School Difficulties Viewed Through The Sensory Lens (Part 2): Task Comprehension, Attention & Handwriting – What The Vestibular System Has to Do With it

Those who perceive an inattentive child as simply unwilling often overlook the underlying causes. From the perspective of Ayres Sensory Integration (ASI), task comprehension, attention control, and handwriting are closely linked to sensory integrative foundations, especially from the vestibular sense.

Why Attention is Not Just a “Problem in the Head”

The vestibular system not only stabilizes posture and controls automatic eye movements and balance, but its signals also modulate the ascending reticular activating system (ARAS) in the brainstem—as described in neuroscientific journals ( Frontiers+1 ). Thus, vestibular input influences our state of alertness and orienting response—and thus the basis for focused attention . When vestibular processing is weak, children oscillate between "fidgety/overexcited" and "easily fatigued"—both states are unfavorable for academic performance.

Bilateral Integration: The “Bridge” Between The Right And Left Hemispheres of the Body/Brain

In order to process tasks in an orderly manner for a longer period of time , the brain must efficiently integrate information from both sides of the body. The vestibular system provides the basis for the exchange of information from both sides of the body - namely, already at the level of the vestibular nuclei in the brainstem. If the brain effectively integrates information from both sides of the body, we can see this in good bilateral coordination. For example, children with good bilateral integration spontaneously and effectively stabilize the paper with one hand while writing with the other. They can draw lines across the paper without turning it. When reading, their eyes can make smooth saccades from left to right, crossing the body's center without hesitation. This is not the case for children with weaknesses in bilateral integration: in preschool, they find it difficult to cross lines , and later diagonals (X, triangle). They frequently turn the paper so that they do not draw a line across need to pull the center of the body – an indication of insufficient awareness of the contralateral space.

In Ayres' factor-analytic studies and their replications (Mulligan 1998 and Mailloux et al. 2011), correlations were found between these behaviors and vestibular hyporeactivity (in the postrotatory nystagmus test), poor postural control and oculomotor skills (in the corresponding SIPT or EASI tests), and low scores in the test of bilateral coordination (in the SIPT or EASI). This pattern is referred to as vestibular-based bilateral integration disorder (VBIS) or vestibular postural-ocular-bilateral integration disorder .

Task Comprehension

The vestibular sense can be involved in (apparent) problems of task comprehension in several ways:

Ayres identified the vestibular system, along with hearing, as the sensory foundations of language acquisition. Attention is most likely the link between these two. If tasks are communicated only verbally, this could be due to either a still-delayed comprehension of language or a lack of attention to the instruction.

But even visual instructions are not necessarily easy for children with VBIS: because they have difficulties with spatial orientation, they often cannot follow instructions.

Reading, Arithmetic, Handwriting: Sensory Integrative Foundations

Reading requires stable gaze tracking, which is related to posture and neck control, and good spatial orientation, which also depend on functions of the vestibular system. Furthermore, various visual perception skills are required. Vestibular hyposensitivity (Isaac et al, 2017) is associated with

• lack of stable field of vision,

• lack of vestibulo-ocular reflex (VOR)

• lack of postural control

• weak bilateral coordination

• Directional instability and spatial weaknesses

and can impair reading. Studies show poorer reading acuity in children with vestibular hyporeactivity and improvements in reading speed after vestibular cognitive training. Reviews link vestibular deficits with cognitive/oculomotor development.

Mathematics is based on spatial experience and spatial orientation (up/down, left/right, near/distance). The vestibular system helps distinguish visual self-motion from object movement and stabilize spatial references – difficulties here can affect geometry, quantity organization, and place value understanding (Wiener-Vacher et al., 2013).

Writing requires postural control, precise tactile information, somatosensory differentiation , and praxis (motor planning). If the internal "map" of the body is undifferentiated, as is the case with somatodyspraxia identified by Ayres due to inaccurate tactile information from the body, start/stop sequences, form transitions, and pressure do not occur automatically: Writing becomes cramped or hasty, often with constant re-starts. Reviews of learning to write summarize these neuromotor components—including bilateral integration and motor planning (Lee et al. 2022).

From “Learning Disorder” to “Attention Problem” – What The Evidence Shows

A. Jean Ayres (1969) was the first to describe recurring patterns of sensory integration deficits in children with poor academic performance:

1. auditory-linguistic-sequential

2. postural-bilateral.

These factors correlated with learning problems – an early hypothesis on the sensory basis of academic performance that remains strong today.

A four-year longitudinal study (Parham, 1998) showed that the results of sensory-integrative tests are concurrently and predictively related to school performance – even when controlling for other variables.

Current work deepens the connections:

• In school-age children/adolescents with autism, sensory characteristics (especially the interaction of hyperreactivity and low avoidance/self-regulation ) significantly predict school skills – more strongly than IQ (Butera et al., 2020)

• Children with dyslexia often show weaker VOR function and balance performance ; vestibular interventions/training can improve reading speed (Ölcek et al, 2023).

