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PART
IV
Intervention
286
CHAPTER
12
The Art of Therapy
Anita C. Bundy , ScD, OT/L, FAOTA ■ Colleen Hacker , MS, OTR
Chapter 12
The kind of involvement necessary to achieve the state wherein the child becomes
effectively self-directing within the structure set by the therapist cannot be
commanded; it must be elicited. Therein lies the art of therapy.
— Ayres, 1972 , p. 259
Upon completion of this chapter, the reader will be able to:
✔ Identify components that facilitate the art of
therapy, including therapeutic use of self.
✔ Discuss how visual, auditory, tactile,
proprioceptive, and vestibular sensory input
can be used to optimize the effectiveness of an
intervention session for a particular child.
✔ Define play, and describe essential components
of play, including inner drive, internal control,
freedom from the constraints of reality, and
framing.
LEARNING OUTCOMES
Introduction
In the varied topography of professional practice,
there is a high, hard ground where practitioners
can make effective use of research-based theory
and technique, and there is a swampy lowland
where situations are confusing “messes” incapable of technical solution ( Schön, 1983 , p. 42).
The children that we see in sensory integrative
therapy often have lives that are mired in muck.
Even the simplest everyday challenges seem too
diffi cult. The muck is a part of what makes them
interesting and what makes their intervention so
important. As Schön ( 1983 , p. 42) reminded us,
“problems of the swamp are those of greatest
concern.” Schön went on to suggest that some
therapists deliberately involve themselves in the
messy, but crucially important, problems of the
swamp. Those highly skilled therapists, who
succeed time after time in these most diffi cult of
situations, rely heavily on art. Therapy with such
children also commonly refl ects the swampy
lowland. An hour-long session where we try to
stretch children to the limits of their abilities can
easily take a dozen unexpected twists and turns.
Very rarely does any therapy session follow the
high, hard ground (i.e., the rules of theory). In
fact, fully half of the Fidelity Measure ( Parham
et al., 2011 ), which operationally defi nes sensory
integrative therapy, refl ects art: collaboration in
activity choice, tailoring activity to present a
just-right challenge, ensuring that activities are
successful, supporting the child ’ s intrinsic motivations to play, and establishing a therapeutic
alliance (see also Chapter 14 , Distilling Sensory
Integration Theory for Use: Making Sense of the
Complexity).
Artful practitioners respond to complexity in
what seems to be simple ways and without disrupting the fl ow. They make therapy look easy,
even with the most diffi cult child and in the most
diffi cult situation. The therapist approaches each
session as though it were unique. That is not to
say that the therapist acts without the benefi t
of theory or prior experience. But she is not
looking to solve a problem by simply rolling out
CHAPTER 12 The Art of Therapy ■ 287
something she has rolled out previously either.
Rather, in each therapy session, the actions and
interactions of an artful therapist change the situation repeatedly. The therapist then considers
how happy she is with each outcome and what
those outcomes have taught her. Schön described
this way of approaching therapy as a kind of
refl ective conversation : refl ection-in-action. The
therapist “speaks”; the situation “talks back.”
The therapist listens, and as she appreciates what
she hears, she reframes the situation once again.
“The process spirals through stages of appreciation, action, and reappreciation. The unique
and uncertain situation comes to be understood
through the attempt to change it, and changed
through the attempt to understand it” ( Schön,
1983 , p. 132).
Purpose and Scope
This chapter has two main sections. After
meeting Phoebe, a 4½-year-old early in her
therapy, we will be voyeurs on a particularly
artful session—one in which, despite the murky
situation, the therapist, at one point, refl ected,
“I was feeling pleased at how the session was
unfolding.” We view the session as a whole and
then de-construct it to examine the therapist ’ s
refl ections. In the second section, we focus on
the therapist as playmate and promoter of play
and we defi ne sensory integrative therapy as a
special form of play and examine the characteristics of this subset of play.
CASE STUDY ■ PHOEBE
Phoebe is an engaging blonde, tall for her age
but otherwise petite. Her overall goal was to be
ready for kindergarten in 6 months. Her family ’ s
concerns included Phoebe ’ s persistent anxiety.
They described her as clingy, cautious, lacking
confi dence, and withdrawn in new or unfamiliar settings. Phoebe also experienced signifi -
cant challenges with gross motor skills. These
concerns, coupled with delays in language and
diffi culties playing and interacting with peers,
resulted in a referral to occupational therapy. In
this fi rst session, narrated by Phoebe ’ s therapist,
the focus is on minimizing gravitational insecurity and improving postural-ocular responses.
The Session: As Told by the Therapist
Even given my observations of Phoebe during
the assessment, and information gathered
during my interview with her parents, I was
still a little surprised at the degree of anxiety
that Phoebe experienced relative to movement
and at the lengths she went to in an attempt to
cope. Her immediate “go-tos” were to get quite
bossy and demanding. Her anxiety and feelings
of being overwhelmed led to a disconnect from
her already poor pragmatic language, making
the communication dance with her even trickier
than it had been during the assessment. After
the fi rst 5 minutes of Phoebe ’ s fi rst intervention
session, I knew I had to use several resources to
draw her in and empower her to participate in
the activities most likely to help her progress.
I start all my therapy sessions expecting that
the child “can” and “will.” My expectations
for Phoebe were no less. My previous refl ections on her needs, based in theory, supported
using vestibular-proprioceptive-based activities
to help move her through some of the gravitational insecurity. Balancing the just-right
amount of vestibular with the just-right amount
of proprioception was an important strategy
to promote her ability to modulate sensation.
Gaining active participation and trust in me
and in the process was even more important.
Phoebe ’ s fi rst session began gently. I followed
her lead as to what toys interested her most and
we began to build a story around those toys.
Following the child ’ s lead in the early moments
not only gains trust but also gives the session a
foundation. If I went in thinking only about the
types of sensation that should help her to regulate and organize herself, I would likely lose
her. But when we construct a story together
and then layer in activity and sensation based
in theory, the session is much more likely to
succeed.
To help Phoebe know that I was “on her
team,” I provided lots of choices early on. I
did not ask her to “repair” her language. Her
meanings were clear even if her words were not
precise. We were, in the early moments, just
gaining a sense of each other and how we would
work together. I was quick to scaffold her and
not leave her hanging too long in spaces created
by defi cits in language and processing. I did not
want to leave her too exposed too early. She
would have trouble trusting me if I did. Though
288 ■ PART IV Intervention
Phoebe initially blanched as she climbed
into the pillow stack and began to slip through
the pillows. My vocalizations matched her
slow-motion descent and helped her regulate,
perceiving the reality of the event rather than
the limbic “fear.” She was able to anticipate
the slow descent, and her anxiety was staved
off once again ( Fig. 12-3 ). Even so, it was
important to acknowledge that she looked a
little worried and check in with her about her
current state. She was okay and ready to try
again! I was feeling pleased at how the session
was unfolding. I had incorporated a fair amount
of movement and resulting vestibular sensation
into the activity while helping Phoebe remain
regulated. I purposefully mediated her anxiety
through therapeutic use of self and judicious
use of proprioception and deep pressure.
We were now halfway through the session
and I wanted to up the ante. My expectations
of what Phoebe could manage had increased.
I continued to embed the story that we had
FIGURE 12-1 A foundation of trust, close proximity,
and weaving “climbing the ladder” into the story
unfolding in our session helped overcome Phoebe ’ s
anxiety initially. Photo courtesy of Colleen Hacker.
FIGURE 12-2 At Phoebe ’ s instruction, I built up the
stack of pillows that she would use as a landing pad
to get down from the loft. Giving her control over
this strategy was crucial to maintaining trust while at
the same time empowering Phoebe to use her own
problem-solving. Photo courtesy of Colleen Hacker.
FIGURE 12-3 As Phoebe moved from the loft to
the stack of pillows, she did so slowly and with
great caution. I stayed close and matched her slow
movements with slower vocalizations to help her
regulate. Photo courtesy of Colleen Hacker.
we began, literally, with our feet fi rmly planted
on the fl oor and slightly uneven surfaces the
only challenge to posture, I moved forward to
bigger challenges within 15 minutes. Phoebe
and I had established a partnership by this time
and I knew that whatever cracks appeared in
the session, we would be able to repair them.
In moving forward to bigger challenges, Phoebe ’ s language defi cits worked in my favor. She
agreed before she quite understood and then we
were in it together. I put my efforts into moving
her through to the other side ( Fig. 12-1 ).
Of course, I did not just ask her to climb the
ladder; I wove the ladder into the story of the
session. Phoebe was halfway up the ladder
before her anxiety kicked in. Then she felt a
little paralyzed. I stayed immediately behind
to lessen her fear of falling. I pushed down on
her hips, hoping this input would help to keep
her calm and able to problem-solve. Although
her mother and a student occupational therapist
were present in the room, it felt like just me and
Phoebe. I whispered encouragement and more
of the “plot line” of the session. This created a
sense of complicity. She climbed the ladder to
the platform on top, moving through her fear.
Once up, she had to come down. I gave
her the power to choose how. Moving down
is often more frightening than moving up, so I
wanted her to feel in control. I kept her actively
engaged in problem-solving and transmitted my
belief that she could work this problem out. She
seemed to feel my belief in her, which helped
her to regulate in what would otherwise have
been a daunting situation. She directed me to
build the just-right stack of pillows so that she
could get down from the platform (which was 6
feet [2 meters] high! See Fig. 12-2 ).
CHAPTER 12 The Art of Therapy ■ 289
created early in the session into each new activity. I added a moving surface, very low to the
ground (a platform swing), and initially gave
Phoebe complete control over the type and
speed of movement ( Fig. 12-4 ). I also added
the possibility of “danger.” When Phoebe lost
her balance and stepped off the “slippery rock”
(a foam step placed on top of a mat), there
could be a “surprise.” Surprising her without
setting the stage would have blindsided her
and undone the trust we had built. Instead, I
helped her anticipate through foreshadowing.
I wanted the level of her arousal to go up. I
wanted her to feel a little bit worried. AND
I wanted her to handle it. When Phoebe lost her
balance and stepped off the rock, the promised
“dangerous surprise” occurred—but in slow
motion. I gave her lots of time to know I was
coming. I kept my body purposefully small and
made sure that I was not looming over her in a
threatening way. I kept her face-to-face as we
wrestled in the pillows. I never wanted her to
feel overpowered. She was always on top. As
we moved, I narrated each action, feeling like
a sports commentator; this kept her in the loop
and prevented her from overloading. I knew
her ability to modulate would improve only if
we could broaden the sensory experiences she
could manage. I had to build the experiences
in a safe way, with just enough intensity and
duration that she could escalate, contain it, and
recover. If I went too far, I would risk the relationship and my ability to help Phoebe interact
in an adaptive manner.
After all this excitement, I wanted to provide
more resistive input (proprioception) to help
Phoebe mediate her own arousal effectively. I
wanted her close to me in order that she could
draw on the trust we had built, so I used my
own body as the source of the resistance:
Phoebe got “stuck” on my lap. I played dumb
as to how this could have happened and made
it clear through my narration that I was trying
to be helpful to Phoebe in her attempts to free
herself. This increased the sense of complicity.
We were working together, not in opposition.
Phoebe ’ s confi dence continued to build. I now
wanted Phoebe to direct a situation that incorporated a little more intensity and risk taking. We
went back to the pillow mountain and “raced”
to the top once again to retrieve a desired toy
that was part of the game. I was less gentle with
Phoebe now, pushing against her as we struggled up the pillows. She responded in kind. She
seemed sure she could win and several times
announced “I ’ m doing it.” This was no small
feat from a little girl who, 45 minutes earlier,
had been fearful of stepping off onto the same
pillows. She was now tumbling with abandon
on the pile of pillows, trying to “win.” She did
win, of course. It was too early in our relationship to impose the idea of losing. However, I
am not a pushover! Phoebe worked for her win,
gaining empowerment as she went.
As the end of the session drew near, I
wanted to create a bigger movement demand
for Phoebe. She readily climbed onto the platform swing but immediately began to “boss,”
attempting to control the degree of movement allowed. We negotiated rotary vs. linear,
one-fi nger vs. two-fi nger pushes, and so on.
Occasionally, I threw in a surprise quick jolt.
She was upset by my change in the routine. I
immediately mirrored her upset face followed
by a deep, regulating breath. Through my
mirroring, she was “heard.” Because she was
heard, she attuned to me, and my breathing
helped her breathe deeply and regulate. She
did not like the jolting movements that I continued to introduce sporadically, but after the
fi rst one, she had no more overt fear responses.
I had taken her a little “over the edge” but
also provided strategies and space for her to
recover—and recover quickly. Time for the
session to close. I felt like Phoebe had taken
important steps. I wanted her to hang on to that
information. I wanted to mark it for her and
help her retell it. So together, we reconstructed
FIGURE 12-4 Providing decision-making control to
Phoebe allowed us to move to a more challenging
activity. Phoebe sits on a platform swing, suspended
close to the ground. Phoebe had full control over
speed, direction, type, and intensity of movement.
Photo courtesy of Colleen Hacker.
290 ■ PART IV Intervention
the sequence of the session and all of Phoebe ’ s
accomplishments. We did not leave out the
fact that she was sometimes worried. We did
include the resolution to each of those worries.
We used adjectives like “awesome,” “incredible,” “brave,” and “strong” to describe Phoebe
( Fig. 12-5 ). Her smile at the end of the session
was exactly what I ’ d been working for. It was
the smile that says, “This is about me. I did it. I
can do it. I own it.”
Phoebe continued in therapy for approximately 18 months. By the time she was in fi rst
grade, she no longer experienced the challenges
that had brought her to therapy initially. Her
language processing was up to speed. She was
excelling academically. She was no longer hesitant on playgrounds, though she still exercised
personal (and appropriate) judgment around
risk taking.
HERE ’ S THE POINT
• Artful therapists constantly evaluate a
child ’ s behavior and responses throughout
intervention sessions so that they can
effectively adjust their approaches and activities
to build a trusting relationship and to ensure
both they and the children are having fun.
• Through active refl ection, thoughtful
application, and readjustments of sensory
experiences, artful therapists optimize the
child ’ s level of arousal, motivation, and
readiness to engage in active play, and
successfully meet challenges.
The Artful Therapist:
A Good Playmate
What made this therapist a good playmate? Skillful playmates have at least three traits:
1. They read the cues of the child accurately
and respond with great skill.
2. They give unambiguous and appropriate cues
as to how the child should act toward them
in play.
3. They play as equals—engaged in give-andtake and not dominating the play.
In addition to being a playmate, the therapist
assumes a caregiving role. Within the session,
the therapist takes on a persona that says, “This
play and the things that you value are important.”
They set clear, but fl exible, rules. They ensure
that the child is physically and emotionally safe
( Skard & Bundy, 2008 ).
During the session, Phoebe ’ s therapist wore
all these hats—changing them without hesitation.
As a playmate, she read Phoebe ’ s cues vigilantly;
she gave out exaggerated cues, changing her
actions and persona as needed. She entered the
play enthusiastically. As a caregiver, she became
guide, narrator, empathic supporter, and cheerleader—without missing a beat. In all these roles,
she was convincing, knowing that Phoebe would
sense artifi ce or discomfort. Alongside her roles
as playmate and caregiver, Phoebe ’ s therapist
also paid close attention to sensory integrative
theory, considering less-than-obvious aspects of
sensation that affect the outcome of the session.
Even before she began the session, she refl ected
on what she had learned from assessment and the
way that she had framed the problem. As Schön
( 1983 ) suggested, she asked, “Can I solve the
problem I have set?” And, as she went along,
she refl ected in action. “Do I like what I get as
I attempt to solve the problem?” Knowing that
Phoebe felt anxious, especially in the context of
movement and when she was not completely in
control, the therapist asked repeatedly, “How is
this sensation (and this activity) affecting and
interacting with Phoebe ’ s emotions?” And, as
she fi nished, it is not diffi cult to imagine that
Phoebe ’ s therapist asked herself, as Schön suggested, “Have I made the situation coherent?
Have I made it congruent with my fundamental
values and with sensory integration theory? Have
I kept the inquiry moving?” (p. 133).
FIGURE 12-5 As our session came to a close,
Phoebe and I paused to refl ect on what had been
accomplished. Although acknowledging that she was
occasionally a bit worried, we celebrated her ability
to problem-solve and to conquer. Photo courtesy of
Colleen Hacker.
CHAPTER 12 The Art of Therapy ■ 291
Perhaps more important even than the equipment or the activities is the intensity of the
sensation created by the interaction between
therapist and child. For the child, sensation
interweaves with emotional state, yielding the
actions and behaviors that the therapist sees. A
thoughtful approach to the sensations embedded
in the interaction is, therefore, part of the art
of therapy. The therapeutic use of self, in this
case the ability to nuance sensation embedded
within the interaction, creates an environment
that promotes change. The therapist responds
mindfully to sensory events in order to “guide”
the child ’ s reaction, helping the child “mirror”
a mediated response. We think of this as “coregulation.” In mirroring the therapist ’ s regulated state, the child comes to associate sensation
with positive emotions. There are many ways
for the therapist to nuance the sensation, partner
empathetically with the child, and sustain the
fl ow of the session. In the section that follows,
we hope to help readers refl ect on the decisions
that Phoebe ’ s therapist made (and that readers
make) about sensation that are embedded in the
therapeutic interaction—beyond the enhanced
sensation that is inherent to sensory integration
(SI) theory.
Vision
Assuming the perspective of a child, consider the
visual input created by the therapist. This is more
than physical appearance; it is about the visual
“feel” created by all aspects of the therapist ’ s
presence. A therapist can communicate with a
child without saying a word, through subtle facial
expressions. The therapist holds expressions long
enough for a child slow to process nonverbal
information to read them. The therapist can also
mirror the child ’ s facial expressions. If the child
seems to feel confronted by too much face-toface contact, the therapist can move subtly in and
out of the child ’ s visual fi eld. All these strategies
support a co-regulated, mutually engaging, collaborative treatment experience. In refl ecting in
and on action, the therapist can ask, “Did my
body language look inviting or imposing? Did I
look relaxed and open to ideas? Was my facial
expression suitably warm and engaging, or did
it feel remote and disinterested? How did the
impact of the size differential between me and
the child inhibit or facilitate the therapeutic
partnership and the child ’ s taking control? Did
my actions seem big and looming? Or did I minimize the size difference and, thus, the power
differential?” Phoebe ’ s therapist made a conscious decision to diminish her size—walking
on her knees to “surprise” Phoebe. She used
exaggerated facial expressions so that Phoebe
knew her fears were “heard” and to help her
co-regulate.
Auditory
The auditory environment is complex and has
a marked effect on the tone of a session. The
therapist ’ s voice is an important aspect of the
auditory environment. Volume, intonation, and
prosody (i.e., tune and rhythm of speech) all contribute. In varying volume, a therapist can draw
the child into partnership. Changes in volume
can be powerful. Sometimes a whisper denoting
collaboration and conspiracy (i.e., “it ’ s you and
me”) is more effective than a shout—as it was
with Phoebe. Tone and prosody also help a child
understand which “hat” the therapist is wearing.
A just-right amount of novelty and contrast
facilitates attention to a task. A therapist ’ s language, although not purely auditory input, also
contributes to the just-right challenge and supports regulation. Words are powerful, and children readily associate them with emotion. The
therapist ’ s words must invite the child toward
mastering rather than impart judgment. Sometimes simply changing one word can change the
whole message. “Can you think of another way
to do that?” is far less judgmental than “Can you
think of a better way to do that?” Quantity of
language is also important; less defi nitely can be
more. Sometimes a simple “hmmmm” or raised
eyebrow communicates more than an in-depth
explanation. Pace and rhythm of language are
also important. Slow rhythmic vocalizations
or verbalizations promote calming, timing, and
sequencing within an activity. Changes to rhythm
promote alertness and can add an element of surprise to an activity. Consider how Phoebe ’ s therapist used all aspects of language to help Phoebe
regulate emotions.
Tactile
Touch can feel supportive, empowering, regulating, or punitive. A therapist can impart feelings
292 ■ PART IV Intervention
of nurturing by cocooning, as Phoebe ’ s therapist
did on the ladder and later in “trapping” Phoebe
on her lap, or empowering, with a gentle tap on
the shoulder. A child inevitably interprets touch
as refl ecting the intent of the person administering it. Thus, the therapist must continually refl ect
on the effects of touch on arousal and well-being.
Touch must always be in line with the recipient ’ s
sensory profi le. A child with challenges modulating sensation may interpret even incidental
touch, from a therapist or equipment, as dangerous and become hypervigilant rather than engaging in the play.
Proprioception
Children often seem driven to generate proprioception. However, although intrinsically motivated, sensory seeking does not always yield
improved organization. Further, proprioception
can be either calming or alerting. Thus, the artful
therapist monitors both the quantity and quality
of proprioception provided during a session.
Endless “heavy work” opportunities are desired
only if they support engagement and function.
Phoebe ’ s therapist used her own arms and legs
to “trap” Phoebe on her lap. Extricating herself
from the cocoon created by the therapist ’ s body
yielded proprioception as Phoebe pushed against
the therapist ’ s arms and legs. Because she used
her own body, the therapist could feel Phoebe ’ s
resistance and adjust her own body as needed to
ensure a just-right amount of proprioception and
also a just-right challenge.
Vestibular
There are many more considerations to providing vestibular sensation than simply choosing a swing that provides the optimal kind of
movement to promote posture or motor planning. The power of vestibular input means that
it is particularly important for the therapist to
help the child maintain a “just right” arousal
state while challenging movement. The therapist might move with the child through space,
serving as a container (e.g., the therapist rolling
together with Phoebe down the mountain of
pillows). The therapist might also be the agent
that helps control speed, direction, and rhythmicity of vestibular input as Phoebe ’ s therapist
did with the platform swing. The therapist ’ s own
movements must be graded in order to give the
intended message and infl uence the child ’ s level
of arousal in a desired way. Rhythmicity and
timing contribute to predictability and assist
the child to anticipate. Although surprise can be
highly motivating for some children, the therapist must grade the degree of predictability and
be mindful of the amount of surprise that a child
can manage—as Phoebe ’ s therapist did. Successful therapy is about pushing against a child ’ s
limits in order to expand possibility; however,
each child has limits and an optimal range of
tolerance and the therapist must refl ect on these
continually.
HERE ’ S THE POINT
• Artful therapists have mastered ways of
applying “therapeutic use of self” so that
children feel and are emotionally and
physically safe.
• They read the cues of children accurately and
respond skillfully by providing unambiguous
and appropriate cues as to how children should
act toward them in play, and they engage as
equal play partners.
• Artful therapists consider how visual, vestibular,
tactile, proprioceptive, and auditory sensory
input can be tailored to meet the child ’ s
sensory needs, enhance play skills, and
address the child ’ s therapy goals throughout
intervention sessions.
Play as the Basis of Sensory
Integrative Therapy
Therapy sessions comprise a special kind of play
between a child and an adult playmate in which
the child is afforded opportunities for enhanced
tactile, vestibular, and proprioceptive sensation.
But how does a therapist ensure that a session
is playful? What is play? In this section, we
defi ne play and examine each of the elements.
In defi ning play, we draw from Neumann ( 1971 ),
an educator, and Bateson ( 1972 ), an anthropologist. Finally, we fi rmly embed sensory integrative therapy in play, suggesting that fully half of
the process elements that Parham and colleagues
( 2011 ) described as essential to SI are, in fact,
elements of play.
CHAPTER 12 The Art of Therapy ■ 293
Defi ning Play
Neumann ( 1971 ) described three criteria for play:
relative internal control, intrinsic motivation,
and freedom to suspend reality. She considered
that transactions containing all three fell toward
the play end of a play–non-play continuum. In
Figure 12-6 , we illustrate Neumann ’ s conceptualization of the three elements of play contained
within a picture frame. The notion of the frame
came from Bateson ( 1972 ) who described the
cues that set play apart from real life as similar
to the way a picture frame separates a painting
from the wall. We, thus, propose the following
defi nition of play:
Play is a transaction that is relatively intrinsically motivated, relatively internally controlled,
free of many of the unnecessary constraints of
objective reality, and that is demarcated by clear
cues, separating play from the rest of everyday
life (i.e., framed clearly as play).
Play that comprises sensory integrative therapy
occurs between a child receiving the therapy
and an adult therapist playmate. For therapy to
be effective, both must be playing; that is, both
must feel relative intrinsic motivation and internal control and both must be free to suspend
some aspects of reality. However, in addition to
playing, the therapist is also assuming a presence
that says, “This is play and play is important”; by
framing and reframing the problems that constitute the session and judging the extent to which
the solutions are congruent with theory and experience, the therapist is refl ecting in action.
Play Element 1: Relative
Intrinsic Motivation
Intrinsically motivated activities are done for their
own sake—for the pleasure of engaging in them.
A child in therapy is not engaged in the activities
to reduce the sensory integrative dysfunction;
because someone asked the child to do them;
or to gain any external reward—even winning
( Ryan & Deci, 2000a, 2000b ). Nonetheless,
winning is sometimes important—as it was for
Phoebe climbing the pillow mountain. Intrinsic
motivation is almost universally acknowledged
as an essential element of play (e.g., Rubin,
Fein, & Vandenberg, 1983 ; Sutton-Smith, 1997 ).
But that does not mean a child or a therapist has
no extrinsic motivation in the session. Children,
for example, often enjoy accruing points when
they hit a target. However, the fun of engaging in the activity—not the points—is the most
important part. Even if there were no points, the
child would still enjoy hitting the target. Therapists are motivated by minimizing the discrepancies that confront the child with whom they
are working—an extrinsic motivator—but for
the time they are engaged in a therapy session,
intrinsic motivators are also very important. The
therapist must be having fun, too; if a therapist is
not playing, the child will not be playing.
Activities are intrinsically motivating for different reasons. Numerous authors (e.g., Ayres,
1972 ; Deci & Ryan, 2000 ; Neumann, 1971 ;
White, 1959 ) emphasized the link between motivation and inner drive or mastery. Relatedness or
social interaction is another common motivator
(e.g., Csikszentmihayli, 1975a ; Deci & Ryan,
2000 ), as is pure sensation ( Caillois, 1979 ).
Sources of intrinsic motivation vary from person
to person ( Csikszentmihayli, 1975a ). We seek to
co-create activities that capture the motivations
of both child and therapist. Phoebe was motivated by the story she had co-created with the
therapist, a giant stuffed snake that she carried
with her in all the activities, and the sense of
accomplishment and relatedness she shared with
the therapist. The therapist too was intrinsically
motivated to engage in the play acting and silliness that characterized the activities. When the
therapist and child are intrinsically motivated,
they can become totally involved in the activities. Csikszentmihayli ( 1975a, 1975b, 1979,
1990 ) referred to this involvement as “fl ow.” In
FIGURE 12-6 The elements of play. studying thousands of people who described fl ow
Internal Control External
Play
Nonplay
Intrinsic Motivation Extrinsic
Free Reality Not free
294 ■ PART IV Intervention
experiences, Csikszentmihayli uncovered traits
of activities that enable fl ow, including clear,
unambiguous feedback that is a part of the activity. Clear, immediate, unambiguous feedback is
inherent to activities used in sensory integrative
therapy. Children know immediately if they have
hit a target or jumped to the desired spot. There
is little, if any, need for the therapist to comment
on success ( Ayres, 1972 ). Phoebe clearly knew
when she made it to the top or the bottom of
“pillow mountain” and when she succeeded (or
failed) at maintaining her balance on the “slippery rocks.”
Persistence, even in the face of signifi cant
obstacles or challenges, is another sign that a
child is intrinsically motivated. Children repeat
activities that present a “just-right challenge”
just as Phoebe required only a few activities to
become totally engaged for the hour-long session.
Therapists sometimes feel compelled to carry out
several activities in a session; however, interrupting an activity in which a child is totally engaged
is very disruptive to fl ow. And, learning a new
skill can require thousands of repetitions. There
are no “rules” about how many activities should
be done in a session or how long each activity
should last, but a small number of activities
with seamless transitions is a mark of an artful
session. Some activities pull for enthusiasm, exuberance, and manifest joy, which may be signs of
intrinsic motivation. But sometimes a child is too
engrossed to exhibit laughing, smiling, or other
signs commonly associated with “fun.” Much
can be learned by keeping track of activities in
which children become totally involved. Careful
analysis of such activities yields important information about the sources of the particular child ’ s
intrinsic motivation.
Finding Inner Drive
Ayres ( 1972 ) wrote that the ultimate goal of
sensory integrative therapy is a child who directs
his or her actions meaningfully and with satisfaction. Because sensory integrative therapy
is fun and seems to tap a common source of
motivation, children generally engage readily.
However, occasionally, a child balks, as Phoebe
did, at activities that involve skilled movements
or enhanced sensation. Then, especially, we
endeavor, as Phoebe ’ s therapist did, to fi nd that
child ’ s inner drive. In our experience, “lack of
motivation” usually means one of two things:
• The activity is too diffi cult or the child
believes it is too diffi cult.
• The child ’ s level of arousal is not optimal.
When an activity is too diffi cult or a child
believes it is, the therapist modifi es the demands
or gives the child additional support. Phoebe
thought several of the activities were too hard,
and the therapist negotiated and enticed in a
playful way. The therapist supported Phoebe from
behind as she climbed the ladder. She offered a
choice between one- and two-fi nger pushes on
the platform swing. She kept up a running story
line starring the large stuffed snake. Enticing
Phoebe or any child to attempt a task is not about
entering into a “power struggle.” The purpose of
enticing Phoebe to continue was to help her discover new skills and how capable she really was,
not for the therapist to be in control. If children
have trouble becoming completely engaged in an
activity, it may be because their level of arousal
is not optimal. Some children whose arousal
level is too high seek or need protected space
and calming activities (e.g., deep pressure or oral
motor activities). Phoebe ’ s therapist described
her as anxious and fearful, suggesting her level
of arousal was too high. Thus, her therapist
engaged her in several activities with calming
components. But she did not simply seek to calm
her. As the therapist said, “I had taken her a little
‘over the edge’ but provided strategies and space
for her to recover—and recover quickly.”
