Sensory Integration Issues
Michelle's birth was preceded by 5 years of parental fertility problems. The mother had a very difficult pregnancy, with 8 months of bed rest, severe morning sickness, and gestational diabetes. At 36 weeks, the mother gave birth to fraternal twin girls, Sarah and Michelle. Due to their prematurity and small size, they were taken to the neonatal intensive care unit (NICU) for observation. Several hours later, the twins were released to the newborn nursery.
Premature babies are at risk for developmental delays and disorders. Areas affected may include auditory processing and language learning; sensory acuity, processing, and integration; neuromuscular control and motor planning; muscle tone; feeding; and learning and cognitive processes.
Children with hearing loss are at risk for having concomitant delays and disorders, some of which are easily misdiagnosed. Children with significant developmental issues may also have other learning issues, including auditory processing disorders.
What types of questions should the audiologist ask the parents at the initial meeting with the child and parents? Many parents, particularly first-time parents, often do not know what to expect in a child's development and do not realize that their child has delays and differences other than the hearing loss. The audiologist may be the first professional to consider the fact that other areas of need may exist. The case history should include questions about motor milestones, feeding difficulties, sensory issues including eye contact, sensitivity to touch, social behaviors, and communication.
Sarah passed newborn hearing screening. Michelle's results were reported as inconclusive. She was retested the next day, and results were again inconclusive. Repeat testing 1 week later was also inconclusive. She was referred to her pediatrician to check for fluid in her ears.
Over the course of the first several months of life, Sarah progressed in her development more quickly than Michelle. The mother was referred to Early Childhood Intervention (ECI) for both girls. During the process of the ECI evaluation, Michelle was checked for strabismus and received a barium swallow test due to a suspicion of a delayed swallowing reaction. Her strabismus check came back negative, but it was found that Michelle did have some residual swallowing issues that were expected to resolve as the muscles in her face, neck, and tongue matured.
At 15 months, ECI came to work with both girls, who were described as very cute with no visible stigmata. ECI helped Sarah fine-tune her gross motor skills, while they taught Michelle skills she was not developing on her own. At 17 months, Michelle started to walk. ECI suggested that the family pursue hearing testing follow-up due to the earlier inconclusive hearing test results.
At 1 year 5 months of age, sedated auditory brain stem response (ABR) results confirmed Michelle's suspected hearing loss. The audiologist's report indicated that the ABR results were consistent with a moderate sensorineural loss bilaterally at 500 Hz, 4000 Hz (40 to 50 dB) using synchronous responses to click and tone burst stimuli. Type A tympano-grams showed normal mobility of the tympanic membranes. Auditory steady-state response (ASSR) results were reported to be consistent with ABR findings. Michelle was fitted with Phonak MAX 311 hearing aids (Phonak AG, Stäfa, Switzerland) and established consistent use of the aids. Two months later, aided visual reinforcement audometry (VRA) responses in the sound booth were reportedly in the slight to mild hearing loss range: the following aided results were indicated on the audiogram: 25 dB speech detection threshold (SDT) and responses at 25 dB, 25 dB at 500 Hz, 35 dB at 1000 Hz and 30 dB at 4000 Hz. At 3 years 4 months, ABR, tympanometry, ASSR, and transient-evoked otoacoustic emission (TEOAE) were repeated. All objective results were consistent with previous testing; however, behavioral testing was not successful at that time. Michelle was afraid of the VRA animals and did not condition to the conditioned play audiometry (CPA) task. When Michelle was 3 years 4 months, the auditory-verbal therapist requested ear-specific soundfield testing.
Were appropriate audiological tests performed? Although ABR and ASSR are critical, at age 17 months, behavioral testing should be part of the diagnostic workup. Behavioral testing can provide more complete information not available from electrophysiological testing, including testing at more frequencies and information about the child's ability to attend to auditory stimuli.
Was sufficient audiological information reported? When there is a question about progress, it is critical that audiological testing be performed frequently. Complete behavioral testing, unaided and aided, including speech awareness threshold (SAT) and speech reception threshold (SRT), and speech perception, when possible, should be attempted on a regular basis. If sensory issues precluded using earphones or ear-insert earphones, soundfield testing could be attempted. When children have problems tolerating earphones, it is sometimes possible to desensitize them by doing some vigorous head rubbing, especially over the ears, prior to attempting earphones. Parents can also be asked to work at home with earphones to teach the child to be more comfortable using them.
Were the audiological results interpreted correctly? Initial results suggested a mild to moderate hearing loss rather than a mild hearing loss. If behavioral testing had been included, the degree of hearing loss might have been identified earlier. Multiple audiologists and facilities were involved in this case; fragmented communication among team members can become a barrier to effective audiological management.
Hearing aids were appropriate. However, because Michelle is in school, an FM system should have been recommended. In addition, an FM system could have been evaluated at home to see if a more redundant signal could facilitate auditory attention and auditory memory.
