cause feeding issues.

‒ If a child fears choking, they will limit food intake.

• Delayed speech can indicate poor oral motor function. If the mouth doesn’t move well, a child may resist nutrient dense foods. This can impact behavior.

‒ Food as a Social Connection.

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Olfactory Sense & Trauma

• Smell has direct path to the amygdala - long term memory

• Therefore, certain smells may be triggers

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Sensory Modulation

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Responses to Sensory Input

• Typical: Individual reacts to a sensory experience as expected, i.e. heard the fire alarm and left the building.

• Hypo-responsive: Under-reacts to a sensory input, i.e. fails to respond to a fire alarm.

• Hyper-responsive: Over-reacts to sensory input, i.e. becomes upset, covers ears in response to a fire alarm.

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Sensory Modulation & Self Regulation

• The ability of the brain to modulate (adjust) the input coming in.

‒ Nervous system organizes sensations and makes an adaptive response

‒ Turns the volume up or down on the world around us‒ Sensory event registration modulation regulation

• Self Regulation is the ability to modulate your level of arousal

• Modulation of each individual sensation may affect our level of arousal

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Modulation/Regulation Problems

• Threshold for Response

• Small band of yellow

• Sensory overload or shut down may be lower than normal

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Modulation/Regulation Problems

• Child has difficulty maintaining arousal level‒ Low arousal

• Difficulty waking up in the morning, constantly needs to be moving to stay awake, easily loses attention

‒ High arousal• Constantly ‘on the go’ • Hyper-verbal• Easily distracted

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Self Regulation Programs

• The Alert Program (Williams & Shellenberger, 1994)

‒ Engine analogy: high gear (hyper), low gear (lethargic) or “just right” gear (attentive and focused)

‒ Develop strategies for changing level of alertness

• Put something in mouth (cold fruit smoothie)

• Move (stretch)

• Touch (squeeze a stress ball)

• Look (watch the sunset)

• Listen (music)48

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Self Regulation Programs

• The Zones of Regulation (Kuypers, 2011)

‒ Cognitive Behavior approach

‒ 4 zones (red, yellow, green, blue) categorize different emotional states and levels of alertness

‒ Develop greater awareness and control of emotions, manage sensory needs, improve conflict resolution skills

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Application to Your Students

Sensory Processing Problems Have Been Linked to…

• Self stimulation behaviors (flapping or spinning)

• Stereotypic behaviors, being rigid, repeating a pattern of behavior

• Aggressive or disruptive behaviors

• Picky eating or restricted eating

• Difficulty in motor planning or clumsiness

• Low or negative affect

• It does NOT appear to be related to IQ

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Sensory Processing and Anxiety

• Relationship between oversensitivity and anxiety

‒ Hypervigilance may lead to increased awareness and reaction to sensory stimuli.

• Anxiety Avoidance of feared sensory stimuli Increased difficulty making adaptive response

‒ Oversensitivity may increase anxiety through conditioning

• Over reaction to sensory stimuli that is frequent and unpredictable Avoidance and hypervigilance generalized anxiety

-(Green & Ben-Sasson, 2010)52

Sensory Processing and Anxiety

• Possible indicators of oversensitivity and anxiety

‒ A child may be overstimulated and overwhelmed in social situations.

‒ A child may crave quiet environments and be fearful of unpredictable environments.

‒ Transitioning to new or unfamiliar environments may cause excessive anxiety or fear.

‒ This child may resist or avoid social environments, such as a party, or transitions to new activities.

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Sensory Processing and ADHD

• Sensory modulation problems have been linked to ADHD.

‒ Increased sensitivity to tactile, visual, auditory, and gustatory stimuli.

‒ Sensory over-responsivity linked to increased anxiety.

‒ Deficits in balance, tactile discrimination, motor coordination and planning.

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Sensory Processing and ADHD

• Certain hyperkinetic children appear to be:

‒ Overstimulated, hyper-responsive

‒ Under stimulated, sensory seeking

• Sensory seeking children tend to be under aroused and are “on the go” to increase their arousal level.

‒ You can identify this child because when he is not very active, he is asleep or drowsy and inattentive.

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Sensory Processing and Autism

• The DSM V has identified sensory processing disorders as part of the autism diagnosis.

• Estimates are that between 67% to 95% of children with ASD have sensory processing disorders.

• Types of problems in ASD are categorized as:

‒ Hyposensitivity (under-responsiveness), e.g., auditory.

‒ Hypersensitivity (over-responsiveness), e.g., tactile, auditory.

‒ Sensory seeking, e.g., seeks movement or pressure. 56

How to Help Children with Sensory Modulation Problems 1) Insight:

Understand what the child is experiencing and how it affects behavior.

2) Specific strategies:

‒ Identify and use tools or activities to support the child’s sensory processing.

‒ Build a sensory diet into the child’s daily routine.

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Insight• Identify which behaviors might relate to a sensory

processing problem:

‒ Restricted eating

‒ Problems sleeping

‒ Fearful on the playground

‒ Difficulty with transitions

‒ Distractible in classroom or during academic activities

‒ Clumsiness, and particular difficulty learning new motor tasks

‒ Melt downs in the mall, grocery store, or at parties58

Insight

• Helps parents and others view the child in a more positive way with an improved understanding of their behaviors.