Other children seem to need intense sensation to attain an optimal level of arousal. When
engaged in activity that provides intense vestibular and proprioceptive sensation, they come
“alive.” Another child, Emily, showed signs of
tactile defensiveness, especially with regard to
clothing. Wanting to make Emily ’ s intervention
as effi cient as possible, her therapist created activities that provided a lot of enhanced tactile sensation. Emily dug in a ball pit, crawled through
a large stockinette tunnel, and played in shaving
cream with her hands and feet. But something
did not seem quite right; the indicators that Emily
was totally engaged were just not present. When
her therapist decided to take another tack, things
changed dramatically. Emily chose to stand on
the glider. The therapist created a “storm” and
gave Emily a rough ride. Periodically, “whales”
(i.e., therapy balls) swam underneath the swing,
causing it to move in unexpected ways. Emily
CHAPTER 12 The Art of Therapy ■ 295
became more animated, directing the therapist
and altering the activity in subtle ways. Although
Emily ’ s tactile defensiveness suggested her
level of arousal was too high, the therapist soon
learned that appearances can be deceiving. Therapists must constantly be aware that therapy is
based on hypotheses; we are constantly looking
for evidence that the hypothesis is incorrect and
that we should alter our approach.
Play Element 2: Relative
Internal Control
Neumann ( 1971 ) believed that relative internal
control is the most important element of play.
Children who feel internally controlled can act
on their motivations by determining how to
play. They are free to suspend some constraints
of reality by transforming objects or themselves
into something different or by bending some of
the usual rules. Clearly, relative internal control
is a critical aspect of play.
In 1988, Jane Koomar and Elise Holloway
made a videotape of Jean Ayres involved in
therapy with an almost 4-year-old child named
Ray. The account of this session, drawn from the
preface of the second edition of Sensory Integration: Theory and Practice ( Bundy & Lane,
2002 ), is an excellent example of Jean Ayres, a
master therapist, whose style was reserved and
step-back, giving control to a child. The session
began with Ray sitting inside a tire tube atop a
platform swing, pulling on handles to make it
move. Within a few moments, Ray held his arms
out to Jean using the age-old gesture that means,
“Pick me up.” The overall impression was of a
very young child. Jean, however, did not pick
Ray up. Instead, she showed him where to place
his leg and facilitated his active movement. In
effect, she nonverbally said, “You do it yourself.
I ’ m here to help.”
Jean and Ray moved from one activity to
another. Each time, he tried to get her to “rescue
him” and each time she gently, fi rmly, and nonverbally insisted that he take control. Ray got on
a “horse swing” suspended from the ceiling by
two points, but it was too great a challenge to
his poorly developed postural mechanism and he
tried to throw himself off onto the mat below.
Jean gently placed his hands back on the horse
and held it to make it more stable. “Give it a
good try,” she seemed to be saying. After a few
moments, she helped him get off by facilitating
his movements again. Within 20 minutes, Ray
had gotten on and off no fewer than six pieces
of equipment. He seemed unable to get really
involved with any of the equipment for more
than a few moments. Jean followed his lead—
always facilitating rather than doing for him.
At one point, Ray stood on a vibrating platform
and Jean offered to brush him using a soft, fl at
paintbrush, but Ray said, “No.” And something
about the way he said it suggested that he was
taking control. Although it had once seemed that
the session might never get underway (which I,
as an experienced practitioner, found oddly comforting), that was no longer the case. A remarkable transformation was taking place: Ray shed
his babyish ways before my eyes.
Ray ’ s growth began surreptitiously but accelerated. He got involved in a game in which he
drove a pretend truck along a makeshift road to
deliver packages to Teresa, the therapist assisting Jean. In his actions and limited words, Ray
became a deliveryman. And the game continued for 15 minutes or more with Ray becoming
more and more assertive. At one point, when
Teresa told Ray that he had room for only two
packages, Ray screeched, “No, no, no, no!” at
the top of his lungs. A sturdy truck driver had
replaced the passive child who had begun the
session.
Balancing Freedom with Structure
Because a child feels in control does not mean
that therapy lacks structure. Ayres ( 1972 ) wrote,
Free play does not inevitably, in itself, further
sensory integration, but too rigid structure will
inhibit the manifestation of potential. . . . Structure may push the child further toward the therapeutic objective than he can reach alone but
too much will defeat its purpose. (p. 259)
Sensory integrative therapy is a special kind of
play. To play, a child must feel in control. But,
because a child feels in control does not mean
therapy is chaotic. Although children are encouraged to initiate and express preferences and
interests, the therapist alters the activities and the
challenge both to help the child succeed and to
be sure the intervention promotes increasingly
complex adaptive behaviors. Had Phoebe been
left on her own to decide exactly what to do and
how to do it, she might have asked the therapist
296 ■ PART IV Intervention
to read her a story. Instead, Phoebe and the therapist acted out a story that they had co-created. The
story involved climbing a “dangerous mountain”
and coming back down again. It involved being
on a boat and rescuing objects from the sea and
stepping across “slippery rocks” without falling
in the water. The story required that Phoebe
be the actor. The therapist, as supporting actor,
coached Phoebe through physical and verbal
prompts as well as slight alterations that served
to scaffold ( Ayres, 1972 ; Dunkerley, TickleDegnen, & Coster, 1997 ; Tickle-Degnen &
Coster, 1995 ). The art was in the balance between
freedom and structure.
Play Element 3: Freedom from Some
Constraints of Reality
In play, children feel free to transform themselves, and activities, into anything they desire
( Neumann, 1971 ). That transformation in the
context of pretend or imaginative play is the
most obvious manifestation of freedom from
unnecessary constraints of reality ( Neumann,
1971 ; Parham et al., 2011 ; Rubin et al., 1983 ;
Sawyer, 1997 ). One of the “paradoxes of play”
( Bateson, 1972 ) is represented in a child ’ s transformation, for example, of a bolster swing into a
horse and himself into a rodeo rider. In making
both himself and the swing into something that
they are not (a horse and a rider), the therapeutic activity takes on “real” meaning for the child.
This increased meaningfulness probably would
not have been present if the activity consisted
only of the child, as himself, trying to stay on
the swing as long as possible while the therapist
shook it.
Relative freedom from unnecessary constraints of reality involves more than pretend.
For children with sensory integrative dysfunction, objective reality commonly presents many
constraints, not the least of which may be fear
of moving or fear of being touched. Gravity
also presents an inordinate constraint to children
whose muscle tone or posture is not adequate
to resist it or who fear falling or being out of
an upright position. Complex toys may inhibit
a child whose motor planning skills are poor.
A therapist seeks to orchestrate intervention so
that constraints are minimized. In creating a safe
environment free of constraints or consequences
that prevent a child from succeeding in “real
life,” reality is temporarily suspended and both
play and therapeutic gain are facilitated ( Vandenberg & Kielhofner, 1982 ).
Similar to Phoebe ’ s therapist, most therapists
who work routinely with children are relatively
comfortable with and quite skilled at participating in pretend play frames and adjusting the
physical environment to minimize the negative
consequences of sensory integrative dysfunction.
However, other aspects of suspending reality
may be more diffi cult. For example, playful mischief is an aspect of suspension of reality that
sometimes makes adults uncomfortable. Mischief involves breaking the usual rules. Squirting
an adult with a squirt gun, hitting an adult with
a pillow, or jumping off a table are not allowed
in most situations. Certainly, they would not be
allowed in therapy if children were doing them
maliciously. However, we must distinguish
between meanness, maliciousness, and playful
mischief. Playful mischief requires skill and is
done with a sparkle in the eye ( Skard & Bundy,
2008 ). Perhaps because children perceive them
as “naughty,” mischievous acts can be highly
motivating. Another benefi t of playful mischief is
that it provides opportunities to learn that certain
behaviors are okay at some times but not okay
at other times. Reading the cues that allow one
to match behaviors to circumstances is a worthwhile goal for many children.
Play Element 4: Framing
Framing is about giving and reading cues that
tell players how to treat one another in play.
Sometimes cues are verbal, “Let ’ s play . . .,”
but, more often, they are nonverbal (e.g., hitting
gently so as not to hurt your playmate in a play
fi ght). When players respond skillfully to the cues
of a playmate, they increase the likelihood that
all players will have fun. Developing the ability
to read cues and support a playmate ’ s play likely
requires a specifi c intervention. Wilkes-Gillan
and colleagues ( Cantrill, Wilkes-Gillan, Bundy,
Cordier, & Wilson, 2015 ; Wilkes-Gillan, Bundy,
Cordier, & Lincoln, 2014a, 2014b ; WilkesGillan, Bundy, Cordier, Lincoln, & Hancock,
2014, 2015 ) described innovative interventions
with children with attention defi cit-hyperactivity
disorder (ADHD) designed to improve play
by helping the children respond to playmates’
cues and support their play. Wilkes-Gillan et al.
CHAPTER 12 The Art of Therapy ■ 297
( 2014a, 2014b, 2014, 2015 ) used three primary
strategies:
1. Playing with the children in the clinic,
modeling supportive play.
2. Review and analysis of videotapes of the
children playing with a regular playmate,
done together with the children.
3. A home-program that involved a videotape of
an alien learning to play as an Earthling.
Reading cues is critical to success as a player
outside of the supportive environment of the
clinic, and children with sensory integrative dysfunction often seem to have diffi culty reading
cues. Reading play cues is not a construct associated with sensory integrative therapy, but therapists might consider building it into the play that
is a part of all sessions.
Particularly in the early stages of therapy,
Phoebe ’ s therapist was closely attuned to
Phoebe ’ s cues. She was a vigilant observer,
deciding exactly how far to push to get the best
from Phoebe. However, it is unlikely that Phoebe
was capable of reading subtle play cues from
the therapist. Thus, the therapist made it easier
by exaggerating her cues. When Phoebe took a
long time to climb the ladder, the therapist began
snoring. When Phoebe complained that the platform swing was moving too much, the therapist
put on a very innocent face and, using a voice
that suggested she just did not believe Phoebe ’ s
complaint, said, “But it was a one-fi nger push. ”
Likely as Phoebe moved through the therapy
process, she would have required the therapist to
exaggerate her cues less.
HERE ’ S THE POINT
• Play is the essence of childhood and of SI
intervention.
• Play is intrinsically motivating, relies on the
child ’ s inner drive, and allows the child to be
and feel in control.
• Play in the context of intervention involves a
careful balance of freedom from rules and the
constraints of reality, with some subtle (and
unobtrusive) structure and framing by the
therapist.
• Being playful with children, and watching them
flourish through play with us, is what makes
our work so enjoyable, satisfying, and effective.
Play and Fidelity to Treatment
Fully half of the process criteria that Parham and
colleagues ( 2011 ) listed as defi ning sensory integrative therapy in their Fidelity Measure pertain
to therapy as play and the therapist as a skilled
playmate and promoter of play. Not surprisingly,
all of Parham and colleagues’ ( 2011 ) key strategies describe ways of helping the child feel
internal control. For example, “providing structure and support for adaptive responses while
allowing the child to be actively in control as
much as possible” (p. 14) is the key issue for
“collaborates in activity choice.” Ayres ( 1972 )
and others ( Lane, Smith Roley, & Champagne,
2013 ; Stackhouse, 2014 ) have called an adaptive
response one that is just a little better, easier, or
more spontaneous. The tie between motivation
and challenge is clear.
Tailoring activity to present the just-right challenge also speaks to helping a child feel control.
Numerous theorists ( Ayres, 1972 ; Csikszentmihayli, 1975a, 1975b, 1990, 1993, 1996, 1997 ;
Poulsen, Rodger, & Ziviani, 2006 ) have indicated that all of us become most involved when
we reach to the ends of our capabilities. Perhaps
refl ecting the intense engagement that accompanies a just-right challenge, Dunkerley and
colleagues ( 1997 ) observed what appeared to
be “working” rather than “playing.” They also
observed that the children appeared “somewhat
anxious” (p. 804), which Neiss ( 1988 ) explained
by saying that a certain level of anxiety may be
needed to perform at peak. Shaping the justright challenge can be diffi cult. Ayres indicated
that these optimum-for-growth moments that
allow the child to experience mastery ( Ayres,
1972 ) are often embedded within moments of
fun and moments of failure. Over-challenges
allow children to experience failure without
dire consequences (also a trait of play). Ensuring success, another process criteria in Parham
and colleagues’ Fidelity Measure, does not mean
that a child never fails to hit a target. In fact, we
all would become quite bored if every attempt
yielded success.
Feeling physically and emotionally safe is a
very basic aspect of internal control, and Parham
and colleagues ( 2011 ) listed it as an important
strategy for “establishing a therapeutic alliance.”
In therapy, unlike in “real life,” children can
joyfully leap off surfaces and swing through the
298 ■ PART IV Intervention
air, all the while feeling safe. They are fi rmly
ensconced in a supportive net hammock, and the
surfaces below them are covered in thick foam
padding. But feeling safe, similar to ensuring
success, does not mean that a child will never
fall down ( Csikszentmihayli, 1975a, 1990, 1993,
1996 ). The artful therapist remains near enough
to be involved (and prevent serious accident), yet
far enough away to promote self-direction and
give the message that the child is capable. The
art lies in knowing how much support and when.
Summary and Conclusions
The most effective intervention refl ects a partnership between art and science. As in all good
partnerships, the relationship is fl uid. One may
predominate for a time, but both make equal
contributions in the long run. Whereas science
is associated explicitly with knowledge and
theory ( Mosey, 1981 ), art seems intuitive, ethereal. Science allows us to situate a session in the
proper constructs of SI theory. Art is fl uid and
allows for the ever-adapting activity required to
meet the moment-by-moment needs of a child
( Creighton, Dijkers, Bennett, & Brown, 1995 ;
Peloquin, 1989, 1998 ). Peloquin ( 1989 ) indicated that art is the soul of occupational therapy
practice. Art transforms therapy. “Without art . . .
occupational therapy would become the application of scientifi c knowledge in a sterile vacuum”
( Mosey, 1981 , cited in Peloquin, 1989 , p. 220).
Artist Alex Grey ( 1998 ) wrote, “The artist ’ s
mission may not ever be reduced to words or
rationally understood, but its invisible magnetizing presence will infuse an artist ’ s work completely” (p. 10).
Peloquin ( 2005 ) concluded, as we do, that
“Grains of sand and waves of sea together
make seaside. Seaside would not be if one were
gone” (p. 619). “Effective practice is artistry and
science” together (p. 613).
Where Can I Find More?
Ayres, A. J. (1972). The art of therapy. In A.
J. Ayres, Sensory integration and learning
disorders (pp. 256–266). Los Angeles, CA:
Western Psychological Services.
In her original book on SI, Ayres clearly articulates that therapy is both art and science.
This chapter describes the art that is needed to
support organization of the brain.
Skard, G., & Bundy, A. C. (2008). Test of playfulness. In L. D. Parham & L. S. Fazio (Eds.),
Play in occupational therapy for children
(2nd ed., pp. 71–94). St. Louis: Mosby.
This chapter contains more information on
observing and promoting play and playfulness.
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Wilkes-Gillan , S. , Bundy , A. , Cordier , R. , & Lincoln ,
M. ( 2014a ). Eighteen-month follow-up of a
play-based intervention to improve the social
play skills of children with ADHD. Australian
Occupational Therapy Journal, 61, 299 – 307 .
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Wilkes-Gillan , S. , Bundy , A. , Cordier , R. , & Lincoln ,
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play-based intervention for children with ADHD.
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Wilkes-Gillan , S. , Bundy , A. , Cordier , R. , Lincoln ,
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ADHD and their playmates. Developmental
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300
CHAPTER
13
The Science of Intervention:
Creating Direct Intervention
from Theory 1
Anita C. Bundy , ScD, OT/L, FAOTA, FOTARA ■ Stacey Szklut , MS, OTR/L
Chapter 13
The child ’ s sense of fulfi llment radiates as he . . . pits himself against gravity
and fi nds that it is not quite the ruthless master it was a short time
before. . . . He is no longer the impotent organism shoved about
by environmental forces; he can act effectively on the world.
—A. Jean Ayres ( 1972 , p. 262)
Intervene: To come between as an infl uencing force.
—Webster ’ s New World Dictionary
Upon completion of this chapter, the reader will be able to:
✔ Apply sensory integrative theory to the creation
of intervention activities.
✔ Generate intervention activities to improve
performance of children with specifi c sensory
integrative disorders.
✔ Integrate practical considerations for practice,
including length of sessions and physical
environment, into the design of treatment
activities.
LEARNING OUTCOMES
Purpose and Scope
In this chapter, we describe the creation of therapeutic activities that directly refl ect sensory
integration (SI) theory: the science of intervention. We present a variety of therapeutic
activities designed to link enhanced sensation
together with a just right challenge in order to
ameliorate particular diffi culties associated with
sensory integrative dysfunction. Rarely does any
therapeutic activity meet only one objective.
The diffi culty is to determine which, of all the
possible applications an activity might have, is
most appropriate for this child at this particular
point in intervention and on this particular day.
Because we frequently alter activities as we
go, we must always have a clear idea of what
we hope to achieve in order to adapt activities
appropriately. To stay true to the science of
sensory integrative therapy, we rely heavily on
the model that depicts the theory. We presented
this model in Chapter 1 (Sensory Integration: A.
Jean Ayres’ Theory Revisited) and reprint it here
1
Suspended equipment is a hallmark of sensory integrative therapy.
Throughout this chapter we refer to several pieces of suspended
equipment. The chapter is sprinkled liberally with photographs of
suspended equipment. The Appendix to this chapter also provides
a list of equipment vendors.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 301
(see Fig. 13-1 ). Throughout this chapter, we will
refer to this model as a continual reminder of the
link between enhanced sensations and desired
therapeutic outcomes.
The science of sensory integrative therapy
helps us tailor the just-right challenge and the
expected adaptive responses to the particular needs of a child. These are key elements of
sensory integrative therapy ( Ayres, 1972 ; Lane,
Smith Roley & Champagne, 2013 ; Stackhouse,
2014 ). That is, in therapy, a child is enabled to
respond adaptively to tasks and environmental
demands at the highest level possible ( Smith
Roley, Mailloux, Miller-Kuhaneck, & Glennon,
2007 ) in ways determined through rigorous
assessment. Activities refl ecting the just-right
challenge are motivating and engaging because
they match the child ’ s interests and the child can
master them using focused effort ( Case-Smith,
2010 ). In addition, problem-solving and the
ability to make ongoing adjustments to a motor
strategy are important components of an adaptive
response.
Parham and colleagues ( 2007 ) defi ned
10 process elements of sensory integrative
therapy. These elements can be divided roughly
into two categories: those that primarily support
science and those that primarily refl ect art. In
Chapter 12 (The Art of Therapy), we addressed
the process elements associated with art. Here
we address those that most closely refl ect the
science of intervention. Thus, the focus in this
chapter is on creating and modifying therapeutic
opportunities that (a) support self-regulation and
sensory awareness; and (b) challenge postural
ocular control, bilateral integration, conceptualizing and planning novel motor tasks, and organizing behavior. Our goal here is to contribute to
readers’ abilities to apply SI theory by providing
ideas for meaningful activities to ameliorate specifi c aspects of sensory integrative dysfunction.
We fi rst present a brief case of a child with
diffi culties common to many who experience
sensory integrative dysfunction. We follow the
case with sections on enhanced sensation and
intervention for diffi culties with sensory modulation and praxis. We then address intervention
to promote sensory discrimination. Finally, we
offer a section on practical considerations for
intervention.
FIGURE 13-1 A schematic representation of sensory integration theory.
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
302 ■ PART IV Intervention
CASE STUDY ■ SAM
Seven-year-old Sam is struggling to participate
successfully in a variety of contexts. He is hesitant to join novel social situations, often clinging to his mother ’ s leg. But, once engaged, Sam
tends to “ramp up” quickly. The pitch of his
voice rises, his activity level increases, and he
becomes “pushy and aggressive” toward others.
Play dates and birthday parties often end, for
Sam, with a “meltdown” that can last up to
20 minutes.
In school, Sam slumps, leans excessively,
and, occasionally, falls out of his chair. He
fi nds it hard to keep up with peers in activities
that involve motor skills. Handwriting is a particular challenge. Sam has diffi culty orienting
his pencil in his hand for optimal use; he uses
a tight pencil grasp and writes with too much
pressure, frequently tearing his paper.
To most observers, Sam looks clumsy. He
has diffi culty kicking, throwing, and catching
a ball and navigating safely and effectively
through space, particularly with moving objects
or people. He cannot ride a bicycle without
training wheels and still descends stairs one
foot at a time. During gym class, Sam is often
seen fl opping onto the ground or crashing into
other children. At recess, he tends to hang back
and watch the other children, or he incites them
to chase him. Chasing frequently ends with
Sam falling and hurting himself or pushing
another child down.
Sam ’ s mother reports that Sam was much
slower than his siblings in developing independence for daily tasks, such as getting dressed,
brushing his teeth, and using utensils. He is
picky about the clothes he wears and foods he
eats. He often complains that clothes are too
scratchy and tooth brushing “hurts.” The sight
of some foods causes him to throw a tantrum in
anticipation of the taste or texture.
Sensory Integration and Praxis Test (SIPT)
scores and clinical observations revealed somatodyspraxia (SD) that stems from poor processing of vestibular, proprioceptive, and tactile
sensations. Sensory Processing Measure (SPM)
results suggested mild over-responsiveness to
all forms of sensation that seem to contribute
to, but not fully explain, his poor regulation.
Based on the model presented in Figure 13-1
and the Ayres Sensory Integration © Fidelity
Measure (ASIFM) that appears in Chapter 14
(Distilling Sensory Integration Theory for
Use: Making Sense of the Complexity), we
will co-create activities with Sam that provide
opportunities for him to take in enhanced
tactile, vestibular, and proprioceptive sensation
in the context of activities that challenge his
postural–ocular control and motor planning at
appropriate levels (i.e., the just right challenge).
We will monitor his ability to attain and maintain appropriate levels of arousal in the face of
enhanced sensation, but even more pertinently,
provide challenges to his posture and motor
planning. We describe such activities in the relevant sections that follow.
Providing Opportunities
for Enhanced Sensation
Sensory integrative therapy is characterized
by enhanced sensation gained through active
engagement in meaningful activities (i.e., play).
Specifi c sensations are selected according to
the intended goal (see Fig. 13-1 ). The essence
of sensory integrative therapy is that enhanced
sensation derived from active movement, when
carefully matched to a child ’ s needs and state,
(a) helps with regulation of arousal to support
engagement and (b) enhances body schema and
postural control for improved motor planning.
In a nutshell, sensory integrative therapy comprises enhanced sensation and active engagement in carefully created, playful activities. In
SI theory, enhanced sensation generally refers to
proprioception, vestibular, and tactile sensations.
See also Chapter 4 (Structure and Function of
the Sensory Systems) for in-depth information
about the specifi c inputs received and interpreted
by each system. Here we provide only a brief
summary.
Proprioception is received by receptors in
the muscles and, to a lesser extent, the joints.
Muscle receptors are activated in response to
resistance, whereas joint receptors are activated
in response to joint movement. Proprioception
contributes to body scheme and our knowledge
of position in and movement through space. Poor
processing of proprioception results in diffi culty
judging the timing of movement and the amount
of force needed for a task. It also leads to diffi -
culty determining the angle of joints and thus the
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 303
relative position of body parts. Sam has a tight
pencil grip and utilizes too much pressure when
writing. His clumsiness might be a function of
poorly timed movements, or inadequate knowledge of where he is in space.
The vestibular system is responsible for discrimination of sensation that helps with maintaining posture and a stable visual fi eld. Two
categories of sensory organs comprise the vestibular system: the otolith organs (linear movement and gravity receptors) and the semicircular
canals (angular movement receptors). Poor processing of sensation received by the otolith organs
results in decreased proximal extensor muscle
tone, as observed with Sam who slumps at his
desk. It can contribute to diffi culty determining
the precise spatial orientation of the head. Is it
tilted or upright? Poor processing of otolithic
information is also thought to contribute to gravitational insecurity and to some compensatory
eye movements. In contrast, poor processing of
sensation received by the semicircular canals is
seen in diffi culty eliciting the small, rapid movements needed for effective equilibrium reactions
and postrotary Nystagmus (PRN) and can also
result in aversive responses to movement. Poor
equilibrium reactions may contribute to Sam ’ s
diffi culty riding a two-wheel bicycle.
The skin is the receptor organ for tactile sensations. Poor tactile discrimination is defi ned as
diffi culty knowing the precise location and properties of touch; it can greatly impact body scheme
because it interferes with our understanding of
body boundaries. Poor tactile discrimination may
also impact the development of oral, fi ne, and, to
some extent, gross motor skills and motor planning. Sam, for example, has struggled with developing independence in activities of daily living
(ADLs) and has diffi culty catching, throwing,
and kicking, all of which could be related to poor
tactile (as well as proprioceptive and vestibular)
discrimination. His diffi culty orienting a pencil
in his fi ngers for writing likely refl ects inadequate tactile discrimination for this fi ne motor
task. When a child with poor tactile discrimination manipulates small objects, it may look as
though the child is wearing gloves. That child
may appear messy or sloppy, with food left on the
face or clothing crooked and disheveled. Visual
hypervigilance during activity may indicate lack
of specifi city of tactile input; the child must rely
on the visual system for activity because of the
inadequate information from touch. Poor processing of tactile sensation can also manifest as
tactile defensiveness, or an exaggerated response
to normal tactile sensations. Sam ’ s complaints
about clothing and responses to food refl ect his
tactile defensiveness.
A child ’ s response to enhanced sensation
varies greatly depending on both internal and
external factors. Thus, vigilant observation on
the part of the therapist is essential. Creation of
effective therapeutic activities depends on several
factors including the particular sensory integrative diffi culties the child experiences and the
desired outcome ( Smith Roley, 2006 ). Chapter 5
(Praxis and Dyspraxia) and Chapter 6 (Sensory
Modulation Functions and Disorders) provide
in-depth information about the nature of sensory
processing problems associated with poor modulation and praxis, and Chapter 7 (Sensory Discrimination Functions and Disorders) comprises
information on discrimination and perception.
Qualities Affecting the Intensity
of Sensation
In addition to considering which sensory systems
to focus on (i.e., tactile, vestibular, proprioceptive), a therapist also must consider the intensity
of the sensation. Several qualities of sensation
infl uence intensity: strength, rhythmicity, duration, frequency, and speed.
Strength is the force with which sensation is
administered. Touch, for example, can be soft or
fi rm. Rhythmicity is the regularity of repetition
of the sensation. For example, a swing yields
rhythmic input when a child propels it smoothly
back and forth or arrhythmic input when a therapist jostles it as though it were being “blown in a
storm.” Tactile and proprioceptive input can also
be rhythmic or arrhythmic. Duration is the length
of time a sensation is present, frequency is how
often a sensation occurs, and speed refers to the
rate of stimulus occurrence. For example, touch
can be slow as in stroking one ’ s arm or fast as in a
tickling. Similarly, movement of a body ’ s muscles
and joints can also occur at various speeds.
Together, the qualities of sensation, in conjunction with the child ’ s current arousal level,
determine the effect. Slow, rhythmic, gentle
sensations tend to be perceived as less intense.
When we think in terms of modulation and
arousal, they have a calming effect, whereas
304 ■ PART IV Intervention
fast, changing rhythms are likely to be perceived
as more intense and to be alerting. The relationship of duration to perceived intensity and
effect depends on the other characteristics. For
example, deep pressure applied for long periods
of time is likely to be calming, whereas light
touch applied for an equal amount of time may
be perceived as very intense and increase levels
of arousal.
Enhanced sensation affects more than arousal
and modulation; it also affects body scheme and
motor functions. Tactile, vestibular, and proprioceptive sensations are associated with different
motor functions (“Indicators of poor sensory
integration and praxis”) as shown in Figure 13-1 ,
which is a model of dysfunction, thereby depicting diffi culties associated with poor processing
of sensation. However, adequate processing of
sensation contributes to strengths in the areas
listed. For example, well-functioning visual, vestibular, and proprioceptive systems contribute to
good postural-ocular control.
Once again, because it bears repeating,
enhanced sensation in the context of meaningful
activity is a core part of all SI therapy. However,
the reasoning behind activity choice and type of
sensation will vary considerably depending on
the desired outcomes and the specifi c needs of
the individual.
A Note on Craving Sensation
Some children who have decreased sensory discrimination or who seek to alter their arousal
levels seem to crave enhanced sensation
( Schoen, Miller, Brett-Green, & Nielsen, 2009 ).
They may love spinning or swinging, intentionally crash into people or things, trail their hands
along the wall as they walk, or put everything
in their mouth. However, craving is not necessarily a sign that enhanced sensation will be
therapeutic. Not all children who crave sensation
have poor sensory processing and not all children who have poor sensory processing crave
the sensations they need. Vigilant observation is
essential to make necessary changes as quickly
as possible if a child ’ s response to the sensation
is undesirable. 2
Intervention for Sensory
Modulation Dysfunction
Sensory modulation defi cits result in responses
that are consistently disproportional to the magnitude of the sensory experience. In this section,
we provide guidelines for utilizing enhanced
sensation to promote modulation. We focus on
the left side of the model shown in Figure 13-1 ,
labeled “Indicators of poor sensory modulation.”
Because each child and each session are unique,
a therapist continually must be aware of the type,
qualities, and effect of the sensations inherent to
an activity and the environment and then compare
the expected responses with the child ’ s actual
responses. We discuss intervention for three
specifi c categories of sensory modulation dysfunction: over-responsivity, under-responsivity,
and paradoxical or fl uctuating responsivity. We
also briefl y address intervention to alter arousal
levels.
Treatment Guidelines
for Sensory Over-Responsivity
In Chapter 1 (Sensory Integration: A. Jean Ayres’
Theory Revisited) and Chapter 6 (Sensory Modulation Functions and Disorders), we described
two categories of sensory over-responsiveness:
defensiveness and aversive responses. Defensiveness can occur in any sensory system: tactile,
auditory, and so on. However, defensiveness to
vestibular sensation has a specifi c name: gravitational insecurity, which can be distinguished
from other aversive responses to movement.
