The process of taking in sensory information, organizing this information in the central nervous system, and using the information to function smoothly in daily life. Sensory integration is a continual process: As children become more competent, their sensory integration improves, so that the more children do, the more they can do. Sensory experiences include touch, movement, body awareness, sight, sound, and the pull of gravity; as the brain organizes and interprets this information, it provides a crucial foundation for later, more complex learning and behavior. This critical function of the brain is responsible for producing a composite picture of a child’s existence, so that the child can understand who he is physically, where he is, and what is going on in the environment around him.

For most children, effective sensory integration occurs automatically and unconsciously, without effort, in the course of ordinary childhood activities. But for some children, sensory integration does not develop as efficiently as it should. When the process breaks down, a number of problems in learning, development, or behavior may develop.

The concept of sensory integration comes from a body of work developed by occupational therapist A. Jean Ayres, Ph.D., who was interested in the way in which sensory processing and motor planning disorders interfere with daily life function and learning. This theory has been developed and refined by the research of Dr. Ayres, as well as other occupational and physical therapists. In addition, literature from the fields of neuropsychology, neurology, physiology, child development, and psychology has contributed to theory development and treatment strategies.

Children with sensory integration problems may be bright, but they may have trouble using a pencil, playing with toys, or taking care of personal tasks, such as getting dressed. Some children with this problem are so afraid of movement that ordinary swings, slides, or jungle gyms trigger fear and insecurity. On the other hand, some children whose problems lie at the opposite extreme are uninhibited and overly active, often falling and running headlong into dangerous situations. In each of these cases, a sensory integrative problem may be an underlying factor. Its far-reaching effects can interfere with academic learning, social skills, even self-esteem.

Research clearly identifies sensory integrative problems in children with developmental or learning difficulties, and independent research shows that a sensory integrative problem can be found in some children who are considered learning disabled by schools. However, sensory integrative problems are not limited to children with learning disabilities; they can affect all ages, intellectual levels, and socioeconomic groups.

A number of situations can trigger sensory integration problems:

Prematurity As more premature infants survive today, they enter the world with easily overstimulated nervous systems and multiple medical problems. Parents need to learn how to give their premature infant the sensory nourishment their child requires for optimal development, and how to avoid harmful overstimulation.

Developmental disorders Severe problems with sensory processing is a hallmark of AUTISM. Autistic children seek out unusual amounts of certain types of sensations but are extremely hypersensitive to others. Similar traits are often seen in other children with developmental disorders. Improving sensory processing will help these children develop more productive contacts with people and environments.

Learning disabilities As many as 30 percent of school-age children may have learning disabilities. While most of these children have normal intelligence, many are likely to have sensory integrative problems. These children are also more likely than their peers to have been born prematurely, to have had early developmental problems, and to have poor motor coordination. Early intervention can improve sensory integration in these children, minimizing the possibility of school failure before it occurs.

Many studies indicate that children with learning disabilities are at risk for later delinquency, criminal behavior, alcoholism, and drug abuse because of repeated failure in school. By interrupting the vicious cycle of failure, intervention to help children with sensory integration and learning problems may also prevent serious social problems later in life.

Brain injury Trauma to the brain as a result of accidents and strokes can have profound effects on sensory functioning. Children who suffer from these effects deserve treatment that will lead to the best possible recovery. In order for this to occur, their sensory deficits must be addressed.

A tick-borne illness whose hallmark symptom is a bull’s-eye-shaped red rash surrounding a tick bite. Untreated Lyme disease can cause a host of problems, including arthritis and disorders of the heart and central nervous system. The disease is most commonly found in the northeast coastal states from Maine to Maryland, in the upper Midwest, and on the Pacific coast. It is usually contracted in the late spring or early summer, when ticks are abundant, although it may occur whenever the temperature is above 40°F for several consecutive days.

While the disease has been portrayed in sometimes frightening fashion, most of the time it is easily treated and does not progress to the chronic stages. It probably causes severe long-term effects in fewer than 10 percent of untreated children; moreover, recent studies indicate that many people who think they have Lyme disease actually have other conditions.

The number of new cases of Lyme disease has doubled in the United States since 1991, from more than 9,000 cases in 1991 to nearly 18,000 new cases in 2000. In 2000 Lyme disease cases increased by 8 percent compared to 1999, when 16,273 cases were reported. The increases in new cases may be partly due to better awareness and reporting of Lyme disease, but it also may be due to the fact that more people were exposed to ticks in densely populated areas.

