Expert support system for occupational therapist in the identification of sensory profile

Introduction: Based on the increasing usability of technology in healthcare, this paper discusses the use of an expert system (ES) to identify the sensory profile of patients starting Occupational Therapy, allowing the professional to make assertive decisions in establishing priorities in the therapeutic plan. Objective: To develop a decision support system from the Infant/Toddler Sensory Profile. Method: Structuring of an ES based on Infant/Toddler Sensory Profile, from terms translation into Portuguese, identification of variables and domain values involved, and construction of production rules. Results: Twelve variables were registered for the construction of the ES, 6 of these were treated as goal-variables, 20 rules being built. Conclusion: This ES is an important support to the occupational therapist in the decision-making process of treatment plans, determining priorities and respecting the sensory profile of each child. In addition, it must be noted that there is no equivalent system. [P ]


Introduction
Occupational therapy is an area of knowledge that investigates strategies for prevention and treatment of individuals with cognitive, affective, perceptual and psychomotor problems resulting from genetic or traumatic disorders or from acquired diseases, using human activity as a therapeutic tool (1).For this, it selects, prepares and proposes activities to be performed by the patient in order to achieve treatment goals.For this process to be successful, it is necessary that all the characteristics peculiar to the patient are considered in the preparation and monitoring of the therapeutic plan.
Currently, researchers have turned their attention to a disorder in the ability to process and integrate sensory information coming from the environment, resulting in inappropriate behaviors, the Sensory Processing Disorder (SPD) (2).This disorder is observed in neurotypical children who have normal neuropsychomotor development.
It is suggested that one in twenty children has some sensory processing disorder (3) and one in six has sensory experiences that interfere with their academic, social, and/or emotional development (4).There are studies showing a higher propensity among autistic children, because they have significantly different sensory responses (5,6,7,8,9) resulting from sensory processing problems (10).
Since sensory processing is crucial for the individual to be able to engage in daily (11) activities, this explains why the SPD is the focus of the occupational therapy area (12).
The concern with the SPD is growing so much that the American Academy of Child and Adolescent Psychiatry's annual meeting, held in 2006, presented the hypothetical case of a child previously diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), whose diagnosis was being investigated as a Nonverbal Learning Disability (NVLD) or Sensory Processing Disorder (SPD), and then there was the suggestion to put both in the Diagnostic and Statistical Manual of Mental Disorders -DSM, since the nosology existing in the current DSM IV does not include them, leading to erroneous diagnoses and treatments (13).
The SPD involves the misperception of the stimulus received from the environment, an aspect influenced by the sensory profile of the child, which results in high and/or decreased perception of sensory stimuli.Examples include behaviors such as: difficulty to brush the teeth, because the sensation is perceived as annoying; or the child who throw him/herself on the floor with frequency because the pain is perceived as insignificant or is even almost imperceptible.
There are several assessment tools to identify the SPD, such as: Infant / Toddler Sensory Profile (14), Sensory Integration and Praxis Test -SIPT - (15), Sensory Profile (16), DeGangi-Berk Test of Sensory Integration (17), Observations Based on Sensory Integration Theory (18) and Test of Sensory Function in Infants (19); but neither is validated in Brazil.
To develop this study, we opted for the Infant/ Toddler Sensory Profile (14).This choice was made the respective differential diagnosis indication for a given set of conditions.
Its application has been employed in higher education, aiming to help the students to understand the criteria used to identify specific diagnoses.As an example, we have: "The use of Expert System to Support the Systematization in Orthopedic Examinations of Hip, Knee and Ankle" (24) and "Intelligent System to Aid Physiotherapy Treatment by Applying the Principle of Neuroplasticity in Patients with Cerebral Palsy" (25).
In the case of sensory processing, the ES contributes in the identification of sensory responses, in the decision-making regarding the therapeutic approach to be adopted, and also in academic teaching, helping in understanding and developing clinical reasoning.
Thus, due to the need for a system that assists the occupational therapist in identifying the sensory profile by supporting the development of the treatment plan, this article aims to present the construction of an expert system of decision support based on the Infant/Toddler Sensory Profile (14).