Sensory Defensiveness
Defensiveness is manifested as a fi ght-or-fl ight
reaction to sensations that most people do not
fi nd uncomfortable. Intervention to ameliorate
defensiveness in any sensory system involves
active movement that yields enhanced vestibular, proprioceptive, or tactile sensation. Sensory
integrative theory postulates that enhanced input
to these basic senses mediates modulation of
all sensation. Ayres ( 1972 ) also suggested that,
because certain sensations have a central effect,
providing input to some areas of the body should
be suffi cient; it should not be necessary to
provide input to the entire body. The mouth and
face may be exceptions. Children who are particularly defensive around the face and mouth may
2
If a child appears to “overload” after receiving intense sensation,
proprioceptive and deep tactile pressure activities can help the
child regain a more optimal level of arousal.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 305
FIGURE 13-2 Deep pressure is often acceptable on the trunk and limbs. Photo courtesy of Shay McAtee,
printed with permission.
need experiences with input directed to those
areas (as tolerated). Whistles, kazoos, straws, or
chew toys can be a good way to provide input to
the sensitive areas of the mouth and face.
In general, children fi nd deep pressure touch,
proprioception, and slow, linear vestibular input
easiest to tolerate. Thus, when children are
particularly defensive, we begin with one of
these. When enhanced tactile sensation is part
of an activity, children usually tolerate input to
the arms and legs more readily than the face.
Deep pressure, however, is often acceptable on
the trunk as well as the limbs, such as using a
therapy ball as a “steam roller” over a child ’ s
back, arms, and legs (see Fig. 13-2 ). Enhanced
sensation to promote modulation is always built
into meaningful activity with the child ’ s active
participation; it is not administered passively.
As children become better able to modulate
sensation, they are able to engage in activities yielding relatively intense or unpredictable
sensation. For example, a child who is able to
modulate sensation well should be able, in most
circumstances, to experience light, unexpected
touch or visual clutter without responding negatively. Any activities that generate the desired
intensity of input can be used. Table 13-1 comprises several activities that provide tactile,
vestibular, or proprioceptive input of varying
intensities.
TABLE 13-1 Examples of Activities Providing
a Range of Intensities of Enhanced Sensation
• Moving in a large container of plastic balls or ball
pit
• Crawling or burrowing under textured pillows
• Painting and drawing in shaving cream, foam
soap, and fi nger paint
• Finding objects hidden in a tactile bin fi lled with
beans, rice, or macaroni
• Playing with a massager or vibrating toy
• Blowing kazoos or whistles
• Swinging—slowly or rapidly—on a swing
suspended from two points while engaged in
activity
• Swinging—slowly or rapidly—on a swing
suspended from one point while engaged in
activity
• Jumping up and down on a trampoline
• Bouncing on a swing suspended from a bungee
cord
• Falling into a crash mat or ball pool from a
stationary object or moving swing
Treatment to promote modulation should not
be confused with approaches that target desensitization. Desensitization involves repeated
stimulation until a person habituates to that stimulus. In contrast, SI therapy focuses on using
combinations of vestibular, proprioceptive, and
tactile sensations to promote modulation across
modalities.
306 ■ PART IV Intervention
FIGURE 13-3 Walking down a ramp. Photo courtesy
of Sensory Gym.
Gravitational Insecurity
Ayres ( 1979 ) described gravitational insecurity
as a particularly devastating form of sensory
integrative dysfunction. Symptoms include fear
or anxiety from moving, particularly into backward space (e.g., tilting backwards, moving into
supine) or being upside down. Everyday activities such as turning somersaults, stepping over
objects, walking on bumpy ground, or getting
onto and off of an escalator can elicit gravitational insecurity. Each of these activities changes
the relationship between our gravity receptors
and gravity input. The child with gravitational
insecurity perceives this discrepancy as alarming
because vestibular and proprioceptive, and likely
visual, input is not being processed and integrated
adequately. High arousal, which often accompanies gravitational insecurity, can severely
impact participation in all daily life occupations.
Chapter 6 (Sensory Modulation Functions and
Disorders) contains a thorough description of
gravitational insecurity.
Intervention for gravitational insecurity involves activities that provide controlled proprioceptive and linear movement (i.e., vestibular
sensation) as tolerated, coupled with simple
visual demands. The therapist carefully alters activities so they do not elicit fear responses and,
by carefully grading activities, providing the
just-right challenge and facilitating comfort with
increasing head and body movement.
Control is particularly important for children
who experience gravitational insecurity. Some
young children cannot tolerate even slow, linear
movement on equipment. For them, walking
across a mattress or up and down a ramp
( Fig. 13-3 ) may provide the just right challenge.
Small linear, vertical movements (e.g., jumping,
bouncing) are typically the fi rst tolerated as they
minimize head movement out of the vertical.
Some children may enjoy sitting on a therapy
ball together with a therapist or using equipment,
such as the whale ( Fig. 13-4 ).
When a child is able to engage in activity on a
swing, sitting with the head upright is least likely
to elicit fear. Further, having the child ’ s feet on
or near the fl oor provides tactile and proprioceptive information that promotes “grounding.”
As the child becomes more comfortable with
moving while sitting, the therapist can incorporate activities in prone with the feet touching the
ground (e.g., swinging prone over a suspended
inner tube or frog swing, Fig. 13-5 ). The therapist
can also position the swing close to the mat and
allow the child to control the speed and direction of motion; a simple visual target provides a
“fi xing point” that can assist in the integration of
the movement. Another tip is to have the child
swing by pulling on a therapist ’ s outstretched
hands, which provides reassuring tactile input
as well as proprioception and a point to fi x on
visually (i.e., the therapist; see Fig. 13-6 ). Work
toward having the child propel the swing using a
less stable point of control such as a hula hoop,
handles, or elastic ropes.
Movement into backward space can be particularly challenging for children with gravitational insecurity because they cannot see where
they are going to anticipate what will happen.
Even a simple swing goes backward half the
time. To help minimize some of the fear experienced by a child with gravitational insecurity,
stack foam blocks or large soft pillows behind
the swing at a distance that the child agrees to;
these provide a clear end point to the motion.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 307
FIGURE 13-4 Bouncing up and down on a whale. Photo courtesy of Shay McAtee, printed with permission.
FIGURE 13-5 Swinging prone in the frog swing. Photo courtesy of Shay McAtee, printed with permission.
Table 13-2 comprises activities to address gravitational insecurity that can be graded for degree
of challenge.
Children who experience gravitational insecurity need a lot of support and encouragement.
They must trust the therapist completely and the
therapist must earn that trust. Chapter 12 (The
Art of Therapy) contains an in-depth description
of an intervention session with a child who has
gravitational insecurity. Some therapists have
reported anecdotally that Therapeutic Listening™ or a similar program can help ameliorate
gravitational insecurity (see Chapter 18 , Complementary Programs for Intervention).
308 ■ PART IV Intervention
FIGURE 13-6 Pulling on the therapist ’ s hands to
initiate swinging provides tactile and proprioceptive
input and a point to fi x on visually. Photo courtesy of
Sensory Gym.
TABLE 13-2 Sample Activities for Treating
Gravitational Insecurity
• Carry a beanbag or stuffed animal across a
mattress-covered surface
• Carry a slightly weighted object up a ramp
• Crawl or walk over a platform swing close to the
ground that has pillows underneath to minimize
movement of the swing
• Bounce up and down while seated on a therapy
ball that is an appropriate size (feet on ground)
• Bounce on a whale swing (with therapist behind
child) (see Fig. 13-4 )
• Bounce on a mini trampoline
• Bounce up and down while seated on a frog
swing suspended by a bungee cord ( Fig. 13-7 )
• Bounce up and down or pull on a cord (child in
control of excursion) while seated on a square
platform swing suspended by a bungee cord, with
tire inner tube for additional support ( Fig. 13-8 )
• Ride prone on a scooter board across the fl oor
• Ride prone on a scooter board down a ramp
• Throw beanbags or balls at a large target while
prone in a frog swing
• Swing back and forth while prone or seated on a
platform glider suspended from two points
• Swing back and forth while seated on a bolster
swing suspended from two points
• “Practice” falling from sitting with feet fl at on the
fl oor into a crash mat or pile of pillows
• Swing side-to-side while prone on a bolster swing
• Laying prone, with body wrapped around a bolster
that the therapist shakes gently; progress to falling
off on soft crash mats or pillows
• Bounce prone in frog swing with gradually larger
excursions of movement
• Ride a zip line or trapeze, landing in large soft
pillows or a crash mat
Aversive Responses to Movement
Aversive responses are manifested as autonomic
nervous system reactions (i.e., nausea, vertigo,
sweating, pallor) to movement that most people
do not fi nd uncomfortable, such as riding short
distances in a car. Avoidance, especially of
angular movement, or an increase in restlessness after a car ride may also suggest an aversive
response. Aversive responses are hypothesized to
be related to poor central processing of sensation
received by the semicircular canals (Fisher &
Bundy, 1989; May-Benson & Koomar, 2007 ).
Chapter 6 (Sensory Modulation Functions and
Disorders) contains more information on aversive responses to movement.
A general goal of intervention is to help children tolerate common movement experiences
(e.g., bending over to tie shoes, riding in a car
or on a swing) without feeling sick or dizzy. The
goal is not for children to tolerate spinning or
another fast rotary movement. Although activities
that provide linear movement coupled with active
resistance (i.e., proprioception) may help to minimize negative responses, aversive responses can
be severe enough to impede progress in sensory
integrative therapy. Therefore, aversive responses
may be most effectively addressed through vestibular rehabilitation (e.g., Boyer et al., 2008 ;
Cohen, 2000 ; Herdman, 1994 ).
Vestibular rehabilitation is a prescribed and
carefully monitored program of desensitization;
in-depth discussion is beyond the scope of this
text. Kawar and colleagues ( 2005 ) also developed a therapy program to address vestibular
concerns, titled the Astronaut Training Program.
Chapter 18 (Complementary Programs for Intervention) contains some information about the
Astronaut Training Program.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 309
FIGURE 13-7 Bouncing while seated on a frog
swing. Photo courtesy of Sensory Gym.
FIGURE 13-8 The square platform swing with an inner tube atop for stability. Photo courtesy of Shay McAtee,
printed with permission.
Treatment Guidelines for Sensory
Under-Responsivity
Individuals who are under-responsive respond
slowly to sensory stimuli and require a greater
intensity or duration of sensation to elicit
a response ( Hanft, Miller, & Lane, 2000 ;
Reynolds & Lane, 2008 ). Children who are
under-responsive may have fewer, muted, or
delayed responses to daily sensory events ( Lane,
Miller, & Hanft, 2000 ; Schoen, Miller, & Sullivan, 2014 ). Sensory under-responsivity can be
diffi cult to distinguish from poor sensory discrimination. Because intervention for these two
concerns overlaps, it is not always necessary
to be able to distinguish between the two. Both
can lead to challenges with fi ne and gross motor
activities.
In intervention we provide frequent opportunities for enhanced sensation in order to reach
the child ’ s sensory threshold and encourage
optimum alertness. This can and should target
any or all of the sensory systems. Enhanced input
must also be part of everyday activities including opportunities for dynamic movement, foods
310 ■ PART IV Intervention
with strong tastes and smells, messy play, music
with fast and changing rhythms, and brightly lit
and multi-sensory environments such as active
playgrounds, public swimming pools, and music
and movement classes. Grading the activities
listed in Table 13-1 for increased intensity can
be helpful when working with children who are
under-responsive.
Paradoxical and Fluctuating Responses
Some individuals who appear under-responsive
to sensory events may actually be overly responsive but protecting themselves by shutting out
input, such as when a fuse blows from having
too many appliances plugged in. During the
course of intervention, we have seen some such
children shift their responses from apparently
under-responsive to overtly over-responsive.
Although this shift can be confusing, we have
found, clinically, that it actually may be a sign
of improvement. Although still out of proportion to the sensation experienced, the child ’ s
responses now genuinely refl ect the state of the
central nervous system (CNS)—that is, a child
who is overly sensitive is now over-responsive,
rather than failing to respond. However, therapists must proceed with caution, matching their
approach to meet the changing needs of a child
and realizing that the child ’ s responses may fl uctuate between over- and under-responsiveness
for a period of time. The responsivity levels of
children with fragile X syndrome ( Miller et al.,
1999 ), and some children with autism, also fl uctuate, both within and between sensory systems,
making it a challenge to create a therapeutic
milieu that promotes engagement in intervention
activities.
In the previous section, entitled Qualities
Affecting the Intensity of Sensation, we described
characteristics of sensation differentially associated with calming or alerting. When we provide
enhanced sensation in the context of an activity, we expect a relatively immediate effect.
Sensation that is calming should help to lower
arousal and sensation that is alerting should raise
arousal levels. However, SI theory suggests that
through time, because of intervention, the CNS
will become better able to modulate incoming
sensation, less often over- or under-responding.
This in turn should lead to a more adaptable
and functional arousal level, with less severe
fl uctuations.
Modulating Arousal
In general, when children are over-responsive
to sensation, they tend toward high arousal,
which, in turn, makes it diffi cult to attend to, and
engage in, activity. Sam is a child who “ramps
up” easily (i.e., enters a state of hyperarousal).
Similarly, under-arousal seems to accompany
under-responsivity to sensation. Children whose
responsivity to sensation fl uctuates may also
fl uctuate between under- and over-arousal. One
way to alter arousal levels is through opportunities for enhanced sensation for a child in the
context of meaningful activity. The particular
characteristics of enhanced sensation will differ
depending on whether the goal is to increase or
decrease arousal.
In addition to providing direct intervention to
change processing in the CNS and help children
attain optimal arousal, monitoring and altering
the environment is also important. A low input
environment with low or natural lights, muted
colors, minimal clutter, and soft background
sounds or silence may promote focus and feelings of calm. In Chapter 12 (The Art of Therapy),
we address a therapist ’ s therapeutic use of self
that also contributes to a calming environment.
Richter and Oetter ( 1990 ) described the Matrix
Model, a model of task and environment interaction. They offered guidelines for creating two
types of environments that may be particularly
useful when children experience over-arousal:
womb space and mother space. Womb spaces
are small, protected, and separate from the
world at large, invoking feelings of security and
safety. A child in a womb space receives physical contact from another person or deep pressure
from a large pillow or blanket and experiences
very few demands. Children with high levels of
arousal may need help from an adult to move into
womb space to encourage regulation. Table 13-3
presents ideas for creating womb space environments. Mother space provides a slightly more
demanding, but nonetheless safe and nurturing
TABLE 13-3 Womb Space Environments
• Large beanbag chair
• Pop-up tent
• Large cardboard box
• Fort made out of blankets and clothes pins
• Piles of pillows
• Spandex hammock
• Spandex cuddle swing
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 311
environment. In mother space, a child is free
to take simple “risks” while remaining in close
proximity to an adult (typically 8 to 10 inches
away). The adult often sits at the child ’ s level and
gives intermittent physical or eye contact along
with short, rhythmic verbal communications.
HERE ’ S THE POINT
• Providing enhanced sensation as the just right
challenge is the key to designing interventions
for sensory over- and under-responsivity.
• Providing direct intervention and making
changes to the environment can help modulate
a child ’ s level of arousal and may increase his
or her level of attention and engagement.
Intervention for Practic Disorders
Ayres ( 1972, 1979, 1985 ) and others ( MayBenson, 2014 ; Miller, Anzalone, Lane, Cermak,
& Olsten, 2007 ; Smith Roley et al., 2015 ) proposed that diffi culty with motor planning is the
primary problem in sensory-integrative-based
dyspraxia. That is, children with dyspraxia
appear awkward because of poor planning rather
than because of a primary problem with motor
execution. They further believed that planning
effective, effi cient actions relies on an internal
body scheme and information about body position in space, derived from the tactile, vestibular, and proprioceptive systems. The underlying
processing diffi culty has implications for the
types of enhanced sensation we build into therapeutic activities. See the right side of the model
shown in Figure 13-1 labeled “Indicators of poor
sensory integration and praxis.”
In sensory integrative theory, we speak of two
major kinds of dyspraxia: vestibular bilateral
integration and sequencing defi cits (VBIS)
and SD. VBIS is thought to be caused by inadequate processing of vestibular and proprioceptive
sensations, manifesting as poor postural-ocular
control, bilateral integration, and sequencing of
anticipatory movements. SD is based in poor
processing of tactile sensation, often in combination with poor vestibular-proprioceptive discrimination. In general, because they have fewer
processing problems, we believe that children
with VBIS have fewer diffi culties than children
with SD.
In this section, we focus on interventions to
increase motor planning. Most projected action
sequences, or anticipatory movements, involve
both sides of the body and most children with
dyspraxia have diffi culty with coordinated bilateral actions. Thus, we include a segment on
bilateral integration. Further, some children with
dyspraxia, especially SD, have diffi culty generating an idea of what to do and generalizing skills.
Therefore, we also include segments on ideation
and generalization. Finally, because some children have diffi culties with both modulation and
praxis, we include a segment on balancing intervention for multiple processing problems.
Promoting Planning
Motor planning is particularly important for new
motor tasks. Not surprisingly, the ability to plan
actions follows a developmental sequence. Very
young, or very unskilled, children lack sophisticated planning ability. They perform motor
skills using feedback (vestibular, proprioceptive,
tactile, visual) gained from the action, rather than
feedforward to plan for the action. For example,
they may catch a ball by trapping it against the
chest, using the feedback from feeling or seeing
the ball at their chest rather than appropriately
setting up (feedforward) to catch the ball in their
hands. Young, or very unskilled, children have
diffi culty anticipating the position where their
hands must be in order to catch the ball as it
moves toward them. In the course of development, they learn to plan and execute progressively more diffi cult motor actions. Older, or
more skilled children easily anticipate where
the hands must be to catch the ball and move
the hands to that place— before the ball hits the
body. With increasing skill, catching a ball has
become a feedforward-dependent task. For a relatively skilled child, the plan to catch the ball
generates a special kind of feedback that is fed
forward to an existing central model of correctness for comparison. That comparison tells the
child how accurate the movement will be before
it occurs ( Fig. 13-9 ). Although a child may know
whether a feedforward-dependent action will
succeed before it happens, the child cannot alter
the movement once the plan has been initiated.
In contrast, feedback-dependent movements,
such as trapping a ball against the chest, can be
changed (or initiated) in response to feedback
312 ■ PART IV Intervention
FIGURE 13-9 Schematic representation of motor planning from a sensory integrative perspective.
that comes from the action (i.e., the ball striking
the body) ( Seidler, Noll, & Thiers, 2004 ).
Feedforward-dependent tasks are often called
projected action sequences because they
involve a sequence of actions to enable projecting arms, legs, or an entire body to a precise
location at an exact time in order to complete an
action. Feedforward-dependent tasks have both
spatial and temporal requirements (i.e., where do
I need to move and when do I need to get there?),
whereas the demands of feedback-dependent
tasks are primarily spatial (i.e., where do I need
to move?). Clearly, feedforward-dependent
tasks are more diffi cult developmentally than
feedback-dependent tasks.
We believe that children with VBIS have
diffi culty with feedforward-dependent actions,
whereas children with SD tend to have diffi culty
with both feedforward- and feedback-dependent
actions. The combined effect of (a) movements
that are ineffi cient and ineffective, thus yielding
poor quality sensory feedback, and (b) a poor
ability to process feedback may mean that children with dyspraxia have diffi culty establishing a central model of correctness. Thus, they
may be unaware of how accurate their movements will be—until they see or hear the effect
that their actions had on the environment (i.e.,
external feedback). In the following section, we
address intervention to promote the spectrum
from simple feedback-dependent to complex
feedforward-dependent tasks.
Feedback-Dependent
to Feedforward-Dependent Actions
Intervention aims to promote the most complex
adaptive responses possible. Thinking very simplistically, we can estimate the degree to which
an activity is feedback- or feedforward-dependent
by examining the movement of the child and the
object(s) on which the child is acting (e.g., a
target). Tasks where the child and target are both
static are the easiest, and often a starting point in
intervention for children with SD; tasks in which
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 313
HERE ’ S THE EVIDENCE
The ability to precisely grip and regulate grip
forces is an important skill for many ADLs including writing, dressing, and eating. Initial grasp is
thought to be guided primarily by feedforward
control mechanisms, whereas the ability to sustain
actions and maintain a constant level of motor
output (grasp) is thought to rely more heavily on
sensory feedback mechanisms. In their 2015 study
published in the Journal of Neurophysiology, Wang
and colleagues set out to objectively measure and
differentiate motor control strategies used by children with autism spectrum disorder (ASD) during
precision gripping. During testing, children with and
without autism pressed against two opposing load
cells while viewing visual feedback on a computer
screen during multiple tests of precision grip. Results
of the study indicated that children in the control
group were able to adapt their initial strategy based
on the task demands (target force); children with
ASD tended to use only one strategy and their initial
force output was less accurate overall than the
control group. Further, when sustaining a constant
force level, children with ASD showed increased
output variability; the authors suggested that this
was because of their inability to translate visual
feedback information into precise motor commands.
Children with ASD also had more diffi culty rapidly
terminating force output. Overall, these fi ndings
suggest that both feedforward and feedback motor
control mechanisms are impaired in children with
ASD, and they may contribute to the sensory-based
motor disorders seen in this population. Although
this study is specifi c to children with ASD, feedforward and feedback control mechanisms are thought
to be compromised in children with other conditions
such as dyspraxia and developmental coordination
disorder. It is important that clinicians working with
these populations assess both feedforward and
feedback mechanisms during the initial evaluation,
and provide therapeutic challenges at the just right
level to elicit adaptive responses from the child
throughout treatment sessions.
Wang, Z., Magnon, G. C., White, S. P., Greene, R. K., Vaillancourt, D. E., & Mosconi, M. W. ( 2015 ). Individuals with autism spectrum
disorder show abnormalities during initial and subsequent phases of precision gripping. Journal of Neurophysiology, 113, 1989–2001.
both the child and the target are moving are the
most challenging. Figure 13-10 shows a schematic representation of the relationship between
the movement of a child and target to the degree
of feedback- or feedforward-dependent control
required. Simple modifi cations make activities
relatively more or less challenging because they
change the precision of the action required to
be successful. We can create an endless array
of activities to encourage planning and which
produce the most diffi cult adaptive responses that
a child can achieve (i.e., just-right challenge) by
varying the size, speed, and distance of a target
or the speed and range of the child ’ s movements.
Figure 13-11 shows activities involving varying
degrees of spatial-temporal demands relative to
the child and object.
When a child is on a piece of moving equipment, such as a swing or scooter board, the
spatiotemporal demand of the activity is in proportion to the amount, speed, and rhythmicity of
the movement of the equipment. Activities that
involve slow rhythmic movement of equipment
have a moderate spatiotemporal demand, especially if the target on which the child is acting is
stable. (See upper right quadrant of Fig. 13-11 .)
A favorite activity is pretending to be a mailman
FIGURE 13-10 A conceptual representation of
feedback or feedforward control, depending on
relative movement of the child and object. Adapted
from Keogh & Sugden, 1985.
Feedbackdependent
Object
Note: the point at which the line depicting the relative movement
of child and object crosses the line marked feedback-dependent,
feedforward-dependent indicates the degree of control required.
Child
Feedforwarddependent
Stationary Moving a lot
Stationary Moving a lot
or Santa ’ s helper and delivering packages to different houses. The size of the target also contributes to spatiotemporal demand. “Houses” made
from large pillows are easy targets, whereas a
small box depicting a “chimney” requires more
precise timing of release of the package, a greater
spatiotemporal demand. Increasing the speed,
continually changing the direction, or decreasing
the rhythmicity of the swing ’ s movement also
increases the challenge.
314 ■ PART IV Intervention
Activities where both the child and the target
are moving represent the greatest spatiotemporal demand. (See the lower right quadrant of
Fig. 13-11 .) “Bumper cars” is a highly motivating activity in that category. Two large tractor
inner tubes are suspended vertically from the
ceiling, about 6 feet (2 meters) apart. The child
and the therapist (or two children) each straddle
a tube, pulling them apart as far as possible and
then swinging and crashing into one another.
The object is to bump the opponent out of the
tube. If a bump is to be hard enough to knock
an adult out of a tube, a child ’ s movements must
be timed, sequenced, and directed precisely. Suspending the tubes high enough that the children ’ s
feet do not touch the ground and using ropes
suspended between the tires to propel the tubes
makes bumper cars more challenging by increasing postural and bilateral demands ( Fig. 13-12 ).
A challenging and fun adaptation of bumper
cars involves having a child running between the
tubes. Two adults can easily grade the movement
of the tubes. Slow, rhythmical swinging decreases
the spatiotemporal demand for the child running
between the tubes, whereas moving the tubes in
unpredictable ways increases the challenge.
Another activity with signifi cant spatiotemporal demand involves two children orbiting around
one another in a dual swing. The two must begin
moving at the same time and at the same speed.
They run for a few steps and then, on cue, simultaneously lift their feet and orbit ( Fig. 13-13 ).
A Note on Sequencing Actions
We have used the term sequencing to refer to
ordering of a series of actions needed for acting
effectively on an object (e.g., sequencing movements to get the hands to the correct place to
catch a tossed ball or sequencing extension and
fl exion of the knees to pump a swing). However,
therapists commonly use the term sequencing in
reference to activities such as obstacle courses.
In fact, obstacle courses represent sequences of
sequences. The diffi culty of an obstacle course is
determined by the relative feedforward demand
of each activity within and the speed with which
a child must transition between activities. A moderately diffi cult obstacle course might include:
• Swinging by a trapeze from a raised surface
• Letting go of the trapeze to swing through a
moving suspended inner tube onto a mat
FIGURE 13-11 Activities illustrating relative movement of the child and object. Adapted from Keogh & Sugden,
1985.
Jump into a hula hoop, pool, or ball pit
Throw beanbag into a large stationary
target
Bat at a suspended ball that is still
Shoot a basketball into the net while
standing in front of it
Stand in front of a stable ball and kick it
Stand in place and kick a rolled ball
Stand in place and catch a thrown ball
Bat at a pitched ball while standing in a
stationary position
Stand and hit a suspended ball that is
swinging back and forth (or tether ball)
Shoot at a moving target with a squirt gun
while standing in place (the larger the
target, the easier)
Throw beanbags at a moving target
Jump up and down on a trampoline
Push or kick a large stationary ball
away while moving on a scooter board
or swinging in a net swing
Grab beanbags or stuffed animals from
the mat while swinging
Propel scooter board around obstacles
or through a block tunnel
Bounce on a hippity hopTM through a
series of small hula hoops
Swing on a trapeze and land in a tire
inner tube filled with pillows
“Slap me five, high and low” while
jumping on a trampoline
Throw beanbags at a moving target
while swinging prone in a net swing
Shoot at a moving target with a squirt
gun while running or swinging
Bat at a swinging target while holding
onto a T swing
Play dodge ball, monkey in the middle,
or flag football
Catch a ball thrown while swinging on
a swing (prone or sitting)
Stable Target Moving Stable
Child
Spatial demand
Feedback-dependent Feedforward-dependent
Spatiotemporal demand
Moving
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 315
FIGURE 13-12 “Bumper cars.” Photo courtesy of Shay McAtee, printed with permission.
FIGURE 13-13 The dual swing. Photo courtesy of
Sensory Gym.
• Leaning down to pick up beanbags
• Turning around and throwing the beanbags
through the swinging tube
• Running back to the raised surface through a
maze of plastic cones
• Catching the trapeze
• Beginning again
Obstacle courses can be fun and can be used to
encourage the generation of ideas and spatial
planning if the child participates in the design
and set-up. However, they inherently decrease
the opportunity a child has for repeating and
mastering a single activity.
Promoting Bilateral Integration
Development of the ability to use both sides
of the body together in a skillful manner (i.e.,
bilateral integration; Williams, 1983 ) begins
very early in life; most skills are in place before
a child reaches 7 years of age ( Gerber, Wilks,
& Erdie-Lalena, 2010 ; Magalhaes, Koomar, &
Cermak, 1989 ). The body midline demarcates
the two body sides and crossing the midline is an
important aspect of bilateral coordination. Movements of the mouth, as a midline structure, also
refl ect bilateral integration.
We create meaningful activities to promote
bilateral integration at the highest level of challenge a child can meet, always trying to stretch
the child ’ s skills just a little. Many skills that
require bilateral coordination also involve projected action sequences (e.g., catching a ball with
two hands). Placement of objects, positioning of
the child relative to a target, and the amount that
equipment moves all infl uence bilateral demands.
Table 13-4 comprises four categories of bilateral
316 ■ PART IV Intervention
TABLE 13-4 Examples of Actions and Activities to Promote Bilateral Integration by Level of Diffi culty
Bilateral Symmetrical: (Hold On and Move Actively Forward and Backward)
• Stable object close to the body: A child, prone or seated on a bolster swing or platform swing and holding onto
the ropes with both hands, propels the swing forward and backward by actively fl exing and extending the arms
( Fig. 13-14 ). The therapist can facilitate rhythmic movement with verbal cues such as “pull-push” or “heave-ho.”
This action can easily be built into an activity such as having the child crash into a stack of cardboard boxes or
blocks, knocking them over. Placing the boxes farther from the swing increases the challenge. A story can make
the activity more meaningful.
• Stable object a short distance from the body: A child, prone or seated on a net swing (hammock), scooter board,
or platform swing, grabs the therapist ’ s hands or a trapeze or hula hoop held by the therapist standing in front.
The child grabs it ( Fig. 13-15 ), pulls up by fl exing the arms, and then releases his or her grip to swing backward.
This action can be built into an activity, such as having the child demonstrate his or her strength by holding to
a particular count. Another variation involves the child pulling up to refuel and hanging on while the therapist
“fi lls the tank.” Increasing the time that the child holds also increases the demand for postural stability. Having
the child sit inside a tire placed on a platform swing decreases the postural demand.