• Children with specific learning disabilities show measurable vestibular functional abnormalities – a further indication of sensory involvement (Demir et al, 2023).

  In school environments, sensory abnormalities impair attention and learning engagement ; interventions that reduce sensory stimulus load can positively influence performance (van der Wurff, 2021).

• Abnormalities in sensory reactivity are associated with poorer academic performance in inclusive settings (Marcham et al., 2024) .

How Do We Detect A Possible Sensory Basis of School Problems?

• Problems in several functions of the vestibular system such as lack of postural stability when sitting upright, high motor restlessness and urge to move (in the sense of a sensory seeking), problems keeping a stable visual field, difficulties in estimating height, speed and distances, insecure orientation on one's own body (left-right) and in space, avoidance of midline crossing, possibly delayed or incomplete development of handedness (De Cicco, 2018).

• Problems crossing the center of the body : Line does not flow smoothly from left to right, paper is turned; X/diagonals insecure – indication of bilateral integration weakness (Ayres 1969).

• Writing : unclear lines/pressure, “jerky” movement planning, low automation – typical of tactile-proprioceptive perception deficits and somatodyspraxia (Lee, 2022).

What does this mean for therapy and school?

• Vestibular activation in an organized setting requiring estimation of speed, distance, and height, postural control, visual localization or tracking, and bilateral coordination improves alertness, attention , and endurance . Just as Ayres predicted, reviews have found associations between vestibular stimulation and cognitive performance and emotional regulation (Wiener-Vacher, 2013).

• Challenges to tactile-kinesthetic perception and praxis through diverse tactile experiences with the hands and the whole body combined with demands on motor planning strengthens the foundations of handwriting .

• Low-stimulus learning environments (uncontrollable tactile stimuli, light, sounds, noise should be avoided) and individual sensory adaptations can positively influence attention and performance (van der Wurff, 2021) .

• OT using the ASI approach (OT-ASI) with fidelity to treatment aims precisely at these fundamentals of school performance and is useful as a causal - in contrast to symptomatic - approach with long-term and extensive effects in combination with educational support measures.

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👉 LISTEN TO THE PODCAST ON THE SAME TOPIC!

Hear more about this in the SiNN-VOLL Podcast , Episode 8 “What parents should know: School difficulties and sensory integration” . The podcast is only available in German at this time.

Literature (selection)

• Ayres, A. J. (1969). Deficits in sensory integration in educationally handicapped children . Journal of Learning Disabilities , 2(3), 160–168. SAGE Journals

• Braswell, J., & Rine, R. (2006). Evidence that vestibular hypofunction affects reading acuity in children . International Journal of Pediatric Otorhinolaryngology , 70(11), 1957–1965. ScienceDirect

• Butera, C., et al. (2020). Impact of sensory processing on school performance outcomes in high-functioning individuals with ASD . Frontiers in Psychology , 11, 3033. PMC

• Caldani, S., et al. (2021). Short vestibular and cognitive training improves oral reading speed in dyslexic children . Brain Sciences , 11(11), 1440. MDPI

• De Cicco et al. (2018). Trigeminal, Visceral and Vestibular Inputs May Improve Cognitive Functions by Acting through the Locus Coeruleus and the Ascending Reticular Activating System: A New Hypothesis. Frontiers in Neuroanatomy 11. DOI: 10.3389/fnana.2017.00130

• Demir, I., et al. (2023). Vestibular evaluation of children diagnosed with specific learning disorders . Turkish Archives of Pediatrics , 58(6), 604–612.PMC

• Isaac V, Olmedo D, Aboitiz F, Delano PH. Altered Cervical Vestibular-Evoked Myogenic Potential in Children with Attention Deficit and Hyperactivity Disorder. Front Neurol. 2017 Mar 13;8:90. doi: 10.3389/fneur.2017.00090.

• Lee ASS, Lee LW, Low HM, Ooi SC. (2022) Revisiting Handwriting Fundamentals Through an Interdisciplinary Framework . Malaysia's J Med Sci. 29(1):18-33. doi: 10.21315/mjms2022.29.1.3.

• Marcham H, Tavassoli T. Relationship Between Directly Observed Sensory Reactivity Differences and Classroom Behaviors of Autistic Children. On J Occup Ther. 2024 May 1;78(3):7803345010. doi: 10.5014/ajot.2024.050345.

• Ölçek, G., et al. (2023). Functional VOR and balance skills in children with dyslexia . Frontiers in Neurology , 14, 1153650. Frontiers

• Parham, L.D. (1998). The relationship of sensory integrative development to achievement in elementary students: Four-year longitudinal patterns . Journal of Occupational Therapy, Schools, & Early Intervention (formerly Occupational Therapy Journal of Research ), 18(3), 121–137. SAGE Journals+1

• van derwurff, I., et al. (2021). The influence of sensory processing tools on attention and school performance . Journal of School Psychology , 85, 110–126. ScienceDirect

• Wiener-Vacher, SR, et al. (2013). Vestibular activity and cognitive development in children: perspectives . Frontiers in Integrative Neuroscience , 7, 92. PMC