Early Intervention Speech Therapy

Interview: Lona Otero-Nardone, OTR/L

Today's post is my in-depth interview with coworker and friend, Lona Otero-Nardone. Lona is an occupational therapist who works in early intervention homecare and has over 8+ years of experience in the field. I have learned so much about Sensory Integration Dysfunction (SID) by watching and working weekly with Lona. As an EI speech therapist, SID affects many of the children and families I see everyday; however I sometimes feel ill-equipped to address their needs appropriately. Lona's incredible knowledge and skill-set has been a blessing for both me and the many children we see everyday, which is why I chose to interview her.

Our interview covers a wide range of information including SID, how it affects a child's body and speech development, as well as Lona's experience with co-treating with speech therapists. Due to the extensive amount of information, this interview will be featured over 3 consecutive posts.

Stephanie: Hi Lona! Thank you so much for speaking with me. Please begin by telling the readers about yourself, your background and what you do as an OT.
Lona: I graduated from Temple University in 2000 with a degree in occupational therapy. Shortly after graduation, I was employed by Elwyn as a pediatric occupational therapist in their Early Intervention program that provides therapeutic and educational services to families with children between the ages of birth to three years. They are children who have been identified as, or at risk of, having a developmental delay in one or more areas. Some of the children I see may have a diagnosis of: Cerebral Palsy, Down Syndrome, Autism/PDD, prematurity, seizure disorders and visual or hearing impairment, to name a few.

Elwyn's Early Intervention team consists of OT's, PT's, SLP's and special education instructors. We work directly with the family and their child within their home and community settings (daycares, libraries, music or play groups, etc.). Our team, which includes the family, a service coordinator and one or more therapist, work closely together following a family centered and trans-disciplinary approach.

In-so-far as what I do as an OT for Elwyn...well, that varies according to the needs of the child and the goals of the family (which is also stated in their Individualized Family Service Plan - IFSP). In general, my role as an occupational therapist is to work with the family to assist their child to learn functional skills in order to maximize their child's independence and improve function during daily activities within the family's routines. These skills include: fine motor, self-care, sensory processing, and play skills (especially since this is the main mode of how children learn and develop).

Given that Elwyn follows a trans-disciplinary approach, the skills I also work on or incorporate into my sessions, also include: gross motor, communication, cognitive and social skills. So, what I do as an OT is pretty all-encompassing, but the ultimate goal is to help the family and their child, reach their maximum potential.

Stephanie: Great! Now let's talk about your forte...please tell us about Sensory Integration Dysfunction and how it affects the body.
Lona:  Hmm...seems like such a simple question for a very complex subject. I will try my best to keep it as basic and as understandable as possible.

First, it is necessary to provide a brief explanation of what sensory integration (SI) is. Sensory integration is a process of alerting to and receiving sensory information, interpreting it correctly, combining it with other senses or previously learned experiences to form the "big picture", deciding on how to respond to the sensory information, and finally, executing an organized an appropriate response through our muscles, joints, actions and behaviors. SI is a process which occurs in the central nervous system. It is the taking in information and experiences in an organized an effective way through one or more of our seven sensory systems, which include:

• Proprioceptive Sense. The sense of body position, body parts/muscles/joints/tissue. It provides body awareness, our relationship of our body and body parts to people or objects. It is related to muscle tone and posture. It helps us to make sense of touch and movement. It helps to regulate our arousal state. This system is closely related to and inner twined with the vestibular system.
• Vestibular Sense. Sense of balance and posture. It provides information about gravity, movement and changes in head position. It also helps to regulate our arousal state. This system is also closely connected to the auditory sense as its receptors are located in the inner ear; as well as the visual sense as our eyes are dependent upon detecting positional changes.
• Tactile Sense. Sense of touch. Provides information all over our bodies about light touch, pressure, vibration, temperature and pain. It helps us to use the process of discrimination (being able to determine the properties of an object by feeling).
• Auditory Sense. Sense of hearing.
• Visual Sense. Sense of sight.
• Olfactory Sense. Sense of smell.
• Gustatory Sense. Sense of taste.

All of our sensory systems work together; and for the most part, sensory integration is an unconscious effort. An example of what SI may look like in a typical daily scenario and how some of the senses work together is this: You hear a fly buzzing around your head (you alert to it and take it in through the auditory sense), you turn your head to look at it to see that it is indeed a fly (involves proprioceptive, vestibular and visual sense - you combine senses and a previously learned experience to determine what it is), and you swat at it to get it away from you ( involves proprioception, vestibular, auditory and visual sense - you have decided on and organized an appropriate response through your actions).

As you can see, there a number of systems interacting with one another, as well as a number of processes that occur within SI. When we speak of a child with "sensory issues" (It also known as sensory integration dysfunction - SID, however this term is used less and less because the acronym is the same as Sudden Infant Death; but for the purpose of this interview, it is what I will call  it.), we are usually referring to multiple issues/challenges. There is rarely only one isolated "thing" that can be "off".