• Unstable object a short distance from body: The child is prone or seated on a net swing (hammock), scooter
board, or platform swing. The child grabs two ropes suspended from the wall or ceiling approximately 6 feet
(2 meters) away and propels the swing by pulling rhythmically on the ropes. This bilateral challenge can be built
into “bumper tires,” an activity described previously (see Fig. 13-12 ). Sitting on a suspended tire tube presents a
greater postural demand than sitting on a hard surface (platform) or a surface that hugs the body (hammock).
Bilateral Reciprocal: (Hold On and Move Actively Side-to-Side)
• Stable object close to the body: A child seated sideways on a glider or bolster swing, holding onto the ropes,
propels the swing side-to-side by alternately fl exing and extending the arms. This action can be built into an
activity where the child swings into “bop bags” (weighted rocking toys that bounce back up when hit by a
swing) placed on either side of the swing. Bop bags can be placed at different distances from the two sides of
the swing to alter the bilateral challenge. Standing on the swing increases the postural challenge. A story can
add meaning to the game.
• Stable object a short distance from the body: A child, prone in a net swing (hammock), uses a hand-over-hand
motion to climb to the top of a rope held by the therapist. This action is easily built into an activity called “steal
my magic rope.” When at the top of the rope, the child “steals” it from the therapist who then grabs the loose
end of the rope and “steals” it back.
Main Actor/Stabilizer (Hold On to Equipment with One Arm; Act with Other)
• A child seated on a t-swing, fl exion disc ( Fig. 13-16 ), in a hammock or other equipment, stabilizes with one arm
and uses the other in activity. For example, the child could use a squirt gun to shoot at a target. Depending on
the location of the target, substantial midline crossing and trunk rotation may be required. For a greater postural
challenge, scatter beanbags underneath the swing for the child to pick up and throw at one or more targets. If
the targets are moving, the spatiotemporal demand increases.
Alternate Opposing Actions of Arms and Legs (e.g., Flex Arms and Extend Legs)
• Swinging on a trapeze or zip line (also known as a fl ying fox) can easily be made into an activity that requires
alternate opposing actions of arms and legs, such as swinging from a trapeze to jump through an inner tube
suspended from the ceiling ( Fig. 13-17 ) or kicking a suspended ball. These challenging bilateral tasks also require
dynamic postural support and the ability to plan and execute projected action sequences.
integration that represent a developmental progression: bilateral symmetrical, bilateral reciprocal, main actor or stabilizer, and alternate
opposing actions of arms and legs. To genuinely refl ect the principles of sensory integrative
therapy, the therapist and child must collaborate
to design meaningful and appropriately challenging activities in the context of intervention.
Promoting Ideation
Children develop ideation through active exploration and interaction with objects and the environment. May-Benson ( 2001 ) proposed that
children develop ideation in four areas:
• Objects: what an object can do and what can
be done with it
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 317
• Actions: what actions the child can do
• Appropriate Action-Object Interactions:
which actions are appropriate for which
objects
• Serial Actions: sequencing steps to
accomplish the goal
Some children with SD and many children with
autism have diffi culty with conceptualizing a
goal and developing a plan of how to accomplish it (i.e., ideation; May-Benson, 2014 ).
Because of diffi culty knowing what they can do
with objects, children who have poor ideation
seem not to recognize the possibilities contained within objects or situations. Consequently,
they often have diffi culty with self-directed or
self-initiated actions ( Ayres, 1985 ). They may
wander aimlessly or gather objects but not use
them. Often, they use all objects in the same very
simple ways (e.g., throwing) or exhibit inappropriate actions with objects, such as trying to
stand on a ball ( May-Benson, 2014 ). They may
require toys that closely resemble real objects
(e.g., a toy telephone) rather than pretending that
an object is something it is not (e.g., a box is
a telephone). Because of the paucity of ideas,
their play themes may be limited or “scripted”
in unvarying ways from stories or shows. They
frequently have diffi culty playing, particularly by
themselves, but playing with others can be problematic if they cannot understand play ideas or
are overly compliant.
In therapy, we are always trying to set up an
environment or activities likely to invite interaction. When working with a child for whom
ideation is a problem, select familiar objects and
set up specifi c activities. Start with activities that
clearly invite a particular action but that allow
the child to generate the “idea” of what to do. For
example, place a familiar toy at the top of a ramp
or ladder to encourage climbing ( Fig. 13-18 )
or hide stuffed animals in a ball pit to give the
child the idea to “dive in.”
Some children pause before initiating a movement as though they are actively connecting the
idea of what they want to do with the plan of
how to do it. Allow time to process, providing
only minimal instruction or feedback. Some children need physical cueing and guidance to initiate. Using a cognitive approach can help children
to see possibilities in objects. For some children,
peer or video modeling can be useful. Leading
FIGURE 13-14 Child holds a trapeze and actively
fl exes both arms to initiate swinging. Photo courtesy
of Sensory Gym.
FIGURE 13-15 Child grabs the therapist ’ s hand, pulls
up by fl exing the arms, and then releases his or her
grip to swing backward. Photo courtesy of Sensory
Gym.
FIGURE 13-16 Child seated on t-swing stabilizes
with one arm and uses the other in activity. Photo
courtesy of Sensory Gym.
318 ■ PART IV Intervention
questions, such as “What could you do with . . . ?”
can be helpful for inviting a child to think of
ideas. Children may be able to identify what they
have done before they can describe what they
plan to do.
Verbalizing a plan can assist some, but not
all, children to organize their actions and carry
out the plan. P.J., a 7-year-old, created a complicated obstacle course involving four pieces
of suspended equipment. He even verbalized a
sequence of movements to move through the
course. But, when asked to demonstrate the plan,
he walked to each piece of equipment and simply
pushed it before moving on to the next. Children
such as P.J., at least initially, may benefi t more
from modeling, photos of another child doing
the task, or physical cues than from verbalizing
a plan.
Coupling a simple motor plan with an imaginative play theme can promote ideation if the
child contributes ideas about what should happen
or how it can happen. Nonetheless, the level
of sophistication must be targeted carefully. As
Ayres ( 1985 ) indicated, “If the child leaves a task
with a feeling of failure, he or she will probably
not want to return to it” (pp. 67–68). Riding a
“train” or a “horse” (e.g., a glider) and getting
off frequently to retrieve or deliver “packages”
(e.g., large, heavy beanbags or containers) is an
FIGURE 13-18 Place a familiar toy at the top of a
ladder to encourage climbing. Photo courtesy of
Sensory Gym.
FIGURE 13-17 Swinging by a trapeze to jump through an inner tube. Photo courtesy of Shay McAtee, printed
with permission.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 319
activity that children can readily embellish (e.g.,
Where are they going? Who lives in the house?
What ’ s in the package?). Imaginative play often
helps to capture a young child ’ s motivation for
engagement. However, children who have great
diffi culty with ideation and imaginative play
may need concrete props such as a real ladder
and rubber tubing to “pretend” to be a fi refi ghter.
Review the case study about a playful therapeutic
interaction, building ideas from a child ’ s actions.
As children gain the ability to formulate ideas
for using objects, they may act more spontaneously in carefully arranged, familiar environments or do what is familiar to them in novel
environments. Through time they may act spontaneously with novel objects in less familiar
environments. However, some children with signifi cant defi cits in ideation may never achieve
high levels of spontaneity and will need a great
deal of help to generalize specifi c skills to home
and school.
CASE STUDY ■ ALEX
When 6-year-old Alex entered the therapy
session, he seemed unable to conceptualize
what he might do with the equipment and
instead began to run around the room. The
therapist pretended that his running was purposeful. Because Alex was very interested in
Winnie-the-Pooh and Pooh ’ s friends, the therapist began talking similar to Tigger (i.e., “I
love to bounce. Oh boy, a running, bouncing,
jumping game!”) as she modeled jumping. The
therapist continued to play the part of Tigger
and began pretending that Alex was Pooh. “Oh,
Pooh, this is so much fun! You are such a good
runner! What else can you do?” When Alex
accidentally bumped into one of the bolsters,
she said in an exaggerated way, “Oh, Pooh,
you are so good at bumping into things!” When
Alex burrowed under a large pillow, the therapist asked, “Are you Rabbit now? You are burrowing just like Rabbit.”
Initiating, Carrying Out, and
Generalizing New Motor Tasks
Children with dyspraxia have diffi culty initiating
and learning new motor skills; thus, intervention
encourages participation in new tasks rather than
simply practicing tasks that a child has mastered.
Verbal mnemonics such as “ready . . . set . . .
go” or “1, 2, 3, go” help some children initiate
actions. Some cue themselves spontaneously but
others benefi t from prompting.
For some children, altering the way a familiar piece of equipment is used produces novelty:
riding a swing in different positions (e.g., prone,
sitting sideways) or suspending a swing from one
point instead of two. The therapist can set up the
environment to provide varied means to accomplish the same task. For example, a child could
access the top of a platform by climbing stairs,
over pillows, or up a ramp. Tasks that involve
projected action sequences such as catching or
kicking remain novel for a long time; a ball
rarely arrives at precisely the same location, even
twice in a row; thus, throwing and kicking tasks
continually require new motor responses.
Actions do not always go as planned for
children with dyspraxia. Understandably, these
children can be easily frustrated. A gentle
or humorous approach can be effective; for
example, “That was the silliest jump I have ever
seen! You landed on your back instead of your
feet. Are those feet going to help you next time?”
Songs or chants can assist in maintaining timing
or rhythmicity of actions and may have the
added benefi t of lowering arousal level. Labeling children ’ s movements as they occur (e.g.,
“push-pull,” “jump-jump-jump”) may help with
both timing and rhythmicity and with cortical
assimilation of body actions. 3
To support generalization of a newly learned
action, create new activities that require similar
actions. For example, a child may jump off a pile
of mats onto pillows during one session and into
an inner tube later in the session or in another
session. During subsequent sessions, the child
may jump off the rungs of a jungle gym into an
inner tube or off a slowly moving swing into
pillows. As a child succeeds with a new task,
point out similarities between the requirements
of the current activity and those of activities
3
A word of caution to readers. Using language does not always
support praxis and, in fact, can interfere with it. Language is
also praxic, and for children with challenges, it may hurt more
than help. Ayres used very little language in her sessions. If
you choose to use words, watch the child ’ s response; determine
if it helped, and fi gure out how much language is too much.
Sometimes it is better to scaffold movement through action; for
instance, simply pointing to where a foot should be placed or
guiding a hand to reach for a ladder rung can be more effective
than a verbal command.
320 ■ PART IV Intervention
already mastered. Generalizing actions in the
clinic, however, may not be enough to allow
children to generalize skills to other environments (e.g., the park or the playground) without
explicit assistance. Importantly, children have
not mastered an activity until they can perform
it automatically and without conscious effort.
Thus, practice is important.
Table 13-5 contains questions therapists might
ask themselves when developing an intervention
plan to promote motor planning in particular
children.
HERE ’ S THE POINT
• Planning effective and effi cient actions requires
adequate processing of tactile, vestibular,
and proprioceptive sensations which provide
information about body position in space.
• In designing treatment activities for children
with dyspraxia, the therapist should consider
the feedforward and feedback demands of the
task, as well as the placement and stability of
the child, objects, target, therapist, and other
equipment.
• For children with defi cits in ideation and motor
planning, the therapeutic environment should
be set up to invite interaction and promote
novel movement experiences.
Intervention for Increased
Sensory Discrimination
Sensory discrimination is the ability to interpret the spatial and temporal qualities of sensation. In sensory integrative theory, poor sensory
discrimination refers particularly to diffi culties
perceiving tactile, proprioceptive, or vestibular
sensation, although some children with sensory
integrative dysfunction also have diffi culties with
visual and auditory discrimination. Unlike poor
sensory modulation, in which symptoms fl uctuate from day to day or even hour to hour, without
intervention, defi cits of sensory discrimination
remain relatively stable. Although diffi culties
with sensory discrimination may occur independently, in children with sensory integrative
dysfunction, they are identifi ed most commonly
in conjunction with dyspraxia. In this section, we
describe intervention for decreased vestibular,
proprioceptive, and tactile discrimination.
Vestibular-Proprioceptive
Discrimination: Postural-Ocular Control
The vestibular and proprioceptive systems are
responsible for understanding body position
in and movement through space, maintaining
posture, and maintaining a stable visual fi eld.
Poor discrimination of vestibular and proprioceptive sensation is manifest in several ways
TABLE 13-5 Supports for Developing
Planning Abilities
• How does the child best generate ideas?
• Specifi c set-up of activities
• Imitation of peers
• Specifi c suggestions
• Picture cards
• Leading questions
• Independently
• How does the child best learn new activities?
• Visually, by demonstration
• With verbal cues
• Through kinesthetic modeling
• Through therapist scaffolding of movement
• Independently by . . .
• What supports does the child need to implement a
workable plan?
• Therapist-directed plan
• Therapist-directed steps
• Therapist-generated supports such as lists,
maps, or picture cards
• Child-generated supports such as lists or
number coding
• Verbal guidance
• What helps the child prepare for action?
• Verbal cues (“Ready, Set, Go”)
• Tactile cues (“This part of your body has to curl
up . . . ” while patting stomach muscles)
• Visual models
• Enhanced sensory input
• Repetition of task
• What assistance encourages the best quality
movements?
• Enhanced sensory input
• Peer imitation
• Specifi c verbal cues
• Specifi c visual cues
• Specifi c tactile-kinesthetic, hand-over-hand cues
• Rhythmical music, beat or verbal cues
• What assistance is needed to facilitate adaptation
of an activity?
• Help to recognize that a plan is not working
• Ability to accept help when a plan is not
working
• Assistance with problem-solving to make the
plan more successful
• Help to adapt the idea, plan, or motor response
• Humor to increase acceptance of error
• Ability to shake it off and try new things
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 321
but most commonly as diffi culty with postural
control: stabilizing or adjusting the body to meet
the demands of a task or a changing environment ( Miller et al., 2007 ; Smith Roley et al.,
2015 ). Postural control is both tonic, needed for
stability, and dynamic, needed for responding to
changes in the environment.
Developing Tonic Postural Control
Tonic postural control depends on interplay
between fl exor and extensor muscles; it begins
to develop in infancy, fi rst in neck extensor
muscles and proceeding to trunk extensors.
Flexion balances extension, developing slightly
later but in a similar pattern. Children with
sensory-integrative-based postural-ocular diffi culties very commonly have poor tonic postural control (i.e., proximal stability). Because
effective and effi cient movements depend on a
stable postural base, development of tonic postural control is often a good starting point for
intervention.
Intervention to improve tonic postural control
includes enhanced vestibular and proprioceptive
sensations and challenges to posture. We match
the characteristics of enhanced sensation with the
desired postural response. Activities incorporate
linear vestibular input and resistance to movement. Linear movement can occur in any plane:
anterior or posterior (e.g., swinging to and fro);
horizontal (e.g., swinging side-to-side); or vertical (e.g., bouncing). Resistance to active extension or fl exion generates proprioception.
Prone and supine are not only the earliest
developmental positions but also the positions in
which gravity provides the greatest resistance to
extension and fl exion, respectively. Thus, a substantial amount of intervention to develop tonic
postural control occurs in these two positions.
Promoting Tonic Extension
The prone position includes more than simply
lying fl at on the belly, head down. As extensor
tone develops, children lying prone are increasingly able to hold the head and upper trunk to
a relatively vertical position. Creating activities
that follow the developmental sequence associated with the prone position provides a way of
grading extension.
Lying prone, propped on forearms while on
a moving glider swing and blowing cotton balls
off raised mats in front is a good starting place
for young children or children with very poor
postural extension; the activity provides linear
vestibular input and demands a relatively easy
postural response. Activities that involve weight
shifting while moving in a prone-on-elbows position (e.g., taking weight off one arm to reach for
and smear shaving cream on a mirror) increase
the need for stability but also provide vestibular
input.
Bouncing while prone in a frog swing
( Fig. 13-19 ) and holding the head up against
gravity provides very strong vestibular input
(from movement up and down) and proprioceptive input (from resisting the pull of gravity). Initially, a child may need to position the frog swing
across the upper chest to provide a stable base
for extending the head. As extension strengthens,
the swing can be moved across the stomach to
increase the challenge to extensor muscles. A net
or spandex hammock also can be used, and positioned similarly on the body, to promote extension. Keep in mind that if the net or hammock
swing supports the entire body, there will be little
challenge to postural extensors.
Activities that require maintaining the upper
and lower body in full extension (i.e., prone
extension) provide considerable challenge to
FIGURE 13-19 Bouncing while prone in a frog
swing. Photo courtesy of Sensory Gym.
322 ■ PART IV Intervention
FIGURE 13-20 Hitting a punching bag while swinging requires careful sequencing of several movements. Photo
courtesy of Shay McAtee, printed with permission.
FIGURE 13-21 Riding prone on a scooter board down a ramp in order to “steal jewels from the queen ’ s
castle.” Photo courtesy of Shay McAtee, printed with permission.
tonic postural extensor muscles and trunk stability. Engaging in activity that involves riding
a dual swing, hammock, or scooter board down
a ramp in prone for vestibular input is a good
example ( Figs. 13-20 and 13-21 ). Keeping the
trunk in alignment without a sagging trunk is
diffi cult.
Engaging in activities that require moving
in and out of full extension are even more diffi cult than maintaining extension because of the
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 323
FIGURE 13-22 “Walking” forward while prone on a barrel to place objects on a magnetic surface. Photo
courtesy of Shay McAtee, printed with permission.
requirement for both eccentric and concentric
muscle contractions. An example of such an
activity is “net basketball” where a child and a
therapist (or another child) lie prone in net swings
suspended 5 to 6 feet (2 meters) apart, grab beanbags from the fl oor, and attempt to throw them
onto one another ’ s back—while avoiding any
landing on them.
Activities that involve weight shifting on
extended arms while maintaining extension
of the head and trunk (e.g., lying over a small
therapy ball or barrel to place objects on a magnetic board) often must be done on a stable
surface ( Fig. 13-22 ). However, the child may
exhibit increased diffi culty maintaining extension without vestibular input derived from a
moving surface.
Promoting Tonic Flexion
When promoting tonic fl exion, create activities
in supine, provide vestibular input to promote
neck fl exion, and carefully grade the demand for
fl exion. For young children or those who have
very low tone in the neck and abdominal muscles,
intervention begins with activities requiring fl exion of only the head and upper trunk.
For example, the child lies supine on a wedge,
blowing bubbles through a wand held in position
by the therapist to encourage slight neck fl exion
and chin tucking or lying supine in a hammock
with the head and neck outside the hammock
( Fig. 13-23 ). The therapist can facilitate neck
and upper chest fl exion by placing a hand on the
child ’ s upper chest and exerting gentle pressure
in a caudal direction. Blowing in and out typically encourages neck fl exion, but some children
hyperextend the neck (lead with the chin) when
lifting the head toward the bubble wand. Careful
observation, as always, is needed. Further, activities such as this, completed with the child in a
stable position, do not provide vestibular input,
which might help to facilitate neck fl exion.
Activities that require fl exion of the legs and
lower trunk (e.g., kicking from supine) can also
facilitate fl exion of the upper trunk and neck
( Fig. 13-24 ). Begin with the child ’ s head and
upper trunk fully supported on a wedge. The
therapist lowers, rolls, or tosses a large lightweight ball toward the child, who fl exes knees
and hips in preparation and then extends them
to kick the ball. After a while, the child usually
lifts his or her head to see the ball. As fl exion
improves, the child can lean back and prop on
elbows without need of the wedge, increasing the
demand for neck and abdominal fl exion. Again,
when working in a static and stable position, vestibular input, which might facilitate neck fl exion,
is not incorporated.
324 ■ PART IV Intervention
Whole body fl exion can be promoted by creating activities that involve movement on a swing
while “hugging” a surface. Hugging a gently
moving bolster swing while lying prone on top of
the swing or sitting and hugging the center post
of a gently moving fl exion disc swing or t-swing
( Fig. 13-25 ) may be enough to challenge a child
who has very poor fl exion. As fl exion improves,
the intensity (speed and extent) of the swing ’ s
movement can be increased, resulting in greater
resistance to fl exion and more proprioceptive
FIGURE 13-24 Kicking a large ball from a supine
position encourages fl exion of the legs and trunk.
Photo courtesy of Sensory Gym.
FIGURE 13-25 Hugging the bolster swing while preparing to fall into a pillow. Photo courtesy of Shay McAtee,
printed with permission.
FIGURE 13-23 Lying supine with the head tilted to
provide unique input to the semicircular canals. Photo
courtesy of Shay McAtee, printed with permission.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 325
FIGURE 13-26 A rough ride on an inner tube swing. Photo courtesy of Shay McAtee, printed with permission.
input. Lying in a supine fl exion position on a
bolster swing or on a scooter board and pulling
along a rope suspended from both walls, approximately 2 feet above the fl oor, can also be very
challenging with regard to sustained fl exion.
Swings suspended from a vertical stimulation
device (i.e., several lengths of bungee cord) are
particularly useful for facilitating fl exion. The
bungee cord allows a therapist to vigorously
bounce the swing, creating a situation in which
the child must hold on tightly in order not to fall
off ( Fig. 13-26 ). Proprioceptive input, provided
by the bungee cord, coupled with vestibular
input gained from the movement helps facilitate
fl exion. A fl exion disc swing ( Fig. 13-27 ) provides a relatively stable base of support, whereas
a T-swing offers less and thus requires greater
fl exor control. Holding onto a moon swing
( Fig. 13-28 ) while throwing a beanbag at a
target provides an even greater challenge to both
fl exion and bilateral integration.
As fl exion improves, additional movement
from equipment or another external source can
be incorporated. When “riding the whale,” a
child lies prone on top of a bolster swing as the
therapist swings it back and forth, sometimes
shaking it for added resistance to fl exion. The
therapist and child can narrate a story where the
movement of the swing changes depending on
whether there are “clear skies” or “rough seas.”
This activity can be great fun, but also it can
be diffi cult and over-stimulating. Therefore, the
therapist and child need to work out ways to give
the child control; one way is to develop code
words to make the whale go “kooky” or “stop.”
A “bucking bronco” game, which involves
hugging a fast-moving tire inner tube that the
therapist shakes, is an even greater challenge to
fl exion ( Fig. 13-29 ). In both “riding the whale”
and “the bucking bronco,” a child sometimes
falls off the swing as the therapist shakes it.
Thus, it is important to have suffi cient padding
(e.g., dense mats, crash mats, pillows) surrounding the excursion of the swing. Ayres ( 1977 )
indicated that, once children developed adequate
fl exion, many enjoy activities that involve falling
such as releasing the bolster swing and falling
onto the crash pads below.
326 ■ PART IV Intervention
FIGURE 13-27 The disc swing. Photo courtesy of
Shay McAtee, printed with permission.
FIGURE 13-28 Moon swing. Photo courtesy of Shay
McAtee, printed with permission.
FIGURE 13-29 Hugging a tire inner tube that the
therapist pushes or shakes challenges fl exion. Photo
courtesy of Sensory Gym.
Promoting Dynamic Postural Control
Although prone and supine are excellent positions for developing extension and fl exion,
children also need dynamic postural control
when moving into other positions or transitioning between positions. Dynamic postural
control is necessary for activities such as rolling
( Fig. 13-30 ), kicking, or catching a ball; these
activities involve trunk rotation and anticipatory actions. Dynamic postural control requires
interplay between fl exion and extension. Anticipatory actions also promote motor planning.
The need to cross the body midline, which often
accompanies trunk rotation, promotes bilateral
integration. The previously described activities that involved an unstable “environment,”
including the “bucking bronco” and riding on a
fl exion-disc swing, challenge dynamic postural
control as the child strives to stay on the piece
of equipment.
Promoting Righting and Equilibrium
An important purpose of dynamic postural
control is to offset environmental events that
might otherwise result in loss of balance or allow
changes in body position (e.g., transitioning from
sitting to hands and knees). Equilibrium reactions
are rapidly occurring limb reactions that help to
maintain body mass over the base of support.
Equilibrium reactions co-occur with righting responses, which keeps the head and trunk
aligned. Activities that promote righting and
equilibrium ( Fig. 13-31 ) involve rapid angular
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 327
FIGURE 13-30 Rolling in an infl atable barrel to encourage rotation. Photo courtesy of Southpaw Enterprises.
FIGURE 13-31 Balancing on a large inner tube while play fi ghting with foam bats. Photo courtesy of Shay
McAtee, printed with permission.
328 ■ PART IV Intervention
(including orbital or rotational) movements. 4
Because the hair cells of the semicircular canals
responsible for equilibrium are stimulated during
acceleration and deceleration, activities should
include frequent starts and stops and changes in
direction and speed.
When we hang a swing from a single suspension point, we promote angular movement. Many
commercially available swings are designed to
be hung from one point: the frog swing, platform swing, net swing, dual swing, fl exion disc,
and t-swing (see Appendix to the chapter). Other
swings designed to be hung from two points,
such as the bolster swing, also can be hung from
a single point. Swings suspended by two points
can also generate angular movement when the
swing moves in an arc, as happens, for example,
when the ropes are short or the swing moves
side-to-side.
To promote equilibrium, create activities in
various positions (i.e., prone, sitting, quadruped,
kneeling, and standing) that require small, rapid
adjustments such as to prevent falling when
jostled. These can involve any piece of equipment
that moves or any activity that involves reaching a distance away from the body. Activities
that involve a narrower base of support, greater
movement of the support surface, or reaching
a long distance require greater stabilization of
trunk muscles (i.e., tonic postural control). Our
goal is to create activities that challenge both
dynamic and tonic postural control but can be
accomplished with automatic, fl uid responses.
Activities that involve changing head
movements to pick up beanbags or balls (see
Fig. 13-27 ) from a mat underneath the swing,
passing objects sideways or over the head to
another, or batting at suspended objects while
swinging also inherently involve angular motion
and promote righting. Any activities that involve
moving from one position to another or transferring from one piece of equipment to another also
promotes righting responses and, when balance
is threatened, equilibrium.
Promoting Ocular Control
Children with sensory integrative dysfunction
often have diffi culty both with refl exive eye
movements (e.g., PRN) and with moving the
eyes independently of the head to follow a target
or scan the environment. Automatic refl exive
movements that help to maintain a stable visual
fi eld depend on the vestibular and proprioceptive
systems, whereas ocular tracking depends on
the visual system ( Purves et al., 2012 ).
Activities that incorporate dynamic postural
control and projected action sequences also
promote ocular control. Almost all total body
movements and motion on any swing stimulate
refl exive eye movements that provide a stable
visual fi eld. Throwing beanbags accurately at
a moving target (e.g., a plastic bottle disguised
as an “alien spaceship”), for example, involves
producing visually controlled ocular movements
(e.g., smooth pursuits and quick localization)
and moving the eyes separately from the head.
Activities where both the child and target are
moving ( Fig. 13-32 ) promote both refl exive eye
movements and ocular tracking, but they are at a
more challenging level of ocular-motor control.
For young children or those with very poor
ocular motor control, begin with activities that
include attaining objects through reaching before
progressing to throwing at a target ( Fig. 13-33 ).
When starting at this level initially, present
objects at midline and slowly extend the visual
range to the sides, upward, and downward, and
fi nally behind the child. Some children with poor
ocular motor control may benefi t from a systematic approach designed by, or in conjunction with,
a developmental optometrist who specializes in
ocular motor training. Mary Kawar ’ s programs
FIGURE 13-32 Activities where both child and target
are moving challenge ocular control as well as timing.
Photo courtesy of Sensory Gym.
4
Always use angular vestibular input with caution because it is
extremely powerful.
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 329
in Chapter 18 (Complementary Programs for
Intervention) also address ocular motor control.
Targeting Other Aspects
of Proprioceptive-Vestibular
Discrimination
Children who experience diffi culty discriminating vestibular and proprioceptive sensations may
have trouble distinguishing head or body orientation in space. At the extreme, they may not
know intuitively whether they are right side up
or upside down. However, more often, they have
diffi culty recognizing an exact vertical. In intervention, emphasize activities that provide linear
movement (i.e., otolithic input). Many of the
previously described activities for children experiencing gravitational insecurity can be useful.
However, unless children also have modulation
dysfunction, we typically are able to incorporate
more movement and larger excursions. Activities
usually involve suspended equipment to facilitate
a variety of head positions (e.g., prone, supine,
sitting). Because linear movement is desired,
swings are generally suspended from two points.
Try to incorporate opportunities for vertical
movements and being upside down because of
the less common occurrence of those in everyday
life. Jumping and riding a swing suspended by a
bungee cord are ways to enhance both proprioception and vertical movement.
Children who have diffi culty with proprioceptive discrimination often have trouble judging
the appropriate amount of muscle force to
exert. They may press too hard with a pencil or
push too hard in a game of tag (as Sam does);
knock over objects because they misjudge the
force needed when reaching; and “sound like
an elephant” when walking down the hall or
the stairs. Enhanced proprioception is essential
to promoting discrimination. Emphasize activities that provide resistance to active movement (i.e., heavy work). Input can be provided
through the muscles of the mouth, neck, trunk,
arms, and legs. The weight of the body against
gravity ensures that many activities that involve
swings, a scooter board, or a trampoline provide
resistance to body movements. Heavy work
from resistance (e.g., pushing, pulling, jumping
on a trampoline) and weight-bearing positions
(e.g., quadruped) provide enhanced proprioception. Other examples include pulling a stretchy
rope to move a swing or propel a scooter board
as well as moving through a spandex hammock
or ball pit. As with all interventions based on
SI theory, active participation in meaningful tasks is crucial. Table 13-6 has a variety of
suggestions for enhancing proprioceptive input.
All these suggestions would be appropriate
for Sam.
Although enhanced proprioception is essential to promoting discrimination, activities
that require judging and adjusting force also
are important; for example, blowing or fl icking cotton balls or ping pong balls to targets
located various distances away, playing catch
with a ball made of foam soap without squashing it, or tossing balls or beanbags into a hoop
or relatively small targets placed at varying
distances.
Promoting Increased Tactile Discrimination
Children with poor tactile discrimination generally come to the attention of a therapist
because of diffi culties with praxis ( Ayres,
1972 ; May-Benson, 2014 ) or fi ne motor skills
rather than as a primary problem. Nonetheless,
increased tactile discrimination is an important
FIGURE 13-33 Blowing bubbles through a long
straw. Photo courtesy of Shay McAtee, printed with
permission.
