Sensory Craving: Low-Tech Assistive Tools for Seating Support

(Toolkit Part A)

Positioning / Seating Supports for Students with Sensory Craving Challenges

Sensory Processing and Sensory Craving - General Overviews

Sensory processing disorder (also known as sensory integration dysfunction - SPD) is a condition existing when one or more of the six senses has difficulty integrating with the central nervous system.  Sensory processing disorders can be further classified into three (still) broad categories:  sensory based motor disorders, sensory modulation disorder and sensory discrimination disorders (American Academy of Paediatrics, 2012; Miller, Anzalone, Lane, Cermak, Osten, 2007). The first one, sensory modulation disorder (SMD) pertains to those who over-respond (are over stimulated by his or her environment) or under respond to sensory stimuli or seeking sensory stimulation (Miller & Anzalone et al, 2007).  Subtypes of SMD break further down into being: over responsive, under responsive or those seeking sensory craving. Sufferers in these groups may exhibit fearful or anxious patterns of behaviours, stubborn or negative behaviours, self-absorbed behaviours that are difficult to permeate or creative / actively seeking sensation behaviours (James, Miller, Schaaf, Nielsen & Schoen, 2012).

It is this last mentioned type of SMD, sensory craving, for whom seating supports will be specifically explored further in this toolkit.

Students Who Might Benefit from Positioning  / Seating Supports

Students with sensory craving needs might: fidget, seek out opportunities to climb, “crash” or jump, like to chew or suck on unexpected objects, demonstrate impulsivity and/or seek to make loud, disturbing noises.  (James & Miller, et al, 2012).  Those preferring to fidget excessively, climb, jump and/or be impulsive often benefit from seating supports.  These supports are not designed for restraint (nor should they be prescribed for restraint) but, rather, are intended to re-direct craved movement into opportunities for the facilitation of learning.

Some of these tools – and ones explored in Part B of this toolkit – include “Hokkie” stools, movement balls and wiggle cushions.

How Seating Supports Might Benefit Learning

Compensatory supports for seating are beneficial because they increase the following conditions favourable to learning in sensory craving students:

-increased focus on instruction or on assignments
-self-regulation- students are supported in their decisions or desires to manage their own physicality

-social acceptance- decrease in negative peer interactions due to fidgety students causing distraction or disruption

-self-esteem- personal satisfaction from decreased re-directions by teachers or classmates

-listening- by managing motor movements the brain becomes more ready to absorb information from external sources

-on-task behaviour -all other learners benefit from fewer environmental distractions as there would be to less time taken away teaching time due to "teacher - fidgeter" interactions

Conditions to Support Seating Tools in a Learning Environment

As the tools in Part B of this post are all low-tech and generally low-cost, there is a correlational, low amount of effort require in adopting these items in a classroom learning environment.  While perhaps obvious to the reader, some of necessary conditions include:

-committed budgets to support purchase

-space for tool storage when not in use

-attitudes of acceptance by educators/parents (and students!); an environment of inclusion and openness to differentiation

-willingness to consider benefit of allowing non SPD children to use the tools (even in the short term)

-plan to assess the tool effectiveness on a ongoing, but individual basis

Planning Considerations for Embedded Use of Supports

Upon determining the conditions for adopting low-tech tools are favourable, there must be plans in place prior, for the following considerations:

-knowledge of potential student users and how seating supports would benefit their learning

-reflection upon appropriate environments for use

-“training” for both adult facilitators and child users to understand appropriateness of use and any applicable parameters (time limits, self-access vs. teacher directed, etc.)

-knowledge of goals for use of AT strategies

-inclusion of AT tool as strategy with related IPP goals

-deliberate plan for evaluation and adjustment of use

-multiple, related tools in a given environment for varied access according to potentially varied learner needs and/or teacher expectations

-transportability (who, how, when, why)

Types of Learning Activities Facilitated by Seating Supports

As mentioned, the purpose of seating supports is not intended to completely disallow a child from moving.  This means, then, there could never be a plan for use to encompass a whole school day.  The learning activities or environments where they would most likely be of benefit include:

-“carpet time” / class meetings where whole groups congregate; receiving instructions, brainstorming activities, story times, etc.

