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Understanding Sensory Integration

Maryann Colby Trott, M.A. with Marci K. Laurel, M.A., CCC-SLP and Susan L. Windeck, OTR/L

(from the book Sensibilities and reprinted here with permission from author Maryann Trott)

Imitation is an aspect of praxis that can be observed early in life. Many early parent-baby games involve imitation. Parents imitate babies’ movements, facial expressions, or vocalizations. Babies then repeat the action that the parents imitated. These first conversations are very important to the development of praxis and also vital to bonding between parents and infants. This infant ability to organize facial expression and body language leads to the later ability to use gesture, facial expression, and so forth. Throughout life, we most clearly communicate what we are feeling through nonverbal means. When babies are not able to process input and organize responses, sensory-motor development is delayed and social-emotional development is often affected.

Another developmental aspect of praxis is ideation. Ideation begins when children are able to base their interactions not only on imitation of others, but also on ideas they have generated and can communicate. Children will usually experiment to see how different things move and how they can move their bodies in relation to those things. They are constantly crawling over or under, swinging, walking, running, or jumping on whatever happens to be available. In order to do these things children must see the possibilities in the environment and organize their motor responses. Children who have problems with praxis do not see their environment in terms of movement possibilities. They often interact in only one way and that one interaction does not improve over time. They may appear to be purposeless, running around or standing in a space rather than exploring the features of that space and challenging their bodies to perform in new ways. Some children are able to imitate but may not be able to generate ideas of their own. While imitating other children during activities they may become confused if the activity changes; they often get stuck with the name “copy cat.

As with many of the aspects of praxis, ideation has a language component. Difficulty with ideation may manifest itself in problems with communicating new ideas. From a relatively early age, children should be able to use communication to respond or answer, to describe or comment, to label, to request or direct, to get attention, and to protest or deny (laurel and Elledge 1985). Children who are unable to generate or communicate new ideas often use only one or two of these types of communication. These children are frequently more likely to relate to adults than to other children since children are less able to understand communication limitations.

Children must also be able to initiate activities. In order to do this, they must have a clear idea of how to begin a certain activity. What appears to be quite simple to us, as adults, may be overwhelmingly complex to children. Many times, children who have trouble with praxis give up on a task before they begin, simply because it appears so complex that they don’t have a clue as to how to begin and may not be able to use language to help them figure it out. Construction is another aspect of developmental praxis. It allows us to put objects together in new and different ways. Children use constructional praxis when they create objects with blocks. This kind of praxis also allows them to organize a play area for different purposes and, therefore, makes an important contribution to the development of language. The ability to build a store or school or have a tea party with the objects available in a room is a precursor to the ability to use abstract thought. Constructional praxis is also important in learning how to organize work spaces, drawers, closets, desks, or lockers. Experienced teachers can often predict which children are likely to have difficulty with certain learning tasks by looking at how those children organize their desks and how well they are able to organize themselves for work. Children who consistently forget to bring books, papers, pencils, and other materials to class may have deficits in constructional praxis.

Feedback is the information we get from proprioception that allows us to refine motor skills. As we repeat tasks, our performance becomes automatic and we know what the correct patterns feel like. If what we are doing doesn’t feel right, we change our performance slightly until it does feel right. Feedback creates a memory of how things are done. That memory can be used again and again in the same or similar situations and can also be changed slightly to fit new situations. Children who do not have adequate feedback may work very hard to learn a new motor act or concept and be unable to remember that information in the next week, day, or even ten minutes.

Feedback and feed-forward work together to help us perform tasks efficiently. Without any conscious awareness, our brains compare what was anticipated to happen (feed-forward) to what actually did happen (feedback). This comparison allows us to self-correct an error quickly. The ability to write or type quickly and efficiently is an example. When you are writing or typing, you know what the next letter should feel like and your fingers quickly and unconsciously move into the correct pattern. When you make an error, feedback and feed-forward cause you to feel the error before you see it.

Our ability to grade motor acts is what allows us to vary the intensity of what we do. Grading allows us to catch balls of different sizes, climb stairs of various heights, and turn the steering wheel of the car just the right amount. Almost everything we do requires some degree of grading. You would use a different intensity of movement to pat a baby to sleep than you would to congratulate a quarterback. Children who have deficits in praxis are unable to make these judgments and may unintentionally hurt their peers. They may gain reputations as bullies simply because they are unable to be gentle.

