Sensory Integration parte 01
Sensory
Integration
Theory and Practice
Anita C. Bundy ScD, OT/L, FAOTA, FOTARA
Professor and Department Head,
Occupational Therapy
College of Health & Human Services
Department of Occupational Therapy
Colorado State University
Fort Collins, CO
Honorary Professor
Occupational Therapy
Faculty of Health Sciences
University of Sydney
Sydney, Australia
Shelly J. Lane PhD, OTR/L, FAOTA, CSU
Professor, Occupational Therapy
College of Health & Human Services
Department of Occupational Therapy
Colorado State University
Fort Collins, CO
Professor and Discipline Lead
Discipline of Occupational Therapy
School of Health Sciences
University of Newcastle, Australia
Associate Editors
Shelley Mulligan PhD, OTR/L, FAOTA
Associate Professor and Chairperson
Department of Occupational Therapy
University of New Hampshire
Stacey Reynolds PhD, OTR/L, FAOTA
Associate Professor
Department of Occupational Therapy
College of Health Professions
Virginia Commonwealth University
THIRD EDITION
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Philadelphia, PA 19103
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The third edition of this book, similar to the second, is dedicated
to A. Jean Ayres, the inspiration for this text
and the intervention and research it represents.
And to those who live with sensory integrative dysfunction,
who are the best teachers.
vii
ACKNOWLEDGMENTS
Whenever the two of us edit a textbook, it seems
to involve moving around the world. This one
was no exception. This time each of us moved
to and/or from Australia (SJL moved both ways).
Those moves undoubtedly contributed to the time
it took for us to complete this edition—and also
makes us very grateful to a number of people,
without whom there would be no third edition.
First, we are indebted to the therapists,
researchers, academics, and occupational therapy
students in many countries of the world who
read—and sometimes re-read—the fi rst two editions of this book. They tell us that those books
informed their practice—and they insisted we do
a third. This third edition is the last for us. We
are very grateful to Shelley Mulligan and Stacey
Reynolds, who joined us in editing this time. We
now pass the torch to them.
It almost goes without saying that the contribution of each author was critical but we would
never want to be silent on this. This group of
scholars is amazing—and amazingly patient. We
are honored to have worked with them. We are
also thankful to the numerous therapists who
gave their time and resources to teach us about
Jean Ayres’ life and the history of sensory integration theory and practice. This information led
to Chapter 2 . Generous fi nancial contributions
from F. A. Davis—and a sabbatical from the
University of Sydney—allowed us to travel all
over the United States in search of their collective wisdom. We hope we have done a good job
of interpreting what they said.
Tammie Fink, from the Sensory Gym in
Hobartville, New South Wales, Australia, is
responsible for many of the photographs in this
edition. The photos bring the content to life.
Our deep appreciation goes to Colleen Hacker
for sharing Tammie ’ s time, organizing children
and families for the photo shoot, and of course
getting those all-important photo releases signed.
We can ’ t even imagine a book without these
“action” photos.
The reviewers of each chapter provided
invaluable feedback. What they had to say was
not always easy to hear—but it was always
correct. We hope we have done justice to their
comments.
Numerous colleagues and friends contributed in enormously important ways by refl ecting
on content, terminology, and interpretations of
content. Judith Abelenda, in particular, not only
spent countless hours discussing ideas, but she
also made her home in Spain a writing retreat.
We made a lot of progress in that week.
The folks at F.A. Davis stood by us through
thick and thin. Christa Fratantoro, in particular,
has been involved since the beginning and key
to the last two editions. She is always our “go-to
person” with any questions or needs. There are
so many others that it would be impossible to
list them without missing some. We are eternally
grateful to all for your support.
Finally, as always, those closest to us, Rick
Thornton and Ginny Deal, literally provided
years of (nearly uncomplaining) support. Shelly ’ s
children, Hannah and Lucas Thornton, provided
her cheering section, something that kept her
going when deadlines loomed. We could not
have thanked them enough—and we ’ re pretty
sure they would say we did not.
We have undoubtedly failed to mention some
key players. That has more to do with failed
memory than lack of signifi cance of their contributions. We hope you will forgive us.
Anita Bundy
Shelly Lane
ix
FOREWORD
The rigor, passion, and vitality that A. Jean Ayres
brought to addressing the problems of sensory
integrative dysfunction in children is alive and
well as proven by this third edition of Bundy and
Lane ’ s Sensory Integration Theory and Practice.
Throughout the book, the authors exhibit current
work that fully understands and implements
contemporary education, research, and practice
agendas related to sensory integration (SI). Each
of the 23 chapters focuses on the importance of
discoveries that advance the initial theory and
application of SI fi rst presented by A. Jean Ayres
nearly 60 years ago.
The legacy of A. Jean Ayres is steeped in a
tradition of inquiry and research. It is humbling
to realize the profound effect that Ayres’ foundational work still holds on the current day practice of occupational therapy. In the early 1960s,
she had a remarkable sense of how a deep and
detailed inquiry into neuroscience could provide
a bridge to the fi eld of occupational therapy when
applied to individuals with SI problems. Her
initial vision of what the marriage of these fi elds
could yield has resulted in a sustained effort of
thought and action that continues to propel us
toward a research agenda for the 21st century
( Chapters 15 and 16 ) and describe both assessment and intervention methodologies ( Chapters 8
to 13 ).
Similar to Ayres herself, the authors in this
book are intrigued and driven by the complicated questions posed by SI dysfunction. Their
curiosity and good science expand her tradition of inquiry by asking diffi cult and probing
questions. Both the questions and the resultant
answers further inform the underlying theory
(Part I), explicate SI disorders and their neuroscience basis (Part II), explore the current status
of assessment and intervention (Parts III and IV),
extend theory application (Part V), and provide
case exemplars (Part VI).
The authors collected together in this edited
text have made longstanding commitments to the
full realization of Ayres’ initial concepts and ideas
for approaching assessment and intervention.
Their chapters provide evidence of their ability
to think scientifi cally and synthesize knowledge
and understanding that readers will fi nd useful
as they defi ne and implement the next wave of
research. These authors exhibit the commitment
and courage refl ective of A. Jean Ayres. They continue the evolution of Ayres’ work, particularly
as evidenced in their consideration of broader
applications of the theory ( Chapter 16 ), inclusion of complementary approaches ( Chapter 17 ),
and application of SI principles beyond traditional diagnostic groups ( Chapter 18 ).
The 1960s as a decade witnessed an explosion
of conceptual and theoretical work across a wide
swath of occupational therapy. Occupational
therapy thinkers sought to import relevant ideas
from neurobiology, kinesiology, psychoanalytic
theory, and the social sciences. Ayres’ contemporaries, including theoreticians such as Mary
Reilly, Gail Fidler, Anne Mosey, Margret Rood,
and Josephine Moore, to name a few, were eager
to develop models that would guide clinicians to
better assess and treat specifi c occupation-based
problems.
These scholars recognized that occupational
therapy was maturing as a profession, shifting away from a dependency on medicine and
rehabilitation. Occupational therapy was ready
to stand on its own two feet. Focused attention
was needed to articulate theories with specifi c
concepts and principles that would sharpen the
understanding of the therapeutic value of an
occupation-based approach. This was to distinguish the focus of occupational therapy as
unique, and, as it turns out, lay the groundwork for what would become a research-based,
evidence-generating, highly valued and widely
Janice P. Burke
“There is no substitute for a good idea” ( Reynolds, 1971 ).
x ■ Foreword
recognized approach to remediating the problems
of occupation. Using strategies from the social
and hard sciences, they set out to understand and
solve problems of occupation and the diffi culties
of fully participating in society.
Ayres, along with her contemporaries in neurobiology and education, were deeply involved
in identifying, defi ning, and understanding children with visual and perceptual motor problems
and learning diffi culties. During the 1960s, they
worked to develop ways for remediating occupational issues in both educational and clinical
settings.
Ayres’ perspective was authentic to its occupational therapy roots. It had a sharp focus on
the needs of a special population of children and
was designed as a bridge on the road to full participation. It provided the fi eld with legitimate,
science-based explanations for the use of specifi c
occupational therapy approaches. Ayres drew the
attention of occupational therapists concerned
with children with neurologically based issues
to the possibilities of a theory rooted in scientifi cally grounded principles. This theory was
testable and subject to validation and proof. The
path Ayres forged was rigorous and would have
scholarly, and demanding, vistas.
I had the great fortune of studying at the University of Southern California with two incredible
pioneers during this time of theoretical explosion
in occupational therapy: A. Jean Ayres and Mary
Reilly. Though their theoretical orientations were
different, Ayres in the neurosciences and Reilly
in social science, they both had a single-minded
perspective of their subject matter that led to an
unwavering commitment that set the stage for a
theory-driven approach to assessment and intervention. Both had a foundational belief in the
power of occupation. They employed similar
strategies, based in evidence and observation, to
test their ideas.
They surrounded themselves with students and
scholars in graduate level education and worked
to engage them in a path to become great thinkers. In this way, A. Jean Ayres and Mary Reilly
planned to seed their ideas and create the next
generation of leaders. All the students in their
classrooms were able to benefi t from the natural
productivity that is inherent when one is curious,
a student, and learning at the table of wonderful
thinkers, mentors, and educators.
Paul Reynolds in A Primer in Theory Construction, his book on theory, wrote: “[T]he ultimate test of any idea is its utility in achieving the
goals of science” ( Reynolds, 1971 ).
I sat in graduate classes with both of them,
on mats in Jean ’ s clinic and at seminar tables
in Mary ’ s classroom. All present listened to the
exquisite ideas they were developing. There I
came to realize what was needed to reach the
infi nite possibilities and potentials that occupational therapy has to understand, articulate, and
remediate problems of individuals as they move
into a world of meaning and purpose.
What is especially intriguing about this period
of theory development is to ask the question of
why some theories, such as that of A. Jean Ayres,
continued to evolve, prove their durability and
applicability to current problems, and ask why
some, even to this day, 60 years later, demonstrate their inherently sound foundation.
A. Jean Ayres had a good idea. This book is
a testament to the durability of Ayres’ initial idea
and the science that followed and is an important
milestone for the editors and authors who have
made contributions to her legacy.
Reynolds , P. D. ( 1971 ). A primer in theory
construction . Indianapolis, IN : Bobbs Merrill
Educational Publishing .
xi
PREFACE
More than a decade has passed since we published the second edition of Sensory Integration:
Theory and Practice. A lot has happened in that
time, and, as much as possible, we have tried
to capture the evolution. We have made several
notable changes from the second edition.
Ayres developed sensory integration (SI)
theory in the 1960s at a time when the occupational therapy profession, struggling to gain
credibility, embraced a medical model. Her
driving force was to explain links between brain
processing and observable behavior. Nonetheless, although participation in everyday activity was traditionally the core of occupational
therapy, Ayres began her work in an era when
many occupational therapists believed that
changing body structure and function would
translate automatically into improved function.
Some therapists who employed SI therapy fell
into that trap. What could be more seductive
than changing the brain? But over-emphasis on
changing the brain sometimes resulted in relegating occupation to the back seat. We now
know that changing the brain matters, but only
if those changes contribute to making everyday
life easier and more meaningful—and that does
not occur automatically. Publication of the International Classifi cation of Functioning Disability
and Health (ICF) has shifted the attention and
beliefs of all health-care professionals toward
activities and participation. In this third edition
of Sensory Integration: Theory and Practice, we
give greater prominence to SI in everyday life.
Among other more subtle changes throughout
the book, we expanded the chapter on SI and
occupation from the second edition and placed it
where it should be—near the front.
Ayres died in 1989 and she still is sorely
missed. For many years, colleagues who had
worked with her carried the torch that Ayres
lighted. Through time, as might be expected,
some of those colleagues shifted their focus
to specifi c aspects of the theory. Ayres emphasized praxis and dyspraxia. She labeled “tactile
defensiveness” and saw it as a refl ection of poor
sensory modulation. However, she did not live
long enough to fully develop her explanations.
In the ensuing decades, while the theory did not
change fundamentally, the terminology associated
with it morphed. At the same time, many occupational therapy educators relegated SI theory and
therapy to continuing professional education,
perhaps believing it was beyond that required for
basic preparation of entry-level practitioners. All
these factors seemed to conspire to make occupational therapists (and ultimately other professionals) increasingly unclear about the terminology
associated with SI theory and what actually constituted sensory integrative therapy. Throughout
this third edition of Sensory Integration: Theory
and Practice, we have attempted to clarify the
terminology and the principles of intervention.
We also offer a new chapter ( Chapter 3 ) tracing
the history of the development of SI theory–with
all its triumphs and dramas—from Ayres through
to the present. We think that chapter makes a particularly good read.
Research evidence for both the theory and the
intervention has risen to a higher level. Studies
of SI now include government-funded randomized controlled trials (RCTs) as well as quasiexperimental, correlational, and descriptive
studies that set the stage for additional RCTs
needed to test the effectiveness of this complex
intervention. In this third edition, we devote
two chapters to that evidence. One chapter
( Chapter 15 ) describes the clinically based
research applicable in everyday practice. The
second ( Chapter 16 ) describes a growing body of
basic research underpinning SI theory. We also
have expanded the chapters on praxis and sensory
modulation. Refl ecting the explosion of research
in the area, we also expanded the chapter on
structure and function of the sensory systems
( Chapter 4 ), augmenting it with some information
on interoception, and added a separate chapter on
sensory discrimination (Chapter 7).
Through time, we became increasingly aware
of the need to illustrate the multiple complex
aspects of assessment related to SI theory. In this
xii ■ Preface
third edition of Sensory Integration: Theory and
Practice, we reintroduced a chapter describing
the Sensory Integration and Praxis Tests (SIPT;
Chapter 8) ; introduced an entire chapter on clinical observations ( Chapter 9) ; and expanded the
information on assessing without the SIPT into a
chapter on its own ( Chapter 10 ). We retained an
updated and expanded version of the chapter on
interpreting test results related to sensory integrative dysfunction, illustrating that process with
multiple case examples ( Chapter 11 ).
Since the second edition of Sensory Integration: Theory and Practice, Parham and colleagues
developed and published a Fidelity Measure that
operationally defi nes sensory integrative therapy.
In providing clarifi cation of what actually constitutes sensory integrative therapy, the Fidelity
Measure has, arguably, had the greatest single
effect on the intervention chapters. In this third
edition, we label sensory integrative therapy as a
direct intervention with particular characteristics.
We offer a new chapter ( Chapter 14 ) illustrating
use of the Fidelity Measure as well as Miller and
colleagues’ STEP-SI and A SECRET models
as a means for distilling theory in practice and
making it more readily accessible. We retained
the chapters describing the art and science of
sensory integrative therapy ( Chapters 12 and 13 ,
respectively), but those chapters are so updated
that they barely resemble their second edition
predecessors.
In this third edition of Sensory Integration:
Theory and Practice, w e clearly separate sensory
integrative therapy from indirect approaches
that often employ SI or related theories (i.e.,
coaching). We offer a new chapter on coaching ( Chapter 17 ) that draws on, but is much
expanded over, the second edition chapter that
described use of SI theory as the basis for consultation in schools.
Recognizing the growth in thinking and options
regarding occupational therapy intervention for
children with motor coordination or sensory
regulation issues, we offer a new case-based
chapter ( Chapter 22 ) in which we view intervention for a child with poor motor coordination,
fi rst through a sensory integrative lens and then
through a Cognitive Orientation to daily Occupational Performance (CO-OP) lens. We retained
and updated a chapter on sensory-based interventions often used as a complement to or instead
of sensory integrative therapy ( Chapter 18 ),
including the Wilbarger Approach; the Alert
Program; Interactive Metronome®; Astronaut
Training; Infi nity Walk Training; Therapeutic
Listening®; Suck, Swallow, Breathe; and Aquatic
Therapy. In an attempt to be clear about the
relationship of each of these programs to SI, we
analyzed each in terms of three factors: whether
(1) the sensation provided is uni-modal or multimodal; (2) the approach is responsive or prescribed; and (3) the setting in which it is delivered
is traditional, nontraditional, or both. The authors
of each program described the background, rationale, and relationship of the program to SI and
occupation; benefi ts; and populations for which
it is appropriate.
We have peppered all the chapters in this
third edition with case examples. In addition, we
have included several chapters entirely devoted
to applying theory, assessment, or intervention
principles in a case context. We retained and
expanded a second edition chapter in which we
illustrate the process of planning and implementing intervention for the child with sensory integrative dysfunction ( Chapter 20 ) who was a case
example in the interpretation chapter described
earlier ( Chapter 11 ). We complement that chapter
with one comprising a case example of planning
and implementing intervention for a child with
autism spectrum disorder ( Chapter 21 ).
The question of whether or not sensory integrative therapy is effective theory has always generated conversation and controversy both within
and outside occupational therapy. In Chapters 15
and 16, we summarize the evidence from basic
science and from clinical studies. We close this
third edition with a chapter ( Chapter 23 ) addressing the complex question of effectiveness explicitly. We remind readers that sensory integrative
therapy comprises both art and science—and that
to try to divorce one from the other is to destroy
the essence of the intervention. Thus, researchers
who have failed to consider both art and science
have failed to test the effectiveness of sensory
integrative therapy. Therefore, they cannot know
whether or not it works.
We closed the Preface of the second edition
with a comment that seems as apt for this edition
as it was more than a decade ago:
Sensory integration theory, as much as any
theory in occupational therapy, depends on a
partnership of art and science. Science gives
sensory integration credibility; art gives it
Preface ■ xiii
meaning. Toward a partnership of art and
science, we offer these [new] works from a
number of outstanding theorists, researchers,
clinicians, and artists. Jean Ayres touched us all.
We carry the torch that she passed to us at her
death, fueling it with new perspectives and new
knowledge.
At the request of several reviewers and to make
this third edition more usable than previous editions for teaching, we added several pedagogical
features. Among these: chapter objectives, periodic “Here ’ s the Point” summaries, refl ections
of Practice Wisdom, brief summaries of relevant
studies we have labeled “Here ’ s the Evidence,”
and “enrichment” reading we have called “Where
Can I Find More?” We hope these, and all the
added features, will make learning and teaching
this content easier and more enjoyable. Above
all, we sought to create a text that students and
practitioners want to read. We hope we have met
our objective.
Anita C. Bundy
Shelly J. Lane
xv
CONTRIBUTORS
Teal W. Benevides, PhD, OTR/L
Department of Occupational Therapy
Jefferson College of Health Professions
Philadelphia, Pennsylvania
Rosemarie Bigsby, ScD, OTR/L, FAOTA
Clinical Professor of Pediatrics, Psychiatry, and
Human Behavior
The Warren Alpert Medical School of Brown
University
Coordinator, NICU Services at the Brown
Center for the Study of Children at Risk
Providence, Rhode Island
Erna Imperatore Blanche, PhD, FAOTA, OTR/L
Professor of Clinical Occupational Therapy
USC Chan Division of Occupational Science
and Occupational Therapy
University of Southern California
Los Angeles, California
Kim Bulkeley, PhD, BAppSc (OT)
Faculty of Health Sciences
University of Sydney
Sydney, Australia
Anita C. Bundy, ScD, OT/L, FAOTA
Professor and Department Head, Occupational
Therapy
Colorado State University
Ft. Collins, Colorado
Sharon A. Cermak, EdD, OTR/L, FAOTA
Professor, Joint Appointment with the Keck
School of Medicine of USC
Department of Pediatrics
USC Chan Division of Occupational Science
and Occupational Therapy
Los Angeles, California
Tina Champagne, OTD, OTR/L
Director of Occupational Therapy
Cutchins Programs for Children and Families
Northampton, Massachusetts
Robyn Chu, MOT, OTR/L
Owner of Growing Healthy Therapy Services
California, USA
Faculty STAR Institute for Sensory Processing
Disorder
Denver, Colorado
Joanna Cosbey, PhD, OTR/L
Assistant Professor
Occupational Therapy Graduate Program
The University of New Mexico
Albuquerque, New Mexico
Rachel Dumont, MS, OTR/L
Research Assistant, Department of Occupational
Therapy
Jefferson College of Health Professions
Philadelphia, Pennsylvania
Patricia Faller, OTD, OTR/L
Children ’ s Specialized Hospital
Toms River, New Jersey
Sheila Frick, OTR/L
Therapeutic Resources Inc.
Madison, Wisconsin
Gudrun Gjesing
Occupational Therapist
Specialist in Children ’ s Health & Baby
Swimming Instructor
Halliwick Lecturer
Haderslev, Denmark
Michael E. Gorman, PhD
Professor of Engineering and Society
University of Virginia
Charlottesville, Virginia
Dido Green, PhD, MSc, DipCOT
Reader in Rehabilitation
Oxford Brookes University
Oxford, United Kingdom
xvi ■ Contributors
Colleen Hacker, MS, OTR
Sensory Gym
Hobartville, New South Wales, Australia
Joanne Hunt, OTD, OTR/L
Children ’ s Specialized Hospital
Mountainside, New Jersey
Mary Kawar, MS, OT/L
Mary Kawar & Associates
San Diego, California
JoAnn Kennedy, OTD, MS, OTR/L
OT-Family Connections
Fairfax, Virginia
Dominique Blanche Kiefer, OTD, OTR/L
Director of Operations
Therapy West, Inc.
Los Angeles, California
Shelly J. Lane, PhD, OTR/L, FAOTA
Professor, Occupational Therapy
Colorado State University
Ft. Collins, Colorado
Teresa A. May-Benson, ScD, OTR/L, FAOTA
Executive Director
Spiral Foundation
Newton, Massachusetts
Molly McEwen, MHS, OTR/L, FAOTA
Consultant
Hillsboro, Oregon
Lucy J. Miller, PhD, OTR/L, FAOTA
Founder and Director Emeritus
Sensory Integration Dysfunction Treatment
and Research Center (STAR)
Research Director
Sensory Processing Disorder Foundation
Denver, Colorado
Shelley Mulligan, PhD, OTR/L, FAOTA
Associate Professor
Department of Occupational Therapy
University of New Hampshire
Durham, New Hampshire
Patricia Oetter, MA, OTR/L, FAOTA
Private Consultant
Therapy Coordinator
Camp Avanti
Amery, Wisconsin
Beth T. Osten, MS, OTR/L
Owner and Director
Beth Osten & Associates Pediatric Therapy
Services
Northbrook, Illinois
L. Diane Parham, PhD, OTR/L, FAOTA
Professor, Occupational Therapy Graduate
Program
School of Medicine
University of New Mexico
Albuquerque, New Mexico
Michele Parkins, MS, OTR
Founder & Executive Director
Great Kids Place
New Jersey, USA
Faculty STAR Institute for Sensory Processing
Disorder
Denver, Colorado
Beth Pfeiffer, PhD, OTR/L, BCP
Associate Professor, Department
of Rehabilitation Sciences
Temple University
Philadelphia, Pennsylvania
Gustavo Reinoso, PhD, OTR/L
Assistant Professor, Department of Occupational
Therapy
Nova Southeastern University-Tampa
Director, Advanced Therapy Systems (ATS)
Dundalk, Co Louth, Ireland
Stacey Reynolds, PhD, OTR/L, FAOTA
Associate Professor
Virginia Commonwealth University
Richmond, Virginia
Eileen W. Richter, MPH, OTR/L, FAOTA
Retired Former Co-Director, Camp Avanti
Amery, Wisconsin
Richter Active Integration Resources http://
www.richterair.com/
Contributors ■ xvii
Roseann C. Schaaf, PhD, OTR/L, FAOTA
Department of Occupational Therapy, Jefferson
College of Health Professions
Faculty of the Farber Institute of Neuroscience,
Thomas Jefferson University
Philadelphia, Pennsylvania
Sarah A. Schoen, PhD, OTR
Associate Director of Research
Sensory Processing Disorder Foundation
Associate Professor
Rocky Mountain University of Health
Professions
Denver, Colorado
Sherry Shellenberger, OTR/L
Co-Owner, TherapyWorks Inc.
Albuquerque, New Mexico
Susanne Smith Roley, OTD, OTR/L, FAOTA
Occupational Therapist
CenterPoint for Children
Founding Partner, Collaborative for Leadership
in Ayres Sensory Integration (CLASI)
Irvine, California
Virginia Spielmann, MS OT, PhD (cand)
Executive Director
STAR Institute for Sensory Processing Disorder
Denver, Colorado
Stacey Szklut, MS, OTR/L
Executive Director
South Shore Therapies Inc.
Weymouth, Massachusetts
Elke van Hooydonk, OTD, OTR/L
Children ’ s Specialized Hospital
Toms River, New Jersey
Julia Wilbarger, PhD, OTR/L
Chair, Associate Professor, Occupational
Therapy
Dominican University of California
San Rafael, California
Patricia Wilbarger, MEd, OTR/L
Retired
Santa Barbara, California
MarySue Williams, OTR/L
Co-Owner, TherapyWorks Inc.
Albuquerque, New Mexico
xxiii
CONTENTS IN BRIEF
Foreword ix
Preface xi
Contributors xv
Reviewers xix
PART I Theoretical Constructs
1 Sensory Integration: A. Jean Ayres’ Theory Revisited 2
2 Sensory Integration in Everyday Life 21
3 Composing a Theory: An Historical Perspective 40
PART II The Neuroscience Basis of Sensory Integration Disorders
4 Structure and Function of the Sensory Systems 58
5 Praxis and Dyspraxia 115
6 Sensory Modulation Functions and Disorders 151
7 Sensory Discrimination Functions and Disorders 181
PART III Tools for Assessment
8 Assessment of Sensory Integration Functions Using the Sensory Integration
and Praxis Tests 208
9 Using Clinical Observations within the Evaluation Process 222
10 Assessing Sensory Integrative Dysfunction without the SIPT 243
11 Interpreting and Explaining Evaluation Data 256
PART IV Intervention
12 The Art of Therapy 286
13 The Science of Intervention: Creating Direct Intervention from Theory 300
14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity 338
PART V Complementing and Extending Theory and Application
15 Advances in Sensory Integration Research: Clinically Based Research 352
16 Advances in Sensory Integration Research: Basic Science Research 371
17 Using Sensory Integration Theory in Coaching 393
18 Complementary Programs for Intervention 423
19 Application of Sensory Integration with Specifi c Populations 479
PART VI Cases
20 Planning and Implementing Intervention Using Sensory Integration Theory 532
21 Planning and Implementing Intervention: A Case Example of a Child with Autism 548
22 Viewing Intervention Through Different Lenses 560
23 Is Sensory Integration Effective? A Complicated Question to End the Book 568
xix
REVIEWERS
Auriela Alexander, OTD, OTR/L
Associate Professor
Division of Occupational Therapy
Florida A&M University
Tallahassee, Florida
Cindy Anderson, OTD, OTR/L
Associate Professor, Occupational Therapy
University of Mary
Bismarck, North Dakota
Evelyn Anderson, PhD, OTR/L
Associate Professor
Occupational Therapy Program
Midwestern University
Downers Grove, Illinois
Amy Armstrong-Heimsoth, OTD, OTR/L
Assistant Clinical Professor, Occupational
Therapy
Northern Arizona University
Phoenix, Arizona
Tamara Avi-Itzhak, D.Sc.
Associate Professor, Occupational Therapy
York College, The City University of New York
Jamaica, New York
Stephanie Beisbier, OTD, OTR/L
Assistant Professor, Professional Entry Program
Director
Occupational Therapy
Mount Mary University
Milwaukee, Wisconsin
Erna Imperatore Blanche, PhD, OTR/L, FAOTA
Associate Professor of Clinical Practice
Chan Division of Occupational Science
and Occupational Therapy at Ostrow
School of Dentistry
University of Southern California
Los Angeles, California
Jason Browning, MOT, OTR/L
Assistant Professor of Occupational Therapy
Jefferson College of Health Sciences
Roanoke, Virginia
Kim Bryze, PhD, OTR/L
Program Director and Professor, Occupational
Therapy Program
College of Health Sciences
Midwestern University
Downers Grove, Illinois
Debra Collette Allen, OTD, OTR/L
Assistant Professor, Occupational Therapy
The Sage Colleges
Troy, New York
Lisa Crabtree, PhD, OTR/L
Assistant Professor, Graduate Faculty
Occupational Therapy and Occupational Science
Towson University
Towson, Maryland
Denise Donica, DHSc, OTR/L, BCP, FAOTA
Associate Professor, Occupational Therapy
East Carolina University
Greenville, North Carolina
Deborah Dougherty, OTD, MS, OTR
Program Director, Graduate Occupational
Therapy Program
Department of Health Professions
Mercy College
Dobbs Ferry, New York
Beth Elenko, PhD, OTR/L
Assistant Professor, Occupational Therapy
SUNY Downstate Medical Center
Brooklyn, New York
Nancy Gabres, MS, OTR/L
Assistant Professor, Occupational Therapy
The College of St. Scholastica
Duluth, Minnesota
xx ■ Reviewers
Elizabeth Hebert, PhD, OTR/L
Assistant Professor of Occupational Therapy
Nazareth College
Rochester, New York
Caroline Hills, DipCOT, BSc, MSc, PCTE, PhD
Practice Education Coordinator, Occupational
Therapy
School of Health Sciences
National University of Ireland Galway (NUIG)
Galway, Ireland
Gregory Patrick Kelly, PhD, BSc (Hons)
Reader in Teaching and Learning, Senior Fellow
of the Higher Education Academy
School of Health Sciences
Ulster University
Newtownabbey, Co. Antrim, Northern Ireland
Mary Khetani, ScD, OTR/L
Assistant Professor, Occupational Therapy
University of Illinois at Chicago
Chicago, Illinois
Heather Kuhaneck, PhD, OTR/L, FAOTA
Associate Professor, Occupational Therapy
Sacred Heart University
Fairfi eld, Connecticut
Fengyi Kuo, DHS, OTR, CPRP
Visiting Professor; Occupational Therapy
Consultant
Occupational Therapy; Training and
Professional Development
Indiana University; LIH Olivia ’ s Place
Beijing & Shanghai, China
Alicia Lutman, OTD, MS, OTR/L, ATC
Associate Professor, Occupational Therapy
Shenandoah University
Winchester, Virginia
Heather Martin, MS, OTR
Instructor, Occupational Therapy
Mount Mary University
Milwaukee, Wisconsin
Ellen McLaughlin, EdD, OTR/L
Associate Professor, Occupational Therapy
Misericordia University
Dallas, Pennsylvania
Constance C. Messier, OTR/L, OTD
Assistant Professor, Occupational Therapy
Department of Occupational Therapy
Salem State University
Salem, Massachusetts
Michelle Mounteney, MS/OTR/L
Occupational Therapist and Clinical Assistant
Professor
Occupational Therapy
D’Youville College
Buffalo, New York
Shirley P. O’Brien, PhD, OTR/L, FAOTA
Professor/Foundation Professor, Occupational
Science and Occupational Therapy
Eastern Kentucky University
Richmond, Kentucky
Laurette Olson, PhD, OTR/L, FAOTA
Professor, Graduate Program in Occupational
Therapy
School of Health and Natural Sciences
Mercy College
Dobbs Ferry, New York
Rena Purohit, JD, OTR/L
Assistant Professor, Occupational Therapy
Touro College
New York, New York
Ellen Berger Rainville, OTD, OTR/L, FAOTA
Professor, Occupational Therapy
Springfi eld College
Springfi eld, Massachusetts
Teresa Schlabach, PhD, OTR/L, BCP
Associate Dean, College of Health and Human
Services
Professor, Occupational Therapy
St. Ambrose University
Davenport, Iowa
Leann M. Shore, OTD, MEd, OTR/L
Assistant Professor, Program in Occupational
Therapy
University of Minnesota
Minneapolis, Minnesota
Reviewers ■ xxi
Patricia Steffen-Sanchez, MS, OTR/L
Assistant Professor, Occupational Therapy
Midwestern University, College of Health
Sciences
Glendale, Arizona
Pamela Stephenson, OTD, MS, OTR/L
Assistant Professor of Occupational Therapy
Murphy Deming College of Health Sciences
(Mary Baldwin University)
Staunton, Virginia
MaryEllen Thompson, PhD, OTR/L
Professor and Graduate Coordinator
Occupational Science and Occupational Therapy
Eastern Kentucky University
Richmond, Kentucky
Ingris Treminio, DrOT, OTR/L
Clinical Assistant Professor
Department of Occupational Therapy
Florida International University
Miami, Florida
xxv
CONTENTS
Foreword ix
Preface xi
Contributors xv
Reviewers xix
PART I Theoretical Constructs
1 Sensory Integration: A. Jean Ayres’ Theory Revisited 2
Anita C. Bundy, ScD, OT/L, FAOTA and Shelly J. Lane, PhD, OTR/L, FAOTA
Learning Outcomes 2
Purpose and Scope 2
Sensory Integrative Dysfunction: Illustrating the Reasoning 3
CASE: Joshua 3
Introduction to Sensory Integration Theory 4
Postulates of Sensory Integration Theory 4
Illustrating Sensory Integration Theory 5
Sensory Integration Theory and Learning 5
Sensory Integrative Dysfunction 6
The Constructs 9
Dyspraxia 10
Sensory Modulation Dysfunction 11
Uniting Sensory Integration with Psychosocial Constructs 12
CASE: Joe 12
The Spiral Process of Self-Actualization 13
All Theories Are Based on Underlying Assumptions 15
Boundaries of Sensory Integration Theory and Intervention 15
Boundaries and the Population 15
Boundaries and Intervention 17
Boundaries and Critique 17
Summary and Conclusions 17
Where Can I Find More? 17
References 18
2 Sensory Integration in Everyday Life 21
L. Diane Parham, PhD, OTR/L, FAOTA and Joanna Cosbey, PhD, OTR/L
Learning Outcomes 21
Purpose and Scope 21
CASE: Nick 22
The Complexity of Everyday Life 23
Sensory Integration and Everyday Life: The Evidence 24
Play, Leisure, and Social Participation 25
Activities of Daily Living and Instrumental Activities of Daily Living 29
Rest and Sleep 30
Education and Work 30
xxvi ■ Contents
Implications for Assessment and Intervention 31
Assessment: Looking to the Future, Considering the Past 32
Consideration of Intervention Options 34
Summary and Conclusions 35
Where Can I Find More? 36
References 36
3 Composing a Theory: An Historical Perspective 40
Shelly J. Lane, PhD, OTR/L, FAOTA, Anita C. Bundy, ScD, OT/L, FAOTA, and Michael E. Gorman, PhD
Learning Outcomes 40
Purpose and Scope 40
A Little Background 40
Ayres the Person 41
Ayres the Professional: Developing Her Knowledge Base 42
Growth of Sensory Integration Theory and Research 45
Research and the Center for the Study of Sensory Integrative Dysfunction 45
SII and Growing Tension 46
Evolution of Ayres’ Work 49
Moving Forward 51
Summary and Conclusions 52
Acknowledgments 53
Where Can I Find More? 53
References 54
PART II The Neuroscience Basis of Sensory Integration Disorders
4 Structure and Function of the Sensory Systems 58
Shelly J. Lane, PhD, OTR/L, FAOTA
Learning Outcomes 58
Purpose and Scope 58
Basic Structure and Function of the Central Nervous System 58
Cells of the Central Nervous System 59
Central and Peripheral Nervous System Structure 60
Central Nervous System Geography 63
Central Nervous System Function 64
Terminology 65
The Somatosensory System 69
Receptors and Transduction 69
Dorsal Column Medial Lemniscal (DCML) Pathway 73
Interpreting Somatosensory Input 74
Spinocerebellar Pathways 77
Anterolateral (AL) System 78
Somatosensation from the Face 80
Functional Considerations 80
Interoception 82
Receptors and Transduction 82
Interpreting Interoceptive Input 83
Functional Considerations 83
The Vestibular System 84
Receptors and Transduction 84
Central Projections 88
Contents ■ xxvii
The Integrative Vestibular System 91
Vestibular and Proprioception Interactions 91
The Auditory System 91
Receptors and Transduction 92
Central Connections 93
Efferent Processes and Feedback Loops 95
The Visual System 95
Receptors and Transduction 96
Central Connections 98
Visual Experience Counts 100
Gustation and Olfaction 100
Taste and Taste Receptors 100
Taste Pathways 101
Smell and Smell Receptors 102
Smell Pathways 103
Clinical Links to Taste or Smell Sensitivity Differences 104
Summary and Conclusions 106
Where Can I Find More? 109
References 109
5 Praxis and Dyspraxia 115
Sharon A. Cermak, EdD, OTR/L, FAOTA and Teresa A. May-Benson, ScD, OTR/L, FAOTA
Learning Outcomes 115
Introduction 115
Purpose and Scope 116
The Role of Sensation in Movement and Praxis 116
Tactile System 117
Proprioception 117
Vestibular System 118
Vision 118
Auditory Processing 119
Assessing Disorders of Sensory Integration and Praxis 119
CASE: Alyssa 120
Reason for Referral 120
Parent Interview and Developmental/Sensory History 120
Teacher Questionnaire 121
CASE: Dalton 123
Reason for Referral 123
Parent Interview and Developmental/Sensory History 123
Teacher Interview 123
Disorders of Praxis 124
Patterns of Practic Dysfunction 124
Neuroanatomical Bases of Praxis 128
Ideation 128
Planning, Motor Learning, and Execution 129
Neuroimaging Findings in Children with Dyspraxia or DCD 131
Related Diagnoses and Terminology 131
Related Diagnoses 131
Dyspraxia Across Ages 133
Early Childhood 133
School Years 134
Adolescence and Adulthood 135
xxviii ■ Contents
Behavioral and Social-Emotional Characteristics of Children with Dyspraxia 135
Cognitive and Executive Function 136
The Intervention Process 137
Sensory Integration Principles for Praxis Intervention 137
Interventions for Motor Planning and Motor Coordination 138
Intervention for Ideation 140
CASE: Intervention for Alyssa and Dalton 141
Evidence for Interventions for Dyspraxia 142
Summary and Conclusions 143
Where Can I Find More? 143
References 143
6 Sensory Modulation Functions and Disorders 151
Shelly J. Lane, PhD, OTR/L, FAOTA
Learning Outcomes 151
Purpose and Scope 151
CASE: Michael 152
Sensory Modulation 152
Modulation as a Physiological Process at the Cellular Level 152
Modulation at the Level of Systems and Behavior 155
Sensory Modulation Dysfunction 157
A Brief Historical Overview 157
Proposed Central Nervous System Links to Sensory Modulation Dysfunction 159
Sensory Modulation Disorders 167
Tactile Defensiveness 167
Aversive Responses to Vestibular and Proprioceptive Inputs, Gravitational Insecurity,
and Vestibular and Proprioceptive Under-Responsiveness 171
Sensory Modulation Dysfunction in Other Sensory Systems 172
Sensory Modulation Disorder in Children with Additional Diagnoses 173
Summary and Conclusions 175
Where Can I Find More? 175
References 176
7 Sensory Discrimination Functions and Disorders 181
Shelly J. Lane, PhD, OTR/L, FAOTA and Stacey Reynolds, PhD, OTR/L
Learning Outcomes 181
Purpose and Scope 181
Sensory Discrimination 181
Sensory Discrimination: An Illustration 183
CASE: Ricky 183
Touch Discrimination 183
Foundations of Somatosensory Discrimination 183
Measurement of Somatosensory Discrimination 185
Movement Discrimination 186
Foundations of Proprioceptive Discrimination 186
Foundations of Vestibular Discrimination 187
Measurement of Movement Discrimination 187
Auditory Discrimination 190
Discrimination of “What” We Hear 190
Discrimination of “Where” We Hear 191
Measurement of Auditory Discrimination 192
