2003 IFA Congress: Montreal, Canada

Sensory Integration and Stuttering Therapy

Caroline Nater-Berkeljon
Stottercentrum Rijnlana’, Hazenboslaan 38, 2341 SC, Oegstgeest, the Netherlands

SUMMARY

Sensory integration is the way we take in information, organize and process this information to give an appropriate response. Comprehension of the process of sensory integration makes it possible to understand why a child has a speech problem. As sensory dysfunction could be a handicap to speak fluently. Speech fluency goals are therefore easier achieved by starting to train the sensory integration in the first place. Sensory integration is also useful to modify stuttering, to increase toleranace to stuttering and to facilitate or automate speech-behaviors.

Introduction

We must understand sensory integration before we apply these principals to stuttering therapy. After describing the outlines of sensory integration and sensory integrative training, the relationship between sensory integration and stuttering(therapy) is illustrated.

Definition of sensory integration

Sensory integration is the ability to gather information through the senses (touch, movement, smell, taste, vision, and hearing), to combine the information with prior information, memories, and knowledge stored in the brain, and to initiate a meaningful response.

The sensory process

The sensory integration process occurs in the central nervous system and generally take place in the mid-brain and brainstem levels. In the process of sensory integration sensory information from five senses: auditory (hearing), vestibulair (gravity and movement), propioceptive (muscles and joint), tactile ( touch) and visual (seeing) are gathered and put together.

The development of sensory integration starts before birth and makes an incredible growth during childhood. Sensory integration provides a crucial foundation for complex learning and behavior. The first requirement for the sensory integration process is an adequate stimulation of the senses and a good flow of impulses from the receptors to the brain. After having been gathered the different sensory information is put together to form specific functions. The sensory integration take place at three more or less sequenced phases. At each phase more different sensory information is integrated. At the first phase vestibular and propioceptive information are combined together, at the same phase or visual, tactile and propioceptive information are also put together. The integration of vestibular and proprioceptive results in well-organized eye-moVements, posture, physical balance, muscle tone, and ‘gravitational security’. The integration of visual, tactile and propioceptive are needed for sucking, eating and our tactile comfort.

At the next phase the three basic senses (tactile, vestibular, and proprioceptive) are integrated into body percept, coordination of the left and right side of the body, motor planning, attention span, activity level, and emotional stability. When auditory and visual sensations enter the process, the auditory information integrates with vestibular information and enables us to speak and understand language, and also to conduct purposeful activity. The visual sensations are integrated with the three basic senses into accurate and detailed visual perceptions as well as eye-hand coordination.

At the last phase everything integrates together to form the functions of a whole brain. This is the end product of every sensory integration process that took place at the earlier levels and gives. us the ability to organize and to concentrate. Self-esteem, self-control, and self-confidence come from feeling the body as a competent sensory-motor being, and represents a good neurological integration. Once the two sides of the body can work. together in purposeful activity, there is a natural specialization of the sides of the body and brain.

Results of an adequate sensory integration process.

Praxis and Appropriate Alertness result from the ability to process, organize, and integrate sensory information as a whole.

Praxis allows us to organize, plan, and execute all kinds of skills in an exact and efficient manner. There are several components of praxis: imitation, ideation, initiation, construction, feedback, feed forward, grading, motor planning, timing and sequencing. Imitation is the copying of an action of others, which can be observed in early life. When ideas meet the imitation, it is called ideation. The component of praxis in which actions are based on generated ideas with a clear idea of how to begin an activity, is known as the phase of initiation. Once being able to initiate actions, we are able to put objects or activities together in new and different ways (construction).. For each adequate action we depend on five other elements of praxis (1) feedback: the information from proprioception to refine motor skills, (2) feed forward: the anticipation of strength or speed required to perform a certain motor act, (3) grading: the variation of the intensity of what we do, (4) motor planning: the creation and combinations of various motor skills to perform new, more complex actions, and (5) timing and sequencing: the appropriate timing of and correct order in activities. The ability to use language to support praxis is very important; it can guide us with new or difficult activities.

