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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

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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

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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

Child Psychology, 26, 114 – 129 .

 May-Benson , T. , Roley , S. S. , Mailloux , Z. , Parham ,

 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:

Theory and practice ( 2nd ed. , pp . 435 – 452 ).

 Philadelphia, PA : F. A. Davis .

 Moncher , F. J. , & Prinz , R. J. ( 1991 ). Treatment

fi delity in outcome studies . Clinical Psychology

Review, 11, 247 – 266 .

 Parham , L. D. , Cohn , E. S. , Spitzer , S. , Koomar ,

 J. , Miller , L. , Burke , J. P. , . . . Summers , C. A.

( 2007 ). Fidelity in sensory integration intervention

research. American Journal of Occupational

Therapy, 61, 216 – 227 .

 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

sensory integration interventions in children

with autism spectrum disorders: A pilot study .

American Journal of Occupational Therapy,

65 ( 1 ), 76 – 85 .

 Schaaf , R. C. , Benevides , T. , Mailloux , Z. , Faller , P. ,

 Hunt , J. , van Hooydonk , E. , . . . Kelly , D. ( 2014 ).

 An intervention for sensory diffi culties in children

with autism: A randomized trial . Journal of Autism

and Developmental Disorders, 44, 1493 – 1506 .

 doi:10.1007/s10803-013-1983-8

 Schaaf , R. C. , & Mailloux , Z. ( 2015 ). Clinician ’ s

guide for implementing Ayres Sensory

Integration ® : Promoting participation for children

with autism . Bethesda, MD : AOTA Press .

 Schön , D. A. ( 1983 ). The refl ective practitioner: How

professionals think in action . New York, NY :

 Basic Books .

 Stackhouse , T. M. , Trunnell , S. L. , & Wilbarger , J. L.

( 1997 ). Treating sensory modulation disorders:

The STEP-SI: A tool for effective clinical

reasoning . Denver, CO : The Children ’ s Hospital .

 Wolery , M. ( 2011 ). Intervention research: The

importance of fi delity measurement . Topics in

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?

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 Schaaf, R. C., & Mailloux, Z. (2015). Clinician ’ s

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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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