Materials and method
The Infant/Toddler Sensory Profile (14) has different versions according to the age group.The version adopted in this study regards the ages between 7 and 36 months, dated from 2002 (14).Since it is an instrument originally presented in English, for its use it was necessary to initiate the process by its translation into Portuguese, which was performed by the first author.
For the preparation of ES, we adopted Expert Sinta (26) tool, which was developed by the Artificial Intelligence Laboratory of the Federal University of Ceará, Brazil (27).
Sensory characteristics were initially identified and defined based on the Infant/Toddler Sensory Profile (14), which consists of a questionnaire to be answered by caregivers, and that addresses the child's sensory processing.It consists of quadrants arranged as follows: 1) 06 of them have a list of behaviors, totaling 48, which, as shown in Table 1, are related to different sensory processing (auditory, visual, tactile, vestibular and oral), and a quadrant related to the general processing; 2) 1 of them presents a Likert scale, with 5 scores to be allocated according to the frequency with which these based on the following reasons: 1) it involves alteration of sensory perception and, consequently, affects the performance of daily activities and social relationships; the early identification of SPD is crucial, and this tool deals with the age group related to the early childhood, favoring its brief identification; 2) it is a significant educational tool, which facilitates the educational process; 3) its wide use and disclosure carries with it the social nature, because it allows disseminating the knowledge related to SPD, enabling people living with children with this disorder to better understand their atypical behaviors.Thus, it favors social relations since it avoids requirements and situations that may cause frustration for both the children and for those who take care of them, contributing significantly to the mental health of all.
The access to information regarding sensory responses is essential for the occupational therapist to identify the sensory profile of the individual and enable the development of an assertive treatment plan.This access to this information can be favored using Information Technology (IT), which favors the greater use of information electronically recorded by health professionals (20), which can be done on paper charts or in the Electronic Patient Record (EPR), allowing professionals not only to store information, but also to share them (21).Overall, IT offers a wide range of alternatives aiming to facilitate the decisionmaking in different areas of knowledge, particularly in healthcare, and one of the means of doing this is using an Expert System (ES).
The ESs are constructed based on the expert knowledge.This system consists of rules that help to solve problems and support decisions (22), and it consists of the following components: knowledge base, mechanism of inference and interface with the user.From the user interface, the query to the system is accomplished by establishing a connection to the inference engine, browsing the knowledge base in search of the best solution for the proposed problem.The knowledge base stores the reasoning process that involves all information, data, cases and relevant relations used by the ES.It also includes a set of concepts that can be represented by sentences that establish relations of cause and effect.One form of representation is widely used by rules of "if ... then" (23), called production rules, which allow the relation between a set of conditions and their respective action, for example, in a system for diagnosis support, a) Translation into Portuguese, since its validation in Brazil has not been performed; b) Identification of the variables involved; c) Among the identified variables, referencing those to be adopted as the objective variables; d) Establishment of the domain values that each variable can take; e) Preparation of production rules.
behaviors are observed (almost always, often, occasionally, rarely, almost never); 3) 4 of them are used to survey the scores of the processing; 4) 1 of them to determine the sensorial profile according to the attributed scores.
The steps for developing the structure of ES Expert Sinta (26) based on Infant/Toddler Sensory Profile (14), were as follows:

Low Registration
The child fi nds ways to make noise with toys.

Low Registration
The child ignores you when you are talking.

Sensation Seeking
The child startles easily at sound, compared to other children the same age.

Low Registration
The child enjoys making sounds with his/her mouth;

Sensory Sensitivity
It is necessary to speak loudly to get the child´s attention.

Sensory Sensitivity
It takes a long time for the child to respond when her name is called.

Low Registration
The child tries to escape from noisy environments.

Sensation Avoiding
The child are distracted and/ or has diffi culty eating in noisy environments.

Sensation Seeking
The child takes a long time to respond, even to familiar voices.

Low Registration
It is necessary to touch the child to gain her attention.