Most of the new cases in 2000 were reported by 12 states in the northeastern, mid-Atlantic, and north-central United States, including Connecticut, Rhode Island, New Jersey, New York, and Delaware. The highest number of cases was reported by Columbia County, New York. Only six states reported no cases of Lyme disease in 2000: Colorado, Georgia, Hawaii, Montana, New Mexico, and South Dakota. Children aged five to nine are among the hardest hit groups, because they are more likely to be exposed to infected ticks and are less likely to use protective measures than other age groups.

History
In the United States, the disease was first recognized in Lyme, Connecticut, after two mothers were told in 1975 that their children had juvenile rheumatoid arthritis, a type of disabling arthritis of childhood characterized by swollen, painful joints. When the women discovered many others in the area had the same disease—which does not normally occur in clusters—they took their concerns to Yale University.

By the late 1970s Yale researchers discovered that many patients they studied were afflicted with a mysterious disease that produced a variety of symptoms in addition to joint swelling. They determined the cause was apparently a microorganism transmitted by at least one species of tick found widely in the woods around Lyme. In 1982 the bacteria was identified by Willy Burgdorfer in Montana, who discovered the spiral-shaped bacterial species that today bears his name: Borrelia burgdorferi.

Once scientists knew the cause, they confirmed that a group of skin conditions and neurological syndromes identified in Europe were also manifestations of Lyme disease. European patients suffer slightly different forms of the disease, probably because of differences in the strains of B. burgdorferi active in different parts of the world. Europeans experience long-term neurological complications, such as thinking problems and dementia; up to 10 percent of untreated Europeans also suffer for many years with a skin condition in which the affected areas of the skin become red, thin, and wrinkled. These symptoms are rarely found among patients with Lyme disease in the United States. Researchers have now identified the disease throughout the world, including Australia, Africa, and Asia.

Cause
The spirochete form of the bacteria is transmitted primarily by the deer tick, the tiniest of which is about the size of the period at the end of this sentence. These ticks are found on deer, birds, field mice, and other rodents. The tick must be attached to its victim for between 36 to 48 hours before an infectious dose of spirochetes are transmitted. For this reason, simply by checking children often for ticks, most can avoid being infected.

Most children are diagnosed in the spring, summer or early fall. In the northern states, about half of all adult Ixodes scapularis ticks are infected. In some places, such as Block Island and Nantucket, the numbers are even higher. Even so, in most sections of the northeast, only between 1 percent and 3 percent of children have contracted Lyme disease.

The tick that transmits Lyme diseases in California relies on intermediate hosts, such as lizards, that are resistant to infection. For this reason, ticks (and, consequently, humans) are infected much less often in the state of California than in the states of the Northeast.

Symptoms
Most children who do become infected with lyme disease usually display one or more symptoms between three days and a month after becoming infected. About 60 percent of victims will notice a small red spot that expands over a period of days or weeks, forming a circular, triangular, or ovalshaped rash. Sometimes the rash resembles a red, raised bull’s-eye with a clear center. The rash can range in size from a dime to the entire width of a child’s body. As the infection spread, several rashes can appear at different places on the body. Without treatment, the rash begins to disappear within days or weeks.

As the spirochetes move through the body via the blood, other symptoms affecting other parts of the body may appear. These may include such flulike symptoms as headache, stiff neck, appetite loss, body aches, and fatigue. Although these symptoms may resemble those of common viral infections, Lyme disease symptoms tend to persist or may occur intermittently.

About 20 percent of children may experience early neurological problems. Some children may have facial paralysis, MENINGITIS, ENCEPHALITIS, or numbness or tingling in other parts of the body.

Complications
After several months of being infected, slightly more than half of those children not treated with antibiotics develop recurrent attacks of painful and swollen joints that last a few days to a few months. The arthritis can shift from one joint to another; most often, the knee is infected. About 10 percent to 20 percent of untreated patients who experience temporary arthritic symptoms will go on to develop chronic Lyme arthritis. In contrast to many other forms of arthritis, Lyme arthritis typically is not symmetrical.

