Sensory Processing

Dysfunction
Occupational Therapy Pre-referral advice for schools
Contents Page Number

Introduction 3

What are our senses? 5

What is sensory processing? 5

What is sensory modulation? 7

What do we mean by over and under responsive? 7

Proprioception – Body Awareness 8

Proprioception Strategies 9

Vestibular – Movement Sense 11

Vestibular Strategies 12

Tactile System – Touch 13

Tactile Strategies 15

Vision 16

Visual Strategies 17

Auditory System – Hearing 18

Auditory Strategies 19

Olfactory System – Smell/ Gustatory System – Taste 20

Olfactory / Gustatory System 21

Oral Motor 22

Oral Motor Strategies 23

Alertness/ Self-Regulation 25

Sensory Diet/Snacks 30

Sensory Dysfunction Examples 33

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Introduction
We have developed this resource pack for those working with children who
have sensory processing difficulties.

The strategies provided in this resource pack are sensory-based interventions

that use discrete sensory experiences, cognitive awareness and
environmental modifications to improve attention to support regulation of
behaviour to prepare the child for engagement and promote organised
behaviour in everyday contexts in order to meet the demands of different
activities in school, home and community.

The aim is to help identify why a child is having difficulties with a particular
activity and to provide advice and some ideas on how to help them.

The pack is suitable for children of all ages with some adjustment of activities
for age appropriateness.

The pack has been set out so you can find the area of difficulty (e.g. tactile,
auditory) and the strategies that can be used to overcome this. Strategies
need to be implemented daily, regardless of how the child presents (e.g. even
on a good day) and progress reviewed.

Many of the strategies could be a benefit to children who do not have sensory
processing difficulties. Think about the situation when a normal baby becomes
distressed: the adult will either hold the baby to provide slow rhythmic
swinging movement stimulation (calming vestibular inputs) or pat the baby
with gentle touch stimulation (calming tactile inputs). These sensory strategies
will help calm the baby down but it does not mean the baby has a sensory
processing disorder / difficulties. Another example is when you are tired and
under-aroused, you will try to do different activities to alert yourself like
stretching your arms up and arching your back, getting up to walk about or
having a glass of cold water. These activities will provide alerting sensory
inputs to increase your arousal levels which will work even if you do not have
difficulties with sensory processing. Therefore consider how you can
incorporate some of the strategies described in this pack to benefit the whole
class.

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Referral to Occupational Therapy

Before we will accept a referral for an assessment we will require evidence

that the advice and ideas provided in this pack have been followed at school
and home for at least one school term.

If, after using the advice provided in the pack, the child still continues to find
tasks hard, it may be appropriate for the child to be referred to the Children’s
Occupational Therapy department for a specialist assessment.
We have included a suggested format of how to log the strategies that have
been tried. In addition we request the most recent education report including
child’s IEP or EHC if applicable is included with the referral for specialist
assessment by the Children’s Occupational Therapy Service.

If a child is experiencing difficulties with fine motor co-ordination then please

refer to the Fine Motor Co-ordination Difficulties: Occupational Therapy Pre-
referral advice for schools for advice and strategies to try.

Please feel free to contact us if you have any questions or you wish to discuss
activities suggested, in relation to a specific child.

Contact Details:

Children’s Acute and Ongoing Needs Service

Occupational Therapy
Callaghan House
Cross Street, off Green Lane
Heywood
OL10 2DY

Tel: 01706 676777

Email: [email protected]
Website: www.pat.nhs.uk/hmr-childrens-occupational-therapy.htm

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What are our senses?

Olfactory (Smell)
Tactile (Touch)
Gustatoty
(Taste)

Auditory
(Sound) Senses Vision

Proprioception Vestibular
(Movement) (Balance)

Each sense will be considered in greater detail with the following information:
• Description of sensory system
• Things you may see if over / under responsive
• Strategies to overcome difficulties

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What is sensory processing?
“We receive a great deal of information from our senses. We use this
information in many ways – to help us understand our body, understand the
environment, and successfully interact in the world”. (Ayres 1979).
When our senses are integrated correctly we are able to respond
appropriately to the sensation.

Imagine peeling and eating an orange. You sense

the orange through your eyes, nose, mouth, the
skin on your hands and fingers, and the muscles
and joints inside your fingers, hands, arms and
mouth. How do you know it’s a single orange
rather than many different oranges? What makes
your two hands and 10 fingers all work together?
All the sensations from the orange and all the sensations from the fingers and
hands somehow come together in one place in your brain and this integration
enables your brain to experience the orange as a whole and to use your
hands and fingers together to peel the orange.

Integration is what turns sensations into perception. We perceive our body,

other people and objects because our brain has integrated the sensory
impulses into meaningful forms and relationships. As we look at the orange
our brain integrates the sensations from our eyes so that we experience its
colour and shape. As we touch the orange, the sensations from our fingers
and hands are integrated to form the knowledge that it is rough on the outside
and moist on the inside. The integration of sensations from the nose tells us
that the orange has a citrus odour (Ayres 1979).

If the brain does a poor job of organising sensations this will interfere with
many things in life. There will be more effort and difficulty, less success and
satisfaction.

Reference: Sensory Integration and the child: Understanding hidden sensory

challenges. A J Ayres 2005

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What is sensory modulation?
Sensory modulation is the ability to respond to sensations appropriately,
maintain an optimal state of alertness to attend to tasks. Some children are
over responsive, some children are under responsive.

