Sensory Integration parte 05

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 395

Holland, Lane, & White, 2012 ) that a child practices in a particular way and that requires regular

oversight by a parent or teacher. There are, of

course, many other procedures commonly taught

in the context of indirect service.

Myth #2: Because a Parent or Teacher

Implements the Intervention, Therapists

Spend Less Time with Children

and, Therefore, Can Dramatically

Increase Their Caseloads

 This idea seems particularly prevalent in schools

where the demand for productivity is high. In

reality, coaching can take quite a lot of time

( Dunn, 1992 ; Hanft & Place, 1996 ). To be effective, a therapist-coach meets regularly with

coaching partners, sometimes intensively for a

relatively short time and sometimes sporadically

during a longer period. Although coaching may

not mean less time from a therapist for an individual child, in the long run, coaching can spread

a therapist ’ s services further in a different way.

Because teachers and parents come to think in

new ways about children ’ s needs, they may be

able to generalize those principles to new situations and different children. Thus, other children,

with or without disabilities or special needs, may

benefi t from coaching directed at ameliorating

diffi culties encountered in teaching or parenting

a particular child. Similarly, when teens or young

adults are the coaching partners, they learn to

identify and solve problems associated with

their own sensory integrative dysfunction and

to advocate for their own needs. Thus, coaching

promotes empowerment and independence of the

coaching partner.

Myth #3: Coaching Is a Substitute

for Direct Intervention

 Coaching can be extremely powerful. We believe

it should be a primary approach to service delivery with families and in schools. In other words,

all children who require therapy to ameliorate

diffi culties meeting the demands of everyday life

should have the benefi t of coaching for their families and teachers. A growing body of research

in collaborative consultation and coaching (e.g.,

 Simpson, 2015 ) supports this view. However,

the goals of coaching can be very different from

those of direct intervention, and even when they

are similar, the strategies differ substantially.

Thus, in addition to coaching, some children also

will require direct intervention to improve SI or

to develop particular skills. Table 17-1 compares

strategies used by a clinic-based occupational

therapist with those of a school-based occupational therapist working with Kyle, the child featured in Chapter 11 (Interpreting and Explaining

Evaluation Data) and Chapter 20 (Planning and

Implementing Intervention Using Sensory Integration Theory). The school-based occupational

therapist serves primarily as a coach to Kyle ’ s

teacher, whereas the clinic-based occupational

therapist provides direct intervention to Kyle and

coaching to his family. Both therapists share the

same goals but the objectives that operationalize

the goals differ as to the strategies for meeting

the objectives.

HERE ’ S THE POINT

Common myths surrounding coaching must be

debunked. The following are accurate statements

about coaching.

• Coaching does not involve teachers or parents

doing the therapist ’ s job.

• At certain stages, coaching requires as much

time as direct intervention and is, therefore,

not a way to increase caseloads.

• Coaching is not a substitute for direct

intervention.

Defi ning Practices

for Implementing Coaching

 Coaching is implemented to help others meet

the demands of their own roles more effectively.

Thus, a parent or the teacher who is a coaching partner owns the goal and has the fi nal say

about which strategies are best for attaining

it. The major role of the therapist-coach is to

help the coaching partner understand the situation (including the effect of sensory integrative

dysfunction); set goals; and create, implement,

and evaluate the effectiveness of strategies for

meeting the goals.