-expectations of seat work

-expectations for quiet work (happening anywhere in a classroom, or nearby, setting - Learning Commons, etc.)

-instructional time when all students are expected to listen from their assigned desk areas

-daily lunch and snack times

-whenever gross motor movements might be a distraction to other learners
-research indicates different tools also decreasing obesity and anxiety, other increase written legibility

Part B of this toolkit will explore three - of several dozen - existing products which offer seating support to students who have sensory craving and other issues (ADHD, etc.) resulting in them finding it difficult to attend to learning due to their desire for movement.

Part A References:

American Academy of Paediatrics. (2012). Sensory Integration Therapies for Children With

Developmental and Behavioral Disorders. Paediatrics, 126(6), 1186-1189. Retrieved March 22,

2015, from http://pediatrics.aappublications.org/content/129/6/1186.full.pdf html

James, K., Miller, L., Schaaf, R., Nielsen, D., & Schoen, S. (2011). Phenotypes within sensory modulation dysfunction. Comprehensive Psychiatry, 52(5), 715-724. Retrieved from spdfoundation.net

Miller, L., Anzalone, M., Lane, S., Cermak, S., & Osten, E. (2007). Concept Evolution in Sensory Integration: A Proposed Nosology for Diagnosis. American Journal of Occupational Therapy, 61(2), 135-140. Retrieved March 22, 2015, from spdfoundation.net

(Toolkit Part B)

 AT Tools for Students with SPD: Sensory Craving –

Seating Supports for those who Fidget / Have Difficulty Remaining Seated

Tool #1 Hokki Stool
What it Is / How it fits for SPD Students	The Hokki stool is an ergonomic stool that allows movement - rocking, turning and twisting - whilst still requiring the user to be engaging their core and, thus, their brain.        According to Wingrat and Exner’s 2005 study into the impacts of school furniture on children’s on-task and sitting behaviours, children spend as much as 30% of their day in school and are often seated for long periods of time during this window.   In secondary settings it can be up to 80% of a student’s expected day!   Providing children with suitable furniture leads to better sitting postures, better attention to task and fewer musculoskeletal complaints (Wingrat & Exner, 2005).       As educators (and others) considered the elaborate interplay of brain and body, a seemingly obvious yet theme emerged; movement is essential to learning.   Especially for SPD children, movement awakens and activates many of their mental capacities. Movement integrates and anchors new information and experiences into one's neural networks. (Kuhn & Lewis, 2013).  Hokki stools allow for one's body to remain in a subtle yet constant state of motion, satisfying the need of a sensory craving student to fidget continuously, yet not to a level of distraction others would notice.
Affordances	-available in varying sizes, depending on height of user making it adaptable throughout many grades -lightweight; easily transported -convex base makes it very safe for children -included slip resistant base and seating surface -durable / easy to clean -distributed by multiple companies -endorsed by OTs and STAR Centre (sensory processing disorder foundation) -no teacher or student "training" required (SETT evaluation encouraged but not required for use) -not obvious as a tool of differentiation -multiple users can use the same stool -most qualitative user reviews by teacher indicate high level of support for the stools to meet fidgety students' needs (-"knock off" brand - Kids Core Wobble Stool - at about half the cost would make multiple purchases even more do-able, provided durability/quality held up.)
Constraints	-despite claims of being stackable, this is not very easily done and so storage becomes an issue -pricing for stools starts at about $105 (taxes and shipping, notwithstanding) with the tallest size being around $130; one of the most expensive seating supports currently available -some anecdotal comments indicate certain children (and adults) do not care for the stool / find it effective -as children grow, one (costly) stool may no longer be viable -no back support provided -may only be used by one individual at a time
Necessary school supports	-budget to support having multiple stools -openness by teachers to use (and store) in classrooms -willingness of students to use a chair unlike that of everyone else -common language amongst staff and students about inclusive environments and "fair not always being equal" -plan to evualate effectiveness and abandon tool, if necessary
References	Image:  https://www.kaplanco.com/product/24498P/20-inch-hokki-stool?c=1|FC1024 Kuhn, D., & Lewis, S. (2013). The effect of dynamic seating on classroom behavior for students in a general education classroom. Unpublished Doctoral Dissertation, University of Puget Sound. Wingrat, J., & Exner, C. (2005). The impact of school furniture on fourth grade children's on-task and sitting behavior in the classroom: A pilot study.              Department of Occupational Therapy and Occupational Science, Towson   University.