Contents ■ xxix
Visual Discrimination 193
Foundations of Visual Perception and Discrimination 193
Measurement of Visual Perception and Discrimination 197
Taste and Smell Discrimination 199
Foundations of Taste Discrimination 199
Foundations of Smell Discrimination 200
Measurement of Taster Status and Taste or Smell Discrimination 200
Summary and Conclusions 201
Where Can I Find More? 201
References 201
PART III Tools for Assessment
8 Assessment of Sensory Integration Functions Using the Sensory Integration
and Praxis Tests 208
Shelley Mulligan, PhD, OTR/L, FAOTA
Learning Outcomes 208
Purpose and Scope 208
Description and Purpose of the Sensory Integration and Praxis Tests 208
Validity and Reliability of the Sensory Integration and Praxis Tests 211
Validity 211
Reliability 213
Analyses of SIPT Scores with Other Assessment Data for Completing Comprehensive
Evaluations of Children 213
Synthesis of Evaluation Data 214
CASE: Using the SIPT in the Evaluation Process: Lilly 216
Summary and Conclusions 220
Where Can I Find More? 220
References 220
9 Using Clinical Observations within the Evaluation Process 222
Erna Imperatore Blanche, PhD, FAOTA, OTR/L, Gustavo Reinoso, PhD, OTR/L, and
Dominique Blanche Kiefer, OTD, OTR/L
Learning Outcomes 222
Purpose and Scope 222
Assessment and Interpretation 226
Postural-Ocular Control 226
Prone Extension 226
Motor Planning 231
Additional Observations of Sensory Processing 236
Interpretation of Results 239
Summary and Conclusions 240
Where Can I Find More? 240
References 241
10 Assessing Sensory Integrative Dysfunction without the SIPT 243
Anita C. Bundy, ScD, OT/L, FAOTA
Learning Outcomes 243
Purpose and Scope 243
Introduction 243
xxx ■ Contents
Sensory Integration Theory Revisited 244
CASE: Lenard 245
Dyspraxia 247
CASE: Looking at Lenard ’ s Praxis 249
Assessment of Somatosensory Discrimination 249
Assessment of Postural and Ocular Control 250
CASE: Lenard ’ s Clinical Observations Performance 251
A Need for Caution and Clinical Reasoning in Testing without the SIPT 251
Assessment of Sensory Modulation Disorders 252
Sensory Processing Measure (SPM) 252
Sensory Profi le-2 (SP2) 252
CASE: Lenard ’ s Sensory Modulation and Our Conclusions 253
Summary and Conclusions 254
Where Can I Find More? 254
References 254
11 Interpreting and Explaining Evaluation Data 256
Anita C. Bundy, ScD, OT/L, FAOTA, Susanne Smith Roley, OTD, OTR/L, FAOTA, Zoe Mailloux, OTD, OTR/L,
FAOTA, L. Diane Parham, PhD, OTR/L, FAOTA, and Shelly J. Lane, PhD, OTR, FAOTA
Learning Outcomes 256
Purpose and Scope 256
Introduction 256
Referral and Developmental History 257
CASE: Kyle 257
Research Related to Sensory Integration and Praxis Patterns 261
CASE: Kyle: Interpreting the Results 272
Meaningful Clusters 272
Using the Interpretation Worksheet 272
The Final Stage of Interpretation 276
Reporting the Results 277
Somatodyspraxia 278
CASE: Jackie 278
Summary and Conclusions 281
Where Can I Find More? 281
References 282
PART IV Intervention
12 The Art of Therapy 286
Anita C. Bundy, ScD, OT/L, FAOTA and Colleen Hacker, MS, OTR
Learning Outcomes 286
Introduction 286
Purpose and Scope 287
CASE: Phoebe 287
The Artful Therapist: A Good Playmate 290
Vision 291
Auditory 291
Tactile 291
Proprioception 292
Vestibular 292
Play as the Basis of Sensory Integrative Therapy 292
Defi ning Play 293
Contents ■ xxxi
Play Element 1: Relative Intrinsic Motivation 293
Play Element 2: Relative Internal Control 295
Play Element 3: Freedom from Some Constraints of Reality 296
Play Element 4: Framing 296
Play and Fidelity to Treatment 297
Summary and Conclusions 298
Where Can I Find More? 298
References 298
13 The Science of Intervention: Creating Direct Intervention from Theory 300
Anita C. Bundy, ScD, OT/L, FAOTA, FOTARA and Stacey Szklut, MS, OTR/L
Learning Outcomes 300
Purpose and Scope 300
CASE: Sam 302
Providing Opportunities for Enhanced Sensation 302
Qualities Affecting the Intensity of Sensation 303
Intervention for Sensory Modulation Dysfunction 304
Treatment Guidelines for Sensory Over-Responsivity 304
Treatment Guidelines for Sensory Under-Responsivity 309
Modulating Arousal 310
Intervention for Practic Disorders 311
Promoting Planning 311
Promoting Bilateral Integration 315
Promoting Ideation 316
CASE: Alex 319
Initiating, Carrying Out, and Generalizing New Motor Tasks 319
Intervention for Increased Sensory Discrimination 320
Vestibular-Proprioceptive Discrimination: Postural-Ocular Control 320
Targeting Other Aspects of Proprioceptive-Vestibular Discrimination 329
Balancing Intervention for Multiple Types of Sensory Integrative Dysfunction 331
Practical Considerations for Intervention 331
Parent Involvement 332
Therapist Training 332
Therapist-to-Client Ratio 332
Length of Sessions 332
Physical Environment 332
Summary and Conclusions 333
Where Can I Find More? 333
References 334
14 Distilling Sensory Integration Theory for Use: Making Sense of the
Complexity 338
Learning Outcomes 338
Purpose and Scope 338
Resources to Guide Direct Intervention 339
Schematic Representation of Sensory Integration Theory 339
Ayres Sensory Integration ® Fidelity Measure (ASIFM) 339
L. Diane Parham, PhD, OTR/L, FAOTA
The STEP-SI 344
Lucy J. Miller, PhD, OTR/L, FAOTA
General Principles of STEP-SI 344
Models to Help Families Thrive 346
xxxii ■ Contents
A SECRET 346
Lucy J. Miller, PhD, OTR/L, FAOTA
Summary and Conclusions 348
Where Can I Find More? 348
References 348
PART V Complementing and Extending Theory and Application
15 Advances in Sensory Integration Research: Clinically Based Research 352
Sarah A. Schoen, PhD, OTR, Shelly J. Lane, PhD, OTR/L, FAOTA, and Lucy J. Miller, PhD, OTR/L, FAOTA
Learning Outcomes 352
Introduction 352
Purpose and Scope 353
Identifying and Defi ning the Disorders; Research Related to Assessment 353
Rating Scales: Standardized Report Measures 353
Standardized Performance Measures 355
Additional Measures of Performance and Parent or Self-Report 356
Research Related to Intervention 357
Previous Studies of Occupational Therapy with a Sensory-Based Approach 358
Future Directions 361
Research Related to the Disorders 362
Research Related to Impairments in Sensory Modulation and Sensory Integration 363
Research Related to Prevalence, Risk Factors, and Clinical Presentation 364
Future Directions 366
Summary and Conclusions 366
Where Can I Find More? 366
References 366
16 Advances in Sensory Integration Research: Basic Science Research 371
Sarah A. Schoen, PhD, OTR, Shelly J. Lane, PhD, OTR/L, FAOTA, Lucy J. Miller, PhD, OTR/L, FAOTA, and
Stacey Reynolds, PhD, OTR/L
Learning Outcomes 371
Introduction 371
Purpose and Scope 373
Research Related to Underlying Neurological Mechanisms 373
Studies of the Autonomic Nervous System 373
Neuroimaging 375
Animal Research: From Cages to Clinics 378
Life Span Studies 378
Impact of Treatment 379
Environmental Infl uences and Epigenetic Mechanisms 381
Drawing from Animal Research 383
Studies of SMD in Populations Comorbid for Other Conditions 383
Sources of Evidence: Physiological and Behavioral 384
Summary and Conclusions 387
Where Can I Find More? 387
References 387
17 Using Sensory Integration Theory in Coaching 393
Anita C. Bundy, ScD, OT/L, FAOTA and Kim Bulkeley, PhD, BAppSc (OT)
Learning Outcomes 393
Purpose and Scope 393
Contents ■ xxxiii
Myths Surrounding Coaching 394
Myth #1: Coaching Involves Therapists Training Teachers or Parents to Implement
Therapy (i.e., Do the Job of the Therapist) 394
Myth #2: Because a Parent or Teacher Implements the Intervention, Therapists
Spend Less Time with Children and, Therefore, Can Dramatically Increase Their
Caseloads 395
Myth #3: Coaching Is a Substitute for Direct Intervention 395
Defi ning Practices for Implementing Coaching 395
Building the Partnership and Need for Resources 398
Building the Partnership 398
Attaining Needed Resources 399
Examples of Coaching 400
CASE: Rebecca 400
CASE: Shaw 401
CASE: Duncan 401
Research Evidence for Coaching- and Sensory-Based Interventions Used Commonly in
Coaching with Families of Young Children with Autism 404
Mutual Information Sharing and Support (Category 1) 405
Adapting Tasks or the Environment (Category 2) 408
Embedding Sensory Input into Everyday Activity to Modulate Arousal (Category 3) 408
Self-Regulatory Strategies (Category 4) 410
Universal Design (Category 5) 410
Summary and Conclusions 411
Where Can I Find More? 412
References 412
18 Complementary Programs for Intervention 423
Learning Outcomes 423
Introduction 423
Three Areas of Sensory Integration 424
Purpose and Scope 424
Section 1: The Wilbarger Approach to Treating Sensory Defensiveness 426
Julia Wilbarger, PhD, OTR/L and Patricia Wilbarger, MED, OTR/L, FAOTA
Background 426
Rationale 426
Program Description 427
Education 427
Sensory Diet 428
Professionally Guided Intervention 428
Relationship to Sensory Integration and Occupation 429
Expected Benefi ts 430
Target Populations 430
Training Recommended or Required 431
CASE: Danielle 431
Section 2: The Alert Program ® for Self-Regulation 432
MarySue Williams, OTR/L, Sherry Shellenberger, OTR/L, and Molly McEwen, MHS, OTR/L, FAOTA
Background 432
Rationale 433
Program Description 434
Relationship to Sensory Integration and Occupation 435
Expected Benefi ts 436
xxxiv ■ Contents
Target Populations 437
Training Recommended or Required 437
CASE: Alert Program ® in a Public School System 437
Section 3: Aquatic Therapy 439
Gudrun Gjesing, Occupational Therapist, Specialist in Children ’ s Health & Swimming, Coach and Lecturer
Background 439
Rationale 439
Program Description 440
Relationship to Sensory Integration and Occupation 442
Expected Benefi ts 442
Target Populations 442
Training Recommended or Required 443
CASE: “The Alarm Clock” 443
Section 4: Interactive Metronome ® 445
Beth Osten, MS, OTR/L
Background 445
Rationale 446
Program Description 447
Relationship to Sensory Integration and Occupation 448
Expected Benefi ts 448
Target Populations 448
Training Recommended or Required 449
Case Examples 449
CASE: Lars 449
CASE: George 450
CASE: Martin 450
Section 5: Astronaut Training Program 452
Mary Kawar, MS, OT/L
Background 452
Rationale 453
Program Description 453
Relationship to Sensory Integration and Occupation 455
Expected Benefi ts 455
Target Populations 456
Training Recommended or Required 456
Case Examples 456
CASE: Rita 456
CASE: Robbie 457
CASE: George 457
CASE: Page 457
Section 6: Infi nity Walk Training 458
Mary Kawar, MS, OT/L
Background 458
Rationale 458
Program Description 458
Relationship to Sensory Integration and Occupation 460
Expected Benefi ts 460
Target Populations 460
Training Recommended or Required 461
CASE: Kevin 461
Contents ■ xxxv
Section 7: Therapeutic Listening® 462
Sheila Frick, OTR/L
Background 462
Rationale 462
Program Description 463
Relationship to Sensory Integration and Occupation 463
Expected Benefi ts 464
Target Populations 465
Training Recommended or Required 465
CASE: Christopher 465
Section 8: Applying Suck/Swallow/Breathe Synchrony Strategies to Sensory
Integration Therapy 466
Patricia Oetter, MA, OTR/L, FAOTA and Eileen W. Richter, MOH, OTR/L, FAOTA
Background 466
Rationale 467
Program Description 468
Relationship to Sensory Integration and Occupation 469
Expected Benefi ts 470
Target Populations 470
Training Recommended or Required 470
CASE: Elisha 470
Summary and Conclusions 472
Where Can I Find More? 473
References 473
The Wilbarger Approach to Treating Sensory Defensiveness 473
The Alert Program ® for Self-Regulation 474
Aquatic Therapy 475
Interactive Metronome® 475
Astronaut Training 476
Infi nity Walk 477
Therapeutic Listening® 477
Suck, Swallow, Breathe 477
19 Application of Sensory Integration with Specifi c Populations 479
Learning Outcomes 479
Introduction 479
Section 1: Sensory Integration Applications with Infants in Neonatal Intensive Care
and Early Intervention 481
Rosemarie Bigsby, ScD, OTR/L, FAOTA
Background and Rationale for Applying Sensory Integration 481
Sensory Integration in Early Infancy and Associated Occupation-Based
Challenges 481
Evaluation and Intervention in the NICU 483
Evaluation and Intervention in Early Intervention Programs 485
CASE: Lily 487
Where Can I Find More? 489
Section 2: Sensory Integration Approaches with Individuals with Attention
Defi cit-Hyperactivity Disorder 489
Shelley Mulligan, PhD, OTR/L, FAOTA
Background and Rationale for Applying Sensory Integration 489
Sensory Integration and Associated Occupation-Based Challenges 490
xxxvi ■ Contents
Evaluation and Intervention 491
CASE: Morgan 494
Where Can I Find More? 496
Section 3: Applying Sensory Integration Principles for Children with Autism
Spectrum Disorder 496
Teal W. Benevides, PhD, OTR/L, Rachel Dumont, OTR/L, MS, and Roseann C. Schaaf, PhD, OTR/L, FAOTA
Background and Rationale for Applying Sensory Integration 496
Sensory Integration and Occupation-Based Challenges 496
Evaluation and Intervention 498
CASE: Martin 499
Where Can I Find More? 502
Section 4: Sensory Integration and Children with Disorders of Trauma and
Attachment 502
JoAnn Kennedy, OTD, MS, OTR/L
Background and Rationale for Applying Sensory Integration 502
Sensory Integration and Associated Occupation-Based Challenges 504
Evaluation and Intervention 504
CASE: Ted 505
Where Can I Find More? 507
Section 5: Sensory Integration Applications with Adults 507
Beth Pfeiffer, PhD, OTR/L, BCP
Background and Rationale for Applying Sensory Integration 507
Sensory Integration and Associated Occupation-Based Challenges 508
Evaluation and Intervention 508
CASE: George 511
Where Can I Find More? 512
Section 6: Sensory Integration Approaches with Adults with Mental Health
Disorders 513
Tina Champagne, OTD, OTR/L and Beth Pfeiffer, PhD, OTR/L, BCP
Background and Rationale for Applying Sensory Integration and the Impact on
Occupation 513
Schizophrenia 513
Anxiety Disorders 514
Trauma and Stress-Related Disorders 515
Mood Disorders 516
Evaluation and Intervention 516
Case Studies 518
CASE: Janelle 518
CASE: Amy 519
Where Can I Find More? 521
Summary and Conclusions 521
References 521
PART VI Cases
20 Planning and Implementing Intervention Using Sensory Integration
Theory 532
Anita C. Bundy, ScD, OT/L, FAOTA and Susanne Smith Roley, OTD, OTR/L, FAOTA
Learning Outcomes 532
Purpose and Scope 532
Contents ■ xxxvii
Introduction 532
Kyle Revisited 533
Conducting the Comprehensive Evaluation 533
Generating Hypotheses 533
Developing and Setting Goals and Objectives 534
Summary of the Intervention Plan 537
Setting the Stage for Intervention 537
Providing Intervention 540
Summary and Conclusions 546
Where Can I Find More? 547
References 547
21 Planning and Implementing Intervention: A Case Example of a Child
with Autism 548
Roseann C. Schaaf, PhD, OTR/L, FAOTA, Joanne Hunt, OTD, OTR/L, Elke van Hooydonk, OTD, OTR/L,
Patricia Faller, OTD, OTR/L, Teal W. Benevides, PhD, OTR/L, and Rachel Dumont, OTR/L, MS
Learning Outcomes 548
Purpose and Scope 548
Introduction 548
Kendra Revisited 549
Identifying Participation Challenges 549
Conducting the Comprehensive Evaluation 550
Generating Hypotheses 551
Developing and Setting Goals and Objectives 552
Context and Schedule for Service Delivery 553
Setting the Stage for Intervention 554
Providing Intervention 554
Ongoing Clinical Reasoning 557
Outcomes Following 10 Weeks of Intervention 557
Summary and Conclusions 558
Where Can I Find More? 558
References 558
22 Viewing Intervention Through Different Lenses 560
Anita C. Bundy, ScD, OT/L, FAOTA and Dido Green, PhD, MSc, DipCOT
Learning Outcomes 560
Purpose and Scope 560
Looking at Lars Through a Modifi ed Sensory Integrative Lens 561
Discussion 562
The CO-OP Approach™ 564
Looking at Lars Through the CO-OP Approach™ Lens 564
Second Goal: Bike Riding 566
Summary and Conclusions 567
Where Can I Find More? 567
References 567
23 Is Sensory Integration Effective? A Complicated Question to
End the Book 568
Anita C. Bundy, ScD, OT/L, FAOTA and Shelly J. Lane, PhD, OTR/L, FAOTA
Learning Outcomes 568
Purpose and Scope 568
Sensory Integration as Science 569
The Art of Therapy 570
xxxviii ■ Contents
The Challenge of Finding Effectiveness 572
Sensory Integration as Part of Occupational Therapy 574
Summary and Conclusions 575
Where Can I Find More? 575
References 575
Appendix The STAR Process: An Overview 578
Lucy J. Miller, PhD, OTR/L, FAOTA, Robyn C. Chu, MOT, OTR/L, Michele Parkins, MS, OTR,
Virginia Spielmann, MSOT, and Sarah A. Schoen, PhD, OTR
Glossary 585
Index 595
PART
I
Theoretical
Constructs
2
CHAPTER
1
Sensory Integration:
A. Jean Ayres’ Theory Revisited
Anita C. Bundy , ScD, OT/L, FAOTA ■ Shelly J. Lane , PhD, OTR/L, FAOTA
Chapter 1
Upon completion of this chapter, the reader will be able to:
✔ Describe the basic principles of sensory
integration (SI) theory.
✔ Compare and contrast the various schematic
representations of SI theory, realizing that they
all illustrate the same theory.
✔ Describe a hypothesized relationship between
constructs associated with SI theory and the
Model of Human Occupation (e.g., volition;
belief in skills).
✔ Compare and contrast two main categories
of SI dysfunction: dyspraxia and sensory
modulation dysfunction.
✔ Distinguish between two types of dyspraxia
(i.e., defi cits in bilateral integration and
sequencing, somatodyspraxia) and two types
of sensory modulation dysfunction (i.e.,
over-responsivity; under-responsivity) in terms
of hypothesized sensory bases and overt
indicators.
✔ Identify assumptions and boundaries of SI
theory and SI intervention.
Just as the continued production of research results in constantly changing
neurological concepts, so also will [sensory integration]
theory need to undergo frequent revision.
—A. Jean Ayres ( 1972b, p . ix)
LEARNING OUTCOMES
Purpose and Scope
A. Jean Ayres’ sensory integration (SI) theory
has sparked more research, had a more marked
effect on, and generated more controversy than
any other theory developed by an occupational
therapist. Originally, Ayres, an occupational therapist with advanced training in neuroscience and
educational psychology, developed SI theory to
explain relationships between defi cits in interpreting sensation from the body and the environment and diffi culties with academic and motor
learning.
Ayres’ knowledge of neuroscience led her to
observe defi cits in learning and behavior and
hypothesize that those defi cits were the result
of poor processing of sensation in the central
nervous system (CNS). In other words, she
hypothesized relationships among areas of the
CNS and various behavioral constructs. Although
knowledge of neurophysiology has grown exponentially in the intervening years, many of the
links that Ayres hypothesized have been upheld.
(See Chapter 4 , Structure and Function of the
Sensory Systems, and Chapter 6 , Sensory Modulation Functions and Disorders.) Some, of course,
remain hypotheses. (See Chapter 23 , Is Sensory
Integration Effective? A Complicated Question
to End the Book.)
Drawing from her doctoral study in educational psychology, Ayres developed tests to
measure the constructs associated with SI theory
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 3
and examine their relationships. Many other
researchers have since replicated and extended
Ayres’ research—for the most part upholding
her fi ndings. (See also Chapter 15 , Advances in
Sensory Integration Research: Clinically Based
Research.)
Based on the hypothesized relationships
among theoretical constructs, Ayres developed SI
therapy. When she observed changes in learning
and behavior in children who received the intervention, she hypothesized that those improvements refl ected improved SI and enhanced
neural functioning. Ayres ( 1972a, 1976 ) then
tested the effectiveness of SI therapy through
research, supporting her hypotheses. Several
other researchers subsequently tested the effectiveness of SI therapy, some supporting the
intervention and others questioning its effectiveness. We summarize some of that research
in Chapter 15 (Advances in Sensory Integration
Research: Clinically Based Research) and refl ect
on the mixed fi ndings in Chapter 23 (Is Sensory
Integration Effective? A Complicated Question
to End the Book).
Ayres died more than 30 years ago. Although
numerous authors have proposed alternative terminology and represented SI theory in different
ways, the theory remains remarkably similar to
that which Ayres proposed. In this chapter, we
demonstrate the continuity of the theory.
SI therapy, too, bears marked similarity
to that which Ayres implemented in her own
clinic. In creating a fi delity measure, Parham
and colleagues ( 2011 ) clarifi ed the criteria for SI
therapy. Those criteria are now applied in, and to,
research and practice. (See Chapter 14 , Distilling Sensory Integration Theory for Use: Making
Sense of the Complexity.) Research, although
not unequivocally demonstrating the effectiveness of the therapy, has made great strides in that
direction. The return to studying SI therapy in its
entirety—art and science—has made important
contributions to demonstrating effectiveness.
This chapter provides an introduction to the
theory now known as Ayres Sensory Integration ® (ASI). We list the constructs associated
with the theory and illustrate their hypothesized
relationships. We describe two major categories of SI dysfunction: dyspraxia and sensory
modulation dysfunction. Within each of those
categories, we defi ne different subtypes: for
dyspraxia, diffi culties with vestibular bilateral
integration and sequencing (VBIS) and somatodyspraxia; for sensory modulation dysfunction,
over-responsivity (i.e., sensory defensiveness,
gravitational insecurity, and aversive responses
to movement) and under-responsivity. We offer
a model expanding Ayres’ conceptualization of
SI to explicitly include psychosocial sequelae.
We compare schematic representations created
by numerous authors illustrating SI theory in different ways. We describe the boundaries of the
theory and intervention with regard to the populations to whom it can be applied and the nature
of the intervention.
In this chapter, we do not attempt to explain
the neurological underpinnings of SI. Neither
do we critique the assessments associated with
the theory, describe the intervention in detail, or
discuss the research examining its effectiveness.
We cover all that in chapters comprising the
subsequent seven sections: (1) Theory; (2) Sensory Integrative Dysfunction and Hypothesized
Neu roscience Underpinnings; (3) Assessment;
(4) Intervention; (5) Research; (6) Complementing and Extending the Theory and Its Application; (7) Applications.
Sensory Integrative Dysfunction:
Illustrating the Reasoning
CASE STUDY ■ JOSHUA
Joshua has poor gross motor coordination and
diffi culty learning new motor tasks. Some of
the other children in his class play baseball on a
local team, but Josh cannot catch, throw, or bat
nearly well enough to be included. Although
he rides his bicycle everywhere, learning to
ride took more effort for him than for others.
However, he prefers riding the bicycle to a
skateboard, which he found “just too hard.”
On standardized testing, Josh had diffi culty
discriminating touch, imitating postures, and
reproducing movement sequences that involve
coordinated use of both sides of the body. On
standard clinical observations, he had poor
posture and ineffective equilibrium reactions.
Josh has no evidence of peripheral nervous
system or CNS damage and he is of average
intelligence. Therefore, because empirical evidence consistently links diminished ability to
discriminate body sensations with poor praxis,
4 ■ PART I Theoretical Constructs
we speculated that Josh ’ s problems were caused
by sensory integrative dysfunction. We further
speculated that sensory integrative therapy
would improve Josh ’ s ability to integrate sensation and plan actions. Sensory integrative
therapy involves active engagement in activities
providing a “just right challenge” and inherent
opportunities to take in enhanced tactile, vestibular, and proprioceptive sensations.
We hypothesized that if, after a trial of intervention, Josh ’ s coordination seemed better, we
would attribute the changes to improved SI
and motor planning. Even without the ability
to directly observe CNS processing, we would
also hypothesize that improvements in processing were present.
Introduction to Sensory
Integration Theory
Ayres ( 1972b ) defi ned sensory integration as
“the neurological process that organizes sensation from one ’ s own body and from the environment and makes it possible to use the body
effectively within the environment” (p. 11). Ayres
focused on the vestibular, proprioceptive, and
tactile systems—perhaps because she believed
that researchers had ignored them in favor of the
visual and auditory systems. Although the vestibular, tactile, and proprioceptive systems take
center stage in Ayres’ theory, she did not discount the importance of the visual and auditory
systems. In fact, Ayres ( 1972b, p . 73) indicated
that “the human being is not only a highly visual
animal, he is . . . so conscious of being visual
that the very word ‘perception’ is usually construed to mean visual perception” (italics added).
Nonetheless, Ayres felt that visual perception
was an end product and that the vestibular system
was its main foundation ( Sieg, 1988 ). Similarly,
Ayres studied the effect of sensory integrative
therapy on children with auditory-language diffi culties, believing that the relationship between
the vestibular and auditory systems meant they
might be good candidates for the intervention.
Although Ayres ( 1979 ) included the auditory
and visual systems in her schematic representations of SI theory (see, for example, Fig. 1-3 ),
she never fully fl eshed out their contributions to
the theory. Currently, therapists implementing
sensory integrative therapy often also prescribe
PRACTICE WISDOM
Theory Is Not Fact
SI is a theory of brain–behavior relationships.
Theories are provisional statements that help to
• Explain why people behave in particular
ways
• Develop intervention to ameliorate related
diffi culties
• Predict how behavior will change because of
intervention
programs such as Interactive Metronome® and
Therapeutic Listening® that target the auditory
system (see Chapter 18 , Complementary Programs for Intervention). Similar to Ayres, we
include the visual and auditory systems in the
model we use throughout this text ( Fig. 1-6 )
and in Chapter 4 (Structure and Function of the
Sensory Systems). However, even now, SI theory
has not expanded to embrace these systems fully.
Postulates of Sensory
Integration Theory
SI theory is not only about dysfunction and
intervention. It also postulates that effi cient SI
underlies learning. Thus, SI theory comprises
three broad postulates. The fi rst describes SI and
learning. The second defi nes sensory integrative
dysfunction. The third guides intervention.
1. Learning, in the broadest sense, is dependent
on the ability to process and integrate
sensation and use it to plan and organize
behavior. This postulate has given rise to
the constructs included in the theory and
described throughout this book.
2. A decreased ability to process and integrate
sensation may result in diffi culty producing
appropriate actions, which, in turn, may
interfere with learning and behavior. This
postulate has given rise to standardized
tests refl ecting the various constructs of
the theory. See Chapter 8 (Assessment of
Sensory Integration Functions Using the
Sensory Integration and Praxis Tests) and
Chapter 9 (Using Clinical Observations
within the Evaluation Process) and also
Dunn ( 2014 ), and Parham, Ecker, Kuhaneck,
Henry, and Glennon ( 2010 ).
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 5
3. Sensations generated and integrated in the
context of a “just right challenge” contribute
to improved CNS processing, thereby
enhancing learning and behavior. This
postulate has given rise to sensory integrative
therapy. See also Chapter 12 (The Art of
Therapy) and Chapter 13 (The Science of
Intervention: Creating Direct Intervention
from Theory).
Illustrating Sensory
Integration Theory
Schematic representations are a good way of
portraying the essence of a theory by displaying
the relationships among the constructs. Creators
of schematics select the constructs and illustrate
their relationships in the ways that make sense
to them and emphasize the points they fi nd most
salient. Thus, different authors often represent
the same theory in slightly different ways.
Sensory Integration Theory
and Learning
In Figure 1-1 , we depict the contribution of SI
theory to learning, very simplistically, as a circular process. The process begins with taking in
sensation and culminates with sensory feedback.
Feedback, together with new sensory intakes,
in turn, initiate a new cycle of learning. In
Figure 1-2 , we broaden the schematic shown in
Figure 1-1 , overlaying the dysfunction, evaluation, and intervention postulates of SI theory on
the intake, processing, and feedback circle.
Ayres ( 1979 ) focused on the contribution of
SI to learning in the complex schematic representation shown in Figure 1-3 . At the far left of
the schematic, she listed all the senses (i.e., the
FIGURE 1-1 A schematic representation of the learning component of SI theory.
FIGURE 1-2 A simple representation of the three
postulates of SI theory.
Intervention
Feedback
Evaluation
Sensory
integration
Sensory
intake
Adaptive
interaction
Hypothesized
Site of Problem
Planning
and
organizing
behavior
6 ■ PART I Theoretical Constructs
sources of sensory intake and feedback). Moving
to the right, Ayres described increasingly complex
outcomes related to effi cient processing of sensation, labeling them “integration of inputs” and
“end products.” On the schematic, Ayres used
brackets to associate the outcomes with relevant
senses. Her schematic clearly shows the hypothesized contributions of the vestibular, proprioceptive, and tactile systems to learning but also
includes the auditory and visual systems. The
further to the right that one moves on Figure 1-3 ,
the more distant the inputs from the simple sensations and the more that other factors potentially
come into play. For example, ability to concentrate, located at the far right, depends on all the
senses, as shown by the bracket. But ability to
concentrate also depends on many other factors
(e.g., cognition, interest, and environment).
Sensory Integrative Dysfunction
In Figure 1-4 , we present a simple schematic
representation of the two major categories of
sensory integrative dysfunction: sensory modulation dysfunction and dyspraxia. As the diagram
shows, individuals with sensory integrative dysfunction can have one or both types of dysfunction. This simple representation is a broad-brush
illustration of sensory integrative dysfunction,
showing the big categories but lacking detail
about subcategories.
Miller and her colleagues ( Miller, Anzalone,
Lane, Cermak, & Osten, 2007 ) also created a
schematic representation of sensory integrative
dysfunction, which they referred to as a “nosology” (i.e., a system for classifying diseases).
However, rather than use the label sensory integrative dysfunction, they coined the term sensory
FIGURE 1-3 Ayres’ ( 1979 ) schematic representation of SI theory. Sample items of the Sensory Integration
and the Child, 25th Anniversary Edition copyright © 2005, by Western Psychological Services. Reprinted by
permission of the publisher, Western Psychological Services. Not to be reprinted in whole or in part for any
additional purpose without the expressed, written permission of the publisher (rights@wpspublish.com). All
rights reserved.
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 7
processing disorder. (See Fig. 1-5 .) The constructs included in the nosology are remarkably
similar to those that Ayres described in SI theory
and, in fact, were determined largely based on
Ayres ( 1972c, 1989 ) and other researchers (e.g.,
DeGangi, 2000 ; Dunn, 2001 ; Mulligan, 1996,
1998, 2000 ) who sought to build on Ayres’ fi ndings ( Miller et al., 2007 ). The nosology confi rms
that it is possible to change a name without
changing the basic theory.
Miller et al. ’ s ( 2007 ) nosology is simple and,
in many ways, elegant. However, one diffi culty
with the nosology is that it fails to depict explicit
links between sensory systems and behaviors.
For example, the links between posture and
the vestibular and proprioceptive systems, or
between praxis and aspects of sensory discrimination, seen in Ayres’ model are not included in
Miller et al. ’ s nosology.
FIGURE 1-5 Miller et al. ’ s ( 2007 ) nosology of sensory processing disorders. Republished with permission of
AOTA, from Concept Evolution in Sensory Integration: A Proposed Nosology for Diagnosis by Lucy Jane Miller,
Marie E. Anzalone, Shelly J. Lane, Sharon A. Cermak, and Elizabeth T. Osten; volume 61, March/April 2007.
We created the schematic shown in Figure 1-6
to represent hypothesized relationships between
the sensory systems and behavioral manifestations of sensory integrative dysfunction.
Although this schematic focuses on dysfunction rather than function, Figure 1-6 is organized similarly to Ayres’ schematic ( Fig. 1-3 ).
However, Figure 1-6 is read outward from the
center column where CNS processing of sensation is depicted. Indicators of poor SI and praxis
are shown on the right, and indicators of sensory
modulation dysfunction appear on the left. This
enables us to show the two manifestations of
sensory integrative dysfunction: dyspraxia and
sensory modulation dysfunction, and their relationship to the processing of sensation. As shown
in Figure 1-4 , an individual can have one or both
of these broad categories of sensory integrative
dysfunction.
In Figure 1-6 , the closer the columns are to the
center, the more direct the relationship with processing of sensation. For example, postural ocular
control appears in the column just to the right of
the center column (i.e., on the praxis side). Processing of vestibular and proprioceptive sensation is related directly to postural ocular control.
In fact, in SI theory, a meaningful cluster of postural ocular reactions is regarded as a direct manifestation of vestibular proprioceptive processing.
(See also Chapter 4 , Structure and Function of
the Sensory Systems, and Chapter 9 , Using Clinical Observations within the Evaluation Process.)
In other words, although we cannot see poor
vestibular proprioceptive processing, we see a FIGURE 1-4 Simplifi ed representation of
manifestation of SI dysfunction.
Dyspraxia Poor sensory
modulation
SI
dysfunction
8 ■ PART I Theoretical Constructs
meaningful cluster of behaviors that defi ne poor
postural control and we interpret these behaviors
as refl ecting diffi culties with processing vestibular proprioceptive sensations. Similarly, body
scheme (i.e., the sense of where body parts are
in relation to one another) is tied directly to the
processing of sensation although it is not readily
observable. We interpret actions in which children seem unaware of the relationship of body
parts to one another or to objects as refl ecting
poor body scheme.
As we move further to the right side
on Figure 1-6 , similar to Ayres’ schematic
( Fig. 1-3 ), the columns contain constructs tied
less directly to processing of sensation. Those
constructs are complex and many factors contribute to their quality. Defi cits in praxis (i.e.,
VBIS, somatodyspraxia) comprise one column.
The columns further to the right contain abstract
constructs common in individuals with poor
praxis but which, by themselves, are not indicators of sensory integrative dysfunction: poor
self-effi cacy, avoidance, and other similar items.
That is, many factors besides sensory integrative dysfunction can cause poor self-effi cacy,
and so on.
In Figure 1-6 , indicators of poor sensory
modulation appear in the columns on the left.
The closer the columns to the center, the more
directly they refl ect processing of sensation. Each
sensory system may be associated directly with
over- or under-responsivity. The constructs that
appear further to the left (e.g., sensory-related
challenges with attention, withdrawal, seeking,
and, ultimately, challenges with occupational
engagement) are common in individuals with
sensory modulation defi cits but they are complex
and infl uenced by multiple factors.
Challenges with occupational engagement
comprise the columns at the farthest left and the
farthest right. Although some of the labels within
those columns are the same, we expect the nature
of the challenges that result from poor modulation to differ from those related to dyspraxia. For
example, both groups of children might have diffi culty with dressing or completing school work.
The challenges for a child with poor modulation
might stem from diffi culties maintaining attention, whereas those for a child with dyspraxia
would refl ect the motor challenge. Similarly, both
groups might have diffi culty with self-esteem or
self-effi cacy. Children with a sensory modulation
FIGURE 1-6 Complex schematic representation of sensory integrative dysfunction.
Autonomic Limbic Reticular Thalamus Cerebellum Basal Ganglia Cortex
Behavioral
consequences
Indicators of
poor sensory
modulation
Over-
responsivity
• Aversive
and
defensive
reactions
Under-
responsivity
• Poor
registration
Inadequate
CNS integration
and processing
of sensation
Visual
Vestibular
Tactile
[lnteroception]
Auditory
Olfactory
Gustatory
Proprioception
Indicators of poor sensory
integration and praxis
Poor
postural-ocular
control
Poor sensory
discrimination
• Tactile
• Proprioception
• Vestibular
• Visual
• Auditory
Poor body
scheme
Sensory reactivity
Sensory perception
VBIS
Behavioral
consequences
Poor selfefficacy,
self-esteem
Sensory
seeking
Poor
organization
Poor gross,
fine, and
visual motor
coordination
Avoidance of
engagement
in motor
activities
Clowning
Occupational Engagement Challenges
Occupational Engagement Challenges
Sensoryrelated
challenges
with attention,
regulation,
affect, activity
Somatodyspraxia
Poor selfefficacy,
self-esteem
Withdrawal
from, and
avoidance of,
sensory
experiences
Sensory
seeking
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 9
disorder, for example, may have decreased
self-esteem because they are often in trouble for
misbehaving, and may come to see themselves
as bad or worthless (i.e., low self-esteem) or
not as capable as others (i.e., low self-effi cacy).
Children with dyspraxia, on the other hand, may
experience low self-effi cacy because they perceive their motor skills as inferior to those of
peers and low self-esteem because they believe
that people with poor motor skills are less valuable than people with good motor skills. Sensory
seeking also appears on the extremes of both
sides of the model as a behavior associated with
sensory under-responsivity or poor body scheme,
when a child seeks unusually great amounts of
sensation to augment the sense of where his or
her body parts are in space.
HERE ’ S THE POINT
• The initial model of SI was developed by A.
Jean Ayres, and it depicts SI function.
• The current model, used throughout this
text, is one depicting two broad categories of
dysfunction, dyspraxia and sensory modulation
disorders.
The Constructs
The two primary categories of sensory integrative
dysfunction, dyspraxia and sensory modulation
dysfunction, deserve some further explanation.
In Table 1-1 , we briefl y defi ne and describe the
constructs associated with each category.
TABLE 1-1 Constructs Associated with Sensory Integrative Dysfunction
CONSTRUCTS ASSOCIATED WITH DYSPRAXIA
Construct Brief Description Hypothesized Cause Related Chapters
VBIS Diffi culty planning and using
the two sides of the body
in a coordinated fashion
and sequencing anticipatory
(feedforward-dependent) motor
actions (e.g., Schmidt & Lee, 2011 )
Poor central processing
of vestibular and
proprioceptive sensations,
seen as poor posturalocular control
5: Praxis and Dyspraxia
9: Using Clinical
Observations within the
Evaluation Process; for
assessment of bilateral
coordination and projected
action sequences
Somatodyspraxia More severe form of dyspraxia
than VBIS
Defi cits in body scheme
resulting from poor
sensory discrimination,
esp. tactile, proprioceptive,
or vestibular
5: Praxis and Dyspraxia;
for a thorough description
of somatodyspraxia
Poor posturalocular control
Basis for VBIS and sometimes for
somatodyspraxia. Seen in
• Low extensor muscle tone
• Decreased ability to assume
anti-gravity postures
• Poor proximal stability
• Poor equilibrium
• Depressed postrotary nystagmus
Outward manifestation
of defi cits in vestibular or
proprioceptive processing
7: Sensory Discrimination
Functions and Disorders
9: Using Clinical
Observations within the
Evaluation Process
Poor body
scheme
Defi cits in the internal map
representing the spatial
relationship of body parts
Poor discrimination of
tactile and proprioceptive
(i.e., somatosensory)
sensations
4: Structure and Function
of the Sensory Systems
5: Praxis and Dyspraxia
Poor sensory
discrimination
Poor interpretation of the
spatiotemporal characteristics
of sensation (i.e., Where? How
intense? Direction of movement?)