 According to Rush and Shelden ( 2011 ), coaching comprises fi ve processes (joint planning,

action, observation, refl ection, and feedback),

implemented in no set order. When coaching a parent or teacher of a child with sensory

396 ■ PART V Complementing and Extending Theory and Application

TABLE 17-1 Comparison of Strategies Used by a Clinic-Based Occupational Therapist

vs. a School-Based Occupational Therapist

GOAL OBJECTIVE

PRIVATE PRACTICE OCCUPATIONAL

THERAPIST *

SCHOOL OCCUPATIONAL

THERAPIST **

Develop belief that

he will succeed at

things he values

(i.e., that he is a

desirable friend

and playmate)

At least once a

week, willingly play

with other children

in the neighborhood

who are about his

age

Coach Kyle ’ s mother on strategies

to help Kyle enter a group; identify

activities where he could invite a

peer

Work with Kyle to develop particular

skills he needs to play with other

children (e.g., sport or game)

Coach Kyle ’ s teacher to help

Kyle enter a group; develop

ideas for activities that he

could do with a partner

Improve (gross)

motor skills

Independently propel

a swing by pumping

Improved bilateral integration

and ability to plan and produce

sequenced projected limb

movements

Work with Kyle on his ability to

propel clinic swings; point out

similarities between clinic and

playground swings

Coach Kyle ’ s teacher to help

Kyle with this skill on the

playground

Improve (fi ne)

motor skills (i.e.,

handwriting);

improve behavior

Complete at least

three of four written

assignments within

the allotted class

time

Improved postural ocular control,

bilateral integration and sequencing,

visuomotor skill, sensory modulation

Design home program specifi cally

addressing handwriting speed

Coach Kyle ’ s teacher

regarding location of Kyle ’ s

workspace (i.e., fi nd quiet

areas); adapt assignments

Improve behavior Not hit classmates

who accidentally

bump into him

Improve ability to modulate

incoming sensory information;

explain tactile defensiveness and

sensory modulation disorders to

Kyle and his parents in terms they

can understand; talk to Kyle about

strategies he might use when he

is feeling overwhelmed; coach

Kyle ’ s parents to help Kyle develop

effective strategies

Explain relationship between

Kyle ’ s behavior, tactile

defensiveness, and sensory

modulation in educational

terms; coach Kyle ’ s teacher

regarding location of Kyle ’ s

workspace (i.e., fi nd quiet

areas); fi nd alternatives to

other circumstances when

fi ghting is a problem (e.g.,

while standing in line)

Note: Italics in the therapist ’ s strategies refl ect the proximal objectives established for Kyle; other strategies refl ect a focus on distal

objectives.

 * Primary role: direct intervention; secondary role: coach to family.

 ** Primary role: coach to teacher.

integrative dysfunction, a therapist has access to

SI theory as a frame for each of those processes.

That is, SI theory helps a therapist-coach and the

coaching partner understand a child ’ s behaviors,

develop strategies, and predict something about

the effectiveness of those strategies. However,

the therapist-coach also has access to a range

of other practice theories. Regardless of which

practice theories a therapist-coach employs, the

goals of coaching are to ameliorate a problem

that interferes with parenting or teaching the

child and with the child ’ s participation at home

or in school. Here we slightly adapt Rush and

Shelden ’ s descriptions of each of the fi ve processes of coaching:

• Joint planning, in which a therapist-coach

and coaching partner clarify the problem,

set a goal, and identify actions to address

the goal. Learning a process for clarifying

the nature of a problem can, in itself, be an

important benefi t to parents and teachers

( Schein, 1999 ).

• Action: Real-life events in the context of

which coaching partners implement new

strategies for parenting or teaching a child.

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 397

• Observation, in which a therapist-coach

observes the actions of a coaching partner

for the purpose of providing feedback, or a

coaching partner observes a coach in order to

develop new ideas, strategies, or skills.

• Refl ection: Analysis, in the moment and

later, of the implementation and outcomes

associated with new strategies to determine

if, and in what ways, the strategies require

modifi cation.

• Feedback, provided in a respectful and

refl ective way, to expand coaching partners’

understanding of the situation and the

strategies.

 To these, we add a sixth process: reframing.

Although reframing is a kind of refl ection, it

generally occurs early in the coaching process.

Reframing involves enabling others to understand

a child ’ s behavior in a different way or to view

behaviors from a new perspective ( Bulkeley,

Bundy, Roberts, & Einfeld, 2016 ; Bundy, 1995 ;

 Niehues, Bundy, Mattingly, & Lawlor, 1991 ).