Results
Twelve variables involved were identified, six of these represent the behaviors that indicate the sensory profile of the processing; and other six were identified as goal-variables in order to represent the sensory profile.The  the child to respond when her name is called; the child tries to escape from noisy environments; the child are distracted and/or has difficulty eating in noisy environments; the child takes a long time to respond, even to familiar voices; it is necessary to touch the child to gain her attention.During ES utilization, screens indicating a sensory processing and behaviors related to it are presented, then, the system user must indicate behaviors corresponding to those observed in child.After finishing filling with information, the system shows sensory modulation, or sensory profile.The ES was develop with 20 rules.months of age with stereotypies such as producing sounds with the mouth.She does not make eye contact and does not accept being touched.She does not socially interact, and she is slow to respond when she is called, she throws toys to the ground; she is agitated and gets even more agitated when the routine is modified, and she does not interact with other children and is very selective regarding her diet.She does not allow caregivers to brush her teeth.She does not recognize herself in the mirror.With this information, it is possible to ascertain, through the Infant/Toddler Sensory Profile (14) applied to the ES, that this is a child with low registration of auditory processing, general processing with sensory sensitivity, visual processing with low registration, and that avoids tactile sensation and prevents oral sensation.The decision structure to exemplify this case is shown in Figure 5, in which we adopted the color criterion for easy viewing and understanding.After identification of behaviors related to a specific sensory system (Figure 3), the sensory profile identified is presented (Figure 4): In order to elucidate, the following hypothetical case will be explained: J. is a child of 2 years and four  -Sensory profile resulted from the processing analyzed resists brushing teeth", "the child refuses to try novel foods","the child is selective in its diet " in order to identify a child who avoids oral sensation.These behaviors alone are already remarkable for hindering the lives of children and their families, and when they are combined, the need for actions to help regulating sensory modulation and promoting quality of life is an emergency and it should be prioritized by the Occupational Therapist when developing the therapeutic plan.
The presentation of the proposed ES promotes the understanding and learning by the user, which can be a family member, an academic on Occupational Therapy or a healthcare professional, showing that this approach can be adopted in other situations of Occupational Therapy.

Discussion
In the area of health, the use of paper records for the record of patient data still prevails, which hinders the access to information.One way to solve this is based on the adoption of an ES, in which, through the interface with the user, the query of information that may be deemed necessary is performed, such as the case of the early identification of the sensory profile of the child starting the treatment of Occupational Therapy.
The use of ES presents, in a didactic way, the clinical reasoning required to identify the sensory profile of the patient, as for example, when the system displays the description of behaviors such as "the child Does not allow caregivers to brush her teeth.
Does not recognize herself in the mirror.

Avoids tactile sensation
Avoids oral sensation.
Auditory processing with low registration.
Visual processing with low registration.
General processing with sensory sensitivity. J.

years and 4 months
Figure 5 -Decision structure of the explanatory hypothetical case data, optimizing the information in order to benefit the patient's health.
For future studies, we suggest the validation of this ES prototype developed by experts in the field, observing a few steps: 1) identifying occupational therapists who work with the methodology of Sensory Integration; 2) implementing an assessment tool that addresses the time of training, experience with the use of IT and the application of the Infant/Toddler Sensory Profile (14); 3) providing this ES for evaluation; 4) collecting opinions on the potential use (29).
Furthermore, the use of ES would contribute to the dissemination of SPD, which affects one (1) in each 20 children (28) and is not present in the DSM, so that its knowledge is limited in the medical field, which results in inappropriate diagnosis and treatment (13).Focusing on the sensory profile, the use of this instrument could contribute to a better understanding of what is happening with the child, allowing families and professionals to understand that behaviors often interpreted as stubbornness or lack of education, have neural explanations, and therefore are unviable to be controlled by the child, requiring an appropriate sensory diet, which considers sensory experiences necessary for the patients in order to meet their physical and emotional needs with the aim of adapting their behavior (29).
The idea is that occupational therapists uses the proposed ES during the treatment of the child, and from the selection of the identified behaviors, the system presents the sensory profile of the child.
It is necessary to emphasize that this study is not objective to the translation and adaptation of the Infant/Toddler Sensory Profile.The ES could use the terms in English.The terms of this instrument were used in Portuguese and when there is an official adaptation, it is easy to change the terms in the system.

Conclusion
This study presents the construction of an ES based on the Infant/Toddler Sensory Profile (14) using the Expert Sinta (26) tool, enabling the support to the Occupational Therapist in developing an assertive treatment plan.This prototype still does not access the required data from an EPR; on the contrary, it requires them via interaction with the user during its execution, because the provision of electronic records it is not yet common in consultation rooms.
To support the development of the therapeutic plan, the ES based on the Infant/Toddler Sensory Profile (14) required that 12 variables were defined for the construction of 20 rules.
It was observed that the use of an ES as aid tool is of significant value, since it enables the identification of data that favor the decision-making regarding the development of the therapeutic plan of the patient and, in association with the EPR it allows us to relate

Figure 1 -
Figure 1 -Definition of variable auditory processing's domain values

Figure 3 -
Figure 3 -Analysis of vestibular processing

Figure 4
Figure 4 -Sensory profile resulted from the processing analyzed Stereotypies -produces sounds with mouthDoes not make eye contact.Does not accept being touched.Does not interact socially.Is slow to respond when called.Throws toys on the floor.Is agitated and gets even more when the routine is modified.Does not interact with other children.Very restricted regarding food.

Table 1 -
Part of Infant/Toddler Sensory Profile