Tool #2 Balance Disc (Wiggle Cushion)
What it is / How it works  for SPD Students	A "wiggle cushion" is a disc - usually about  35cm in diameter, with raised bumps on one side - to stimulate body parts in contact (or the smooth surface can be used, if preferred).  Discs can be inflated, firmer or softer, using a traditional sports ball pin/pump.        Wiggle cushions provide SPD "sitters" with an unstable surface, requiring them to use more muscles to stay balanced.  This, in turn, promotes focus and (according to some reports) can even reduce anxiety.      Manufacturer claims, and/or those found in online blogs (often written by moms of ADHD children) generally preach the effectiveness of these cushions for increasing on-task behaviour.  There hasn’t been a lot of in-depth disc-cushion research done, to date.  Occupational therapy literature suggested using dynamic seating systems in classrooms as one strategy to improve a student’s sensory modulation and attention (Pfeiffer, Henry, Miller & Witherall, 2008) often in conjunction with already effective movement breaks.  “Providing movement while sitting provides consistent sensory input without the frequent need to get up out of one’s seat” (p. 275) and disc cushions offer this possibility in an unobtrusive manner.  The Pfeiffer, Henry, et al (2008) study into the effectiveness of disc cushions provide preliminary evidence for the disc’s use as an intervention to improve attention in the school setting.  Their results identified an increase in attention while students engaged in sedentary tasks although they recommend additional research with regard to overall results for a larger school population.         A 2011 study by Umeda and Deitz found the seat cushions did not have any impact on in-seat / on-task behaviour for two children with autism spectrum disorder, but this was in comparison to previously finding therapy balls especially effective.  Their limited sample size must also be taken into consideration.  Kuhn and Lewis (2013) hypothesize disc-seating may only benefit children with fewer sensory input needs.  A more comprehensive approach could be considered.
Affordances	-extremely affordable; approximately $15 each -lightweight; very easily transported -durable / easy to clean -distributed by multiple companies -endorsed by OTs and STAR Centre (sensory processing disorder foundation) -no teacher or student "training" required -not obvious as a tool of differentiation -multiple users can use the same stool (although not at the same time) -most qualitative user reviews by parents indicate high level of support for the stools to meet fidgety students' needs
Constraints	-may only be used one individual at a time -some research indicates cushions not providing enough sensory stimulation for some students -varying quality, and thus durability, depending on manufacturer
Necessary school supports	-budget to support having multiple stools -openness by teachers to use (and store) in classrooms -willingness of students to use a tool potentially unlike that of everyone else -common language amongst staff and students about inclusive environments and "fair not always being equal" -plan to evualate effectiveness and abandon tool, if necessary
References	Image: http://www.amazon.com/Isokinetics-Brand-Exercise-Balance-Cushion/dp/B000WQ4Z7Q Pfeiffer, B., Henry, A., Miller, S., & Witherell, S. (2008). Effectiveness of disc 'O' sit cushions on attention to task in second grade students with attention           difficulties. American Journal of Occupational Therapy, 62(3).  274-281. Umeda, C., & Deitz, J. (2011). Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder. American Journal of Occupational Therapy, 65(2), 152-159.