330 ■ PART IV Intervention
goal of intervention as it is thought to underlie
body scheme and motor planning. 5
Promoting increased tactile discrimination
involves enhanced tactile and proprioceptive
sensations as well as activities that ask a child to
distinguish the temporal and spatial qualities of
touch (e.g., matching objects according to tactile
qualities). Utilizing a variety of different shapes,
sizes, and textures can provide enhanced tactile
input, and can also be used to incorporate opportunities for matching and labeling. For Sam,
fi nding objects ( Fig. 13-34 ) hidden in a mixture
of dried macaroni, beans, corn, lentils, and rice
presented a substantial challenge to tactile discrimination. Table 13-7 provides a variety of
tasks that provide enhanced tactile input (primarily deep pressure) and encourage tactile
discrimination.
Because children with poor tactile discrimination often have decreased body scheme,
games such as hide and seek can be a challenge.
FIGURE 13-34 Digging for objects buried in a box
fi lled with dried beans. Photo courtesy of Shay
McAtee, printed with permission.
TABLE 13-7 Activities to Encourage Tactile
Discrimination
Providing Enhanced Tactile Input
• Moving in a large container of plastic balls or
ball pit
• Crawling or burrowing under textured pillows
• Painting and drawing in shaving cream, foam
soap, and fi nger paint
• Moving hands and arms through a bin fi lled with
beans, rice, or macaroni (generally to fi nd an
object)
• Playing with a massager or vibrating toy
• Using a vibrating toothbrush
• Blowing kazoos or whistles
• Blowing through a straw to create a bubble
mountain
Promoting Tactile Discrimination
• Identifying objects hidden in a container using only
touch (stereognosis)
• Identifying letters or shapes drawn on the back
• Describing or identifying objects placed under
clothing (e.g., a beanbag under a shirt)
TABLE 13-6 Proprioceptive Activities
Pushing, Pulling, and Carrying
• Pushing heavy objects, grocery cart, and so on
• Pulling ropes tied to large beanbags
• Burrowing under large pillows
• Pushing a therapy ball through a spandex tunnel
• Carrying books, boxes, heavy objects
• Tug of war, push of war
Oral Motor Activities
• Sucking a resistive substance through a straw
• Chew toys or objects
• Chewing gum or chewy, crunchy foods
Movement Activities
• Jumping, bouncing
• Pulling oneself up (bending arms while pulling) on
a jungle gym or ladder
• Holding oneself actively on (with bent arms) and
riding a trapeze or zip line
• Pulling a rope or pushing off a vertical surface
with feet while swinging
• Making a swing or scooter board go by pulling a
stretchy rope or tire inner tube
5
Many children with poor tactile discrimination also have defi cits
in vestibular and proprioceptive processing. (See Chapter 5 :
Praxis and Dyspraxia.) Therefore, intervention for poor tactile
discrimination is usually done in conjunction with other sensory
systems and related to the end product of praxis. (See also section
on intervention for promoting praxis in the previous text.)
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 331
Children may believe they are hidden completely
when, in fact, they are only partially hidden. Hide
and seek can help children to utilize cognitive
strategies to compensate for poor discrimination.
HERE ’ S THE POINT
• Poor discrimination of vestibular and
proprioceptive sensations can manifest as poor
tonic or dynamic postural control, poor ocular
control, and trouble distinguishing head or
body orientation in space.
• Interventions to improve postural control may
include enhanced vestibular and proprioceptive
sensations, challenges to posture and
equilibrium, and transitions into and out of
various positions.
• Promoting increased tactile discrimination
involves enhanced tactile sensations, and often
deep pressure touch and proprioception.
Balancing Intervention
for Multiple Types of Sensory
Integrative Dysfunction
Some children have diffi culty with both modulation and praxis. For example, a child could
have tactile defensiveness, gravitational insecurity, and SD. All problems must be addressed in
intervention—often within the same session.
Until and unless a child establishes, and can maintain, a functional level of arousal, it is diffi cult
to make signifi cant changes in postural-ocular
control, bilateral integration, or motor planning.
A child with tactile over-responsivity may not
be able to interact with tactile media that could
support improved discrimination. Children with
gravitational insecurity may be so fearful of
moving that it is impossible to engage them in
activities that provide enhanced vestibular input.
Further, gravitational insecurity may mask poor
discrimination of head position in space and
postural-ocular diffi culties, such as delayed righting. Thus, modulation is a top priority within
and across sessions. Interspersing activities that
provide enhanced sensation with those that are
calming may prevent some children who have
both praxis and modulation diffi culties from
becoming so overly active that their behavior
deteriorates.
Practical Considerations
for Intervention
Sensory integrative theory is complex and continually evolving. Sound understanding of the
theory, and the ability to translate it to practice,
are essential to providing safe, effective, state-ofthe-art intervention. The Fidelity Measure developed by Parham and colleagues ( 2007, 2011 ) lists
structural elements for evaluating research into
ASI therapy. These same elements provide guidance to therapists in the implementation of ASI
in practice. We discuss these elements and some
additional practical factors. See also Chapter 14
(Distilling Sensory Integration Theory for Use:
Making Sense of the Complexity), which contains the Fidelity Measure.
PRACTICE WISDOM
Throughout this chapter, we present a variety
of activities that can be used to improve performance of children with specifi c sensory integrative disorders. However, it takes a trained and
practiced clinician to implement these activities
at the right time, in the right way, with the right
child. SI therapy requires constant monitoring of
the child ’ s level of interest and arousal as well
as the challenge of the task (i.e., too diffi cult or
too easy) and then changing features within the
environment. Therefore, a clinician cannot walk
into a session with a set plan for how the hour
will go. Rather, he or she needs to gauge the
specifi c needs of the child continuously within
the context of the child ’ s goals and desires. This
can be challenging for new therapists or for
therapists who have not had appropriate training or mentorship in SI theory and intervention.
Videotaping therapy sessions (with child and
caregiver permission) can be a useful strategy for
new clinicians to learn about their own therapeutic strengths and weaknesses. After watching
themselves during treatment, therapists often
will state things such as: “I ’ m talking way too
much,” “He (the child) was not into that activity at all; I should have made it more fun,” or
“That activity was too easy—I could have moved
the target and then he would have had to cross
midline.” Ideally, the therapist will have a mentor
to review the videos with; but even without a
mentor, the exercise of critiquing one ’ s own
therapy sessions can be a useful learning tool
for therapists learning to use an SI approach.
332 ■ PART IV Intervention
Parent Involvement
Many parents become involved actively in direct
intervention sessions. Such involvement can
lead to a special bond between child and parent
and assist both parent and therapist to develop
new strategies for interacting effectively with a
child. Miller and colleagues refer to “magic moments”—times when a child fi rst achieves something new in therapy. Having parents actively
engaged in such moments is a way of “sharing
the magic.” See text Appendix : The STAR Process: An Overview. Nonetheless, it is important
that parents not try to modify their child ’ s behavior in therapy, thereby disrupting the session.
Therapist Training
In the Fidelity Measure, Parham and colleagues ( 2007, 2011 ) specifi ed specialized,
post-professional education, such as SI certifi cation, as well as mentoring from an expert. This
education base provides a foundation for the
clinical reasoning required to implement ASI.
Attending continuing education presented by
experts and reading current research are excellent ways to stay abreast of current thinking and
research related to SI. Mentoring from an expert
in treating disorders of SI can be invaluable.
Therapist-to-Client Ratio
Implementing ASI requires constant vigilance
and adaptation to meet a child ’ s changing needs
and ensure successful participation. Because
each child is different, it is very challenging, if
not impossible, for a single therapist to provide
ASI to more than one child at a time. However,
it can be benefi cial to have more than one therapist, each working with one child, sharing a
therapy space. The interactions among children
may contribute to problem-solving, planning,
and negotiation, all valuable social skills.
Length of Sessions
Length of sessions can be determined by a
variety of factors, including the age and profi le
of the child, the setting, and the pragmatics of
reimbursement. For children whose modulation
issues interfere with attaining and maintaining
a functional level of arousal, we need to allow
enough time to establish a state of optimal, or
near-optimal, arousal. As a child becomes capable
of increasingly complex adaptive responses, it is
helpful to have a long enough session to develop
and adapt activities suffi ciently. Further, because
the aim of occupational therapy is for children
to develop and better manage the challenges of
everyday life, we also may need time to work on
specifi c skills (e.g., shoe tying, trying new foods,
or bicycle riding). In our experience, an ideal
session length is 45 to 60 minutes.
Physical Environment
In the Fidelity Measure, Parham and colleagues
( 2007 ) clearly described the importance of a
space that is big enough and confi gured in such
a way as to support the physically active play
characteristic of sensory integrative intervention. A room size of at least 12 feet (4 meters)
square is needed, but a space that is 14 x 20 feet
(5 x 7 meters) is ideal as it ensures safety during
large excursions of a swing and provides fl exibility for arranging equipment. To ensure emotional
and physical safety, the fl oor must be covered
with mats; additional soft cushions or pillows are
useful. At least one small quiet space should be
available.
Suspension System
A treatment space should have at least three suspension points placed in a line with a minimum
distance of 2.5 to 3 feet (1 meter) between. This
allows for combining equipment (e.g., swinging on a trapeze to jump through two suspended
inner tubes, bumper tires, swinging while throwing at a suspended target). A rotational device
and strong bungee cords on one or more suspension points allow the maximum range of movement of equipment.
Installing a suspension system correctly is
essential to safety. Suspension systems must sustain a minimum working load of 1,000 pounds.
Although many children weigh fewer than 100
pounds, when they bounce and orbit on a piece
of suspended equipment the shearing forces on
the suspension system are tremendous. Further,
adults or other children often are part of activities on the equipment, increasing the demand on
the system.
Southpaw Enterprises ( https://www.southpaw
.com/safety-tips/ ) publishes a guide for installing a
suspension system in the ceiling. When installing
a suspension system, contact a structural engineer
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 333
or contractor with a background in design. Even
then, you will likely have to explain the need
for a system that supports such a large working
load. Consultants often incorrectly assume that a
structure similar to an outdoor swing set is suffi -
cient—and it is not.
Suspension points must be high-grade forged
steel eyebolts (indicated by a fully closed circle
on the eyebolt) installed through support beams
and locked securely with nuts and washers. Never
hang equipment from eyebolts screwed directly
into the ceiling without going all the way through
a part of the ceiling structure and locking, even
with lag bolts or bolts that expand as they are
tightened. Only bolts that go all the way through
(i.e., throughbolts) and are locked on the other
side can safely support the strong shearing forces
generated by suspended equipment. In addition,
rotational devices should be used with any piece
of equipment that orbits or rotates in order to
minimize the torque on the ceiling suspension
point from which it is hung.
Commercially available, freestanding suspension systems can be used in places where a
ceiling system cannot be installed. Large, heavy,
non-portable systems with a working load of
1,000 pounds are preferred (see also Koomar,
1990 ). Many lightweight, portable systems have
a working load of fewer than 1,000 pounds.
These systems are limited as far as the type of
activity that can be done on them.
Equipment and Storage
Enhanced sensation, a basic element of ASI,
depends on access to a variety of swings, bouncing
equipment (e.g., therapy ball, mini-trampoline),
ropes for pulling, weighted objects, spandex
fabric and tactile mediums, vibrating toys, visual
targets, and props to support engagement in
play ( Parham et al., 2011 ). Equipment must be
stored in such a way as to minimize the chances
of injury from tripping or falling and to prevent
the space from being so cluttered that children
become distracted.
Summary and Conclusions
Direct intervention based on SI theory can be
powerful for effecting change but implementing intervention effectively is challenging. This
chapter is devoted to meaningful activities in
which enhanced sensation is matched with the
characteristics of desired adaptive interactions,
established through rigorous ongoing assessment. Throughout a session, the therapist continuously observes the child ’ s responses and alters
activities without disrupting the overall fl ow.
The most effective therapy is a marriage of
science and art. Interweaving the two enables a
therapist to engender trust and facilitate increasingly complex adaptive responses. A hallmark
of sensory integrative therapy is that it is childdirected. Child-directedness is a complex concept, closely aligned to the art of therapy. (See
also Chapter 12 , The Art of Therapy.) At the
very least, child-directedness involves co-creating
activities and ensuring success. But success does
not mean that children never miss a target or fall
off equipment onto a mat. Total, 100% success
in every attempt would be boring and would not
result in improved SI or greater skill. The justright challenge, which requires children to work
at the edge of their capabilities, is an important
hallmark of sensory integrative therapy.
Direct SI therapy should always be provided concurrently with coaching to parents and
other caregivers, and, whenever possible, direct
involvement of the caregivers in therapy sessions. Practitioners communicate with caregivers to help them understand the daily life effects
of sensory integrative dysfunction and develop
strategies to minimize negative effects. Caregiver
input into goals and priorities for therapy must
also be a part of creating SI intervention. Therapists will also regularly check in with caregivers to assure that the effects of intervention are
positive, make adjustments as needed, and facilitate generalization of newly acquired skills. Best
practice dictates that all therapy is goal driven
and addresses daily life demands. Together, the
child, caregivers, and therapist monitor progress
toward the goals to ensure that the child has generalized skills and abilities for everyday life and
feels competent doing them. Based on the result
of these assessments, the team recommends a
time when intervention should be discontinued.
(See also Chapter 17 , Using Sensory Integration
Theory in Coaching.)
Where Can I Find More?
Ayres, A. J. (2005). Sensory integration and the
child: 25th anniversary edition. Torrance,
CA: Western Psychological Services.
334 ■ PART IV Intervention
This seminal resource by A. Jean Ayres outlines the underlying theory of sensory integration
and how sensory integration therapy can be used
to ameliorate underlying differences in neurological functioning.
Mailloux, Z., & Schaaf, R. C. (2015). Clinician ’ s
guide for implementing Ayres Sensory Integration: Promoting participation for children
with autism. Bethesda, MD: AOTA Press.
This research-based resource provides a stepby-step guide to implementing ASI for children
with autism. Features include how to set goals,
conduct the intervention, and evaluate treatment
outcomes.
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336
List of Vendors and Equipment
APPENDIX 13-A
COMPANY FLOOR EQUIPMENT SUSPENDED EQUIPMENT
Southpaw Enterprises Crash mats
Air mattress
Ball pit and balls
Barrel
Fold and go trampoline
Bounce disc
Spiral fl oor disc
Foam blocks
Body sox
Scooter board ramp
Scooter board
Massagers
Weighed vests, toys
Linear platform glider
Bolster swing
Square platform
Tire inner tube (tube swing)
Rubber dual swing
Flexion disc
Flexion t-swing
Moon swing
Net swing
Tadpole (frog) swing
Cuddle swing
Acrobat swing (spandex hammock)
Purple people eater swing
Trapezes
Vertical stimulation device (bungee cords)
Flaghouse Floor mats
Wedges
Foam platforms and ramps
Ball pit balls
Air cushion
Balance disc
Belly bumpers
Medicine balls
Rings and handles
Circle platform swing
Log (bolster) swing
Fun and Function Crash mats
Ball pits and balls
Whisper tilt and spin
Cozy canoe
Foam balance beam
Hopper balls
Tunnels
Textured platform swing
Air-lite raft platform swing
Air-lite seal bolster swing
Skateboard swing
Airwalker
Hammock chair
Net chair
CHAPTER 13 The Science of Intervention: Creating Direct Intervention from Theory ■ 337
COMPANY FLOOR EQUIPMENT SUSPENDED EQUIPMENT
Achievement Products Floor mats
Balance beams
Ball pit balls
Weighted vests, toys
Therapy putty
Flexidisc
Net swing
Airwalker
Vestibulator platform swing
Roll (bolster) swing
Therapro Scooter board
Body sox
Therapy balls
Medicine balls
Theraband and tubing
Oral motor activities
Therapy putty
Tiffi n Athletic Mats Ramps
Octagon
Achievement Products (800) 373-4699 www.achievement-products.com
Flaghouse (800) 793-7900 www.fl aghouse.com
Fun and Function (800) 231-6329 www.funandfunction.com
Southpaw Enterprises (800) 228-1698 www.southpawenterprises.com
Therapro (800) 257-5376 www.theraproducts.com
Tiffi n Athletic Mats (800) 843-3467 www.tiffi nmats.com
338
CHAPTER
14
Distilling Sensory Integration
Theory for Use: Making Sense
of the Complexity
Lucy J. Miller , PhD, OTR/L, FAOTA ■ L. Diane Parham , PhD, OTR/L, FAOTA
Chapter 14
If it is true . . . that social reality has . . . [created] new zones of complexity and
uncertainty, it is also true that practitioners . . . do sometimes fi nd ways to
make sense of complexity and reduce uncertainty to manageable risk.
— Schön, 1983 , p. 18
Upon completion of this chapter, the reader will be able to:
✔ Describe three resources that distill Ayres
Sensory Integration © (ASI) theory, reducing
its complexity for the purpose of guiding the
provision and evaluation of direct intervention:
the schematic representation of sensory
integration (SI) theory used throughout this
text, the ASI Fidelity Measure (ASIFM), and the
S ensation, T ask, E nvironment, P redictability, S elfmonitoring, and I nteraction (STEP-SI) model.
✔ Describe a problem-solving resource that
draws from ASI and helps families develop
workable strategies to ameliorate everyday
problems associated with poor regulation and
modulation: Attention, Sensation, Emotion
regulation, Culture, Relationships, Environment,
and Tasks (A SECRET).
LEARNING OUTCOMES
Purpose and Scope
Occupational therapy practice theories are
complex. Because practice demands application of
theory, an important day-to-day aim of therapists
is to manage complexity ( Schön, 1983 ). Sensory
integration (SI) is among the most complex of
occupational therapy theories. Thus, it is not surprising that therapists using Ayres Sensory Integration © (ASI) in practice and reading research
regarding its effectiveness seek “short cuts”
that make the theory and its tenets more accessible. Such short cuts do not provide recipes.
Rather, they prompt reasoning and problemsolving critical to planning and refl ection.
SI theory offers a way to understand the
behaviors of a particular group of children and
frame intervention to help ameliorate the problems those children face every day. Therapists
also apply SI theory in coaching to help families and teachers reframe children ’ s behavior and
adapt tasks and environments so that the children
succeed and the parents and teachers feel, and
are, more effective in their own roles.
Several theorists, researchers, and practitioners have developed resources to help therapists or families manage the complexity of SI
theory in everyday practice. These resources take
the form of:
• A conceptual framework illustrating the
hypothesized relationship among constructs
(i.e., the schematic representation of ASI
used throughout this text)
CHAPTER 14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity ■ 339
• An instrument to plan direct intervention and
evaluate research examining the effectiveness
of ASI for congruence with SI theory (i.e.,
ASI Fidelity Measure [ASIFM])
• A discussion guide for clinical decisionmaking based on SI theory (i.e., S ensation,
T ask, E nvironment, P redictability, S elfmonitoring, and I nteraction [STEP-SI]
model)
• A practice model illustrating a clinical
reasoning process developed for families
to ameliorate common everyday problems
associated with poor regulation and sensory
modulation (i.e., Attention, Sensation,
Emotion regulation, Culture, Relationships,
Environment, and Tasks [A SECRET])
We describe these four resources in the following sections, showing them briefl y and reiterating the purpose of each.
Resources to Guide
Direct Intervention
Three of the resources that we include simplify
ASI for the purpose of creating direct intervention or evaluating the effectiveness of research.
These are the schematic representation of SI
theory used throughout this text, the ASIFM, and
the STEP-SI model.
Schematic Representation of Sensory
Integration Theory
Throughout this book, we have utilized a schematic representation of SI theory that illustrates
hypothesized relationships among vestibular,
proprioception, and tactile sensations and particular types of sensory integrative dysfunction
(see Fig. 14-1 ). In Chapter 13 (The Science of
Intervention: Creating Direct Intervention from
Theory), we used this schematic as the basis
for creating therapeutic activities that match the
type of enhanced sensation with the most logical
proximal objectives of therapy. We apply this
model to practice by beginning at the center (in
the column labeled “Inadequate CNS Integration and Processing of Sensation”) and reading
either to the left for outcomes related to sensory
modulation or to the right for outcomes related
to praxis.
HERE ’ S THE POINT
• The schematic representation of SI theory
that we use throughout this book is a model
for creating therapeutic activities that match
the type of enhanced sensation with logical
proximal objectives of therapy. This model
depicts the science of SI therapy.
Ayres Sensory Integration ®
Fidelity Measure (ASIFM)
■ L. Diane Parham, PhD, OTR/L, FAOTA
Although the science of therapy is a critical aspect of ASI, the art of therapy is equally
important (see Chapter 12 , The Art of Therapy).
In fact, arguably, without art, an intervention is
not ASI. The schematic representation shown in
Figure 14-1 does not capture art and thus does
not allow a therapist or a researcher to be faithful
to all the tenets of ASI.
Parham and colleagues ( 2007, 2011 ) referred
to fi delity as faithfulness to the tenets of ASI.
Although the concept of fi delity is most often
applied to research testing the effectiveness of
ASI, fi delity is also very relevant to practice.
This is because fi delity addresses whether the
intervention being provided in real-life practice
is actually what the provider claims that it is.
The need to make accessible the science and
art as well as other important underpinnings
(structures) led Parham and colleagues to create
the ASIFM. They created and fi rst applied the
ASIFM in the context of research. When conducting a systematic review of 61 published,
peer-reviewed studies claiming to evaluate the
effectiveness of SI intervention, Parham and colleagues found that the descriptions of treatment
procedures differed dramatically across studies
( Parham et al., 2007 ). Although all the authors of
the studies claimed that their interventions were
SI, none addressed the fi delity of their interventions to the tenets of Ayres’ theory.
According to experts on outcomes research
( Kazdin, 1994 ; Moncher & Prinz, 1991 ; Wolery,
2011 ), fi delity of intervention should be reported
and monitored throughout any study of treatment effectiveness in order to demonstrate that
the intervention is actually what it claims to be
and is provided with a high degree of fi delity
340 ■ PART IV Intervention
PRACTICE WISDOM
Here are a few examples of situations in which the
fi delity of ASI intervention is compromised:
• The occupational therapist applies a brushing
protocol as the intervention and calls it SI
treatment, citing Ayres.
• The occupational therapist provides a weighted
vest for the child to wear at intervals during
the school day and calls this SI therapy.
• The occupational therapist prescribes a sensory
diet of strategies for the teacher or parent to
implement throughout the day and calls this SI
intervention based on Ayres.
In each of the scenarios listed, fi delity is compromised because the therapist providing the
intervention inaccurately represented it as ASI. Each
of these examples may be a helpful way to intervene in particular cases, but none of these intervention procedures comprises all, or even most, of the
concepts of ASI theory; thus, they cannot be called
ASI intervention. Although they may be delivered
with the best of intentions, such misrepresentations of ASI intervention are problematic because
they create confusion among therapists who wish
to understand SI, and, perhaps even more disconcertingly, they lead to misunderstandings of ASI
theory and practice among other professionals and
the public.
FIGURE 14-1 Schematic representation of sensory integration theory.
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
to all participants. In order to accomplish this,
researchers need to carefully defi ne (a) who is
qualifi ed to provide the intervention, and (b) the
principles and procedures essential to the intervention. Furthermore, they need to use an instrument to measure fi delity of the intervention in a
reliable and valid manner during the intervention
phase of the study.
Seeking to systematically evaluate the fi delity to ASI of the 61 effectiveness studies noted
previously, Parham and colleagues needed fi rst
to identify the key elements of ASI intervention.
They addressed two elements:
1. Process elements, shown in Table 14-1 ,
which refl ect the therapist ’ s use of
CHAPTER 14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity ■ 341
therapeutic strategies while interacting with
the child during a therapy session. Process
elements refl ect both the art and science
of therapy. They are very germane to this
chapter because they guide the content and
tenor of each session. The process elements
make the theory accessible and underpin the
therapist ’ s reasoning both in- and on-action.
2. Structural elements, shown in Table 14-2 .
Although we show them second here because
they are less relevant to this discussion,
the structural elements appear fi rst in the
ASIFM. They underpin the context of all
interventions. They must be present, but
because they pertain to the characteristics of
the space and the qualifi cation of therapists,
they are reasonably static. Once in place,
they generally remain in place.
The ASIFM has been used to document or verify
fi delity of ASI intervention in both research and
practice. It is a useful teaching tool for clarifying
the essential elements of ASI intervention and
how this intervention can be distinguished from
other intervention approaches, such as the examples of compromised fi delity presented at the
TABLE 14-1 Process Elements of the ASIFM
1. Therapist ensures physical safety of child.
The therapist anticipates physical hazards and attempts to ensure that the child is safe, and feels physically
and emotionally safe, through manipulation of protective and therapeutic equipment or the therapist ’ s physical
proximity and actions.
2. Therapist presents sensory opportunities to the child.
The therapist presents the child with at least two of the following three types of sensory opportunities: tactile,
vestibular, and proprioceptive; the therapist ’ s intent is to use sensory input to support the development of
self-regulation, sensory awareness, or movement in space. The therapist may provide a variety of sensory
opportunities with varying intensities, qualities, speed, and duration to improve perception, challenge postural
control or praxis, or to attain an adequate arousal state for sustained engagement.
3. Therapist supports sensory modulation for attaining and maintaining a regulated state.
The therapist modifi es sensory conditions as well as activity challenges and supports to help the child attain
and maintain appropriate levels of arousal and alertness, as well as an affective state and activity level that
supports engagement in activities.
4. Therapist challenges postural, ocular, oral, or bilateral motor control.
Challenges are embedded in sensory-motor activities that build bilateral integration, strength, dexterity, speed,
and agility in static and dynamic postural control, and in fi ne motor, gross motor, and oral motor skills.
5. Therapist challenges praxis and organization of behavior.
Challenges may address the child ’ s ideation (ability to conceptualize and plan novel movement activities),
motor planning (ability to plan a novel sequence of movements to engage effectively in a new activity), or
organization of behavior in blocks of proximal or distal time and space (e.g., planning activities to do in today ’ s
session, or next week).
6. Therapist collaborates with child in activity choice.
The therapist negotiates activity choices with the child, allowing the child to choose equipment, materials,
or specifi c aspects of an activity. Activity choices and sequences are not determined solely by the therapist.
Instead, the therapist provides structuring and support while maximizing the child ’ s active control.
7. Therapist tailors the activity to present a just right challenge.
The therapist presents or facilitates challenges that are not too diffi cult or too easy for the child to achieve.
This may involve altering an activity so that it is easier (more attainable) or more diffi cult (requiring more
effort). Challenges require some degree of effort and may address motor control, bilateral coordination, sensory
modulation, self-regulation, discrimination and perception, or praxis and organization of behavior.
8. Therapist ensures that activities are successful.
Ensuring success means that the therapist supports the child ’ s experience of success in doing part or all of an
activity. For example, this may be done by altering the task at any point in the activity sequence, by coaching
the child on alternative ways to do the activity, or by prompting the child to fi nd another strategy.
9. Therapist supports child ’ s intrinsic motivation to play.
This is done by creating a setting that supports play as a way to fully engage in intervention activities. The
therapist builds upon the child ’ s intrinsic motivation and enjoyment of activities through strategies such as
communicating nonverbally or verbally that play is encouraged, allowing the child to explore or experiment
with actions or objects, or engaging with the child in motor, object, pretend, or social role-play.
10. Therapist establishes a therapeutic alliance with the child.
The therapist promotes and establishes a connection with the child that conveys they are working together
in a mutually enjoyable partnership. Overall, there is a climate of trust, emotional safety, connectedness, and
appreciation of the child.
342 ■ PART IV Intervention
TABLE 14-2 Structural Elements of the ASIFM
Therapist Qualifi cations
1. Postgraduate training in sensory integration: Certifi ed in Sensory Integration or Sensory Integration and
Praxis Tests (SIPT; Ayres, 1989 ) through a graduate level university course, with a minimum of 50 education
hours in sensory integration theory and practice.
2. Supervision: History of mentorship, with an equivalent of 1 hour per month for 1 year, from an advanced-level
therapist with at least 5 years of experience providing occupational therapy using ASI intervention.
Safe Environment
1. Mats, cushions, and pillows are available to pad the fl oor underneath all suspended equipment during
intervention.
2. Equipment is adjustable to the child ’ s size.
3. Therapist can monitor equipment easily to ensure safe use.
4. Equipment not being used is stored, anchored, or placed at the side of the room so children cannot fall or trip
on it.
5. Frequent monitoring and documentation of equipment and safety occurs (e.g., frayed ropes and bungee cords
replaced; loose bolts secured for suspended equipment).
Assessment Report Content
1. Medical, educational, and therapeutic history, as appropriate
2. Developmental history
3. Occupational profi le or interview documenting activities the child and family have done, are doing, and want
to do
4. Reason for referral
5. Activities child currently seeks and enjoys
6. Results of structured evaluations (i.e., standardized and norm-referenced measures)
7. Results of unstructured evaluations (i.e., clinical observations, parent reports)
8. Sensory modulation, including sensory sensitivities, sensory seeking, and self-regulation
9. Sensory discrimination or perception in tactile, vestibular, and proprioception systems
10. Postural-ocular control (static and dynamic), including ocular, oral, and bilateral motor control
11. Visual, perceptual, or fi ne motor skills
12. Motor coordination or gross motor skills
13. Praxis: Imitating, constructing, planning, and sequencing one or more activities or interactions
14. Infl uence of SI on performance and participation
15. Organization skills, such as managing materials, schedules, transitions, and social expectations
16. Interpretation of the relationship of sensory integration and praxis to referring problems
17. Goals and objectives (if applicable) developed in collaboration with signifi cant caregivers
18. Goals (if applicable) focused on presenting concerns based on assessment fi ndings
19. Goals (if applicable) focused on improved skills and abilities to enhance performance
Physical Space for ASI Intervention
1. Adequate space to allow for fl ow of vigorous physical activity
2. Flexible arrangement of equipment and materials to allow for rapid change of the physical and spatial
confi guration of intervention environment
3. No fewer than three hooks for hanging suspended equipment, minimal distance between hooks of 2½ to 3 ft.
(enough room to allow for full orbit on suspended equipment); additional hooks recommended depending on
size of room
4. One or more rotational devices attached to ceiling support to allow 360 degrees of rotation
5. A quiet space (i.e., tent, adjacent room, or partially enclosed area)
6. One or more sets of bungee cords for hanging suspended equipment
Available Equipment
( Note: Facility requirements differ; therefore, similar equipment may be substituted.)