What do we mean by over and under responsive?

Sometimes the body doesn’t receive enough information and is under
responsive. This is when the body doesn’t process sensory information
effectively and therefore seeks more sensory input.

Sometimes the body struggles to manage sensory input coming in and is over
responsive. This is when the body misinterprets sensory information as
aversive, negative and out of proportion to sensory input that most of the
population wouldn’t.

A child can be over responsive in one system and under responsive in

another. There are many contributing factors.

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Proprioception - body awareness
This is about our movement and body position (like internal eyes). It’s the
messages we get from our muscles and joints about where we are in space
and how our body parts relate to one another without needing our eyes to tell
us. It informs us how fast we are moving and how much force to apply.

What might an under responsive What might an over responsive

proprioceptive system look like? proprioceptive system look like?

• Child is a fidgeter and This is extremely uncommon as

struggles to sit/stand still proprioceptive input has the potential
• Child leans on people when to be both calming and alerting.
sitting or standing
• Child is heavy footed
• Child seeks extra movement
e.g. crashes, bumps,
constantly jumps
• Child is heavy handed e.g.
throws ball too hard, presses
on hard when writing, gives
really firm hugs
• Child has a high pain threshold
• Child chews on inedible
objects
• Child tends to play more rough
than peers and breaks items
without meaning too
• Child might need to use their
eyes to feel a movement e.g.
looks at their feet when riding a
bike
• Child may find some activities
more difficult to pick up than
their peers e.g. riding a bike,
swimming, team games
• Child presents as floppy and
appears to have weak muscles

All children may demonstrate some of these behaviours, but a child with
sensory processing difficulties is more likely to present with many of these, or
some to an extreme degree.

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Proprioception strategies
We use proprioceptive activities to calm and organise all our systems (also
see self-regulation section) For example if we are having difficulties in our
tactile sense we use proprioceptive activities to override these difficulties. E.g.
when we bump into something and hurt ourselves we automatically rub it
better. This is utilising the proprioceptive system (rubbing uses deep
muscles) to inhibit the tactile response (pain to area bumped).

Under Responsive – consider any activity that causes

muscles to repetitively stretch, bend, move, put extra
weight through, activities that are hard work or resistive.
Can include, but not limited to:
• Jumping on a trampoline
• Pillow fights
• Playing tug of war
• Animal walks – crab walk, bear walk, duck walk,
kangaroo jumps
• Chair push ups - Place palms on each side of the seat, push down and lift
your bottom off chair. Hold position for as long as you can; make sure feet
are off the floor, as this means you will put more weight through your arms.
• Wall pushes - Stand arms length away from the wall, with hands at shoulder
height, keep back and legs straight and bend your arms to do push ups
• Floor push-ups
• Rolling games e.g. Roll the child up tightly in a
blanket or rug leaving their face exposed
• Any leisure / sports activities such as
swimming, climbing, ball games, crawling
through tunnels
• Wheelbarrow walks
• Carry a backpack with a bit of weight in (no more than 10% of child’s body
weight)
• Wear leg weights during P.E or when walking to and from school (no more
than 10% of child’s body weight)
• Massage – using firm pressure touch on arms, legs, palms of hands and
feet
• Use lap pads (or wheat bags) for increased
proprioceptive input when seated
• During school allow for regular movement
breaks
• Playdough or theraputty use – can be used to
warm up the hands ready for handwriting
tasks
• Allocate the child jobs to provide movement breaks, e.g. library book
collector/monitor, taking messages to the office
• Try tying theraband around the legs of a chair for child to push legs against
for resistance

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• Pull theraband/resistive bands and hold for 10 seconds
• Fidget toys
• Helping to re-arrange furniture (supervised)
• Hand out heavy books in class
• If using too much pressure when handwriting try
placing work on a surface that gives more sensory
feedback e.g. bubble wrap, Dycem mat (if the
child presses on too hard he will go through the paper and therefore learns
how much pressure to apply), on a pad of paper etc.
• See oral motor section on page 22 for proprioceptive activities involving the
mouth

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Vestibular - movement sense
The vestibular system is located in our inner ear. It is a movement-detection
system that consists of gravity receptors to inform us about movement of our
head and body against gravity.

It helps us understand the position of our head and body in space and gives
us information about which way is up and where we are going. It helps us with
balance, spatial orientation, and maintaining a stable visual image, even when
we are in motion.

The information from the vestibular sense also passes through an area of the
brain that impacts on our attention and arousal level (sleep/wake cycles).

Since movement is a part of everything we do, the vestibular system is

important for all of our interactions with the sensory world (Kawar, M. J. et al).
The vestibular system is a major organiser of sensory input and is considered
to be an influential sensory system and has tremendous impact on a child’s
ability to function daily.

What might an under responsive What might an over responsive

vestibular system look like? vestibular system look like?

• Excessive movement and • Avoids movement and

difficulty sitting still playground equipment
• Excessive spinning or • Gets car/ travel sick easily
watching things spin • Poor balance (static or when
• Inability to sustain listening moving with fear of moving)
without moving the body • Excessive emotional response
• Difficulty maintaining attention with movement e.g. when lifted
• Often oblivious to safety up child screams or cries
concerns • Difficulty walking on uneven
• Doesn’t get dizzy with spinning surfaces
• Poor balance (static or when • Difficulty scanning and reading
moving with no fear of • Very cautious and hesitant with
movement) movement
• Trouble walking on uneven • Poor eye hand coordination
surfaces (with no fear of • Dislikes head tilting backwards
movement) • Avoids sports
• Difficulty reading and scanning • Always holds rails or furniture,
• Poor eye hand coordination especially when coming down
stairs
• May manipulate their
environment or other people to
avoid vestibular input

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Some vestibular difficulties may fit into either category e.g. poor balance,
difficulty walking on uneven surfaces, poor hand eye coordination etc.