We speak of re- framing , rather than “setting the

frame” ( Schön, 1983, 1987 ) because, almost

invariably, teachers and parents already have set

a frame for a child ’ s behavior. Setting the frame

is only necessary when coaching recipients have

no prior view or interpretation of a child ’ s behavior. In the case of children with sensory integrative dysfunction, often the frame that teachers or

parents have set is negative ( Case-Smith, 1997 ).

The child is framed as poorly disciplined, immature, destructive, careless, rigid, or over-reactive.

The frame that teachers and parents have for

viewing behavior determines how they will react

to that child ’ s behavior (i.e., the strategies they

will use in teaching or parenting). By using SI

theory to change the frame, we provide coaching

partners with the basis for developing different

strategies for interacting with students. In turn,

these strategies often result in a dramatic lessening of problem behaviors because situations or

activities that are diffi cult for the child can be

avoided or made easier.

 Refl ective discussion is the essence of all

coaching processes. Rush and Shelden ( 2011 )

described traits that ensure that coaching promotes discussion that is genuinely refl ective. Not

surprisingly, the fi rst of those traits is: consistency

with the principles of adult learning. Rush and

Shelden ( 2011 , p. 8) cited Cox ( 2006 , p. 195):

 The person who will receive coaching support

is perceived to be a mature, motivated and

equal participant in a learning relationship with

a facilitator (coach) whose role is to aid the

learner in the achievement of his or her primarily self-determined learning objectives.

 Coaching should be:

• Aimed at building coaching partners’

capacity, performance, and refl ective

ability.

• As directive and hands-on as necessary.

Although coaching is not about telling people

what to do, a therapist-coach possesses

knowledge and ideas for strategies that can

be extremely helpful to parents and teachers.

A therapist-coach may assist coaching

partners to identify options or resources,

share information to build knowledge, model

an action, and provide feedback after the

partner has engaged in self-refl ection

( Berg & Karlsen, 2007 , cited in Rush &

Shelden, 2011 ). The key to effective

coaching is knowing when, how, and why

to ask questions and share information or

feedback ( Rush & Shelden, 2011 ).

• Goal-oriented and solution-focused. Although

the desired outcomes of coaching are

clearly stated in the planning phases, the

therapist-coach and coaching partner often

refi ne the goals as the process unfolds. When

the goals and underlying reasons for a child ’ s

performance diffi culties become clearer, the

coaching team also may alter strategies they

developed for meeting the goals. As much as

possible, coaching partners should develop

the strategies. The therapist-coach primarily

helps the partner fi gure out what will work

( DeBoer, 1995 ; Schein, 1999 ). However,

through time, each therapist-coach acquires a

repertoire of strategies, which he or she can

share judiciously. Appendix 17-A presents a

list of strategies that may be useful in school

settings. Some involve activities children

commonly perform during the school day

and that provide enhanced sensation. Some

strategies are for problems commonly

encountered by children with sensory

integrative dysfunction but that do not

necessarily incorporate enhanced sensation.

Of course, many of the strategies could be

adapted for home.

398 ■ PART V Complementing and Extending Theory and Application

• Refl ective. Through reframing, a

therapist-coach aims to use SI (and other)

theory to help a coaching partner attain new

or deeper understanding of how various

everyday tasks and environments affect a

child. In so doing, goals become more precise

and new strategies are identifi ed. Throughout

the process, both therapist-coach and

coaching partner refl ect on goals, strategies,

and outcomes. What is working? What is

not? Should strategies be tweaked, and, if

so, in what ways? Are there things that the

coaching partner needs in order to implement

strategies more easily or more effectively?

• Collaborative. Coaching is a partnership.