Poor CNS processing of
inputs in any sensory
system
4: Structure and Function
of the Sensory Systems
7: Sensory Discrimination
Functions and Disorders
10 ■ PART I Theoretical Constructs
Dyspraxia
In sensory integrative theory, dyspraxia refers to
diffi culty planning new movements stemming
from poor body scheme that, in turn, results from
defi cits in processing vestibular, proprioceptive,
or tactile sensation. Ayres ( 1985 ) described ideation (i.e., the formation of ideas for action) as
a cognitive component of praxis. Two decades
later, May-Benson ( 2001, 2005 ; May-Benson &
Cermak, 2007 ) explored ideation and sensoryintegrative-based dyspraxia more fully. And
although it seems clear that some children with
dyspraxia, particularly those with more severe
forms, have diffi culty with ideation, to date no
researchers have included data refl ecting ideation in a factor analytic study examining its
relationship to other constructs of SI theory or
situating it within types of dyspraxia.
In this text, we describe two types of dyspraxia: VBIS dysfunction and somatodyspraxia.
As you see in Table 1-1 , we hypothesize that
VBIS is a less severe practic defi cit than somatodyspraxia. We base that on research suggesting that praxis is a single construct (e.g., Lai,
Fisher, Magalhaes, & Bundy, 1996 ; Mailloux
et al., 2011 ; Mulligan, 1996, 1998, 2000 ) and on
extensive practical experience. The argument for
praxis as a single construct with VBIS as less
severe and somatodyspraxia as more severe is
logical given that children with somatodyspraxia
have diffi culty with both simple (feedbackdependent) and complex (feedforward-dependent)
PRACTICE WISDOM
When actions are controlled by feedback, they
can be adjusted in response to that feedback.
For example, when a child stops a ball with his
or her foot before kicking it, the child can adjust
the direction of the kick in response to the tactile
and proprioceptive feedback received through his
or her foot and leg. When movements are under
feedforward-control, a child must move his or her
hand or foot to a particular location before the
object on which he or she will act arrives at that
location. Feedforward-dependent actions cannot
be adjusted after the command to execute the
movement has been issued. So, the child who runs
to meet the ball and kicks it in mid-stride cannot
adjust the kick once it has been initiated. Not surprisingly, many feedforward-dependent actions are
bilateral.
Sugden and his colleagues ( Henderson &
Sugden, 1992 ; Keogh & Sugden, 1985 ) offered a
simple model for gauging the degree to which an
action is under relative feedback or feedforwardcontrol. These investigators indicated that control
(feedforward vs. feedback) is a function of movement of both the child and any object(s) on which
the child is acting (e.g., a ball). The more or the faster
that the child or an object moves, the more control
must be feedforward-dependent. Feedforwarddependent actions are more diffi cult than feedbackdependent actions. Here is an adapted version of
Sugden ’ s model.
In the fi gure, a line connecting points representing relative movement of a child and an object
passes through a point on the line illustrating the
degree to which the action is feedforward- or
feedback-dependent. Clearly, this diagram is overly
simplistic but it can be useful for understanding the
motor planning diffi culties of children with dyspraxia and for grading the diffi culty of intervention
activities.
Control of movement as a function of the mover and the object.
Feedback
B A C
Object movement
(degree, speed)
Person movement
(degree, speed)
Feedforward
Control of
movement
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 11
actions whereas children with VBIS primarily
have diffi culty with the high-level feedforwarddependent tasks.
Sensory Modulation Dysfunction
The concepts of sensory modulation and
sensory modulation dysfunction are somewhat
abstract. Although the term modulation is familiar to many therapists, its precise meaning can
be somewhat elusive. Ayres ( 1979 ), who fi rst
applied the concept to SI theory, defi ned modulation as the CNS ’ s regulation of its own activity.
Engineers liken modulation to tuning a radio to
the amplitude and frequency of the sound waves
emitted by a station. When the amplitude and
frequency detected by the radio tuner match
those of the station ’ s sound waves, the station
comes in clearly. However, when the tuner is not
properly modulated, the radio is rendered ineffective. Individuals who have diffi culty modulating sensation behave as though the amplitude of
their response is consistently greater or less than
that of most individuals, decreasing the effectiveness of their performance. This is illustrated in
Figure 1-7 .
In this text, we describe two types of sensory
modulation dysfunction (i.e., over-responsivity
and under-responsivity). The responses of a child
who is overly responsive to sensation are of
greater amplitude than expected. We label overresponsivity to tactile or auditory sensations as
defensiveness (i.e., a fi ght-or-fl ight reaction) and
to vestibular sensation as gravitational insecurity
FIGURE 1-7 Schematic representation of modulation and modulation defi cits.
HERE ’ S THE EVIDENCE
For more than four decades, factor analyses of data
from the Sensory Integration and Praxis Tests ( Ayres,
1989 ) and its precursor, the Southern California
Sensory Integration Tests ( Ayres, 1972c ), along with
the Southern California Postrotary Nystagmus Test
( Ayres, 1975 ), yielded patterns of test scores that
describe sensory-integrative-based dyspraxia ( Ayres,
1965, 1966a, 1966b, 1969, 1972d, 1977, 1989 ;
Ayres, Mailloux, & Wendler, 1987 ; Mailloux et al.,
2011 ; Mulligan, 1996, 1998, 2000 ). Ayres found
that tests requiring bilateral integration, sequencing of fi nger and arm movements, and postural
control typically loaded together on a factor known
most recently as VBIS. 1
She also found that tests
of imitation, oral praxis, tactile discrimination, and
proprioception consistently loaded together; she
called these somatopraxis. More recent researchers
( Mailloux et al., 2011 ; Mulligan, 1996, 1998, 2000 )
found slightly different loadings of tests, although
they found relationships among all factors. Mailloux
et al. ( 2011 ) labeled their practic factors “Visuodyspraxia and Somatodyspraxia” and “Vestibular and
Proprioceptive Bilateral Integration and Sequencing” (VPBIS). VPBIS contained loadings of both
sensory and motor tests, but Visuodyspraxia and
Somatodyspraxia did not. Mulligan ( 1998 ) similarly
failed to fi nd loadings of sensory and motor on the
same factor. She concluded, cogently, that it is best
always to describe the nature of a particular child ’ s
sensory integrative dysfunction. For example, a
child with both dyspraxia and poor somatosensory
discrimination is best described using both labels.
1
VBIS has been known by several names: for example, just BIS, and Postural and Bilateral Integration (PBI).
12 ■ PART I Theoretical Constructs
(i.e., fear) or aversive (i.e., autonomic) responses.
Under-responsivity refers to reactions of lessthan-expected amplitude. We can see them in
any sensory system. It is worth noting that underresponsivity can be diffi cult to differentiate
from poor discrimination. Clinically, therapists
have also identifi ed fl uctuating responsivity, a
term used with children whose responses are
sometimes greater-than-expected and sometimes
less-than-expected in any sensory system or
across systems.
Review Table 1-1 for a description of the
major constructs associated with SI theory. We
begin with indicators of poor SI and praxis
and then move to indicators of poor sensory
modulation.
HERE ’ S THE POINT
• Problems in sensory discrimination may lead
to poor postural-ocular control and poor body
scheme which, in turn, contribute to dyspraxia
(i.e., VBIS and somatodyspraxia).
• Sensory modulation dysfunction is seen
as persistent over- or under-responding to
sensations.
Uniting Sensory Integration
with Psychosocial Constructs
Kielhofner and Fisher ( 1991 ) felt that viewing
poor self-esteem as simply a byproduct of
sensory integrative dysfunction failed to consider
suffi ciently how a child ’ s view of self emerges
and how self-perception infl uences that child ’ s
behavior. They indicated that psychosocial events
are at least as complex as SI and pointed to the
need for a sophisticated view. Kielhofner and
Fisher illustrated the complexity of the relationship between sensory integrative dysfunction and
common psychosocial sequelae with the story of
Joe, a 9-year-old boy up to bat in a Little League
practice session.
CASE STUDY ■ JOE
Joe ’ s brain appeared to lack the ability to integrate sensation from his body and the environment effectively and effi ciently. His diffi culty
integrating sensation seemed to explain his
struggles with planning and producing motor
actions that caused him to appear clumsy. But
what does SI theory tell us about how or what
Joe felt? Joe deeply wanted to play baseball
well. But he felt extremely frightened as the
pitcher got ready to throw the ball. Joe knew
the challenge was to meet the pitched ball with
the swing of his bat, but he did not know how to
do it. He had little awareness of how it should
HERE ’ S THE EVIDENCE
Statistical evidence of sensory modulation dysfunction was not available until the 1990s when
formal tests were fi rst developed. Before that
time, a diagnosis of sensory modulation dysfunction was based on observation and informal
interview. For example, Ayres’ ( 1972c, 1989 ) statistical analyses included only her observation of
a child ’ s discomfort in response to being touched
during testing, which she labeled tactile defensiveness. Now, standardized tests exist that,
although not purely measures of modulation
or even of dysfunction, contain items refl ecting processing vulnerabilities (e.g., under- and
over-responsiveness, sensory seeking) in multiple sensory systems. Identifi cation of fl uctuating responsivity across sensory systems requires
examining and comparing scores for sensory
domains. We do not have a standardized test
that clearly identifi es fl uctuating responsivity
within a single sensory system.
Two “families” of tests are used most commonly: (1) Sensory Profi le 2 ( Dunn, 2014 ) with
versions for infants, toddlers, and children, and
the Adolescent/Adult Sensory Profi le ( Brown
& Dunn, 2002 ) and (2) Sensory Processing
Measures ( Parham, Ecker, Kuhaneck, Henry, &
Glennon, 2010 ). Factor analytical studies of data
from these various parent- and self-report measures have revealed patterns of sensory modulation or sensory modulation dysfunction (e.g.,
Dunn, 1994, 2014 ; Dunn & Brown, 1997 ; Dunn
& Westman, 1997 ). More recently, researchers (e.g., A. E. Lane, Young, Baker, & Angley,
2010 ; S. J. Lane, Reynolds, & Dumenci, 2012 ;
S. J. Lane, Reynolds, & Thacker, 2010 ; Reynolds,
Bendixen, Lawrence, & Lane, 2011 ; Reynolds,
Lane, & Thacker, 2011 ) have paired parent and
self-report measures with behavioral tests and
physiological measures in an attempt to gain
further understanding of sensory modulation
and sensory modulation dysfunction.
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 13
feel to swing the bat and hit the ball. What he
could feel was the eyes of his peers bearing
down on him as the ball raced in his direction.
Joe became increasingly aware of an aching
feeling in the pit of his stomach; his anxiety
was acute and distressing. Joe had a deep and
pervasive feeling that he was “no good” and
that he would not be able to hit the ball.
Joe ’ s emotional state manifested as overarousal and anxiety. As the ball approached,
it seemed to disappear from sight and he was
unaware of his relationship to it in time and
space. He swung the bat almost in self-defense
and in the vain hope that somehow it would
connect with the ball. But he missed widely
and the whole performance had a tragicomic
appearance. A chorus of jeers and laughter from
his peers painfully drove home his error. And
this was not a new experience; Joe ’ s discomfort
with using his body for any of the coordinated
actions required in sports was familiar to him.
The harder he tried, the more diffi cult it was
to get things right. For Joe, not being able to
execute motor actions as he wished and feeling
uncomfortable around peers as his performance
missed the mark was a familiar and uncomfortable experience.
In Joe ’ s case, we may speculate that ineffi -
cient processing of sensation was responsible
for the quality of his motor performance. But
we can hardly argue that Joe ’ s diffi culty processing sensation, and nothing else, caused his
poor performance. Clearly, Joe ’ s psychological state had something to do with how he
performed. What went on as Joe missed the
ball was much more than just a case of poor
SI and uncoordinated motor behavior. Neither
Joe ’ s performance nor his experience could be
captured adequately by explanations grounded
only in SI. Rather, the psychosocial experience
was an equally important part of what Joe did
and felt.
Kielhofner and Fisher ( 1991 ) cited DiJoseph
( 1982 ) in pointing out that when a therapist focuses only on SI, paying little attention to psychosocial phenomena—or vice versa—intervention
is necessarily incomplete. A therapeutic approach
that appreciated how they were interrelated had
obvious advantages over a narrow or fragmented
approach. Thus, in an attempt to address the very
real concerns that Kielhofner and Fisher discussed, Fisher and Murray ( 1991 ) adopted a spiraling model often used in occupational therapy
theory. Their Spiral Process of Self-Actualization
(see Fig. 1-8 ) blended SI theory with constructs
drawn from the Model of Human Occupation to
explore self-actualization.
The Spiral Process of Self-Actualization
In Fisher and Murray ’ s ( 1991 ) Spiral Process of
Self-Actualization, SI theory is depicted in the
medium gray spiral, and concepts drawn from
the Model of Human Occupation are depicted
in the white spiral. Inner drive, which provides
the impetus to become involved in meaningful
activities, is at the base of the spiral. Fisher and
Murray defi ned “meaningful” as having signifi -
cance, value, or purpose. For an activity to be
meaningful, a child must be in control and able
to make sense of the experience.
Actively taking in sensation (sensory intake)
is an early step in the sensory integrative
process. There are many sources of sensation,
including the physical and social environments
(represented by arrows labeled environment )
and production and outcome feedback. Production feedback arises from the body and informs
the child how it felt to move; outcome feedback
arises from actions that produced a change in the
environment.
Sensations are integrated (i.e., combined),
enabling a child to act effectively and effi ciently
on objects in the environment. Ayres referred to
these successful actions as adaptive interactions.
Adaptive interactions give rise to production and
outcome feedback. Adaptive (and sometimes
not-so-adaptive) interactions are the behaviors
we observe during evaluation.
Planning an adaptive interaction means
knowing “what to do” and organizing “how to do
it.” Successful plans depend on a desire to participate, a suffi cient body scheme developed from
previous production feedback, and knowledge of
outcome feedback from previous adaptive interactions. Production and outcome feedback are
important to planning and ultimately to learning.
After a neuronal model of an action is developed, it can be used as the basis for new, more
complex interactions. Thus, Fisher and Murray
added a third loop (dark lines) to their spirals to
depict neuronal models (see Fig. 1-8 ).
14 ■ PART I Theoretical Constructs
FIGURE 1-8 Spiral process of SI.
The white loop of the spiral refl ects a core
assumption of occupational therapy: Humans
have an occupational nature. According to Fisher
and Murray ( 1991 ), the addition of this loop to the
traditional depiction of SI theory shows its place
in the greater context of occupational science.
Adaptive interactions are basic to occupational
behavior. Two core assumptions of occupational
science are that humans have an innate need to
participate in occupation and that occupation is
intrinsically motivating. In turn, humans develop
meaning, satisfaction, confi dence, self-control,
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 15
and a sense of mastery from participation ( White,
1959 ). Thus, the impetus for planning and organizing adaptive interactions includes both sensation and volitional factors (e.g., motivation,
self-direction).
Adaptive interactions imply that individuals
feel a certain amount of control over the task and
the environment. Children who develop a sense
of mastery also develop belief in their abilities
(i.e., belief in skill, self-effi cacy ). Self-effi cacy
enables children to self-direct. They become
motivated to explore their capacity through planning and producing adaptive interactions and
participating in meaningful occupations.
In summary, through a spiral process of
self-actualization, SI, beliefs about the self, and
volition, together, contribute to adaptive interactions. In turn, adaptive interactions yield organized and effective occupational behaviors (e.g.,
self-care, play, academic performance). As children develop control over the environment and
belief in their own skills, interactions with the
environment become more meaningful and satisfying and children are likely to want to engage
in similar actions and occupations repeatedly.
Importantly, however, increased belief in skill
does not necessarily or automatically accompany
the ability to produce higher quality adaptive
interactions. Therapists must ensure that children
know that they have developed a new skill.
HERE ’ S THE POINT
• Blending psychosocial constructs with those
inherent in SI theory, as is represented in
the spiral model presented, provides a more
complete picture of the child ’ s strengths and
needs, and lays a broader foundation for
intervention.
• In the spiral process of self-actualization, SI,
beliefs about the self, and volition are seen
as contributing to adaptive environmental
interactions. Adaptive interactions are the
foundation for effective occupational
behaviors.
All Theories Are Based
on Underlying Assumptions
Accepting any theory means accepting the
assumptions that underlie it. The assumptions
underlying SI theory relate to its neural and
behavioral bases. In Table 1-2 , we describe four
assumptions associated with sensory integrative
therapy. We explain those assumptions and their
rationale. We also list chapters in this text where
readers can fi nd more information.
Boundaries of Sensory
Integration Theory
and Intervention
Ayres envisioned the application of SI theory and
intervention with particular populations: children with learning disabilities or autism. More
recently, Parham and colleagues ( Parham et al.,
2011 ) defi ned specifi c criteria for sensory integrative therapy. Nonetheless, both practitioners
and researchers sometimes apply SI theory in
ways that are outside its boundaries. When therapists apply SI theory in other-than-intended
ways, they must always proceed with particular
caution. When researchers say they are investigating the effi cacy of SI, they must ensure that
their procedures are faithful to the principles of
the theory. When they critique the theory, particularly through meta-analysis or systematic
review, they must be certain that the papers they
include actually refl ect SI and not, as often seems
to happen, prescribed techniques that include
enhanced sensation but do not meet Parham
et al. ’ s criteria. See also Chapter 14 (Distilling
Sensory Integration Theory for Use: Making
Sense of the Complexity) and Chapter 23
(Is Sensory Integration Effective? A Complicated
Question to End the Book).
Boundaries and the Population
SI theory is intended to explain problems associated with dyspraxia or sensory modulation
disorders. A diagnosis of sensory integrative
dysfunction requires evidence of defi cits in the
central processing of vestibular, proprioceptive,
or tactile sensation that are not attributable to
frank peripheral nervous system or CNS damage
or associated with cognitive defi cits. Although
Ayres ( 1972b ) wrote initially about the diffi -
culties of children with learning disorders, she
( Ayres, 1979 ; Ayres & Tickle, 1980 ) later focused
on children with autism. In the ensuing decades,
we have learned unequivocally that many (or
16 ■ PART I Theoretical Constructs
TABLE 1-2 Four Assumptions Associated with Sensory Integrative Therapy
ASSUMPTION EXPLANATION RELATED CHAPTERS
The CNS has
neuroplasticity.
Plasticity refers to the ability of brain structures to change.
Ayres hypothesized that sensory integrative therapy could
effect changes in the brain because of plasticity. Although
Ayres emphasized the structural and behavioral plasticity
of the young brain, there is ample evidence that plasticity
is also present in the adult brain. Much of the support for
plasticity and SI therapy is drawn from studies of the impact
of enriched environments on the structure and function of
the nervous system in animals (see, for example, Reynolds,
Lane, & Richards, 2010 ).
18: Complementary Programs
for Intervention; for review
of literature on sensorimotorbased plasticity
21: Planning and
Implementing Intervention: A
Case Example of a Child with
Autism
The brain
functions as an
integrated whole.
Ayres felt that SI occurred mainly in subcortical centers
whereas cortical centers were responsible for abstraction,
perception, reasoning, language, and learning. We
now know that both cortical and subcortical structures
contribute to SI.
4: Structure and Function of
the Sensory Systems
5: Praxis and Dyspraxia
Adaptive
interactions are
critical to the
development of SI.
The CNS is an open system, capable of self-regulating, selforganizing, and changing. Adaptive interactions promote
SI, and the quality of a child ’ s actions refl ects SI. Active
movements produce sensory feedback that forms the basis
for neuronal models of “how it felt” to move. Knowledge
of the outcome of an action forms the basis for memories
of “what was achieved.” Neuronal models, derived from
production and outcome feedback, form the basis for
planning increasingly complex adaptive interactions ( Schmidt
& Lee, 2011 ).
5: Praxis and Dyspraxia
Children have
an inner drive to
develop SI through
participation in
sensorimotor
activities.
Ayres believed that all children have an inner drive to
master their bodies and the environment. According to
Ayres, inner drive is seen in excitement, confi dence, and
effort. She felt children with sensory integrative dysfunction
sometimes seem to have little evidence of inner drive.
Intervention leads to stronger evidence of the inner drive
to seek out self-actualizing activities that, in turn, enhance
SI ( Ayres , 1972b ). Fisher and Murray ’ s Spiral Model of SelfActualization, described previously, adds to this fundamental
assumption.
12: The Art of Therapy;
for in-depth depiction of
capturing inner drive
most) children with autism process sensation
abnormally ( American Psychiatric Association,
2013 ). Several researchers (e.g., Baranek, Foster,
& Berkson, 1997 ) as well as people diagnosed
with autism (e.g., Grandin & Scariano, 1986 )
related poor processing of sensation to autism.
Recent research utilizing rigorous designs including sophisticated case reports ( Schaaf, Hunt, &
Benevides, 2012 ), multiple baseline single case
methodologies ( Bulkeley, Bundy, Roberts, &
Einfeld, 2016 ), and quasi-experimental or experimental designs ( Pfeiffer, Koenig, Kinnealey,
Sheppard, & Henderson, 2011 ; Schaaf et al.,
2013 ) have demonstrated decreases in problematic or stereotypic behaviors and increases in
attainment of specifi c goals.
Sensory integrative dysfunction is a diagnosis of exclusion. That is, it is used to explain
dysfunction in motor planning or sensory modulation that cannot be explained by frank CNS
damage, genetic issues, or other diagnostic conditions. Children with a range of developmental
disorders may have defi cits in functions typically
associated with sensory integrative dysfunction.
However, SI theory is not intended to explain,
for example, the depressed postrotary nystagmus, low muscle tone, poor proximal stability,
or poor equilibrium experienced by children with
Down syndrome or hearing loss. Their problems
are more clearly attributed to abnormalities of
the cerebellum ( Nommensen & Maas, 1993 ) or
damage to the eighth cranial nerve, respectively.
CHAPTER 1 Sensory Integration: A. Jean Ayres’ Theory Revisited ■ 17
Boundaries and Intervention
The boundaries of SI theory also apply to intervention. Sensory integrative therapy involves
taking in sensation actively in the context of
meaningful, self-directed, adaptive interactions.
The emphasis is on the integration of vestibular, proprioceptive, and tactile sensations and
the promotion of posture, bilateral integration,
praxis, or sensory modulation. Many direct intervention programs referred to as SI probably are
more appropriately referred to as sensorimotor
because, although they promote engagement
in activities that involve sensory experiences,
they are adult- rather than child-directed. Some
involve only sensory stimulation because they
involve passive application of sensation in a prescribed manner. Parham ’ s and colleagues’ ( 2011 )
criteria defi ne sensory integrative therapy (i.e.,
ASI). (See also Chapter 12 , The Art of Therapy,
and Chapter 13 , The Science of Intervention:
Creating Direct Intervention from Theory.)
Boundaries and Critique
Not infrequently, critics apply the term sensory
integration inappropriately to interventions that
are purely sensory stimulation. Consider, for
example, Lang et al. ( 2012 ), who published a
systematic review entitled “Sensory Integration
Therapy for Autism Spectrum Disorders.” In
reality, 9 of the 25 studies they reviewed evaluated the effectiveness of weighted vests, an
example of passive application of tactile sensation
(i.e., sensory stimulation), not of SI. Nonetheless, Lang et al. concluded, quite inappropriately given the papers included in their review,
that there is insuffi cient evidence to support
sensory integrative therapy for children with
autism spectrum disorder (ASD). When reading
or responding to such systematic reviews, we
must consider carefully the nature of the individual papers included. Do they actually meet the
criteria for SI? Neither publication in a credible
peer-reviewed journal nor mention of Parham et
al. ’ s fi delity measure in the introduction to their
paper meant that the studies Lang et al. reviewed
met the criteria for SI. When researchers such as
Lang et al. conclude, based on studies that are
not SI, that sensory integrative therapy is not
effective, they simply fuel controversy inappropriately. (See also Chapter 15 , Advances in
Sensory Integration Research: Clinically Based
Research, and Chapter 17 , Using Sensory Integration Theory in Coaching.)
HERE ’ S THE POINT
• Understanding the boundaries of SI theory and
intervention is essential.
• Constructs consistent with SI theory are
useful in explaining the problems associated
with dyspraxia and sensory modulation
disorders. They are not intended to explain all
developmental disorders.
• SI intervention elements have been captured
in the fi delity measure developed by Parham
and colleagues. They importantly include
meaningful, self-directed, and adaptive
interactions that are child directed and
focused. Other sensory-based approaches may
not include these central “ingredients.”
• When considering intervention effectiveness
studies, we must all remain vigilant that the
intervention under scrutiny adheres to the
essential features of ASI ® .
Summary and Conclusions
In this chapter, we presented an overview of SI
theory and sensory integrative dysfunction, comparing and contrasting two main categories of
dysfunction: dyspraxia and sensory modulation
dysfunction. We distinguished between two types
of dyspraxia (i.e., defi cits in bilateral integration
and sequencing, somatodyspraxia) and two types
of sensory modulation dysfunction (i.e., overresponsivity and under-) in terms of hypothesized
sensory bases and overt indicators. We identifi ed
assumptions and boundaries of SI theory and SI
intervention.
What makes occupational therapy practice
different from all other health professions is our
unique emphasis on “doing” occupation. The
term praxis, derived from the Greek, also means
doing, reminding us that, in employing SI theory,
our primary concern is whether the children and
adults with whom we work are able to do what
they need and want to do.
Where Can I Find More?
Ayres, A. J. (1981; 2005). Sensory integration
and the child. Torrance, CA: Western Psychological Services.
18 ■ PART I Theoretical Constructs
Lane, S. J., Smith Roley, S., & Champagne, T.
(2013). Sensory integration and processing:
Theory and applications to occupational performance. In B. Schell, G. Gillen, & M. Scafa
(Eds.), Willard & Spackman ’ s occupational
therapy (12th ed., pp. 816–868). Philadelphia,
PA: Lippincott, Williams, & Wilkins.
Parham, L. D., & Mailloux, Z. (2015). Sensory
integration. In J. Case-Smith & J. C. O’Brien
(Eds.), Occupational therapy for children and
adolescents (7th ed., pp. 258–303). St. Louis,
MO: Mosby.
Smith Roley, S., Schaaf, R. C., & Baltazar Mori,
A. (2019). Ayres Sensory Integration® Frame
of Reference. In P. Kramer, J. Hinojosa, &
T.-H. Howe (Eds.), Frames of Reference for
Pediatric Occupational Therapy (4th Edition,
pp. 87–153). Philadelphia, PA: Wolters
Kluwer.
Smith Roley, S., Blanche, E. I., & Schaaf, R. C.
(2001). Understanding the nature of sensory
integration with diverse populations. Philadelphia, PA: Harcourt Health Sciences Company.
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21
CHAPTER
2
Sensory Integration
in Everyday Life
L. Diane Parham , PhD, OTR/L, FAOTA ■ Joanna Cosbey , PhD, OTR/L
Chapter 2
Upon completion of this chapter, the reader will be able to:
✔ Explain how sensory integration (SI) fi ts into a
view of development as multidimensional and
transactional.
✔ Describe the relationship between sensory
processing characteristics and participation in
the everyday occupations of play and leisure;
activities of daily living (ADLs) and instrumental
activities of daily living (IADLs); rest and sleep;
and education and work across the life span.
✔ Describe how assessment and intervention
decisions are infl uenced by the complexity and
transactional nature of development.
It ’ s not some big event that creates the drama, it ’ s the little
things of everyday life that bring about that drama.
—Asghar Farhadi
LEARNING OUTCOMES
Purpose and Scope
The ultimate aim of occupational therapy practice
using sensory integration (SI) principles is to help
children meet the challenges that they encounter
in their everyday lives at home, in school, and at
play. These challenges can be as commonplace as
realizing that one has been gently touched by a
classmate or as unique as inventing a new game
to play with friends on the playground.
Across the past fi ve decades of research into
SI, much work has focused on identifying patterns of sensory and movement diffi culties and
on documenting outcomes of interventions.
Although the link between SI and what children do in everyday life has been evident since
the early years of Ayres’ work, it would be
useful to cultivate a deeper understanding of the
ways in which SI affects—and is affected by—
participation in the daily activities that structure
and give meaning to children ’ s lives. A deeper
understanding of these connections may lead
to interventions that are more effective because
they are more fi nely tailored to the life situations
of individual children.
Ayres ( 2004 ) defi ned SI as the “organization
of sensations for use” (p. 5). Those last two
words, “for use,” are revealing. Unlike neuroscientists, who often aim to isolate neural mechanisms, Ayres’ central concern as an occupational
therapist was with how the nervous system organizes sensory information so that the person can
participate in meaningful and in productive occupations. SI-based intervention, therefore, became
a tool for helping children engage in occupations
that lead to rich and meaningful lives.
The primary purpose of this chapter is to help
readers understand the important relationship
between SI and everyday life—particularly the
performance of everyday occupations, that is,
the activities that people want or need to do. It
also aims to raise questions that may guide future
thinking about this relationship and how knowledge of this relationship might infl uence the
22 ■ PART I Theoretical Constructs
design of programs and environments to benefi t
all people—not just those with clinically identifi ed SI problems.
CASE STUDY ■ NICK
Nick is an 8-year-old boy assessed as having
sensory integrative diffi culties involving hazy
tactile discrimination and immature visual
perceptual processing. In addition, he has diffi culty with the sequencing and timing aspects
of motor planning. These praxis diffi culties
make it cumbersome for Nick to manage his
body and objects in physical space and in synchrony with time constraints imposed by social
expectations.
Nick is very aware of the general behavioral expectations placed on him by his teacher
at school. However, his problems with SI and
praxis make it diffi cult for him to comply
with some of these expectations, even though
he wants to do so. For example, he knows he
is supposed to be able to reach into his desk
and fi nd his workbooks and tools (e.g., pencil,
eraser, ruler) quickly, but his desk is chaotic,
and he seems unable to keep it neat for longer
than half a day. His tactile sense is not developed well enough to enable him to fi nd and
handle objects quickly and effi ciently. He needs
to rely on visual inspection to help him fi nd
things in his desk, but his visual system is not
highly skilled either so this becomes an arduous
task. His somatodyspraxia further interferes
with his adeptness in handling classroom materials and tools. His classmates, whose sensory
integrative and praxis abilities are well developed, are able to fi nd and manage their materials quickly and easily, even those who do not
have stellar desk organization habits.
Closer observation of Nick may reveal that
he actually does not seem aware of some of
the fi ner nuances of his teacher ’ s expectations
for her students. Whereas other students fi gure
out that her expectations require that they work
out strategies for desk management, Nick does
not realize that he needs to do this. This may
be caused at least partially by his sensory and
praxis diffi culties, which have limited his experiences and his success in developing effective
and sophisticated strategies for the organization
and manipulation of objects. In Nick ’ s eyes,
other kids just magically know how to reach
into their desks and instantly fi nd their school
materials. His lack of recognition of the need
for organizational strategies to manage his body
and physical objects in space and time extends
beyond desk management into other realms,
such as playground games and sports with peers.
Thus, he does not realize the full ramifi cations
of many social expectations, such as the expectations for team members during a soccer game.
Nick ’ s experiences as he engages in a
variety of daily routines—his successes and
failures, pleasures and pains—will infl uence
his future preferences and choices of occupations. He has strong verbal skills and already
shows a defi nite preference for occupations
such as reading and telling jokes. He also has
an avoidance of sports and games that require
skill in sequencing of actions or precision in
object manipulation. Of course, not all of his
choices will be related to his verbal talents or
his sensory integrative diffi culties; many will
be derived from personal experiences with signifi cant people, places, things, and events. For
example, the fl owers that brighten his loving
grandmother ’ s backyard give him feelings of
joy, security, and contentment. The pleasant
memories of his grandmother ’ s garden, as well
as the sensory experiences that he enjoys while
gardening, eventually may lead him to value
the occupation of gardening. Yet, it is possible that his sensory integrative characteristics
will have a lifelong infl uence on his choices
of leisure and work occupations. In an optimal
scenario, he may become a successful attorney
if he has supportive family and friends, if he
continues to hone his verbal talents, and if he
learns to exercise good judgment in deciding
when to use verbal strategies to organize tasks
and when to delegate. He may experience a
great deal of satisfaction and enjoyment while
gardening at home. However, it is very unlikely
that he will become a professional athlete, and
he probably will not choose to participate regularly in a team sport as a leisure activity.
Clearly SI is a factor in the formation of
Nick ’ s identity, although it most certainly is not
the only factor, and it may not even be the most
important factor. The formation of his identity
is shaped by—and shapes—the occupations
in which he engages. Through time, Nick ’ s
appraisal of who he is becoming in relation
to what he values most in life will affect his
CHAPTER 2 Sensory Integration in Everyday Life ■ 23
overall satisfaction with his life circumstances.
The presence of sensory integrative diffi culties defi nitely does not mean that a person is
doomed to be unsuccessful or unhappy. But
it may present special challenges. Repeated
experiences of failure may cumulatively lead
to feelings of hopelessness and incompetence,
avoidance and fear of challenge, a constricted
range of meaningful occupations, and poor life
satisfaction. Conversely, if a person ’ s experiences lead to a strong sense of self-effi cacy, the
challenges posed by sensory integrative diffi -
culties actually may contribute to the forging of
self-discipline, determination, hope, character,
and, consequently, a rich occupational life with
a high degree of life satisfaction.
The Complexity of Everyday Life
Occupational therapists have long recognized
that engagement in everyday activities is not
as simple as meets the eye. Getting dressed, for
example, requires the activation and coordination of physical body structures by processes
that involve genomic, physiological, cognitive,
and affective events, all working in synchrony.
Moreover, the specifi c actions and experiences
that occur while getting dressed are shaped by
the constraints and opportunities presented by
the physical environment—materials, objects,
surfaces, and ambient surroundings—as well as
the person ’ s interpretation of the place where
the actions occur and the sociocultural expectations that permeate the situation. Even spiritual
aspects of experience (i.e., the experience of life
meaning and purpose) may be evoked during
commonplace activities, such as dressing. For
example, when diffi culties arise during the performance of ordinary activities, the person may
not only become dissatisfi ed and frustrated but
also may question the worth of his or her own
life. (See also Chapter 1 , Sensory Integration: A.
Jean Ayres’ Theory Revisited.)
The complexity and multiplicity of factors
that shape lives make it impossible to predict
with any precision what the specifi c life outcomes will be for a particular child who has
sensory integrative problems. The developmental process is extremely complex because,
not only are multiple factors simultaneously
involved, but also it is transactional in nature.
That is, biologically based predispositions and
environmental infl uences mutually affect each
other through dynamic interchanges, so developmental outcomes are the result of a confl uence
of multiple factors that change through time as
they infl uence each other ( Sameroff, 2009 ). This
means that not only is it impossible to predict
long-term life outcomes for an individual child,
but also it is usually inappropriate to look back
across the life of a person who has signifi cant
life problems in search of a single, specifi c cause
of those problems.
As an example, consider an infant who is
over-responsive to tactile, vestibular, and auditory stimuli and has a young, impulsive mother
who is very stressed by her low-income living
situation and the very limited support she
receives from family or friends. The baby recoils
when touched by his mother, and if environmental sounds become intense (as they often do in
the small apartment with thin walls), he screams
inconsolably. The infant ’ s defensive behaviors
heighten the stress of the mother, who begins to
dread interacting with her infant. She perceives
him as a problem baby who does not like her so
she tries to complete infant caregiving activities
(e.g., feeding, diapering, and bathing) as quickly
as possible in order to be freed to leave him alone
in the bedroom to cry and eventually fall asleep.
Her insensitive handling of him aggravates his
sensory defensiveness, and consequently he cries
increasingly more often and more intensely. In a
worst-case scenario, the mother may try to cope
with this escalating situation by physically and
emotionally neglecting or even abusing her baby.
Four years go by, and we see the baby grow
into a preschooler who struggles to engage in
play for more than a fl eeting time. Not only does
he have trouble with solitary play but also he
seems unable to play with peers without acting
out aggressively and destructively. In the preschool setting, he stands out as a child who is
having great diffi culty.
In this example, what was the original cause
of the child ’ s preschool diffi culties? His sensory
defensiveness or his mother ’ s stress? The mother ’ s impulsive personality or the baby ’ s diffi cult
temperament? Is the cause the mother ’ s lack of
access to resources and supports or her lack of
knowledge regarding how to engage with the
child sensitively during daily routines? All are
legitimate causes because each of these issues
24 ■ PART I Theoretical Constructs
affects the others, and all of them interact synergistically to shape the child ’ s life. It would be
inappropriate to single out one as the sole cause,
although some may exert more powerful effects
than others.
Even in such an extreme example as this one,
the very rocky beginning in the mother-infant
relationship will not necessarily doom this infant
to future failure. (See also Chapter 19 , Application of Sensory Integration with Specifi c Populations.) All along the life course, events and
experiences arise that shape and guide who the
child is becoming. We can imagine a different
preschool outcome for the diffi cult infant in our
previous example if, for example, we introduce
a day-care provider into the picture when the
baby is a toddler. Let us imagine that this daycare provider is gifted at intuiting the toddler ’ s
needs and fi ne-tunes the day-care environment
so that he is not overwhelmed by sensations,
he experiences pleasure and mastery in simple
sensory-motor activities, and he is cared for by
an adult who is nurturing but also sets limits on
his behavior in a consistent manner. Furthermore, the day-care provider forms a positive
relationship with the infant ’ s mother and mentors
her in mothering. It is likely that the child ’ s later
preschool experiences will not be as negative in
this scenario compared with what the situation
might have been had he not had the good fortune
of an optimal day-care experience.
SI is one of the factors that shapes life outcomes. However, it is only one of many potentially powerful factors. It is probably never
appropriate to identify poor SI as the sole cause
of a child ’ s problems in everyday life or to claim
that a child will have specifi c problems in the
future because of the presence of sensory integrative diffi culties. But SI does contribute to what,
how, and why a person engages in particular
activities at particular times in the life cycle. For
Nick, who was introduced earlier in this chapter,
SI may be a key contributor to his diffi culties
when trying to play sports or manage items in
and around his desk. However, the reactions of
peers and teachers to his disorganization on the
sports fi eld and in the classroom may be just as
powerful, perhaps even more so. For example,
peer ridicule or rejection on the sports fi eld may
instill embarrassment and shame, leading him to
avoid these activities. Avoidance, in turn, results
in fewer opportunities to acquire and master the
motor skills required in these activities, so the
gap in motor skills between Nick and his peers
widens through time.
So, the answer to the question, “Does poor
sensory integration cause problems in everyday
living?” is “Probably, but it does not determine
outcomes by itself.” Poor SI does not singlehandedly cause diffi culties with daily activities.
It interacts with talents, physical attributes, environmental opportunities, contexts, past experiences, social expectations and responses, and a
host of other factors, all changing through time
and affecting one another, to shape and color
the person ’ s occupational life. (See also the
Spiral Process of Self-Actualization described in
Chapter 1 , Sensory Integration: A. Jean Ayres’
Theory Revisited.)
Given the complexity of multiple infl uences
on developmental outcomes, how can we be
sure that SI is a signifi cant factor in daily life,
deserving of attention? Is SI critical enough that
we should pay attention to it when conducting
assessments and planning interventions for children with developmental, learning, or social
diffi culties? The following section examines
research that addresses this issue.
HERE ’ S THE POINT
• Everyday life activities involve ongoing
transactions between complex aspects of
the person—including SI characteristics—and
complex aspects of the activity context.
• SI is one of many factors that shape our
relationships with others and what we are able
to do across the life span.