A child with an over responsive vestibular system is likely to resist input and
will have high levels of anxiety or fear in response to movement. They may
have excessive emotional reactions, even when there is no danger of falling.

A child who is under responsive to vestibular input will often enjoy

movement and seek it out but may be uncoordinated.

Vestibular strategies:
When working with a child with vestibular difficulties you need to be careful to
monitor all input. It is important to discourage spinning as this can be very
disorganising.

Vestibular work should be followed by a calm proprioceptive activity to assist

with organisation and correct level of self- regulation.

If you feel the child has anxiety and fear in relation to movement please make
a referral to occupational therapy. Within the referral provide details and
examples of the child’s anxiety/fear in relation to movement.

If Under Responsive If Over Responsive

Consider activities which challenge • Use a firm supportive seat that will
the centre of gravity and cause the not tip, to help the child feel stable
head to move out of alignment. Can and secure whilst sat at their desk.
include, but not limited to: Make sure their feet stay flat on
• Jumping on a trampoline the ground
• Hopping, skipping and running
• Tumbling and gymnastics • Make allowances in PE, e.g.
• Animal walks – crab walk, bear reduce the amount of vestibular
walk, duck walk, kangaroo activity, i.e. forwards roll or
jumps activities where the feet are off the
• Monkey bars, climbing frames, ground etc.
spinning wheels, slides
• Yoga or Pilates • Allow the child to be at the front or
• Using a therapy/exercise ball back of the line when negotiating
(bounce stairs
on/roll over
etc.) • When ascending and descending
• Boxing stairs, allow child to use the
• Wheelbarrow handrail
walks
• Allow child to leave class 5
minutes early to avoid busy
corridors
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 • During school, allow for regular • Gentle activities incorporating
movement vestibular input e.g. row row row
breaks your boat, rocking in a rocking
chair etc.
• Swings, both
indoor and
outdoor

• Use a ‘move
and sit’
cushion

Tactile system - touch

Our skin is our largest most sensitive organ; it has different receptors that give
more detail about what the skin is feeling.

The tactile system registers light touch, pain and temperature and serves to
protect us. It acts as an alarm informing us of danger. Our body has a fight or
flight response and the tactile system uses this to protect the body e.g. an
insect lands on our arm we automatically brush it off to prevent it from stinging
or biting. Our bodies respond to danger in one of three ways

1 = Fight – we stand and fight the danger

2 = Flight – we run from danger
3 = Fright - we freeze in response to the danger.

If the body misinterprets tactile information the person is often in a fight or

flight state and therefore it takes very little to evoke a reaction.

Other receptors in our tactile system are pressure touch known as

discriminative touch.

Through touch we gain information about where and how our bodies are
positioned. We get information about objects and our environment that allows
us to develop refined fine motor skills.

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The tactile system helps with motor planning, body awareness, self regulation
(the ability to achieve an optimal state of alertness in order to achieve the task
in hand), and it helps us form relationships and emotions e.g. giving hugs.

What might an under responsive What might an over responsive

tactile system look like? tactile system look like?

• Child isn’t aware of touch e.g. • Child avoids messy play or

when you brush past them wants to wash hands
they do not acknowledge this. immediately after
• Child leaves clothes twisted on • Child avoids contact with other
their bodies children, e.g. stays on the
• Child has messy face and outskirts
hands and doesn’t seem to • Child is
notice irritated by
certain
types of
clothes,
labels and
seams in
clothes and may avoid wearing
them
• Child avoids crowded
environments such as
playtime, assemblies or lining
up, or these times are when
the child gets into more
• Child constantly touches things trouble.
within their environment • Child avoids going barefoot
• Child dislikes daily living
activities such as having hair
washed, cut and brushed,
brushing teeth

The over responsive child may react

with whining, clinging (fright), lashing
out (fight) and running away (flight).

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Tactile strategies
Sensory information travels to the central nervous
system on one of two pathways. Proprioception and
tactile input use different pathways and the route
proprioception travels can override (cut off) the tactile
system.

If Under Responsive If Over Responsive

• Encourage the child to • Use proprioceptive activities –

experience as many tactile see proprioceptive section on
experiences as possible e.g. page 8 especially before and
- Messy play – sand, after activities with a tactile
water, finger paint, element
shaving foam, jelly, • Allow child to stand at the front
slime, mud box or end of line to avoid being
- Use different textures – bumped into or brushed past
lentils, rice, seeds, • Arrange seating in classroom to
beans, pasta, cotton avoid risk of being bumped by
fellow class mates
wool, sand paper
• Consider tactile element to
- Feely box – make a box
activity and where possible
with different objects
modify, e.g. when painting or
inside and use hands to using playdough, allow use of
identify objects (start tools and/ or wearing gloves or
with objects with allow child to wash their hands if
different shapes and requested
textures and then try • Avoid light touch – use firm
objects with similar pressure when touching the child
shapes and textures). and always approach from the
- Playdough / Theraputty front
– pinch, roll, squeeze, • If touch is necessary give the
pull, find objects hidden child prior warning
inside • Allow child to leave the
classroom a couple minutes
early for transitions to avoid busy
environments

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Vision
There are different aspects of our visual system.