Tool  #3 Therapy / Movement Ball
What it is / How it works for SPD students.	Therapy balls (also sometimes called stability, movement, balance or fit balls) are rubberized, pressure filled balls used often in fitness classes (and schools) today but previously in physical therapy.  Users might sit, lay / balance or support other body parts on the inflated ball, and apply varying degrees of pressure depending on the outcome sought.  The ball itself offers safe resistance.  Developed in the 1960s, for purposes of PT, occupational therapists began using therapy balls with special needs students during the 1980s.   In the early 2000s, Mayo clinic research proved the effectiveness of therapy balls with SPD and ADHD students.  Sitting on a therapy ball decreased their fidgetiness and increased time on task behaviours (Schilling, Washington, Billingsly & Deitz, 2003). Although the first studies were originally designed to examine the use of balls in preventing or reducing obesity rates among users, researchers found the opportunity for children to move around more - while still in a seated position on a ball - allowed them to improve their demonstration of teacher desired behaviours, increase focus and even write more legibly (Schilling, Washington, et al, 2003).  Other positive effects from the Schilling, et al study included increased safety of high movement students who needed to keep one foot on the floor at all times to keep the ball balanced – as opposed to tipping back or over from a four-legged chair.  An explanation of the stability balls’ effectiveness is found in the self-modulation of personal sensory needs by each user in order to maintain optimal levels of arousal.  “A person’s sensory needs continually change as they are affected by interactions with tasks, environments and people”  (Schilling, Washington, et al, 2003, p. 44). Approximately eight years later a related, ADHD study by Alicia Fedewa and Heather Erwin (2011) examined the integration of stability balls in lieu of chairs and found favourable, although anecdotal results.  Teachers reported ADHD students being more attentive, having higher achievement outcomes and being better able to concentrate.  Levels of hyperactivity were decreased and time on task, as well as in-seat (on-ball) compliance increased (Fedewa & Erwin, 2011). Interestingly, they reference Schilling et al’s 2003 study as being a more systematic study than theirs although they confidently summarize the use of stability balls in classrooms as a promising practice and a recommended intervention.
Affordances	-designs include "ball chairs" which have a base - to prevent rolling away -  and castor "feet" -Balance Ball Chairs about $100, general Fit Balls about $20, depending on size -ball available in varying sizes, depending on height of user -lightweight; easily transported -durable / easy to clean -distributed by multiple companies -endorsed by OTs and STAR Centre (sensory processing disorder foundation) -no teacher or student "training" required -not obvious as a tool of differentiation -multiple users can use the same ball -possible decrease in obesity -alleged improvement in legibility of writing
Constraints	-as children grow, a particular ball may no longer be viable -no back support provided -difficult to store when inflated -difficult to manage when not in use (if not a chair on castors or sitting in some sort of guide) -may only be used by one individual at a time -perception of it being a toy and temptation for misuse if not trained in expectations -pressurized and prone to being punctured by other tools commonly found in a classroom -could potentially result in injury if a child fell backwards
Necessary school supports	-budget to support having multiple ball/chairs -openness by teachers to use (and store) in classrooms -willingness of students to use a chair unlike that of everyone else -common language amongst staff and students about inclusive environments and "fair not always being equal" -plan to evualate effectiveness and abandon tool, if necessary
References	Image:  http://www.especialneeds.com/blog/wp-content/uploads/2014/03/Therapy_Ball_Set.jpg Bagatell, N., Mirigliani, G., Patterson, C., Reyes, Y., & Test, L. (2010). Effectiveness of therapy ball chairs on classroom participation in children with autism Spectrum Disorders. American Journal of Occupational Therapy, 64(6).  895- 903. Fedewa, A., & Irwin, H. (2011). Stability balls and students with attention and hyperactivity concerns: Implications for on-task and in-seat behavior.             American Journal of Occupational Therapy, 65(4).  393-399. Schilling, D., Washington, K., Billingsly, F., & Deitz, J. (2003). Classroom Seating for  Children With Attention Deficit Hyperactivity Disorder: Therapy Balls Versus Chairs. American Journal of Occupational Therapy, 57, 534-541.