Sensory Integration and Everyday
Life: The Evidence
Research exploring the relationship between SI
and participation in everyday life activities is
growing. During the past 10 years, it has become
increasingly clear that SI differences can affect
individuals in all areas of life, starting at birth
and continuing throughout the life span. A systematic review of 35 studies on children with SI
diffi culties indicated that sensory problems were
related to occupational performance diffi culties
in all areas of everyday life: play, activities of
daily living, sleep, and work, including school
CHAPTER 2 Sensory Integration in Everyday Life ■ 25
performance ( Koenig & Rudney, 2010 ). Taken
together, these studies provide evidence that
sensory integrative characteristics are a potentially critical factor in shaping lives, particularly
with respect to people ’ s engagement in occupations. For example, sensory integrative differences may affect how people use their time,
relate to others, and interact with their physical
and social worlds across the life span.
In this section of the chapter, we will briefl y
examine the relationship between engagement
in occupations across the life span in four major
life areas: (1) play, leisure, and social participation; (2) activities of daily living and instrumental activities of daily living; (3) rest and sleep;
and (4) education and work. Although the majority of the research presented here addresses the
diffi culties and limitations associated with SI
differences, it is important to recognize that it
is possible for there to be some benefi t to these
differences as well. When planning intervention,
the challenge is identifying the combination of
environments, relationships, and activities that
best supports an individual ’ s participation.
Several specifi c diagnostic groups have been
found to have high rates of SI differences,
such as individuals with autism spectrum disorder (ASD) ( Bagby, Dickie, & Baranek, 2012 ;
Baranek, David, Poe, Stone, & Watson, 2006 ;
Hilton, Graver, & LaVesser, 2007 ; Hochhauser
& Engel-Yeger, 2010 ; Lane, Young, Baker, &
Angley, 2010 ; Leekam, Nieto, Libby, Wing, &
Gould, 2007 ; Miller Kuhaneck & Britner, 2013 ;
Reynolds, Bendixen, Lawrence, & Lane, 2011 );
some genetic conditions, such as Fragile X syndrome (FXS) ( Baranek et al., 2002 ); and developmental coordination disorder (DCD) ( Smyth
& Anderson, 2000 ). However, each of these
diagnoses, by defi nition, involves diffi culties
in areas of functioning, such as communication
skills, motor skills, or intellectual ability, any of
which can interfere with participation in everyday activities. The confounding of SI problems
with developmental and medical diagnostic conditions makes it diffi cult to ascertain whether SI
differences play a signifi cant role in child participation beyond the impact of concomitant diagnostic conditions.
Few researchers have attempted to extricate the impact of SI factors from other factors
on functional performance. An exception is
research conducted by Reynolds and colleagues
on children with ASD ( Reynolds, Bendixen, et
al., 2011 ). Their multivariate analyses of data for
52 children (26 with ASD and 26 with typical
development) showed that high levels of sensory
over-responsiveness (i.e., sensory sensitivity and
sensory avoidance) were signifi cantly associated with lower levels of competence in activity,
social, and academic participation, suggesting
that sensory diffi culties adversely affect participation regardless of diagnosis. Furthermore, in
these analyses, cognition (as measured by nonverbal IQ) did not signifi cantly contribute to any
aspect of participation.
In the remainder of this discussion of evidence regarding SI and participation, we will
focus primarily on individuals who are not identifi ed as having a particular diagnostic condition,
although, where appropriate, we refer to similar
fi ndings in children who have diagnosed conditions often characterized by diffi culty processing
sensation (e.g., FXS, ASD, DCD). As you will
see, even individuals who are otherwise typically
developing can experience signifi cant participation diffi culties that are related to their SI abilities. For individuals with diagnosable conditions
involving motor skills or communication, the SI
diffi culties are likely to be even greater. Therefore, by focusing the discussion on individuals
without concomitant developmental or medical
conditions, this chapter aims to present a conservative picture of the impact of SI differences on
everyday life. The reader should keep in mind
that the impact of SI problems is likely to be
compounded by other diagnosable conditions,
when these are present. Conversely, in some situations and tasks, having a sensory difference
may provide an advantage.
Play, Leisure, and Social Participation
Currently, most of the research that addresses the
impact of SI characteristics on everyday life is
focused on play, leisure, and social participation.
The existing evidence indicates that, even for
individuals without an identifi ed medical diagnosis or disability, sensory integrative characteristics may impact signifi cantly on participation
in play and leisure activities ( Watts, Stagnitti, &
Brown, 2014 ).
The impacts of sensory integrative differences
can be seen in young infants. An infant ’ s ability
to process and integrate sensory information
26 ■ PART I Theoretical Constructs
effectively can have a clear impact on motherinfant coregulation, which, in turn, directly
affects infant engagement in co-occupations
( Esdaile & Olson, 2003 ; Pierce, 2009 ; Zemke
& Clark, 1996 ), such as simple reciprocal social
interactions and play with the caregiver (e.g.,
reciprocal vocalizations and games, such as
peekaboo) ( Fig. 2-1 ). Researchers have found
that infants with SI differences may be fussier and
have more diffi culty forming typical attachments
than infants with developmentally appropriate SI
( DeSantis, Coster, Bigsby, & Lester, 2004 ; Hofer,
2006 ; Purvis, McKenzie, Cross, & Razuri, 2013 ).
These challenges affect the quality of engagement as well as the amount of time that infants
can sustain engagement in play and social participation and can be magnifi ed when the mother
as well as the infant has diffi culties integrating
sensory information effectively ( Turner, Cohn, &
Koomar, 2012 )—a refl ection of the transactional
nature of the developmental process.
Researchers have found that early diffi culties
connecting with and relating to other people can
persist throughout childhood. In early childhood,
SI differences appear to be related to play in
children with ASD. Specifi cally, a child ’ s praxis
skills and abilities to process visual, touch, proprioceptive, and vestibular information are associated with social play (e.g., sharing or playing
cooperatively) ( Miller Kuhaneck & Britner,
2013 ). Additionally, sensory integrative characteristics are related to the types of toys children
select for play in early childhood. A study of
typically developing 3- to 5-year-olds showed
that children who demonstrate a preference for
toys that promote fantasy play (e.g., dollhouses,
toy dinosaurs) had a tendency to exhibit more
sensation-seeking behaviors than peers who
preferred creative art and building materials
( Mische Lawson & Dunn, 2008 ). Further evidence indicates that sensory over-responsiveness
of parents is signifi cantly associated with overresponsiveness in their otherwise typically developing children and that parent tendency to not
engage in sensory-seeking activities may limit
child exposure to sensory-stimulating activities
( Welters-Davis & Mische Lawson, 2011 ). These
fi ndings, again, suggest that SI may play an
important role in the transactional processes of
child development.
The impact of SI on activity choices and play
continues through middle childhood. Many children with sensory integrative diffi culties may be
able to compensate well for their sensory differences by harnessing strengths to develop typical
play skills ( Bundy, 1989 ; Clifford & Bundy,
1989 ). However, recent studies indicate that
sensory differences often interfere with play participation ( Fig. 2-2 ). Bundy, Shia, Qi, and Miller
( 2007 ) found that sensory modulation dysfunction has a negative impact on the playfulness
of children. A case study presented by Benson,
Nicka, and Stern ( 2006 ) illustrates how this may
be manifested. They described the play characteristics of a 6-year-old boy with sensory integrative dysfunction who demonstrated limited and
cautious play, poor attention to play activities,
and minimal emotional investment in his play.
In middle childhood, SI diffi culties may lead
to limited play preferences and restricted social
networks with peers. Cosbey, Johnston, Dunn,
and Bauman ( 2012 ) found that children with SI
differences engaged in more solitary play than
their peers and did not show the same shift to
organized games-with-rules play as their peers.
Similar fi ndings have been discovered for children with DCD ( Smyth & Anderson, 2000 ).
Additionally, through structured interviews of
children with and without SI differences, Cosbey,
Johnston, and Dunn ( 2010 ) found that children
with SI differences tended to demonstrate more
limited social networks, and spent less time
FIGURE 2-1 Sensory integrative abilities in both the
mother and child are important for bonding as well
as the development of the infant ’ s social and selfregulatory abilities.
CHAPTER 2 Sensory Integration in Everyday Life ■ 27
with friends, than peers without SI diffi culties.
Although the children ’ s activity preferences were
similar across the two groups, children with SI
differences indicated the least enjoyment for
activities with formal rules and clear expectations. Interestingly, three of the most preferred
activities for children with SI differences (quiet
tabletop activities, pretend play, and computer
or video games) were the three areas that were
the least preferred by their peers. Hochhauser
and Engel-Yeger ( 2010 ) reported similar fi ndings
for children with ASD, indicating that the children with ASD had limited ranges of activities
and tended to have a smaller social network than
their typically developing peers.
Other researchers examining the play, leisure,
and social participation of children with ASD
have found that there is a link between social
competence and sensory processing abilities,
with the presence of more sensory diffi culties
related to poorer social competence ( Hilton et al.,
2007 ; Reynolds, Bendixen, et al., 2011 ). Further,
sensory integrative abilities impact family activity choices of families of children with and
without ASD ( Bagby et al., 2012 ). Collectively,
this body of research suggests that a school-aged
child ’ s play, leisure, and social participation may
be impacted by SI differences. The impact seems
to be even more pronounced when the sensory
integrative differences are concomitant with
other conditions, such as ASD.
Limited research examines the relationship
between SI and everyday life for adolescents.
Existing studies indicate that risk-taking and
sensation-seeking behaviors are characteristic
of typical adolescents (e.g., Lightfoot, 1997 ;
Zuckerman, 1994 ). Zuckerman ( 1994 ) defi ned
sensation seeking as “the seeking of varied,
novel, complex, and intense sensations and experiences, and the willingness to take physical,
social, legal, and fi nancial risks for the sake of
such experience” (p. 27). Some evidence (e.g.,
Greene, Krcmar, Walters, Rubin, & Hale, 2000 )
suggests that adolescents who engage in more
sensation-seeking behaviors (as defi ned by Zuckerman) are more likely to engage in delinquent
behaviors. These teens seem to have intense
responses to novel stimuli and seek out activities
and opportunities to experience these stimuli.
However, other researchers ( Shea & Wu, 2012 )
have found that adolescents who are involved
with the juvenile justice system tend to show
fewer sensation-seeking behaviors and more
sensation-avoiding behaviors than other teens.
These two sets of fi ndings appear to contradict each other, but this may be because of
the use of different theoretical models by the
researchers. The term sensation seeking connotes different meanings depending on the theoretical framework being used. In contrast with
the Zuckerman conceptualization, Shea and Wu
( 2012 ) used this term in a manner that is consistent with Dunn ’ s conceptualization of sensory
seeking as a manifestation of high neurological
threshold for responses to sensory stimulation
(i.e., requiring intense sensory input in order to
respond to stimuli) and in combination with a
tendency to actively seek out input to reach that
threshold ( Dunn, 1997 ). Shea and Wu ( 2012 )
also used Dunn ’ s conceptualization of sensation
avoiding (i.e., active avoidance of sensations in
conjunction with a low neurological threshold
for responses to sensory stimulation). Regardless
FIGURE 2-2 Children with sensory-based dyspraxia
may have diffi culty learning new motor skills and get
left out of social activities and experiences typically
engaged in by their peers.
28 ■ PART I Theoretical Constructs
of whether the Zuckerman or Dunn conceptualization of “sensation seeking” was used, the
researchers found that adolescents who have
intense reactions to sensory input (either actively
seeking or actively avoiding) are more likely
to engage in delinquent behaviors. What is not
clear from the current research is how active
sensory-seeking and avoiding behaviors may be
related to delinquent behavior.
Other researchers have found that teens who
have been involved negatively with law enforcement tend to have SI diffi culties as demonstrated
by their performance on vestibular- and praxisrelated tests ( Fanchiang, Snyder, Zobel-Lachiusa,
Loeffl er, & Thompson, 1990 ). In another study,
sensory integrative differences were found to be
related to non-suicidal self-injurious behaviors
(e.g., self-cutting) in young adolescents ( Christensen, 2012 ). Teens engaging in these behaviors
demonstrated greater sensitivity to sounds as
well as tendencies toward sensation avoiding and
low registration. Although this body of research
does not directly address conventionally accepted
modes of play, leisure, and social participation,
it provides some insight into some behaviors
in which teens with SI differences may engage
outside of time designated for school, work, selfcare, and sleep.
SI differences may indirectly affect engagement in play, leisure, and social participation
in adulthood through its impact on emotional
states and social relationships. SI differences are
strongly associated with anxiety ( Engel-Yeger
& Dunn, 2011b ; Green & Ben-Sasson, 2010 ;
Kinnealey, Koenig, & Smith, 2011 ; Reynolds &
Lane, 2009 ), and a growing body of evidence
on adults suggests a relationship between SI and
affect ( Engel-Yeger & Dunn, 2011a ); relationship styles and ability to cope ( Jerome & Liss,
2005 ); and temperament, including expression
of anger ( Stols, van Heerden, van Jaarsveld, &
Nel, 2013 ), social introversion, depression, and
HERE ’ S THE EVIDENCE
Reynolds, S., Bendixen, R. M., Lawrence, T., & Lane,
S. J. (2011). A pilot study examining activity participation, sensory responsiveness, and competence
in children with high functioning autism spectrum
disorder. Journal of Autism and Developmental Disorders, 41, 1496–1506.
This descriptive cross-sectional study compared
activity participation and perceived competence in
two groups of children with ( n = 27) and without
( n = 28) ASD from 6 to 12 years of age. The Child
Behavior Checklist (CBCL) competence scales were
completed by parents who answered questions
related to their child ’ s participation in the areas of
activities, social life, and school performance. The
Sensory Profi le also was completed by parents as a
means of comparing children ’ s sensory processing
abilities to their competence in performing and participating in daily life tasks. When the researchers
examined the types of leisure activities participated
in by each group, the children with ASD had more
involvement in video games, playing with transportation vehicles, and reading books; they had
less involvement in dramatic play, play with dolls
or action fi gures, or in arts and crafts activities.
Overall, parents of kids who were developing typically were able to identify more leisure activities
participated in by their children than parents of kids
with ASD. Children with ASD were also found to
participate in fewer jobs or chores at home, with
27% of children with ASD having no chores at
home compared with only 7.6% of kids developing
typically who had fewer than two chores. Overall,
children with ASD had less involvement in chores
related to animal care, babysitting, or general
cleaning around the home. When the researchers
compared competence scores between the two
groups, the group with ASD was found to have signifi cantly lower levels of competence in each area
( p = .000 across all three domains: activity participation, school performance, and social participation). Subsequent analyses identifi ed that sensory
over-responsive scores on the Sensory Profi le (elevated behaviors of sensation avoiding and sensory
sensitivity) were signifi cantly correlated with lower
levels of competence. The authors suggest in their
discussion that children who show sensory overresponsiveness may be less likely to engage in activities that require the processing of self-perceived
noxious sensory inputs and that they may not
perform tasks successfully when they do attempt to
engage. This study suggests a role for occupational
therapists in helping children with sensory modulation disorders fi nd and be successful in meaningful
play and leisure activities as well as helping parents
to determine which jobs or chores the child can
take on within the household to ensure he or she
experiences the same types of learning and maturational opportunities as other children.
CHAPTER 2 Sensory Integration in Everyday Life ■ 29
impulse control ( Kimball, Birstler, Bosse, Nelson,
& Woods, 2012 ). Further, research ( Kinnealey
et al., 2011 ) suggests that adults with SI differences may have more limited social supports
and lower perceived health-related quality of life,
including social functioning. Finally, quantitative research as well as fi rst-person accounts of
living with SI differences ( Kinnealey, Oliver, &
Wilbarger, 1995 ; McCarter, 2010 ) suggest that
sensory integrative differences may impact
adults’ interpersonal relationships via physical
intimacy and activity choices.
This rapidly growing research base provides
evidence that SI differences are related to occupations (e.g., play, leisure) and performance,
especially social interaction, skills. Throughout
the life span, SI has the potential to infl uence our
occupation and activity choices, from the types
of toys a toddler plays with to the leisure activities of adolescents and engagement in social
activities by adults. Additionally, SI differences
are connected to diffi culties in fundamental
social-interaction skills that affect engagement
in play and social participation, from fussiness
in an infant to anger and anxiety in an adult.
However, because of the transactional nature of
the developmental process, negative outcomes
for individuals with sensory integrative differences are not inevitable. Supportive contexts and
environments that permit an individual to capitalize on strengths and talents (i.e., client factors)
while building new performance skills may lead
to a highly successful and satisfying life.
Activities of Daily Living and
Instrumental Activities of Daily Living
Engagement in activities of daily living (ADLs),
such as dressing, eating, and bathing, as well as
instrumental activities of daily living (IADLs),
such as shopping, preparing food, and housekeeping, are essential and often time-consuming
aspects of everyday life. As with play, leisure,
and social interaction skills, evidence shows
that SI differences impact performance of ADLs
and IADLs beginning in infancy. Infants with
SI differences tend to be fussier and have more
diffi culty establishing appropriate attachment to
caregivers (e.g., DeSantis et al., 2004 ; Hofer,
2006 ; Purvis et al., 2013 ), which can affect an
infant ’ s ability to participate in co-occupations
with caregivers, such as dressing, bathing, and
eating. Sensory defensiveness may have a negative effect on breastfeeding ( Radzyminski, 2005 ;
Weiss-Salinas & Williams, 2001 ).
Eating diffi culties appear to persist through
childhood and adolescence. One of the most
widely documented ADL areas impacted by SI
differences is the area of feeding and mealtimes.
Children with sensory integrative differences tend
to have inordinate diffi culty accepting new foods
( Blissett & Fogel, 2013 ), and many children
referred to feeding clinics tend to have sensory
integrative differences ( Davis et al., 2013 ). They
also may have diffi culty participating in family
routines related to meal preparation because of
the sensory characteristics of those routines, such
as loud appliances and the tactile and olfactory
aspects of cooking ( Bagby et al., 2012 ). Sensory
integrative diffi culties also have been implicated
in other areas of children ’ s ADLs, such as toileting and dressing ( Bellefeuille, Schaaf, &
Polo, 2013 ; O’Neil, 2010 ; Schaaf, 2011 ). Reynolds and Lane ( 2008 ) presented case reports of
children with tactile sensitivity, illustrating that
ADLs, including diffi culties with hair washing
and combing, nail clipping, toothbrushing, dressing, and eating, can be diffi cult for them. These
diffi culties may be compounded by other conditions. For example, Baranek and colleagues
( 2002 ) reported that boys with FXS who had
increased aversive and avoidance reactions to
sensory stimulation were also more likely to be
less independent with their ADLs.
Sensory integrative diffi culties are related
to ADL and IADL performance by adults. In a
qualitative study, Kinnealey, Oliver, and Wilbarger ( 1995 ) documented that adults with
sensory integrative differences reported restrictions in clothing and food choices, diffi culty
with meal preparation activities, and diffi culty
with visits to the dentist. The adults in this study
also reported that their sensory integrative differences impacted other aspects of self-care, such as
choice of jewelry and whether or not they wore
make-up. Pohl, Dunn, and Brown ( 2003 ) found
that adults tend to demonstrate lower levels of
registration of sensory input as they age, which
has potential negative implications for their
ability to drive, navigate within their community,
and complete self-care activities appropriately.
This research indicates that sensory integrative differences have a lifelong impact on an
individual ’ s participation in ADLs and IADLs.
30 ■ PART I Theoretical Constructs
Feeding, the earliest and most pervasive ADL,
appears to be related to sensory integrative abilities from birth through adulthood and may affect
nutritional intake as well as ability to participate
in meals shared with others. As the performance
demands increase, individuals with sensory
integrative diffi culties are increasingly likely to
encounter ADLs and IADLs that are stressful.
The presence of sensory diffi culties, therefore,
may restrict engagement in a wide range of
activities and, ultimately, may limit the person ’ s
access to community places and events.
Rest and Sleep
Little research has examined the relationship
between SI differences and the vitally important
occupations of rest and sleep, but the existing
evidence is consistent in fi nding a signifi cant
association between sensory differences and
sleep diffi culties. Researchers ( Wiener, Long,
DeGangi, & Battaile, 1996 ) have found that
full-term infants who demonstrated SI differences at 7 to 18 months of age were likely to
have diffi culties with sleep ( Fig. 2-3 ). Other
researchers have documented a link between
sensory hypersensitivity and disrupted sleep
among children without disabilities ( Shochat,
Tzischinsky, & Engel-Yeger, 2009 ) as well as
adults ( Engel-Yeger & Shochat, 2012 ). At least
one study ( Reynolds, Lane, & Thacker, 2011 )
has documented that children with ASD have a
high prevalence of atypical sensory behaviors
that are associated with sleep disturbance. Furthermore, in this study, behavioral and physiological (i.e., body function) measures of sensory
responsivity distinguished between good and
poor sleepers with 85% accuracy, suggesting
that sensory diffi culties are important factors in
understanding and planning intervention for the
many children with ASD who have sleep defi cits.
Further research is necessary to fully describe the
relationship between rest and sleep and SI patterns, but this preliminary research suggests that
there is a potentially powerful link that should be
explored more completely.
Education and Work
Although little research has specifi cally assessed
the relationship between SI and education or
work performance, many researchers have
theorized about the potential relationship. For
example, Geva and Feldman ( 2008 ) presented
a conceptual framework of infant development
that places the ability to regulate and integrate
sensory information as a key element of development. According to their model, secondary skills
of emotion and attention regulation, which ultimately lead to higher level learning skills (e.g.,
cognitive processing and self-regulation), are
dependent on SI. There are several other models
that also identify SI as an essential foundational
element of learning experiences, which could
include participation in education and work
activities ( Dunn, 1997 ; Trott, Laurel, & Windeck,
1993 ; Williams & Shellenberger, 1996 ).
The relationship between SI and education
has been explored in school-aged children and
adolescents. SI differences have been found to be
related to academic achievement in both reading
and math ( Parham, 1998 ). Specifi cally, sensory
integrative differences in children who were
6 to 8 years old were found to predict arithmetic achievement 4 years later, after statistically
FIGURE 2-3 Sensory sensitivities may make it more
diffi cult for children to fall asleep and stay asleep.
CHAPTER 2 Sensory Integration in Everyday Life ■ 31
controlling for intellectual ability and family
socioeconomic level. This relationship was
strong, particularly with regard to praxis skills.
A different relationship was found between SI
and reading achievement, with SI demonstrating a predictive relationship at the older (but not
younger) ages ( Parham, 1998 ). A similar fi nding
was reported for children with FXS ( Baranek et
al., 2002 ), with lower scores in school functioning linked to greater SI differences. Diffi culties
with participation in typical school activities,
including navigating the school environment,
recess, assemblies, lunch, handwriting, and participating in other classroom activities, also have
been reported ( Bagby et al., 2012 ; McCarter,
2010 ; Reynolds & Lane, 2008 ; Smyth & Anderson, 2000 ).
Although the relationship between SI and education or work has not been thoroughly explored
during adulthood, our understanding of SI and
the critical role it plays in supporting participation in life activities suggests that it is likely that
a relationship exists ( Fig. 2-4 ). Some fi rst-person
narratives and case reports support this hypothesis. For example, Fanchiang ( 1996 ) presented a
case report of a young man with a learning disability and SI differences. Fanchiang theorized
that the young man ’ s career choices may have
been infl uenced by his SI characteristics, with
the role of massage therapist fulfi lling his own
needs for intense sensory input. Temple Grandin,
a well-known adult with ASD, has written about
the relationship between vocational choices and
sensory integrative as well as cognitive characteristics and interests ( Grandin, 2006 ), and her
own highly successful career in designing equipment for the cattle industry clearly capitalizes on
her visual strengths. Therefore, it appears that
SI characteristics infl uence career choices and
that building on strengths while acknowledging
sensory-based challenges may lead to a more
successful and satisfying work life.
HERE ’ S THE POINT
• Research evidence indicates that SI
characteristics infl uence a person ’ s participation
in various occupations—play and leisure, ADLs,
sleep and rest, and work and education—
across the life span.
• Limitations in participation, attributable to
differences in sensory integrative processing,
may be seen in diagnostic populations typically
seen by occupational therapists, including
adults and children with ASD, DCD, FXS, and
sensory integrative disorders.
Implications for Assessment
and Intervention
In this chapter, we have focused on how SI infl uences participation in everyday occupations. So
far, we have discussed the transactional process
of development, which infl uences how SI interacts with other factors to affect participation, and
we have summarized the research evidence surrounding the infl uence of SI on engagement in
everyday occupations. Now we will consider a
few of the implications that these ideas have for
clinical practice.
FIGURE 2-4 An individual with sensory overresponsivity may choose to pursue work activities
that require limited social interaction and occur in a
controlled, low stimulation environment.
32 ■ PART I Theoretical Constructs
Assessment: Looking to the Future,
Considering the Past
Because occupational therapy is a practice profession that is centrally concerned with occupation as a key aspect of health and well-being,
therapists should place occupation at the front
and center of the assessment process. But
because occupation is complex and affected by
multiple ongoing transactions between person
and context, the assessment process must be
fl exible and responsive to the unique situation of
each child and family.
Periodically, leaders in different areas of
occupational therapy practice (e.g., Brown,
2012 ) have recommended that therapists avoid a
bottom-up assessment approach, instead embracing a top-down approach. By “bottom-up,” we
mean that assessment begins with a focus on specifi c components believed to be affected by the
child ’ s condition, such as strength, coordination,
or perceptual skills ( Trombly, 1993 ). In the fi eld
of SI, an example of a bottom-up assessment
strategy might be administration of the Sensory
Integration and Praxis Test (SIPT) ( Ayres, 1989 )
as a fi rst step in assessment of a child with a
diagnosis of attention defi cit disorder. If this
is the initial approach to assessment, we might
consider it to be component driven ( Gray, 1998 )
because concerns with sensory, perceptual, and
motor components are driving the assessment
and subsequent intervention.
In contrast, “top-down” refers to an assessment process that begins with informationgathering related to occupation; in other words,
what the person wants and needs to do, the contexts for performing these occupations, and the
current strengths and limitations in performing
the desired occupations ( Brown, 2012 ; Coster,
1998 ; Fisher, 1998 ; Fisher & Marterella, 2019 ;
Fisher & Short-DeGraff, 1993 ). For example,
an occupational therapist who uses a top-down
strategy with a child diagnosed with attention
defi cit disorder initially will gather information regarding what the child wants and needs
to do (according to the child, the parents, and
other important people in the child ’ s life, such
as teachers), what the contexts are for the child ’ s
current occupations (e.g., school, home, community settings), and what the child and others
perceive as the current successes and problems
the child experiences in doing valued occupations. This initial investigation then will lead to
decisions regarding whether further assessment
of specifi c skills or abilities is warranted, including administration of the SIPT.
Use of a top-down strategy, therefore, puts
the assessment of sensory integrative functioning into the broader context of the child ’ s life.
This contextualizing of SI assessment is potentially more likely to be perceived by families as
helpful and relevant, compared with assessment
procedures that seem remote from everyday life.
A problem with the top-down assessment
approach is that it focuses on problems in occupation only at the time of assessment ( Coster, 1998 ;
Fisher, 1998 ). However, occupational therapists
project into the future as they plan the course of
therapy with their patients. In fact, in their qualitative study of occupational therapists engaged in
practice, Mattingly and Fleming ( 1994 ) claimed
that occupational therapists imagine who their
patients will become in the future and, further,
that they create stories with the patient about
what has happened in the past and what will
happen in the future as the person ’ s life unfolds.
Perhaps occupational therapists should include in
their clinical assessments the hopes and wishes
of the family for the future, especially with
regard to the occupations that the child will want
and need to do in a few years (for example, see
Cohn, Kramer, Schub, & May-Benson, 2014 ).
The transactional view of development also
suggests that assessment should be future oriented.
Because development is continually shaped and
channeled by transactions between the child and
the environment, assessment should be repeated
through time. This could take place during the
ongoing process of intervention or it could be in
the form of intermittent monitoring. The purpose
of reassessment is to ensure that the child ’ s occupational development is moving in the desired
direction, to detect when new issues related to
the child ’ s occupations have emerged, and to
re-evaluate intervention or occupational options
in order to reformulate the most benefi cial plan
for helping the child and family, given changes
that have occurred. Note that this assessment
strategy continues to use a top-down approach,
with occupation as the primary reference point,
but assessment is not conducted only at one specifi c point in time. Instead, assessment is ongoing
or recurs intermittently as time moves forward.
An implication of bringing a future orientation into clinical assessment is that prevention of
CHAPTER 2 Sensory Integration in Everyday Life ■ 33
potential problems comes to the forefront. When
assessment addresses only concerns related to
the present, one ’ s attention is not drawn systematically to information that may signal risk
for future problems. A present-only assessment
strategy may lead to concluding that a particular
child or family will not benefi t from intervention
because there is limited evidence of an occupational problem at the current time, when, in fact,
some assistance or guidance at the present time
may avert problems that are likely to emerge in
the future. If one is consciously imagining the
future occupational life of a child by extrapolating from what is known about present occupational patterns and contexts, as well as the
current status of performance components,
including SI, it is more likely that risk factors for
later occupational diffi culties will be identifi ed
and that something will be done to minimize or
counteract the risk. For example, Kyle, the child
featured in Chapter 11 (Interpreting and Explaining Evaluation Data), experienced success in
kindergarten, despite sensory integrative dysfunction, because his teacher accommodated so
well for his diffi culties. However, in evaluation,
his family and therapist sought to offset the diffi -
culties they anticipated Kyle having in fi rst grade
with a different teacher and when classroom
demands increased.
Granted, not much is known about factors
that predict future problems with a satisfying,
productive, and enjoyable work and play life.
Additionally, health-care and education systems
in much of the world are not prepared to designate funding for large-scale preventive programs. Nevertheless, preventive efforts may
be economically advantageous in the long run.
Perhaps future research will identify powerful early predictors of occupational problems
in childhood, adolescence, and adulthood. We
may fi nd that there are times when screening or
assessment of functions, such as SI, is appropriate for preventive purposes, as when children
are screened for vision or hearing problems so
that intervention can be introduced before such
problems have adverse effects on school performance ( Fig. 2-5 ). For example, Thomas and colleagues ( 2015 ) found preliminary evidence that
they could predict the development of sensory
over-responsiveness in childhood using the presence of feeding and sleep diffi culties of young
infants as a proxy. They hypothesized that early
identifi cation and intervention could minimize
the impact of the sensory diffi culties on attachment, emotion regulation, and, later, engagement
in play, self-care, sleep, and school participation.
Possibly intervention aimed at minimizing the
impact of sensory diffi culties at a young age may
PRACTICE WISDOM
Recently adding part-time clinical practice in an
outpatient occupational therapy clinic to my
daily activities, I found that each of the four children I was seeing had some features of sensory
integrative disorder, including problems with
sensory modulation, discrimination, and praxis.
For each child, performance of functional skills
and participation was impacted by these sensory
integrative problems. Some kids had issues with
toileting, hair brushing, or sequencing their
nighttime hygiene routines, whereas others
had diffi culty participating with peers in agelevel games and sports. However, the goals that
had been written previously for each child were
focused neither on function nor participation.
There were goals for demonstrating in-hand
manipulation skills but not for being able to open
milk containers at lunch. There were goals for
being able to sequence an obstacle course but
not goals for being able to sequence the steps
needed to brush teeth. And there were goals
for improving self-regulation but no mention
for how self-regulatory skills would transfer over
into being able to play a board game with a
friend. I found, in talking to parents, that what
they were really hoping their child got out of
occupational therapy was much different from
established goals. I also found that the kids had
expressed goals that weren ’ t refl ected in the
evaluations or therapy goals—one adolescent
noting, “I would just like to be able to make
a real friend.” In modifying treatment goals to
be more function- and participation-focused, I
found that I got better buy-in overall from the
children and their parents. I enjoyed seeing how
working on the children ’ s underlying sensory
issues in an outpatient setting could translate
into meaningful gains in occupational performance in home, school, and community settings. Take home message: Meaningful goals
focus on what children and parents want within
the context of their real lives. Theory helps us
develop interventions and predict change, but
the needs of families and children always take
priority over theoretical constructs.
34 ■ PART I Theoretical Constructs
maximize children ’ s later occupational participation. Ultimately, this use of performance components for anticipating diffi culties is directed
toward enhancing the future occupational life
of the child; therefore, we can think of it as a
top-down approach in which the top is projected
into the future. Even though research is limited
and we must keep in mind the limitations of the
existing research, occupational therapists can
incorporate estimations of risk into their assessments by imagining where the child and family
might end up in the future if they continue on
their current course.
In considering how to minimize child and
family risk, occupational therapists need to consider all potential resources available to the child
or family. For example, we have evidence ( Reynolds, Lane, & Thacker, 2011 ) that sensory modulation diffi culties in early childhood are strongly
associated with sleep disorders, particularly in
children with ASD. Occupational therapists can
contribute to intervention programs for children
with ASD by sharing this information with families
whose children with ASD have sensory overresponsiveness and helping them to develop
family strategies that promote healthy sleep patterns by creating soothing environments and predictable bedtime routines. We also have evidence
( Parham, 1998 ) that praxis diffi culties in early
childhood place a child at risk for later academic
problems, especially in mathematics. Occupational therapists working with young children
with dyspraxia may want to share this information
with parents and help them plan ways to give the
child additional support for academic skill development before the child experiences repeated
failure. Referrals to social workers, psychologists,
other professionals, family and child-care service
providers, and community children ’ s programs
also can be important for connecting families
with resources that can help minimize risk.
Consideration of Intervention Options
The multidimensionality of occupation and its
enmeshment with environmental contexts suggests that many options for intervention should
be considered if clinical assessment indicates
that a child is experiencing diffi culty with occupations. The occupational therapist ’ s challenge is
to identify variables that can be altered in order
to affect a positive change in the entire system
comprising a child ’ s transactions with his or her
environment and to envision how a process of
change might unfold through time. Then intervention options are selected and orchestrated to
channel the child ’ s and family ’ s occupations in a
direction that will move them toward achieving
the desired occupational goals.
When sensory integrative diffi culties contribute to a child ’ s occupational problems, the
occupational therapist must consider whether
intervention should focus on altering the child ’ s
ability to participate in occupations, on changing
the child ’ s experience by altering aspects of the
environment to support the child ’ s engagement,
or on some combination of these strategies. If
improvement in sensory integrative abilities is
desirable, then individual occupational therapy
using an Ayres SI approach should be given the
fi rst consideration, as evidence of its effectiveness
is supported by several well-designed randomized clinical trials ( Miller, Coll, & Schoen, 2007 ;
Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011 ; Schaaf et al., 2014 ). Alternatively,
FIGURE 2-5 Children with praxis problems in early
childhood are at risk for academic problems later on.
Image courtesy Thinkstock/jupiterimages.
CHAPTER 2 Sensory Integration in Everyday Life ■ 35
or in conjunction with individual therapy, it may
be helpful to encourage the family to advocate for
school-based group programs (e.g., Hartshorn et
al., 2001 ; Koenig, Buckley-Reen, & Garg, 2012 )
or enroll the child in enrichment programs that are
available in the community, such as gym classes
or swimming. If the child has signifi cant sensory
modulation issues, perhaps a program that helps
the child develop strategies to cope better with
everyday routines and environments (e.g., the
Alert Program; Williams & Shellenberger, 1996 ;
see also Chapter 20 , Planning and Implementing
Intervention Using Sensory Integration Theory)
would be benefi cial. If specifi c motor or social
skills are key problems, then skill training, either
individually or in a group, might be appropriate.
Is immediate success in troublesome occupations
an urgent need? If so, consultation or coaching
to suggest changes in tasks or activities and
their environmental contexts may be the priority
(see also Chapter 17 , Using Sensory Integration
Theory in Coaching). Dunbar ( 1999 ) and Bundy
and Green (see Chapter 22 , Viewing Intervention
Through Different Lenses) provided relevant
case examples. Alternatively, occupational therapists may collaborate with families to organize
their lifestyles so that sensory needs and interests of children are integrated into daily family
routines at the same time that parental needs,
interests, occupational styles, and values are
accommodated ( Dunn, 2014 ; Dunn, Cox, Foster,
Mische-Lawson, & Tanquary, 2012 ).
Consideration of family and child resources,
preferences, and occupational styles, as well as
community resources, is critical in recommending and discussing intervention options with families. When considering how to be most helpful
to a child and family, it is useful to imagine the
transactional process of development projecting into the future. Who is this child becoming? Where are the lives of the child and family
headed? What resources are available to them?
How supportive is the environment? How might
the trajectory be altered if various intervention
options are introduced?
HERE ’ S THE POINT
• Assessment using the SI approach should take
into account the complex, transactional nature
of participation in everyday activities, including
strengths and resources available.
• SI approaches should address goals that refl ect
the values and needs of the child and family,
are focused on function and participation, and
refl ect outcomes that are evidence-based.
Summary and Conclusions
From its inception, SI theory has viewed the child
as an active agent in the world, whose engagement with the environment affects the development of competence and satisfaction in doing
occupations. Within this theory, the neurobiological construct of SI holds an important position
as a mediator between the child ’ s physical self
and the external world. Because the neural processes and behavioral expressions of SI shape
the person ’ s capacity and willingness to act on
the environment, SI is relevant to the construction of the self through the doing of occupations.
However, SI is only one of many factors that
infl uence occupation; it interplays with social
expectations, physical environments, and personal experiences in shaping an individual ’ s
occupational life. (See also Chapter 1 , Sensory
Integration: A. Jean Ayres’ Theory Revisited.)
We have evidence that sensory integrative characteristics infl uence the person ’ s competencies
in doing various activities as well as personal
choices of occupations and how to perform them,
throughout the life span.
The reciprocal relationship between SI and
occupation opens the door to a multitude of intervention possibilities. Because SI affects engagement in occupations, it is one of the many factors
that may be considered in assessing the reasons
for why a child may be experiencing diffi culties with occupations, such as participating in
home, school, and play activities. One valuable,
evidence-based course of action for intervention
is to strengthen sensory integrative capacities
through provision of individual Ayres Sensory
Integration ® (ASI) intervention. An additional
option is to use knowledge of a child ’ s SI strengths
and limitations to modify the tasks, routines, and
environments of the child ’ s occupational life in
order to maximize the child ’ s success and family
satisfaction in the immediate contexts of daily
life. Several researchers (e.g., Bulkeley, Bundy,
Roberts, & Einfeld, 2016 ; Dunn et al., 2012 ;
Kientz & Dunn, 2012 ) have had some degree of
success with context-based interventions. Future
36 ■ PART I Theoretical Constructs
research also may assist us in evaluating the
extent to which sensory integrative abilities can
be developed through community-based activity
programs, such as classes in creative movement,
yoga, swimming, or other physical activities.
Research remains to be done to clarify when particular approaches are most benefi cial, for whom,
and under which circumstances.
SI is not simply a neurological process contained entirely within the individual. It is a
complex process through which the nervous
system mediates transactions between individuals and the world. In this view, SI serves as a
scaffold for human agency and, therefore, is
linked inextricably with occupation.
Where Can I Find More?
Schaaf, R., & Mailloux, Z. (2015). Clinician ’ s
Guide to Implementing Ayres Sensory Integration ® : Promoting Participation for Children
with Autism.
A step-by-step guidebook that describes the
most effective, evidence-based way to implement ASI into clinical practice by using a
data-driven decision-making approach.
DeMonia, L., & Turchan, M. (2015). Love for
Logan. San Antonio, TX : Halo Publishing
International.
An inspirational story based on actual events.
A young girl learns to better understand why
day-to-day life can be challenging for her
older sister. A kid-friendly picture book, told
through the eyes of a sibling, will help children understand others’ sensory diffi culties,
and explain sensory processing disorder.
Bialer, D., & Miller, L. J. (2011). No Longer A
SECRET : Unique Common Sense Strategies
for Children with Sensory or Motor Challenges. Arlington, TX: Sensory World.
A resource for parents, teachers, and therapists
helping children with sensory or motor issues.
It includes cost-effective, functional, on the
spot tips to use for children with sensory
issues at home, at school, or in a community
setting.
