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Sensory Integration - Notes from my meeting with Annette Grounds Vision Training Clinic in Colchester, Colchester Hospital University NHS Foundation Trust, Essex - November 2012

These are some notes i took after an inspiring visit with Dr Annette Grounds in November 2012 as i had found out about her work on Mumsnet and was delighted that she worked just down the road at Colchester Hospital. Dr Grounds work is an integrative approach to sensory processing difficulties in children. The Vision Clinic - although 'vision' is in it's name is really an integrated service working with any form of learning difficulty or sensory integration difficulty in children. Referrals come via GPs or Occupational Therapists etc..

Background - Dr Annette Grounds started the clinic from her background in Behavioural Optometry and having a masters degree in Developmental Neuroscience. She expressed concern around the compartmentalisation of disciplines in the NHS such that professionals who work with auditory processes are not integrated with professionals who work with eyes and vision for example. She felt that children are far more effectively handled by an integrated service working around sensory difficulties. 

What does the Vision Clinic work with? The clinic works with children with any form of learning or sensory processing difficulty. Reading and writing difficulties are obvious ones. Balance and coordination problems are common. Auditory problems such as hypersensitivity or hyposensitivity in any sensory area. A lack of integration or interference between different sensory processes (I.e. how vision, balance, and our sense of physical space are linked), Dyspraxia - the ability to sequentially order different movements, Dyslexia, ADHD, and Autism

It seems that regardless of causation, many children struggle with sensory processing difficulties that can deeply affect their confidence, their sense of esteem, their behaviour, how they are perceived by others, their ability to read, write and perform many other tasks important for learning, and how they relate to others and their environment.

My meeting with Annette Grounds was inspiring for me at many levels. Although her clinic is called the Vision Clinic, and her original training was in Behavioural Optometry, she has broadened her approach to include a profound understanding of sensory processing issues occurring within or through the interplay of senses of perception, effecting the lives of children and adults alike. 

Some central messages I took from my visit

  • The importance and potential cost savings of early interventions around sensory processing. Dr Grounds pointed at how children learn to compensate for difficulties in particular senses and how patterns of behaviour can become ingrained. Children for example may compensate with their vision for deficits in their hearing. Sensory processing difficulties compound themselves and become more complex as the child develops. The earlier you catch them the less of a problem they become.
  • Causation of the difficulties is not always the most important thing - I.e. about 60 percent of the children she sees with auditory processing difficulties had hearing infections during the first 6 months of life. This is a very critical period for the development of hearing and thus hearing difficulties (you basically are deaf or partially deaf for a few weeks following the infection) lead to auditory disruption or the compensation from other senses such as vision.
  • Pushing development is a central problem in child learning and development. Government supported programmes that attempt to encourage young reading ages for example work against the natural development process of the child, and can create more problems unless the child is an early developer.
  • All of the senses of perception impact support and influence one another. Thus, for example, it is possible that when we get wax in our ear in later life it can directly affect our sense of where a doorway is in our visual perception. 
  • Many of our sense have 'fast acting' dorsal stream and slow-acting parvacellular system aspects. Many of the sensory disruptions tend to occur in the fast acting sensory processing systems. 
  • Retained reflexes - children sometimes retain reflexes that should have become inhibited by other behaviours. Two commonly retained reflexes are the Moro Reflex and the ATNR reflex - Asymmetrical Tonal. These reflexes are inhibited in most people as a new behaviour becomes dominant, but also we tend to naturally regress to these behaviours when stressed, during depression, anxiety, or in dementia or Alzheimer’s. The retention of these reflexes can make certain developmental or learning processes difficult, such as reading, writing, doing two things simultaneously - multi-tasking, and riding a bike.
  • Working with retained reflexes often involves making the movement of the reflex, bringing it to awareness and then enabling something beyond the reflex to happen. I.e. making movements associated with the Moro Reflex and then doing the opposite. This is like visiting the time of evolution where the development was disrupted, and then through revisiting history (evolutionary) allowing things to move forward. 
  •  Switching-on unoccupied senses or sub-channels. Annette showed me many ways in which it is possible to switch-on an unused sensory ability. I.e. enabling a child to develop their capacity to visualise objects, numbers, letters, the letters of their name 'MARK' and later words and sentences. Or a child may be taken back to a very simple tracking ability to follow an object with their eyes. Then learning to have a simple conversation whilst visually tracking automatically. Many children can't do this. This is needed in order to be able to read and write. For some children this is so difficult that you have to lie them on their back so they don't even have to deal with balance, coordination and gravity and then letting them track a ball on a string.

