BULLETIN

Jeanette Suen, our Clinical Director, is a registered occupational therapist of Canada and United Kingdom. In her seventeen years of experience working with children, she has worked as a practising therapist and the department head in paediatric settings in both Hong Kong and Canada. She is certified in the administration and interpretation of the Sensory Integration and Praxis Tests, and in the use of the Bobath Method. Also, she has a special interest in the use of Conductive Education in her treatment with the children with cerebral palsy. Recently, Jeanette has completed the advanced level training in Therapeutic Listening in the States. With that, she has started incorporating sound therapy in the therapy intervention program for the children in the clinic.

Alvin Chan is an occupational therapist from Canada. Before joining us, he was the sole-charge therapist at Dover Court Preparatory School. He is experienced in working with mainstream school children with sensory integrative dysfunction and is adept in the provision of both clinic and school based intervention. With his previous experiences in Canada, the United States and Singapore, he has equipped himself with skills in the fields of Sensory Integrative Therapy and CranioSacral Therapy. Alvin is an enthusiastic therapist. His endeavour to learn and his effort to improve his clinical knowledge and skills are seen in both his work and his time spent on continued education. Within the last two years, he has attended various courses on the latest techniques used in Sensory Integrative Therapy, CranioSacral Therapy and play.

Hand in Hand Occupational Therapy Centre for Children is a centre that provides client-centred Occupational Therapy services for children aged 0 to 12 years. Our services include assessment, treatment and consultation in areas that enhance the performance and independence of children in their activities of daily living. The focus is on enhancing performance as well as preventing much of the deterioration that can accompany disabilities. The areas of our service include:

• motor planning and sensory modulation
• Developmental motor skills (gross and fine motor skills)
• Handwriting
• Feeding and oral motor skills
• Activities of Daily Sensory integration – postural control, praxis / Living – Toiletting and Dressing

In our centre, our therapists use meaningful activities to enable the children to reach their full potential. The treatment approaches and techniques that our therapists use to improve on the children’s independence and performance include:

• Sensory Integration Therapy including the use of movement-based activities, M.O.R.E., Alert Program, Floortime Model, etc.
• Sensory-motor Training
• Neurodevelopmental Therapy (Bobath Method)
• Therapeutic Listening (Sound Therapy)
• Conductive Education
• Developmental Therapy
• Skill Training (such as handwriting, social skills, and dressing, etc.)

Other than providing therapy at our centre, our therapists also

Children who may benefit from our services include those with but not limited to:

• Dysfunction of Sensory Integration (DSI)
• Learning Disabilities
• Attention Deficit Disorder
• Autism
• Cerebral Palsy
• Developmental Delay
• Downs Syndrome

The role of occupational therapy in pediatrics has received thoughtful consideration over the years revealing no substantive changes in its objectives. It remains that assessment and treatment should be directed at enabling a child’s occupation (i.e. self-care, productivity, and leisure). That is, much attention is given to enhance a child’s ability to be an independent and productive individual namely in his/her ability to participate in daily self-care activities, school and play/social situations. Although the role of occupational therapy has remained clearly delineated over the years, the content and structure of occupational therapy practice has continued to grow. Pertinent factors that have played an important role in the growth and evolution of pediatric occupational therapy to its present state are threefold. These include 1) the continuing sophistication of intervention methodology, 2) the expanding scope and understanding in the realm of human sciences, particularly in neurosciences and child development, and 3) the impact of regulatory bodies that factor into the application of occupational therapy practice. With these changes, it has brought about much discussion on what constitutes an effective occupational therapy practice in pediatrics.

As mentioned before, although the methodology and knowledge base and research has continued to evolve, there remains one constant in what defines a service delivery that is efficient and effective. Effective intervention continues to involve the concept of the provision of a client-centered practice and its related facets of enablement and empowerment. Although client centeredness is one of the important premises in an effective service delivery model, it is often times not accurately adhered to in pediatrics. Why?