• Helps parents and others develop and adopt preventive interventions so that the child is better able to self regulate within the environment.

• We are not built to be healthy/functional under sensory-deprived conditions.

• Children and youth are supposed to be active and it is known to help with regulation of mood, self-regulation, attention, and learning.

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With an Understanding of Sensory Problems or Needs…• We can:

‒ Avoid certain situations or activities

‒ Prepare the child for an activity or new environment

‒ Explain the child’s behavior to others

‒ Recognize when a behavioral approach is NOT appropriate

‒ Use sensory tools to support the child’s participation

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With an Understanding of Sensory Problems or Needs…• Children & Youth Can:

‒ Begin to understand how to meet their own sensory needs

‒ Learn words to explain how they are feeling

‒ Begin to learn new, more appropriate behaviors for managing sensory modulation issues

‒ A developmental approach is needed to help children understand their sensory needs and ways to accommodate

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Needs for Sensory Regulation

• Nutrition Met

• Sleep needs met

• Available emotional support

• Postural Support, Felt

• Safety of Current Environment

• Medical Diagnosis (understand if it impacts regulation)

• Sensory Systems, intact

• It is important to understand where the child was supposed to be developing at the time of trauma. Often, if we do not have that history, we can look to symptoms within behaviors for clues.

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The Role of the OT• Do a comprehensive sensory assessment

‒ Identify hypo- and hyper-sensitivities

• Educate on effects of trauma on cognitive, social, emotional, sensory, behavioral development

• Create sensory diet and strategies to facilitate level of arousal

• Educate child and caregivers on sensory preferences

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The Role of the OT• Implement Zones of Regulation or The Alert Program

• Implement OT-SI or Ayres SI

• Recommend sensory equipment and TRAIN family/caregivers on how to use them.

• Monitor child’s responses and progress to the suggestions

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Key Points to Remember

• Sensory strategies work best as an antecedent/adjacent event to an expected behavior

‒ They are not a reward or something to be earned.

• Everyone is different‒ What works in one situation may not work in the next.

• Personal needs change‒ What worked an hour ago may not work now.

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The Role of OT

• Many Occupational Therapists have training in sensory integration and all have training in mental health

• Present the child with a ‘just right’ challenge

• Help the child produce an adaptive response in a sensory rich environment

• Relate the challenges to every day activities

• Help the child recognize their own sensory needs

• Help parents and teachers meet sensory needs at home in the community

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Trauma Care & Occupational Therapy

• http://www.caot.ca/otnow/nov%2007/survivor.pdf

• http://www.caot.ca/otnow/nov12/trauma.pdf

• https://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/childhood-trauma.pdf

• http://www.traumainformedcareproject.org/index.php

References• American Occupational Therapy Association. (2014). AOTA. Retrieved July 24, 2016, from

https://www.aota.org/.

• Ayres, A.J. (1979). Sensory integration and the child. Los Angeles: Western Psychological

Services.

• Case-Smith, J., Weaver, L. L., & Fristad, M. A. (2015). A systematic review of sensory processing

interventions for children with autism spectrum disorders. Autism: the International Journal of

Research and Practice, 19, 2, 133-148.

• Cermak, S., & Groza, V. (1998). Sensory processing problems in post-institutionalized children:

Implications for social work. Child and Adolescent Social Work Journal 15 (1): 5-37.

• Ghanizadeh, A. (2011). Sensory processing problems in children with ADHD, a systematic

review. Psychiatry Investigation, 8, 2, 89-94.

• Green, S. A., & Ben-Sasson, A. (2010). Anxiety disorders and sensory over-responsivity in children

with autism spectrum disorders: Is there a causal relationship?. Journal of Autism and

Developmental Disorders, 40, 12, 1495-1504.

• Kuypers, L. (2011). Zones of Regulation. Minneapolis, MN: Social Thinking.

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References• Parham & Mallioux (2001). Sensory integration. In Case-Smith, J. (Ed.). Occupational therapy for

children (pp. 329-379). St. Louis: Mosby.

• Quirk, N. & DiMatties, M. (1993). The relationship of learning problems and classroom performance

to sensory integration. Framingham, MA: Therapro, Inc.

• USC/WPS comprehensive program in sensory integration. (2008). Course 4: Sensory integration

intervention. Los Angeles, CA: University of Southern California and Western Psychological

Services.

• Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration ® and sensory-based

interventions for people with autism spectrum disorder: A systematic review. American Journal of

Occupational Therapy 69(5), doi: 10.5014/ajot.2015.018051.

• Williams, M. S., & Shellenberger, S. (1994). “How does your engine run?” A leader’s guide to the

Alert Program for Self-Regulation. Albuquerque, NM: TherapyWorks.

• Yochman, A., Parush, S., & Ornoy, A. (2004). Responses of preschool children with and without

ADHD to sensory events in daily life. The American Journal of Occupational Therapy : Official

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Thank You!www.wexnermedical.osu.edu

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