Auditory aspect

Johansenn auditory integrative training is used by Dr Grounds. Annette explained to me about hearing tests and hearing different frequencies at different decibel levels. She showed that the average test just works on the ability to hear at a particular decibel each different frequency. However the true curve of hearing is a curve with speech occurring in high frequencies. 

The ear has two auditory systems (similar to visual) 1) the slow functioning sustained system which deals with sounds like ???? 2) The fast acting auditory systemm that responds to rapid changes in sound. It is the fast acting  system that is most affected in children with dyspraxia, etc..etc.. These children are fine on acuity checks or hearing checks, but they are unable to deal with the information in background noise (maybe filtering it out). So background noise is experienced as far more dominant, and the higher frequencies of human voice etc.. are not picked up so well. There is also an issue of ear dominance. Speech is in the higher frequencies, and the left and right ears are more sensitive to different parts of speech, and with the ears processing sounds at different speeds there can be a jumbling or muddling up of what is actually heard by the child (a kind of dyslexia of hearing). 

The Johanssen system works on developing and pushing the sensitivity of higher frequencies such that speech is better picked out. It also works on ear dominance and the CDs played to the children have different volumes for left and right or use a beat in the ear side that needs to be accentuated. There are different listening programmes available and based on similar principles but the Johanssen approach is cheaper.

Annette uses checklists to work out different auditory processing difficulties. 

She highlights for schools things to look out for. Teaching them for example to muffle background sounds. No plain walls and the use of thick carpets and curtains to deaden sound. Also using screens to block out sound. 

I spoke to her of a child that had strong difficulties with background sounds and how the mother had pushed him into busy enviornments such as the O2 arena to see if he could deal with it, but he just became overwhelmed. Annette explained how these systems need to be challenged very gently and slowly in a bearable fashion. 

You can say to the parents 'i bet when you played musical statues they were always out first'. Not using their ears but using their eyes.

A major feature is ear infections. -- Not just nurture or nature, but semi-deafness up to 6 weeks with ear infection. You therefore learn to use your eyes, because listening is so hard work. Preferential sensing. Children don't know you are there until they have eye contact. 60% of children who come here have those problems.

Their hearing is fine, but just have to switch their hearing back on. Back to back noise making.

Maths is musical oriented.

Speech needs to be done to certain rhythms.

[The basic principles of these sensory approaches seems to be to reduce the stress on the child's system, to take them to a resourceful place and then to very slowly introduce them to challenge, to switch on unused senses or abilities, and to help them to exercise and develop capacity to interact with different sense experiences. In terms of retained reflexes the approach seems to be to revisit the reflex, actualise it physically and then to move beyond it]

Exercises for children

Listening to targetted signs. Clap in time with beats while watching visual cues. Then do it with shutting the eyes.

So they help them move and march in times with beats and not see them.

Switching on - starting with musical things... get parents to get 6 things that look different and sound different. squeaky duck, castanet, cymbals, penguin, whistle etc.. you go through them and decide what you are calling them. When i make the noise tell me what it is. Associating them. Then facing away with no visual contact. Then target a particular sound. Pick them up one after another and put the target sound every now and then. Keeping listening until they hear the target. Then putting it in later. Then this can lead to sequencing and verbal stuff. Then putting in background noise. making sure the sounds are audible above the background noise. You are gradually building up and building up. 

You can later on do phonetic sounds later on. P B D V F L R W all get confused. Have parents put those sounds in with target sounds.