Both the therapist-coach and coaching

partner possess knowledge and skills about

a child and a situation ( Hanft et al., 2004 ). A

therapist-coach must learn what the partners

believe about the child and situation and

what they have tried previously. Parents

and teachers have an opportunity to access

specialized knowledge from a therapist-coach

and, perhaps even more importantly, learn a

process for refl ecting on everyday problems

as well as strategies for ameliorating the

problems.

 Of course, both the therapist-coach and

coaching partner have assumptions about

the situation; it is important that each make

the assumptions explicit to themselves and

to each other ( Schein, 1999 ). Further, there

are many reasons why a strategy may not

feel comfortable. Perhaps it does not refl ect

the coaching partner ’ s style or values.

Perhaps the partner just needs to practice

until a strategy becomes his or her “own.”

Some partners need modeling before

implementing a strategy. Some strategies just

are not practical. When a strategy feels

wrong, the coaching team tries to uncover

the source of the discomfort so that they

can make appropriate changes. The solution

to the problem when a partner needs a

model is very different from the solution

when the partner simply needs practice. A

therapist-coach must take care not to give up

on a strategy because it does not work the

fi rst time. However, we also need to modify

strategies that clearly are not working.

• Context driven. Coaching deals with goals

germane to the everyday experiences and

situations of parents, teachers, and the

children that they parent or teach. Because

contributors to a child ’ s behavior depend

on the context, strategies developed in

coaching need to be context-specifi c ( Joosten,

Bundy, & Einfeld, 2012 ).

HERE ’ S THE POINT

• Coaching is a collaborative, refl ective, hands-on

process that involves the use of thoughtful

feedback. It is context driven, and involves joint

planning, observations, and actions by both the

therapist-coach and coaching partner.

• A major purpose of coaching is to enhance the

coaching partner ’ s capacity for solving everyday,

real life problems.

• The quality of the partnership between

coach and coaching partner is key to success;

the partnership must be built upon mutual

respect for one another ’ s expertise, previous

experiences, and the priorities of the coaching

partner.

Building the Partnership

and Need for Resources

Building the Partnership

 Not all aspects of coaching are visible; some

aspects occur behind the scenes. In fact, coaching begins before the therapist-coach and coaching partner begin to work together. In preparing,

both individuals, consciously or unconsciously,

formulate expectations of what will happen

during, and because of, coaching. Mattingly

and Fleming ( 1994 ) suggested that expectations

take the form of real or imagined stories created

using information from several sources. These

sources may include information that members

of the coaching team have because they have

worked together previously; information shared

with one of them by a colleague or parent; past

experiences that they have had working with or

observing other therapists, teachers, or parents;

or their own imaginations.

 Formulating expectations is part of preparing. However, those expectations are “fi ction.”

When we understand that, we are prepared to

seek new information and build our expectations in response to the actual situation when

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 399

we begin working together. In instances where

a therapist-coach and coaching partner have

worked together before, the stories or expectations that the two create may be very similar to

what actually happens. However, in situations

where the two have not worked together, one

or both may have created stories, or set expectations, that impede the development of the

relationship.

 The relationship between therapist-coach and

coaching partner is critical. Because it is not

about solving a problem explicitly, thinking about

forming the coaching relationship may feel “soft”

and somehow less important. Thus, coaching

teams (and, indeed, authors writing about coaching) may minimize the importance of formulating

the relationship and move on to the “more important business” that lies ahead. However, when

coaching teams fail to give enough consideration

to forming an equal partnership, the process may

go awry. For example, if the therapist-coach

jumps in too quickly with solutions, the coach

may give the impression of “knowing all the

answers,” which, in turn, may make the coaching

partner feel dependent or even angry.

 Clearly, perceived inequality in the relationship will hamper both the development of a

partnership and the effectiveness of the process.

This is particularly true when coaching teams

have not worked together before or when one

team member has considerably less experience

than the other. Of course, a therapist-coach does

sometimes offer solutions early in the process.