A normal state of alertness develops as a result of the ability to regulate or modulate sensory input and is essential for impulse control. Many of us have discovered things which helps us to achieve and maintain an appropriate state of alertness. For example, music helps one to concentrate when working but distracts during conversations. Sometimes rough-and-tumble play with the kids makes one become alive, while other times you prefer no physical contact.

Nervous system hierarchy

Sensory integration occurs in sequences. The phylogenetic heritage and the otogenetic subsystems are sources of understanding of the hierarchic levels in sensory integration. There are three hierarchic systems:

  1. Archi system: gives us all of our automatic rhythmic activities related to reflexes and visceral input which is vital for survival and health.
  1. Paleo system: this system is triggered by the higher brain centers, provides synergy for all automatic, rhythmic movements (e. g. walking, dancing) and automatic, goal- directed activities (e. g. typing), postural regulations, speech breath and the expression of cmotiones.
  1. Neo system: this system provides the coordination for speed and dexterity of all higher cortical skills (e. g. precise perception, cognitions, controlled reactions). Actions involving this system require our attention and concentration and therefore we only can carry out one activity at the time. 

New, unknown sensations or activities are processed by the neo system, once the activity becomes more automatic, it will be processed by the paleo-system.

Characteristics of sensory integrative dysfunction

For most of us, effective sensory integration occurs automatically and unconsciously without effort. For some of us, the process is inefficient and demands effort and attention with no guarantee of accuracy. When the process is disordered a number of problems in learning, development, or behavior can be observed.

Ayers (1994) describes the sensory integrative dysfunction as follows: “Good sensory processing enables all the impulses to flow easily and reach their destination quickly. Sensory integrative dysfunction is a sort of ‘traffic jam’ in the brain. Some bits of sensory information get ‘tied up in traffic’, and certain parts of the brain do not get the sensory information they need to do their job.”

Because of the complexity of the various areas which are dependent upon and interact with each other as well as the child’s own personality and environment, it is not possible to have a single list of symptoms which identify sensory integrative dysfunction.

The sensory dysfunction can be observed in different ways:
  1. Attention and regulatory problems which are generally based on responding to or registration of sensory information without an efficient screening of the necessity of the information. These children are always alert to sensory input which is ignored by others. These children are seen as easily distractible, hyperactive, uninhibited, very irritable, difficult to soothe, and emotionally labile. They often have problems with establishing daily patterns like going to bed or problems consoling themselves.
  2. Sensory defensiveness which is characterized by an automatic â_˜fightâ ,  ight’ or â_˜freezeâ_ reaction to sensory information which most individuals consider as harmless. It can occur in all sensory areas. A few examples are: aggressive reactions to unexpected touch, avoidance of certain textures of clothing-or food, withdrawal from activities like shampooing hair, cutting fingernails or brushing teeth, negative reactions or fears related to sounds and noises (mostly associated with loudness and frequency), and fearfulness of movement or unstable surfaces. Children with a sensory defensiveness need to control every aspect of their life, frequently accompanied with an emotional reaction.
  3. Activity level problems which are evident in disorganization and lack of purpose in activity, not moving around to explore the environment, lack of variety in activities, difficulty to calm down after physical activity or after becoming upset, seeking to excessive amounts of vigorous input and appearing to be clumsy, tripping easily and poor balance.

Sensory integrative dysfunction often will result in behavioral problems. The malfunction adversely affects a child’s development, including both emotional and social development, which leads the child to become discouraged or to develop poor self-concept and may result in the child being inflexible, explosive, excessively demanding; unreasonable, picky, bossy Or have difficulty with transitions such as leaving one place to go to another. Many children with sensory processing problems have difficulty with one or more aspects of the components of praxis.

