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Objectives
Observations Based on • Identify evidence supporting the use of Sensory
Sensory Integration Theory in Integration Theory to support participation at school.
School Based Practice • Administer and interpret clinical observations of
proprioceptive, postural, vestibular functions and
Erna Imperatore Blanche, PhD, OTR/L, FAOTA praxis.

• Learn to use clinical observations to enhance school-

based assessments of sensory integration.

• Interpret clinical observation findings to support

intervention plans in school-based practice.
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Clinical Reasoning Uses Critical Thinking Clinical Reasoning Assessment Model: A 3

Skills STEP PROCESS
• Def: the therapist’s thought process used to make
decisions about client care (Schell and Schell, 2008) • STEP 1: Choose the best method to gather
information
• “the part of practice that therapists do not notice –
their own everyday storytelling” (Mattingly, 1994) • STEP 2: Identify the difficulties affecting functional
performance
• Influenced by several factors including therapists’ talk
as a powerful source for learning and sharing (Burke,
1998) • STEP 3: Choose evidence based intervention
strategies
• This model will make the “talk” noticeable
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The child’s functional problems

STEP 1: CHOOSE THE BEST
And the parents’ or teacher’s
METHOD TO GATHER
concerns
INFORMATION STEP 1: CHOOSE THE BEST METHOD
( Thechild’s diagnosis age, & TO GATHER INFORMATION
related factors
STEP 2: IDENTIFY THE
DIFFICULTIES AFFECTING WHAT NEEDS TO BE TAKEN INTO CONSIDERATION:
MOVEMENT, SOCIAL INTERACTION,
EMOTIONAL STABILITY AND
EXECUTIVE FUNCTIONS
• The child’s functional and participation issues
Other concerns
• The parents’ and teachers’ concerns
The Context of Intervention
The literature • The child’s diagnosis
supporting choices of
intervention (CAT)
STEP 3: CHOOSE STEP 4: • Other concerns
INTERVENTION IDENTIFY
STRATEGIES OUTCOME
The child’s interests
and the family’s MEASURES
priorities
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Gathering Information Methods Unstructured and Structured Observations

• Histories, surveys, interviews
• What information is provided by unstructured
observations?
• Skilled observations
• Unstructured observations • Sensory needs and preferences
• Structured observations • Motor difficulties and compensations
• Behavioral organization
• Standardized Clinical Tools • Play preferences and avoidances
• Functional limitations and strategies utilized
How do we choose the method to gather information?

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Structured Observations Standardized Clinical Tools

• Developmental Evaluations

•More specific strategies • Evaluations of Body Functions: Movement, Motor

Coordination, Sensory Processing
•Controlled by therapist to collect
specific information • Evaluations of Functional Performance and Participation

•Some norms exist • Evaluations of Quality of Life and Sense of Wellbeing

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
The Process of Gathering Information

STEP 2: IDENTIFY THE DIFFICULTIES

AFFECTING MOVEMENT, SOCIAL
INTERACTION, EMOTIONAL STABILITY AND
EXECUTIVE FUNCTIONS

• Based on clinical reasoning and clinical judgment

• Requires organization of the data to draw a conclusion

• Data Organization

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What Information Needs to be Gathered? Choosing the Best Evaluation Tools

Sensory System Proximal Functions Distal Functions
• Most accurate
Vestibular Antigravity Extension
Maintaining a Stable Visual
Field
Neck Co contraction • Easier to administer
Bilateral Motor
Coordination
Arousal • Less intrusive
Proprioceptive Joint stability and
cocontraction (alignment)
Postural Control • Less expensive
Motor planning
Tactile Tactile comfort
Motor planning
Fine motor
• Less time consuming

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Analysis (Imperatore Blanche, 2010, 2012) Are difficulties primarily related to sensory
processing?
1. Are the difficulties primarily related to sensory Observations Sensory Neuro- Interactive
processing ? (primary or secondary)
motor
2. If related to sensory processing, are the difficulties
related to arousal modulation or motor Tremor
performance?
Increased
3. What type of sensory processing difficulties are tone
present?
Echolalia
4. Conclusion based on the number of data points that
support the hypothesis
5. Relate difficulties to participation or the “so what?” Copying
What other areas need to be addressed?
Postural
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control

If the difficulties are related to sensory

Arousal: How is it evidenced?
processing , are difficulties related to arousal
modulation or to motor performance?
Or what affects specific performance issues? •Attention, regulation of emotions, organization
of behavior

•Name issues related to arousal •Arousal tone: high, low, fluctuating with the
situation
•Name issues related to motor performance