A simple suggestion can go a long way toward

gaining a coaching partner ’ s interest in, and

respect for, the process. However, we must guard

against being perceived as the expert rather than

a conduit. To be effective, a therapist-coach must

demonstrate respect for the partner ’ s knowledge

and skills, willingness to respect the constraints

under which the partner works, the ability to

listen, and the ability to share knowledge and

skills in a meaningful way.

 Sometimes a parent or teacher may hesitate to

enter into a coaching partnership. There are many

valid reasons for that reluctance. The parent or

teacher might believe a therapist is “invading”

or interrupting the important business of home

or classroom or judging the partner ’ s abilities as

a teacher or parent. An individual who has not

previously worked with a therapist-coach might

fear that coaching will be additional work or too

much responsibility. That parent or teacher may

perceive that therapy is a mysterious process

carried out directly with a child and should not

involve other adults. An effective and insightful

coach understands that there are real reasons for

reluctance to enter a coaching relationship. The

power of coaching lays in the combined expertise

of both team members. Thus, a therapist-coach

does what it takes to facilitate the coaching partnership. Above all, the therapist-coach realizes

that, although forming the relationship sometimes takes a great deal of time, the benefi ts are

well worth the time and energy .

 Therapists also sometimes hesitate to enter

into coaching. Some believe that a coach must

be an expert, and they do not feel as if they are

experts. Others think “real therapy” involves

“laying hands on” the child. Working with parents

and teachers, although important, is secondary

( Niehues et al., 1991 ). Still others, knowing that

their mandate is to provide family- or clientcentered care, become confused when parents or

teachers seem to want only direct intervention.

 We believe that many of these fears and

beliefs arise from myths and misconceptions. We

addressed some of those earlier in the chapter.

Historically, occupational therapy practitioners

were not trained as coaches. Although research

has emerged in this area ( Simpson, 2015 ), few

therapists, particularly those implementing SI

therapy, envision their primary role as a coach.

Those therapists may have diffi culty effectively

explaining—or perhaps believing in—the power

of coaching.

Attaining Needed Resources

 All service provision requires resources. Coaching is no exception. Without proper resources,

coaching cannot be effective. Thus, to some

extent, a discussion of the required resources also

describes some potential obstacles to coaching.

Once again, the success of coaching depends on

commitment and the strength of the partnership.

Coaching requires a relationship of equals; each

team member must respect the other ’ s skills and

knowledge and openly demonstrate that respect.

Team members must communicate regularly, and

the therapist-coach must listen actively to the

coaching partner ( DeBoer, 1995 ).

 Success also requires shared skills. The

coaching team must believe that, between them,

400 ■ PART V Complementing and Extending Theory and Application

they have the skills and commitment to solve

the problem. Both must feel comfortable with

their own professional identities; they must feel

free to admit when they do not know an answer

( Niehues et al., 1991 ). Each must be willing to

take risks and credit the other for the contributions toward improving the child ’ s performance

( Case-Smith, 1997 ). In addition, the consultant must be willing to ask for and obtain other

needed support.

 Coaching requires time. It can be a challenge to schedule time to meet when a teacher

or parent is not worried about what other children are doing or the therapist is not thinking

about the next family or school ( Hanft & Place,

 1996 ). Providing coaching is a team decision,

and the team has responsibility for providing

resources. Consideration of the needed resources

must be part of the decision-making process. For

example, if, in school, it is not possible to schedule uninterrupted time before or after school or

during breaks, the principal or some other adult

may need to take responsibility for a class during

coaching.

 Asking a school principal for help is a strategy that some therapist-coaches use in schools.

We describe this in a case illustration later in

this chapter. In asking a school principal for

assistance, that therapist-coach explained what

she hoped to accomplish and why she needed

a particular block of time. The principal agreed

that he or another adult would be free during that

half hour. The principal was willing to provide

support once he understood the problem. Had

the therapist not gone to talk with him, the principal probably would have remained unaware

that there was a problem, and the teacher and

therapist-coach might have given up needlessly.