Well, in the realm of pediatrics, client centeredness takes on a significant role in intervention planning and prescription. This is because in pediatrics, the "client" becomes not only the patient or child but also includes his/her advocates (teacher, parents). Therefore, to be client centered in intervention planning, there needs to be a close collaboration with all parties involved. The intervention team then will include not preclude the child, the family, all professionals and educators who spend time with the child. In doing so, all involved will serve as either facilitators or advocators for the child.

With the client being defined as the child and his/her advocates, the processes of enablement and empowerment can take its proper course. With enablement, it is defined as "the processes of facilitating, guiding, coaching, educating, prompting, listening, reflecting, encouraging, or otherwise collaborating with people so that individuals, groups, agencies, or organizations have the means and opportunity to be involved in solving their own problems" (CAOT, 1997). Being an educational process that occurs within the client-occupational therapist relationship, enablement assists the child and his/her advocates to gain a better awareness of their inherent strengths and limitations, and of their situation. In doing so, the client is equipped to be strong advocates of what they need and how to fulfil their needs to be successful participants in daily living. Enablement is the basis of occupational therapy's client-centered practice and a foundation for client empowerment.

Empowerment, is defined as "a social action process that promotes participation of people, organizations, and communities in gaining control over their lives in their community and the larger society"(CAOT, 1997) is not characterized as achieving power to dominate others, but rather power to act with others to effect change. Empowerment reinstates a sense of control for the client to make choices and decisions that will enhance their ability to be successful in fulfilling their occupations.

Therefore, an effective service delivery is such. Its method of delivery should be successful in transferring the locus of control back to the client, enabling and empowering them to be strong advocates and successful participants of what is their sense of fulfillment and purpose in life.

With this astute definition of a client centered practice, the role of a pediatric occupational therapist needs to be re-examined. Within this construct of client centeredness, the role of a pediatric occupational therapist is not to provide "cookbook" intervention approaches for the child without the consent of the child. Intervention focus and practice is not to perform treatment "to" the child but to work "with and for" the child to equip him/her with the tools needed to be successful in the job of daily living. To be truly client centered in our practice, we, as therapists should not work under the fallacy of being too focused on treating the diagnosis and accompanying deficits. When we do this, we are guilty of neglecting the child within the diagnosis. Thus, to be client centered is to adhere to the guiding principles so aptly delineated within the traditional constructs of occupational therapy practice. Within the profession’s code of practice belies the very definition of a client centered practice. Therefore, therapists and parents alike, we should all ensure that the services provided are founded on these important premises of client centeredness, empowerment, enablement and advocacy.

Sensory Integration is the process in the brain that organises sensory information for use. It is also a theory developed by the late Dr. A. Jean Ayres, PhD, OTR (1922 to 1988), a well-distinguished occupational therapist in the States. According to Ayres, sensory integration is that process in the brain by which people organise their sensation (such as those from skin, eyes, joints, gravity and movement sensory receptors), and from which they learn and react to the world around them. For instance, when a person sees a bright blue sky, he knows it is a sunny day. Through the information this person obtains from his eyes, he knows about the weather. In Sensory Integration, other than the senses that people commonly think of, such as that of vision, hearing, smell, etc., special attention is given to that of touch (tactile), movement and balance (vestibular), and muscles and joints (proprioceptive). People use these three senses constantly in their daily activities, but very often, they are not aware of them. For example, a person is using his proprioceptive and vestibular senses when he is adjusting his posture, he is using his sense of touch when he is picking up a pencil and adjusting it in his hand for writing.

The tactile, vestibular and proprioceptive systems are at the subcortical level in the central nervous system. They provide an individual with input from his body for unconscious neural control of sensory-motor activities, of which the higher cortical organisations (academic learning) are dependent upon. In other words, the higher cortical level will not function optimally without the adequate functioning at the subcortical level. In very simple terms, a good internal / subconscious concept of an individual’s body and movement serves as the foundation upon which the ability for exploration and learning can be developed. Without such foundation, learning takes place without true understanding, resulting in performance relying on memory. Such performance is usually robotic and non-spontaneous.