Yes. The child does not adapt well to new situations, persisted in being afraid of the animals used in the VRA procedures, and was not able to condition to auditory stimuli, although nearly 3½ years of age. These results suggest other developmental concerns and should trigger referrals.
When Michelle was 23 months of age, her clinical audiologist referred her for auditory-verbal therapy. Michelle's mother indicated that her daughter was wearing the hearing aids during her waking hours. Parent questioning during the first few visits indicated sensory and developmental delays. When Michelle entered therapy, she was speaking in a limited set of single words such as down, more, yeah, that, bye-bye, no, and uh-oh. Her speech imitation skills were limited. The auditory-verbal therapist demonstrated teaching strategies to the parents to facilitate motor imitation, integration of motor and speech imitation, and the use of functional words. A portion of each session was devoted to parent education in the areas of interpreting an audiogram, speech acoustics, speech and language acquisition, and sensory processing issues as they relate to communication development. Michelle's tactile/sensory defensiveness was evident during therapy activities as she resisted hand-over-hand teaching procedures.
Therapy goals included the expansion of Michelle's cognitive processes involving audition. These included but were not limited to the following: auditory attention, auditory memory, auditory discrimination, auditory sequencing, auditory feedback, recognition of spoken words, comprehension of spoken language, and integration of audition into other senses. Six months into therapy, Michelle was approximating imitation of two-term utterances such as “mama key” and “duck fall down.” At 2½ years of age, she started attending a private preschool for typical children to provide typical models of communication and behavior and to facilitate her interaction in the mainstream.
At 2 years 7 months of age, informal analysis of a language sample suggested a language level of ~2 years. At 3 years of age, Michelle's mother described sensory concerns, including significant problems in toilet training. In addition, Michelle would eat foods only at room temperature, would take a shower in cool water, would not tolerate lotion, was tactilely defensive on the hands and feet, would only tolerate hugs from a few people, was standoffish at school, and at times “acted like a bully.”
The auditory-verbal therapist suggested a referral to the occupational therapist who specialized in sensory processing disorders because these behaviors sometimes have a sensory base.1,2 Michelle was also referred to the team speech-language pathologist to address her feeding issues and oral delays, which were thought to be affecting her speech intelligibility. Over the next year of therapy, Michelle progressed in her acquisition of speech and language.
She was very astute in observing her child; she reported her concerns to the auditory-verbal therapist for her advice and guidance. She was not in denial regarding the delays Michelle had and wanted to do what she could to help her improve in these areas.
By recognizing that there were other issues in Michelle's development, she was able to refer the child for appropriate evaluations, including to a speech-language pathologist who had expertise in feeding disorders and oral/sensory/motor deficits in children.
Her mother indicated that she was becoming very frustrated. The mother was working with Michelle very diligently, yet Michelle was not able to acquire the new vocabulary, concepts such as color words, and other language structures. If Michelle had no other learning difficulties, language development should have been relatively good.
Yes, if Michelle was not receiving sufficient auditory input and was not hearing speech at a sufficiently loud level, or if it was not clear, then we can expect that Michelle would be delayed in speech and language development.
A sensory processing history and the sensory processing profile revealed motor, tactile, oral, feeding, vestibular, and visual differences and delays. The treatment plan focused on normalizing responses to movement activities, improving postural and balance responses, and providing opportunities for controlled vestibular input. Other goals included developing functional fine motor skills such as cutting and assembling puzzles, and visual goals such as visual discrimination and matching.
Michelle was fearful of movement and was insecure in play and playground activities due to her difficulties with balance. She had feeding and toilet-training diffculties and socialization problems, and she could not tolerate warm water, lotion, and hugs.
Michelle is a twin and was born prematurely. She has a moderate sensorineural hearing loss, sensory processing difficulties and sensory integrative disorder, oral/sensory/motor delay, social delay, and language learning difficulties. She has parents who are optimal in their care for her, participate in her therapies, and carry out her multiple home programs.
Michelle has moderate, sensorineural hearing loss bilaterally. To date she has shown no progression of the hearing loss. She wears hearing aids on a consistent basis. She is sensitive to and afraid of some sounds, such as sirens. She has not yet been assessed for FM use.
After 2 years of auditory-verbal therapy, at age 3 years 10 months, Michelle's sentence complexity was increasing and included sentences such as: “I see the bear ears,” “Police car go fast,” “Boy girl go to school bus,” “Doggie go bye bye in the car.” She continues to progress in language learning, but problems persist in learning concepts and other areas of language that require abstraction. She enjoys her preschool, and her teacher has noted marked progress in communication, participation, and socialization.
During the 6-month course of occupational therapy, improvement was noted in her tolerance of movement and increased confidence in gross motor skills. Fine motor tasks such as cutting and puzzle construction improved markedly. Michelle was dismissed from therapy, and a home program was initiated to give her continued opportunities to improve.