Further, the therapist, rather than the teacher,

was responsible for securing the necessary assistance, although she must do so with the teacher ’ s

knowledge and approval.

Examples of Coaching

CASE STUDY ■ REBECCA

 Rebecca was a 5-year-old who was extremely

hypersensitive to touch and minor pain but

often had very delayed reactions to touch sensations. Sometimes 5 or more minutes passed

after a minor incident, such as pinching her

fi nger, before Rebecca erupted in tears and

screams of agony: “This is gonna hurt me

forever!” Initially, Rebecca ’ s parents viewed

Rebecca ’ s reactions as melodrama. “After all, if

she really were hurt, wouldn ’ t she cry immediately?” they asked. Believing that Rebecca was

only “acting” to get attention, her parents tried

ignoring her wails and telling her that she was

not hurt and was “acting silly.” However, both

responses only resulted in Rebecca screaming

more loudly.

 Using evaluation results in conjunction

with parent observations, the therapist-coach

explained Rebecca ’ s behaviors in terms of SI

theory. “Rebecca ’ s sensory integrative dysfunction seems to result in taking longer to process

sensation. When she does process it, Rebecca

interprets many stimuli as painful.” The result

was that Rebecca ’ s parents came to view this

very problematic behavior in a different way.

Rather than seeing her behavior as melodrama,

they understood that Rebecca ’ s intense but

delayed reaction was the result of diffi culty

processing sensation. The frame was changed.

 Reframing provided the basis for developing

new strategies for parenting Rebecca. Working

with the therapist-coach, Rebecca ’ s parents

used their new-found knowledge to develop

new strategies for responding to her outbursts.

They began to acknowledge that what Rebecca

felt was pain and that she truly believed it

would “hurt forever.” They asked to see the

hurt place and applied deep touch pressure and

fi rm rubbing to the area. Using these strategies,

they found that, although her reaction to minor

pain remained intense and delayed, they could

more easily console Rebecca.

PRACTICE WISDOM

Three decades ago, Bundy, Lawlor, Kielhofner,

and Knecht ( 1989 ) reported the results of a large

U.S. survey of special education administrators.

When asked what one thing therapists could do

to improve their effectiveness in public schools,

these administrators commonly answered, “Be

more assertive.” This need continues today. In

order to provide high-quality service, we need

support from those around the child. Unless we

make our needs known, those needs cannot

be met.

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 401

 Rebecca ’ s parents felt better in their parenting role. They no longer dreaded taking

Rebecca to friends’ homes. They stopped

believing that they had to apologize for Rebecca ’ s “overreactions.” They used their new strategies and behaved as though nothing out of the

ordinary had occurred. Other adults picked up

on this new strategy and also began to implement it. In this case, the feedback came from

the adults in Rebecca ’ s life. The new strategies

worked, and everyone, including Rebecca, was

more comfortable with Rebecca.

 With the story of Rebecca, we illustrated an

example of coaching with parents. However,

coaching just as frequently happens at school.

For example, a teacher who believed that a

child constantly got into fi stfi ghts while standing in line because he was poorly disciplined

behaved differently once she understood the

child ’ s tactile defensiveness and knew that the

child was probably jostled accidentally from

behind. With the old frame, the teacher made

the child stand near the front of the line where

she could keep an eye on him but, unfortunately, where others were more likely to jostle

him accidentally. With the new frame in place,

the teacher suggested that the child stand at the

back of the line where there was less chance

of unexpected touch, fewer fi stfi ghts, and less

need for punishment for circumstances beyond

the child ’ s control.

CASE STUDY ■ SHAW

 Shaw, a seventh grader, had signifi cant diffi culty with organization. His case illustrates

how coaching might happen with an older child

or teen. His occupational therapist initially provided Shaw with direct services. She developed

and implemented solutions to assist in managing Shaw ’ s organizational diffi culties. She

installed dividers in his locker and arranged to

have a second set of books at home. Such strategies were moderately successful. However,

when the therapist became a coach rather

than a direct service provider, she no longer

assumed that she was the expert on Shaw ’ s

diffi culties. Rather, Shaw became the expert.