1. Our eye movements

- The movements of our eyes are controlled by muscles, these allow
us to follow a moving object with our eyes, fix on an object, scan a
page of writing and focus our eyes on one object then move to
another and refocus quickly.

2. Visual processing
- The brain selects and responds appropriately to visual input. It
processes information that enables us to evaluate the environment
and recognize similarities and differences between object forms,
sizes and positions.

What might an under responsive What might an over responsive

visual system look like? visual system look like?

• Likes to • Prefers to be in the dark

watch • Becomes frustrated when
things like trying to find objects in
the competing backgrounds or
washing messy environments
machine • Express discomfort/avoids
or toy cars bright lights – struggles with
wheels change in lighting in different
spin environments
(excessively)
• Spins objects
• Stares intently at people or
objects
• Blinks a lot
• Scrunches eyes up
• Squints
• Child brings things very
close to their eyes • Takes longer to adjust to lights
• Child looks out of the and change in lights
corner of their eyes • Complains of headaches,
frequently rubbing eyes or squinting
• Child struggles to cease (where medical reasons have
noticing the pictures or been ruled out)
people in the room
The over responsive child may react
with whining, clinging (fright), lashing
out (fight) and running away (flight).

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Visual strategies
Prior to completing these activities ensure vision has been assessed to rule
out any underlying visual problems which may be contributing to the child’s
difficulties.

If Under Responsive If Over Responsive

• Dot to dots, mazes, word • Use proprioceptive activities –

searches, Where’s Wally, find see on page 8 to help calm an
it books, colour by numbers overly alert sensory system
• Where possible reduce visual
distractions or have a
designated area for child to
work in with reduced visual
stimuli
• Position child near the front of
the classroom preferably not
facing the window
• Create an individual
workstation with built up sides
• Place work on a bright piece of – a pop up visual screen
paper to draw attention to task • Clearly display/highlight
• Clearly display/highlight important information in the
important information in the same place e.g. when working
same place e.g. when working have date and time in same
have date and time in same spot on wipe board
spot on wipe board • Consider the lighting in the
classroom
• Wear sunglasses and a hat
when outside

• Use neutral colours

For children with suspected difficulties with vision check they have had their
vision tested recently.

For children with suspected difficulties with eye movements please make a
referral to ophthalmology.

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Auditory system - hearing
Auditory processing refers to how the brain recognises and makes sense of
sounds. Sound consists of loudness, pitch, how long it lasts for and where it
is coming from.

What might an under responsive What might an over responsive

auditory system look like? auditory system look like?

• Makes noise for noise sake • Places hands over ears in

e.g. sings, taps response to noise e.g. when
• Talks in a loud voice the bell rings, when the hoover
• Appears not to hear what you is on, hand dryers
say but you know their hearing • Responds negatively to
is good unexplained noise
• May hum to themselves • Overly reacts to sound that
others barely notice
• Can’t stop noticing the noise of
the fan, air con, lights buzzing
etc which interferes with
participation in tasks

The over responsive child may react

with whining, clinging (fright), lashing
out (fight) and running away (flight).

For children with suspected difficulties with auditory input (hearing) check they
have had their hearing tested recently.

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Auditory strategies
Prior to completing these activities ensure hearing has been assessed to rule
out any underlying auditory problems which may be contributing to their
difficulties. Please note children with underlying auditory conditions i.e. glue
ear/ cochlear implants etc. may display sensory behaviours.

Under Over

• Make sure the child is • Use proprioceptive activities –

facing you when giving see proprioceptive section on
instructions page 8 to help calm an overly
alert sensory system
• Respect their sensitivity it really
does hurt!
• Try to forewarn the child of any
loud noises before they occur
• Minimise auditory distractions
e.g. use a rug in a classroom to
• Give simple instructions – reduce excess noise
don’t use too many words • Consider ear defenders or ear
plugs
or use visual cues
• Allow child to work in a quieter
alongside
environment for activities that
• Speak loudly and clearly
require prolonged focused
• Simplify instructions and attention
ask the child to repeat the • At lunchtime allow the child to
instructions back to you eat in a quieter room if required
• Wait for the child to • During assembly allow the child
process and respond to to sit at the end of the line to
auditory information – minimise noise. Allow them to
remember this may take go in first and the noise to build
them longer around them
• Get the child to focus on • Consider quieter spaces on the
the task in hand playground for the child to
socialise or take part in quieter
activities
• Allow child to leave classroom a
couple minutes early for
transitions to avoid noisy
environments
• Use visual cues to support
auditory instructions and
minimise the number of
instructions given

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Olfactory system – smell / Gustatory
System - taste
Smell is often our first response to stimuli, it alerts us to fire before we see the
flames

Smell is a chemical sense, when a smell is detected it passes on electrical

impulses to the brain which interprets its odour.
Smell passes through the limbic system in the brain which is vital to our
behaviour, mood and memory. Smell can often trigger memories good or bad.
Smell is closely linked to our sense of taste; think about how bland food tastes
when we have a cold.

The taste system with smell indicates whether food should be eaten. Taste
buds interpret the identity concentration and pleasant/unpleasant quality of
the substance. This information also prepares the gastrointestinal system to
receive food by causing salivation and swallowing (or gagging and
regurgitation if the substance is noxious)

What might an under responsive What might an over responsive

smell / taste system look like? smell system look like?