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What Type of Sensory Processing Difficulties

Motor Performance: How is it evidenced? are Present?
• Under responsiveness to vestibular
• Postural control, motor planning (feedback related), • Over responsiveness to vestibular and GI
motor planning (feedforward related), construction, • Tactile discrimination difficulties
copying/imitation, gross motor, fine motor
• Over responsiveness to touch (tactile defensiveness)
• Under responsiveness to proprioception (or
• Motor performance related to sensory processing proprioceptive discrimination)
• Proprioceptive seeker
• Other motor performance issues

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OBSERVATION VESTIBULAR BIS PROPRIO SOMATO TACTILE OTHER

Analysis: Developing a Hypothesis about hyporesponse PRAXIS

Sensory Processing Hypo

res ponsiv
Modu
lation Tactile discrimination
Modulation
/
e defensive
Automatic
Data Interpretations Pos tural Control

 Hesitant on the  Tactile a nd Antigravity

Movements
swing hypersensitive AUTOMATIC Poor – Poor – Poor – related
 Sits with rounded  Vestibular POSTURAL becomes becomes to poor trunk
upper back hyposensitive ADJUSTMENTS
Ada ptive (on
s i gnificant
l y worse
s i gnificantly
wors e with
s ta bility

 Runs and crashes

 Does not like to play  Neuromotor ba ll, balance
boa rd, or single
wi th eyes
cl osed
eyes cl osed

sports difficulties l i mb balance)

Anti cipatory Poor Poor If ta ctile
 Difficulty writing  Gravitational (postural di scrimination
name insecure background) is also poor

 Prefers inner tube  Tactile Anti gravity

Extension
Poor If the child
ca n’t assume
Neuromotor
deficits
 Fine motor tremor discrimination (observe with but ca n
 Low scores in the difficulties a nd without ma i ntain the
VMI ves t. i nput) pos ition

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OBSERVATION VESTIBULAR BIS PROPRIO SOMATO TACTILE OTHER

hyporesponse PRAXIS

Hypo Modu Modulatio

res pons l a tion
i ve
Ta cti le discrimination n/
defensive
Culminating in a Conclusion
Anti gravity Flexion Di fficult Poor If poor,
y wi th ma y
neck rel ate to

•Counting the data points that support each

s ta bility s omatop
ra xi s
POSTURAL
TONE/MUSCLE
Decreas
ed
Ma y be l ow
overall
Decreased flexor tone Increased –
neuromotor hypothesis/weighing
TONE extenso deficits
r tone

PROTECTIVE Poor or •Questioning the data and identifying needed

REACTIONS delayed
information
BILATERAL MOTOR Poor If ta ctile Motor

•Conclusion
COORDINATION (for di scriminati coordination
a ge) on i s also di sorder
poor.

CROSSING BODY Mi xed

MIDLINE ha nd
& HAND pref.copyright
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PREFERENCE poor X

OCULO-MOTOR Poor Poor

CONTROL a bility vol untary
to control of
ma i ntai movements –
na ma y a lso
s ta ble rel ate to
vi s ual vi s ual system
fi eld,
poor
coordin
a ti on of
bilateral
eye
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ACTIVITY BODY FUNCTION Sensory Process.

Functional Interpretations Interpretations
Observationss. Conclusion
Identifying Needed Information
Low registration
Falls and trips often Decreased vestibular
Decreased prop
Hipo to proprio
Decreased post. control

Short attention span

Constantly in motion Poor ideation Hipo to
from one activity to Decreased motor plan vestibular
Seeks vestibular
the other
Decreased motor plan
Likes puzzles/avoids Poor ideation
balls Poor ideation
Decreased sensation
Objects fall from his
hands Decreased
feedforward
Decreased post. Control
Leans/ Decreased proprioceptive

Etc.
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ACTIVITY Sensory Process. PARTICIPATION

Functional Interpretations &
So what? Relating the difficulties to Observations Conclusion
participation • Falls and trips often Under responsive to • Academic
proprio performance
• Constantly in
motion from one Under responsive to
activity to the other Vestibular
• Playing in team
• Likes puzzles/avoids Poor ideation
balls sports

• Objects fall from his

Decreased feedback
hands

• Leans/
Etc.
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SI Evolution
• Emerge from Ayres’ original description of sensory
processing related soft neurological signs
The Role of Structured
• Traditionally described as “clinical observations” or a group
Skilled Observations of structured observations of sensory processing and its
(Clinical Observations) effect on movement and behavior originally described by
Ayres (1984) to help DIAGNOSE sensory processing
difficulties.