Timing and sequencing allow us to perform motor acts at the appropriate time and in the correct order. In addition, they help us to string movements together without hesitating or stopping. Timing and sequencing require an ability to perceive correctly and understand how we move in relation to an environment that may or may not be in motion. This ability, in turn, requires accurate information from the vestibular system as well as the ability to follow objects with both eyes. Our ability to sequence is also somewhat dependent on our ability to use language to talk our way through the completion of a task. We are sometimes aware of this process, particularly when we perform a new or difficult task. It is, however, more common that we do it without even being aware of using language to sequence tasks. If you are playing catch and make all the right moves at all the wrong times, the game is not going to be very successful. If you learn all that is required to drive a car but perform the skills in the wrong sequence, you are not likely to pass the driver’s test. If you had to stop every few seconds to figure out the next move, how efficiently could you write?

Motor planning is what allows us to create, use, and combine various skills to perform new, more complex acts. After a new act has been planned and used several times (that is, practiced), it becomes automatic. Even seemingly simple tasks, such as feeding, dressing, and getting from one place to another require motor planning until the skill becomes automatic. Other tasks, such as speaking, writing, riding a bike, or jumping rope are exceedingly complex and require a great deal of motor planning when they are first attempted or, in some cases, whenever a component of the act is new or slightly different. “Perhaps the best way of illustrating the roles of the different aspects of praxis is through an example. Most of us can relate to the experience of learning how to drive a car. Initially, we had to think about the placement of our hands, legs, and feet (imitation, motor planning, feedback, and feed-forward). We had to think about how much pressure to apply and how far to turn the wheel to head in the desired direction. We were probably unable to do anything in a smooth, efficient manner (feedback, feed-forward, grading, timing, sequencing, and motor planning). Most of us had to talk our way through each step, using our language skills to help us figure out how to perform each step (sequencing and motor planning). Eventually, the skill became automatic and we no longer have to think about how to drive a car each time we want to go somewhere. Our legs and arms make the proper responses smoothly and efficiently without our conscious thought.

Many children with sensory processing problems have difficulty with one or more of the components of praxis. Frequently, they have difficulty creating, organizing, or learning new movement patterns or combining those patterns into new sequences. These children appear to be clumsy and accident-prone. They may trip and fall over nothing or over their own feet, and may seem to be constantly running into things. They may also frequently drop things because they are unable to plan adequately or grade the motor patterns required to pick up and carry them. Simple rhythm or other activities, such as jumping rope or catching a ball, require timing and sequencing and may be quite difficult. Even practicing a certain skill a great deal will not always help. Children may not be able to learn how it feels to do some things efficiently. This is referred to as an inability to process feedback and can change from day to day so that children who are able to perform a certain skill one day may not be able to do it the next, no matter how hard they try.

The ability to use language to plan and organize before an activity is a very important part of praxis. Very young children begin pairing movement and words early in their development (Meacham 1979). You may hear young children talking to themselves as they perform certain motor tasks such as going down a slide. At this point their movement and words are not necessarily related to each other. Later, children will use words to describe the outcome of their movement, such as saying “slide down,” after getting to the bottom of the slide. Eventually, children begin to use language to describe their goals and compare these goals to the outcome of the activity. On the slide, you may hear something like “I’m gonna slide down backwards, then turn around … oops!–I didn’t turn around.” Just as children may have difficulty using language because of problems processing information that comes from movement and touch, they may also have difficulty continuing to develop praxis because of problems using language for organization. Children who are unable to use language in the way may have a difficult time “talking themselves through” new or difficult activities.

All of us experience some difficulty in these areas from time to time and, obviously, some of us are better than others in certain skill. We learn to avoid or compensate for the things that we cannot do well. It is, however, important to experience more success than failure and to perform basic skills without having to think about how to do them. For some children the goal of therapy is to improve sensory processing which will, in addition to other strategies, improve praxis. Improved praxis will help to clear the “roadblocks” in the brain and allow children to be better able to perform old skills and learn new skills with confidence and ease.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)