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See this case study published online at the International Brain Injury Neurotrauma newsletter for June 2015!

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A CASE STUDY ON THE RELATIONSHIP BETWEEN SENSORY PROCESSING SKILLS AND ACADEMIC ACHIEVEMENT WITH A 14 YEAR OLD WITH ACQUIRED BRAIN INJURY AND ELECTROGRAPHIC STATUS EPILEPTICUS IN SLEEP (ESES)

Authors: Dechantal C. V. Montano, OTR/L, Sara T. Naegele, MS Ed,  Ronald C. Savage, Ed.D.

Introduction

Children with acquired brain injuries face an array of cognitive, behavioral, and sensory-motor problems.   In particular, many of these children have problems with sensory processing, which, in turn, interfere with their neuro-development. Sensory processing (sometimes called “sensory integration” or SI) is a term that refers to the way the nervous system receives messages from the senses and turns them into appropriate motor and behavioral responses. Sensory Processing Disorder (SPD) is a condition that exists when sensory signals do not get organized into appropriate responses. Dr. A. Jean Ayres (Ayres, 2005), an occupational therapist and developmental psychologist, pioneered work in sensory integration dysfunction in the 1960s. She proposed that in order to function the brain needed to receive and interpret sensory information correctly using a seven-sense sensory system, which includes the tactile, visual, auditory, gustatory, olfactory, vestibular and proprioception systems. She likened sensory dysfunction to a neurological “traffic jam” because problems occur when sensory input is not processed or misrouted in the brain. “SPD is not one specific disorder…but rather an umbrella term to cover a variety of neurological disabilities,” explains Carol Kranowitz (Kranowtiz, 2005), an educator and expert in sensory processing and integration. Children with SPD, especially children with acquired brain injuries, will find it difficult to process and act upon information received through their senses, which creates challenges in performing countless everyday tasks. Learning difficulties, motor clumsiness, behavioral problems, anxiety, depression, school failure, and other impacts may result if the disorder is not treated effectively.

SPD is not presently recognized as a distinct and separate group of disorders in The Diagnostic and Statistical Manual V but is recognized as occurring in individuals with other neurological disorders. Most research to date involving SPD has involved individuals with Attention Deficit and Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD). Few isolated studies on how Sensory Processing Disorder manifests as an image of brain dysfunction have been conducted. This could be in part because its existence as a separate and distinct neurological disability is still quite controversial. According to a recent policy statement put forth by the American Academy of Pediatrics, “the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive,” (2015). However, Owen et al. (2013) in a landmark study showed that children who met criteria only for sensory processing disorder have anatomical differences in their brain structure than children who do not present with sensory processing difficulties. Owen and her colleagues at The University of California San Francisco found that children affected specifically with Sensory Processing Disorder (SPD) have abnormal white matter microstructure. This is the first time that a biological basis for the disease, which sets it apart from other neuro-developmental disorders has been found. According to the researchers, one of the reasons SPD has been overlooked until now is that it often occurs in children who also have ADHD or autism. This study also shows that SPD may in fact be a distinct disorder that affects individuals with and without other neurological disabilities. Therefore, more research into this disorder as well as treatment for this disorder needs to be further explored in other populations.

As mentioned above, the common pediatric conditions of study with Sensory Processing Disorder are Autism and ADHD; therefore, the uniqueness of this study is that it focuses on SPD in a population other than those previously studied. The subject is a 14-year-old female who has had early biological insults to the developing brain via infantile stroke and the condition Electrical Status Epilepticus of Sleep (ESES). This is a rare form of epilepsy that produces subclinical (unseen) seizures during sleep. This type of epilepsy is characterized by the presence of generalized 1-3 Hz spike-wave discharges occupying 85% or more of the EEG of non-REM sleep. Overall, she presents with a neuro-developmental disorder due to an acquired brain injury (ABI) occurring both in utero and continuously due to the ESES. Ungerleider (1995) states “recent functional brain imaging studies in humans indicate that learning and memory involve many of the same regions of the cortex that process sensory information and control motor output.” This study shows that there is a potential for a positive correlation between SPD, learning and memory.      Furthermore, findings from a study by Tarapore et al (2013) support the hypothesis since “disruption of the long-range communication between brain regions, as measured by reductions in functional connectivity, would be found in patients [with TBI] compared with matched controls.” The results from this study and Owen et al show that both individuals with traumatic brain injury (TBI) and SPD have reduced connectivity between brain regions. Therefore, SPD could be a prevalent issue either dependent or independent of the brain injury for individuals with ABI; subsequently, the intervention for SPD could be effective for individuals with ABI.

Given the lack of research in the area of SPD for acquired brain injury populations coupled with the researchers’ combined therapeutic and educational experiences an interest was taken into studying the relationship between increased sensory processing skills and academic achievement for a 14-year-old female with infantile stroke and Electrical Status Epilepticus of Sleep (ESES) among other neurological disorders. The objective of this study was to determine the relationship between an increase in sensory processing alertness/engagement and academic achievement for a subject with neuro-developmental disorders specifically ESES. Since there was evidence that Sensory Processing Disorder was indeed a neuro-developmental brain disorder, and manifested in a neurologically similar way as ABI, it was hypothesized that the similarities between the deficit manifestations could respond to an external intervention previously used for individuals with SPD and ultimately improve cognition and learning. As previously stated very few studies have been conducted to investigate this theory; however, Polatajko et al (1991) found that a sensory integrative intervention was as effective as perceptual-motor training,  “when administered for 1 hour, once a week, for 6 months…in improving academic and motor performance in children with learning disabilities associated with SI dysfunction.”

Subject Background
The subject was internationally adopted at seven months old. Her hospital records contained insufficient documentation of parental pre-adoption history; however, according to medical records, her weight was reported to be 700 grams, and she had APGAR scores of 3, 5, and 5. Her hospital birth records noted the amniotic fluid smelled fetid.  It was later that an analysis of an MRI of her brain indicated interruption in blood flow to the brain. This occurred at approximately the 23rd week of gestation.  Based upon a CT scan taken at 9 months, doctors estimated she had lost approximately 30 percent of brain matter. Subject’s current head circumference is 43.3 cm, which is considered to be in the first percentile for a 20-month-old girl and indicates microcephaly.Her motor and cognitive developmental milestones were all delayed or never occurred.  In regards to her gross motor development, her records indicated that she began standing alone while holding onto a stable object at 3.5 years; she began to walk independently on a flat surface at 4.5 years, and was able to navigate stairs with assistance at 6.5 years. In regards to her cognitive development with a focus on communication, her records indicated, she was interested and attracted to sound at 7 months, she spoke her first word at 3 years, she spoke unintelligible words and phrases at 9 years, and began speaking in some intelligible short simple sentences in combination with a high-tech communication device at 13 years.