One out of 100 Lyme patients develop temporary heart problems (such as irregular heartbeat) several weeks after infection. Most children will not be aware of this problem unless their doctor detects it. Other nervous system complications include memory loss, concentration problems, and changes in mood or sleeping habits. Nervous system abnormalities usually develop several weeks, months, or even years after an untreated infection. These symptoms may last for weeks or months and may recur.

Diagnosis
Lyme disease is not easy to diagnose because its symptoms mimic those of many other diseases, such as viral infections or MONONUCLEOSIS. Joint pain can be misdiagnosed as inflammatory arthritis, and neurologic signs may be misidentified.

Diagnosis includes a history of exposure to ticks, typical symptoms, and blood tests revealing antibodies to Lyme bacteria. The tests are most useful in later stages.

Treatment
Antibiotics usually provide a complete recovery if given early enough. Most children who are treated in later stages of the disease also respond well. Unfortunately, cases that are not diagnosed soon enough may resist antibiotic treatment. In a few children, symptoms of persistent infection may continue, or the disease may recur, so that doctors prescribe repeated long courses of antibiotics. The value of this approach remains controversial.

Children with chronic Lyme disease may exhibit varying degrees of permanent damage to joints or the nervous system. This usually occurs among children who were not diagnosed in the early stages of the disease, or for whom early treatment was not successful. Deaths from Lyme disease have been reported only rarely.

However, experts at the Centers for Disease Control and Prevention do not recommend automatic treatment with antibiotics after every tick bite. Instead, they say it is better to avoid ticks in the first place.

Prevention
Lyme vaccine Although a vaccine against Lyme disease (LYMErix) had been approved in 1998 for people aged 15 to 70 years, in, 2002 the manufacturer announced that the vaccine would no longer be commercially available, citing poor sales. LYMErix had caused controversy in recent years, as patients complained that they were sickened by the vaccine and asked the government to restrict sales; some filed lawsuits against maker GlaxoSmith Kline. Federal health officials insisted there was no evidence that the vaccine was dangerous.

When the vaccine was first approved, the Centers for Disease Control and Prevention (CDC) had urged that only people at high risk of Lyme disease get vaccinated because the expensive vaccine did not offer complete protection. Studies had showed it was 80 percent effective after people got all three required shots. After vaccinations began, however, some patients reported arthritis, muscle pain, and other symptoms similar to Lyme disease itself. Because 15 percent of the U.S. population has arthritis anyway, scientists found it difficult to determine how the symptoms were connected to LYMErix.

When the CDC reexamined 905 possible side effects reported to the government between 1998 and July 2000, they found no signs that LYMErix caused arthritis although they did find 22 cases of allergic reaction. Nevertheless, at least 60 patients are suing the manufacturer for monetary damages. Other class action suits also have been filed.

Other prevention Ticks do not hop, jump, fly, or descend from trees, although they may blow in a strong breeze. In the woods, children should walk only on trails and avoid brushing against low bushes or tall grass. To prevent tick bites, children should wear protective clothing, with long-sleeved shirts and pants tucked into boots or socks. Light-colored clothes allow ticks to be more easily spotted.

An insect repellent may be used on bare skin and clothing, but all insect repellents should be used with caution in children and should not be used on hands or face. Repellent should not be used at all on infants.

Ticks and their hosts (chipmunks, voles, mice, and other small mammals) need moisture, a place hidden from direct sun, and a place to hide. Therefore, the cleaner the area around a house, the less chance there will be of getting a tick bite. All leaf litter and brush should be removed as far as possible away from the house. Low-lying bushes should be pruned to let in more sun. Leaves should be raked up every fall, since ticks prefer to overwinter in fallen leaves. Woodpiles are favorite hiding places for mammals carrying ticks; to discourage mammal visitors, woodpiles should be neat, off the ground, in a sunny place, and under cover. Gardens should be cleaned up every fall; foliage left on the ground over the winter provides shelter for mammals that may harbor ticks. Stone walls on the property increase the potential for ticks as well. Shady lawns may support ticks in epidemic areas; lawns should be mowed and edged. Entire fields should be mowed in fall, preferably with a rotary mower. Bird feeders attract birds that carry infected ticks, so feeders should not be placed too close to the house. The ground should be cleaned under the feeder regularly. Bird feeding should be stopped during late spring and summer, when infected ticks are most active. Building eight-foot fences to keep out deer may significantly reduce the abundance of ticks on large land parcels. Pets allowed outside should be examined daily.