Sensory Integrative Therapy is an approach of treatment that occupational therapists, especially those working with children, use in treating their patients with Dysfunction in Sensory Integration (DSI). Prior to Ayres’ work, children with DSI were often misunderstood as being naughty, restless, troublesome, and disorganised. Through her innovative research, Ayres discovered that the behaviour of such children was a result of inefficient organisation of the sensory information they received by their nervous systems. She developed diagnostic tools and a treatment approach that have benefited many children with such dysfunction.

Sensory Integrative Therapy aims to facilitate the development of the nervous system and to eliminate the inappropriate behaviour by providing the necessary sensory input through age-appropriate and socially acceptable therapeutic activities in an environment that the child feels secure enough to have active participation in the process. One of the major objectives is to facilitate the production of adaptive response in the child.

Adaptive response is the best possible action / behaviour that an individual can have in successfully meeting the demands from the environment. It is purposeful and goal-directed. It allows the individual to learn something new. For instance, when a child is placed on a swing the first time, he reaches out voluntarily to hold on to support so as not to fall. Such behaviour is an adaptive response as that is a new experience to the child. In new experiences, an individual has to process the incoming sensory information, such as that from his own body and movement, effectively so as to produce the appropriate motor response, as he cannot rely on his memory. On the other hand, if the motor action is taught, e.g. the child is told to hold on so as not to fall, the individual does not need to process the incoming sensory information from the body and movement, sensory integration will not take place. The ability to produce adaptive response reflects sensory integration. Its production requires effective sensory integration and promotes further integration of sensory information. For instance, the child on the swing, after being able to hold on so as not to fall, will surely feel good about himself, and will want to do more on the swing.

Most people tend to view adaptive response from a motor perspective, as most activities in Sensory Integrative Therapy are movement based. Children are placed on different suspended equipment, such as swings and hammocks, and unstable surfaces, such as air mattresses and big therapy balls, to work on their postural attention and control, motor planning, etc. With improvement in these fundamental areas, children are seen to have better performance in their motor co-ordination, posture, motor skills, such as handwriting, and attention.

Recently, with the work of well-distinguished occupational therapists, such as Patricia Wilbarger and Patricia Oetter, and new findings from neuroscience, more attention is placed on sensory modulation. Other than praxis and postural mechanism, sensory modulation plays an important role in an individual’s ability in making sense of out the sensory information he receives (sensory integration).

Sensory modulation can be defined as the ability to attain, maintain and change arousal level appropriately for a task or situation. For instance, one’s arousal level has to be low in order to fall asleep at night, high in order to enjoy a rock concert, and just right in order to concentrate in an academic task. It is an important element in learning, attention and behaviour. Some of the signs of dysfunction in sensory modulation are sensory defensiveness (over-sensitive to certain sensory stimuli), great mood swing, withdrawal and poor attention. In the recent years, more different treatment strategies for treating Sensory Modulation Dysfunction have been developed, such as the Wilbarger Program, M.O.R.E., Alert Program, OT Tool Chest, etc. With such programs, the effectiveness of the Occupational Therapy intervention program using the approach of Sensory Integrative Therapy is greatly enhanced.

As a conclusion, the concept of sensory integration is evolving. Sensory integration is now more viewed as an umbrella under which there are postural mechanism, praxis, sensory discrimination and sensory modulation. With such a view of sensory integration, dysfunction in sensory integration (DSI) is not something that just belongs to the "clumsy children" or the "funny little kids". How about the mainstream school children who are identified as naughty, lazy, hyperactive, difficult, oppositional-defiant, underachieving? Could they be suffering from this hidden dysfunction DSI? Nevertheless, with a more comprehensive view of sensory integration, the children with DSI can be much better understood and more effective treatment tools can be developed.