When initial researchers’ interventions with the subject began, formal education had stopped for an entire academic year. The subject was instead receiving traditional out-patient therapies (OT, PT, and speech), and Augmentative and Alternative Communication (AAC) Training for her Dynavox device for approximately 20 hours each week.

Methodology
Researchers gathered baseline academic achievement through scores indicated on her Individualized Education Plan (IEP) from September 2013. The scores were taken from an independent psycho-education evaluation. Additionally, modified testing using the Brigance Inventory of Early Development III (2013) was completed in order to corroborate results specified in her IEP. Tests included: color identification, identifies uppercase letters, identifies basic personal information, rote counting, reads words from common signs, word recognition grade placement test (modified). Subject responded to questions utilizing her AAC device and verbal responses to closed questioning. Additionally, researchers collected baseline sensory systems data. Both cognitive and sensory intervention was delivered in school and home with participation of medical, educational and technical staff.

Research clinicians used an experimenter designed 7-sense diet and tracking sheet to measure outcomes from the Experimenter Sensory Diet, based on the sensory diet theory from research conducted on subjects with sensory defensiveness by Occupational Therapist Patricia Wilbarger in 1991. “A sensory diet is a form of a home program intervention plan that incorporates organizing sensory input, or utilizes already existing sensory input, into everyday life in order to assist the person to maintain a regulated behavioral state, such as the calm, alert state required during certain school activities (Wilbarger, 1991). Multiple sensory diet strategies may be implemented at regular intervals throughout the day. In particular, these strategies may be performed prior to times that may be considered challenging, in order to prepare or set up the body to maintain an organized state throughout the activity, or they may also be used during activities in order to assist the client to maintain an organized state throughout the activity (Williams & Shellenberger, 1994). In this study, the diet tracking sheets were designed by the research clinicians to measure the observable sensory strategies via Levels of Engagement (LoE) and Levels of Alertness (LoA) on a 5-point scale, and were recorded by a trained technician on specific diet adjustments dependent upon the various phases of the research.

Direct Instruction coupled with aspects of strategy-instruction was utilized during individual/small group instruction. Glang et al (1991) found that after 12 hours of direct instruction, “both Subject made substantial academic progress in their targeted instructional areas.” Direct Instruction is a teacher-directed method of instruction in which cognitive skills are broken down into very basic components and explicitly taught. “Specific techniques include: breaking down the instructions and tasks into small steps, teaching modeling of skill or task, administering feedback repeatedly…allowing independent practice and individually paced instruction. “ In addition, aspects of Strategy Instruction such as “verbal modeling, questioning, reminders to use strategies or procedures,” (Sohlberg, M, et al, 2005) were utilized. Direct Instruction was utilized because it is one of the only researched methods of instruction shown to be effective in teaching Subjects with Acquired Brain Injury.  Glang et al (2008) concluded in a literature review that “Two instructional approaches—Direct Instruction and cognitive strategy intervention—have significant evidence supporting their use with many populations of children, with and without disabilities, and address many of the common needs and learning characteristics of Subjects with TBI, thus showing particular promise for these Subjects.”

Review of Process
Modified 7- sense (visual, tactile, auditory, vestibular, proprioceptive, olfactory, and gustatory) sensory diets were assigned in three phases: The Introductory Phase, The Second Phase (Extremity-Specific Phase), and The Third Phase (Subject Initiation Phase). In the first 4 months, diets were implemented up to 6 times a day on the subject (Head, Upper and Lower Extremities). During the next 8 months, diets were scaled back and implemented to 3 times a day.

During all of the phases, a modified 7-sense tracking sheet was aligned to the specific extremity and the protocol order with (Levels of Alertness) LoA and Levels of Engagement (LoE). Likert Scales for LoA and LoE were developed by the researchers and attached to the protocol.  LoA were measured as: 1 (deep sleep); 2 (sleepy/intentional eye closure), 3 (calm/neutral/awake); 4 (wide-awake); and 5 (hyper-active). LoE were measured as: 1 (unengaged); 2 (engaged 25%); 3 (engaged 50%); 4 (engaged 75%); 5 (engaged 100%). In addition, pictures accompanied each Likert demarcation for added clarity of the descriptions.

In the Introductory Phase, a Proximo-distal, hierarchical arrangement of the sensory protocol was performed on both upper and lower extremities at one session.  The hierarchical arrangement included, in order: modified milking massage (15 repetitions on every extremity), modified Wilbarger brushing (unidirectional, from proximal to distal, 15 repetitions on every extremity with moderate pressure), localized extremity joint vibration with battery-operated 4 prong Homemedics handheld massager (Proximal to distal: UE shoulder, elbow, wrist; LE hip, knee, ankle, 15 counts per joint), modified auditory integration program (50% volume on source, Sound Health Series mix, Sennheiser Closed 202 headphones). Each sensory diet lasted between 15 to 30 minutes in total length.  Each part of the diets was labeled and defined to the subject by provider prior, during and after the diet was completed. This lasted for the first 3 months.

The Second Phase was a division of the Introductory Phase into extremity-specific sessions. One 15- 30-minute session would be dedicated to the Upper Extremity protocol; another 15-30 minute session would be dedicated to the Lower Extremity protocol. Both types would use the modified Auditory Integration Therapy respectively. Diets lasted between 15 to 30 minutes in total length, and these were repeated up to three (3) times a day respectively. Diets were labeled and defined by provider prior, during and after the diet was completed. This was initiated immediately after the Introductory Phase, the next 3 months.

The Third Phase required Subject determination and use of communication strategies embedded in her AAC device. The provider would inquire what body extremity (UE/LE or R/L), and what specific diet was preferred. Diets lasted between 15 to 30 minutes in total length, and these were repeated up to five (5) times a day respectively.  Diets were labeled and defined by Subject choice prior, during and after the diet was completed. This came immediately after the Second Phase, the last 3 months.