Does your facility have at least one of each of the following pieces of equipment?
CHAPTER 14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity ■ 343
1. Bouncing equipment (e.g., trampoline)
2. Therapy balls
3. Rubber strips or ropes for pulling
4. Platform swing—square
5. Glider swing—rectangular platform
6. Frog swing (sling swing for prone or sitting)
7. Scooter or ramp
8. Flexion disc swing
9. Bolster swing
10. Tire swing
11. Weighted objects, such as balls or beanbags in a variety of sizes
12. Inner tubes
13. Spandex fabric
14. Crash pillow or pad that can be moved quickly to cushion child ’ s impact when landing or bumping onto hard
surfaces
15. Ball pit or ball bag (large bag containing balls in which a child may play)
16. Variety of tactile materials and vibrating toys, such as massagers (e.g., textured fabrics, brushes, carpet square,
beans, rice, etc.)
17. Visual targets (e.g., balloons, Velcro darts, hanging objects)
18. Inclines or ramps
19. Climbing equipment (e.g., wooden, plastic, steps, ladders, or stacking tire tubes)
20. Barrels for rolling
21. Props to support engagement in play (e.g., dress up clothes, balls and bats, stuffed animals, dolls, puppets,
sports equipment, bikes)
22. Materials for practicing daily living skills (e.g., pencils, pens, and other school supplies; clothing, grooming, and
other home-related objects)
Communication with Parents and Teachers
1. Therapists routinely have ongoing interchanges with the child ’ s parents or teacher regarding the course of
intervention.
2. Therapists routinely discuss with the parents or teacher the infl uence of sensory integration and praxis on the
child ’ s performance of valued and needed activities.
3. Therapists routinely discuss with the parents or teacher the infl uence of sensory integration and praxis on the
child ’ s participation at home, in school, or in the community.
TABLE 14-2 Structural Elements of the ASIFM—cont’d
HERE ’ S THE EVIDENCE
Research on the ASIFM has revealed that the
total fi delity process score has high reliability
( ICC = .99, Cronbach ’ s alpha = .99) and is a valid
discriminator of ASI from alternative interventions ( Parham et al., 2011 ). Structural fi delity
items have evidence for:
• Content validity as determined by ratings of
international experts in ASI ( Parham et al.,
2011 )
• Inter-rater reliability and validity in
discriminating settings that provide ASI
intervention from those that do not,
indicated by analysis of ratings from
different groups of international therapists
with expertise in ASI ( Parham et al., 2011 ;
May-Benson et al., 2014 ).
beginning of this chapter. The measure was also
used to develop the Clinician ’ s Guide for Implementing Ayres Sensory Integration ® ( Schaaf &
Mailloux, 2015 ), a guidebook for training occupational therapists to provide ASI intervention based on the manualized treatment used in
Schaaf and colleagues ’ ( 2014 ) randomized trial.
The ASIFM guided and verifi ed the interventions provided in two randomized clinical trials
( Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011 ; Schaaf et al., 2013 ) as well as a
cohort study of children with autism spectrum
disorders ( Iwanaga et al., 2013 ). Future applications of the ASIFM may prove useful in identifying groups of children who are likely to be the
best responders to this intervention and in determining outcomes that can be expected from this
intervention at different dosages.
344 ■ PART IV Intervention
HERE ’ S THE POINT
• The ASIFM gives ready access to ASI to
guide the creation of direct interventions and
evaluate the fi delity of effectiveness research.
• The ASIFM includes process elements
that address both the art and science of
intervention and structural elements that
address contextual characteristics. Both are
equally important to fi delity.
• Data gathered with the ASIFM have shown
preliminary evidence for validity and reliability.
The ASIFM is beginning to be used to guide
research in occupational therapy.
The STEP-SI
■ Lucy J. Miller, PhD, OTR/L, FAOTA
The STEP-SI ( Miller, Wilbarger, Stackhouse, &
Trunnell, 2002 ) is another resource for making SI
theory accessible for direct intervention. Similar
to the ASIFM, the STEP-SI addresses both art
and science. In the publications of the STEP-SI
( Miller et al., 2002 ; Stackhouse, Trunnell, &
Wilbarger, 1997 ), the authors refer to it as a clinical reasoning model for intervention with children with sensory modulation disorder. But, of
course, promoting self-regulation is an important
principle for all children. See also Miller and
colleagues ( 2002 ) for additional detail.
The STEP-SI model was developed originally
for a randomized controlled trial evaluating the
effectiveness of sensory integrative therapy; it
is expressed in a treatment manual and a fi delity to treatment scale. In creating the STEP-SI,
expert occupational therapists extracted what
they considered to be the essential elements of
the therapeutic process from videotaped therapy
sessions. The acronym, STEP-SI, serves as a
prompt for remembering the active components
(dimensions) of treatment: S ensation, T ask,
E nvironment, P redictability, S elf-monitoring,
and I nteraction ( Miller et al., 2002 ). The therapist manipulates each of the STEP-SI dimensions
to support or challenge a child ’ s developmental
capacities, serving to develop capacities or skills
in identifi ed problem areas. The appropriateness of the child ’ s adaptive response becomes a
monitor that guides modifi cation of intervention.
The components or dimensions of the STEP-SI
intervention model comprise these variables:
S Sensation: Sensory modalities: tactile,
vestibular, proprioception, audition, vision,
taste, olfaction, oral input, and respiration.
Qualities of sensation: duration, intensity,
frequency, complexity, and rhythmicity.
T Task: Structure, complexity, demand
for skill, demand for sustained attention,
level of engagement, fun, motivation, and
purposefulness (based on standard task
analysis)
E Environment: Organization, complexity,
perceived comfort and safety, and
possibilities for engagement, exploration,
expansion, and self-challenge
P Predictability: Novelty, expectation,
structure, routine, transitions, and
congruency; level of control by child or
practitioner and control of events and
routines
S Self-Monitoring: Moving children from
dependence on external cues and supports
to a self-directed and internally organized
ability to modify their own behavior and
manage challenges
I Interactions: Interpersonal interaction style,
including responses to supportive, nurturing
styles vs. more challenging, authoritative
styles; locus of control (practitioner
guided vs. child directed); and demands or
expectations for engagement (i.e., passive
awareness to active collaboration)
General Principles of STEP-SI
The STEP-SI framework comprises a series of
implementation segments (aims) and questions
that guide intervention and assist therapists to
make effective decisions that maintain the fl ow
of a session. The method assists practitioners to
design interventions to impact a child ’ s ability
to self-regulate. This information, combined
with standardized assessment data, helps establish levels of adaptation in each of the STEP-SI
dimensions.
In the context of a session, a therapist uses the
implementation segments (aims) and questions to
think about each STEP-SI dimension and how the
child is responding. Which will be held constant
and which subtly changed? Once a practitioner
understands the child better by testing what challenges and supports the child, the practitioner
can balance multiple challenges with multiple
CHAPTER 14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity ■ 345
supports. The therapist’s goal within each treatment session is to keep the child moving forward
at a “just right” rate of challenge and achieving
a balance between child-directed activities and
challenges the child avoids. Therapists must
support the child right to the edge of his or her
ability to adapt, but not beyond. The push toward
the edge of adaptive ability allows children to
expand their adaptive capacities.
The general principles of the STEP-SI model
are also used to plan for future sessions. Clinicians refl ect after each session regarding the
appropriateness of activities, tasks, and the environment. The information gleaned is shared with
the family and used to make suggestions for the
child at home and in the community.
Intervention Segments (Aims)
In each session and afterward, the therapist
seeks to:
1. Understand the child ’ s arousal state and
adaptive capacity. The therapist determines
the child ’ s state of arousal and ability to
attain appropriate behavioral organization
and then seeks to help the child maintain
a level of arousal within an optimal range.
The therapist must be aware of the child ’ s
responses to challenges in the day or week
and compare the conditions that result in
organized versus disorganized responses.
2. Examine how each STEP-SI dimension
affects the child ’ s state of arousal and ability
to attain or maintain appropriate behavioral
organization. The therapist determines which
aspects of each STEP-SI dimension enable
the child to have the best adaptive response
and which challenge the child ’ s adaptation.
3. Prioritize the utilization of each STEP-SI
dimension to support or challenge children.
The therapist manipulates each dimension
of the model one at a time to maximize
appropriate levels of adaptation and
occupational performance.
4. Monitor and re-adjust each STEP-SI
dimension based on ongoing assessment of
adaptive responses. Once optimum adaptive
performance is achieved, the therapist
introduces another “just right challenge” by
altering some aspect of the situation. This
constant “upping the ante” while scaffolding
the child to maintain organization within
each new “challenge state” is the key to
making the adaptive changes suggested by
Ayres ( 1972 ).
The guiding questions listed here assist the therapist in implementing intervention and families
to understand and interact most effectively with
their child.
1. How does sensation serve to challenge or
support the child? What, if any, sensation
does the child crave? Avoid? Seem unaware
of? How do these craving, avoiding, or
unaware behaviors enhance or diminish the
child ’ s behavioral organization and functional
performance?
2. What kinds of tasks and qualities of tasks
serve to challenge or support the child?
What qualities of tasks, task structures, or
task complexity enhance or support the
child ’ s behavioral organization or functional
performance?
3. What kinds of environments and qualities
of the environment serve to challenge or
support the child? What qualities of the
environment or level of environmental
stimulation, enrichment, structure,
organization, and perceived safety enhance or
support the child ’ s behavioral organization or
functional performance?
4. How does predictability serve to challenge
or support the child? What qualities of
predictability, including child-controlled
actions, enhance or support the child ’ s
behavioral organization or functional
performance?
5. How does the child ’ s ability to self-monitor
serve to support him or her in challenging
situations? Can the child recognize which
strategies and activities help his or her own
internal state or his or her ability to complete
activities or have appropriate adaptive
responses?
6. How do interactions challenge or support the
child? What qualities of interactions (e.g.,
active scaffolding) enhance or support the
child ’ s behavioral organization or functional
performance?
Table 14-3 contains options for using the
STEP-SI dimensions to support a particular
child in a challenging activity in an upcoming
intervention session. Before beginning the intervention session, the therapist has nearby all the
346 ■ PART IV Intervention
TABLE 14-3 Example of the Use of STEP-SI Dimensions to Support a Challenging Sensory Activity
TASK ENVIRONMENT PREDICTABILITY SELF-MONITORING INTERACTION
Use structured
activities during
swinging on
bolster or a
motor challenge
(e.g., shooting
arrows at a target
during swinging
to practice for
battle).
Use low levels
of background
noise and light. Be
structured and neat.
Provide only a few
interesting options
for activities (e.g.,
clear the battle fi eld
so the great warrior
can focus).
Set up a routine
for beginning and
ending the session
with taking shoes off
and putting them
back on. Start with a
familiar activity from
the previous session.
Give the child control
through choices (e.g.,
warriors must have a
ritual they follow).
Provide a hideout
space. Give the child
verbal feedback
regarding when he
or she is able to
stay calm and when
he or she is getting
overwhelmed (e.g.,
use the hideout
when the battle
“gets too rough”).
Use a nurturing,
low demand, calm
and steady voice
(e.g., you are the
battle coach and
you don ’ t want the
other side to hear
you).
TABLE 14-4 Refl ective Questions for Therapists:
Following a Direct Intervention Session
• How did the child respond? What was the
adaptive response? Did the child or therapist fi nd
the just right challenge? Was any of the session
child-directed? Was the child purposeful and
intrinsically motivated? What worked to provide
support and appropriate challenges?
• What questions do you have for the next
intervention session?
sensory equipment and STEP-SI tools that he or
she will use in the session. Table 14-4 contains
refl ective questions the therapist might ask following a direct intervention session.
Establishing Specifi c Goals and Priorities
for STEP-SI Intervention
The primary focus of occupational therapy is
to assist children and families to improve their
occupational roles and functional performance.
Therapists may assist a child by remediating specifi c sensory or motor dysfunction but always in
the context of occupations and always focusing
on the family ’ s priorities ( Cohn, 2001a, 2001b ).
Although beyond the scope of this chapter,
Bialer and Miller ( 2011 ) emphasized that intervention guided by the STEP-SI model is situated
in goals to address occupational performance,
performance components, self-regulation, social
participation, and self-esteem.
HERE ’ S THE POINT
• STEP-SI is a clinical reasoning guide that
assists therapists to conduct direct intervention
sessions in the most effective and effi cient
manner for each individual child.
• STEP-SI directs therapists to consider six
dimensions that affect a child ’ s regulation and
performance: sensation, task, environment,
predictability, self-monitoring, and
interactions.
• Therapists can use the STEP-SI to reason
“in-the-moment” and reflect on a session
following its conclusion.
Models to Help Families Thrive
Not only therapists seek tools that give them
ready access to theory. Families also seek simple
ways to draw from SI theory in order to interact
effectively with their children in the context of
problematic everyday activities and routines. A
creative and fl exible problem-solving approach
can be even more useful than set techniques; the
latter begin to feel similar to the cookbook that
we try to avoid when applying ASI.
A SECRET
■ Lucy J. Miller, PhD, OTR/L, FAOTA
So many parents expressed that occupational
therapists seem to have “a secret” for solving
everyday problems of children with sensory
processing (i.e., sensory integrative) dysfunction
that Bialer and Miller ( 2011 ) used the acronym A
SECRET to defi ne a problem-solving approach
for parents and children. A SECRET is predicated on the notion that families and children
can manipulate any of seven elements to solve
CHAPTER 14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity ■ 347
problems wherever and whenever they arise—at
home, in school, or in the larger community. The
acronym provides an easy way to remember and
use problem-solving fundamentals in everyday
life. The seven elements of the acronym are as
follows:
A Attention
S Sensation
E Emotion regulation
C Culture
R Relationships
E Environment
T Tasks
The fi rst three elements—attention, sensation,
and emotion regulation—are internal characteristics that infl uence a child (i.e., internal
dimensions). The last four elements—culture,
relationships, environment, and tasks—are the
contextual elements that infl uence a child from
the outside (i.e., external dimensions).
In any problematic situation, a parent or
child who knows A SECRET can fi rst defi ne the
child ’ s problem area (e.g., will not sit through
dinner; cannot play successfully with a peer).
Then the therapist and parent can work together
to explore the elements of A SECRET to plan
for what can be done before or during a diffi cult
episode outside of therapy to assist the child in
regaining regulation:
A: Is there a way I can draw my child ’ s (or my)
attention away from this problem?
S: Is there a sensation that is alarming my
child (or me) right now? If so, what is it,
and can it be modifi ed? Can I use another
sensation to override the alarming one?
E: What emotion is my child (or am I)
experiencing, and what techniques do I
know to support emotion regulation for the
child (or myself) that work when the child
feels (or I feel) this way?
C: What part of the culture (context) can be
changed to avoid situations such as this
in the future? For example, upsets in the
grocery store: Could I do this activity
without my child? Could we do something
to change the activity or context to make
it easier or more pleasant for my child (or
for me) (e.g., couple the activity with a task
such as matching coupons to items selected
at the store)?
R: Is there something in a relationship with me
or someone else right now that ’ s causing my
child (or me) to act this way? What can I do
about it? Or how can I use the power of my
relationship to lessen the situation?
E: What in the environment is setting off my
child (or me)? How can I modify it? Or is
there something in the environment I can
use to help my child (or myself)?
T: What is troubling my child (or me) about
the task at hand? How can the task be
modifi ed so that it is not so problematic
for my child (or me)? Is there a task that I
can use to provide a calming infl uence? For
example, the problem area is that the child
is unable to maintain regulation during a
worship service. Can I discover what tasks
will keep the child engaged (e.g., a color-bynumber or dot-to-dot activity)?
Using the problem-solving approach defi ned by
A SECRET, families and children can incorporate workable strategies into daily routines—
getting up in the morning, eating, going to school
and work, coming home, doing homework, and
ending the day. For example, a child at risk for
melting down in the supermarket might have a
T ask that helps him get through the experience
more easily: “Can you cross off each item on
the shopping list when I fi nd it?” Or, that same
parent might alter her R elationship with the child
in the moment—if he ’ s little, picking the child
up and carrying him through the store or introducing an interactive game: “Let ’ s see who can
fi nd the most yellow boxes in this row.” Or, the
parent might provide S ensory input with a hard,
calming hug or a thick drink the child could suck
through a straw while shopping. More details for
implementing A SECRET are available in Bialer
and Miller ( 2011 ).
HERE ’ S THE POINT
• A SECRET is an example of a reasoning
tool that extends SI theory to families and
children for use in everyday activities and
routines.
• A SECRET describes both internal infl uences
(i.e., attention, sensation, and emotion
regulation) and contextual infl uences
(i.e., culture, relationships, environment,
and tasks).
348 ■ PART IV Intervention
• A SECRET involves guiding questions that help
a parent or child develop a strategy to address
problematic situations in context.
Summary and Conclusions
SI is arguably the most complex of the occupational therapy practice theories. The four resources
we presented in this chapter can guide therapists’ clinical reasoning and parents’ problemsolving in problematic situations by providing
them with ready access to SI theory.
As useful as it can be for evaluation and intervention, SI theory is only one practice theory
within the broad fi eld of occupational therapy.
For occupational therapy to be optimally effective, most children and families will require
intervention drawn from more than one practice
theory. Thus, therapists using SI theory to intervene with any particular child and family must
see how it fi ts into their broader professional
role.
Further, occupational therapy is only one
service that many families and children receive.
Therapists also must be clear about the place
of occupational therapy, as a whole, within the
health or educational services that a child and
family require. Many therapists have created
comprehensive programs that involve occupational therapy and SI but that go beyond them.
The STAR Treatment Model is one of those. We
include specifi c information about the STAR
model in Appendix A .
Where Can I Find More?
Bialer, D. S., & Miller, L. J. (2011). No longer
A SECRET: Unique common sense strategies
for children with sensory or motor challenges.
Phoenix, AZ: Future Horizons/Sensory World.
This book, written in simple language, provides
access to several strategies families can use in
the context of everyday routines to increase
their sustainability.
Miller, L. J., Wilbarger, J., Stackhouse, T., &
Trunnell, S. (2002). Use of clinical reasoning in occupational therapy: The STEP-SI
model of intervention of sensory modulation
dysfunction. In A. C. Bundy & S. J. Lane,
Sensory integration: Theory and practice
(2nd ed., pp. 435–452). Philadelphia, PA:
F. A. Davis.
The full STEP-SI model is published as an
appendix to the second edition of this text.
The authors describe use of the model in
assessment, intervention, and to develop
home and community programs. They provide
an in-depth case study to illustrate use of the
STEP-SI.
Parham, L. D., Roley, S. S., May-Benson, T.,
Koomar, J., Brett-Green, B., Burke, J. P., . . .
Schaaf, R. C. (2011). Development of a Fidelity Measure for research on Ayres Sensory
Integration. American Journal of Occupational Therapy, 65, 133–142. doi:10.5014/
ajot.2011.000745
Parham and colleagues describe the process for
developing the ASIFM.
References
Ayres , A. J. ( 1989 ). Sensory Integration and
Praxis Tests (SIPT) . Los Angeles, CA : Western
Psychological Services.
Ayres , A. J. ( 1972 ). Sensory integration and
learning disabilities . Los Angeles, CA : Western
Psychological Services.
Bialer , D. S. , & Miller , L. J. ( 2011 ). No longer
A SECRET: Unique common sense strategies
for children with sensory or motor challenges .
Phoenix, AZ : Future Horizons/Sensory World .
Cohn , E. S. ( 2001a ). From waiting to relating:
Parents’ experiences in the waiting room of an
occupational therapy clinic . American Journal of
Occupational Therapy, 55 ( 2 ), 167 – 174 .
Cohn , E. S. ( 2001b ). Parent perspectives of
occupational therapy using a sensory integration
approach. American Journal of Occupational
Therapy, 55 ( 3 ), 285 – 294 . doi:10.5014/
ajot.55.3.285
Iwanaga , R. , Honda , S. , Nakane , H. , Tanaka , K. ,
Toeda , H. , & Tanaka , G. ( 2013 ). Pilot study:
Effi cacy of sensory integration therapy for
Japanese children with high-functioning autism
spectrum disorder . Occupational Therapy
International, 21, 4 – 11 . doi:10.1002/oti.1357
Kazdin , A. E. ( 1994 ). A model for developing
effective treatments: Progression and interplay of
theory, research, and practice . Journal of Clinical
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L. D. , Koomar , J. , Schaaf , R. C. , . . . Cohn , E.
( 2014 ). Interrater reliability and discriminative
validity of the structural elements of the Ayres
Sensory Integration ® Fidelity Measure. © American
Journal of Occupational Therapy, 68, 506 – 513 .
doi:10.5014/ajot.2014.010652
CHAPTER 14 Distilling Sensory Integration Theory for Use: Making Sense of the Complexity ■ 349
Miller , L. J. , Wilbarger , J. , Stackhouse , T. , &
Trunnell , S. ( 2002 ). Use of clinical reasoning in
occupational therapy: The STEP-SI Model of
Intervention of Sensory Modulation Dysfunction.
In A. C. Bundy & S. J. Lane , Sensory integration:
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J. , Miller , L. , Burke , J. P. , . . . Summers , C. A.
( 2007 ). Fidelity in sensory integration intervention
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Parham , L. D. , Roley , S. S. , May-Benson , T. ,
Koomar , J. , Brett-Green , B. , Burke , J. P. ,
. . . Schaaf , R. C. ( 2011 ). Development of
a Fidelity Measure for Research on Ayres
Sensory Integration. American Journal of
Occupational Therapy, 65, 133 – 142 . doi:10.5014/
ajot.2011.000745
Pfeiffer , B. A. , Koenig , K. , Kinnealey , M. , Sheppard ,
M. , & Henderson , L. ( 2011 ). Effectiveness of
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Schaaf , R. C. , Benevides , T. , Mailloux , Z. , Faller , P. ,
Hunt , J. , van Hooydonk , E. , . . . Kelly , D. ( 2014 ).
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Schaaf , R. C. , & Mailloux , Z. ( 2015 ). Clinician ’ s
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Early Childhood Special Education, 31, 155 – 157 .
PART
V
Complementing
and Extending Theory
and Application
352
CHAPTER
15
Advances in Sensory
Integration Research:
Clinically Based Research
Sarah A. Schoen , PhD, OTR ■ Shelly J. Lane , PhD, OTR/L, FAOTA ■ Lucy J. Miller , PhD, OTR/L, FAOTA
Chapter 15
Research is formalized curiosity. It is poking and prying with a purpose.
—Zora Neale Hurston
Upon completion of this chapter, the reader will be able to:
✔ Identify and compare features of reportbased and performance-based measures used
in clinical research for evaluation of sensory
integrative disorders.
✔ Analyze the state of current intervention
research for sensory integrative disorder and
identify tools for enhancing rigor in intervention
research.
✔ Identify clinical outcomes that can be expected
to change following sensory integrative
interventions.
✔ Examine genetic, prenatal, and perinatal
factors influencing the development of sensory
integrative disorders and how these issues can
infl uence function and participation.
LEARNING OUTCOMES
Introduction
Sensory integration (SI), as described by Ayres,
refers to a theory, a group of clinical disorders, and a treatment approach ( Ayres, 1972a ).
Considerable research has been conducted to
support the identifi cation of clinical disorders,
and to examine treatment effi cacy and effectiveness. Ayres relied on early neuroscience
research (1960–1988) to gain insights into the
characteristics of sensory integrative disorders,
explain relationships among neurological processes and overt behaviors, and to develop an
intervention approach ( Ayres, 1972a ). SI theory
aims to increase our understanding of underlying
mechanisms that result in behavioral, emotional,
motor, and social diffi culties as well as problems
in learning. SI theory also highlights underlying
neuroscience principles that guide the clinical
practice and provides a rationale for the way
intervention is administered.
Although occupational therapists have been
using an SI frame of reference for decades,
controversy still exists regarding the effectiveness of this approach both within and outside
of the profession. Somewhat earlier research
found that evidence was promising but inconclusive ( Case-Smith, Weaver, & Fristad, 2015 ;
May-Benson & Koomar, 2010 ). In response to
the American Academy of Pediatrics (AAP)
statement in 2012 , Miller and colleagues state,
“We agree with the AAP committee ’ s conclusion
that caution is warranted in labeling the disorder;
treating the symptoms is much more important
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 353
than the diagnostic category into which the
label falls” ( Miller, 2012 , para. 2). In a systematic review, Schoen et al. (2019) concluded that
ASI is effective for children with autism. In fact,
the time is ripe for producing the scientifi c data
needed to establish sensory processing disorder
(SPD) as a unique diagnosis, often comorbid in
other clinical conditions in children and adults,
as well as evidence of the effectiveness of the
intervention.
As was noted in Chapter 1 (Sensory Integration: A. Jean Ayres’ Theory Revisited) relative
to SI theory, terminology in the research lacks
consistency. Although Ayres used “SI disorders,”
Miller and others chose to use the phrase “sensory
processing disorders” (SPD) to describe the same
phenomena. Further, the differentiation between
the collection of disorders identifi ed in Chapter 1
(Sensory Integration: A. Jean Ayres’ Theory
Revisited) and the specifi c category of sensory
modulation disorders (SMD) has also become
blurred. In this chapter, we will use sensory integrative disorders as the broad term; research that
looked at the full array of sensory integrative
concerns will be covered here. SMD will be used
when discussing research relative to modulatory
functions of the central nervous system (CNS).
Grouped under SMD we will present research
that has focused on sensory over-responsivity
(SOR). This will often differ from terminology
used in individual articles.
Purpose and Scope
The focus of this chapter is to unpeel the evidence supporting SI identifi cation and the
defi nition of SI disorders, links between neuroscience and behavior, and sensory integrative
treatment. We summarize recent advances in
applied research on sensory processing, modulation, and integration, focusing on disorders of
sensory modulation. We covered the vast body
of research on dyspraxia, including research on
related diagnoses such as developmental coordination disorder and links with autism spectrum
disorder, in Chapter 5 (Praxis and Dyspraxia)
and will not repeat that here. However, when
appropriate, we address aspects of motor function and dysfunction. A subsequent chapter will
address basic science research related to sensory
processing and SI.
Identifying and Defi ning
the Disorders; Research Related
to Assessment
An important prerequisite for acceptance and
defi nition of a disorder is a gold standard tool
that describes its characteristics. Because sensory
integrative disorders are not accepted by the
Diagnostic and Statistical Manual or International Classifi cation of Disorders, it is not yet
considered a “real” diagnosis or stand-alone
condition. The occupational therapy literature
contains many standardized measures, most of
which rely on informant report (parent, teacher,
caregiver); these will provide information “by
proxy” and should be interpreted carefully. There
is a growing awareness of the need for standardized performance measures of sensory modulation and SI to supplement these proxy report
measures in the evaluation and identifi cation of
sensory integrative disorders.
Rating Scales: Standardized
Report Measures
The most widely used report measures are the
family of assessments known, collectively, as
the Sensory Profi le (SP), developed by Dunn
( 1999, 2006, 2014 ) and Brown and Dunn ( 2002 ).
Recently revised, the Child SP TM 2, the School
Companion SP TM 2, and the Short SP TM 2 are
applicable to children from 3 to 10 years of age
( Dunn, 2014 ). Also included in this revision are
the Toddler SP TM 2 and the Infant SP TM 2, for
children 7 to 35 months of age and birth to 6
months of age, respectively. The Adolescent and
Adult SP is applicable for children 11 years of
age and older ( Brown & Dunn, 2002 ). The SPs
examine sensory processing patterns in individuals who are at-risk or have specifi c disabilities
related to sensory processing issues. Responses
are based on self- or caretaker reports. Resulting
profi les from the measures highlight the effects
of impaired sensory processing on functional
performance in the daily life of an individual.
The original scales were standardized nationwide
(samples ranging from 500 to 1,200); the revised
tools were standardized on samples ranging from
n = 68 (Infant) to n = 697 (Child SP2, Short SP2,
and School Companion SP2). Information on
reliability of the SP TM 2 and the Adolescent and
354 ■ PART V Complementing and Extending Theory and Application
Adult SP can be found in Table 15-1 . Discriminate and convergent validity have been examined
by the authors and is available in the manuals for
each tool ( Brown & Dunn, 2002 ; Dunn, 2014 ).
The Sensory Processing Measure TM (SPM:
Parham, Ecker, Kuhaneck, Henry, & Glennon
[ 2010 ]) is modeled on diagnostic subtypes in the
Diagnostic Manual for Infancy and Early Childhood: Mental Health, Developmental, RegulatorySensory Processing and Language Disorders
and Learning Challenges (ICDL-DMIC Work
Groups, 2005 ) and the DC: 0-3 ( Zero to Three,
2005 ). Not unlike the SP, the SPM has versions
for children 5 to 12 years of age and for preschool children from 2 to 5 years of age (SPM
Preschool). The SPM screens for SOR, sensory
under-responsivity (SUR), and sensory seeking,
as well as posture, praxis, and discrimination
challenges specifi cally with both home (caretaker) and school (teacher) scales. The SPM
was standardized on 1,051 children in grades K
through 6 and the SPM-P on 893 children from
2 to 5 years of age. Both have excellent reliability
(scale internal consistencies range from 0.75 to
0.95; 2-week test-retest correlations range from
0.94 to 0.98) and validity (evidence for validity includes factor analytic studies, correlational
results, and clinical discrimination studies). False
positive rates are 15% using a cutoff T -score of
60 (lower bound of “Some Problems”) and 2%
using a cutoff T -score of 70 (lower bound of
“Defi nite Dysfunction”). Table 15-2 provides a
comparison of features offered by the SP2 and
the SPM.