Basics of sensory integrative training

The central idea of sensory integrative training is to provide and control sensory input in such a way that the child spontaneously forms the adaptive responses that integrate those sensations. Therapy is most efficient when the child directs his own actions (inner-drive) while the therapist unobtrusively directs the environment. 

The child’s motivation plays a crucial role in the selection of activities. Most children tend to seek out activities that provide sensory experiences most beneficial to them at that point in development. It is this active involvement and exploration that enables the child to become a more mature and eficient organizer of sensory information. The therapist designs an environment :0 enable the child to interact more effectively by encouraging and assisting the child in choosing activities that provide the appropriate amount of sensory input. The therapist tries to balance structure and freedom in a way that leads to constructive exploration. This balance is not easily achieved. Free play itself does not inevitably further sensory integration, but too much structure does not allow growth either. With this balance of structure and freedom, the therapist helps the child to develop both his neural organization and his inner direction. The child is given as much control over the therapy as he can handle, as long as his activity is therapeutic. The child becomes more in command of his life because he develops better control of his body as his nervous system functions better. Self-confidence, or an improved attitude about one self, is often the first change that is noticed

Clinical framework stuttering

Figure 2 depicts the clinical framework for stuttering as proposed by Bertens (1993).

In this framework stuttering is based on an inherited predisposition for a neuromuscular timing disorder of speech movements which will result in stuttering if the circumstances for proper timing are negative. The response to the lags and disruptions in the timing of the complicated movements that are required for speech are part word repetitions and/or prolongations. There are three groups of factors which can trigger the manifestation of part-word repetitions and prolongations: time- pressure and rate, tension, and concomitant problems called handicaps.

Negative reactions to stuttering symptoms result in the reaction patterns of Fight, Flight, and Freeze, or a mixture of these. Fight, fight and freeze reactions in speech are automatic defensiveness responses of the nervous system. By fighting the stuttering, all kinds of learning patterns will turn the stuttering into a bizarre way of talking. When a stutterer freezes, he doesn’t do anything, waiting until the stutter disappears, which results in more time consuming stuttering. If the reaction pattern to stuttering is flight, the stutterer stutters ‘inside’, trying to hide the stutter by using all kinds of tricks. The sum of these negative reactions is a stuttering pattern that can be very complicated, and far away from the core behavior. These reactions only cause the stuttering to decrease temporarily and therefore increases the communicative stress. This makes the timing of speech even more difficult.

SOS_f1.png

Figure 2. The clinical framework stuttering (Bertens, 1993, published with permission of Ad Bertens.)

Stuttering and sensory integration.

To speak fluently an adequate sequencing and timing of speech-movements is required. Stutterers mostly have difficulties with not only the timing and sequencing of speech-movements but also in planning and grading. All these are aspects of praxis which is, as mentioned above, the result of an adequate sensory integration process. Two examples:

  1. Speech-motor-timing problems can be caused by a tactile defensiveness in the mouth which makes the sensations of speech-movements uncomfortable resulting in a lack of tongue movement.
  2. A child with an under-reactivity to vestibular and propioceptive information will have a hypo muscle tone and problems with the regulation of muscle tone (grading), see figure 1. This also affects speech. To compensate the hypo muscle tone the child uses too much effort to achieve goals resulting in the use of too much muscle tone. This may cause fight reactions which influences the speech-behavior and stuttering.
In this manner, sensory integration problems can been seen as a handicap to speak fluently.

The treatment of stuttering combined with sensory integration

Combining the treatment of stuttering and sensory integration means a big change in how to organize the therapy work-out. The basics of sensory integrative training have to be met. This means that speech skills are not taught to the child but the goal of therapy is to help the child to create the ability to achieve the learning skills. The inner-drive of the child is essential.

If the sensory integrative disorder is a handicap to speak fluently, it is useful to determine what the problem is and what the child needs before starting with speech-fluency training.