Direct Instruction coupled with aspects of strategy-instruction was utilized during individual/small group instruction. The aspects of strategy-instruction included verbal modeling, questioning, and verbal reminders to use support strategies. When subject mastered content with at least 80% accuracy over five consecutive sessions, new topics were introduced. Previous skills were consistently revisited during the first five minutes of lessons as well as incorporated into lessons when applicable to the new skill being taught. Subject’s academic program took place five days a week and consisted of two-three formal 30-minute individual or small group  (2-3 Subjects) periods, and two formal 30-minute whole group (6 Subjects) periods over the course of 480 minutes per day for 12 months.

Post-Test academic achievement and sensory processing was taken one year after baseline. Post-Test academic achievement was taken again via an independent psycho-educational testing and modified Brigance testing which was completed in October 2014. Brigance testing included: knows personal information, Identifies parts of the body, word recognition grade placement test, counts by rote, reading comprehension grade placement, recognizes quantity, understands qualitative concepts, identifies common signs, reads words from common signs, recognizes quantity, adds numbers, subtracts numbers, multiplies numbers, divides numbers. Subject responded to both assessments utilizing a combination of AAC device, open and close verbal questioning and a touch screen device.  A case study by Kirsch, et al (2004) concluded, “ATC interventions can facilitate functional performance and contribute to learning of specific adaptive skills. Wireless, interactive, Web-based interventions appear particularly suited to tasks in the home and community, permitting remote intervention and monitoring of task status.”

Results
At baseline, the subject presented with aversion to the diet protocol (0% for both levels of engagement and alertness). The subject required maximal technical assistance for 2 months (October-November 2013) prior to responding positively to the diet protocol; the protocol was narrowed from a 7 sense to a 5 sense during this time period to accommodate the subject’s sensory processing needs as recorded by the technician on the LoA and LoE tracking sheets. From December 2013 to January 2014, a segmented protocol was introduced, also known as phase-two, to isolate sense stimulation with the head and extremity stimulation. From February 2014-May 2014, the subject continued with phase 2 and the technician recorded trends of responses.

It was also noted at baseline that the subject tested at a pre-kindergarten level for word recognition and kindergarten level for computation. Results corroborated with the independent psycho-education evaluation.

Evidence from assessments demonstrated a positive correlation between increased and consistent levels of alertness and engagement during improvements in segmented diets and academic achievement.

Post-Testing Sensory Diet Tracking results in May-June 2014 showed the subject to be alert at level 3 (calm/neutral/awake) for 86.7% and at level 2 (sleepy, intentional eye-closure) for 13.3% of the recorded sessions. The tracking sheets also showed the subject to be engaged at level 4 (engaged for 75% of the activity) for 68.3%, at level 3 (engaged for 50% of the activity) for 26.7% and at a level 2(engaged for 25% of the activity) for 5% of the recorded sessions. This is in comparison to the results from baseline upon introduction of the protocol for which the subject responded aversively and therefore was reported to be at 0%.

In addition, post-testing cognitive results via the modified Brigance testing had subject at a 3rd grade level on word recognition and computation (addition, subtraction, multiplication and division), in comparison to subject’s baseline testing which was respectively at a Pre-Kindergarten and Kindergarten level.

Conclusion
Based on the results, this case study shows a positive correlation between increased sensory processing alertness/engagement and increased academic achievement when sensory diets are administered. It is showing a significant change in percentage of optimal alertness and engagement for this 14-year old with neuro-developmental disorder specifically ESES Subject who displayed an 87% LoA (wide awake) and 68% LoE (engaged 75%) in the sensory diet protocol with an improvement in performance in modified Brigance testing from a Pre-K work recognition to 3rd grade, and K Comp to 3rd grade. This reveals a 4 and 3-grade level jump, respectively, over the course of one year. This case study validates the hypothesis that increased sensory processing alertness/engagement plays a part in increasing academic achievement in an adolescent female with neuro-developmental disorder specifically ESES.

This study utilized a single-subject design, which strengthens the internal validity of the study; however decreases the external validity of the study as it is not generalizable to other individuals within this population as it only pertains to the change evidenced with this particular subject. Furthermore, it needs to be noted that additional traditional therapies, including physical therapy, occupational therapy, speech and language therapy including augmentative and alternative communication therapy as well as modified conductive education, a program designed for children with motor dysfunction, which integrates education and rehabilitation into one program with the goal of achieving ortho-function–the capacity of individuals to respond to biological and social demands (Darrah, 2003)–were performed throughout the Subject’s day, which decreases the internal validity of the study as these interventions were not controlled for and may have played a role in her overall increase in academic achievement.

However, the results of this study indicate that a comorbidity of SPD and subsequent interventions for SPD need to be further explored for individuals with ABI as a way to increase sensory processing and academic achievement. Further work on the efficacy of sensory processing skills needs to be studied within a clinical based setting to determine if the benefits are generalizable to other children within this population as well other populations. Future studies should control for factors including but not limited to therapeutic interventions and duration of interventions on a daily basis.

Finally, according to a recent policy statement put forth by the American Academy of Pediatrics, “the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive,” (2015). Therefore, more clinical based research regarding SPD as a distinct diagnosis and as a co-morbidity with the ABI population needs to be conducted in clinical based settings in order to address the controversy and limitations surrounding diagnosis and interventions for SPD either as a distinct or co-morbid diagnosis. This case study and the few that proceeded serve as first step in a relatively unexplored field that stands to yield significant benefits for both individuals with and without ABI.

References
Ayres, A. Jean. (2005). Sensory integration and the child. Torrance, CA: Western Psychological
Services.

Brigance, Albert H. (2013). The inventory of early development III. North Billerica, MA:
Curriculum Associates, LLC.

Darrah, Johanna et al. (2003). Effects of conductive education intervention for children with a
diagnosis of cerebral palsy: an AACPDM evidence report.

Glang, Ann et al. “Using Direct Instruction with Brain Injured Subjects.” Direct Instruction News.
Fall 1991: 23-28.

Glang, Ann et al. (2008). Validated instructional practices: applications to Subjects with    traumatic brain injury. The Journal of Head Trauma Rehabilitation, 23(4), 243-251.

Kinnealey, M., Oliver, B., & Wilbarger, P. (1995). A phenomenological study of sensory defensiveness in adults. American Journal of Occupational Therapy, 49(5), 444-451.