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40
CHAPTER
3
Composing a Theory
An Historical Perspective
Shelly J. Lane , PhD, OTR/L, FAOTA ■ Anita C. Bundy , ScD, OT/L, FAOTA ■ Michael E. Gorman , PhD
Chapter 3
Upon completion of this chapter, the reader will be able to:
✔ Recognize how Ayres’ personal traits and
professional training led to the development of
sensory integration (SI) theory.
✔ Describe how a community of clinicians and
scholars, led by Ayres, emerged and grew the
fi eld of SI within occupational therapy.
✔ Identify how SI research and practice has
evolved while continuing to be grounded in
Ayres’ original theory.
Take criticism seriously, but not personally. If there is truth or merit in
the criticism, try to learn from it. Otherwise, let it roll right off you.
— Hillary Clinton
LEARNING OUTCOMES
Purpose and Scope
Ayres’ work has been, and continues to be,
admired by some and rejected by others.
Throughout her professional life she seemed to
take both in stride. Although the rejections and
misunderstandings were distressing to her, she
had learned in childhood how to withdraw into
her own mind and to use willpower to get past
unhappiness. She worked, studied, and read
relentlessly, never certain how much time she
would have to complete her life goals ( Gorman
& Kashani, 2017 ; Sieg, 1988 ).
Endeavoring to understand both the history
of sensory integration (SI) and current research
and practice trends, we interviewed colleagues
who had the opportunity to learn, study, and
work with Ayres and were infl uential in shaping
SI theory and related concepts. We have also
conducted in-depth reviews of related literature.
Based on this work, we conclude that, although
we have seen evolution, the core construct of
Ayres’ Sensory Integration ® (ASI) theory, linking
brain processing with observable behavior, continues to be a focal point in theory and practice.
Here we present a historical account of the
evolution of SI theory and practice, drawn from
our interviews and readings. We have chosen
to acknowledge contributors at the close of the
chapter rather than attribute individual comments
to individual colleagues.
A Little Background
ASI theory is globally used in pediatric practice,
and core constructs are applied across many other
areas of practice. This theoretical foundation has
engendered much research and collegial discourse, likely more than any other theory in the
profession of occupational therapy ( May-Benson
& Koomar, 2010 ; Schaaf et al., 2015 ). SI theory
emerged because of Ayres’ constant imperative to
look beyond behavior and gain an understanding
CHAPTER 3 Composing a Theory ■ 41
of the neurological underpinnings of disorders, in
order to support engagement and participation in
the activities of daily life. Blending research with
clinical practice, the children with whom Ayres
interacted were her motivation to link neuroscience and behavior. An emergent leader around
whom people congregated, Ayres embodied the
roles of clinician, researcher, and teacher, always
encouraging others to do the same.
According to Kielhofner ( 2004 ), Ayres’ work
evolved at a time of “crisis” in occupational
therapy. Up to this point, roughly through the
1960s, occupational therapy had focused on the
importance of occupation in daily life, using
“doing” as therapy. However, the medical fi eld
indicated that, although it seemed apparent that
engagement in occupation was benefi cial, there
was no comprehensive theory and no documented evidence that occupational therapy was
effective ( Kielhofner, 2004 ). Ayres, in the mid- to
late 1950s, had begun her work examining proprioceptive facilitation for the upper extremities,
with an interest in understanding the underlying
mechanisms of both function and dysfunction.
Kielhofner suggested that Ayres became part of
a newly emerging mechanistic paradigm in occupational therapy, emphasizing that the benefi ts
of engagement in occupation and activity were
best explained by understanding the underlying
mechanisms. Although Ayres was highly invested
in understanding the neurological mechanisms
of sensory integrative function and dysfunction,
she never lost sight of the bigger picture, that of
supporting engagement in childhood occupations
(see Fig. 3-1 ).
Ayres may not have set out to become the
“heart” of SI. In fact, accounts suggest that
she wanted anything but to become the center
of this universe; rather, she preferred that there
be centers of sensory integrative knowledge all
around the world. Nonetheless, she was driven
to understand the underpinnings of the disorders
she saw clinically. She pursued advanced training in research and neuroscience to guide her
growing knowledge of links between neurophysiological mechanisms and clinical practice, and,
through time, developed the theory and practice
of SI. She became the hub of knowledge about
SI. According to Kielhofner ( 2004 ), the model
of SI became a “conceptual practice model.”
Such models emerge as a means of explaining
phenomena, developing tools for practice, and
setting the stage for research on the model. By
their very nature, these models are dynamic; they
are revised in an organic way as new knowledge
develops through both research and clinical
application. This is certainly true of SI.
Ayres the Person
Sieg ( 1988 ) summarized Ayres’ childhood as one
in which she found comfort in being outdoors
on the family farm and enjoyed being with her
brother and younger sister. Ayres reportedly had
a diffi cult relationship with an older sister as well
as her mother, becoming increasingly introverted
in response to these relationships. She also grew
up dealing with what she saw as a “damaged
left hemisphere,” which caused her to struggle
to understand spoken words, particularly if the
speaker had an accent ( Sieg , 1988 ). Although
Ayres went on to do a great deal of reading,
writing, and speaking, writing and lecturing
remained a challenge for her throughout her life
FIGURE 3-1 Ayres, always a clinician, “learning”
from a client. Used with permission by Franklin B.
Baker/A. Jean Ayres Baker Trust.
42 ■ PART I Theoretical Constructs
( Fig. 3-2 ). According to one colleague, Ayres
“didn ’ t like lecturing, she didn ’ t like writing,
but she had to do it because she wanted to do
her research . . . if you ever look at one of her
lectures, they ’ re color coded all the way through
. . . she needed that coding visually to get her
through her lectures.”
Only a small number of therapists that
we interviewed felt they truly knew Ayres
as a person. She was described as “. . . [not]
social-social, but she was very relational.” Ayres
was noted to be amazingly kind and an excellent
listener. In spite of what may have been a childhood challenged by many factors (including her
own health), Ayres put family, and her husband,
Franklin, at the center of her world: “Her family
was probably central . . . her family was like her
nest and her comfort. That was like a cocoon for
her . . . she never really talked about her family
or anything. [But] in her writing you can see
that was her main core heart of her life. . . .”
Her love of family is refl ected in Love, Jean,
published after her death. This compendium of
letters between herself and her nephew, Phillip,
refl ects her love and concern for him as they
worked together to treat his sensory integrative
disorder, “by remote control,” through letters.
Her dedication to Franklin became apparent in
Sieg ’ s narrative, in which Ayres stated, “I have a
nearly perfect, just nearly perfect marriage. Just
a real love relationship. A complete pair bond”
( Sieg, 1988 , p. 96). Ayres’ fi rst book, Sensory
Integration and Learning Disorders, was simply
dedicated, “To Franklin.”
Ayres the Professional: Developing
Her Knowledge Base
Most colleagues that we interviewed offered
more insight into Ayres as a therapist and scientist
than Ayres on a personal level. Ayres completed
her coursework in occupational therapy in 1944
at the University of Southern California (USC),
and she performed her clinical internships in
1946, the same year that she successfully passed
the occupational therapy registration examination. Working clinically in psychiatry (Birmingham Veterans Hospital, Brentwood Sanatorium)
and rehabilitation (Kabat-Kaiser Institute) fueled
her already established need for knowledge.
Her investment in occupational therapy drove
her to investigate underlying components of
the disabilities that she saw in her patients; she
wanted to better understand the cause so she
could better focus the treatment. She began with
adults, in rehabilitation, and as such was always
invested in a better understanding of neurological functions. In 1949, Ayres fi rst published a
paper on craft analysis following electroshock
treatments ( Ayres, 1949 ). She became interested
in hand functions, publishing on this topic, and
her research career bloomed with her master ’ s
degree awarded by USC. Her thesis comprised a
series of three manuscripts addressing her work
on proprioceptive facilitation of the extremities
in occupational therapy, published in the American Journal of Occupational Therapy in 1955
( Ayres, 1955a, 1955b, 1955c ). Ayres had been
inspired by her mentor, Margaret Rood. Rood,
with degrees in both occupational and physical
therapy, was a motor control theorist, one of the
fi rst. Rood ’ s focus on refl exes, and her emphasis
on the use of proprioceptive inhibition and facilitation, led Ayres to begin her research on the
basics of proprioception from a neurological perspective, as well as the application of this basic
science information to occupational therapy. In
the conclusion of her fi nal paper, Ayres stated:
It seems, then, that the fundamental organization of the neuromuscular system is based on
function. When something disturbs that fundamental organization, it is reasonable to presume
that treatment might well be based on function—on activities simulating simple, normal,
life-like processes utilizing neurophysiological
mechanisms recognized for the integrative role
they play. . . . [While] this sounds very logical,
it has not been found to be entirely practical.
FIGURE 3-2 Although Ayres did not enjoy writing,
she knew it was crucial to move her work forward.
Used with permission by Franklin B. Baker/A. Jean
Ayres Baker Trust.
CHAPTER 3 Composing a Theory ■ 43
This suggests that the treatment of neuromuscular disorders is in the early developmental
stages. . . . Treatment procedures will have to
adjust accordingly as progress is made. ( Ayres,
1955c , pp. 125–126)
Such a statement captures core characteristics
that underlie Ayres’ subsequent work: a grounding in neuroscience, a focus on the importance of
sensation and SI in the production of movement,
an appreciation for the importance of engagement in daily life activities including play, and
the recognition that there is much to understand
related to implementing occupational therapy.
Ayres gained further clinical experience in
rehabilitation, and she worked at the United
Cerebral Palsy Pre-nursery School and Vocational Training Center before returning to USC
to pursue her doctoral degree. In 1955, she
joined the Occupational Therapy faculty at USC,
continuing there until 1964. While pursuing
her PhD in Educational Psychology, completed
in 1961, Ayres’ interest in the neuroscience of
sensory systems moved her toward examining
visual spatial abilities and body scheme. During
this time, she developed an appreciation of the
need for tools that would enable her, and other
clinicians, to better understand the role played
by perceptual and motor processes in learning.
Ayres had developed the Motor Accuracy test
before entering her doctoral program, and she
went on to focus on other tests of visual perception, developing the Ayres Space Test through
her doctoral degree ( Gorman & Kashani, 2017 ).
Linking her clinical work with the neuroscience
literature led her to a deeper understanding of the
integrative nature of sensory processing; Ayres
determined that visual perception relied heavily
on the processing of vestibular and proprioceptive
inputs ( Sieg, 1988 ). “The employing of neural
mechanisms to enhance motor development is
now well established; the current area of major
growth and controversy lies in the use of neurological constructs to aid in understanding and
ameliorating cognitive functions such as learning
disabilities; the next step may well be a more
fruitful attack on emotional and behavior disorders” ( Henderson, Llorens, Gilfoyle, Myers, &
Prevel, 1974 , p. xii). Ayres completed a postdoctoral fellowship at the Brain Research Institute
(BRI) at UCLA from 1964 through 1966, where
she could study with neuroscientists and expand
her thinking on brain function and dysfunction.
Although the neuroscientists did not uniformly
accept her ideas and perspective, the BRI provided a great learning opportunity and environment for her ( Sieg, 1988 ). During this same time
frame, she was working on, and deeply passionate about, her fi rst text, Sensory Integration and
Learning Disorders ( Ayres, 1972 ). One of Ayres’
colleagues indicated the following:
The quandary of deciding what research to
include and what she needed to leave out was
something Jean talked about all the time. Whenever Jean talked about this future publication
the creative passion that fueled her capacity
for work visibly energized her body; her eyes
brightened, her face lit up, and everything about
her animated. It was amazing and beautiful
to watch.
On the heels of completing her postdoctoral
fellowship, Ayres returned to USC. However,
Ayres reported not being accepted in occupational therapy, indicating “I became so disgusted
with occupational therapy in general because
I kept wanting to push the fi eld and the fi eld
pushed back. . . . I just couldn ’ t tolerate the negativism toward me” ( Sieg , 1988 , p. 97). Consequently, Ayres initially joined the Department of
Special Education; she was later appointed as
Adjunct in Occupational Therapy. She opened
the Ayres Clinic in Torrance, California, in 1977
and taught the fi rst SI treatment course linked
with USC, OT610 (see Fig. 3-3 ).
By all accounts, Ayres was brilliant, insightful,
and committed, and she was considered a mentor
by many (see Fig 3-4 ), as is clearly evident in the
following statements from interviewees:
She was such a wonderful mentor because not
only did she have the intelligence to formulize
her hypothesis, and it was way out there then,
but she designed the equipment; she designed
the tests. It was amazing. Plus, she developed
her clinical practice to do all the research.
I am still learning from her and if I go back
to what she has written it astounds me sometimes. There will be one or two little sentences
and I will go, “Oh my God, I missed that.” . . .
Ayres has informed me about everything really.
There ’ s so much that I learned from her
about just how you do science that I mean, it
was always with me.
Ayres required that I ask her questions
during my mentorship with her (1973). She
said, “You must question me or you won ’ t be
able to question yourself. If you can ’ t question
44 ■ PART I Theoretical Constructs
FIGURE 3-3 Ayres at her clinic. Used with permission
by Franklin B. Baker/A. Jean Ayres Baker Trust.
FIGURE 3-4 Ayres with Virginia Scardina. Ginny
always viewed Ayres as a mentor who guided her
clinical career. Used with permission by Franklin B.
Baker/A. Jean Ayres Baker Trust.
yourself, you ’ ll never be a researcher.” She
gave me some really poignant and good advice.
In our interviews, Ayres was described as
focused, perhaps driven by her need to understand herself. Ayres was strongly intrinsically
motivated in her work, and she appeared never
to rest her mind. “One thing Jean always did
was read the neurophysiological research. I mean
that was primary in her mind when she was
looking and developing and thinking in terms of
treatment and mechanisms and giving her lectures on theory and all. She was always reading
the literature.” Although it appeared that Ayres
spent a considerable amount of time reading and
applying the neurophysiological literature, her
interests and knowledge extended well beyond
neuroscience. “I learned at that time really how
widespread her reading was; I had no idea, I
thought she just lived neuroanatomy, not so. So, I
found that she was really [widely] read and very
experimental and experimented with herself over
everything.”
Ayres tried many of the activities on herself
that she would use eventually with children; “She
had problems herself, and so she kind of was analyzing what she felt were underlying things in her
and then developed tests to test them. She was
that way all the way along.” We were told that it
was not easy for Ayres to try out her ideas: “One
time I said, ‘Jean, why are you doing this? How
come? It ’ s so hard!’ She said, ‘Do you think I
could stop if I wanted to?’ So, it was her inner
drive and I learned that about her.” Ayres was
seen to be in constant search of an answer to her
current burning questions and in search of a tool
or an approach that would help her focus her own
mind. “She was always trying to keep her own
brain focused and get the energy out. Then she
would come back later, ‘Damn, it wore out.’ She
habituated and it didn ’ t work out as well.”
Importantly, Ayres was child-centered in all
her interactions with her young clients. In fact,
several interviewees commented on her way with
children, her deep ability to read their cues and
provide the support and challenge they needed to
do the things they wanted to do. These perspectives are refl ected in the following comments:
I mean to watch her treat . . . that was something that just really kept striking me because
I knew she was this marvelous researcher and
test developer and everything, but I think to
watch her treat was just a gift because she could
CHAPTER 3 Composing a Theory ■ 45
just pick up exactly what the kid needed at that
point in time and do it.
It was how she treated kids and how she
interacted with kids, and how she seemed to go
deeper with them . . . just watching her treat;
her quietness, and the trust that the children
had in her. Her presence with the children was
pretty amazing, as well as her way of bringing
the energy in the room to a just-right level.
In addition to her sensitivity in working with
the children, she also had a way with parents.
This becomes evident in reading Love, Jean
( Ayres, 2004 ) as well as in statements such as the
following: “The greatest contribution that I think
Ayres has made is helping parents to understand
their children ’ s behaviors.”
Throughout her career, Ayres mentored hundreds of practitioners, researchers, and theorists,
and she infl uenced countless more. Essentially,
against her will, Ayres became a transformational
leader ( Northouse, 2015 ), leading by example,
inspiring and motivating others to create change
in the fi eld of occupational therapy. She enjoyed
interaction with therapists who asked questions,
therapists who she could see thinking. We were
told, “She liked people asking, questioning, and
not believing her . . . not swallowing hook, line,
sinker.” Before her untimely death in 1988,
Ayres had presented widely on SI, and she had
published several manuscripts linking clinical
and research fi ndings, as well as several book
chapters, two distinctive texts, and two full
assessment batteries.
HERE ’ S THE POINT
• ASI theory is based on linking observable
behavior with neural underpinnings to support
engagement and participation.
• Ayres did not set out to be a famous scholar
but was driven by her desire to understand
herself and her work.
• Ayres’ teaching and mentorship of clinicians
and scholars has helped her theory evolve and
has created widespread change in the fi eld of
pediatric occupational therapy.
Growth of Sensory Integration
Theory and Research
Until 1971, Ayres had been able to get private and
federal funding for her work. Even in the 1970s,
obtaining grant funding was no small feat, so this
accomplishment needs to be acknowledged. It is
quite likely that Ayres’ ability to obtain funding
was related to her research focus grounded in
hard science. However, once this support ceased,
Ayres knew she still needed to do research and
that it would require funding.
Research and the Center
for the Study of Sensory
Integrative Dysfunction
In conjunction with colleagues, Dottie Ecker
and Sue Knox, Ayres began to generate research
dollars from teaching endeavors; by and large
in these early days, income from courses was
managed on an informal basis, with courses
run by a small committee. The initial courses
focused on perceptual motor skills rather than
SI. Ayres was the primary lecturer, although she
was joined by such fi gures as Margaret Rood
and, gradually, by other presenters, such as Knox
and Ecker. Aside from academic contributions,
Knox reported that she and Ecker also brought
“goodies” for course participants. As the teaching grew, the core group decided to form a nonprofi t organization into which funds from courses
could be placed and subsequently used to support
research. In 1972, with private funding, Ayres
formally established the Center for the Study
of Sensory Integrative Dysfunction (CSSID).
Lawrene Kovalenko spearheaded the establishment of CSSID, with the crucial support of Sue
Knox and Dottie Ecker. According to Knox, Pat
Wilbarger and Ayres were among the original
trustees, and the Education Committee consisted
of Dottie Ecker, Mary Silberzahn, and Maryann
Rinsch. Rinsch resigned soon after the establishment of CSSID, leaving an opening that Knox
fi lled. In addition to the large private donation
that Ayres secured for research, there were other
contributions. Sharon Cermak indicated she wrote
the fi rst check to CSSID, for $25, and in 1975
Judy Kimball sponsored Ayres to do a conference in Syracuse, New York, yielding more than
$8,500 in proceeds for CSSID, much to Ayres’
appreciation and delight. Although establishment
of a center did not sit well with Ayres, she felt it
was necessary to support ongoing research.
Although CSSID started small, the demand
for courses grew such that additional teaching faculty were recruited beginning in 1974.
46 ■ PART I Theoretical Constructs
Simple courses morphed into conferences
with a certifi cate of attendance; these would
morph again into workshops leading to certifi cation. The certifi cation process required
additional faculty and, from this need, faculty
training developed. The fi rst training was held
in 1976, and gradually the faculty ranks grew.
During training, faculty listened to presentations
related to theory and testing, and Ayres shared
case studies and aspects of her current work
( Fig. 3-5 ). Many therapists currently associated
with SI, as well as therapists currently more
closely associated with sensory-based and complementary interventions, had their start with
CSSID. All contributed to the dissemination of
SI theory and practice and, to some extent, to its
research base. Faculty met yearly, sharing developing knowledge. One colleague refl ected, “We
were literally a think tank, and not only did we
talk about teaching the course, we also talked
about theory and treatment. We talked about
the research.”
In these early years, there were great learning opportunities and a great deal of sharing
among faculty. The need for courses continued,
and the number of CSSID faculty grew. Therapists around the country applied, or were invited,
to join this perceived “elite” group of instructors. Not everyone who wanted to be part of
the faculty was included, and some individuals
maintain they were actively discouraged or even
blackballed from becoming faculty. At some
point there was a moratorium on adding additional faculty, creating a sense of those who were
“in” and those who were not, fostering unrest
and potentially adding fuel to a smoldering fi re.
In 1983, CSSID became Sensory Integration
International (SII). This was reportedly prompted
because there was increasingly “. . . big international interest . . . some of the faculty being
international [e.g., Canadians] . . . and they
wanted more of . . . a name that didn ’ t sound so
small and isolated. . . .” The name change was
not a point of contention; faculty supported the
need to have a name that captured their growing
international presence.
SII and Growing Tension
Courses offered by SII were doing well, and the
Ayres Clinic appeared to be thriving. However,
Ayres, the reluctant but admired leader, was battling cancer for the second time in her short life.
When she received the second diagnosis, she
began to withdraw from activities not directly
related to completing the Sensory Integration
and Praxis Test (SIPT; Ayres, 1989 ) . Perhaps in
response to the impending loss of Ayres and her
separation from the role of “leader,” colleagues
began to move in different directions. According
to Ballinger ( 2007 ), this is to be expected with
leader succession. The response of members
within the group varies depending on their relationship with the leader. Ballinger indicated that
responses of those closest to the leader likely
include loyalty, respect, and high levels of affect,
whereas individuals farther from the core fi nd
themselves less affectively infl uenced by the
impending loss. With regard to the fi eld of SI,
this appears to be a time when many sensoryintegration-informed, but more sensory-based,
therapies began to develop, and when schisms
among and between individuals and groups
became more apparent.
With her illness, Ayres planned to sell the
Ayres Clinic, offering it fi rst to USC. Although
the Occupational Therapy Department seriously
considered the purchase, it did not happen, and
in 1985 SII purchased the Ayres Clinic. USC Professor Florence Clark became the director, maintaining the strong link with USC until 1989 when
she resigned to concentrate on the establishment
of the Occupational Science PhD program. This
was something that “Jean would have wanted,
that her clinic would be associated with the university and led by a prominent scholar with a
FIGURE 3-5 Ayres teaching OT610 in the Ayres
Clinic. Used with permission by Franklin B. Baker/A.
Jean Ayres Baker Trust.
CHAPTER 3 Composing a Theory ■ 47
PhD.” Others who had long been associated with
both OT610 and the Ayres Clinic (Parham and
Mailloux) maintained their roles.
Unfortunately, SII administrative leadership
at this time was somewhat divisive and unstable.
Following removal of one director, there was a
period when things went well; “[Steve Leinau]
came in . . . and he put [SII] on the map. He
began doing international conferences, and the
fi rst one I went to was Marian Diamond and
Temple Grandin and not a lot of people knew
about them then. So, he started doing conferences, started publishing and doing all that, for
about 2½ years. . . .” Steve moved on, and a
series of executive directors passed through the
organization, one who provided stability and
forward momentum, and others who had considerably less positive infl uence, possibly engaging
in unethical practice. The SIPT was published in
1988; new certifi cation courses were introduced;
and practitioners were required to retool, another
source of tension. Several changes took place in
the SII Board of Directors through the ensuing
years, and power appeared to shift. There was a
sense that some members of the Board had an
agenda that was not consistent with the direction of the organization; “They kind of had
other interests as well, sensory integration and
not strict areas of SI kind of things. . . . They
started micromanaging the clinic . . . telling . . .
the group what they could do and they couldn ’ t
do and everything else.” Differences developed between clinicians in the Ayres Clinic and
members of the Board of Directors relative to
the clinical application of SI, with the board supporting what would be termed “sensory-based”
approaches and the clinic therapists feeling that
this deviated too far from the core principles of
SI. Following what was described as “a very
uncomfortable meeting for everybody,” the clinicians who had been involved with the Ayres
Clinic for years left en masse. This proved problematic for SII as the clinic had been a major
source of revenue; the majority of clients from
the clinic followed the clinicians, leaving no one
to run it and a limited clientele. Attempts to bring
in clinicians to bolster the clinic failed. In addition, courses began to falter; course quality was
seen to be diminishing; course attendees became
disgruntled as courses were scheduled and cancelled; the certifi cation process suffered; and
teaching faculty withdrew. In the end, Western
Psychological Services withdrew its support for
the certifi cation process, instead backing USC
and OT610, which was being offered through the
re-established clinic, Pediatric Therapy Network.
In our interviews, we had talked with therapists who had been in the central core of Ayres’
infl uence and work, as well as those who were
increasingly more removed from her immediate sphere. Through these discourses we were
able to get a general sense of the process, some
insight into the impact on SI theory and ongoing
development of knowledge, but little agreement
as to exact timing or cause and effect relative to
unfolding tensions. Clearly, Ayres was aware of
developing discontent among the SII teaching
faculty. They were a group of independent thinkers, and this appeared to lead to multiple disagreements. We were told, “she knew she had not
prepared the fi eld for her leaving. And that when
she left, because of such strong belief systems, it
[teaching faculty] was gonna divide into at least
two factions. . . . [There was] bad blood between
them, and . . . nobody was willing to compromise
or see it as a research issue. . . . [Disagreements]
were about personalities and not about research,
and she didn ’ t know what to do.” Another interviewee stated an alternative impression, indicating that, having heard someone other than Ayres
conduct an SI lecture, Ayres responded, “I think
things are gonna be in good hands.”
Perspectives on the directions taken after
Ayres’ death vary. We were told, “I think it gave
us all an extra impetus to carry on her legacy. . . .
And I think people really had a feeling that we
wanted to really carry on Jean ’ s legacy.” Another
interviewee indicated, “Different people took different pieces and tried to advance theory . . . and
practice. . . . That ’ s not a criticism. I think there
was a lot there that you could take and develop,”
indicating that individuals took “branches” of
the theory and practice to move them forward.
For instance, applying the theory to populations
of children other than those with learning disabilities was one “branch,” formalizing clinical
observations another, and specifi c prescribed
interventions (e.g., Therapressure Program) was
yet another.
We wondered whether everyone saw growing
tension, and many people saw a “fray”; most
commented that they tried hard to stay out of it,
not wanting to take sides: “I tried to stay out of
it as much as possible”; “I saw it as somewhat
48 ■ PART I Theoretical Constructs
‘political.’” “I stayed out of what I saw as a
‘political mess.’” Generally, these individuals
did not necessarily see anything wrong with the
various directions people went. One interviewee
saw the work of Miller and colleagues in developing the Scientifi c Workgroup and encouraging
and facilitating research funding for colleagues
from a variety of disciplines as highly positive. “Lucy Jane Miller and that group that the
Wallace [Research] Foundation funded has had
tremendous impact on sensory integration . . .
people studying it from a wide variety of disciplines and publishing . . . would never have happened without an OT working within that group.
. . . Aligning ourselves with people like that
makes a big difference. . . . I think the intent
was to help to get us accepted by other professionals and disciplines.” However, other scholars
expressed concern that the different directions
would eventually lead to confusion. This concern
centered around a shift in terminology from
what had been “SI” to what Miller was calling
“sensory processing.”
The use of different terminology was seen as
both positive and negative. On one hand, the shift
to sensory processing addressed the concern of
some that SI, as used by occupational therapists,
was not a term that was universally accepted and
understood . “So, by using a term that psychologists were more comfortable with, they had been
using [the phrase] sensory processing regulatory disorders already, . . . we would be more
accepted. I think that has actually happened.”
Others saw it as a potential source of misunderstanding. The lack of clarity relative to defi ning SI and sensory processing was substantial.
Some scholars saw SI as the overall function, and
they included sensory processing as a component of SI. Other scholars saw the opposite, with
sensory processing as the umbrella term, within
which SI was a component. Unfortunately, this
conundrum continues to the present.
One interviewee suggested that, with this
level of confusion, we would do best to dispense
with labels altogether, using descriptive language
instead:
. . . the language is still confusing, haven ’ t
made much progress at all with language . . .
may be more useful to describe the behaviors that we see. For example, rather than the
term sensory modulation, let ’ s just say overreactivity to sensation, or under-reactivity. . . .
Let ’ s just describe the behavior and stop trying
to label it until we understand it better.
We heard this call for a better understanding, for stronger science and research, and a
new wave of well-educated young scientists in
several interviews.
Terminology was an ongoing issue in our
interviews. In part, the concern was regarding
use of the term sensory integration to describe an
intervention that we, in this book, have termed
sensory-based. We have included several sensorybased interventions in Chapter 18 (Complementary Programs for Intervention). Approaches such
as The Wilbarger Approach to Treating Sensory
Defensiveness, Therapeutic Listening®, and the
Astronaut Training Program have a foundation
in understanding how sensation is received, processed, and integrated to produce environmental
interaction, and here we include them as sensorybased. The treatment approaches described in
these programs are missing some of the essential
features of what is now called Ayres Sensory
Integration ® (ASI). In fact, the trademarked
symbol that now stands at the end of “Ayres
Sensory Integration” was a response to what
some saw as misappropriation of Ayres’ name
and work. Calling these approaches SI was seen
by some of our interviewees as problematic in
terms of theory development: “[this] has big consequences for the evolution of the theory, these
things calling themselves sensory integration, but
not being sensory integration.” It is also seen as
posing problems and confusion for teaching and
clinical practice.
We get parents that say they want the brushing
protocol and we say, “No, we don ’ t do that,
but this is what we will do.” . . . It makes it
harder to teach some of the real SI kind of stuff
because people pull in . . . those kinds of things.
And, in some cases . . . when we ’ re teaching
. . . and we tell ‘em to come up with some treatment strategies and sometimes the fi rst thing is
brushing, and I think, “where did we miss out?”
And, so, it makes it harder. So, in some ways,
I think it can be harmful. It makes it harder for
. . . whoever ’ s trying to teach what we ’ re trying
to get across.
Another point of ongoing contention has been
around the application of the phrase sensory
processing disorder. As the umbrella term in
the nosology ( Miller, Anzalone, Lane, Cermak,
& Osten, 2007 ), this phrase encompassed both
CHAPTER 3 Composing a Theory ■ 49
sensory modulation disorders and praxis disorders. However, as the term was applied to the
efforts toward inclusion in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5), the focus was on sensory modulation. The medical fi eld had, at least partially,
embraced the construct of regulatory sensory disorder ( Miller, Lane, Cermak, Anzalone, & Osten,
2005 ), and many of the constructs of praxis were
already included in the developmental motor
coordination diagnostic category. Sensory processing disorder did not get accepted as a diagnosis in the DSM-5; however, “hyper-responsivity,”
“hypo-responsivity,” and “unusual interests
in sensory aspects of the environment” were
included in the criteria for autism ( American
Psychiatric Association, 2013 ). The DC: 0-5™
( Zero to Three, 2016 ) uses the term sensory
processing disorder to encompass sensory overand under-responsiveness, as well as sensory
seeking. As such, the issue with clarity on this
phrase remains, and it provides another point of
tension among SI scholars.
I think when you ’ re talking about the language,
using the term sensory processing, which
is mostly about sensory modulation, versus
sensory integration, has confused people and led
them to believe that it ’ s all about modulation.
Another commented,
It ’ s kind of interesting to see how it all plays
out, but students don ’ t get it, and they think
that SI is just sensory modulation but then you
should add in some fi ne motor activities, and a
little bit of this and a little bit of that. But that
isn ’ t modulation; that is really looking at praxis,
and they don ’ t understand the praxis piece.
[Ayres] had developed a SIPT, which was
a Sensory Integration and Praxis Test, and all
of a sudden the only thing we were talking in
the ’90s was about modulation . . . it was like
we had left some of the praxis out of the study
and everything was modulation . . . some of the
models on modulation were confusing for most
of the people. So, I think that we derailed for
many reasons.
The tensions regarding developing branches
and terminology issues have not dissipated to
any substantial degree at the time of this writing.
Relative to “branches” we have tried to capture
those sensory-based therapeutic approaches
in Chapter 18 (Complementary Programs for
Intervention); we recognize that many of these
approaches have roots in Ayres’ theory of SI.
Further, we have decided in this book to use SI
to refl ect the theoretical and therapeutic foundation developed by Ayres, covering sensory modulation, sensory discrimination, and praxis; this
is refl ected in our model, presented in Chapter
1 (Sensory Integration: A. Jean Ayres’ Theory
Revisited). However, there are times when contributors preferred the term sensory processing
and we have left this terminology as is.
HERE ’ S THE POINT
• The CSSID (eventually renamed SII) was a
nonprofit organization formed to support SI
research via revenue generated from teaching.
• Ayres’ illness and withdrawal from both SII and
the Ayres Clinic resulted in a lack of leadership
and discord among members.
• Terminology around SI theory, intervention, and
classification of disorders has been an ongoing
point of contention among leaders in the fi eld.
Evolution of Ayres’ Work
Through time, Ayres’ theory and models have
been revisited and adapted by others, as refl ected
in many of the comments noted previously.
These adaptations were fueled by several motivations. Some colleagues ( Fisher & Murray,
1991 ) sought to capture and expand on SI in
ways consistent with Ayres’ writing but not specifi cally depicted in her models. Others (e.g., see
Chapter 1 , Sensory Integration: A. Jean Ayres’
Theory Revisited; Miller, Anzalone, et al., 2007 )
sought to clarify links between sensory integrative processes and clinical fi ndings and behavior, sometimes in an attempt to simplify Ayres’
models and make them more readily available
outside the fi eld ( Miller, Anzalone, et al., 2007 ).
Still others (e.g., Dunn, 2014 ) focused on and
augmented particular aspects of Ayres’ theory.
In fact, so many new models have been created
that practitioners, and indeed researchers, often
seem confused about what constitutes SI theory.
Has one or more new theories emerged? Based
on our interviews and our review of various
published models, the answer to this question
is, decidedly, “ NO! ” As noted earlier, one of the
people we interviewed suggested “branches,”
and this analogy seems fi tting. Many of our SI
50 ■ PART I Theoretical Constructs
scholars have expanded their own work into particular areas of interest, extending the model of
SI and at times coupling it with other theoretical
models in their efforts to best serve children and
families. However, there remains a core; even as
available neuroscience knowledge has ballooned,
the inferences drawn and hypotheses put forward
by Ayres have been shown to be amazingly accurate. The core constructs of Ayres’ SI theory,
linking brain processing and observable behavior, have remained remarkably stable.
We discuss some of the different published
models, endeavoring to show how they depict
the evolution of a single theory. As noted earlier,
Ayres’ original model was one of sensory integrative function. In her model, she illustrated the
ways in which the integration of various sensory
inputs contributed to different behaviors and performance skills, all in the end resulting in higher
level “end products.” None of the published
models contradicted these original relationships.
We asked each of our interviewees to sketch
a model that depicted the way that they thought
about, or taught, SI theory, and none of those
deviated substantially from the relationships
that Ayres originally hypothesized. Instead, each
of the models expanded one or more aspects of
the original model. For instance, most further
defi ned “integration of sensory inputs” to include
both sensory discrimination and sensory modulation. Similarly, there was consensus that it is
the sensory discrimination aspect of integration
that supports the development of postural, ocular,
or bilateral skills; somatopraxis; and visuopraxis
(when this later construct is included). Sensory
modulation was generally seen to support behavior, attention, and arousal. Our scholars did not
always include the end products that Ayres had
included, but when they did, they were highlevel skills (e.g., academics, abstract thought).
Some of the scholars listed praxis as an end
product; others included praxis as a more basic
product of integration. It is safe to say that all
our interviewees would have added end products
had we specifi cally asked.
At the STAR (Sensory Therapies And
Research) Institute, Miller and colleagues ( 2007 )
developed a model of practice grounded in ASI
theory that also includes core constructs from
specifi c sensory-based interventions and other
theories or models: caregiver-child interaction,
caregiver engagement in therapy, and caregiver
coaching and education. As noted earlier, one
of the skills Ayres brought to therapy was her
ability to help parents better understand children. However, this reframing was not explicit
in Ayres’ theory, which was focused on the
child rather than the family. Keep in mind that
Ayres’ work appeared during an era ensconced
in the medical model; SI theory was somewhat
more comprehensive than other theories of the
day in that it was closely tied to both evaluation and treatment. However, Ayres died before
family-centered care took hold, and she did
not formalize her concepts of family-centered
intervention.
From a sensory integrative point of view, the
STAR Institute model emphasizes arousal regulation, linked, in many of our interviewees’
models, with sensory modulation, and focuses on
engagement and relationships. The STAR model,
then, does not refl ect a new “theory” but rather
the integration of theoretical models, linking SI
with engagement and relationships. More details
on the STAR model can be found in the Appendix to this text .
Other models that will be familiar to many
practitioners are those developed by Dunn ( 1999,
2014 ). Dunn ’ s models focus on sensory modulation, one of the integrative functions. Dunn
expanded upon our understanding of the modulation defi cits that Ayres had originally identifi ed.
Ayres defi ned tactile defensiveness, postural/
gravitational insecurity, and aversiveness to
movement. Dunn, however, examined the interface between behavioral responses and neurological thresholds across sensory systems. Her
work expanded our understanding of differences
in the ability to modulate responses to sensation,
linking this to thresholds for activation within
the nervous system. Again, this was not a new
theory but rather a perspective on what underlies sensory responsivity. There is more information on Dunn ’ s model in Chapter 10 (Assessing
Sensory Integrative Dysfunction without the
SIPT), in the discussion of Dunn ’ s tool, the
Sensory Profi le 2.
Since Ayres’ death, others have developed
interventions drawn in part from SI theory; we
have previously referred to many of these and
have captured several in Chapter 18 (Complementary Programs for Intervention). By and
large, they are sensory-based or regulationoriented. As with Dunn ’ s model, then, these other
CHAPTER 3 Composing a Theory ■ 51
interventions have branched from Ayres’ conceptualization of sensory modulation, and they do
not refl ect a new theory. Instead, they may be
best viewed as lines of thinking that grew from
the core of SI, making SI a theory with multiple expressions. Providing this expanded view
on aspects of Ayres’ work has moved our understanding forward in some areas. For instance, the
neurophysiological correlates of sensory overresponsivity (see Fig. 3-6 ) have been investigated
by several researchers (e.g., Lane, Reynolds, &
Thacker, 2010 ; Mangeot et al., 2001 ; McIntosh,
Miller, Shyu, & Dunn, 1999 ; Reynolds, Lane,
& Gennings, 2009 ; Schaaf et al, 2010 ; Schoen,
Miller, Brett-Green, & Nielsen, 2009 ), and added
to our understanding of this aspect of sensory
integrative dysfunction. More details on this
research can be found in Chapter 16 (Advances
in Sensory Integration Research: Basic Science
Research).
Alongside of this increased knowledge base
regarding modulation, some of our interviewees expressed a fear that we had lost praxis:
one of the core components of SI theory. Ayres
completed the SIPT just before her death, and,
as such, the emphasis of the approach had been
on praxis. After her death, many researchers and
practitioners moved on to focus on modulation
and, as mentioned earlier, seemed to leave praxis
behind. Interviewees had this to say:
It would be interesting to see where her research
would ’ ve gone . . . where would she be now
. . . when you look at the different eras . . .
there ’ s the era of the visual, more of the visual
motor. And with this space visualization and
fi gure ground tests coming out, and then vestibular becomes such a big deal, and then praxis
becomes such a big deal, and then sensory modulation or sensory registration becomes a big
deal, but it kind of stops there. . . . It feels like
we ’ re sort of stuck in that era of sensory modulation being the most important thing where in
the past it would be sort of like a 10-year period
where a lot of research was done and then we ’ d
move on to the next area, or Jean would move
on to the next area.
I think it ’ s not just modulation. You certainly have to deal with modulation, but then
also people kind of have the idea [that] you
need to deal with the modulation fi rst, before
you can deal with the praxis, and don ’ t see it
[modulation] as something that just is all the
way through.