The therapist-coach helped him set his own

goals. She was surprised when Shaw indicated

that keeping track of his schedule was most

important to him. Having identifi ed the goal,

Shaw developed a strategy for meeting it. He

fastened a schedule permanently to his backpack. Because the schedule had been his idea,

Shaw felt empowered to alter it to fi t his needs

and did so without assistance from his coach.

 The concept of coaching is deceptively

simple. The process, however, can be complicated. Success hinges on properly identifying the problem, which often is more diffi cult

than it seems ( Schein, 1999 ). Identifying the

problem involves eliciting as much detail as

we can about what the parent, teacher, or child

is experiencing. We ask questions and make

observations until we jointly pinpoint a solvable problem. We fi nd out as much as we can

about how and when a child ’ s diffi culties affect

the child ’ s participation and the parents’ or

teacher ’ s abilities to carry out their own roles.

We also try to learn which strategies have been

tried by coaching partners and how well those

strategies worked.

CASE STUDY ■ DUNCAN

 Duncan was an 8-year-old second grader in a

combined fi rst and second grade classroom. His

teacher, having attempted unsuccessfully for

more than a year to teach Duncan handwriting,

asked for help from an occupational therapist.

When asked about the problems that Duncan

had reproducing letters with a pen or pencil, the

teacher showed the therapist some of Duncan ’ s

papers. The letters were poorly formed and so

light that they were barely legible. Upon questioning, the therapist learned that the teacher

had attempted numerous strategies, and that she

was currently using a “multisensory approach.”

The teacher indicated that Duncan practiced

making letters with various media, including

sand, rice, fi nger paint, chalk, and markers.

 The therapist spent time in the classroom,

and, as she watched, she noted that Duncan

did not have a consistent pattern for forming

letters; they looked different in each medium.

The therapist realized that rather than practicing the same letter formation over and over,

Duncan actually performed different motor

patterns in each medium. When he formed the

letter in fi nger paint, he used fi nger motions;

however, when he wrote on the chalkboard, he

402 ■ PART V Complementing and Extending Theory and Application

used whole arm movements. Both of these were

different from the motor patterns he used when

he wrote with a pencil. Although most individuals would create letters that looked essentially

the same no matter whether they used arm or

fi nger movements, Duncan did not.

 The therapist hypothesized that sensoryintegrative-based dyspraxia affected Duncan ’ s

ability to learn cursive handwriting. She suggested to the educational team that she coach

the teacher. Although the therapist believed that

Duncan would probably benefi t from direct

therapy using a sensory integrative approach,

she knew it could take months of direct intervention using SI to see a big effect on handwriting. In addition, although the therapist

could have developed a direct intervention

program that simply targeted handwriting, she

could only have provided that intervention periodically. The teacher instructed Duncan daily in

handwriting. Furthermore, the therapist knew

far less than the teacher about teaching proper

letter formation.

 The teacher ’ s openness to working with the

therapist was an important factor in the recommendation for coaching. This master teacher

had invested a lot of time and effort trying

to teach Duncan to write. However, nothing

worked. She knew that his problems required

input from another professional and was eager

for help. Although the teacher had taught letter

formation for years, her knowledge of dyspraxia

was limited. Therefore, she unknowingly developed a method to teach letter formation that

“played to Duncan ’ s weaknesses.” This method

resulted in Duncan ’ s formulating several different motor responses for each letter. Because

forming new motor responses was his greatest

defi cit, Duncan had not learned to write.