Kirsch, Ned, L. et al. (2004). Web-based assistive technology interventions for cognitive

impairments after traumatic brain injury: a selective review and two case studies. Rehabilitation Psychology, 49(3), 200-211.  

Kranowitz, Carol S. (2005). The out-of-sync- child: recognizing and coping with sensory processing disorder. New York, NY: Penguin Group.

Owen, Julie, P. et al. (2013). Abnormal white matter microstructure in children with sensory
processing disorders. NeuroImage: Clinical, 2, 844-853.

Polatajko, Helene, J. et al. (1991). The effect of a sensory integration program on academic achievement, motor performance, and self-esteem in children identified as learning disabled: results of a clinical trial. The Occupational Therapy Journal of Research, 11(3), 155-176.

Shellenberger, S., & Williams, M. (2002). How does your engine run?. The Alert Program for self-regulation. In A. Bundy, S. Lane, E. Murray (Eds.), Sensory integration: Theory and practice, 342-345.  

Sohlberg, McKay, M. et al. (2005). Instructional techniques in cognitive rehabilitation: a  preliminary report. Seminars in Speech and Language, 26(5).  268-279.

Tarapore, Phiroz E. et.al, (2013). Resting state magnetoencephalography functional connectivity   in traumatic brain injury. Journal of Neurosurgery. 118(6), 1306-1316.

Ungerleider, Leslie, G. 1995. Functional brain imaging studies of cortical mechanisms for memory. Science, 270(5237), 769-775.

Wilbarger, J., & Wilbarger, P. (2002). Clinical application of the sensory diet. Sensory integration: Theory and practice. 2nd ed. Philadelphia: FA Davis Company, 339-341.

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ESNP Podcast 8: User-Friendly Interpretation on Sensory Processing Science and The Learner’s Consciousness: Part Two

ESNP Podcast 7: User-Friendly Interpretation on Sensory Processing Science and The Learner’s Consciousness: Part One

User-Friendly Interpretation on Sensory Processing Science and The Learner’s Consciousness: Part Two

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In the previous article, we discussed the science behind sensory processing skills, the brain centers involved, and the signs and symptoms of the modulation disorders. We also mentioned that the most efficient ways to encourage development of these skills was through a sensory diet targeted toward executive function skills. In this article, we shall break down these skills and match them with the suggested sensory diets that will not only enhance but continue to decrease chances of modulation meltdowns and difficulties with comprehending the overall environment.

First however let us define what we mean by Sensory Diet in the first place.

The term “Sensory diet” was coined by Occupational therapist, Patricia Wilbarger (1984), and can be defined as a carefully designed, scheduled activity plan, that provides the sensory input a person’s nervous system needs to stay focused and organized throughout the day. Each sensory diet is specially designed to meet a child’s specific sensory needs. Wilbarger and Wilbarger (1991) developed the approach to provide the “just right” combination of sensory input to achieve and maintain optimal levels of arousal and performance in the nervous system. The ability to properly identify and respond appropriately to sensations can be enhanced by a proper sensory diet.

There are certain types of sensory activities that are similar to eating a “main course” and are very powerful and satisfying. The most powerful and longest lasting activities on the nervous system include deep pressure touch, joint compression or traction, movement, and heavy work (Wilbarger, 1995).

The Wilbarger Approaches target the seven senses based on a person’s defensiveness or modulation symptomatology. The difference in the Execu-Sensory Diet that we utilize is the focus on the preparation of the sensory system for cognitive input. What that means is the diet is meant to support the growth of Executive Function Skills, no matter what the age or the need for a surrogate Pre-Frontal assistance from an adult.

Here are the major sensory components and the executive function skills they target:

1. Therapeutic Massage – Response Inhibition, Sustained Attention

Acure-Organics-Body-Lotion-Calming-Lavender-and-Lotus-Flower-854049002040Therapeutic massage is utilized to improve the tactile and proprioceptive systems. We utilize this on four extremities in an orderly fashion, and is usually done in a proximal to distal motion to desensitize the sensory nerves and ultimately send messages to the brain that a particular arm and/or leg is being isolated and given feedback. Usually also during the therapeutic massage, relaxing oils or lotions such as lavender chamomile scents that are hypoallergenic and have thick consistencies help reduce the friction and improve the natural biological feedback.Therapeutic Massage stimulates Gamma-Amino Butyric acid (GABA) in the brain, which is responsible for the sense of well-being, calming the nervous system down.

Response Inhibition is the suppression of a person’s actions that are inappropriate in a given context and that interfere with goal-driven behavior. For example, it is one’s ability to control calling out, storming out of a classroom, or touching others or other people’s property. Sustained Attention, or vigilance, as it is more often called, refers to the state in which attention must be maintained over time. It would be listening and attending to a classroom lesson or mini lesson for at least 5 minutes even when there are distractions in the room.

Therapeutic massage supports the development of these two skills by giving the extremities the grounding force to be able to attend to the task and decrease impulsive responses because the brain is able to map out where the person is in space and can maneuver the environment appropriately depending on what the current demands are required of them.

2. Therapeutic Brushing – Emotional Control, Flexibility

Wilbarger brushTherapeutic Brushing is more famously associated with the Wilbarger Brushing Protocol that is commonly used for people with tactile defensiveness, and for Autism-like presentations of touch sensitivities. The Therapeutic Brushing we utilize however does use the Therapressure Brush that the WIlbarger Protocol uses, however it is similar to the Therapeutic Massage wherein it is done proximal to distal and only on four extremities in an orderly fashion; whatever arm or leg that was started on with the massage will also be the same arm/leg that will initiate the brushing as well. We strongly suggest that the brushing technique be performed ONLY AFTER the massage in order for the sensory nerves to “zero out”  and not be stimulated to a negative “high” to where the fight or flight status of the brain becomes activated. The purpose of the Therapeutic Brushing is to increase awareness centers and promotes Serotonin in the brain, which is the neurotransmitter that helps improve mood and social functioning.