In order to improve the diagnosis of SMD in
adults, a newer scale, the Sensory Responsiveness Questionnaire (SRQ; Bar-Shalita, Vatine, &
Parush, 2008 ), was developed as a comprehensive measure to assess SMD in adults 20 to
60 years. This self-report questionnaire contains
58 items representing all sensory modalities.
The tool uses a fi ve-point Likert scale on which
individuals respond to two previously understudied components of SPD: “intensity of affective response to sensory stimuli” and “frequency
of occurrence of affective responses.” The questionnaire had high test-retest reliability ( r = 0.71
to 0.74), moderate criterion validity ( r = 0.34 to
0.61), and strong signifi cant construct validity.
In addition to scales specifi cally designed
for individuals with SI and processing disorders, there have been a growing number of
non-standardized parent and self-report measures
designed to assess sensory modulation dysfunction in other clinical populations. The goals are
to promote improved differential diagnosis and
to inform development of future report measures.
Most notable are three caregiver or parent report
measures: The Sensory Experiences Questionnaire ( Baranek, David, Poe, Stone, & Watson,
2006 ); the Sensory Sensitivity Questionnaire
( Minshew & Hobson, 2008 ; Talay-Ongan &
Wood, 2000 ); and the Diagnostic Interview for
Social and Communication Disorders (DISCO;
Leekam, Libby, Wing, Gould, & Taylor, 2002 ).
The Sensory Experiences Questionnaire is a brief
questionnaire for caregivers designed to refl ect
behavioral responses to typical daily sensory
experiences in infants, toddlers, and young
children (ages 5 months to 6 years of age). Its
primary purpose is to discriminate symptoms of
SOR from SUR. The questionnaire has strong
internal reliability consistency ( α = 0.8) and
discriminates between children with autism,
TABLE 15-1 Reliability for the Sensory Profi le 2 Tools
INTERNAL CONSISTENCY TEST/RETEST RELIABILITY INTER-RATER RELIABILITY
Infant 0.75 0.86
Toddler 0.57–0.8 0.83–0.92
Child 0.60–0.90 0.87–0.97 0.49–0.89
School 0.81–0.92 0.66–0.93 0.53–0.90
Child/Short 0.79–0.93 0.93–0.97
Adolescent/Adult 0.64–0.78
Note: Adapted from Pearson. ( 2005 ). Adolescent/Adult Sensory Profi le technical summary. Downloaded 7-31-2015 from http://www
.pearsonclinical.com/therapy/products/100000434/adolescentadult-sensory-profi le.html#tab-resources ; and Pearson ( 2014 ). Sensory
Profi le 2 technical summary. Downloaded 7-31-2014 from http://www.pearsonclinical.com/therapy/products/100000822/sensory
-profi le-2.html#tab-resources .
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 355
developmental delays, and typical controls. The
Sensory Sensitivity Questionnaire is a self-report
measure that consists of 13 items related to SOR.
Signifi cant differences are reported between
the autism and control groups for tactile sensitivities as well as sensitivity to heat, cold, and
pain. In addition, there were important individual differences within the autism sample with
some individuals showing substantial sensory
sensitivities and others scoring within a typical
range. The DISCO is a semi-structured parent
interview designed to recognize and identify the
impairments and core features of autism spectrum disorders ( Wing, Leekam, Libby, Gould, &
Larcombe, 2002 ). It includes 25 sensory items
that are similar to items on the Sensory Profi le
( Kientz & Dunn, 1997 ). A child ’ s response to
sensory stimuli is rated as “marked abnormality,”
“minor abnormality,” or “no problem” ( Leekam,
Libby, Wing, & Gould, 2007 ).
Standardized Performance Measures
The Sensory Integration and Praxis Test (SIPT;
Ayres, 1989 ) scale has been widely used by
occupational therapists to evaluate SPD based on
Ayres’ ( 1972a ) constructs. Standardized nationwide on 1,997 children, the SIPT includes
17 subtests, each having separate reported reliability and validity. More information on the
TABLE 15-2 Comparison of Sensory Profi le (SP) and Sensory Processing Measure (SPM)
FORMS
PUBLICATION
YEAR AGES SCORES
SP2; Adolescent/
Adult SP
• Infant SP2
• Toddler SP2
• Child SP2
• School Companion
SP2
• Short SP2 (SSP2)
• Adolescent and
Adult SP (AASP)
2014
2002
Infant SP2: birth–6
mo
Toddler SP2: 7–35
mo
SP2, School
Companion SP2,
SSP2: ages 3–10
yrs
AASP: 11 yrs +
Sensory section
• Auditory
• Visual
• Touch
• Movement
• Body position
• Oral
Behavioral section
• Conduct
• Social-emotional
• Attention
Sensory quadrant
• Registration
• Seeking
• Sensitivity
• Avoiding
School Companion SP2,
School Factors
• Supports
• Awareness
• Tolerance
• Availability
SPM SPM Preschool
SPM Home, Main
Classroom, School
Environments
2010
2007
2–5 years
5–12 years
Home and Main Classroom,
8 scores:
• Social participation
• Vision
• Hearing
• Touch
• Body awareness
(proprioception)
• Balance and motion
(vestibular function)
• Planning and ideas (praxis)
• Total sensory systems
356 ■ PART V Complementing and Extending Theory and Application
SIPT can be found in Chapter 8 (Assessment of
Sensory Integration Functions Using the Sensory
Integration and Praxis Tests). Content, construct,
and discriminative validity have been examined for the SIPT ( Carrasco, 1991 ; Lai, Fisher,
Magalhaes, & Bundy, 1996 ; Royeen, Koomar,
Cromack, & Fortune, 1991 ; Royeen & Mu,
2003 ; Walker & Burris, 1991 ) and include the
many factor analyses conducted by Ayres ( 1969,
1972b, 1977, 1989 ) and others ( Mailloux et al.,
2011 ; Mulligan, 1998 ). Table 11-3 in Chapter 11
(Interpreting and Explaining Evaluation Data)
provides a summary of the outcomes of factor
analyses. The largest of these, using more than
10,000 SIPT protocols, used structural equation
modeling as a means of confi rming existing factor
models and exploring models that might produce
a better fi t for existing data ( Mulligan, 1998 ).
This work confi rmed that sensory integrative
disorders are multidimensional. Mulligan found
that the SIPT defi nes one higher order model,
which she termed practic dysfunction, as well as
four fi rst order factors (visual perceptual defi cit,
bilateral integration and sequencing defi cit, dyspraxia, and somatosensory defi cit). Although the
SIPT does not provide a direct measure of SMD,
clinical observations of the child ’ s performance
on specifi c subtests ( Fig. 15-1 ) provide important information regarding the presence of SOR,
SUR, or sensory craving symptoms.
Mailloux and colleagues ( 2011 ) combined
information from the SIPT, items chosen from
the SPM to refl ect tactile defensiveness, and
behavior ratings of attention in their factor analysis. They also found that a four-factor solution
was the best fi t for the data:
• Visuodyspraxia and somatodyspraxia,
verifying previous work, and substantiating
disorders of praxis
• Vestibular and proprioceptive bilateral
integration and sequencing (vestibular and
proprioceptive BIS), substantiating the
hypothesized relationship between vestibular
under-responsivity and other measures of
vestibular and bilateral function
• Tactile and visual discrimination, similar to
a sensory factor found by both Ayres and
Mulligan
• Tactile defensiveness and attention problems,
substantiating this proposed link
Additional Measures of Performance
and Parent or Self-Report
A review of the occupational therapy literature
demonstrates some early attempts to develop
a performance measure specifi c to SMD. One
involved the development of an observation
scale that categorized the clinician ’ s observations of responses to tactile stimulation ( Bauer,
1977 ), another was a scale piloted on children
with severe cognitive defi cits ( Kinnealey, 1973 ),
and a third was developed to measure tactile
over-responsivity in children with developmental
disabilities ( Baranek, 1998 ).
There has been a growing realization of the
importance of performance measures in accurately assessing sensory integrative disorders in
other clinical populations. Most notably is the
work of Baranek and colleagues ( 2007 ) who
have been developing the Sensory Processing
Assessment for children with autism and developmental delays. This play-based assessment is
designed to characterize sensory processing patterns of hyper- and hypo-responsiveness in the
auditory, visual, and tactile domains for children
with ASD, from 6 months of age to 6 years of
age, based on whether the stimuli are social or
nonsocial. None of these scales is readily available for use by clinicians, and limited normative
data has been reported.
Miller and colleagues have been working on
a standardized method to assess SMD through
the development of the Sensory Processing
3 Dimensions Scale, previously known as the
Sensory Processing Scale (SP3D; Schoen,
Miller, & Green, 2008 ; Schoen, Miller, & Sullivan, 2014 ). In development since 2004, the
FIGURE 15-1 The SIPT provides a performance-based
measure of sensory discrimination and praxis abilities
for children from 4 years of age to 8 years,
11 months of age.
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 357
SP3D scale measures sensory processing in
all sensory domains (vision, audition, touch,
olfaction, taste, proprioception, and vestibular;
Fig. 15-2 ). The scale includes both a parent or
self-report inventory ( Schoen, Miller, & Sullivan,
2016 ) and a performance assessment where specifi c standard items are administered by a trained
examiner. Psychometrics of the instrument were
established in three stages of study: (1) instrument development; (2) reliability and validity of
the research edition; and (3) cross-validation of
fi ndings on the research edition with a second
sample. Analyses of the SOR portion of the
SP3D revealed moderate to high internal consistency of reliability for the domains ( α = 0.60
to 0.89) and the total test ( α = 0.92). The reliability estimates for the SOR Inventory (parent
report companion) ranged from α = 0.65 to 0.88
for the domains and 0.97 for the total test. Both
the total test and domain scores discriminated
groups (over-responsive vs. typically developing) at a meaningful and statistically signifi cant
level (signifi cance by domain ranged from p <
.05 to p < .001) ( Schoen et al., 2008 ). Preliminary evidence was found for construct validity
through factor analyses and by the signifi cant
relations between the assessment subtest and its
corresponding inventory subtests. Evidence that
both the performance measure and the caregiver
report measure are needed is highlighted by their
moderate correlation, near 0.40, suggesting that
different information is provided by the respondent versus direct observation scales.
Recently the SP3D was expanded to include
SUR and sensory craving ( Schoen et al., 2014,
2016 ). Both the parent or self-report measure and
a performance assessment have been fi eld tested.
Following item reduction, reliability and validity at the level of sensory domains and total test
was established. Factor analysis confi rmed the
theoretical structure of sensory modulation subtypes. Similarly, the new assessment appears to
be a reliable and valid measure of sensory modulation (scale reliability, α > 0.90; discrimination
between groups’ effect sizes > 1.00) ( Schoen
et al., 2014 ). The preliminary psychometric integrity of the scale and its clinical utility provide an
important contribution toward development of
a “gold-standard” to evaluate SMD. This scale
has the potential to aid in differential diagnosis
of sensory modulation issues. Mailloux and colleagues (Mailloux, Parham, Roley, Ruzzano, &
Schaaf, 2018) are standardizing, worldwide, a
new performance-based assessment for children
3 to 12 years. The Evaluation of Ayres Sensory
Integration (EASI) measures sensory perception,
sensory responsiveness and motor abilities. Preliminary investigation yielded evidence for good
construct validity and internal reliability.
HERE ’ S THE POINT
• SMDs have been most commonly assessed
using caregiver report tools such as the Sensory
Profi le and the SPM.
• Performance-based assessments, such as the
SIPT, have been used clinically and in research;
more performance-based measures are
currently in development.
• Factor analyses conducted during the past
several years largely support each other and
confirm the existence of hypothesized patterns
of dysfunction.
Research Related to Intervention
To be consistent with the American Occupational
Therapy Association ’ s Centennial Vision, interventions we employ must be science-driven and
evidence-based. As stated in the 2011 research
agenda ( AOTA, AOTF, 2011 ), interventions
must be defi ned, described, and tested. This has
been an area of concern, particularly for research
related to SI. There is a long history of misinterpretation, with researchers reporting on sensorybased interventions that do not adhere to the
techniques and principles of SI as defi ned by
FIGURE 15-2 The SP3D scales are currently in
development and will include both report and
performance-based measures of sensory modulation.
358 ■ PART V Complementing and Extending Theory and Application
Ayres and subsequent researchers. Therefore,
evaluating the literature on the effectiveness
of SI means knowing that it is not the same as
using a weighted vest ( Cox, Gast, Luscre, &
Ayres, 2009 ; Fertel-Daly, Bedell, & Hinojosa,
2001 ; Hodgetts, Magill-Evans, & Misiaszek,
2011a, 2011b ; Kane, Luiselli, Dearorn, & Young,
2004 ; Leew, Stein, & Gibbard, 2010 ; Reichow,
Barton, Sewell, Good, & Wolery, 2010 ), applying a brushing protocol ( Davis, Durand, & Chan,
2011 ), swinging, jumping, bouncing on a ball,
being wrapped in a blanket ( Devlin, Healy,
Leader, & Hughes, 2009 ; Van Rie & Hefl in,
2009 ), sitting on a ball chair ( Bagatell, Mirigliani, Patterson, Reyes, & Test, 2010 ; Schilling &
Schwartz, 2004 ), or a sensory diet ( Fazlioglu &
Baran, 2008 ). Readers are reminded to refer to
Chapter 12 (The Art of Therapy) and Chapter 13
(The Science of Intervention: Creating Direct
Intervention from Theory), respectively, for thorough defi nitions and descriptions of the sensory
integrative approach.
The gold standard for outcome studies is
randomized controlled trials ( Bury & Mead,
1998 ) comparing the targeted intervention with
an alternative treatment, an active placebo, or a
passive placebo or no treatment condition (e.g., a
wait-list). Criteria for rigorous randomized trials
are well established ( Boruch, 1997 ; Friedman,
Furberg, & DeMets, 2015 ) and mandate inclusion of four primary criteria: (1) an objectively
defi ned sample that is homogeneous with regard
to the impairment studied ( Bulpitt, 1983 ); (2) a
“manualized intervention” where treatment is
detailed in a manual that others can obtain to
replicate the procedures ( Boruch, 1997 ) with
a method to monitor adherence to the specifi ed delivery of treatment ( Ottenbacher, 1991 );
(3) outcomes that are meaningful, appropriate,
and sensitive to hypothesized changes ( Fuhrer,
1997 ); and (4) methodology that is rigorous
(e.g., [a] random allocation to experimental and
control treatment groups, [b] blinded outcome
evaluators, and [c] adequate power to evaluate
the signifi cance of effects [ Jadad, 1998 ]).
Previous Studies of Occupational
Therapy with a Sensory-Based
Approach
Before 2007, there was little consensus in the literature as to the effectiveness of the SI approach.
In spite of relatively universal agreement about
the lack of well-controlled outcome studies, signifi cant controversy existed regarding the interpretation of the fi ndings of published articles
from the fi eld regarding the effectiveness of
occupational therapy using a sensory integrative
approach. Relevant publications included two
meta-analyses ( Ottenbacher, 1982b ; Vargas &
Camilli, 1999 ) and four research syntheses
( Arendt, MacLean, & Baumeister, 1988 ; Hoehn &
Baumeister, 1994 ; Polatajko, Kaplan, & Wilson,
1992 ; Schaffer, 1984 ). One meta-analysis suggested that the intervention approach did have a
positive effect, but the article is over 30 years old
( Ottenbacher, 1982a ). The four review articles
concluded that previous studies were not rigorous
enough to make valid conclusions; at the same
time, they concluded that occupational therapy
was not effective. The other meta-analysis
suggested that SI was more effective than no
intervention in earlier studies, but it had no positive treatment effect in later studies; SI was
found to be as effective as alternative interventions ( Vargas & Camilli, 1999 ), but signifi cant
methodological fl aws in the SI articles were
identifi ed in this paper, including: (1) studies had
extremely small sample sizes (median sample
size = 4.5 for 13 studies), (2) samples were heterogeneous regarding diagnostic groups, (3) such
general descriptions of treatment were provided
that replication was impossible, and (4) studies
had such poor power that an effect was unlikely
to be detected if present (type 2 error). These
reviews found that none of the research studies
published previously that evaluated treatment
outcomes met all four rigorous criteria for a randomized trial (and often did not meet even one
criterion) ( Miller, 2003 ). Thus, as of 2003, the
only accurate conclusion that could be proffered
was that no rigorous evidence exists supporting
or denying the effectiveness of this treatment.
Since these reviews were conducted, there
have been 12 additional studies, eight of which
were included in the systematic review described
next.
In 2010, a systematic review of evidence for
the effectiveness of SI was published in a special
issue of the American Journal of Occupational
Therapy ( May-Benson & Koomar, 2010 ). This
review paper included 27 research studies conducted from 1972 through 2007. In addition, specifi c inclusion criteria were used for the selection
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 359
of qualifying studies such as (1) authors had
reported the intervention was based on an SI
approach, (2) participants identifi ed as having
defi cits in sensory processing and integration,
and (3) control groups refl ected children with
clinical problems.
This review makes an important contribution
to the literature by analyzing studies based on
the level of evidence as well as examining specifi c outcome areas. Low-level evidence includes
such things as expert opinion and case reports;
the highest level of evidence is refl ected in randomized controlled trials and meta-analyses.
Levels of evidence are often depicted using a
pyramid, such as that in Figure 15-3a , or a table,
as in Figure 15-3b .
Reported are 13 level I randomized controlled
trials, fi ve level II studies, three level III studies,
and six level VI studies. Results are as follows:
In the area of motor performance, improvements
were noted in 10 out of 14 studies for fi ne and
gross motor skills ( Fig. 15-4 ), motor planning
abilities, and participation in gross and fi ne motor
play. In terms of sensory processing, seven out
of 13 studies reported a positive outcome including improvements in sensory discrimination, a
reduction in sensory defensiveness, and changes
in physiological sensory reactivity. Behavioral
outcomes were identifi ed in six studies reporting changes in attention, self-esteem, social
interaction, and decreased disruptive behaviors.
Academic and psychoeducational outcomes
were used in 12 studies, with six showing positive gains in such skills as reading, math, and
visual performance. Overall fi ndings suggested
that these gains were at least as positive as gains
FIGURE 15-3a When a pyramid is used to depict
levels of evidence, then level I is the highest.
Metaanalyses
Systematic
reviews
RCTs
Cohort studies
Case-control studies
Case reports/Case series
FIGURE 15-3b The benefi t of using a table to present levels of evidence is that it includes the numeric levels.
Strength
High
Low
Level
Level 1
Level 2
Level 3
Level 4
Level 5
Design
Randomized control trial (RCT)
Meta-analysis of RCT with homogeneous results
Prospective comparative study (therapeutic)
Meta-analysis of Level 2 studies or Level 1
studies with inconsistent results
Retrospective cohort study
Case-control study
Meta-analysis of Level 3 studies
Case series
Case report
Expert opinion
Personal observation
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Randomization Control
FIGURE 15-4 Sensory integrative intervention has
been shown to help improve motor planning abilities
and increase children ’ s participation in gross and fi ne
motor play.
360 ■ PART V Complementing and Extending Theory and Application
achieved by alternative interventions. Only three
studies examined changes in occupational performance outcomes using individualized goals.
Most promising for future research, all these
studies demonstrated signifi cant gains in parentidentifi ed goals.
Miller and colleagues’ treatment studies,
included in the previous review ( Miller, Coll, &
Schoen, 2007 ; Miller, Schoen, James, & Schaaf,
2007 ), attempted to correct previous research limitations by utilizing a homogeneous sample, manualized treatment, outcome measures sensitive to
change from treatment, and rigorous methodology. Results of the pilot treatment study (without
control groups) demonstrated signifi cant pre-post
changes from treatment ( Miller, Schoen, et al.,
2007 ) and provided needed data for implementing a randomized treatment trial. Subsequently,
Miller and colleagues ( Miller, Coll, et al., 2007 )
conducted a pilot randomized controlled trial of
the effectiveness of occupational therapy in children with a sensory integrative disorder. They
evaluated the effectiveness of three treatment
groups: occupational therapy, an active placebo
called the Activity Protocol (a play protocol),
and a passive placebo (e.g., wait-list condition).
Twenty-four children were randomly assigned to
one of the three treatment conditions. Pre- and
post-measures of behavior, sensory function,
adaptive function, and physiology were administered. The manualized treatment was administered twice a week for 10 weeks in 50-minute
sessions. Fidelity to the treatment protocol, or the
extent to which the treatment was carried out as
intended, was analyzed using a Fidelity Measure
created for this study and later expanded for
future research (Parham, Ecker, et al., 2007).
The Fidelity Measure captures the structural and
process elements that are core to SI intervention.
Results demonstrated that the group that received
occupational therapy, compared with the other
two groups, made signifi cant gains on individualized goals using Goal Attainment Scaling
(GAS) ( p < 0.001), on attention measures, and
on the Cognitive/Social Composite of the Leiter
International Performance Scale-Revised ( Roid &
Miller, 1997 ) ( p = 0.02). For both the Short
Sensory Profi le (SSP) total test score and the
Child Behavior Checklist (CBCL) internalizing
composite score, change scores were greater, but
not signifi cant, in the hypothesized direction for
the occupational therapy group. Physiologically,
a small subsample of the occupational therapy
group showed greater reduction in amplitudes of
electrodermal reactivity (EDR) compared with
the other two groups, although not signifi cant
due likely to the small sample size.
Since publication of these pilot studies, there
have been two additional randomized controlled
trials published, one conducted by Pfeiffer and
colleagues ( 2011 ) and the other by Schaaf and
colleagues ( 2014 ). Both studies addressed the
question of effectiveness of SI intervention for
children with ASD.
The pilot treatment study by Pfeiffer and
colleagues ( 2011 ) sought to expand on Miller ’ s
model for randomized controlled trial research
and to identify appropriate outcome measures for
children with autism spectrum disorder. Thirtyseven children between 6 and 12 years of age
participated; fi ve were female. Intervention consisted of eighteen 45-minute sessions during
a 6-week period. Twenty children received
SI intervention, and 17 received a fi ne motor
intervention. Fidelity to treatment was examined by scoring videotaped sessions using the
fi delity instruments. Results showed signifi cant
improvement in autism mannerisms and significant progress toward individualized goals. No
signifi cant differences were found in sensory
processing as measured by the SPM (Parham,
Ecker, et al., 2007) or in neurological integration
as measured by the Quick Neurological Screening Test-3 ( Mutti, Martin, Sterling, & Spalding,
2011 ). These fi ndings supported earlier fi ndings
obtained by Watling and Dietz ( 2007 ) and Smith
and colleagues ( 2005 ). In particular, in a singlesubject multiple-baseline design of four children with ASD, Watling and Dietz ( 2007 ) found
a reduction in stereotypical movement patterns
after a latency period, although not immediately
after treatment. Similarly, Smith and colleagues
( 2005 ) conducted a two-group non-randomized
controlled trial with seven adolescents who
were severely impaired with self-stimulatory
and self-injurious behaviors. They found a
reduction of 11% in self-stimulation at 1 hour
post-intervention.
Schaaf and colleagues ( 2014 ) conducted a
randomized controlled trial of SI intervention for
32 children from 4 to 8 years of age with ASD.
Subjects were assigned randomly to the SI group
or to the usual care control group. Treatment
was provided in 1-hour sessions, three times a
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 361
week during 10 weeks. Building on the previous SI randomized controlled trials, this study
utilized a manualized protocol and a validated
measure of treatment fi delity (Parham, Ecker,
et al., 2007; Parham et al., 2011). In addition,
pre- and posttest evaluators were blind to each
child ’ s treatment condition. The primary fi ndings
of this study were as follows: Children in the SI
group showed greater improvements in individualized goal attainment, needed signifi cantly less
caregiver assistance during self-care and social
activities, and showed a decrease in sensory-related behaviors that interfere with daily life.
These positive preliminary fi ndings suggest
the need for completion of a larger randomized
controlled trial of the effectiveness of occupational therapy using an SI treatment approach,
so that a more defi nitive conclusion can be
offered with reasonable assurance that results
are not attributable to chance and that external
and internal sources of invalidity have been fully
controlled.
Future Directions
Based on the studies described previously, there
are several factors that need to be considered
in future research. Studies need to improve the
homogeneity of the participants and increase
sample sizes to improve statistical power.
Further exploration of duration and intensity
is needed as well as consistency across studies
related to the frequency, duration, and amount of
intervention provided. Studies need to focus on
outcome measures that are meaningful and relevant to changes valued by clients and families
and that are based on occupational performance
or participation. In particular, measures of direct
PRACTICE WISDOM
Whether you are working with children with
sensory integrative disorders in a clinic, community
setting, or in a school, setting goals and measuring
progress can be challenging. This is particularly true
if you are trying to measure progress in a group of
children who all have very specifi c needs and individualized goals. GAS has gained popularity during
the past decade as a means of setting individualized
goals but scaling them all in the same way as to
allow meaningful comparisons. When using GAS,
a specifi c goal is developed with the client and set
on a scale that ranges from least to most favorable
outcomes. Points on the scale are given objective
descriptions and are assigned numerical values (for
instance, –2 for the least favorable outcome, 0 for
the most likely treatment outcome, and +2 for the
most favorable treatment outcome). Thus, this scale
has a mean value of zero and a standard deviation
of 1. Although GAS has been used for goal setting
in high-level research studies (see Miller, Coll, et al.,
2007 ; Pfeiffer, Koenig, Kinnealey, Sheppard, &
Henderson, 2011 ; Schaaf et al., 2014 ), it also may
be useful in clinical settings for program evaluation and in schools for monitoring progress of students ’individualized education plans. GAS has the
advantage of being low cost and useful for tracking
progress across a variety of treatment goals. One
crucial challenge in establishing GAS goals is in
defi ning the outcomes; the challenge for the child
to move from a “0” to a “1” must be equivalent
to the challenge in moving from a “1” to a “2.”
Outcomes must be considered carefully. Training in
the use of GAS is available and will help in learning
how to best establish outcome scales. Here is an
example of how GAS could be used with a child
with sensory integrative disorder:
Goal: Increase sequencing and planning abilities as a basis for getting ready for school in the
morning.
Current Level of Functioning: At 12 years of age,
Meghan currently needs 20 to 30 verbal prompts
from her mother to sequence her morning routine,
which includes getting dressed, putting on deodorant, brushing her teeth, eating breakfast, and
packing her lunch and belongings for school. Even
with support, Meghan almost always will leave the
house having forgotten something.
Goal Attainment Scaling:
• +2 (most favorable outcome likely): Will get
ready in the morning with 0 to 4 verbal
prompts
• +1 (greater than expected outcome): Will
get ready in the morning with 5 to 9 verbal
prompts
• 0 (expected outcome): Will get ready in the
morning with 10 to 14 verbal prompts
• –1 (less than expected outcome): Will get ready
in the morning with 15 to 19 verbal prompts
• –2 (most unfavorable outcome): Will get ready
in the morning with 20 + verbal prompts
362 ■ PART V Complementing and Extending Theory and Application
observation are needed to supplement existing
caregiver questionnaires. Continued efforts need
to be directed toward the development of intervention manuals that provide a description of
the intervention along with a measure to demonstrate fi delity to the intervention. Although this is
being done more often, we need to be consistent
in using these tools. Most existing studies measured change immediately following intervention. However, what is not known is how long
the effects of treatment last.
HERE ’ S THE POINT
• Research has shown that interventions using
a sensory integrative approach improve motor
planning, participation, motor skills, self-care,
behavior, academic, and psycho-educational
outcomes.
• Research on the effectiveness of sensory
integrative intervention is ongoing, with studies
aiming for greater power, consistency, and
a focus on functional outcomes. Currently
there is some evidence supporting sensory
integration intervention as an evidence-based
and effective intervention.
Research Related to the Disorders
Examination of sensory integrative disorders has focused most extensively on disorders of modulation and, within this category,
on the identifi cation and understanding of
sensory over-responsiveness. There is some,
albeit limited, data on sensory integrative disorders as a whole, and another body of investigation focused on praxis and postural control
HERE ’ S THE EVIDENCE
In their 2007paper, “Fidelity in Sensory Integration Research,” Parham, Cohn, and colleagues
used expert review and a nominal group process
to identify core SI intervention elements. Findings
were organized into structural elements (observable
and easily quantifi ed characteristics, such as environmental features and professional training of the
therapist) and process elements (dynamic qualities of
the intervention, such as therapeutic alliance, which
are often more diffi cult to measure). Structural elements of SI intervention identifi ed in the literature
included professional training of the interventionist
who was usually an occupational therapist as well as
the presence of equipment such as scooter boards,
suspended equipment, and tactile materials. Core
process elements of SI intervention were also identifi ed and included provision of the following:
• Sensory opportunities
• Just-right challenges
• Collaboration with the child on activity choice
• Support for the child ’ s self-organization
• Support for maintenance of optimal arousal
• Creating a context of play
• Maximizing the child ’ s success
• Ensuring physical safety
• Arrangement of the room to entice
engagement
• Fostering of a therapeutic alliance
The authors noted in their review that most published studies did not address fi delity in their
research design and subsequently identifi ed the
need for a fi delity instrument to measure adherence
to the underlying intervention principles related to
Ayres Sensory Integration ® (ASI) theory. In 2011,
Parham and colleagues published a follow-up
paper entitled “Development of a Fidelity Measure
for Research on the Effectiveness of the Ayres
Sensory Integration ® Intervention.” In this paper, a
fi delity instrument intended to measure the structural and process aspects of ASI is presented along
with assessment of the tool ’ s reliability and validity.
Overall, the tool was found to have strong content
validity and was deemed to be reliable when scored
by trained raters with expertise in ASI. These papers
provide an outline of what should be included in
interventions claiming to be SI intervention and
provide a tool (the fi delity instrument) that can be
used to enhance the rigor of clinical research.
Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J., Miller, L. J., Burke, J. P., . . . Summers, C. A. (2007). Fidelity in sensory integration
research. American Journal of Occupational Therapy, 61(2), 216–227.