However, occupational therapists often use two general terms when describing issues that we may see in children with SID; they are hypo-responsive/hyposensitive (under responsive, requires more intense levels to register and respond to sensory information, response often takes longer) and hyper-responsive/hypersensitive (over responsive, requires much less input to register and respond, response is often quick). Hypo and hyper sensitivities can occur in any one or all of the systems. To further complicate things, sensory issues can change over time or fluctuate. The only exception to describing issues as hypo or hyper, is proprioception. When we discuss issues within this system, we are usually talking about difficulties with motor control and motor planning (also known as dyspraxia).

When determining what areas or systems are not functioning properly, an OT must have good observational and listening skills and a strong knowledge base of SI and SID. A Sensory Profile or similar tool may be performed as well to further help gather information and determine areas of weakness. But, I believe that observation of responses and behaviors of a child is key...observation over time is even better. I often tell my parents that if you listen to and really observe your child, your child is telling you what his system needs.

Stephanie: I have heard you say that to parents and I have learned how true it is. I think the difficulty for me, as a speech therapist, and for parents is to decipher what exactly the signs look like and what each means. Can you give us a description of how SID presents itself in children to help our readers know what to look for when treating children with both speech and language and SI needs?
Lona: Sure...here are some common ways in which SID can be seen in a child according to the seven sensory systems.

Proprioceptive Sense:

• Trips over or bumps into objects.
• Enjoys "rough-housing", likes to crash into things or seems aggressive.
• Assumes slumped body postures, or W-sits.
• Has difficulty properly grading movements; may over/under shoot movements.
• Has difficulty using correct force, may break things easily, draw very lightly or seem heavy handed or heavy footed.
• Has difficulty planning sequences of actions/movements.
• Walks on toes.
• Has difficulty manipulating small objects, especially fasteners.
• Has difficulties with transitions and may prefer more predictable activities and routines.
• May avoid trying new things or dislike being in new settings or social situations.
• Seems to "zone out" or doesn't respond when called. May seem "lazy".
• May stuff large quantities of food in the mouth or seem to pocket food in the mouth.
• May have preference for certain foods such as hard, crunchy or chewy foods. May have difficulty handling softer, lighter foods such as pudding or yogurt.
• Chews on toys, clothes or other non-food items.

Vestibular Sense:

• Seems to seek out or have a high threshold for excessive movement experiences such as running, jumping, swinging, rocking, spinning or climbing.
• May avoid or be fearful of movements, especially when feet leave the ground (also called gravitational insecurity).
• Eyes may not seem to move in conjunction with the head.
• Has difficulty staying seated or maintaining attention during more sedentary activities.
• Assumes precarious positions or likes to hang upside down.
• May have difficulties with communication/speech.
• May seem over-active or "always on the go".
• Gets upset when head is tilted back when washing hair.

Tactile Sense:

• Seems to seek out a variety of things to touch. May repetitively manipulate or feel objects.
• Is constantly touching people.
• Demonstrates fearful reaction or avoids touching or eating certain textures (also called tactile defensiveness).
• Gets upset when face and hair are washed.
• Gets upset when hands are dirty and insists hands be washed.
• Dislikes, upsets or avoids certain food textures.
• Dislikes brushing teeth.
• Has difficulty with discrimination of objects.
• Avoids playing with play-doh, paints, glitter, glue, etc.
• May have delayed fine motor skills.

Auditory Sense:

• Upsets or avoids loud noises, may cover ears.
• Gets easily distracted by environmental noises, has difficulty filtering or screening out background noises.
• Has preference for or responds only to certain sounds or intonations.
• Has difficulty with communication/speech.
• Does not respond when name is called.
• Seeks sensory input to ears or head area. May press objects against ears.
• Gets overwhelmed or seems "oblivious" in an active environment.

Visual Sense:

• Avoids or upsets in presence of bright lights. Prefers to be in the dark.
• Avoids eye contact.
• Stares intensely at people or objects.
• Hesitates or is fearful of going up/down stairs.
• Has difficulty picking out items from a background.
• Has difficulty assembling puzzles.
• Has difficulty visually attending to tasks.
• Is easily distracted by lights or moving/spinning objects.
• Eyes may not seem to work together or fixate well, especially when head position is changed.

Olfactory Sense:

• Avoids or upsets with certain smells. May hold nose to avoid.
• Appears to seek out certain odors. May smell many non-food objects. May press nose against objects.
• Does not seem to respond to many odors.
• May avoid or prefer certain foods based on smell.

Gustatory Sense:

• Is a picky eater.
• Avoids or upsets with certain tastes. Prefers to eat only bland foods.
• Craves very strong, sharp, sweet or sour tastes. May refuse to eat bland foods.
• Can't seem to tell the difference between foods.
• Mouths/chews/licks many non-food items.

Join us on Friday when our interview continues! Lona will share numerous ways for therapists and parents to address sensory integration needs both at home and in early intervention treatment.