Emotional Control is defined by Dr. Richard Guare and Dr. Peg Dawson as the ability to manage emotions to achieve goals, complete tasks, or control and direct behavior. People who struggle with emotional control tend to have angry outbursts or behavior outbursts such as destroying or throwing objects, aggression towards self or others, and threats to harm oneself. Flexibility on the other hand is the skill that is defined as the ability to adapt to new situations, improvise, and shift strategies to meet different types of challenges. For example, a child who may be expecting to see a movie at a particular time and would not be able to due to circumstances would be able to bounce back and restructure the day or be able to find a solution to the disappointing outcome in a more proactive manner.

Therapeutic brushing supports the development of Emotional Control and Flexibility mainly due to the release of Serotonin right after the GABA process from the Therapeutic Massage. The sense of well-being meeting the sense of mood stabilization, which includes digestion, appetite and overall memory in learning. Frustration tolerance improves with different situations and thinking processes are supported efficiently by the calming effects and mood stabilization brought about by Serotonin.

3. Joint Vibration – Metacognition, Working Memory, Organization

HOmemedics handheld massagerJoint Vibration is unique to the Execu-Sensory Diet because we utilize a battery operated 4-point massager which is gives out a medium vibration cycle to the major joints of the extremities, such as the shoulder, elbow, wrist, fingers for the arm and the hip, knee, ankle and toes for the leg. As with the first two techniques, the extremity that was started on the first two will also be the extremity that will be utilized to initiate this technique. Of all of the techniques, this is the one that requires the most care; some people will react to the low-medium vibration as ticklish, while others will claim that it is painful and can incite fight, flight or freeze. Usually, however, the reason why this is the third step in the diet is because GABA and Serotonin have already been activated and the sensorimotor system is in ‘trust’ mode. This may not be true for students with extreme sensory processing deficits, thus training is essential for this particular modality.

The neurotransmitter that is released by Joint Vibration is Dopamine. This is the neurotransmitter that helps control the brain’s reward and pleasure centers. Dopamine also helps regulate movement and emotional responses, and it enables us to take action to move toward rewards that we see.

Metacognition is the awareness and understanding, analysis, and control of one’s cognitive processes, especially when engaged in learning. The overused thinking about thinking is what pop culture uses to define this skill. Working Memory on the other hand, is involved in the selection, initiation, and termination of information-processing functions such as encoding, storing, and retrieving data. It is usually referred to as the RAM system of our cortices, constantly remembering tasks or sequences of skills that need to be rearranged and retrieved at any given moment. An example or using working memory is taking a test that requires one to have access to formulas in short term recall that can be used.

Lastly, Organization is considered the skill of putting things into a logical order or the act of taking an efficient and orderly approach to tasks. The ability to prioritize what should come first, next etc. is how organization is developed and displayed on a daily basis.

Now, Joint Vibration supports Metacognition, Working Memory and Organization by the release of Dopamine. With the sensation of the brain being rewarded by the experience of joint vibration, the calm of GABA and the stabilization of emotions by Serotonin, the efficiency in short-term recall, hierarchical assignment of tasks needing to be accomplished and the awareness of the processes involved in being efficient and organized are enhanced by the neurotransmission of Dopamine. Learning is equated as something pleasurable and positive.

4. Modified Auditory Integration – Goal-directed Persistence, Time-Management

Seinnheiser202Modified Auditory Integration is a modality that we use with children who have difficulty maintaining where they are spatially in relation to the environment and to others in their immediate proximity. We also tend to use the Sound Health Series at 50% volume with closed, supra-aural, dynamic hi-fi stereo headphones. Auditory Integration is based on the Tomatis Method which is to improve the auditory system, people who can hear sounds may not be able to take in the full spectrum of these sounds, which means they might find it difficult to listen properly. According to Dr Tomatis, this happens when muscles are not working properly and through auditory stimulation it is possible to retrain the muscles of the inner ear so that it can function without distortion. Overall, Auditory Integration initiates Dopamine release in the brain similarly to Joint Vibration however from a direct sensory system rather than from a joint receptor system. This is the only modality that is used from start to finish of the ESD.

Goal-directed persistence is the capacity to have a goal, follow through to the completion of the goal, and not be distracted by competing interests. A good example would be when there is a game or a toy that the child may want, and a structured process of steps are put in place in order to ‘earn points’ to get closer to earning the reward, such as doing chores efficiently, or doing well in school allows the child to delay gratification and continue to persist toward the final achievement of the goal.

Time Management is ability to plan and control how you spend the hours in your day to effectively accomplish your goals, such as being able to gauge how long an assignment will take to finish or how much longer one needs to be able to get from one place to the next. The opposite of course to efficient time management is procrastination, and for some whose sensory processing systems limit their understanding of time, rigidity in multiple step task accomplishment.

Modified Auditory Integration supports development of Goal-Directed Persistence and Time Management by continuing the Dopamine release happening with the Joint Vibration protocol. It meets the joint receptors sense of reward by allowing the auditory system to ‘listen’ not only to the music but also to the body, and ultimately provide that platform to improve and build on sitting throughout the whole diet protocol; time management on the other hand is measured by the ability of the neurotransmission to relay the benefits from Serotonin, GABA and Dopamine thus signalling indirectly the beginning, middle and end of the protocol via the use of the Modified AIT.

5. Counting and Hierarchy – Planning/Prioritization, Task Initiation

Counting and Hierarchy involves a specific rote and tonal count in a calm voice from 1-15 for every single extremity and every single modality and technique used. The Hierarchy obviously provides predictability and structure to the diet, to a point that the child can self-direct the diet and ultimately tailor the diet according to his/her needs at given points in time, ultimately breaking them down into what has been coined as Sensory Snacks. 

Planning and Prioritization is when one organizes work, sets priorities, and determines resource requirements. In this case, the counting and the order of the diets assist with determining the generalized prioritization of the diet as well as anticipation of what is next, and last without increasing Acetylcholine release.

Task Initiation is knowing how to get started on a task and sustaining the attention and effort levels needed to complete the task, which in this case again is supported by the predictability of the materials, the diet protocol from one time to the next, the language, the tone of voice up to the signaling of when it is the end.

For more detailed information on training of the Execu-Sensory Diet, or for more related literature that supports this particular methodology, please email us or check out our published abstracts related to this topic. Hopefully this will provide you with some clarity on how the sensorimotor systems play an integral part in wholistic cortical development, especially in regards to supporting the development of Executive Functioning Skills.