In the earlier given example of stuttering with fight reactions caused by an under reactivity to vestibular and proprioceptive sensations, the main therapy goal should not focus on speak- more-fluent skills but on the underlying problem namely the under-reactivity to vestibular and proprioceptive information. The therapist will determine what combinations of sensory-motor experiences (in this case vestibular and propioceptive) will help to develop the areas targeted for therapy. Another handicap to speak fluently may be problems with the alertness of the child. In this case the use of an sensory diet will be helpful. A sensory diet is a technique to create an appropriate alertness. Actually this technique is commonly used by all of us: we all have sorted out ways in which we are able to maintain a state of alertness that allows us to work, play, learn and perform in all areas of life. Many of these habits and preferences that we have developed, are results of meeting our sensory needs. In the sensory diet sensations of a special kind and of a special intensity are used at specific times and in specific circumstances. For example, the child may need to move during work to help its concentration but on the other hand may need an auditory input to relax before bedtime. This means that if this child needs to perform but the alertness is not efficient, it will be helpful to choose a movement activity right at the start of the performance. On the other hand, if this child is too excited an auditory activity can help to calm the child down.

If the sensory dysfunction is a handicap to speak fluently it must be treated by a well trained therapist with special education in sensory integrative training. The principals of sensory integrative training can be used to facilitate and automate speech goals in stutter therapy and is helpful to train stutter tolerance and stutter modification.

Where sensory integrative principals are used to facilitate therapy-goals, the chosen therapy activity must lead to the required result. For example the use of a trampoline will facilitate repetitions in speech, but a sliding or rolling activity will not. A sliding or rolling activity will, however, facilitate prolongations and no repetition of speech.

When sensory integration is used to automate speech-goals, it is important to offer the therapy goal on paleo-level, rather than at the neo-level. This can be done in two ways. By using a facilitation or by chosing an accompanying activity which demands attention and concentration.

An example of this would be to play football during oral motor training. The attention and concentration will be on the football game allowing the oral motor training to take place at the the paleo-level. A condition for this to work is that the child’s basic sensory integration must be healthy. This would thus not work for children who have impaired sensory integration. Sensory integration can also be used to improve the tolerance to stuttering and to modify stuttering. In addition, the freeze, fight and flight reactions can be overcome. The use of sensory integration also gives more pleasure during the therapy.

The treatment is composed of four specific variables, that of the client, the therapist, the environment and the material. These variables should be unique for each person. _

The client’s specific variables are the sensory preferences and the shortcomings of that child. This demands a sound knowledge of sensory integration, and a detailed sensory analysis of the individual.

The therapist’s variables are the skills, abilities, and shortcomings of the therapist.

The environmental variables refer to the optimization of the surroundings. This requires that the environment is suitable and provides the correct amount of stimulus. For example, a child with a hyper-sensitivity to light will feel more comfortable in an environment with little direct sunlight and a lot of indirect light.

The material variables are the specific attributes of the material used during the therapy. The jumping on a trampoline gives a better stimulus to vestibulair information than the sitting on a big ball. This requires a great dose of creativity and flexibility on the part of the therapist to choose and mix the suitable ingredients. _ '

Sensory integration is not only valueable within the direct treatment of the child, but also in parent/teacher support.

Given the plasticity of the brain, the principles of sensory integration also work in the therapy for both adolescents and adults.

Conclusion

Sensory integration is the neurological process that organizes sensory sensations. Sensory integration problems can be related with dysfluent speech. Sensory integration training can give an opportunity to improve the basis of fluent speech. In the treatment of stuttering the principles of sensory integrative training can be useful to facilitate or automate speech goals It also can be of use for stutter modification and stutter tolerance. By combining sensory integrative training and the treatment of stuttering, the therapy becomes a very pleasant way of working on the dysfluency speech.

References
Ayres, A.J. (1987), Sensory integration and the child. LA.Western psychological services

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