• Child likes to smell objects • Child becomes distracted by a

(food and non food) smell and cant refocus on task

• Child gags or has an aversive

• Likes spicy/sour foods response to smells / tastes
• Adds extra flavour to foods i.e. • Child comments on smells
extra salt, pepper, ketchup other people may not notice
• Child may struggle at
dinnertime or in restaurants
due to strong or complex smell
of foods
• Dislikes foods with flavour e.g.
prefer bland foods
• Child dislikes food with
different texture/consistencies
e.g. pasta with sauce
The over responsive child may react
with whining, clinging (fright), lashing
out (fight) and running away (flight).

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Olfactory/gustatory strategies
If Under Responsive If Over Responsive

• Encourage the child to have as • Use proprioceptive activities –

many smell experiences as see proprioceptive section on
possible e.g. page 8 to help calm an overly
- Scratch and sniff alert sensory system
stickers • Allow child to have their
- Aromatherapy oils favourite scent or object that
- Scented felt tips they like the smell of to block
- Scented candles out the offensive smell e.g.
sweat band with aromatherapy
• Encourage the child to try a oil or mums perfume on
variety of tastes e.g. spicy, • Try scented candles for home
sour, zingy and school
• Be considerate of taste
requirements – never force a
child to eat something they feel
uncomfortable doing

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Oral motor
Oral motor control is important for many activities such as managing
secretions (saliva), speech, feeding etc. The face, mouth and tongue are
made of many small muscles. The first thing a baby has to learn to do is suck,
swallow and breathe.

As we develop the mouth is crucial in exploring and learning about the

environment. From an early age babies explore their environment by taking
things to their mouth. This is a normal developmental stage, as a child gets
older they no longer need their mouth to explore as they start to use their
hands to interact with their environment.

Oral motor can also be used in self- regulation (see self-regulation section for
further information) and to enable us to calm or increase our levels of
alertness e.g. by sucking or chewing.

What might an under responsive What might an over responsive

oral motor system look like? oral motor system look like?

• Child puts non-food objects in • Child dislikes having their teeth

mouth to chew and suck cleaned
• Chews on clothing • Child is picker eater
• Child gags easily
• Child refuses to participate in
any food based activity

• Child over fills mouth when

eating
• Child puts food too far back in
their mouth
• Child dribbles/spits

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Oral motor strategies
If Under Responsive If Over Responsive

• Dots around the outside of • Use activities for under

the mouth – using your index responsive as these use the
finger press firmly on a spot proprioceptive system and help
around the mouth then take reduce sensitivities.
your finger off and repeat
further along until you have • Be considerate to child’s
gone all around the mouth. dislikes – don’t force them to
Repeat three times eat things or participate in food
• Facial massage – Use firm based activities
pressure to massage the
cheeks in small circular
movements. Repeat three
times
• Bite and tug – Bite on a
chewy tube or piece of
theratubing on the back molars
and pull, repeat ten times then
repeat on opposite side.
• Wake the mouth up – Use a
vibrating / electric toothbrush
and brush across the tongue.
Move the back of the vibrating
toothbrush along the outside of
the cheeks.
• Blowing – Blow toys may help
to increase oral-muscle-tone
and awareness of the mouth.
Toys that help include:
harmonicas, blowing bubbles,
pin wheels, hooters, balloons,
ball blowers, whistles, blow
pens. Other games include:
blowing through a straw in the
bath into soapy water to make
bubbles, blowing a ping-pong
ball through a straw around an
obstacle course etc.

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 • Sucking – Use activities that
use suck e.g. suck up cotton
wool balls or smarties using a
straw
• Cheek exercises
o Put lips together and
puff cheeks out. Hold
for 10 seconds whilst
breathing in and out of
the nose
o Puff one cheek out then
the other
o Use the tongue to push
the cheek out
• Chewing 2/3 pieces of chewing
gum at the same time
• Eat crunchy or chewy foods
• Try spicy or strong flavoured
foods ie, pickled monster
munch, chutney, pickles

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Alertness / self-regulation
Alertness can be considered a state of the nervous system describing how
alert we feel. To attend, concentrate, and perform tasks in a manner suitable
to the situational demands our nervous system must be in an optimal state of
alertness for that particular task (Mercer and Snell 1977).

“How does your engine run? The Alert Programme for Self-Regulation”
(Williams and Shellenberger, 1992 & 1994) uses the principles of sensory
integration and involves matching cognitive awareness with sensory
experience.

Although initially designed for children 8-12 years, the Alert Programme has
been adapted for preschool through to high school and even adults.

The Alert programme is designed to improve awareness of self-regulation

through the use of charts and activities. Adults guide children to recognise
the way in which sensory modulation disorder affects alertness and help them
to learn strategies to change their levels of alertness or arousal.

The Alert programme helps children realise that their “engines” (i.e. nervous
system) need the proper amount and kind of sensory information to function
optimally. It increases the child’s collection of strategies for changing levels of
alertness.

The goal of the programme is not only to teach children how to get their
“engines to run just right” and remain there throughout the day but also how to
change their level of alertness to meet situational demands (Shellenberger
and Williams 2002).