Parham, L. D., Smith Roley, S., May-Benson, T. A., Koomar, J., Brett-Green, B., Burke, J. P., . . . Schaaf, R. C. (2011). Development of
a Fidelity Measure for research on the effectiveness of the Ayres Sensory Integration ® Intervention. American Journal of Occupational
Therapy, 65(2), 133–142.
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 363
disorders. Research in each area will be
summarized next.
Research Related to Impairments
in Sensory Modulation
and Sensory Integration
Pre- and perinatal birth factors have been associated with general sensory integrative problems.
In a large retrospective sample of primarily
Caucasian two-parent families, May-Benson,
Koomar, and Teasdale ( 2009 ) found a relatively
high incidence of prenatal stress and prenatal
health-related problems in mothers of children
with sensory integrative disorders, and with ASD
with co-occurring sensory integrative disorders.
Delivery complications were also reported for
37% to 42% of this sample, and a higher percentage of assisted deliveries (e.g., C-section,
induced labor) were reported in the group with
ASD and co-occurring SPD (43.5%). Factors
such as birth weight and gestational age, which
have been suggested as potential risk factors for
sensory integrative disorders and autism, were
not signifi cantly higher in this population as
compared with the national average.
In both children and adults, a growing body
of literature supports the relationship between
sensory integrative disorders and signifi cant
impairments in the ability to perform daily
routines. Sensory processing is cited as a foundational ability contributing to the acquisition
of higher order functions ( Cheng & BoggettCarsjens, 2005 ) such as affect regulation
( Fig. 15-5 ). Other studies document social,
emotional, and behavioral disturbances in children with sensory integrative disorders ( Cohn,
Miller, & Tickle-Degnen, 2000 ; Kinnealey, 1998 ;
Roberts, King-Thomas, & Boccia, 2007 ). In particular, the following impairments have been
highlighted: decreased engagement, poor socialization, poor self-regulation, low self-confi dence
and self-esteem, and decreased functional competence ( Cohn et al., 2000 ), success, enjoyment,
and frequency of performing functional activities
( Bar-Shalita et al., 2008 ). Performance can be
affected in all areas of daily function, including self-care, home and academic activities,
play, leisure activities, and daily habits and routines ( Bar-Shalita et al., 2008 ; White, Mulligan,
Merrill, & Wright, 2007 ). In addition, sensory
integrative disorders impact family function,
affect the ability to complete self-care activities (grooming, dressing, eating), and impact the
ability to communicate or engage in fi ne or gross
motor activities ( Kinnealey, 1998 ).
Finally, Carter, Ben-Sasson, and BriggsGowan ( 2011 ) examined the impact of SOR in
children from 7 to 11 years of age ( n = 413)
on family life using the Family Life Impairment Scale (FLIS; Briggs-Gowan, Horwitz, &
Carter, 1997 ). Mothers of children who had SOR
reported greater amounts of family impairment
than mothers of children with either externalizing or internalizing symptoms alone.
The impact of disorders of SI into adulthood
is highlighted in the research of Kinnealey and
Fuiek ( 1999 ). Adults with SMD require excessive time and energy to cope with and recuperate from daily life routines. They tend to isolate
themselves, which affects their ability to fully
participate and engage in the range of everyday activities that most adults enjoy ( Kinnealey,
Oliver, & Wilbarger, 1995 ; Pfeiffer & Kinnealey,
2003 ). Also associated are physical and social
isolation, poor social skills, decreased participation in social roles, and decreased involvement in
community activities ( Kinnealey & Fuiek, 1999 ;
Kinnealey, Koenig, & Smith, 2011 ; Pfeiffer,
Kinnealey, Reed, & Herzberg, 2005 ). Reports
of increased anxiety and depression have been
noted in adults with sensory integrative disorders
( Kinnealey & Fuiek, 1999 ). In addition, adults
with sensory integrative disorders have fewer
perceived social supports and lower healthrelated quality of life scores in the areas of
bodily pain, general health vitality, and social
functioning ( Kinnealey et al., 2011 ). Thus, disorders of sensory modulation were found to be a
risk factor for health-related problems.
FIGURE 15-5 Research suggests that sensory overresponsivity in children may limit the family ’ s ability to
participate in desired routines, leading to feelings of
isolation.
364 ■ PART V Complementing and Extending Theory and Application
Research Related to Prevalence, Risk
Factors, and Clinical Presentation
Research related to the uniqueness or distinctiveness of sensory integrative disorders in large part
comes from studies that were conducted in an
effort to obtain recognition of these disorders in
the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5). This work,
spearheaded by Dr. Lucy Jane Miller, focused
on SOR because it had the greatest amount of
face validity (e.g., the symptoms are readily
observable and consistently result in referrals for
treatment). However, research is accumulating
related to SMD more broadly as well.
Although sensory modulation diffi culties have
been described in diagnostic groups for many
years, the presence of SMD in the absence of
other clinical conditions provides an important
foundation for understanding this disorder. Characteristics elucidated through case study presentation, and prevalence estimates and longitudinal
studies, provide additional evidence.
Reynolds and Lane ( 2008 ) presented a
detailed multiple case study on three children
with SOR, documenting the independent existence of SOR. Careful testing ensured that the
sample had average intelligence and no other
comorbid diagnosis, thus excluding common
comorbid conditions such as autism and ADHD,
along with other mental health and stress-related
disorders. The sensory processing profi les of the
sample included actively avoiding stimuli as well
as defensive or sensitive responses to stimuli perceived as unpleasant. Parents indicated that their
children became overwhelmed in certain environments and showed strong emotional reactions
to some sensory stimuli, resulting in disruptive
or aggressive behaviors.
Two primary research teams provide broader
support for the distinctiveness of SMD compared
with other established diagnostic categories. In
a recent study, Goldsmith and colleagues ( Van
Hulle, Schmidt, & Goldsmith, 2012 ) screened
765 school-aged children for both SOR (either
tactile or auditory) and common diagnoses
reported in the DSM-5 ( American Psychiatric
Association, 2013 ). Approximately 58% of the
children who screened positive for SOR did not
qualify for any other DSM diagnosis. Analyses
were conducted that ruled out physical health
problems as the source of SOR. Similarly,
Carter and colleagues ( 2011 ) found that 75% of
children identifi ed with elevated SOR symptoms
did not qualify for any other DSM diagnosis.
Additionally, parents of children with increased
SOR reported greater restrictions in their social
lives (e.g., “I rarely take the child to visit friends
or family,” “We rarely leave the child with relatives”) and personal lives (e.g., “I am usually
exhausted all day,” “We rarely make changes
in daily schedule”), independent of sociodemographic risk.
Examination of prevalence of SMD in a
non-referred population of children began with
a small population-based study of kindergartenaged students in one school district ( n = 703)
( Ahn, Miller, Milberger, & McIntosh, 2004 ).
Results defi ned a conservative prevalence estimate of 5.3% of the sample who met criteria
for SMD based on parental report using the SSP
( McIntosh, Miller, Shyu, & Dunn, 1999 ). In a
larger population-based study of SOR, data from
1,394 toddler-aged twins indicated rates of SOR
that ranged from 2.8% to 6.5% (Goldsmith, Van
Hulle, Arneson, Schreiber, & Gernbacher, 2006).
There was also a strong association between
SOR and fear-related aspects of temperament
and anxiety, including object fear, social fear,
sadness, and anger. Findings also suggested that
children with SOR were at greater risk for internalizing problems, dysregulation problems, and
maladaptive problems.
Higher prevalence was identifi ed in a large
sample of elementary school-aged children
(followed as part of a longitudinal prospective birth cohort in the Greater New Haven
area [ n = 925]). Investigators ( Ben-Sasson,
Carter, & Briggs 2009 ) used the Sensory OverResponsivity Scales ( Schoen et al., 2008 ), now a
part of the Sensory Processing Scale (SP Scale),
with a validated cutoff score provided by the
scale authors, and they reported that 16.5% of
children from 7 to 11 years of age had elevated
levels of tactile or auditory over-responsivity.
Associated with elevated SOR behaviors were
such risk factors as having a single parent and
living in poverty. Parents of children with SOR
reported more social-emotional problems and
concerns regarding social competence in their
children at school age; children with SOR were
also four times more likely to have clinically signifi cant internalizing problems and three times
more likely to have clinically relevant externalizing problems.
CHAPTER 15 Advances in Sensory Integration Research: Clinically Based Research ■ 365
SMD prevalence and the occurrence of
comorbid psychiatric disorder was examined
in a racially and ethnically diverse sample of
preschoolers ( n = 696) recruited from a 3-year
longitudinal study on the development of oppositional defi ant disorder, anxiety, and depression
in young children ( Gouze, Hopkins, Lebailly, &
Lavigne, 2009 ). Depending on the criteria used,
overall prevalence rates varied from 3.4% to
15.6%. No ethnic or racial differences appeared;
however, more symptoms were reported in
males. Depending on the sensory scale or criteria
used to defi ne SMD, between 37% and 67% of
the children identifi ed with SMD did not meet
criteria for a psychiatric disorder. This data suggests that SMD exists independent of psychiatric
disorder but is also a signifi cant risk factor for
other childhood psychopathology.
In addition to prevalence, the developmental
trajectory of children identifi ed in early childhood with SOR was examined at four time-points
between infancy and early elementary school
( Ben-Sasson, Carter, & Briggs-Gowan, 2010 ).
Data were collected using the Infant-Toddler
Social Emotional Assessment (ITSEA) ( BriggsGowan, Carter, Bosson-Heenan, Guyer, &
Horwitz, 2006 ) and the SP Scale ( Schoen et al.,
2008 ). Results indicated that children with elevated levels of SOR between 11 and 24 months of
age, or children who showed signifi cant increases
in SOR symptoms from 11 to 51 months of age,
tended to have greater SOR symptoms at 7 to
10 years of age. This study suggests that SOR
symptoms are relatively stable in the general
population.
Symptoms of SOR have also been reported in
more diverse groups. For example, Gouze and
colleagues ( 2009 ), cited previously, included
an ethnically varied population in their study.
Reynolds and Lane ( 2008 ) reported elevated
levels of SMD symptoms in a Head Start population consisting of primarily minority and lower
income families.
These data collectively indicate that SMD can
be identifi ed in children with no other diagnoses, or in conjunction with several mental health
disorders; it is found across racial and ethnic
groups, and prevalence varies considerably.
More information is needed to defi ne optimal
identifi cation, utilizing tools of direct observation as well as parent report. There also appear
to be early indicators placing children at risk of
developing SMD. Although we do not yet know
the cause(s) of SMD subtypes, research using
primate models provides some evidence that
SOR may be attributed, at least in part, to factors
such as lead exposure, prenatal alcohol exposure,
and prenatal stress ( Moore et al., 2008 ; Schneider
et al., 2008 ), factors that may be more common
in low-income and urban communities ( Gee &
Payne-Sturges, 2004 ). Another explanation for
higher rates of SMD in children from families
with lower income may be the living conditions and family environments associated with
poverty. With some indicators that poorer families live in more crowded, noisier, and less structured and predictable households ( Brody & Flor,
1997 ; Evans, Gonnella, Marcynyszyn, Gentile, &
Salpekar, 2005 ), it is possible that these contextual factors may contribute to the manifestation
of SMD in children who are already genetically
susceptible to this disorder.
Investigations have begun examining a potential genetic basis for SOR. Studies conducted
with non-human primates at the Harlow Laboratory at the University of WI-Madison examined
potential etiological factors and interactions with
genetic variation, controlling for and manipulating environmental factors ( Schneider et al., 2009 ).
More than 10,000 monkeys born at the Harlow
Primate Laboratory in Madison, Wisconsin, from
the 1950s to the present (10 to 12 generations)
were entered into a genetic program. Investigators concluded that the relationship between
the phenotype presented (e.g., the magnitude of
the sensory responses [degree of withdrawal or
over-responsivity]) and genetic relatedness were
statistically signifi cant, providing preliminary,
but quite convincing, evidence that the etiology
of SOR may have a genetic infl uence.
Paralleling this work, Goldsmith and colleagues used a population-based sample of 1,394
twin pairs (mean 27 months of age) to examine
genetic infl uences on tactile and auditory overresponsivity ( Goldsmith et al., 2006 , Fig. 15-6 ).
If genetic effects are present, classic genetic
assumptions imply that identical (MZ) twins, who
share 100% of their genes, should be more similar
than fraternal (DZ) twins, who share only 50% of
segregating genes, on the average. Concordance
rates for auditory SOR were MZ = 0.72 and
DZ = 0.53, and for tactile SOR were MZ = 0.82
and DZ = 0.27, suggesting that SOR has moderate
genetic infl uences with tactile over-responsivity
366 ■ PART V Complementing and Extending Theory and Application
demonstrating somewhat greater heritability than
auditory over-responsivity.
Future Directions
Future research into the prevalence of SMD
across a range of racial and socio-economic
groups is warranted, and specifi c focus should
be placed on increasing our overall knowledge
of which factors contribute to the development
of or exacerbation of specifi c sensory behaviors (e.g., under-responsivity, over-responsivity).
Understanding the association between sensory
symptoms within families will also contribute to
this knowledge as well as identifi cation of early
risk factors in siblings of children with sensory
modulation or integration disorders. It is likely
that future studies in behavioral and molecular
genetics will play a signifi cant role in helping the
health community to classify and identify individuals who are predisposed to SMD and conditions such as autism in which they often co-occur.
HERE ’ S THE POINT
• Disorders in SI may be a risk factor for other
health-related problems and can impact both
the individual ’ s and family ’ s function and
participation.
• Research suggests that SMD, specifi cally
SOR, exists independent of other psychiatric
conditions, but is also a risk factor for other
childhood psychopathology.
• SOR has a strong genetic basis, but it may
be infl uenced by environmental factors (e.g.,
prenatal alcohol use or lead exposure, family
poverty) or issues related to the child ’ s birth
(e.g., delivery complications).
Summary and Conclusions
We are making progress toward a better understanding of SI dysfunction. Research using factor
analyses supports consistency in the identifi cation of patterns of sensory integrative dysfunction using existing and emerging assessment
tools. In addition, recent high-quality effectiveness research has shown positive outcomes for
many domains of child and family life. Our
understanding of SOR has expanded; we know
that it is identifi ed both with and without other
childhood disorders, that there appears to be a
genetic link, and that there also may be contextual risk factors associated with its expression.
There is much yet to be done, and our ongoing
research must be of high quality. We need greater
research rigor (e.g., increased statistical power,
consistent use of intervention fi delity tools,
identifi cation of outcomes that are meaningful
to child and family) as we move forward and
answer increasingly complex questions.
Where Can I Find More?
Law, M., & MacDermid, J. (Eds.). (2014). Evidence-based rehabilitation: A guide to practice. Thorofare, NJ: Slack Inc.
Miller, L. J., & Roetenberg, J. (2014). Sensational kids: Hope and help for children with
sensory processing disorder (SPD). New
York, NY: Perigee Books.
Schaaf, R. C., & Mailloux, Z. (2015). Clinician ’ s
guide for implementing Ayres Sensory Integration ® : Promoting participation for children with autism. Bethesda, MD: American
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371
CHAPTER
16
Advances in Sensory Integration
Research: Basic Science Research
Sarah A. Schoen , PhD, OTR ■ Shelly J. Lane , PhD, OTR/L, FAOTA ■
Lucy J. Miller , PhD, OTR/L, FAOTA ■ Stacey Reynolds , PhD, OTR/L
Chapter 16
Why do we do basic science research? To learn about ourselves.
—Walter Gilbert
Upon completion of this chapter, the reader will be able to:
✔ Recognize and describe various measurement
techniques currently being used to measure
neurological processes associated with sensory
integration.
✔ Describe brain regions and systems implicated
in sensory integrative disorders.
✔ Describe how animal research can contribute
to our understanding of sensory integrative
disorders and sensory integration
intervention.
✔ Compare and contrast neurological and
physiological patterns in children with sensory
integrative disorders with and without
comorbid psychiatric conditions.
LEARNING OUTCOMES
Introduction
Ayres’ theory of sensory integration is heavily
grounded in neuroscience literature and hypothesizes intimate links between brain and behavior.
In order to make links between brain function
and behavioral outcomes, however, a continuum of sensory integration research is required
( Fig. 16-1 ). At one end of the continuum are
studies that look at the effi cacy or effectiveness
of interventions for human subjects in laboratory or clinical settings. This type of research
was described in Chapter 15 (Advances in
Sensory Integration Research: Clinically Based
Research), as was more translational research
that focused on development of outcome measures and design of specifi c interventions. At
the other end of the continuum are basic science
research studies (sometimes called preclinical
studies) that attempt to defi ne mechanisms underlying disorders and identify potential targets for
intervention ( Fig. 16-1 ). This chapter will focus
on these types of basic science studies.
At the heart of sensory integration theory and
intervention is the belief that the brain is capable
of change throughout the life span; changes in
brain organization and connectivity are called
neuroplasticity. As clinicians, we assume neuroplasticity is occurring when we see changes in
performance or behavior. As clinical researchers,
we endeavor to control for other factors that may
also result in behavior or performance change, to
allow us to suggest that our intervention approach
is linked to behavioral and performance changes.
However, basic science research allows us to
examine structural changes that occur at the level
of the individual neuron (e.g., enhancements in
dendritic spine density or dendritic branching),
372 ■ PART V Complementing and Extending Theory and Application
in CNS regions (e.g., the autonomic nervous
system), or in groups of neurons that form pathways in the brain.
Lane and Schaaf ( 2010 ) ’ s systematic review
of the sensorimotor-based plasticity literature
across various disciplines provides evidence to
support the basic tenets of Ayres’ theory. Specifi cally, this review demonstrates important
links among sensory input, brain function, and
behavior. They found that much of this literature focuses on animal studies that explored the
impact of enriched environments on the structure and function of the nervous system. Among
these studies, the most important fi ndings were
(1) increased dendritic branching, particularly
in the occipital cortex, were evident in response
to active engagement within enriched environments ( Diamond, Rosenzweig, Bennett, Lindner,
& Lyon, 1972 ; Kempermann & Gage, 1999 ;
Mollgarard, Diamond, Bennett, Rosenzweig, &
Lindner, 1971 ); (2) changes in neuronal structures were related to improved maze navigation
performance, providing a link between structure and behavioral change ( West & Greenough,
1972 ); and (3) links between improvements
in motor performance and active participation
inherently incorporate somatosensory feedback
( Lacourse, Turner, Randolph-Orr, Schandler, &
Cohen, 2004 ; Rosenzweig et al., 1969 ; Rosenzweig & Bennett, 1972 ).
The motor and neurological changes reported
in this body of literature can occur very rapidly
( Pantev et al., 2003 ) and can be long lasting
( Stoeckel, Pollok, Schnitzler, Witte, & Seitz,
2004 ). It may be important to consider critical
periods in sensory system infl uence ( Bavelier
et al., 2001 ; Zhang, Bao, & Merzenich, 2001 )
as well as evidence that suggests the benefi t of
multisensory experiences ( Stein, Stanford, &
Rowland, 2014 ).
Paralleling the development of this foundation, there is a branch of neuroscience currently
engaged in the study of multisensory processing
and integration. Advances in research evident in
both basic multisensory processing and sensory
integration have enhanced our understanding
of the disorders and informed the treatment
approach.
Ayres proposed that the subconscious, simultaneous interaction of multiple sensory systems
is critical to how we make sense of daily sensory
experiences. She stated, “Sensory integration
sorts, orders and eventually puts all of the individual sensory inputs together into whole brain
function” ( Ayres, 1979 , p. 28). This premise is
well supported in a recent neuroscience study of
multisensory integration, which suggests that the
speed, effi ciency, and meaning of experiences are
enhanced through the transmission of multisensory inputs ( Stein et al., 2014 ). Recent evidence
suggests that multisensory integration (MSI)
is acquired through experience and interaction
with the environment. Documented in children
as early as 3 to 5 months of age ( Lewkowicz &
Röder, 2012 ), the process is thought to experience the greatest maturation within the fi rst
8 years of life ( Ernst, 2008 ). Critical to understanding the advances in sensory integration is to
recognize the contributions from both basic and
applied science related to the underlying neurophysiology of the disorder and the value of multisensory strategies used in the intervention.
FIGURE 16-1 Continuum of sensory integration research.
Basic Science or
Pre-clinical Research
Intermediate or
Translational Research
Goal: Determine how
underlying mechanisms
influence human behavior
as a basis for developing
interventions and
choosing appropriate
outcome measures.
Clinical Research
and Implementation
Goal: Implement
interventions in controlled
clinical settings and as part
of routine clinical practice;
evaluate the results of
clinical trials and develop
new clinical questions.
Goal: Identify underlying
neural mechanisms of
sensory processing and
integration disorders
and identify targets for
treatment. Techniques
used include:
• Brain imaging
• Psychophysiological
measures
• Genetics research
• Animal studies
CHAPTER 16 Advances in Sensory Integration Research: Basic Science Research ■ 373
Purpose and Scope
This chapter focuses on the basic research related
to sensory integration, focusing on MSI and
sensory modulation. We will review research
designed to gain a better understanding of the
physiological mechanisms underlying sensory
modulation, examine some of the research on
animal models of sensory integration and processing defi cits, and consider work being done on
children with diagnoses that are comorbid with
sensory disorders. This body of work extends our
understanding of the neural processes associated
with sensory integration and processing defi cits,
and it lays a foundation for understanding behavior. Specifi c links between the basic science fi ndings and our understanding of sensory integration
and processing defi cits are suggested throughout.
There are many abbreviations used in the following summaries of existing basic research. We
defi ne each abbreviation in the text, and we have
collected them together in Table 16-1 .
Research Related to Underlying
Neurological Mechanisms
Research into the physiological mechanisms that
underlie sensory modulation disorder (SMD) has
taken various forms. Each approach is based on
Ayres’ original theories. The autonomic nervous
system (ANS) was fi rst targeted because arousal
mechanisms often appear disrupted in children
with SMD. Brain mechanisms responsible for
automatically fi ltering out redundant or unnecessary stimuli from the environment have also
been targeted using high density electrophysiology recordings during a sensory gating paradigm. Because SMD is a hypothesized disruption
in “sensory integration,” neuroscience techniques
that study MSI have also been investigated. What
follows is a summary of each line of research.
Studies of the Autonomic
Nervous System
Studies related to the role of the ANS in SMD
are based on the observation that children with
sensory over-responsivity (SOR) display fi ght-orfl ight behaviors in response to adverse sensory
experiences and have diffi culty regulating their
recovery from a perceived sensory challenge
( Miller, Anzalone, Lane, Cermak, & Osten,
2007 ). The ANS regulates activity through the
sympathetic and parasympathetic branches,
which are responsible for our ability to adapt
internal processes in response to ongoing changes
in the environment. The sympathetic branch is
most often referred to as a quick, mobilizing
system that controls our fi ght-or-fl ight response;
changes in sympathetic activity are often measured using electrodermal response, or EDR,
TABLE 16-1 Table of Abbreviations
TERM ABBREVIATION
Sensory modulation disorder SMD
Autonomic nervous system ANS
Sensory over-responsivity SOR
Electrodermal response EDR
Sensory Challenge Protocol SCP
Evoked response potential ERP
Electroencephalogram EEG
Functional magnetic resonance
imaging
fMRI
Positron emission tomography PET
Magnetoencephalography MEG
Diffusion tensor imaging DTI
Attention defi cit-hyperactivity
disorder
ADHD
Multisensory integration MSI
Autism spectrum disorder ASD
Hypothalamic–pituitary–adrenal HPA
Sensory Processing Scale for
Monkeys
SPS-M
Borderline personality disorder BPD
Somatosensory evoked potential SEP
Electrodermal activity EDA
Attention defi cit-hyperactivity
disorder with sensory
over-responsivity
ADHDs
Attention defi cit-hyperactivity
disorder with typical sensory
functioning
ADHDt
374 ■ PART V Complementing and Extending Theory and Application
parameters. The parasympathetic system is a
slow, dampening system that helps maintain or
regain homeostasis and self-regulation; changes
in parasympathetic activity are refl ected in heart
rate variability, respiratory sinus arrhythmia
(RSA), or vagal tone. The two branches work
together to control internal functions related to
sensory, motor, visceral, and neuro-endocrine
functions (refer to Chapter 4 , Structure and
Function of the Sensory Systems, Fig. 4-4 ).
Since 1995, Miller and colleagues have had a
program of research examining ANS regulation
in response to sensory stimulation in children
with SMD. Since initiating this program, and in
part supported by the Wallace Research Foundation as well as through a federal grant obtained
by Miller, several other labs around the country
have become engaged in physiological data collection (Lane and colleagues; Schaaf and colleagues; Parham and colleagues).
Results from several studies showed that
children with SOR demonstrated elevated EDR
( Mangeot et al., 2001 ; Schoen, Miller, BrettGreen, & Nielsen, 2009 ) and slower habituation
to repeated sensory stimuli using a paradigm
known as the Sensory Challenge Protocol
(SCP) ( McIntosh, Miller, Shyu, & Dunn, 1999 ).
Figure 16-2 shows manual application of sensory
stimuli during the SCP; electrodes are attached
to the child in order to measure physiological
responses to the stimuli during multiple trials.
This research suggested that children with SOR
have sympathetic over-activity in comparison
with typically developing children and compared
with children with autism ( Schoen et al., 2009 ).
There was also a signifi cant association between
children ’ s physiological responses and their functional behavior scores based on parent report as
measured by the Short Sensory Profi le ( Mangeot
et al., 2001 ; McIntosh et al., 1999 ; Miller,
McIntosh, Shyu, & Hagerman, 1999 ). Similarly,
adults with SOR demonstrated a signifi cantly
elevated initial skin conductance response compared with controls, when presented with a loud
sound through headphones ( Brown, Tollefson,
Dunn, Cromwell, & Filion, 2001 ). Collectively,
these studies demonstrate that physiological
measures can differentiate individuals with and
without SOR.
Because regulation of an individual ’ s reactivity involves a balance of activity within both
the sympathetic and parasympathetic divisions
of the autonomic nervous system, Schaaf and
colleagues ( 2003 ) examined the parasympathetic nervous system response across the SCP
using vagal tone as the index of parasympathetic activity. Children with SMD had signifi -
cantly lower vagal tone compared with typically
developing children, suggesting less effective
parasympathetic functioning. Subsequent investigation examined vagal tone within each domain
of the SCP and found a nonsignifi cant trend
( p = 0.083) for baseline vagal tone to be lower in
children with SMD than in typically developing
controls ( Schaaf et al., 2010 ). However, in this
study children with SMD reacted with increased,
rather than decreased, vagal tone to cope with the
stimuli. Only vagal tone at baseline was lower
and appeared to be associated with the severity
of SMD based on Short Sensory Profi le scores.
In addition, the children with severe SMD also
had signifi cantly lower scores on Communication, Daily Living, and Adaptive Behavior Composite scores of the Vineland Adaptive Behavior
Scales compared with typical children ( Schaaf
et al., 2010 ).
Together, these fi ndings suggest that children with SMD show atypical parasympathetic
regulation, which may infl uence their ability
to self-regulate and cope with environmental stimuli. Further, these children may have
FIGURE 16-2 The Sensory Challenge Protocol was
administered in a room decorated to resemble a
spaceship. Children were presented with a sensory
stimulus repeated eight times, in each of six sensory
domains. Data were collected on sympathetic,
parasympathetic, or stress responses to the stimuli
over time.
CHAPTER 16 Advances in Sensory Integration Research: Basic Science Research ■ 375
different physiological-behavioral relationships
than typical children. An under-reactive parasympathetic system in children with SMD may
not be able to provide the support needed for
normal physiological regulation during daily
life activities. Adequate regulation of parasympathetic activity provides a basis for behavioral
fl exibility and adaptation needed to cope with the
various changing inputs in one ’ s daily environment and thus the ability to successfully engage
in normal routines and activities of daily life.
Neuroimaging
Neuroimaging technology has evolved such
that it can be used as a quantitative measure of
neural activity that can help expand our knowledge of the relationship between physiological
processing and behavioral manifestations. Many
modalities can be used to assess functional brain
imaging, including evoked response potential
(ERP), electroencephalogram (EEG), functional magnetic resonance imaging (fMRI),
positron emission tomography (PET), and
magnetoencephalography (MEG) and diffusion tensor imaging (DTI; an alternative method
of magnetic resonance imaging).
Sensory Gating Studies and ERP Studies
The inability to fi lter out unnecessary stimuli
from the environment, also known as sensory
gating, is one characteristic of SOR described
by Ayres ( Ayres, 1972 ; Davies & Gavin, 2007 ).
Thus, sensory gating paradigms have been used
to investigate the neurophysiology of sensory
processing in many disorders including schizophrenia, attention defi cit-hyperactivity disorder
(ADHD), and traumatic brain injury.
Sensory gating paradigms typically involve
measuring the amplitude of particular ERP components as a function of the relative “salience,”
or potential importance, of a stimulus: as
salience goes down, ERP amplitude goes down,
refl ecting reduced neural processing of relatively
unimportant stimuli. ERP data is collected using
EEG technology in which surface electrodes are
placed on a person ’ s scalp, and sometimes the
face, to measure electrical activity in the brain
( Fig. 16-3 ). In sensory gating studies, salience is
operationalized as novelty by presenting stimuli
in pairs: the fi rst (“conditioning”) stimulus of
the pair is relatively novel and thus of higher
salience than the second (“test”) stimulus of the
pair. The effi ciency with which the brain “gates
out” the second stimulus of the pair is typically
quantifi ed by comparing ERP amplitude evoked
by the second stimulus to ERP amplitude evoked
by the fi rst stimulus of the pair ( Fig. 16-4 ).
FIGURE 16-3 EEG cap worn by children to obtain
data about underlying mechanisms related to
multisensory integration.
FIGURE 16-4 Sensory gating is measured using
the P50 EEG peak. P50 is the most positive peak
following a stimulus. S1, the red line, shows the
initial response to the stimulus. S2, the pink line,
shows the reduced response to the second stimulus
and refl ects fi ltering or gating of the CNS response to
redundancy of input and a lack of salience. Amplitude
(V)
3
5
4
3
2
1
20
0
40
S1
S2 P50
Times (ms)
60 80 100 120 140
1
2
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