• She proposed that they be part of every assessment of

sensory integration. Ayres (1984) utilized these observations
in a structured or unstructured manner, depending on the
context of the assessment.

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Unstructured Observations (Blanche and Reinoso. 2008) Unstructured Observations (Blanche and Reinoso, 2008)

Linked to vestibular functions

Linked to Proprioceptive Functions
• Muscle tone is decreased (not hypotonia)
A. Vestibulo-spinal functions: • Joint Hypermobility
•-Extensor tone • Inadequate joint alignment and co-contraction
• Inefficient ankle strategies on uneven surfaces
•-Neck stability • Decreased, slow, or absent weightbearing and weight shifting strategies
• Inappropriate grading of force
• Tiptoeing
B. Vestibulo-ocular: • Tendency to push, pull, or hang
•Stabilization of the visual field • Tendency to lean on others
• Need of visual input when copying simple body movements

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Unstructured Observations (Blanche and Reinoso, 2008) Structured Observations (Blanche and Reinoso, 2008)

Linked to Vestibular / Proprioceptive Linked to vestibular functions

Functions • Vestibulo-spinal:
• Prone Extension
• Falling and tripping
• Supine Flexion (neck stability)
• Catching/throwing balls
• Postural measures with eyes closed on soft surface
• Activity level (both overly active and overly passive)
• Tendency to crash, run, fall, jump, bump into others and objects
• Vestibulo-Ocular:
• Avoidance of movement experiences, fear, anxiety.
• Eye tracking
• Side to side movements of the head while maintaining a stable visual
field

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Structured Observations (Blanche and Reinoso, 2008) Structured Observations (Blanche and Reinoso, 2008)

Linked to Vestibulo / Proprioceptive

Linked to Proprioceptive Functions Functions
• Schilder’s arm extension test
• Slow ramp movements
• Finger to nose •Jumping Jacks, Symmetrical Stride Jumps &
• Sequential finger touching Reciprocal Stride Jumps
• Alternating movements
•Postural measures with eyes closed

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The importance of observations in the evaluation

process: Essential
• As accompanying data to standardized testing
• They allow the therapist to utilize clinical judgment
skills and analyze strengths and weaknesses in the
context that they occur; • Pivotal when other forms of gathering information
• They allow adaptation of the demands of the task to fit cannot be utilized.
the child’s abilities;
• They can be performed in a structured manner as well • Need to be carefully analyzed
as can be observed during functional tasks in a variety
of environments; and • HELP DIAGNOSE SI DIFFICULTIES so the intervention
• They enable the therapist to plan treatment based on targets specific problem areas
the child’s difficulties

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Modified Clinical Test of Sensory STANDING WITH FEET TOGETHER (ROMBERG)

Interaction for Balance
•Standing with Feet Together (Romberg) What do we need to observe?
•Standing on One Foot
•Heel To Toe

Feet Together One Foot Heel to Toe

L R

Open, Firm

Closed, Firm

Open, Soft

Closed, Soft
What does it mean?
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Preliminary Data STANDING ON ONE FOOT

What do we need to observe?

What does it mean?

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HEEL TO TOE MODIFIED POSTURAL SCHILDER’S ARM EXTENSION

TEST
What do we need to observe? What do we need to observe?

What does it mean?

What does it mean?
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Skipping SERIES OF JUMPS –

JUMPING JACKS
What do we need to observe?

•What do we need to observe?

•What does it mean?

What does it mean?

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SERIES OF JUMPS – SERIES OF JUMPS –

SYMMETRICAL STRIDE JUMPS RECIPROCAL Stride JUMPS
What do we need to observe? What do we need to observe?

What does it mean?

What does it mean?

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High Kneeling Antigravity Extension

What do we need to observe?

What do we need to observe?

What does it mean?

What does it mean?

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Antigravity Flexion Ocular Movements

What do we need to observe? What do we need to observe?

• What does it mean? What does it mean?

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Slow Ramp Sequential Finger Touching

What do we need to observe? What do we need to observe?

What does it mean? • What does it mean?

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Diadokokinesis Projecting Actions in

Time & Space
What do we need to observe?
What do we need to observe?

What does it mean?

What does it mean?

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Comfort with Gravity

OTHER OBSERVATIONS
What do we need to observe?

•Comfort with tactile input

•Comfort with vestibular input
•Constructional abilities
•Ideation and executive functions

What does it mean?

•Proprioceptive skills (COP)

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