Children and adults can together determine the strategies that support optimal
functioning. In cases where children are too young to use the programmes
concepts parents and teachers become the detectives identifying and
providing the type of sensorimotor input that best supports the child’s self-
regulation and performance. We can use these principles with children who
struggle to self-regulate for example have difficulty sitting on the carpet or
fidget in their chairs or seem switched off. We can use our activities within
our sensory diet (see sensory diet section on page 30) to change our levels of
alertness

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What do our “engine” levels look like?
When my engine is too When my engine is When my engine is too
low just right high

• Talks slowly and • Uses his/her “just • Speaks with a

quietly. right voice” to talk. loud voice.
Not too loud and not
• Is too tired to too soft. • Has a hard time
listen to his/her listening to
teacher • Listens to his/her his/her teacher
teacher and follows because his mind
• Is too tired to do her directions is racing
his/her work. because his/her
body is “just right.” • Has a hard time
doing his/her
• Gets his/her work work because
done because his/her body is
his/her body is “just moving too fast.
right.”
• Is always moving.
• Plays the same
• Moves slowly. game with his/her • Body and mind is
friends and talks moving fast when
• Is too tired to play about the same he/her plays with
with his/her things his/her friends his/her friends.
friends. are talking about. Others or
himself/herself
may get hurt.

We typically learn to self-regulate on our own. For example, have you ever
been sitting in a class or meeting, and realise that you are daydreaming or
getting sleepy. As adults, to self-regulate, we simply begin to bounce our leg
up and down, click the top of our pen, or pop in a piece of chewing gum.
Soon we find ourselves paying attention. That is an example of our car
engine running “Too Low” and naturally bringing it to “Just Right”.

Another example, you are getting ready to leave for a 5-day holiday to Spain.
You have to get through your last full day of work. You are so excited that
you find it really hard to pay attention and concentrate. You find yourself
doing breathing exercises, stretches, or drinking a warm cup of tea, so you
are able to calm down and concentrate to get your work done. That is an
example of your car engine being “Too High” and naturally bringing it to “Just
Right”

The following are some examples of activities to help a person achieve a calm
alert state.

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It is important to note that although most children respond in a calming or
alerting manner to the activities listed below, some children may have an
opposite response. Therefore, it is important to monitor a child’s response to
make sure it is the type desired. For example, chewing gum and sucking on
hard sweets may be alerting to some children but calming to others, active
play can be calming for some children but for others this is stimulating. For
children who fluctuate between high and low levels of alertness refer to the
multi-effect modulation technique section in the table below.

Calming Techniques Multi – Effect Alerting Techniques

(for children in a high Modulation (for children in a low
engine level) Techniques engine level)
(for children
fluctuating between
high and low engine
levels)

• Use low level lighting • Give the child a • Give the child cold or
or dim the lights bear hug in order to iced water in a water
provide deep bottle
• Encourage the child pressure touch
to listen to quiet (Krauss, 1987)
music or stories with
headphones • Provide
proprioceptive
• Use a soft voice and inputs by placing • Use bright lighting
slow down your your hands on the
movements and your child’s shoulders • Have the child pat
speech when he or she is cool water on his or
• Provide a quiet seated and push her face
hidden corner to down
• Take frequent breaks
work or play in • Teach the child to during more difficult
• Provide a rocking self- modulate by tasks (march, hop,
chair or bean bag to placing both hands skip, jump, run in
sit in on top of head and place, do 10 sit ups)
push down with
• Play loud, fast paced
slow counting
music before doing a
• Have the child push lesson or homework
hard on the wall, do
• Encourage an active
wall push ups on a
break time or outside
desk or table top
playing time with
• Provide the child swinging, running,
with pushing, sliding and climbing
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• Suggest that the pulling, carrying and • Have a mini
child use a lap pad lifting activities with trampoline available
less body in the classroom or
• Avoid rushing or movements P.E hall.
hurrying the child as
much as possible – • Allow the child to
plan ahead manipulate hand
fidgets or squeeze a
• Have chewy food small, hand held
available – liquorice, pliable ball
fruit roll ups, raisins,
carrots, celery. • Have squeezing
and stretching
• Have crunchy food objects available
available – dry such as theraband,
cereal, crisps, trail theratubing, koosh
mix balls, theraputty,
play doh, clay and
hand fidgets

• Allow the child to

chew sugar free
gum or suck on
sugar free hard
sweets
• Allow bubble blowing
during break time • Allow the child to sit
on a therapy ball or
move ‘n’ sit cushion
while doing his or
her school work
(Schilling et al
2003)

If you notice during break time a child is spinning a lot and after break then
struggles to sit and complete work you may introduce a different sensory
experience to better prepare their body for work.

Below is an example of a chart that can be used in the classroom on the

child’s desk to help them indicate where their engine levels are at any given
time. If it helps the child could identify their own pictures to illustrate their
engine levels (‘too high’; ‘just right’; ‘too low’) instead of the colours shown
below.

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The box opposite can be filled with activities which you and the child have
identified help change their engine level. Initially you can help the child label
their engine speed and then use the activities to change it. The ultimate goal
is for the child to start to do this independently (e.g. to recognise their own
engine speed and know what activity they need to do to achieve a calm-alert
state).

How’s My Engine?

Things I can do in my seat when my engine Too High

• Squeeze hands together (push or pull)

Too High • Chair push-ups (Put hands on seat and use arm muscles to
push you up)
• Take 3 deep breaths
• Stretch your arms and legs

Just
Right

Things I can do in my seat when my engine Too Low

Too low • Blowing bubbles/ whistles

• Movement break – star jumps
• Have a drink of iced water

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 Sensory diet/snacks
A sensory diet is an individualised program that is practical, carefully
scheduled and based on the concepts that controlled sensory input can affect
functional abilities. The specific sensory diet will vary according to an
individual’s goals, preferences, resources and limitations (Wilbarger 1984).