Please Share This Resource With Parents

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Thank you to the parents of East Harlem Scholars Academy in New York, NY for coming to a seminar today on campus.  This brochure was provided to them by one of ESNP’s therapy partners to the parents as a quick reference to help their children at home. If you would want to use this free resource, or want to use the information in the brochure, just contact us via email or through this site.

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User-Friendly Interpretation on Sensory Processing Science and The Learner’s Consciousness: Part One

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We have touched on the subject on our previous articles on how negative behavior is often times intermixed or interpreted as willful or choice-driven, while in some cases, these behaviors have an underlying sensory processing root. To cite a specific example, let’s say that one  who utilizes public transportation when going to work daily is unable to tolerate other people’s conversations on the shared space and would require noise cancelling headphones to be able to survive the commute.  What we oftentimes call as our preferences or likes boil down to what ‘makes sense’ or ‘computes’ with the section of the brain that processes all of the sensorimotor experience: the temporo-parietal sliver that receives and interprets all of what surrounds us and is experienced within us.

Because these systems are so automatic, just as the heart beats without us having to remind it to do so, we often take it for granted that without the ‘correct’ interpretation of what is going on, we will not make the appropriate response. Majority of our reflexes also come from this section of automaticity due to either a retrieved and learned sensory experience (e.g. touching a boiling kettle once before will permanently recall the sensory experience of fight-or-flight burning pain on the particular body part).

The Sensory Processing of a Learner: Many Intelligence Types

Let’s Look at the two pictures below. On the left side you will notice that we have named the seven (7) senses of the body as primarily responsible in processing the information from the environment.  The vision,  hearing,  smell,  touch,  taste,  movement or kinesthetic sense, and proprioception or position in space sense all come together and interpret the environment for the person based on each of the sensation’s primary function. Thus we call this the Stimulation Source.  We will discuss the details of processing science in the next section. The Stimulation Source in the simplest sense is  the interpretation of the sensations in the brain after it had been given meaning by the cerebral cortex, specifically the temporo-parietal sections. These are the many directions an interpretation of the sensations can be expressed by a person: visual-spatial, bodily kinesthetic,  musical, interpersonal,  intrapersonal, musical,  linguustic, logical-mathematical,  and ecological. These were initially introduced into the mainstream by Howard Gardner in his Theory of Multiple Intelligences.  In our practice however we take it a step further and consider it as the Learner’s Response.  What we have seen is that the interpretation of the senses can only be expressed accordingly based on the abilities of the brain to coordinate the meaning of the sensations received,  thus the Learner’s Response is tied to a person’s natural inclination dependent on the correct release of the information to the external environment.

The Learner's Response: Sensations Transformed into Many Intelligences
The Learner’s Response: Sensations Transformed into Many Intelligences

The Stimulation Source: Seven Bodily Sesnations
The Stimulation Source: Seven Bodily Senses Gathering Information from the environment

If we created an example from listening to ones ipod,  as soon as the brain realizes that  it’s the sense of hearing that is stimulating it, the sound is processed and given meaning by the cerebral cortex and then sent back out to the Learner. Depending on the Learner’s natural abilities, the responses will vary from person to person. One who is kinesthetic may decide to get up and dance.  One who is visual-spatial may decide to research the singer online for a live version of the song. While someone who is intrapersonal may become reflective and try too recall an association of the song with a memory or a personal thought. This explains why even if the senses are receiving the information from the environment accurately, the responses vary from  person to person depending on their natural ability.

Sensory Processing Science: A. Jean Ayres in User-Friendly Language

Dr. A. Jean  Ayres, the pioneering Occupational Therapist in sensory integration theory summed up best the process of  the body’s ability to process sensory input. She posited that there were 7 steps that went into the brain’s processing: reception, detection, integration, praxis, discrimination, postural responses and modulation. She also did say that these steps are done in heirarchy, in order. If one step is missing, then the processing becomes faulty and the brain will not be able to send out the accurate interpretation to the learner to respond to. And of all of these steps, it is Sensory Modulation that is externalized by the Learner; by having a sensory modulation disorder, that is the obvious signal there is a hiccup in the flow of the sensory system from the einformation gathering to the brain processing, to of course the Learner’s responses.

The Sensory Processing Science: User-Friendly Language
The Sensory Processing Science: User-Friendly Language

Focus on Sensory Modulation Disorder: Impact on Learner’s Consciousness

As was mentioned in the previous section, it is the Sensory Modulation Section that mist if not all sensory issues are evidenced, based on Learner’s Response.  Now there are several types of Sensory Processing Disorders: Sensory Modulation Disorders (Sensory Hypo and Hypersensitivity,  and Sensory Seeking), Postural Disorders, and Sensory Discrimination Disorders. Of all of these however,  it has bern shown that Sensory Modulation,  the very last step of the hierarchy of sensory pricessing has the most damaging effects on the Learner’s ability to process academic and social information.

For specific details on the manifestations of Sensory Modulation Disorder, we created a table using research information by Carol Kranowitz in her book, The Out of Sync Child.

Refer to the table below:

Synthesized Sensory Modulation Disorder Chart (As Based Off of Carol kranowitz)
Synthesized Sensory Modulation Disorder Chart (As Based Off of Carol Stock Kranowitz)

Now that we have made the connection between the Learner’s Response to Stimulaton Source, how then can we correct the sensory modulation deficits? The answer: An Executive Functioning- Sensory Based Diet of course, composed of targeted activities  from a sensation to cognitive develomental perspective that are aimed to correct the gathering-interpretation process in order to align the learning responses as well . That discussion will be part two of this discussion, the next post to this series. In the meantime, check out our ESNP Recommends tab for more resources and our articles under Body Breakthroughs for additional ideas.

The Article as seen in Brainblogger.com: The Fundamentals of Neuropedagogy

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Thanks to our friends at Brainblogger, here you can read the complete article. Happy reading!

Introduction

Over the past decade, we have learned that for every student who is simple to understand or figure out, there are one or two who are a conundrum. Over this same decade we as separate and collaborative professionals have also discovered that the answer to these students’ needs being met is two-fold: 1. Education looks only at symptomology not etiology 2. Education fails to integrate disciplines effectively. Special education needs to stop being about labels and start being about the whole child.