An acute viral disease of the central nervous system that is usually transmitted to humans by a bite from an infected warm-blooded animal. Untreated, the disease is a swift, deadly killer, and there is no cure; the only hope lies in giving a vaccine immediately after a bite from a rabid animal.

Although most people tend to associate rabies with dogs, in fact rabies today is more likely to be found in cats. Together with dogs and cattle, these animals make up nearly 90 percent of rabies cases in domestic animals, with horses, mules, sheep, goats, swine, and ferrets making up the rest. However, most cases of human rabies in the United States are caused by bats. Human cases have averaged just three cases a year since 1990; a total of 26 (74 percent) of the 35 human rabies deaths in the United States have been associated with batvariant rabies viruses. Other wild animals that carry the disease include skunks and raccoons, foxes, mongooses, groundhogs, and some rodents. Rabies has been on the rise in the northeastern United States, increasing dramatically between 1990 and 1993.

Cause
Rabies is actually a form of viral ENCEPHALITIS transmitted through infected animal saliva. The virus is concentrated in the salivary glands, which is why the disease is usually spread by a bite. The virus also invades and damages muscles involved in drinking and swallowing, causing excruciating pain when swallowing liquids. Although suffering from thirst, animal and human rabies victims can be terrified by the sight of water; hence, the other name for the disease—hydrophobia.

Rabies also can be transmitted when infected saliva comes in contact with a cut or skin break. Infected bat droppings also may transmit the disease, as can transplants from patients with undiagnosed rabies.

Symptoms
The incubation period in humans may range from 10 days to more than a year, although 30 to 50 days is average. (Animals usually develop symptoms between 20 and 60 days.) The length of the incubation period seems to depend both on the location of the wound (the farther from the brain, the longer the incubation) and the dose of the virus received. Without treatment, severe bites on the head or upper body could lead to symptoms sooner than a mild scratch on the ankle.

There are two forms of the disease. “Furious” rabies primarily affects the brain and causes an infected animal to be aggressive, highly sensitive to touch, and vicious—the “mad dog” image. “Paralytic” (or “dumb”) rabies primarily affects the spinal cord, weakening the animal so that it cannot raise its head or make sounds because its throat muscles are paralyzed. In the beginning stage of paralytic rabies, an animal may seem to be choking. In both forms, death may occur a few days after symptoms appear.

Symptoms in humans are mild at first and worsen over time, starting with an itching or burning at the bite site, followed by malaise, fever, headache, fatigue, and appetite loss. The child begins to grow restless, excitable, anxious, and irritable, with insomnia or depression. The child may begin to hallucinate, salivate, and have periods of intense excitement and painful muscle spasms of the throat induced by swallowing. As time goes on, other signs of nervous system damage, including disorientation or coma, follow. Four or five days later, the patient either may slip into a months-long coma ending in death, or die suddenly from respiratory or cardiac arrest.

Diagnosis
There are no tests that can detect rabies in humans at the time of a bite, and by the time symptoms appear, it is too late for treatment. The transmission of rabies by a bite can be hard to detect.

Treatment
If a child is bitten by a suspected rabid animal, the wound should be immediately washed with soap and water; the bite should be allowed to bleed to help wash out the wound. Medical help is needed at once. (If possible the animal should be trapped and confined.)

Rabies prevention no longer means a series of painful injections in the abdomen. If a child’s doctor decides to begin the antirabies immunization, it will involve a monthlong series of five intramuscular injections together with human rabies immune globulin that should be started on the day of the bite. Part of rabies human immunoglobulin is usually injected near the bite area.

Unlike other vaccines, the rabies immunization is administered after exposure to the virus. This unusual technique works because the rabies virus takes a long time to induce disease. Injections of rabies vaccine may prevent the disease from developing in a person bitten by an infected animal. There are currently two vaccines licensed in the United States, both of which work the same way— triggering the immune system to produce antibodies that neutralize the virus before it causes disease. The modern vaccines are highly effective and produce few side effects. It is the only way to treat the disease in humans.

Prevention
A pre-exposure vaccine series is available that is designed for people at high risk for exposure, such as veterinarians, cave explorers, animal handlers, and those who travel to countries where rabies is common. The series is given in three shots.