The goals of a sensory diet are to reduce or eliminate sensory behaviours,

promote an optimal level of alertness and organise a child’s sensory system
to allow better engagement with his/her environment.

When planning a sensory diet consider:

• What are you trying to achieve (GOALS)
• Structure and routine (times of day, frequency, duration)
• Consistency
• How to incorporate activities into daily life

Sensory diets need to be done consistently every day at home and school for
maximum affect, therefore good liaison between home and school is vital for
its success. The frequency of activities will depend on the needs of each child.
Discussing what works in different environments will help to get the best
effects from your sensory diet e.g. How much space is there in the home?
What can be done if the weather is poor? Could activities be completed at the
child’s desk?

Ongoing communication between home and school is needed to review and

adjust to ensure success.

Sensory diet example

Time of Sensory activity Duration
day
7am Put bright light on / warm up light (VISION) 5 minutes
Big bear hugs when getting out of bed
(TACTILE/PROPRIOCEPTION)
Breakfast – something crunchy, chewy or sour
(ORAL MOTOR/TASTE)
8am Trampoline or jumping and crashing on the sofa. 10- 15 minutes
Big squashes with a therapy ball/ pillow
(VESTIBULAR/PROPRIOCEPTION)

10.00 Use proprioceptive work such as: 10-15 minutes

- Wheelbarrow walks
- Row your boat
- Rolling over a big ball
- Obstacle course

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 Try some vestibular activities as well including:
- Swings
- Hot dog rolling (roll Child up in a blanket and
squish with some pillows. He is the hot dog in
the bun). Ensure face is not covered.
11.00 - Chair push ups 10-15 minutes
- Wall push ups
- Movement break

11.30 Oral motor work including: 15 minutes

- Bite and tug activities with a chewy tube
- Blowing out a candle Oral work is used as it is a
- Drinking through a straw fantastic way for Child to
self-regulate.
Some proprioceptive input such as:
- Row your boat pulls
- Weighted back pack
- Moving furniture
- Digging in the garden etc.
1pm More proprioceptive work: 15 minutes
- Animal walks
1. crab walk Ensure the animal walks
2. bear walk are done in a slow and
3. frog jump calm manner so as not to
4. commando crawl over- arouse.

- Jumping on the trampoline This will help to improve

- Running around outside shoulder stability and
- Climbing on climbing frames muscle tone
- More bite and tug activities with the chewy
tube

2.30pm Oral motor work: 20 minutes

- Blowing bubbles in a cup using water and a
straw. These are called ‘bubble monsters’
- Blowing steam on a mirror
- Blowing suds off his/her hands
- Bite and tug activities with chewy tube

4pm Proprioceptive and vestibular work such as: 10- 15 minutes

- Cuddle Swings or regular swings
- Jumping on the trampoline
- Having a crunchy or chewy snack
- Drinking liquids through straws
- Bite and tug with chewy tube
- Crashing on a big pile of pillow
- Hot dog rolling
- Rocking horse

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5.30pm Bath time: 10 minutes
- Having cups to pour water in and out
- Blowing bath bubbles of his hands
- Giving firm wash with a sponge
- Firm rub down with towel after the bath
- Massage with firm touch

7pm - Quiet music (AUDITORY) 10 minutes

- Aromatherapy oils e.g lavender (SMELL) **Note activities before bed
- Gentle but firm massage should be non alerting
- Big bear hugs therefore no spinning, play
- Teddy/comfort toy to snuggle into (TACTILE) fighting etc.
- Reduce lighting (VISION)

Remember, siblings and other class members can join in with these activities
too. We can use activities that include sensory experiences for all the senses
(see relevant sections)

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Sensory dysfunction examples
• Child uses too much force or intensity when using pencils or
during play.

What could this mean?

Child is not getting enough feedback through the proprioceptive system and is
therefore is unable to detect or sense the amount of pressure he/she is
applying.

Ideas to help:
Implement a good sensory diet that includes activities which use the
proprioceptive system (see proprioceptive system on page 8).

• Child has difficulty at circle time

What could this mean?

Circle time not only involves the child being required to sit still; there are
unpredictable bumps and brushes against the skin from others, a child talking
too loud next to them, and the demands of following instructions and possibly
having attention drawn to the child during a circle time activity. Prior to circle
time, have the child engage in heavy hard work activity.

Ideas to help:
Provide a fidget toy, use a lap pad and weighted blanket or provide a chewy
tube. Prior to circle time, have the child engage in heavy hard work activity
(proprioception).
Have a designated space for a child to sit e.g. carpet square or hoop. Sit
child at end of the line or front or back so they are not surrounded by other
children.

• Child appears switched off in lessons

What could this mean?

Child may have low levels of alertness at various times of the day impacting
on his/her ability to focus during classroom activities.

Ideas to help:
Introduce sensory diet to increase levels of alertness. Teach child (where
appropriate) levels of alertness and ways to change their engine level
independently. See sensory diet section on page 30 and alertness section on
page 25.

• Child puts non food objects in their mouth frequently

What could this mean?