Enter the practice of Execu-Sensory and Neuropedagogy. When we look at the child as a whole: brain, body and mind, we begin to understand that more than what teachers are taught in school is at play. Take child development, for example, this class may or may not be required to earn a Masters in Educations, especially if the focus is middle childhood rather than early or elementary.  Yet, the brain is not done growing, literally, until the age of 19 or 20 and the prefrontal cortex continues to develop until the age of 25. Not to mention, the developmental surge that takes places during adolescence is akin to the one which occurs during early childhood. How then are teachers prepared to teach the ever evolving whole child if they lack the basic knowledge of brain development.  The simple answer is they most likely cannot. The brain is a vastly complex system of electrical wiring and firing that is critical to understanding, given the goal is not only to teach, but teach effectively.

However for the purposes of this blogpost, we shall focus the discussion on the fundamentals of Neuropedagogy in practice with some aspects of Execu-Sensory components.

Structure of Neuropedagogy

Neuropedagogy in its most basic state begins with the executive function skills and the developing Pre-Frontal cortex. However when we attempt discussion with other educators, the typical response is,  “Executive what in the where? Neuro?”

Understandable response, seeing as this predominantly European concept is commonly referred in the United States as Educational Neuroscience or Neuroeducation--or perhaps more commonly not discussed among educators at all. It was introduced during an educational summit in 2009 at Johns Hopkins University simultaneously with a “Learning and the Brain” wherein organizers and educators alike agreed there needed to be an interdisciplinary field that combines neuroscience, psychology and education to create improved teaching methods and curricula. It was bringing into focus new links between arts education and general learning, how learning physically alters the brain, and what goes wrong in students with learning disabilities.

Neuropedagogy however went further than Neuroeducation. The European definition of Neuropedagogy is when science and education meet and whose scientific aims are to learn how to stimulate new zones of the brain and create connections. It is targeted at stimulating the brains of all types of learners, not only those with students who have learning disabilities. Dr. Judy Willis a practicing neurologist made a conscious transition to the classroom as an educator feels that there needs be research about the brain’s neuroplasticity and the opportunities we have as educators to help students literally change their brains — and intelligence. To become a teacher without understanding the implications of brain-changing neuroplasticity is a great loss to teachers and their future students.

Based on the experience and the research we have done on current classroom structures in New York City, we have found that the most effective use of Neuropedagogy was in three sections: Brain Element Neuropedagogy, Body Element Neuropedagogy, and Mind Element Neuropedagogy. The hierarchy of training is dependent on the prior knowledge of brain function, thus beginning the discussion with the brain was the most functional and useful approach. The body then and it’s organic processes were the next step in the training and understanding connections between innervation and control, and lastly the mind which not all fields of classroom instruction fully develop or are able to reach without the clear understanding of how the brain and the body encompass the physics of the mind.

To say the least, one would need basic brain to facilitate the body and change the mind.

The Brain Element Neuropedagogy

The most obvious reason to share information is for learning, and learning can only be achieved if there is sufficient brain function. In our practice, we lay the foundation for understanding the Central Nervous System (CNS) neurotransmission, the utilization of approximate brain mapping of the cerebral hemispheres, and raise awareness of the unmistakable impact of the digital society on the organic brain.

By organizing the hierarchy of understanding based on the processes involved from brain neurotransmission in each section of the cerebrum at any given time, we shed more light into the powerful effects of neuroplasticity, the endless ability for the brain to change itself. There are four that have been identified for learning: Acetylcholine (ACH), Serotonin, GABA, and Dopamine. Ultimately these are the communicators responsible in delivering the information to all the lobes, including the Pre-Frontal Cortex. The PFC is not currently recognized as a lobe; however, the role that it plays in learning and behavior have been measured via Executive Function Skills.

Many definitions for executive function skills exist and they all essentially make the same point. The National Center for Learning Disabilities defines executive function skills as,” mental skills that help the brain organize and act on information… [it is the ability to use] information and experiences from the past to solve current problems.” These skills are critical to understand because when they are weak or delayed in developing, they can mask themselves as an educational disability which may lay the groundwork for an Individualized Education Plan (IEP) as determined by a mutlidisciplinary team.  For example, let’s say a child is referred for an evaluation for special education services because he is showing consistent negative behavior, such as being unable to focus for more than a few minutes at a time, constantly calling out, and failing to complete homework, all of which lead to decreased academic gains.  The child will most likely be mis-classified as having ADHD or a learning disability, which ultimately leads to inefficient or worse ineffective solutions. If the interventionists applied an interdisciplinary Neuropedagogical Approach, a different and more effective outcome may have played out.

Now, let’s add a layer of dynamic complexity to Neuropedagogy. Neuroscience has looked at the brains, personalities, strengths and weaknesses of people born after 1986 and compared them with brains, personalities, strengths and weaknesses of people born before 1986. The studies show a significant difference between the two. The over-arching difference: access to the digital world.  The first group is digital natives; the second digital immigrants. Digital natives have brains that have weakened pathways for interaction, decreased activity in anterior cingulate gyrus and medial orbital frontal cortex, increased isolation, aggression, passivity, loneliness, etc, increase in cortisol due to excessive brain fatigue, decreased hippocampal size. Digital immigrants, the ones who have the capacity to hand down life experiences effectively via examples and who can communicate thoughts personally are ones who are usually comfortable with familiar technology and shy away from change in that department. They have been found to have faster PFC circuitry as they have had abilities to strengthen neuronal circuits with numerous life experiences, including delaying gratification.

WIth all of the Brain Element Neuropedagogy, one can proceed to appreciate understanding the Body and it’s unique processes.

The Body Element Neuropedagogy

In our modern society, people are perceived initially from the way they present themselves. Usually what is displayed from the external body is what immediately connects one person to the next. The body’s senses take in the physical and external world, neuronally process the input and in the cortex it’s given meaning.

From a learner’s perspective, the body is both intake and output. As interdisciplinary brain-based practitioners, we shed light into the Sensory Processing Systems, the limitless potential of a person’s Multiple Intelligences and Emotional Quotient (EQ), culminating on the influence of what we have managed to call the 3 External E’s (Ergonomics, Economics, and Environment).  The body by itself is a complete sensory organ, however it has been proven by evidence-based practice that the seven (7) senses are the checkpoints of the body: sight, sound, smell, touch, taste, movement and position in space. Research in this area was pioneered by Dr. A. Jean Ayres and current practitioners include Dr. Lucy Jane Miller and Carol Kranowitz all of who have contributed to the education and learning landscape. One simply cannot function by brain alone!