This emphasis, this focus, had become a point
of disagreement for some of our interviewees,
potentially because it appeared that “sensory
processing” now meant “sensory modulation,”
which, in turn, is synonymous with SI. With this
chain of events, the place of praxis in SI (i.e.,
the impact of poor integration on the development of praxis) appears to have been lost. Given
that Ayres’ fi nal contribution to the fi eld was all
about praxis, this loss is disturbing. It is possible
that the apparent emphasis on sensory modulation was fueled by the growing understanding of
sensory modulation dysfunction in children with
autism, at a time when the diagnosis of autism
was on the rise. We were told:
So, I think that we were caught in this also
because autism started being so prevalent, and
in the autism world . . . that was where the
money was. The money was in autism and . . .
into social and repetitive behaviors, and not so
much into praxis.
This same interviewee went on to state: “the
evidence itself for the theory is more tipped to
modulation or to the social, emotional, repetitive
autism than the praxis, and it ’ s not like the praxis
is not present in the autism . . . but . . . it ’ s not
central in the diagnosis.”
Moving Forward
Diversity in thinking is never a bad thing; it has
the potential to move things forward, uncover
alternative ways to accomplish tasks, and display
alternative ways to interpret situations ( Zollman,
2010 ). Zollman explained that, as scientists, we
FIGURE 3-6 The Sensory Challenge Protocol,
developed by Miller, has been used to examine neural
underpinnings of sensory over-responsivity in various
populations of children.
52 ■ PART I Theoretical Constructs
actively seek information that guides us to determine the effectiveness of our methodologies.
Zollman argued for “transient diversity” (p. 32),
which can be understood as diversity of thought,
present for enough time that we carefully and
thoughtfully examine our own theories but not
so long that it interferes with the development of
a unifi ed direction. Diversity in thinking is consistent with the multiple directions and models
presented here. The unanswered question is
whether this diversity continues to benefi t the
broader fi eld, or if it is time to work toward
unifi cation.
What have we gained from the diversity in
models and approaches; how have they moved
us forward? Certainly, we have gained a greater
understanding of the underpinnings of sensory
modulation. And perhaps we have developed
greater insight into the effect of specifi c sensory
and motor systems on behavior and development,
and gained perspectives on how to use sensation
in, and for, intervention. Some therapists might
also fi nd a renewed understanding of the nature
of family-centered and child-focused intervention. The various models and “branches” have
common roots in Ayres’ mission to understand
links among neurophysiological mechanisms,
sensory integrative dysfunction, clinical practice,
and occupational engagement and performance.
Whether these common roots are enough to work
toward unifi cation is itself a question that would
fuel debate.
What hurdles will get in the way? Inconsistency in terminology is problematic; it confuses
the public; it confuses other professionals; and it
confuses our own practitioners. We are unlikely
to agree as to whether “SI,” “sensory processing,”
or “sensory integration and processing” is the
best descriptor. Nonetheless, our roots are in SI
theory, assessment, and intervention as developed
by Ayres. Use of the terms sensory processing
versus sensory modulation presents another
stumbling point although one, it seems, on which
we could come to consensus. Moving our understanding of praxis forward, and developing a
deeper understanding of sensory perception and
discrimination and their links to praxis, is crucial.
It is important to recognize that research funding
is increasingly diffi cult to obtain, and this area
of research will be no exception. However, other
investigators within and outside of occupational
therapy are engaged in research on interventions
for motor incoordination; the longer we wait, the
less likely SI theory is to be linked with praxis.
There are other considerations as we look to
models and their application in practice. Parham
and colleagues ( 2007 ) identifi ed the core elements of sensory integrative therapy in the ASI
Fidelity Measure ( Parham et al., 2007, 2011 ).
This tool, based on the fi delity measure developed by Miller, Coll, and Schoen ( 2007 ), guides
practice and research to maintain “fi delity” to the
core principles of ASI. Although some research
has been conducted on the effectiveness of the
intervention, more needs to be done, and funding
will be needed to accomplish this research.
Schaaf and Mailloux ’ s ( 2015 ) clinical reasoning
approach, focused on using assessment fi ndings
to guide the choice of goals and defi ning clear
outcomes when using SI in treatment, has merit
but has not been thoroughly investigated. In this
text we have addressed SI theory as a basis for
coaching (Chapter 17, Using Sensory Integration
Theory in Coaching) as a tool to enable children
to succeed in everyday tasks despite sensory
integrative dysfunction. Clearly integrating and
evaluating the effectiveness of task and environment interventions within models of SI intervention also requires investigation.
HERE ’ S THE POINT
• New conceptual models and models of
intervention have emerged based upon Ayres’
work, but they largely align with her original
theory.
• Since Ayres’ death, much research has emerged
in the area of sensory modulation; however,
more focused study is needed in the areas of
sensory discrimination and praxis.
• Continued research is needed on the effect of
interventions that have their roots in SI theory.
Summary and Conclusions
Conducting these interviews shed important
light on the history of SI theory and practice.
Our colleagues refl ected on their understanding
of SI along many different paths, and by listening and considering their comments, we came to
realize there was a base of positive intent that
ran through each perspective. The interviews
pointed to more similarities than differences. The
CHAPTER 3 Composing a Theory ■ 53
stories we heard were heart-warming and heartwrenching. Only one scholar we wished to
include in these interviews refused to talk to us.
We gained a better picture of Ayres as a person,
a scholar, a researcher, a clinician, a theoretician,
and a reluctant leader. We heard remarkably little
disparity on how history unfolded. Although relevant scholars were not fully unifi ed in modeling
SI, the differences seemed more to refl ect different emphases rather than schisms in the theory.
Nonetheless, there remains much to do, much to
learn, and much to understand as we continue to
study and apply SI theory to practice.
Acknowledgments
Although we decided not to identify individual
contributions to the information presented in this
chapter, we do want to express our sincere thanks
to all who we interviewed as we pursued these
historical insights. To Erna Blanche, Sharon
Cermak, Florence Clark, Dottie Ecker, Diana
Henry, Judy Kimball, Sue Knox, Lawrene Kovalenko, Zoe Mailloux, Shay McAtee, Lucy Miller,
Shelley Mulligan, Diane Parham, Roseann
Schaaf, Sarah Schoen, Susanne Smith Roley, and
Pat Wilbarger: We thank you all for your knowledge and wisdom, your willingness to share, and
your time in interviews, reviews of transcripts,
and review of this chapter. To say the chapter
would not have been possible without you is a
signifi cant understatement.
Where Can I Find More?
Here you will fi nd some of Ayres’ early work.
You might enjoy reading this history for yourself!
Ayres, A. J. (1954). Ontogenetic principles in
the development of arm and hand functions.
American Journal of Occupational Therapy,
8 (3), 95–121.
Ayres, A. J. (1958). The visual-motor function.
American Journal of Occupational Therapy,
12 (3), 130–138.
Ayres, A. J. (1961). Development of the body
scheme in children. American Journal of
Occupational Therapy, 15 (3), 99–102.
Ayres, A. J. (1963). The development of
perceptual-motor abilities: A theoretical basis
for treatment of dysfunction. American Journal
of Occupational Therapy, 17, 221–225.
Ayres, A. J. (1964). Tactile functions. Their
relation to hyperactive and perceptual motor
behavior. American Journal of Occupational
Therapy, 18, 6–11.
Ayres, A. J. (1965). Patterns of perceptualmotor dysfunction in children: A factor analytic study. Perceptual and Motor Skills, 20,
335–368.
Ayres, A. J. (1966a). Interrelation of perception, function, and treatment. Journal of the
American Physical Therapy Association, 46,
741–744.
Ayres, A. J. (1966b). Interrelationships among
perceptual-motor abilities in a group of
normal children. American Journal of Occupational Therapy, 20 (6), 288–292.
Ayres, A. J. (1966c). Interrelationships among
perceptual-motor functions in children. American Journal of Occupational Therapy, 20 (2),
68–71.
Ayres, A. J. (1969a). Defi cits in sensory integration in educationally handicapped children. Journal of Learning Disabilities, 2 (3),
160–168.
Ayres, A. J. (1969b). Relation between Gesell
developmental quotients and later perceptualmotor performance. American Journal of
Occupational Therapy, 23 (1), 11–17.
Ayres, A. J. (1971). Characteristics of types of sensory integrative dysfunction. American Journal of Occupational Therapy, 25 (7), 329–334.
Ayres, A. J. (1972a). Basic concepts of occupational therapy for children with perceptualmotor dysfunction. In Proceedings of the
Twelfth World Congress of Rehabilitation
International, pp. 154–161.
Ayres, A. J. (1972b). Improving academic scores
through sensory integration. Journal of Learning Disabilities, 5 (6), 23–28.
Ayres, A. J. (1977). Cluster analyses of measures
of sensory integration. American Journal of
Occupational Therapy, 31 (6), 362–366.
Ayres, A. J. (1978). Learning disabilities and the
vestibular system. American Journal of Occupational Therapy, 11 (1), 30–41.
Ayres, A. J., & Mailloux, Z. (1981). Infl uence of
sensory integration procedures on language
development (aphasia, apraxia, vestibular
disorder). American Journal of Occupational
Therapy, 35 (6), 383–390.
Ayres, A. J., & Tickle, L. S. (1980). Hyperresponsivity to touch and vestibular stimuli
54 ■ PART I Theoretical Constructs
as a predictor of positive response to sensory
integration procedures by autistic children.
American Journal of Occupational Therapy,
34 (6), 375–381.
Cermak, S. A., & Ayres, A. J. (1984). Crossing
the body midline in learning-disabled and
normal children. American Journal of Occupational Therapy, 38 (1), 35–39.
Sieg, K. W. (1988). Six perspectives on theory
for the practice of occupational therapy.
Salem, MA: Aspen Publishers, Inc.
Here are some additional reads that you might
fi nd interesting:
1. Ayres, A. J. (2004). Love, Jean: Inspiration
for families living with dysfunction of
sensory integration. Santa Rosa, CA:
Crestport Press.
A compilation of letters written by Ayres
to her nephew, Philip Erwin, that provides
unique insights into her thoughts about her
research in SI and her own sensory needs.
2. Henderson, A., Llorens, L., Gilfoyle,
E., Myers, C., & Prevel, S. (1974). The
development of Sensory Integrative Theory
and Practice: A collection of the works of
A. Jean Ayres. Dubuque, IA: Kendall/Hunt
Publishing Company.
A collection of scholarly works written by
Ayres that outline the development and
refi nement of SI theory and practice.
3. Cermak, S. A., Ayres, A. J., Coleman, G.,
Smith Roley, S., Mailloux, Z., & McAtee, S.
(2011). Ayres dyspraxia monograph, 25th
anniversary edition. Seattle, WA: Amazon
Digital Services LLC.
Original work by Ayres that provides
a foundation for understanding the
neurobiological basis for praxis and
dyspraxia, with additional material provided
by current clinicians and scholars.
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Ayres , A. J. ( 1955a ). Proprioceptive facilitation
elicited through the upper extremities. American
Journal of Occupational Therapy , 9 ( 1 ), 1 – 9 , 50 .
Ayres , A. J. ( 1955b ). Proprioceptive facilitation
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Ayres , A. J. ( 1972 ). Sensory integration and learning
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Ayres , A. J. ( 1989 ). Sensory Integration and Praxis
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Koomar , J. , Brett-Green , B. , Burke , J. P. , . . .
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doi:10.1007/s10670-009-9194-6
PART
II
The Neuroscience
Basis of Sensory
Integration Disorders
58
CHAPTER
4
Structure and Function
of the Sensory Systems
Shelly J. Lane , PhD, OTR/L, FAOTA
Chapter 4
. . . the structure/function duality is merely a didactic convenience. In reality,
structure allows function and function gives meaning to structure.
— Cohen, 1999 , p. 3
Upon completion of this chapter, the reader will be able to:
✔ Identify components of the central and
peripheral nervous systems.
✔ Review the structure and function of the
primary sensory systems associated with sensory
integration theory.
✔ Develop an understanding of links between
sensory system structure and sensory integrative
function and dysfunction.
LEARNING OUTCOMES
Purpose and Scope
Students faced with their fi rst neuroanatomy
class commonly feel a sense of foreboding.
There is seemingly endless detail within the
central nervous system (CNS) and the connecting peripheral nervous system (PNS), and
developing a thorough understanding not only
of structure and function but also of interrelationships between and among structures and
functions seems a daunting undertaking. In this
chapter, the learning process is a little less daunting: A small piece of the neuroscience pie is presented, beginning with some basics relative to
the central, peripheral, and autonomic nervous
systems, and then emphasizing sensory system
structure, function, and integration. We will
address in most detail the sensory systems most
closely aligned with sensory integration (SI)
theory, the tactile and proprioceptive (together
referred to as somatosensory ), as well as vestibular, systems. Auditory and visual systems
will be covered in somewhat less depth, and
the olfactory and gustatory systems will also be
presented. A single chapter on only the sensory
systems can hardly do justice to these topics;
entire books have been written about each. Thus,
this should be considered an overview, a review
for many readers. For each system, an attempt
has been made to provide integrative information
that combines structure and function. For more
detailed information, readers are referred to the
books listed in the reference list and to the other
chapters of this book.
Basic Structure and Function
of the Central Nervous System
Before diving into the structure and function of
the sensory systems, we need to consider where
this information fi ts in SI theory. In Chapter 1
(Sensory Integration: A. Jean Ayres’ Theory
Revisited), a schematic of sensory integrative
dysfunction was presented, and it is reproduced
here, adapted to include “interoception” ( Fig. 4-1 ).
CHAPTER 4 Structure and Function of the Sensory Systems ■ 59
As previously described, the fi gure is best understood by fi rst considering the sensory systems,
located at the center of the schematic. Understanding the sensory systems is central to understanding SI theory; this is where we begin.
Cells of the Central Nervous System
The basic building block of the nervous system
is the neuron. The neuron consists of a cell body,
axons, and dendrites ( Fig. 4-2 ). The cell body
is the metabolic center of the neuron. Extending from the cell body are two types of processes: axons and dendrites. Typically, there is
only one axon, which carries information from
the cell body to the target. Although generally
only a single axon exits a cell body, it may split
into many branches, thereby allowing a single
neuron to infl uence many targets. Axon diameter varies from 0.2 to 20 μ m, a feature that will
help determine the speed with which information
is transmitted; the larger the axons, the more
rapid the transmission. Axons may be myelinated or surrounded by a nodular sheath of fatty
substance. Myelin offers insulation to the nerve
fi ber and increases transmission speed along the
axon. Axons act similar to cables in a communication network, carrying information within
and across regions of the CNS. And, similar
to cables, larger axons with more insulation
(myelin) transmit information more quickly
and with less loss of signal strength than do
the small, uninsulated axons ( Bear, Connors, &
Paradiso, 2015 ).
Dendrites are responsible for bringing information into the cell body. Dendrites are often
extensively branched, allowing communication
with many other neurons. The dendritic branches
are rich in synapses, allowing for immense
communication with other neuronal fi bers. This
structure is foundational for the integration of
inputs, a basic function of the nervous system
( Bear et al., 2015 ). Dendrites and axons combine
to form the pathways of the CNS. Fiber bundles
and pathways travel varying distances within the
CNS and carry information from the CNS to the
effector organs and muscles in the body.
Glial cells surround and greatly outnumber
neurons. One form of glia, the astrocyte, is shown
in Figure 4-3 . Glial cells do not have the same
FIGURE 4-1 Complex schematic representation of sensory integrative dysfunction. In this version of the model,
we have added interoception as a sensory input.
Autonomic Limbic Reticular Thalamus Cerebellum Basal Ganglia Cortex
Behavioral
consequences
Indicators of
poor sensory
modulation
Over-
responsivity
• Aversive
and
defensive
reactions
Under-
responsivity
• Poor
registration
Inadequate
CNS integration
and processing
of sensation
Visual
Vestibular
Tactile
[lnteroception]
Auditory
Olfactory
Gustatory
Proprioception
Indicators of poor sensory
integration and praxis
Poor
postural-ocular
control
Poor sensory
discrimination
• Tactile
• Proprioception
• Vestibular
• Visual
• Auditory
Poor body
schema
Sensory reactivity
Sensory perception
VBIS
Behavioral
consequences
Poor selfefficacy,
self-esteem
Sensory
seeking
Poor
organization
Poor gross,
fine, and
visual motor
coordination
Avoidance of
engagement
in motor
activities
Clowning
Occupational Engagement Challenges
Occupational Engagement Challenges
Sensoryrelated
challenges
with attention,
regulation,
affect, activity
Somatodyspraxia
Poor selfefficacy,
self-esteem
Withdrawal
from, and
avoidance of,
sensory
experiences
Sensory
seeking
60 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
electrical transmission properties of neurons, but
instead they:
• Provide structural support to the nervous
system.
• Insulate groups of neurons from each other.
• Remove debris after injury or cell death.
• Buffer the electrochemical environment in
which neurons exist.
• Nourish neurons.
• Act as stem cells, able to give rise to new
glial cells and possibly new neurons.
HERE ’ S THE POINT
• There are multiple resources to support
learning in neuroscience, and they tend to
take different approaches to the topic. Readers
may need to access more than one resource to
develop a thorough understanding of structures
and functions in the nervous system.
• The basic building block of the nervous system
is the neuron, consisting of a metabolic center
(cell body), input (dendrite) and output (axon)
fi bers.
Central and Peripheral Nervous
System Structure
The CNS and PNS are the anatomical divisions of our nervous system; the brain, spinal
cord, and meninges form the CNS, whereas
the cranial and spinal nerves make up the PNS.
There are neuronal cell bodies, axons, and dendrites in both divisions. The nervous system can
also be characterized functionally as autonomic
(ANS) and somatic. The ANS consists of central
FIGURE 4-2 The neuron, with a myelin sheath around the axon. From Thompson, G.S. [2013]. Understanding
Anatomy and Physiology [1st ed.]. Philadelphia: F.A. Davis, p. 157, with permission.
Nucleus
The cell body (also called the soma) is the
control center of the neuron and contains the
nucleus.
Gaps in the myelin sheath, called nodes of
Ranvier, occur at evenly spaced intervals.
The end of the axon branches extensively, with
each axon terminal ending in a synaptic knob.
Within the synaptic knobs are vesicles containing
a neurotransmitter.
Dendrites, which look like the bare branches of a
tree, receive signals from other neurons and
conduct the information to the cell body. Some
neurons have only one dendrite; others have
thousands.
The axon, which carries nerve signals away from
the body, is longer than the dendrites and contains
few branches. Nerve cells have only one axon;
however, the length of the fiber can range from a
few millimeters to as much as a meter.
The axons of many (but not all) neurons are
encased in a myelin sheath. Consisting mostly of
lipid, myelin acts to insulate the axon. In the
peripheral nervous system, Schwann cells form
the myelin sheath. In the CNS, oligodendrocytes
assume this role.
CHAPTER 4 Structure and Function of the Sensory Systems ■ 61
FIGURE 4-3 Glial cells in the CNS take different forms. In A, oligodendrocytes form myelin sheaths around
axons. B. Microglia are macrophages, the immune cells of the brain and spinal cord. C. Astrocytes provide
metabolic support for neurons and help regulate neural transmission. D. Ependymal cells line the ventricles in
the brain and the central canal of the spinal cord, serving as a brain and cerebral spinal fl uid interface.
Oligodendrocyte A B
C D
Microglia
Astrocytes
Myelin
sheath
Neuron
Neuron
Neuron
Neuron
Capillary
Cilia
Ependymal cells
structures and nerve processes that innervate
smooth muscle and glands, and the somatic
nervous system consists of the components that
carry neural signals to or from muscles, joints,
and skin (Siegel, Sapru, & Siegel, 2015). These
aspects of the nervous system are shown in
Figure 4-4 . Simplistically, the human nervous
system can be likened to a communications
network with central hubs and projections transmitting messages into and out of the central core
(i.e., the CNS).
Beginning with structural organization, the
PNS is composed of receptors, or specialized
nerve endings, and the neurons that conduct
information to and from the CNS. The PNS then
connects the outside world and peripheral structures (e.g., skeletal muscles and glands) to the
brain and spinal cord.
Each sensory system has unique and specialized receptor cells or nerve endings that are
particularly sensitive to one form of physical
energy; for instance, rods and cones in the retina
are specialized receptor cells that respond to light
energy, whereas the Pacinian corpuscle in the
skin is a specialized nerve ending that responds
to deep pressure and vibration. Once a receptor responds to a sensory stimulus, a cascade of
events takes place that results in transmission of
the specifi c features of that input over afferent
fi bers to the CNS. Features of sensation that are
sent to the CNS include the characteristics such
as the intensity of the input, the duration, and,
of course, the kind of sensation ( Purves et al.,
2011 ). The PNS also has efferent nerve fi bers
and specialized receptors that transmit the signal
from the CNS to effectors. When the effectors
are muscle fi bers, the receptor is the neuromuscular junction. Effectors may also be visceral
structures, innervated by fi bers associated with
the ANS. Here, too, there will be specialized
receptors.
The ANS mediates homeostasis; it regulates
such things as blood pressure, heart rate, respiration, and digestion by responding to pressure and
stretch in organs and glands, changes in body
chemistry, pain, and temperature ( Purves et al,
2011 ; Siegel & Sapru, 2013 ). The use of the label
“autonomic” indicates that this component of
62 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
FIGURE 4-4 Central (pink), peripheral (light pink), and autonomic (black and dark pink) nervous system
distribution. The ANS is further broken out into parasympathetic (black) and sympathetic (dark pink)
components. Note that most internal organs and glands receive both parasympathetic and sympathetic
innervation. From Eagle, S., et al. (2009). The professional medical assistant. Philadelphia, PA: F.A. Davis
Company: p. 438; with permission.
Cerebrum
Cerebellum
Brainstem
Spinal cord
To arm
and head
To trachea
and lung
To heart
To kidney
To liver
and spleen
To intestines
To thigh To colon
and rectum To knee,
lower leg,
and foot
Central nervous
system
Peripheral nervous
system
Autonomic nervous
system
Parasympathetic
system
Sympathetic
system
To bladder
To external
genitalia
To eye
To glands
in head
To stomach
CHAPTER 4 Structure and Function of the Sensory Systems ■ 63
the nervous system functions without conscious
control in maintaining the body ’ s physiological
homeostasis. Information received is transmitted
to the CNS through peripheral and cranial nerves.
Within the CNS, the hypothalamus, thalamus,
and limbic system, along with areas within the
medulla and pons, are responsible for mediating
autonomic functions. The efferent fi bers of this
system innervate smooth muscle, cardiac muscle,
and glandular epithelium.
The efferent component of the ANS is composed of two major divisions: sympathetic and
parasympathetic. The sympathetic division functions to prepare the body for fi ght or fl ight; it is
most active during periods of stress and serves to
increase the body ’ s use of energy. The parasympathetic division has a “rest and digest” function, restoring the energy stores in the body by
promoting digestion of food and absorption of
nutrients. These two major divisions of the ANS
may innervate the same organ and act in concert
to continuously regulate activity in that organ.
For example, the heart is infl uenced by both
sympathetic and parasympathetic inputs that
control functions such as heart rate. Sympathetic
activation will increase heart rate whereas parasympathetic activation will decrease heart rate.
The systems act in concert to mediate cardiac
response to changes in the internal or external
environment.
The enteric nervous system is an additional
aspect of the ANS that functions in a semiindependent manner ( Fig. 4-4 ) ( Purves et al.,
2011 ). This system innervates the gastrointestinal
(GI) tract, carrying both sympathetic and parasympathetic information. Interestingly, there are
many neurons in the GI system that are not under
ANS control, yet they are still part of the enteric
nervous system; this is why it is considered
“semi-independent.” The enteric nervous system
monitors and controls chemical and mechanistic
aspects of GI function.
We will talk more about interoception, but
we will not further address the specifi cs of ANS
structure or function in this text. However, the
way in which sensory processing takes place
within the nervous system is often interpreted as
a refl ection of ANS activity. For instance, when
a child with tactile defensiveness overreacts to a
nudge from a classmate, the sympathetic component of the ANS may have been activated. Similarly, when we suggest the use of deep pressure
or heavy work to act as a calming or focusing
agent for a child, we are considering the potential ability of this input to increase activity in
the parasympathetic division of the ANS. Thus,
as you read, consider how the behaviors identifi ed in children or their responses to intervention
potentially refl ect activity within the ANS. We
have pointed out when systems project to components of the ANS.
Central Nervous System Geography
The CNS consists of the brain and the spinal
cord. The spinal cord contains both afferent and
efferent fi bers carrying information to and from
the brain and cell bodies located in the PNS.
In addition, there are numerous local interneurons (small neurons that reside entirely within
the cord) that are responsible for information
processing and integration. Using a computer
analogy, the spinal cord is roughly equivalent
to a large housing through which several cables
run from peripherals to the computer tower.
However, because processing does occur in the
spinal cord, this analogy falls somewhat short.
The brain can be grossly divided into the cerebrum or cerebral hemispheres, diencephalon, cerebellum, and brainstem ( Fig. 4-5 ). The cerebrum
includes four lobes with which you are likely
familiar (i.e., frontal, parietal, occipital, temporal; see Fig. 4-6 ) and two others, the limbic lobe
or cingulate gyrus (visible on the medial surface
of the brain) and the insular lobe (forming the
fl oor of the lateral fi ssure). The diencephalon
is composed of the thalamus, hypothalamus,
epithalamus, and subthalamus. The brainstem
is made up of the pons, medulla, and midbrain
( Fig. 4-5 ).
The midbrain is also referred to as the mesencephalon, a refl ection of terminology used
in describing embryological brain development.
Within the midbrain are the inferior and superior
colliculi, associated with the auditory and visual
systems, respectively; together they are referred
to as the tectum, forming a tent over the cerebral
aqueduct. As an aside, the superior colliculus (SC)
is also considered an important integration center
for sensory input because it receives input from
multiple sensory systems ( McHaffi e, FuentesSantamaria, Alvarado, Gutierrez-Ospina, & Stein,
2012 ). Another midbrain region, the periaqueductal gray, surrounds the region of the cerebral
64 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
FIGURE 4-5 Two regions of the diencephalon, the thalamus and the hypothalamus, are shown here. Gylys &
Wedding: Medical Terminology Systems, A body systems approach, 6e. F.A. Davis, Philadelphia, with permission.
Cerebrum
Diencephalon
(interbrain)
Thalamus
Hypothalamus
Pons Medulla
Midbrain
(mesencephalon)
Cerebellum
Spinal cord
aqueduct and thus is located adjacent to the
tectum. In the subsequent sections of the chapter,
we discuss each of these CNS components as
they relate to the sensory systems.
Brodmann areas are also referred to throughout this chapter. Brodmann areas represent a
numbering system of brain regions developed by
Brodmann in 1909. He thought that each of the
52 numbered regions defi ned a discrete histological unit within the brain. Subsequent work has
shown that only some of these areas have clear
functions. However, the numbering that has survived is a useful reference point for identifying
cortical regions. Brodmann areas are shown in
Figure 4-7 .
Central Nervous System Function
Organization of function within the CNS was once
thought to be strictly hierarchical, with increasing complexity in the interpretation of input and
planning of output as information moved from
the spinal cord to the cerebral cortex. According
to Squire and colleagues ( 2012 ), this hierarchical
organization exists and is very apparent in the
motor system. In addition, there is a hierarchy in
FIGURE 4-6 Lobes of the brain.
(1) Frontal lobe
(2) Parietal lobe
(4) Occipital lobe
(3) Temporal lobe
CHAPTER 4 Structure and Function of the Sensory Systems ■ 65
processing sensory input such that at each level
within the CNS, greater specifi city in interpretation of input is attained. However, the complexity of interactions within and between CNS
levels indicates that a heterarchical or network
organization also exists. Sensory information
reaches all levels within the motor systems, and
motor system output is infl uenced not only by
sensory input but also by cognitive processing,
other intrinsic activity (e.g., sleep–wake cycles,
behavioral state, arousal level, motivation), and
sensory feedback from ongoing motor activity.
Thus, organization of the CNS is best considered as complex, embracing some aspects of a
hierarchy and other interactions more consistent
with the intense interaction found in a network of
linkages ( Squire et al., 2012 ).
Terminology
Some functional considerations become important as we begin to study the CNS. Because they
are all at work in all sensory systems, we defi ne
them here and then refer to them within each
system as appropriate.
Stimulus Reception and Transduction
Receptors within each system respond optimally
to specifi c types of sensory input. Thus, specifi c
tactile pressure receptors respond best to touch or
pressure, and photoreceptors in the eye respond
best to light. Although the receptors are different for each system, the process of changing
the input from physical to electrochemical has
some similarities. Using the tactile system as an
example, deep pressure activates a receptor, such
as the Pacinian corpuscle. The pressure changes
membrane characteristics in the receptor, and
this process leads to transduction of the mechanical (pressure) input into an electrical signal.
From physiology class, you may recall that all
cells have an “electrical potential” established by
the distribution of charged ions on the inside and
outside of the cell membrane. Activation of the
receptor (in this case, touch pressure) leads to
changes in the distribution of these ions, which
changes the charge distribution across the membrane and results in a local depolarization of the
immediately surrounding membrane. The term
applied to this local depolarization is a receptor
potential ( Fig. 4-8 ). At times, when the stimulus
is very weak, the electrical charges are minimal
and the receptor potentials are not strong enough
to lead to transmission beyond this level, so the
input is transmitted only a short distance from
where it began, similar to a whisper spoken to a
large group of people. Those close by may hear
it, but unless they pass it on, those on the far side
of the group will not, and the message will die a
short distance from where it began.
If the stimulus is of suffi cient intensity or
applied for a long enough period of time, receptor potentials can be added together, and the
result is the production of an action potential
in the sensory neuron. An action potential is
also a change in the distribution of charge on
the membrane, but it is strong enough to depolarize neighboring areas on the neuron, and a
wave of depolarization is generated that carries
the information to its fi rst synapse on the way to
the CNS.
FIGURE 4-8 Receptor potential; local change in ion
distribution that, if of suffi cient intensity, will transmit
information from the receptor toward the CNS.
Reprinted with permission from Clinical
Neuroanatomy, 26th edition, by Stephen Waxman.
Copyright McGraw-Hill Education.
FIGURE 4-7 Brodmann areas on the lateral surface
of the brain.
1
2 3
5 7
8 6
4
46
45 44
47
9
10
11
40
39
19
37
20
22
52
21
43 41 42
38
18
17
66 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
Stimulus Encoding
One action potential, in any system, generated by
any input is the same as another. How, then, does
the CNS discriminate between bright light and
fi rm touch? Discrimination relies on the specifi city of receptors for a type of sensory input and
requires interpretation within the CNS, based
on pathways and connections of the sensory
neurons. Receptors convey the information that
a touch was fi rm instead of soft by encoding the
stimulus characteristics into a pattern of action
potentials that represents intensity, duration, and
movement of the stimulus. A stronger stimulus
results in an increase in the frequency of action
potentials sent to the CNS and is likely to activate more receptors when applied. Thus, strong
inputs are read as such in the CNS because
they generate more action potentials within one
neuron and because the input is detected by
multiple receptors so that action potentials are
transmitted by a large number of neighboring
neurons. This process of specifi city in receptors
has parallels in computer systems as well. The
electrical wires that connect both the keyboard
and mouse to your computer are essentially the
same; they transmit electrical current in the same
manner after the current is generated. The specifi city comes from the receptors, in this case the
keyboard keys and mouse pad. The keys respond
to pressing, and they respond best when we press
them in an appropriate sequence, as in spelling a
word. The mouse responds to a different input, a
dragging touch that moves around the mouse pad.
We can change the frequency (hitting a keyboard
key multiple times) or infl uence the “intensity”
of the input or word we are typing by doing such
things as typing in bold or in all capitals.
Receptor Fields
The term receptor fi eld or receptive fi eld
refers to the area around a receptor from which
input can be transduced into an electrical signal
( Fig. 4-9 ). This concept is applied to mechanical receptors of the tactile system where the
receptor fi eld is that area of skin surrounding a
single receptor, which activates the receptor. In
the visual system, the receptor fi eld of a photoreceptor is that area of the retina in which it is
found. Small receptor fi elds are associated with
fi ne discriminative function because they contribute to a precise representation of input at the
CNS. Returning to the computer analogy, this is
similar to the receptive area available on a standard keyboard compared with the key pad on a
smartphone.
Receptor Adaptation
Receptors adapt to continued input, and depolarization of the receptor membrane ceases, even
with continued input. Some receptors are considered rapid adapting, responding only at the
onset and offset of input. Others are slow adapting, responding in a more continual manner to
ongoing input, but eventually even these will
cease to produce action potentials. The adaptation of receptors becomes critical in the function of the sensory systems, and this function
plays a role in providing ongoing information
about what is happening (slow adapting receptors), along with information on changes in the
internal or external environment (rapid adapting
receptors).
Lateral Inhibition
Lateral inhibition ( Fig. 4-10 ) is another phenomenon that is important to understanding how
we receive and interpret neural signals. It is the
mechanism used by the CNS to focus input from
the receptors and thereby sharpen its interpretation. Lateral inhibition relies on the presence
of inhibitory interneurons. It happens like this:
a stimulus—for example, a touch—is applied
to the hand. Receptors in the skin are activated,
FIGURE 4-9 Large and small receptive fi elds. Note
that with smaller receptive fi elds the same stimulus
(in this image, the two red arrows) activates two
neurons, whereas with larger receptive fi elds only a
single neuron is activated. The smaller receptive fi eld
transmits more detailed information about what has
touched the skin.
Region with small
receptive fields
Large RF
low resolution
Small RF
high resolution
Region with large
receptive fields
No
response
Neural firing
from one
receptive field
Neural firing
from both
receptive fields
CHAPTER 4 Structure and Function of the Sensory Systems ■ 67
and those with their receptive fi elds centered
under the stimulus respond with greater strength
(more action potentials and more rapid fi ring).
This is analogous to speaking softly to a group
of people; those directly in front of the speaker
will hear the bulk of the message, but those on
the edges will capture less of the information.
Fibers from the receptor will synapse with other
sensory neurons as they transmit information to
the CNS, much as the people in this group talk
with their neighbors. In the absence of lateral
inhibition, the activation pattern spreads widely,
with increasing numbers of sensory neurons activated, and the result at the CNS is some general
awareness that a large region of the skin was
touched. In the speaking example here, it would
be as though each person who heard the message
spoke it again to a neighbor, and the neighbor
shared it with another neighbor so that soon
the whole room would be buzzing with sound.
However, the specifi cs of that sound would be
rather vague. Lateral inhibition is used to focus
the input rather than allow it to be diffused over
many neurons. In sensory systems using this
focusing mechanism, the neurons at the center of
the receptor fi eld (i.e., those most intensely activated by the input) activate inhibitory interneurons at their fi rst synapse within the CNS. These
inhibitory interneurons connect with sensory
neurons farther from the center of the receptive
fi eld (i.e., less active neurons) and inhibit transmission at the periphery of the receptive fi eld.
Other terms used to defi ne this process include
surround inhibition and inhibitory surround.
The process is the equivalent of people in the
center of a room gently shushing their neighbors
to prevent them from speaking. This cuts down
on the background noise in the room, making the
original message more clearly delivered, at least
to the people permitted to hear it. In the CNS,
lateral inhibition serves to focus the input at each
relay station, reducing background noise. This
results in the ability to discriminate and localize the input we receive. Sensory systems with
well-developed discriminatory functions rely on
this mechanism.
Convergence and Divergence
Convergence and divergence ( Fig. 4-11 ) are
concepts that need to be understood in order
to appreciate the accuracy with which information is conveyed from the PNS to the CNS.
With convergence, many cell processes synapse
at one site. Thus, many axons may synapse on
the same neuronal cell body or dendrite. When
this happens, a great deal of information is condensed. This can be useful for increasing the
intensity of the information in the CNS and for
promoting integration, but the tradeoff is that
the specifi city of the original input is decreased,
similar to several members of an audience offering input to the speaker in rapid succession. The
speaker can listen and integrate the information,
but the specifi cs of where each bit of information
came from, exactly what was said and by whom,
are likely to be lost.
Divergence, on the other hand, occurs when
one process synapses with many different cells
in the CNS. Earlier in this chapter, we mentioned that axons can divide and infl uence many
other cells; divergence is such an example. An
axon leaves a cell body and subsequently makes
contact with cell bodies or dendritic branches in
FIGURE 4-10 Schematic of lateral inhibition. In
this diagram, the stimulus is applied as shown, and
the receptors directly under it will respond with full
strength, whereas those located laterally will respond
with less strength. Thus, receptor B will respond at
100%, A and C at 80%, and D at 60%. The small
inhibitory interneurons reduce the stimulus by 20%.
Thus, stimulus strength in each neuron is reduced
by 40% at this level, and neurons A and C now
transmit at only 40%, B at 60%, and D at 20%. This
information transmitted from this point forth then is
more focused; little information is transmitted over
neuron A and none over neuron D. This process can
occur at all synapses along the route of transmission,
and it will serve to sharpen the initial input received
by the receptor. (The values associated with stimulus
strength and interneuron inhibition are arbitrary.)
Stimulus
Receptors:
receive stimulus
at strength related
to location
A
Inhibitory
interneurons:
Each inhibits
strength of signal
by 20%
BC D
68 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
several other areas of the CNS. The functional
association here is that the same information is
represented at many places, repeated over and
over. Thus, the potential impact of this information can be widespread.
Habituation and Sensitization
Our neural networks are highly malleable;
changes in synaptic connectivity can be both
short or long duration. One of the goals of occupational therapy using SI is to impact neural
connectivity through the long term. Two mechanisms have been linked with long-term changes:
habituation and sensitization. Behaviorally, you
are likely well aware of habituation; you put on
clothes in the morning, adjust them to feel comfortable, and then quickly forget about them.
This is habituation, a process of adapting to
sensory input, of becoming less responsive to
repeated sensation. Sensitization occurs when an
aversive response to a specifi c stimulus is generalized to other, previously non-aversive stimuli.
For instance, a child contentedly eats lunch in
the school cafeteria until one day when a cart
with 20 trays topples, causing a very loud crash
and instant chaos. Greatly startled by the combination of the crash and the chaos, the child now
pairs these inputs with the cafeteria environment
and refuses to go there for lunch. The effect can
be either short- or long-lasting, depending on
other aspects of CNS processing.
Distributed Processing and Control
The CNS can be masterful in its capacity to
“multitask.” You read this chapter while you
maintain your posture, shift weight to relieve
uncomfortable pressure, possibly eat and drink,
and digest whatever it is you are drinking or
eating. All activities are organized and directed
by the CNS. You are engaging sensory and
motor systems, cognitive processes, and autonomic functions simultaneously via distributed
processing within the CNS. When it works well,
distributed processing allows for effi cient and
effective interactions with the world because
the load is distributed among different centers
of control.
Serial and Parallel Processing. Underlying distributed control of activities are two processing
methods: serial and parallel. In serial processing, things occur in sequence, one after another,
in a hierarchical manner. Transmitting information from a touch receptor to the CNS occurs this
way as the information is mechanically received,
transduced into an electrical signal, summed to
form an action potential, and transmitted to the
CNS. Parallel processing involves the work of
more than one pathway working simultaneously.
Visual, vestibular, and proprioceptive systems
often use parallel processing to orient us to our
position in space. Each system processes different bits of information about our bodies and
FIGURE 4-11 A schematic depicting convergence and divergence in the CNS.
Reprinted with permission from Lundy-Ekman, L. Neuroscience: Fundamentals for Re-habilitation , p. 37.
Philadelphia, PA: WB Saunders Co., 1998.
Convergence Divergence
Principles of nerve centers
coordination
CHAPTER 4 Structure and Function of the Sensory Systems ■ 69
the space around us with the integrated endpoint
being maintenance of upright posture.
Parallel processing is a term also used when
the same sensation is carried and processed in
two pathways that have some redundancy. For
instance, pain input is processed via both the
dorsal column medial lemniscal (DCML) and the
spinothalamic pathways. This functional overlap
can be very useful in the face of disease or dysfunction that interrupts the fl ow of information in
one system. The fact that the same information
can be processed in a parallel system can be capitalized upon in intervention.