Child is seeking extra sensory input through their mouth. This could be a
strategy used to help them self regulate or manage anxieties in the
classroom.
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Ideas to help:

Encourage regular crunchy snacks throughout the day.

Allow child to chew on more appropriate items e.g. chewy chews, chewelry,
chewy gems, chewing gum.

Complete oral motor activities such as blowing (bubbles, whistles,

harmonicas) and sucking as part of a sensory diet. See oral motor section on
page 22.

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Example sheet for recording what has been tried and whether it was useful

Record of Strategies Tried and Progress

(To be completed by the staff member working with the child)
Please also attach a copy of your sensory diet that has been used in school, ensuring it details activities used, times and duration.

Pupils Name__________________ Class_______________

TA’s Name____________________ Hours per week______

Date Activity / strategy Areas targeted within Summary Staff

sensory system
Daily X engages in Oral Motor Reduce oral motor seeking Continues to mouth pencil topper during classroom activity ST
7-21 Sept games 5-10 min per day behaviour Reduced incidences of mouthing other objects
Provision of chewy pencil Unable to blow consistently / grade force
topper
Daily X engages in 5min Increase body awareness and X is now able to sit nicely and listen to teacher during carpet time using ST
7-21 Sept proprioceptive activity force grading move ‘n’ sit cushion
before school, at break, at Reduced fidgeting X is now able to throw a ball back and forth with appropriate force
lunch and before end of Manage arousal levels grading
school
Use move ‘n’ sit cushion
Daily Movement breaks added Manage arousal levels X is able to concentrate for 5 min but struggles with longer pieces of
7-21 Sept into daily routine work or in a multi sensory environment
Participated in gross motor
group with proprioceptive
activities twice a week for
30min wearing 0.5kg leg
weights
st
Daily Access to quiet Manage arousal levels X accessed quiet room 3 times from 21sept – 21 Oct when over
21 Sept environment to complete stimulated but needed adult direction to initiate.
onwards targeted work or when over Completed oral motor strategies in quiet place to reduce over
stimulated stimulation to good effect.

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Sensory Processing Dysfunction: Record of Strategies Tried and Progress
(To be completed by the staff member working with the child)
Please also attach a copy of your sensory diet that has been used in school, ensuring it details activities used, times and duration.

Pupils Name__________________ Class_______________

TA’s Name____________________ Hours per week______

Date Activity / strategy Areas targeted within Summary Staff

sensory system

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References
Ayres, A.J (1979). Sensory Integration and the Child. Los Angeles: Western Psychological Services.

Ayres, AJ (2005). Sensory Integration and the child: Understanding hidden sensory challenges

Williams, M.S., and Shellenberger, S. (1992). An introduction to “How does your engine run?”. The Alert programme for Self
Regulation. Alberquerque NM: Therapy –Works.

Williams, M.S., and Shellenberger, S. (1994). How does your engine run?. The Alert programme for Self Regulation. Alberquerque
NM: Therapy –Works.

VandenBerg, N.L. (2001). The use of weighted vest to increase on-task behaviour in children with attention difficulties. American
Journal of Occupational Therapy, 55(6), 621-628

Krauss, K.E. (1987). The effects of deep pressure touch on anxiety. American Journal of Occupational Therapy, Vol 4(6), 366-373.

Schilling, D.L., Washington, K., Billingsley, F.F and Deitz, J. (2003). Classroom seating for children with attention deficit
hyperactivity disorder: therapy balls versus hair. American journal of Occupational Therapy, Vol.57(5), 534-541.

Addy, L & Teodorescu, J (1996) Teodorescu Perceptuo-Motor Programme (book 1 and 2), LDA Cambs

Mercer, C. D., & Snell, M.E. (1977). Learning theory in mental retardation: Implication for teaching. Columbus, OH: Charles E.
Merrill Publishing Company.

Kawar, M. J., Frick, S.M. & Frick, R (2005), Astronaut Training: A sound Activated Vestibular- Visual Protocol)

Wibarger, P. (1984). Planning an adequate sensory diet: application of sensory proessing theory during the first year of life. Zero to
three, 5(1).

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Further information and details about equipment suggested
The suppliers listed are only examples if you Google the name of the piece of equipment alternative suppliers can be found and
many of the items can be found on Amazon.

Equipment/ Information Places to buy

Move n’ Sit and Wobble Cushions

www.backinaction.co.uk/move-n-sit

fledglings.org.uk/docs/pdf/brochure

Theraputty
www.sensoryplus.co.uk

www.nrs-uk.co.uk

fledglings.org.uk/docs/pdf/brochure
Theratubing www.thera-bands.co.uk

www.rompa.com

Theraband www.thera-bands.co.uk

www.thera-bands.co.uk

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Chewy tubes / toys
www.sensorydirect.com

fledglings.org.uk/docs/pdf/brochure

Leg weights www.sensorydirect.com

Lap pads / wheat bags www.resourcesforautism.org.uk

Weighted vest www.resourcesforautism.org.uk

(no more than 10 % of child’s
body weight) www.sensorydirect.com

www.rompa.com

Fidget toys
fledglings.org.uk/docs/pdf/brochure

www.sensorydirect.com

Dycem
www.dycem.com

www.nrs-uk.co.uk

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Suggested Further Reading
Out of Sync Child Carol Stock Kranowitz

Out of Sync Child has fun Carol Stock Kranowitz

Understanding your child’s sensory signals Angie Voss

Your Essential Guide to Understanding Sensory Processing Disorder Angie Voss

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