Multiple Intelligences Theory was pioneered by Howard Gardner, a developmental neuropsychologist,who played the violin well, wondered if a tool, aside from the Intelligence Quotient (IQ test), could be developed to measure additional attributes to determine a person’s complete intelligence. Another factor we considered was Daniel Goleman’s Emotional Quotient (EQ) as this too plays an important factor externally; even as the limbic system is brain centric in it’s processing of emotions, the manifestation on the outside is clearly body centric.

Education in the twentieth and now twenty first century tends to teach to two types of learners: visual and auditory. Yet, research has shown that multiple types of learners exist, not just two. Teaching methodologies need to start designing lessons, activities and classrooms not only for the typically forgotten or ever present kinesthetic learners, but for the quiet introvert and the shy extrovert and multiple combinations of them.

Simple modifications such as state changes, strategically planned brain gym breaks or yoga ball chairs have shown to improve the executive functioning skills of sustained attention and task persistence. Additionally, when inserting brief yet planned breaks of any type, students are given an opportunity to work on set-shifiting a skill in high demand in the modern digital-world.  Modifications for the introvert include quiet spaces in the classroom or projects with an option to work alone.  The shy extrovert, may benefit from group projects with assigned jobs. However, this type of differentiated instruction is believed to be fitting only to the special education population. The rest of these students, rather than adopting a label that may or may not fit, they are instructed to adapt their bodies to fit because that is what the ‘real world’ will expect of them. Meanwhile, that potential intelligence lays mostly dormant because teachers are not teaching to them, and were probably never taught how. Neuropedagogy recognizes the learning process that processes from a brain and proceeds into the body offers perspective and solutions to teaching with the body in mind.

The Mind Element Neuropedagogy

Of all of the Elements that we train, it is the Mind Element that is the most challenging to explore.The brain and the mind are used interchangeably in the realm of education; however, scientists have discovered that although they do seem to be influential of the other, the brain and mind affect each other in very different but significant ways. The psyche in psychology practice have also been associated with the mind, and pop culture usually uses the word mind loosely as choice or state of one’s mental being.

In referencing the brain, it  is the material organic matter that has the physical manifestation of the neuronal processes while the mind is where consciousness and active thinking occur. However a thought may occur from consciousness which may alter the neuronal process that was intended to happen and vice versa. The mind discussion includes: theory of mind, the belief-desire reasoning in learners, and neuroplasticity in the habit loop, Behavior Modification and Habit Routine change that can have both positive and negative effects.

Neuropedagogy of the mind starts with the premise that the mind of a child is complex. The Belief-Desire Reasoning from H.M. Wellman’s The Child’s Theory of Mind Mechanism shows just that.  Thinking, perception, sensations, beliefs, cognitive emotions, physiology, basic emotions are all interconnected and simultaneously interacting to produce desires, intentions, actions and inevitably reactions. Actions are merely the tip of the iceberg to the ongoings of a child’s, and ultimately a learner’s mind. Educators who understand and teach with Executive Function Skills such as Metacognition, Emotional Control and Response Inhibition in mind, essentially have x-ray vision, which provides them the insight to ask the questions that will reveal the iceberg. Intention is marked by a WHOLE person, a product of perception, inception and conclusions.

Conclusion: The Neuropedagogy Synthesis

ESNP's Unique Neuropedagogy Synthesis
ESNP’s Unique Neuropedagogy Synthesis

When science and education meet it is called Neuropedagogy, whose scientific aims are to learn how to stimulate new zones of the brain and create connections. The information that is presented here may appear overwhelming and less comprehensive in practice however it the changing the lens and perspective that allow best practices to occur, to remind those involved in direct service that people are not formulaic in their learning.

The Neuropedagogy synthesis demonstrates just that. One of our current partnerships, The Teaching Firms of America Professional Charter School in Brooklyn, New York applies these principles by tying choice and action to their basis in the brain, Theory of Mind, and most importantly, the brain has the ability to change.  They empower their scholars to be thinkers and owners of their actions and choices by giving them knowledge from the world of neuroscience.  Finally, the utilize the principles of Neuropedagogy to guide and inform their instruction, interactions and interventions. It is a common occurrence to hear students say, “I can change my brain.” From initial classroom set-up to end of day classroom clean up, they created and continue an atmosphere of curiosity and intellect, which always seems to start and end with the brain.

Visually Processing Emotions

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When a person interacts with the immediate external environment, they utilize the seven senses: sight, sound, touch, taste, hearing, vestibular and proprioceptive senses. One is a complement to the rest of the senses, and ultimately, it is through these senses that we are able to function and respond appropriately to our environment.

Pillsbury
Many unique neuronal responses, one Pillsbury Doughboy picture across generations.

Vision is one of the richest senses that happen to cross both gray and white matter, and one that requires all of the brain to give ‘meaning’ and attach this ‘meaning’ to an emotion. It touches all of the cerebrum before it gets completely processed by the Occipital Lobe.

We have a responsibility, especially to the young humans in our lives,  to consciously select the visual stimulation we are viewing and/or exposing others to.  In no way, can we or should we eliminate  exposure to the 24/7 media  that proliferate nearly all aspects of living in the twenty-first century. However, we do have some control over the reading material, games (video vs. educational)  and outings ( movies vs. museums) to name a few. These experiences are processed in all areas of our brains before we have even visually processed the image in our occipital lobe.

When video games became a part of mainstream culture and presented as mostly games focused on violence, social psychology professor Dr. Bushman began investigating the effects of excessive exposure to these video games. He and his colleagues have found that exposure to violent video games increases aggressive behavior as well as

Do you want to feel like this…

desensitize players to violence, which leads to an increase in aggressive behavior. It goes without saying that these experiences, which are highly visual, are leading to negative emotions. Furthermore, the opposite has also been proven: exposure to images that may be classified as serene or non-stressful, reduce stress, which can indirectly lead to positive emotions.

or this?

Creating environments with visually positive imagery can then plausibly decrease cortisol and other stress-related hormones from flooding our brains. This in turn will keep our pre-frontal cortex functioning, since cortisol is known to block access to it, sending us into fight, flight or freeze mode.

Imagine the possibilities of streaming the visual processing skill with positive, stress reducing imagery on the state of consciousness–not only for the individual, but for the those that individual interacts with!