There are other processes and mechanisms
that could be discussed in this background
section, but the ones offered here provide a very
basic anatomic and functional baseline. We now
focus on the individual sensory systems and integration among sensory systems as a basis for
understanding their contributions to SI and occupational performance.
HERE ’ S THE POINT
• The nervous system can be conceptualized
as consisting of anatomic divisions (CNS and
PNS) or functional divisions (ANS and somatic).
Together these approaches provide insight into
structure and function.
• The PNS connects our periphery and
environment to the CNS, bringing sensory
input to the brain (afferent input) and carrying
central commands away from the brain to the
muscles and organs (efferent output).
• Similar to the PNS, the ANS has afferent and
efferent components; these components
mediate physiological homeostasis.
• The enteric nervous system functions in a
semi-independent way to mediate functions of
the gut.
• Organization of the CNS, comprising the brain
and spinal cord, is best considered a complex
interaction of hierarchical and heterarchical
structure and function confi gurations.
• Knowledge of common neuroscience-related
terminology supports an understanding of
structure, function, and dysfunction in the
nervous system.
The Somatosensory System
We begin our discussion of the somatosensory
system by reviewing the receptors associated
with somatosensation. After being gathered by
the receptors, somatosensory inputs are processed over the DCML pathway, spinocerebellar
pathways, and the pathways of the anterolateral system (AL). We present each separately.
We also discuss the trigeminothalamic pathway,
which is responsible for the transmission of
somatosensory information from the face. A brief
description of the functional overlap between
the somatosensory pathways completes this
section.
Receptors and Transduction
The majority of receptors in the somatosensory
system are mechanoreceptors. This means that
when a mechanical force (e.g., light touch, deep
pressure, stretch, or vibration) is applied to the
receptors, the process of neural transmission
begins. Proprioceptive input from joints and
PRACTICE WISDOM
Why do we care about things such as receptor
types, receptive fi eld, speed of transmission,
and neuronal functions such as lateral inhibition, as well as processes such as divergence,
convergence, and habituation? Understanding these functions helps us understand what
we are doing clinically when we make sensory
experiences available to the children we treat.
For instance, if a child brushes lightly against
a fuzzy surface and this triggers a defensive or
withdrawal response, we likely have triggered
a hair cell receptor. We know that these receptors are connected to small neural fi bers, and
the information will travel to the CNS relatively
slowly. When we use fi rm pressure to rub the
spot where the fuzzy surface touched, we are
activating deeper receptors, such as the Merkel
disc or Pacinian corpuscle. These receptors are
connected to larger diameter fi bers that are
myelinated. This information travels faster to the
CNS, and we can use it in effect to diminish the
effect of light touch on orienting and arousal. So
even though you might not be thinking about
receptor types and speed of transmission, you
are likely using these constructs clinically and in
everyday life.
70 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
TABLE 4-1 Locations, Modalities of Sensation, Adaptation Rates, and Fiber Types Associated with
Skin Receptors
TYPE LOCATION STIMULUS FIBER TYPE ADAPTATION
Free nerve ending Dermis, joint capsules,
tendons, ligaments
Pain, temperature A-delta, C Slow
Hair follicle plexus Deep dermis Hair displacement; pain A-beta Fast
Meissner corpuscles
(tactile corpuscles)
Papillae of skin, mucous
membranes of tongue tip
Touch A-beta Fast
Pacinian corpuscles Subcutaneous tissue Pressure, vibration A-beta Fast
Krause end bulb Papillae of hairless skin;
near hair follicle plexus
Cold A-delta, C Below 20°C;
no adaptation
Merkel disc Epidermis of hairless skin;
hair follicles
Deformation of skin A-beta Slow
Ruffi ni ending Joint capsules; connective
tissue
Touch; skin stretch;
joint movement
A-beta Slow
muscles is certainly a mechanical input, and proprioceptive input is carried along somatosensory
pathways. Although we discuss proprioception
briefl y here, readers will also fi nd proprioception covered in conjunction with the vestibular
system in other chapters of this book. The tactile
system also includes thermoreceptors and is thus
responsible for the interpretation of temperature
input. Table 4-1 lists the receptors within this
system and their various characteristics.
Tactile Mechanoreceptors
Mechanoreceptors within the skin subserve different types of sensory activation. Some respond
to the initiation and cessation of input (Meissner
corpuscle, Pacinian corpuscle, some hair follicles) but not to sustained input. These receptors
are considered fast adapting because they stop
responding to maintained stimuli. They are sensitive to changes in tactile input. Slowly adapting
receptors include Merkel discs, Ruffi ni endings,
and some hair follicle receptors. In contrast to
the fast-adapting receptors, this second group
of receptors provides the CNS with information
regarding the intensity, duration, and speed of
input ( Fig. 4-12 ).
Our tactile discrimination ability depends, in
part, on the density of receptors and the associated size of the receptor fi eld. In areas of fi ne
tactile discrimination (e.g., fi ngertips, palms,
around the mouth), receptor density is high and
the receptor fi eld is small. Areas of high receptor
density are more skilled. However, in areas where
less specifi c information is needed about tactile
input (e.g., abdomen and back), receptor density
is low and receptor fi elds are larger. Researchers
(e.g., Jones & Smith, 2014 ) examining discrimination abilities have shown that, although some
things can be distinguished using either active
or passive touch, the use of active touch allows
fi ner and more accurate discrimination. The
tactile system also capitalizes on lateral inhibition to focus input and refi ne discrimination.
The somatosensory system, which carries
information from the body to the CNS, has two
main subdivisions: the DCML system and the AL
pathways; there are also crucial projections of
proprioception to the cerebellum. The pathways
will be described later in this section. Together,
the information received by receptors and transmitted over these pathways provides us with the
ability to interpret our tactile world and respond
appropriately to touch. Because of the pervasive nature of these two somatosensory subdivisions, they are critical to our interactions with
the world. Likewise, the pervasive nature of the
somatosensory system means that when problems exist, the impact can be widespread.
Proprioception and Proprioceptors
Sherrington ( 1906 ) defi ned proprioception as
perception of joint and body movements as well as
position of the body, or body segments, in space;
this defi nition is consistent with what we read
CHAPTER 4 Structure and Function of the Sensory Systems ■ 71
today in the literature (e.g., Croker, 2013 ; Proske
& Gandevia, 2012 ) and most neuroscience texts
( Bear et al., 2015 ; Purves et al., 2011 ; Siegel,
Sapru, & Siegel, 2015). Proprioceptors provide
a continuous fl ow of sensation from muscles,
joints, and tendons, and they inform us about
the spatial orientation of the body or body parts,
the rate and timing of movements, the amount
of force our muscles are exerting, and how
much and how fast a muscle is being stretched
( Proske & Gandevia, 2012 ). The continuous fl ow
of information is essential; imagine how it would
be to have only intermittent information about
your limb and body position in and movement
through space. Although Sherrington ( 1906 ) and
others identifi ed muscle afferents, joint receptors,
and the vestibular labyrinth as proprioceptors,
we will confi ne the discussion in this section to
the non-vestibular proprioceptors.
Before the early 1970s, researchers distinguished between conscious joint proprioception
(kinesthesia), thought to arise primarily from
joint receptors, and unconscious proprioception,
thought to arise from the muscle spindle and
tendon receptors. However, this distinction is not
clearly made, and older experimental evidence
indicates that all proprioceptive inputs can contribute to conscious proprioception ( Matthews,
1988 ; McCloskey, 1985 ; McCloskey, Cross,
Honner, & Potter, 1983 ; Moberg, 1983 ; Tracey,
1985 ).
For purposes of studying SI theory, it is more
important to understand the distinction between
proprioceptors (i.e., proprioceptive receptors)
and proprioception (i.e., proprioceptive feedback
and perception of joint and body movement). Not
all proprioception is derived from peripheral proprioceptive receptors. Internal correlates of the
motor signals that are sent to the muscles after
an action is planned are also an important source
of proprioception; the process is termed corollary. Corollary discharge happens when the plan
for movement is sent to the cerebellum; the cerebellum “previews” the plan, and it makes some
updates based on current information it receives
from the muscles and joints. It helps us to fi nesse
FIGURE 4-12 Skin touch receptors include free nerve endings (dermis and superfi cial epidermis), Merkel disc
and Meissner corpuscle (dermis), and Ruffi ni ending or corpuscle and Pacinian corpuscle (subcutaneous tissue).
Free nerve
endings
(temperature
receptor)
Merkel disc
(touch receptor)
Ruffini corpuscle
(pressure receptor) Meissner corpuscle
(touch receptor)
Pacinian corpuscle
(pressure receptor)
Subcutaneous
tissue
Dermis
Epidermis
Free nerve endings
(pain receptor)
72 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
our motor actions. Corollary discharge is important for differentiating between active (internally
generated) and passive movement (generated
by an external stimulus), identifying if we have
programmed an appropriate level of motor
activity, the development of body scheme, and
perception of force ( Crapse & Sommer, 2008 ).
Knowledge of the body and its movements is
important in motor planning and is also addressed
in Chapter 5 (Praxis and Dyspraxia).
Sources of Proprioceptive Input. Proprioceptive feedback arises from several sources.
Muscle spindles, located in the muscle and
running parallel to muscle fi bers ( Fig. 4-13 ), are
the primary source of proprioception, providing
input relative to joint position and movement
through the midrange of movement. Proske and
Gandevia ( 2012 ) indicated that there is indirect
evidence for a contribution from Golgi tendon
organs (GTO) relative to weight and force. The
GTO is located in the muscle tendon. Proprioception from joint receptors is minimal and primarily at the end range of movement ( Proske
& Gandevia, 2012 ), serving primarily as limit
detectors ( Ferrell & Smith, 1988 ).
Looking more closely at how the muscle
spindle functions, the effective stimulus for the
primary and secondary endings of this receptor is stretch. Primary fi bers transmit information regarding the velocity of change in muscle
length, as well as amount of change, and secondary fi bers transmit information on static positions
and sustained stretch and contraction. Both types
of fi bers are critical for ongoing information
about the location of the body and limbs in space.
Information about muscle stretch travels to
the spinal cord, where the sensory input connects with ascending fi ber pathways (discussed
later) and locally with the alpha motor neuron
of the same muscle. Alpha motor neurons are
efferent fi bers coming from the spinal cord and
going to muscle fi bers to produce muscle contraction. One alpha motor neuron may connect
with several muscle fi bers; the name for the
alpha motor neuron and all the muscle fi bers to
which it connects is a motor unit. Stretch of the
muscle activates the muscle spindle, which, in
turn, activates the alpha motor neuron, leading
to muscle contraction. Muscle contraction leads
to increased muscle tension and activation of the
GTO, a tension-sensitive receptor.
FIGURE 4-13 The muscle spindle with afferent (sensory) fi bers carrying proprioception to the CNS, and efferent
(motor) fi bers to muscle (extrafusal fi ber) and muscle spindle (intrafusal fi ber). In the tendon there is the Golgi
tendon organ, responding to muscle tension.
Motor neuron
to extrafusal
muscle fiber
Motor neuron
to intrafusal
muscle fiber Muscle
spindle
Tendon
organ Sensory
axon
Muscle spindle connective
tissue capsule
Sensory axons
Sensory nerve endings
Sensory
nerve endings
Intrafusal
muscle fibers
Extrafusal muscle fibers
Tendon organ capsule (connective tissue)
To CNS
From CNS
CHAPTER 4 Structure and Function of the Sensory Systems ■ 73
Stretching or contracting a muscle a little
bit results in a little bit of proprioceptive input;
working against resistance recruits motor units,
providing more information to the CNS about
body and limb position in and movement
through space ( Schmidt & Lee, 2011 ). This is
a concept we can use clinically. For example,
when we extend the head and upper trunk against
gravity from the prone-lying position, extend
weight-bearing limbs to jump on a trampoline, or
fl ex our arms while swinging on a suspended trapeze, we are contracting against the resistance of
gravity and body weight. In contracting against
resistance, we recruit motor units to produce the
needed force for the activity. Therefore, evincing
an adaptive behavior against resistance may be
the most effective means available for generating
proprioceptive feedback.
Stimulation of cutaneous or skin mechanoreceptors and joint receptors by active joint movement is believed to be particularly important in
the perception of movement in some, but not
all, body areas. For instance, loss of cutaneous
input during movement of the knee has not been
shown to impair the ability to determine joint
position (see Gokeler et al., 2011 for review),
and loss of one source of proprioception can be
compensated for by input from other receptors
( Bear et al., 2015 ).
Although tactile and proprioceptive information travel in the same pathway (see the text that
follows), it is important not to confuse cutaneousgenerated proprioception with tactile sensation.
Proprioception refers to sensations of movement
or position that arise because of an individual ’ s own movement. Tactile sensation pertains
to awareness or perception of the location, or
change in position, of an external stimulus
applied to the skin. Tactile sensation provides an
individual with information about the external
environment acting on the skin and skin receptors. Often, tactile information is gathered from
movement of joints; this can be a bit confusing. However, by defi nition, inputs such as deep
touch pressure and passive joint compression are
not sources of proprioception.
As an example, consider a child swinging on
a swing. Proprioceptors are activated by body
movements such as holding onto the swing,
pumping with the legs, and leaning forward and
back with the trunk. Touch receptors are activated in the hand as it feels the rope handles as
well as on the head and body as air fl ows around
the movement and the child ’ s hair moves from
one direction to the next. Both sources of input
provide information about position in and movement through space. The vestibular system plays
a role here as well, something that we will come
back to soon.
Centrally generated motor commands and
efference copy are also sources of proprioceptive feedback. They are thought to be responsible
for the sense of effort or conscious awareness
that proprioception is happening ( Schmidt &
Lee, 2011 ). According to the classic work of
McCloskey ( 1985 )
We have all experienced the sensation of
increasing heaviness of a suitcase which we
carry with progressively fatiguing muscles.
Ultimately, we put down such a load and rest
when it has “become too heavy.” But the load
has not really become heavier: the pressure
and tensions in the supporting limbs have not
increased, and there is no reason to assume that
the discharges from sensory receptors signaling
pressures or tensions will have increased either.
What makes the load seem heavier is that one
perceives the greater effort, the greater efferent barrage of voluntarily-generated command
signals, which has been necessary to maintain
a contraction with progressively fatiguing and
so less responsive muscles. Similar sensations of heaviness or increased muscular force
accompany all other states of muscular weakness whether caused experimentally . . . or by
disease. (p. 152)
Centrally-generated motor commands and
efference copy from motor centers are speculated to be necessary for accurate interpretation
of sensation ( Schmidt & Lee, 2011 ). Centrallygenerated motor commands and efference copy
are also important in motor control, that is, in
the planning and producing of an adaptive motor
behavior. We present more information on these
concepts in Chapter 5 (Praxis and Dyspraxia).
Dorsal Column Medial Lemniscal
(DCML) Pathway
Receptors associated with the DCML respond
to mechanical stimuli, transmitting primarily
tactile, vibratory, touch-pressure, and proprioceptive information. The DCML is associated
with functions inherent to tactile discrimination
or perception: detection of size, form, contour,
74 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
texture, and movement across the skin. Because
it carries proprioceptive information, the DCML
also transmits information relative to the position
of the body and limbs in space.
Inputs are transduced into a set of action
potentials and transmitted over the axon to the
cell body, which, in this case, is in the dorsal root
ganglion. There is no synapse here, and the information is passed from the dorsal root ganglion cell
body to dendrites that enter the spinal cord and
travel to the brain via the dorsal columns of the
spinal cord. The DCML is shown in Figure 4-14 .
The fi rst synapse of the DCML is in the medulla,
in the gracile and cuneate nuclei.
From the medulla, fi ber tracks cross and form
the medial lemniscal fi bers, traveling through the
brainstem reticular formation and ascending to
the ventral posterior lateral (VPL) nucleus of the
thalamus. The fact that fi ber tracks cross in the
brain rather than in the spinal cord has functional
implications in the face of an injury or dysfunction. If there is a problem with this pathway at
or above the medulla, the functional loss will
be on the opposite side of the body. If there is a
problem within this pathway below the medulla,
it will be refl ected on the same side of the body.
Fibers enter the thalamus, synapse, and then
send third-order neurons to the cortex. Cortical reception areas for the DCML include the
primary and secondary somatic sensory cortex
(S-I and S-II, respectively; Fig. 4-15 ), as well as
Brodmann areas 5 and 7 of the posterior parietal lobe, the somatosensory association cortex
( Figs. 4-7 and 4-15 ). The processing up to this
point has been an example of hierarchical processing, with more refi ned information processed
at each level. Within the cortex, the hierarchy is
less obvious.
In S-I, the somatosensory receptor density and
location are precisely represented in a somewhat
distorted image of the body known as the sensory
homunculus ( Fig. 4-15 ). Interestingly, it has
been shown that this representation of the body
at the cortical level is fl exible. Classic research
has shown that areas representing specifi c body
parts can be increased in size with intense use,
and, likewise, representation is decreased with
disuse and concomitant diminished skill ( Coq &
Xerri, 1999 ; Jenkins, Merzenich, Ochs, Allard,
& Guic-Robles, 1990 ; Mogliner et al., 1993 ;
Recanzone, Merzenich, & Jenkins, 1992 ). These
fi ndings are important to occupational therapy
intervention in general and sensory integrative
intervention specifi cally.
Processing throughout the DCML promotes
its discriminative functions. The somatotopic
organization of the fi bers is precise, with fi bers
from the leg and foot taking a medial position.
As fi bers representing the upper leg, trunk, and
upper extremity enter the cord, they are added
to the pathway laterally. The relationship of
the fi bers to each other is maintained with high
integrity as they travel through the CNS. The
somatotopic organization of the fi ber pathways is
also maintained in the medullary nuclei and in
the pathway as it ascends. However, the pathway
twists as it approaches the thalamus so that fi bers
from the arm come to lie medial to those from
the leg.
Precise somatotopic organization is only one
reason that information in the DCML is transmitted with great accuracy. Other reasons include:
• A minimal number of relays where the signal
must be processed
• Little convergence of input en route to
the CNS
• Heavy reliance on lateral inhibition to
maintain the integrity of a stimulus from the
periphery to the CNS
These features allow the brain to interpret the
temporal and spatial aspects of DCML inputs,
yielding a great deal of information about the
location and type of somatosensory information
received ( Abraira & Ginty, 2013 ; Bear et al.,
2015 ).
Interpreting Somatosensory Input
Although we generally consider interpretation
of sensation to be a function of the cortex, or at
least higher levels of the CNS, some processing begins within the gracile and cuneate nuclei
in the medulla for the DCML. In addition to
somatosensation, these nuclei receive input from
the primary sensory cortex and the reticular formation. This convergence of input means that
activity in the primary sensory cortex, as well as
the reticular formation, infl uences the interpretation of tactile input, even before it reaches a
cortical level.
Thalamic interpretation of DCML inputs is
thought to permit vague conscious discrimination of tactile input. There exist inhibitory
CHAPTER 4 Structure and Function of the Sensory Systems ■ 75
FIGURE 4-14 Dorsal column medial lemniscal system. Note that the information transmitted over this pathway
comes from muscle spindles, skin, and joint receptors. That from the lower extremity is transmitted to the
nucleus gracilis and that from the upper extremity to the nucleus cuneatus. Reprinted with permission from
Gilman, S., and Newman, S. W. Essentials of Clinical Neuroanatomy and Neurophysiology , 9th edition, p. 62.
Philadelphia, PA: F.A. Davis Co., 1996.
76 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
FIGURE 4-15 The primary sensory cortex (S-I) and secondary sensory cortex (S-II) are shown in fi gure A. Within
S-I is the sensory homunculus (fi gure B). From Kandel, ER, and Jessell, TM: Touch. In Kandel, ER, Schwartz, JH
and Jessel, TM: Principles of Neural Science, ed 3. Appleton and Lange, Norwalk, CT, 1991 with permission,
pp 368 [A] and 372 [B].
Foot
Trunk
Hip
Leg
Shoulder
Head
Neck
Forearm
Elbow
Arm
Waist
Hand
Little finger
Ring
Middle
Index
Thumb
Eye
Nose
Face
Upper lip
Lower lip
Teeth, gums, and jaw
Tongue
Pharynx
Intra-abdominal
Toes
Genitals
A
B
interneurons in the VPL that are activated by
fi bers from the cortex as well as inhibited by
fi bers from other thalamic nuclei. Cortical activation of inhibitory interneurons interferes with
further transmission of DCML inputs beyond the
thalamus. On the other hand, if the inhibitory
interneurons are themselves inhibited by other
thalamic projections, information can be processed and sent onto cortical areas. Thus, there
is some processing at this level that infl uences
transmission beyond the thalamus.
The primary somatosensory cortex (S-I, Brodmann areas 3, 1, and 2; Figs. 4-7 and 4-15 ) is
subdivided into different processing areas associated with differing types of sensation. Area 3a
receives a great deal of input from the thalamus
but primarily related to body position in space as
opposed to touch. Area 3b is considered to be the
primary somatosensory processing region because
neurons here respond only to somatosensation
(touch and proprioception) ( Bear et al., 2015 ).
Considerable somatosensory information passes
through 3b before going to areas 1 and 2. Projections to area 2, from area 3b, relate to size and
shape. Area 2 also receives signifi cant amounts
of information from muscle spindles and GTOs,
CHAPTER 4 Structure and Function of the Sensory Systems ■ 77
giving it an important role in proprioception and
kinesthesia. Loss of texture discrimination has
been associated with damage to area 1, and loss
of stereognosis has been associated with damage
to area 2. Area 3b has been associated with losses
of both of these functional skills, as 3b processes
information before passing it on to the areas 1 and
2. This means that areas 1 and 2 likely elaborate
sensory input and are, therefore, associated with
higher level interpretation of information.
The secondary sensory cortex (S-II, Brodmann
area 43; Figs. 4-7 and 4-15 ) receives input from
the VPL as well as from S-I. However, without
a functioning primary sensory cortex, neurons
within the secondary cortex do not fi re. Thus, the
secondary cortex depends on the primary cortex
for input. Within the S-II, new sensory discriminations are thought to take place. Projections
from the secondary cortex to the insular lobe
are believed to be involved in tactile memory
( Purves et al., 2011 ).
Further interpretation of somatosensory
inputs takes place in the somatosensory association cortex, areas 5 and 7 of the parietal lobe
( Figs. 4-7 and 4-15 ). These regions not only
receive input from the thalamus but also from
S-I and S-II, and they are connected bilaterally.
Some images show these areas to be part of S-II
in that they are projection areas from the primary
sensory cortex. Both of these parietal regions
play sensory integrating roles: area 5 for touch
and proprioception, and area 7 for somatosensory and visual inputs. Such processing of inputs
from multiple sources makes this a good example
of heterarchical organization within the CNS.
Because of these connections, lesions in areas
5 and 7 result in defi cits in spatial perception,
visual-motor integration, and directed attention.
Both areas are also associated with the manipulation of objects and are important in discerning
their tactile qualities (i.e., haptic perception). Any
clinician who has tried to evaluate stereognosis
in children who do not automatically manipulate
objects can appreciate the importance of manipulation for tactile perception. Lesions in these areas
within the right hemisphere have been associated
with agnosia of the contralateral side of the body
and body space. Tactile sensation is not impaired,
but individuals fail to recognize and attend to this
side of the body and the environment around it.
Also, within the parietal lobe, aspects of
tactile and proprioceptive input converge and
subsequently project to anterior motor planning
areas of the brain. Thus, output from the DCML
could be expected to have an impact on both
object manipulation and motor planning. In fact,
when outputs from area 2 (a subregion of S-I) to
the primary motor cortex are disrupted, hand use
becomes uncoordinated. A decrease in sensory
feedback to the motor cortex that occurs secondary to interruption of the DCML interferes with
the production of coordinated fi ne motor acts.
Proprioceptive input has been linked with
arousal ( Rose, Ahmad, Thaller, & Zoghbi, 2009 ),
and inputs from the DCML may have a role in
arousal modulation. Clinically, certain types of
sensory information have been observed to have
a calming effect clinically. Deep touch pressure
and proprioceptive information have been theorized, and shown by some, to have this quality
( Ayres, 1972 ; Chen, Yang, Chi, & Chen, 2013 ;
Edelson, Edelson, Kerr, & Grandin, 1999 ;
Reynolds, Lane, & Mullen, 2015 ; Vasa et al.,
2014 ); both are carried to the CNS via the dorsal
columns.
Clinicians and researchers have indicated that
poor tactile perception may be related to diffi -
culties in manipulative hand skills ( Goodwin &
Wheat, 2004 ; Haron & Henderson, 1985 ; Johansson & Flanagan, 2009 ; Yu, Hinojosa, Howe, &
Voelbel, 2012 ). Furthermore, diffi culty in perceiving the size and form of an object during the
process of active manipulation results in diffi -
culty handling the object. We may also speculate
that diffi culty in perceiving the boundaries of the
hand and the relationship of the fi ngers to one
another interferes with manipulation skills.
Spinocerebellar Pathways
Crucial as a foundation for movement and tone,
proprioceptive inputs are also projected to the
cerebellum ( Fig. 4-16 ). The cerebellum uses this
input, along with vestibular input, to monitor
body and limb position in and movement through
space, and to regulate the timing of movement.
Spinocerebellar inputs form the dorsal spinocerebellar pathway, carrying proprioceptive input
from the lower part of the body, and the cuneocerebellar pathway, carrying proprioceptive input
from the upper extremities. In addition, proprioceptive information from the face is relayed
to the cerebellum from the trigeminal mesencephalic nucleus.
78 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
Anterolateral (AL) System
The AL ( Fig. 4-17 ) is composed of separate pathways that function primarily to transmit pain,
crude touch (the detection of an object ’ s position
but not its movement across the skin), and temperature. Neutral warmth and the “tickle” sensation are also related to transmission within these
anterolateral pathways. The term anterolateral
system is sometimes used interchangeably with
spinothalamic pathway because the thalamus is
a major projection point for many fi bers traveling
in the anterolateral fasciculus. In fact, some texts
have indicated that the AL is but one pathway,
the spinothalamic pathway, with intermediate
projections to the reticular formation, cranial
nerve nuclei, and parts of the mesencephalon
and hypothalamus on the way to the thalamus.
Individual projections are sometimes classifi ed
as specifi c pathways (spinothalamic, spinoreticular, spinobulbar, spinomesencephalic, and spinohypothalamic) but sometimes not. Determining
which nomenclature is correct is beyond the
FIGURE 4-16 Spinocerebellar pathways (dorsal, ventral, and cuneo) carrying proprioceptive information from
the body to the cerebellum.
Parietal lobe
Somatosensory
cortex
Thigh
area
Leg area
Foot area
Perineal area
Trunk
Arm area
area
Forearm
area
Hand
area
Face
area
VPL
Superior cerebellar peduncle
Cuneocerebellar tract
Inferior cerebellar
peduncle
Nucleus
gracilis
(NG)
Nucleus
cuneatus
(NC)
Accessory
cuneate nucleus
(ACN)
Medial lemniscus
NG
NC
ACN
Ventral spinocerebellar tract
Dorsal spinocerebellar tract
Ventral spinocerebellar tract
Dorsal spinocerebellar tract
Muscle spindles, cutaneous and
joint receptors
Muscle spindles
Muscle spindles, cutaneous and
joint receptors
Muscle spindles
Alpha motor neuron
Ventral spinocerebellar tract
Dorsal spinocerebellar tract
Alpha motor neuron
Fasciculus cuneatus
Fasciculus gracilis
Fasciculus gracilis
Fasciculus dorsalis
Cutaneous, joint
and muscle receptors
Spinal cord L1
Spinal cord T1
Lower medulla
CHAPTER 4 Structure and Function of the Sensory Systems ■ 79
scope of this text. For clarity in identifying the
beginning and end of the projections, we will use
the individual pathway designations.
Receptors for the AL system include those that
respond to rough stimuli (e.g., rubbing, squeezing, pinching) that do not result in tissue damage
as well as those that do respond when tissue is
damaged. These latter receptors are mechanonocioceptors. When tissue is damaged, the release
of chemical substances activates a third class of
receptors, called chemonocioceptors. There are
also receptors for sensations of cold and heat.
None of these receptors localizes inputs well
when compared with receptors associated with
the DCML.
As with the DCML, cell bodies for neurons
associated with the AL are in the dorsal root ganglion. Projections from dorsal root ganglion cells
enter the spinal cord, and the fi bers ascend or
descend one or two spinal segments before synapsing in the dorsal horn. The interconnections
of these fi bers can be complex. After synapsing, the majority of second-order neurons cross
to the other side of the cord and project to the
brainstem reticular formation and the thalamus.
The crossing pattern defi nes a different picture
for injury or dysfunction than that seen for the
DCML. Any injury to this system above the level
of fi ber entry into the spinal cord results in defi -
cits on the opposite side of the body.
As suggested by the pathway names, information carried within the AL system projects to
the reticular system (spinoreticular), thalamus
(spinothalamic), periaqueductal gray and the
tectum (spinomesencephalic), and hypothalamic
(spinohypothalamic) areas. Interestingly, a large
portion of fi bers within the AL terminate within
the reticular formation. The transmission of both
diffuse and chronic pain is thought to be projected to this area of the brain, where arousal is
associated with pain. Spinothalamic projections
carrying nonspecifi c touch, temperature, and pain
FIGURE 4-17 The anterolateral pathway consists of several fi ber pathways. Shown here are the spinoreticular,
spinomesencephalic, and spinothalamic.
Lumbar
spinal
cord
Cervical
spinal
cord
Cerebrum
Midbrain
Pons
Medulla
Thalamus and
hypothalamus
Periaqueductal
gray matter
Reticular formation
Reticular formation
Locus coeruleus
Somatosensory cortex
and limbic system
Spinothalamic tract
Spinoreticular tract
Spinomesencephalic tract
80 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
go to the VPL as well as other thalamic nuclei.
The thalamus also receives tactile projections
from the reticular formation. Fibers sent to midbrain regions (periaqueductal gray and tectum)
and the hypothalamus permit information about
pain to become available to the limbic system
and the ANS, generating emotional, neuroendocrine, and cardiovascular responses to pain.
Interestingly, the emotional components of pain
can be separated from pain perception, probably because of the variety of projections within
the AL. Medications in the benzodiazepine class
(e.g., Valium), when used for pain, do not mask
pain perception. Instead, they make the sensation
of pain less distressing through their action on
the limbic system. Projections to the tectum may
be associated with the visual (superior colliculus) and auditory (inferior colliculus) systems;
however, the tectum is also an important center
for pain reception.
Perception of pain relies on projections to
the VPL of the thalamus, where it may be interpreted as paresthesia or dull pain and pressure.
Pain projections in the thalamus are more widespread than those from the DCML, and the projections for pain and touch remain segregated
( Bear et al., 2015 ). Projections from the VPL
go to the somatosensory cortices (both S-I and
S-II), which, therefore, are also potential anatomic sites for interaction between DCML and
AL inputs. Precise localization of pain is thought
to take place at the cortical level.
Somatosensation from the Face
The trigeminothalamic pathway ( Fig. 4-18 )
transmits tactile and proprioceptive input from
the face. The cell bodies for the fi bers in the
peripheral aspect of this pathway are located
in the trigeminal ganglion. From there, fi bers
project to the pons and the spinal cord, where
they both ascend and descend before synapsing.
Fibers carrying pain and temperature information
form the spinal trigeminal tract. From there projections go to the contralateral ventral posterior
medial thalamic nucleus and onto the primary
and secondary sensory cortices; these projections
provide the discriminative aspect of facial pain.
The affective aspects of pain follow pathways
to the reticular formation, areas in the midbrain,
and midline thalamic nuclei, which then connect
with the cingulate gyrus. Pain and temperature
information from the face are also transmitted by
way of the facial, glossopharyngeal, and vagus
cranial nerves, VII, IX, and X, respectively.
Cell bodies for neurons carrying proprioceptive information from muscles of the face are
found in the mesencephalic trigeminal nucleus,
located in the midbrain. From here, this information projects to the thalamus and on to the primary
sensory cortex, where the regions around the
mouth have a wide representation. The sensory
homunculus refl ects this wide representation.
Functional Considerations
In SI theory, the tactile system is thought to be
of the utmost importance in determining behavior. The sensation of touch is, in fact, the “oldest
and most primitive expressive channel” ( Collier,
1985 , p. 29), and it is a primary system for
making contact with the external world. We are
extremely dependent on touch until language,
motor skills, and cognitive processes develop
and can guide our experiences and interactions
( Collier, 1985 ; Diamond & Hopson, 1998 ). Touch
has been called our fi rst language; it is the fi rst
system to function in utero, and it mediates our
fi rst experiences in this world. We are nourished,
we are calmed, and we fi rst become attached to
others (i.e., bonding) through touch ( Montagu,
1978 ). The somatosensory system differs from
other sensory systems in that the receptors are
widely distributed ( Bear et al., 2015 ), a fact that
has potential ramifi cations from a sensory integrative perspective; we can close our eyes when
light is too bright or put fi ngers in our ears to
block out sound, but it is very diffi cult to effectively “turn-down” tactile input. This system also
differs in that it responds to multiple types of
sensation rather than the more unitary responses
seen with other sensory systems.
In a review of literature, Blackwell ( 2000 )
summarized the power of the tactile sensory
system:
There remains little doubt that tactile stimulation
is an important factor in the social, emotional,
physiological, and neurological development of
infants and young children. Consequently, it is
one of the most essential elements in the nurturing and healing environment of the infant and
child. (p. 37)
With widespread receptors that respond to
several different types of input, the potential
CHAPTER 4 Structure and Function of the Sensory Systems ■ 81
for multiple occupational roles to be disrupted
by inadequacies in processing tactile input is
worth considering. For example, a diffi cult time
with performance of activities of daily living
(ADLs) may be related to inadequate integration
of input from tactile receptors responsible for
discrimination. Poor student performance may
result from diffi culty manipulating writing and
cutting tools in the classroom. Poor peer interactions may result from inadequate modulation of
tactile sensation. Many aspects of touch associated with tactile defensiveness are hypothetically
associated with transmission through the AL
pathways and with the central interpretation of
the input ( Ayres, 1972 ). Given that the AL pathways project to the regions of the brain responsible for arousal (reticular system), emotional
tone (limbic structures), and autonomic regulation (hypothalamus), we postulate that tactiledefensive behaviors may be related to the
connections among these systems and brain
regions. Tactile over-responsivity is discussed in
more detail in Chapter 6 (Sensory Modulation
Functions and Disorders).
Although functionally it appears that the
DCML and the AL are separate and discrete,
considerable functional overlap can be seen. For
example, the DCML plays an important role in
the localization of pain. Furthermore, children
with lesions in the DCML retain some skill in
tactile discrimination. Thus, some information
about pain is transmitted through the DCML,
and some aspects of tactile discrimination must
be carried in the AL. Many authors have discussed this redundancy of function in terms of
parallel pathways and serial processing. Parallel
pathways are advantageous because they add to
the depth and fl avor of a perceptual experience
by allowing the same information to be handled
in different ways, and they offer a measure of
FIGURE 4-18 Trigeminothalamic pathway. This pathway carries light touch, pain, temperature, deep touch, and
proprioception from the face to the thalamus.
Cerebral
cortex and
thalamus
Midbrain
Dorsal trigeminothalamic tract
Pons
Mechanoreceptive
fibers in cranial
nerves V, VII, IX, and X
Posterior
limb of
internal
capsule
Primary
somatic
sensory
cortex
Secondary
somatic
sensory
cortex
Ventral
posterior
medial
nucleus
Trigeminal lemniscus
Main trigeminal
sensory nucleus
82 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
insurance. If one pathway is damaged, the other
can provide residual perceptual capability. Such
functional redundancy in the organization of the
nervous system may play a role in the effi cacy of
intervention.
Proprioceptive inputs to the cortex combine
with tactile inputs to support the somatotopic
mapping associated with this region. In fact, in
the sensory cortex there are four complete maps
of the body (homunculus), one each in area 3a,
3b, 1, and 2; recent research has identifi ed
area 3b as the primary sensory cortex. Maps
in each of these regions refl ect the density of
sensory receptors on the body. Because there
is greater density of receptors in regions where
more precise information is required for function,
these regions appear large in the homunculus.
The area associated with the hand, for instance,
is quite large, and the thumb/index region even
larger. Similarly, the area associated with the
mouth is disproportionately large, refl ecting
the important role that somatosensation plays
in speech and eating. As noted earlier, area 3a
receives substantial proprioceptive input, giving
it a primary role in the sense of body position.
Proprioceptive inputs to the cerebellum contribute to our ability to monitor and adjust movement as it takes place. The cerebellum has an
error correction function, resulting in our ability
to make changes in motor output to meet changing environmental demand. Proprioceptive inputs
then support the comparator function of the cerebellum, allowing the cerebellum to compare the
plan for action with the action itself as it unfolds.
The end result of this process is the production
of smooth, coordinated, multi-joint action. When
there is damage to the spinocerebellum, disrupting the processing of proprioceptive input
and feedback, it may be seen as a wide, shuffl ing gait, diffi culty performing rapid alternating
movements, and over- and under-reaching. Interestingly, cerebellar inputs remain ipsilateral; this
means that when there are cerebellar defi cits,
they are seen on the same side of the body. This
is in contrast to the processing of proprioception
at higher levels, which is contralateral.
HERE ’ S THE POINT
• Receptors for touch are found primarily in the
layers of the skin; those for proprioception are
found in muscles, joints, and tendons.
• Somatosensory information from the body
travels from receptors to the cerebellum
(spinocerebellar pathways for proprioception),
regions of the reticular formation,
hypothalamus, limbic system, and thalamus
(anterolateral system and dorsal column medial
lemniscal pathway), and from the thalamus to
the primary and secondary sensory cortices, as
well as areas 5 and 7 of the parietal lobe.
• Somatosensory information from the face is
carried by the trigeminothalamic pathway
to the thalamus and from there projects to
regions of the cortex for the somatosensation
from the body.
• Somatosensory receptors are pervasive
throughout the head and body; their central
influences are broad. These characteristics
support widespread infl uence of this sensory
input on occupational engagement and
participation.
Interoception
Although the perception of sensation relative
to the internal body has not been a focus of SI,
it warrants consideration here. Interoception
involves sensing the physiological condition of
the body. Thus, we are aware of such internal
sensations as hunger, satiety and thirst, heartbeat,
and visceral sensations. As will be discussed
next, the interoceptive pathways function in conjunction with motor and autonomic pathways,
giving us the ability to have an internal sense of
self and a means of acting on the environment.
Receptors and Transduction
We have already addressed one set of receptors for this system; they include the tactile
receptors described previously for the anterolateral pathway. This may seem counterintuitive; although Sherrington ( 1906 ) fi rst coined
the term interoception to include only information from the interior of the body (viscera),
more recently Craig ( 2002, 2009 ) indicated
that we needed to broaden our defi nition of this
term to include all sensory inputs that provide
the CNS with information regarding how the
body, internal and external, feels. Receptors in
our internal organs and blood vessels, schematically shown in Figure 4-4 , include free nerve
CHAPTER 4 Structure and Function of the Sensory Systems ■ 83
endings, mechanoreceptors, chemoreceptors, and
thermoreceptors. Cell bodies of primary afferent neurons reside in spinal and cranial nerve
ganglia. Interoceptive input travels to the CNS
over small diameter fi bers, and it provides us
with an understanding of our internal state.
One rationale for including skin receptors as
interoceptors has to do with their role in providing the CNS with information about the state
of the body; another rationale has to do with
how the receptors are activated and how this
information is transmitted. In contrast to other
somatosensory input, sensations of pain, itch, or
temperature can be activated by internal stimuli
as well as external or mechanical stimuli. And
they are activated continuously, providing us
with ongoing information about our physiological state. Interoceptive signals, such as pain,
temperature, and itch sensation, as well as other
chemical and hormonal signals, are projected to
the spinal cord over relatively small fi bers. As
such, interoceptors are the basis for homeostasis.
Interpreting Interoceptive Input
The projection target for interoceptive fi bers
entering the cord is in one particular region,
lamina 1 ( Fig. 4-19 ). Within lamina 1 are
modality-specifi c cells that respond to changes
in blood chemistry (e.g., oxygenation, glucose
levels), hormone levels, and by-products from
muscle activation. Fibers projecting from lamina
1 go to autonomic cell columns and homeostatic
centers in the brainstem. In the brainstem, tactile
information from the body is joined by sensory
information from the heart, viscera, tongue, and
pharynx, conducting information related to such
things as taste, thirst, nausea, and dyspnea (diffi -
culty breathing), projecting to the solitary nucleus
in the medulla. The combination of these two
sources of interoceptive input forms what is considered the afferent or input aspect of the ANS,
allowing us to map an internal awareness of self
and integrate sensation related to functions of
the ANS and homeostasis. Multiple connections
take place in the brainstem, and from here these
integrated sensations are sent to the hypothalamus, amygdala, and thalamus. The hypothalamus
is the seat of autonomic regulation and homeostasis. Activation of the cells in this structure
leads to hormonal, visceral, and somatic motor
responses designed to re-establish the body ’ s
status quo. Hypothalamic hormones are responsible for negotiating signals refl ecting changes in
temperature, thirst, hunger, sleep, stress, mood,
and sex drive. The amygdala is linked with fear
conditioning, regulating our autonomic and emotional responses to environmental danger. Projections of interoception then continue to the insular
cortex, where research has identifi ed sensory
maps of the body, and groups of cells with some
differential responsiveness, that defi ne distinct
sensations (such as sharp pain) and less distinct
interoceptive sensations (such as gastric distention) ( Craig, 2015 ). This region of the cortex is
linked with actual and perceived stimulus intensity and, consistent with its role in interoception,
tracking the body ’ s physiological state ( Uddin
& Menon, 2009 ). The insula is also important
in attaching emotional signifi cance to body state
(for instance, a rested body state may be associated with feeling happy), and in our awareness
of environment, self, and others ( Craig, 2009 ).
These sensations are linked with homeostasis,
and they guide emotional behaviors. There are
also interoceptive projections to the anterior cingulate cortex, termed the limbic motor cortex,
guiding action in homeostasis.
Functional Considerations
Recent research suggests defi cits in interoceptive
processing in individuals with autism spectrum
disorder (ASD) ( Elwin, Schröder, Ek, & Kjellin,
2012 ; Fiene & Brownlow, 2015 ). Participants
in the study by Elwin and colleagues indicated
they experienced over-responsivity to external
sensation and under-responsivity to inner/body
sensation. The work of Fiene and Brownlow
FIGURE 4-19 A cross section of the spinal cord
showing spinal lamina (left) and associated labels for
cell groups (right).
I
Central canal
Marginal zone
Gelatinous
substance
Nucleus
proprius
Lateral motor
neurons
Medial motor
neurons
II
III
IV
V
VI
VII
VIII
IX
X
84 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
extended these fi ndings, looking more specifi -
cally at internal body awareness in individuals
with ASD. These investigators found reduced
awareness of the body and feelings of thirst in
adults with autism. The anterior insula, a region
thought to process interoceptive input, has been
shown repeatedly to be under-active in individuals with ASD (see Di Martino et al., 2009
for meta-analysis). Regions of the insula, along
with the anterior cingulate cortex, are also linked
with empathy. Individuals with autism, as well
as typical individuals with lower empathy, show
decreased activity in the anterior insula, leading
Uddin and Menon to suggest that these limbicsystem-linked structures function in social and
emotional responses relative to both the self and
others. Given the importance of interoception for
homeostatic regulation and its apparent contributions to social functioning, a better understanding
of interoceptive processing and its relationship
to processing within other sensory systems and
functional behaviors is warranted.
HERE ’ S THE POINT
• Interoception, the sense we have of the
physiological condition of the body, is detected
by receptors in our internal organs and
subsequently projected to the spinal cord and
onto the brainstem, forming the afferent arm
of the ANS. Some tactile inputs are linked to
interoception.
• From the brainstem, interoceptive information
is sent to the hypothalamus, thalamus, and
amygdala and then on to the insular cortex.
These connections subserve our knowledge of
our body ’ s physiological state, link this with
emotion, and provide us with an awareness of
the environment.
• Under-responsiveness to interoceptive signals
has been identifi ed in individuals with ASD.
The Vestibular System
We approach the vestibular system in the same
manner as the somatosensory system, beginning with receptor structure and function and
then examining vestibular projections within the
CNS. Similar to other sensory systems, there are
both peripheral and central components to the
vestibular system, comprised of the receptors
and vestibular nerve fi bers (peripheral) and the
vestibular nuclei and multiple projection pathways (central). Following the vestibular system,
we will discuss proprioception from a functional
perspective and briefl y look at the interaction
between vestibular and proprioceptive sensation as they relate to the control of posture and
movement.
Receptors and Transduction
The vestibular apparatus sits inside the body labyrinth within the temporal bone, adjacent to the
cochlea ( Fig. 4-20 ). It includes the semicircular
canals and the otolith organs, the utricle and the
saccule ( Fig. 4-21 ). Receptors for the vestibular system are located within these structures in
the inner ear, and the endolymph that bathes the
receptors for the auditory system moves freely
between the auditory and vestibular systems.
Vestibular receptors are hair cells located in
the otolith organs and in swellings at the base
of the three semicircular canals (i.e., anterior,
lateral, posterior). The otolith organs are responsible primarily for static functions, concerned
with head translation and changes in head position relative to gravity. The information processed by these receptors is used to detect the
position of the head and body in space as well
as control of posture. The semicircular canals are
the dynamic component of the vestibular system,
responding to rotation and angular movement of
the head. These structures respond to movement
of the head in space.
Vestibular receptors are chalice-shaped with
hair-like processes extending from their apices.
At the base of each cell lies the afferent process
of the vestibular nerve fi bers. The vestibular
component of the vestibular-auditory cranial
nerve is formed from the axons of these fi bers.
Each cell has a single kinocilium and several
stereocilia. Although movement of the kinocilium in one direction leads to depolarization of
the hair cell, movement in the opposite direction
leads to hyperpolarization. Hair cells within each
semicircular canal have a specifi c orientation
such that they are all depolarized or hyperpolarized by movement in one direction. Cells in the
otolith organs are also polarized, but, because of
the structure of these organs, cells respond to a
vast array of directions of movement. When the
otolith cells depolarize, glutamate, an excitatory
CHAPTER 4 Structure and Function of the Sensory Systems ■ 85
neurotransmitter, is released into the synaptic
cleft. The transmitter interacts with the afferent
fi ber of the vestibular nerve, sending information about movement to the CNS ( Soto & Vega,
2010 ). We discuss the specifi cs of depolarization
within the semicircular canals and otolith organs
next.
In addition to the afferent fi bers at the base of
each hair cell, there are also efferent fi bers that
originate in the vestibular nuclei. These efferent
fi bers provide inhibitory control of the transmission of information from the hair cell and can
prevent information from traveling beyond the
receptor site.
Utricle and Saccule
The otoliths are saclike organs oriented in horizontal and vertical planes ( Fig. 4-21 ). In the
macula, which is the receptor region of the
otolith organs, hair cells synapse with processes
from the vestibular ganglion cells. Hair cell processes extend into an overlying substance with
gelatin-like qualities, the otolith membrane, in
which are embedded otoconia (calcium carbonate crystals). In the upright position, the hair
cells in the macula of the utricle are oriented in
a horizontal plane, whereas those of the saccule
are oriented in the vertical plane. In both sets of
organs, the otoconia rest on top of the hair cells.
When the head tilts or moves in any plane (side
to side, up/down, forward/backward), there is displacement of the otoconia and the embedded hair
cell stereocilia, beginning the process of stimulus detection and transduction. Movement of the
stereocilia creates electrical discharges within
the hair cell. This electrical energy is changed
to chemical energy at the synapse between the
macular hair cells and the vestibular ganglion
projections. Thus, together, the utricle and saccule
respond to head tilt in any direction and to linear
movement. It is important to remember that we
get directionality because the system is bilateral
and these structures are paired; activation on one
side of the head is matched with inhibition on the
FIGURE 4-20 Vestibular and auditory receptor systems are both located in the temporal bone, in close proximity
to each other.
(1) Auricle
Temporal bone
(4) Malleus
(5) Incus
(6) Stapes
(10) Semicircular canals
Vestibular
branch
Cochlear
branch
(7) Cochlea
Vestibulocochlear
nerve
(8) Oval window (3) Tympanic
membrane
(11) Vestibule
(2) External auditory
canal
External ear Middle ear Inner ear
(9) Eustachian tube
86 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
other side of the head. The otolith maculae constitute slow-adapting receptors and provide tonic
input to the CNS pertaining to head position and
movement. The tonic input is crucial in supporting upright posture and equilibrium.
Semicircular Canals
The semicircular canals ( Fig. 4-21 ), which are
actually closed tubes, detect changes in the direction and rate of angular acceleration or deceleration of the head. Angular acceleration results
FIGURE 4-21 Structures of the inner ear. The vestibular apparatus on the left side of the image shows three
semicircular canals as well as the receptor region in the ampulla at the swelling of one of the canals. Within
the ampulla is the crista, which consists of the hair cells and the overlying gelatinous mass, called the cupula.
The otolith organs, the utricle and the saccule, are also identifi ed. Within the saccule, the macula, or receptor
region, is shown.
Semicircular canals
Endolymph
Crista
Saccule
Vestibular nerve
Cochlear nerve
Vestibulocochlear
nerve
Scala
tympani
Cochlear
duct
Scala
vestibuli
Cochlea
Round window
Oval window
Utricle
Ampule
Kinocilium
Type I hair cell
Nerve fiber
Basement membrane
Supporting cells
Type II hair cell
Stereocilia
Otolithic
membrane
Otoconia
CHAPTER 4 Structure and Function of the Sensory Systems ■ 87
in rotary head movements—that is, head movements that, if continued far enough, would result
in the head turning in a circle (e.g., spinning,
head nodding). Within each vestibular apparatus, the three semicircular canals are oriented
at right angles so that they represent all three
planes in space. When the head is tilted forward
30 degrees, the horizontal canal is oriented in the
horizontal plane, with the anterior and posterior
canals positioned vertically and oriented at right
angles to each other.
The semicircular canals have an enlarged
ending called the ampulla. Within the ampulla
is the receptor apparatus for the semicircular
canals, the crista ampullaris, which contains the
hair cell receptors. The receptors are embedded in the cupula, a substance with gelatin-like
characteristics similar to the macula. There are
no otoconia in the crista ampullaris. Instead, the
cupula extends nearly to the top of the ampulla,
and its edges are, for the most part, anchored to
the epithelium that lines the canal. The canals
are fi lled with endolymph. When the head moves
(accelerates), inertia causes the endolymph to lag
behind head movement. This is often paralleled
with swirling water in a glass; when you begin
to swirl the glass, you can see that water “lags”
behind the speed of movement of the glass. If
you continue to swirl, the water speed will catch
up, and the glass and water will move “as one.”
In the semicircular canals, the initial lag results
in pressure on the cupula and its displacement in
a direction opposite to that of head movement.
Displacement of the cupula leads to bending of
the hairs, and this mechanical distortion begins
the process of transduction. As head movement
continues, the speed of the endolymph catches
up with that of the head, the cupula returns to its
resting position, and the hair cells are no longer
mechanically distorted. With continued movement of the head at a relatively constant velocity,
the semicircular canal receptors return to a basal
fi ring rate. When head movement stops or decelerates, the inertia again acts on the endolymph,
and it continues to move in the canals, this time
in the direction of head movement. Again, pressure is placed on the cupula, bending the hairs in
the same direction in which the head had been
moving. This then changes transmission and
activity in the vestibular nerve. Several seconds
after the head stops moving, the cupula and hairs
return to their normal resting positions.
As is the case for the otolith organs, the
semicircular canals are paired structures. The
horizontal canal on one side is paired with
the horizontal canal on the other side of the head,
whereas one anterior canal is paired with the
posterior canal on the opposite side of the head.
The alignment of hair cells in the crista ampullaris of each member of the pair is opposite, so
when the hair cells on one side are excited, those
in the matching canal on the other side are inhibited. As was the case with the otolith organs, this
orientation and pairing provides directionality to
movement.
Afferent and efferent fi bers meet the hair cells
at their base. Afferent fi bers carry information
from the receptors to the vestibular ganglion,
and, from there, fi bers join to become the vestibular nerve ( Fig. 4-21 ), one part of cranial nerve
VIII, the vestibulocochlear nerve. The vestibular fi bers project to the vestibular nuclei. Efferent input from the nuclei may form part of an
early feedback mechanism within the vestibular
system or may serve to guide typical development of vestibular structures ( Baloh & Kerber,
2010 ). Investigation continues to be warranted
on the precise function of these efferent fi bers;
however, output from these fi bers results in
modifi cation and, potentially, modulation ( Holt,
Lysakowski, & Goldberg, 2011 ).
Because the hair cells in each pair of canals
are maximally stimulated by head rotation in the
same plane, they are able to detect movement
of the head in the three orthogonal (right-angle)
planes of three-dimensional space. The most
effi cient stimuli for the semicircular canals are
angular, transient (short-term), and fast (highfrequency) head movements of at least 2 degrees
per second. When the head moves at slower
speeds, the endolymph, cupula, and hair cells all
move at the same speed as the head. As such,
the cupula does not bend, and hair cells in the
ampulla are not activated.
As noted earlier, the otolith inputs are a
foundation for upright posture and equilibrium
because these inputs are tonic. Semicircular
canal inputs are phasic; sensory information is
sent only as long as the cupula bends the hair
cells. These inputs then are important in triggering righting responses, supporting our ability
to master perturbations from movement in and
through the environment. Afferent fi bers in the
vestibular nerve transmit both tonic and phasic
88 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
information from the receptors, which is critical
to function within this system.
Central Projections
There is always some activity within the vestibular nerve, primarily because of tonic activation
of otolith organs by gravity. Activation of the
receptor organs either increases or decreases
this baseline activity, depending on the type and
direction of movement. Activation in one half of
the pair of canals is met with decreased activity
in the parallel canal on the other side of the head.
Because the vestibular nerves project both ipsilaterally and contralaterally, the vestibular nuclei
interpret direction of movement by comparing
the frequency of impulse fl ow between left and
right canals and otolith organs.
The cell bodies for the vestibular nerve are
located in the vestibular nerve ganglion, also
known as Scarpa’s ganglion. From these cell
bodies, the vestibular nerve carries information
to the vestibular nuclei in the brainstem. There
are four nuclei on each side: lateral, medial,
superior, and inferior ( Fig. 4-22 panel A). A great
deal of sensory processing takes place at this
level within the vestibular system. Each nucleus
receives direct ipsilateral input as well as contralateral input via fi bers crossing from the opposite
nuclei. These nuclei also receive inputs from the
spinal cord, cerebellum, and visual system. The
organization of these inputs allows detection of
direction and speed of head movement as well as
position of the head relative to gravity.
Vestibular nuclei receive input from other
sensory systems, notably the visual system.
According to Purves and colleagues ( 2011 ),
this makes the vestibular system unique among
sensory systems; there is multisensory integration in the fi rst site of central vestibular processing and throughout all subsequent projections.
Visual inputs are relayed through the inferior
olive and cerebellum, and the interaction of these
inputs is thought to be important in generating
eye movements, as described later.
From the vestibular nuclei come many fi ber
pathways that connect the vestibular system
extensively within the CNS. Direct connections are found between vestibular nuclei and
the cerebellum, oculomotor nuclei, and spinal
cord. Projections have also been described to
parts of the reticular system, the thalamus, and
the cortex (frontal lobe, parietal-insular cortex).
This organization within the vestibular system
is an example of heterarchical processing rather
than hierarchical; each connection has a unique
function.
Vestibular-Cerebellar Connections
The vestibular system is the only sensory system
with direct connections from receptors to the
cerebellum. Projections come from the vestibular nerve directly ( Fig. 4-22 ) and from vestibular
nuclei. In turn, there are direct connections from
the cerebellum to the vestibular nuclei. These
reciprocal connections from the cerebellum go
primarily to the medial and lateral vestibular
nuclei. As noted later, ascending fi bers from the
medial vestibular nucleus project to oculomotor
nuclei, allowing the cerebellum to infl uence eye
position; descending projections from this same
nucleus give the cerebellum control of head and
neck movements ( Fig. 4-22 panel A). Reciprocal connections between the cerebellum and the
lateral vestibular nucleus infl uence output over
the lateral vestibulospinal pathway, thus infl uencing postural control. Together then, the vestibular
system and the cerebellum coordinate eye, head,
and trunk movements and are critical for posture,
balance, and equilibrium.
Vestibulospinal Connections
The vestibular nuclei send projections to the
spinal cord via lateral and medial vestibulospinal pathways (LVST and MVST, respectively;
Fig. 4-22 panel A). These pathways are responsible for infl uences on muscle tone as well as
for ongoing postural adjustments. The LVST
receives input from semicircular canal pairs,
otolith organs, the vestibulocerebellum, and the
spinal cord. Fibers from the LVST terminate
directly on alpha and gamma motor neurons in
the spinal cord at the cervical, lumbar, and sacral
levels. Alpha motor neurons supply muscle
fi bers, and gamma motor neurons project to the
muscle spindle; thus, the vestibular system has
a strong infl uence on postural muscles, postural
control, and stability. The MVST receives input
from the cerebellum and from skin and joint proprioceptors. The fi bers in this pathway project
to fl exor and extensor motor neurons in the cervical region of the cord. This input assists with
the maintenance of a consistent position of the
head in space. Thus, with descending vestibular
CHAPTER 4 Structure and Function of the Sensory Systems ■ 89
projections, we see the interaction of vestibular
and proprioceptive inputs.
Responses elicited because of stimulation of
the utricle or semicircular canal activate extensor muscles, eliciting compensatory movements
of the head, trunk, and limbs. Such movements
help oppose head perturbations, postural sway,
or tilt and keep us upright ( Fisher & Bundy,
1989 ; Goldberg et al., 2012 ). However, as might
be expected, there are differences between the
kinds of postural responses ultimately elicited by
stimulation to the different receptors. Utricular
inputs, conveyed primarily via the LVST to limb
and upper trunk alpha and gamma motoneurons, result in ipsilateral facilitation of extensor
muscles and inhibition of fl exor muscles. Semicircular canal inputs are conveyed primarily via
the medial vestibulospinal pathway to axial alpha
and gamma motoneurons and result in bilateral facilitation of neck and upper-trunk fl exor
muscles. Functionally utricular inputs elicit more
sustained postural responses (i.e., tonic postural
extension and support reactions); semicircular canal inputs elicit more phasic equilibrium
FIGURE 4-22 A. Central vestibular connections. Ascending fi bers connect with oculomotor nuclei to coordinate
movement of the eyes relative to the head. Vestibular projections are also found to the thalamus and on to
regions in the cortex. The vestibular system has a reciprocal connection with the cerebellum, and fi bers descend
to the spinal cord as the medial and lateral vestibulospinal pathways. B. One of the cortical projection regions of
the vestibular system, found at the base of the precentral gyrus and the intraparietal sulcus.
Vestibular nuclei
Medial vestibulospinal tract
Lateral vestibulospinal tract
Anterior
semicircular canal
Posterior
semicircular canal
Horizontal
semicircular canal
Utricle
A Saccule
B
Inferior
cerebellar
peduncle
Fastigial
nucleus
Vestibulocerebellum
Feedback loop
Ventral posterior nucleus
in thalamus
Vestibular area in
cerebral cortex
Oculomotor nerve
(III) nucleus
Trochlear nerve (IV)
motor nucleus
Abduceus nerve (VI)
motor nucleus
Vestibular
cortex
90 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
responses ( Fisher & Bundy, 1989 ; Roberts, 1978 ;
Wilson & Melvill Jones, 1979 ).
Functionally then, if the goal is to facilitate
tonic postural or support reactions, activities that
provide utricular stimulation may be more appropriate. If the goal is to encourage the use of more
phasic or transient postural reactions, then activities that provide stimulation to the semicircular
canal may be indicated.
Vestibular-Oculomotor Connections
Vestibular fi bers directly project to oculomotor
nuclei for cranial nerves III (oculomotor), IV
(trochlear), and VI (abducens) via the medial
longitudinal fasciculus ( Fig. 4-22 panel A).
Fibers are both crossed and uncrossed as they
reach these nuclei. These connections serve to
provide an ongoing stable visual image; as the
head turns in one direction, eye movement occurs
in the opposite direction, preventing retinal slip
and maintaining visual acuity ( Goldberg et al.,
2012 ). Inputs that mediate these responses come
from the semicircular canals and are active in
any plane of movement. When the head is not
moving, the eyes remain still. However, with head
movement comes activation of the vestibuloocular refl ex to enable the visual fi eld to remain
stable even as the head and body move.
Nystagmus is a specialized compensatory
vestibulo-ocular movement. As the head moves
in an angular fashion, interactions between the
oculomotor nuclei and the vestibular system
allow the eyes to remain fi xed on an object in
space. With continued angular movement of the
head, the eyes reach the end of their range of
motion; this comprises the slow phase of nystagmus. Once the end of range is reached, the
eyes spring back to a central position; the quick
movement to a central position comprises the
fast phase of nystagmus. The nystagmic eye
movements are tied to the movement of endolymph in the semicircular canals, which results
from angular movement of the head. At the
onset of head movement, endolymph movement
lags behind head movement, bending the cupula
in the semicircular canal as it moves. As head
movement continues at a steady pace, the speed
of endolymph movement catches up with the
speed of head movement, and the cupula regains
an upright position. This stops activation of the
hair cell receptors, and input to the CNS returns
to baseline.
Nystagmus is named for the direction of the
fast phase, which is the same as the direction of
head movement. When nystagmus occurs during
head movement, it is termed per-rotary nystagmus (i.e., nystagmus that takes place during
movement). Per-rotary nystagmus declines and
eventually stops as described previously. When
the head stops, endolymph in the canals continues to move in the direction of head turn. This
activates the cupula again, in the opposite direction, and triggers the same sequence of events
described previously but in the opposite direction, this time leading to postrotary nystagmus.
Measurement of postrotary nystagmus is a
tool that has been used to examine one aspect
of the integrity of the vestibular system. When
using this measurement, it is important to have
a more complete understanding of the processes
underlying nystagmus. These processes were
well described by Fisher ( 1989 ); we summarize
them briefl y here. Movement of endolymph in
the semicircular canal and displacement of the
cupula initiate nystagmus. However, the cupula
returns to a resting position and stops activating
the vestibular receptors several seconds before
nystagmus ceases. This phenomenon is related
to velocity storage, a mechanism associated
with the vestibular nuclei in which velocity
information generated by movement is collected
and stored and then released slowly, generating
nystagmus ( Baloh & Kerber, 2010 ; Goldberg
et al., 2012 ). Fisher, Mixon, and Herman ( 1986 )
suggested that this mechanism was impaired in
individuals with a vestibular-based dysfunction
in SI, resulting in shortened duration of postrotary nystagmus. Further investigation is needed
to confi rm this possibility.
Vestibular-Thalamic
and Cortical Connections
Vestibular connections project bilaterally to the
VPL of the thalamus as well as to the lateral and
paramedian nuclear groups of the thalamus. The
VPL receives somatosensory input and is one
anatomic region where interaction of somatosensory and vestibular inputs takes place. From the
thalamus, fi bers project to the cortex, to the base
of the precentral gyrus (area 3a), and to the base
of intraparietal sulcus (area 2V) ( Goldberg et al.,
2012 ) ( Fig. 4-22 panel B). Area 2V neurons
respond to head movements, and activation of
this region leads to sensations of dizziness or
CHAPTER 4 Structure and Function of the Sensory Systems ■ 91
awareness of movement. Neurons here receive
not only vestibular input but also visual and proprioceptive inputs, and this area is likely involved
with the perception of motion and spatial orientation. A lesion here leads to confusion in spatial
orientation. Area 3a receives vestibular and
somatosensory inputs and projects to area 4 of
the motor cortex. These connections likely serve
to integrate motor control of the head and body.
The Integrative Vestibular System
By nature of the multiple connections with other
sensory inputs and motor output systems, the
vestibular system is a multisensory integrative
system, as has been noted previously. Vestibular
pathways are both unilateral and contralateral,
with recent evidence indicating fi bers cross at the
vestibular nuclei, in the pons, the midbrain, and
at the corpus callosum ( Kirsch et al., 2014 ). The
bilaterality of this system is considered crucial
to its function ( Rine & Wiener-Vacher, 2013 ).
According to Dieterich and Brandt ( 2015 ), vestibular inputs are multimodal, activating other
sensory systems as they are used to mediate our
perception of body position in and movement
through space, as well as gaze stabilization.
Unique among sensory systems, the vestibular
system has no primary sensory cortex; regions
of the cortex receiving vestibular inputs (i.e.,
the parietal-insular area) also respond to other
sensory inputs. The vestibular system then uses
multimodal and multilevel integration in conducting its critical functions.
Vestibular and Proprioception
Interactions
Vestibular and proprioceptive processing are
hypothesized to contribute jointly to the perception of active movement, the development of
body scheme, and the development and use of
postural responses—especially those involving
extensor muscles (e.g., extensor muscle tone,
equilibrium). Reviewing available research at
the time, Matthews ( 1988 ) indicated that, under
typical circumstances, the role of proprioception
was to provide the motor system with a clear and
unambiguous map of the external environment
and of the body. Other investigators of the time
had suggested that proprioception played a role in
programming and planning of bilateral projected
action sequences ( Goldberg, 1985 ). Nashner
( 1982 ) had already proposed that inputs from
the vestibular system could be used to resolve
vestibular-visual-somatosensory (proprioceptive)
confl icts, and, as such, the two systems worked
together to provide a stable frame of reference
against which other sensory inputs were interpreted. These early indications of function have
remained with us ( Goldberg et al., 2012 ). Thus,
vestibular and proprioceptive inputs, together
with vision, provide:
• Subjective awareness and coordination of
movement of the head in space
• Postural tone and equilibrium
• Coordination of the eyes, head, and body, and
stabilization of the eyes in space during head
movements (compensatory eye movements)
HERE ’ S THE POINT
• Peripheral vestibular receptors (hair cells) in
the inner ear respond to linear (otoliths) and
angular (semicircular canals) movement. All
movement input automatically infl uences
activity on both sides of the head.
• The central vestibular system begins with the
brainstem nuclei, which themselves receive
multisensory inputs.
• Vestibular inputs to the cerebellum are both
direct, from the receptors, and indirect, by
way of vestibular nuclei, indicating the close
relationship these structures share in the
production of movement.
• Projections from vestibular nuclei also include
fibers descending to regions of the spinal
cord and ascending to oculomotor nuclei, the
thalamus, and the cortex.
• The vestibular system is a multisensory system
throughout its course; it is part of a network
involving vestibular nuclei, the cerebellum,
proprioception, spinal cord motor neurons,
oculomotor neurons, the thalamus, and the
cortex in supporting its functions related to
eye, head, and trunk control and body position
in and movement through space.
The Auditory System
Activation of the auditory system is a complex
process; sound waves are received by the external
92 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
ear, transmitted via the middle ear, and fi nally
transduced into action potentials within the inner
ear. The structure of the auditory system can be
seen situated in the temporal bone, adjacent to
the vestibular apparatus in Figure 4-20 . Receptors for the auditory system are located in the
inner ear, in a membranous structure called the
cochlea (see Fig. 4-21 ). The receptors are hair
cells, which are components of the organ of
Corti ( Fig. 4-23 ). As you may recall, hair cells
are also the receptors in the vestibular system,
and the mechanism of transduction from hair cell
receptors in the auditory system is similar to that
described for the vestibular system.
Receptors and Transduction
Sound begins as sound waves, corralled by the
external ear and transmitted through the external auditory meatus to the tympanic membrane
( Fig. 4-23 ). Attached to the tympanic membrane
are the ossicles of the middle ear. The ossicles
act to optimize the transfer of sound energy from
air to the fl uid-fi lled inner ear, where the organ of
Corti lies. There are two muscles in the middle ear
that serve to alter responsivity of the ossicles to
movement of the tympanic membrane: the tensor
tympani and the stapedius. The tensor tympani
is attached to one ossicle (malleolus), and it is
innervated by a branch of the trigeminal nerve
(cranial nerve V). The actions linked with biting
and chewing lead to refl exive contraction of this
muscle, pulling on the malleus and stiffening the
tympanic membrane. This process effectively
prevents lower frequency sound (background
noise) from being transmitted and, therefore,
can improve our ability to understand speech
in the face of background noise. The stapedius
muscle attaches to the ossicle called the stapes;
it is innervated by the facial nerve or cranial
nerve VII. The stapedius refl exively contracts
with sounds at a sound pressure level of 65 dB
and 500, 1,000, and 2,000 Hz, frequencies often
associated with vowel sounds in speech. Refl exive contraction of the stapedius acts in a manner
similar to that described previously, stiffening
the tympanic membrane and blocking lower frequency sounds from entering the ear. Because
of the relationship between the ossicles and the
tympanic membrane, diseases that impede movement of the ossicles decrease energy transfer and
interfere with hearing. This is what happens with
inner ear infections (e.g., otitis media).
The transduction of sound into a neurochemical signal begins with movement of the tympanic membrane, creating a chain of events in
this closed system ( Fig. 4-23 ). Movement of
the tympanic membrane creates movement of
the ossicles, small bones, in the middle ear. The
malleus fi ts into the oval window, the opening to
FIGURE 4-23 A. The auditory system within the temporal bone. B. Cross section through the cochlea, showing
the three regions of the auditory canal. C. The organ of Corti, receptor cells for sound.
Helicotrema
of cochlea
Scala vestibuli
Cochlear duct
Scala tympani
Cochlear aqueduct
Round (cochlear) Vestibule
window
Stapes in oval
(vestibular) window
Incus
Malleus
Tympanic cavity
External acoustic meatus
Sound
Tympanic membrane
Tectorial
membrane
Basilar
membrane
Inner
hair cell
Outer
hair cell
Supporting
cell
Corti
tunnel
Scala vestibuli
(perilymph)
Scala tympani
(perilymph)
Cochlear duct
(endolymph)
Cochlear
nerve
Spiral
ganglion
Organ of
Corti
Spiral
ligament
Stria
vascularis
Vestibular
(Reissner)
membrane
Basilar
membrane
Eustachian
tube
Stereocilia
A
B C
CHAPTER 4 Structure and Function of the Sensory Systems ■ 93
the inner ear. Movement of the ossicles leads to
movement of the oval window. As the membrane
of the oval window moves in and out, it creates
waves of movement in the fl uid in the auditory
canal of the inner ear (perilymph). Within the
auditory canal is the basilar membrane; as the
perilymph moves, the basilar membrane also
moves. Sitting on the basilar membrane is the
organ of Corti, which contains hair cells. These
hair cells have projections into a second membrane, the tectorial membrane, which sits atop
hair cell projections. Movement of the basilar
membrane and hair cells results in bending of
the hair cell projections, beginning the process
of depolarization. The basilar membrane changes
thickness throughout its length, being thinner at
the base than at the apex. This makes it sensitive
to different frequencies (i.e., pitches) along its
length. The process from this point parallels that
in the vestibular system. Depolarization of the
hair cell releases a neurotransmitter (glutamate)
that interacts with receptor sites on the afferent
component of the auditory nerve, and information is carried to the CNS.
Within the auditory system, the fi rst synapse
is very close to the point of transduction, at
the base of the hair cells. Activation of the hair
cells turns physical energy into electrical energy
and, almost immediately, chemical energy, as
the impulse is transferred to the dendrites of
the spiral ganglion, which synapse with the hair
cells. The organ of Corti includes two types of
hair cells, those thought to control the sensitivity of the receptor apparatus, the outer cells,
and those thought to be responsible primarily
for actual hearing, the inner hair cells. A single
spiral ganglion cell may innervate as many as
50 outer hair cells. In contrast, the inner hair cells
may receive dendritic connections from as many
as 10 spiral ganglion cells. Thus, whereas outer
hair cells converge, inner hair cells diverge at the
fi rst synapse in the pathway. The organ of Corti
is tonotopically organized such that high sounds
activate cells on the basilar membrane near its
narrow end, and low sounds activate cells at the
wide end of the membrane. In addition, inner
hair cells and the spiral ganglion cells synapsing
with them show a “tuning curve,” where there
is a relationship between the amplitude of sound
needed to induce a barely detectable neuronal
discharge and the sound frequency. These characteristics of the receptive apparatus account for
the accuracy with which sound information is
transmitted to the brain.
As in the vestibular system, the auditory nerve
has both afferent and efferent components. The
afferent components form the cochlear portion of
the vestibular-cochlear nerve (cranial nerve VIII).
The efferents come from the superior olivary
complex (SOC) and innervate the outer hair cells
directly and the inner hair cells indirectly. When
active, the efferent fi bers inhibit transmission of
information to the CNS and may play a role in
the discrimination of specifi c sounds in the presence of background noise.
Central Connections
The auditory system has two primary pathways
to the CNS: the core pathway, which maintains
tonotopic organization of input and transmits
sound frequency with speed and great accuracy,
and the belt pathway, which is less well organized and transmits information relative to the
timing and intensity of input. This latter pathway
contributes to bilateral interaction of sound input.
Information on both pathways is integrated into
the information that I will describe next. Core
and belt pathways project to primary (core) and
secondary (belt) cortical regions. Pathways and
cortical regions are described next.
Axons from the spiral ganglion cells form the
cochlear nerve, which travels from the ear to the
brainstem where it synapses with ventral and
dorsal cochlear nuclei, ipsilaterally. All fi bers
have synapses in both nuclei. The tonotopic organization of these connections is maintained at this
level. From this point, three routes carry acoustic
information onward. From the dorsal cochlear
nucleus come fi bers that cross to become part of
the lateral lemniscus. From the ventral nucleus,
one group of fi bers follows those of the dorsal
nucleus, also becoming part of the lateral lemniscus. Another group passes to the ipsilateral and
contralateral nuclei of the trapezoid body and the
superior olivary nuclei and, from there, joins the
lateral lemniscus. Thus, the lateral lemniscus has
both ipsilateral and contralateral representation
of acoustic information, although contralateral
fi bers predominate. The superior olive is the fi rst
place where information from both ears converges. This convergence occurs with accurate
representation of the timing of auditory input to
the two ears, which is continued onto the cortex.
94 ■ PART II The Neuroscience Basis of Sensory Integration Disorders
Stimulus localization depends on the accurate
rendition of the temporal aspects of sound reception ( Fig. 4-24 ).
Fibers within the lateral lemniscus travel
to the inferior colliculus and the medial geniculate body. The inferior colliculus receives
essentially all auditory input, both core and belt
pathway input, as well as input from the contralateral auditory cortex. As such, it is a major
integrating center for the auditory system. The
main nucleus of the inferior colliculus is the
central nucleus, where cells are sensitive to both
timing and intensity differences in the sound
transmissions received; this structure then functions in detecting both sound frequency and
sound temporal characteristics. Regions of the
inferior colliculus are also sensitive to differences in time of arrival of sound, giving it a
role in sound localization and binaural hearing
( Sahley & Musiek, 2015 ). Another site for auditory input in the inferior colliculus is the paracentral nucleus. This structure receives not only
auditory input but also inputs from the spinal
cord, dorsal column, and SC. This nucleus is
FIGURE 4-24 Central auditory pathways. Some auditory fi bers project in the inferior colliculus, whereas others
project to the medial geniculate nucleus of the thalamus and on to the auditory cortex.
Auditory
cortex
Section of
mesencephalon
Section of
brainstem
Thalamus
Inferior
colliculus
Reticular
formation
Reticular formation
Cochlear
nuclei
Superior
olive
Cochleo-vestibular
nerve (VIII)
Type 1 neuron
CHAPTER 4 Structure and Function of the Sensory Systems ■ 95
thought to play a role in multisensory integration
and auditory attention.
The inferior colliculus sends fi bers on to the
medial geniculate body, a specialized nucleus
within the thalamus. From there, information
travels to the transverse temporal gyrus, also
called Heschl gyrus, occupying Brodmann areas
41 and 42 within the primary auditory cortex.
It receives input from the core pathway and is
tonotopically organized. The belt area surrounds
the area of core pathway input; it is both less
organized and less well understood. When information reaches the primary auditory cortex, a
sound is heard and interpretation begins. The
primary auditory cortex receives both ipsilateral and contralateral input, further supporting
the mapping of sound. Neurons in this area also
map loudness, modulation of loudness, and modulation of frequency ( Kandel, Schwartz, Jessell,
Siegelbaum, & Hudspeth, 2013 ). This cortical
region is critical for the perception of speech.
Brodmann area 22 ( Fig. 4-7 ) corresponds to
the secondary auditory cortex, where discrimination of location and direction of sound take
place. The secondary auditory cortex receives
input from the paracentral nucleus of the inferior colliculus. As noted, this projection is likely
responsible for detecting and directing attention
to auditory input that is novel or moving. The
planum temporale is a part of this area, and it
is an area implicated in dyslexia. It is an area
that shows bilateral asymmetry, with somewhat
different functions for each side. The planum
temporale plays a role in processing complex
sound as well as processing basic auditory input
and speech ( Liem, Hurschler, Jancke, & Meyer,
2014 ). Area 22 also receives input from the
visual and somatosensory pathways.
The auditory association cortex encompasses
areas 39 and 40 ( Fig. 4-7 ), the angular gyrus and
supramarginal gyrus, respectively. These areas are
associated with reading and writing. Damage to
area 39 leads to an inability to recognize speech.
Projections from the primary auditory cortex are
also found in other cortical regions associated
with speech. Areas 44 and 45 have been called
the Broca area; damage in that area results in
speech that is nonfl uent, although speech recognition is not impaired by such damage. The association area of the auditory cortex also receives
input from other systems, such as the vestibular and somatosensory systems. Thus, there is
multisensory interaction here, and this may play
a role in arousal or attention.
Efferent Processes and Feedback Loops
Within the auditory pathways are numerous
efferent processes thought to act as feedback
loops. Functionally, they may contribute to
selective auditory attention. Reticulospinal pathways “sample” activity in the lateral lemniscus
and play a role in auditory startle responses. In
addition, the inferior colliculus and the auditory
cortex project to the SC, where information is
integrated with somatosensory inputs. These
pathways are likely responsible for controlling
orientation of the head, eyes, and body to sound.
HERE ’ S THE POINT
• Auditory receptors (hair cells), found in the
organ of Corti in the inner ear, are activated
through a series of events that begin when
sound waves create movement of the
tympanic membrane separating the outer
and middle ear.
• Sound input is projected to brainstem nuclei,
and from there information from both ears
is projected to the superior olive. The receipt
of bilateral auditory input allows for temporal
interpretation of sound, and sound localization.
• Multisensory integration (somatosensory,
visual, and auditory) takes place in the inferior
colliculus and supports auditory attention.
• Projections of auditory input to the primary and
secondary auditory cortices subserve a higher
level of sound interpretation and complex
mapping of the sound environment.
• Additional cortical projections, some to
multisensory integration areas, are associated
with such functions as sound interpretation,
auditory attention, speech, reading, and
writing.
The Visual System
Despite the pervasive nature of the tactile system
and the importance of the vestibular system,
we rely most heavily for day-to-day function
on visual input. According to one neuroscience
text, “It is vision that helps us to navigate in the
world to judge the speed and distance of objects;
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