 When the therapist presented her recommendation for coaching to Duncan ’ s education

team, including his parents and teachers, they

agreed. In fact, her presentation of Duncan ’ s

motor planning diffi culties and the potential

benefi ts of coaching was so convincing that

the physical education teacher also requested

coaching. The therapist-coach listened carefully

to the classroom teacher ’ s problem teaching

Duncan to write. She observed Duncan in his

classroom. She did a little testing with Duncan

(see Chapter 10, Assessing Sensory Integrative

Dysfunction without the SIPT) and interpreted

the results in light of what she saw and heard.

She offered a new frame, explaining Duncan ’ s

diffi culties as they applied to handwriting. She

told the teacher that Duncan seemed to get

poor feedback from touch and body movement.

She did not explain the neuroanatomy of the

tactile, vestibular, and proprioceptive systems.

Rather, she made it clear that, in children such

as Duncan, there is a hypothesized causal relationship between diffi culty interpreting sensation from the body and the ability to learn

new motor tasks. The therapist then went on to

show the teacher that the multisensory teaching

method she had devised unintentionally made

learning handwriting more diffi cult. With the

frame shifted in this way, the teacher understood Duncan ’ s problems differently. The new

frame also suggested new strategies.

 Simple reframing was all that the teacher

needed to understand the problem. She had

known that Duncan was poorly coordinated

and seemed not to know how his body moved.

Therefore, she reasoned that providing a lot of

sensation might help him learn to write better.

However, she had not recognized that, with

each new medium, Duncan formulated a new

plan. She reasoned, “I guess I should pick one

medium and stick with it.” The therapist-coach

agreed. Together, they concluded that Duncan

needed to concentrate on writing with a pen

or pencil. They discussed Duncan ’ s diffi culties

forming letters and pressing hard enough. The

therapist-coach, believing that Duncan was not

getting adequate feedback from his body as

he wrote, suggested a grease pencil because

its increased resistance would provide a lot of

feedback. The teacher agreed. The coaching

team planned to meet the next week to discuss

the outcomes.

 The next week, the teacher reported that

the grease pencil did not work. Duncan still

did not press hard enough to make his handwriting legible and he did not enjoy using it.

The teacher and therapist-coach devised a new

plan for Duncan to write on carbonless paper,

an offi ce supply usually used to produce multiple copies simultaneously. The teacher taught

Duncan to check periodically to see if he had

been pressing down hard enough for his writing

to come through.

 Duncan responded very well to the carbonless paper. Within a short time, he learned to

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 403

press harder and his writing became much more

legible. After a couple of weeks, the teacher,

working with the therapist-coach, decided that

the carbonless paper might no longer be necessary. The teacher prepared Duncan for the

change by trying to make him conscious of the

amount of pressure he used when he wrote on

the carbonless paper. She gave Duncan fewer

carbonless papers each day.

 Having explained that Duncan was not

getting adequate feedback from his body, the

therapist-coach suggested a different kind of

writing implement. When Duncan ’ s problem

of not pressing hard enough on the paper persisted, the teacher and therapist-coach decided

he should continue to use carbonless paper.

Using standard paper, Duncan did not seem

to be able to determine how hard was “hard

enough.” With the carbonless paper, “hard

enough” became defi ned as hard enough to

make marks appear on the paper underneath.

This was the kind of feedback Duncan needed.

The carbonless paper provided concrete evidence of whether he was writing hard enough.

Consequently, the teacher did not have to give

him verbal feedback. In a relatively short

period of time, Duncan seemed to internalize

the amount of pressure needed and no longer

needed the prompt. This mutually developed

strategy was agreeable to everyone. Ideally, all

strategies are mutually developed and agreeable

to all. However, coaching partners are primarily responsible for implementing the strategies,

so the decision about whether a strategy is a

good one rests with them ( Schein, 1999 ).

 As part of her role, the therapist-coach provided alterative writing utensils and paper.

These materials were not really “adaptive

equipment,” per se. However, one important

role of a therapist-coach is to provide adaptive

or alternative devices and materials ( Kielhofner, 2009 ). This is an important tool of coaching and a way of modifying the environment

so that it better fi ts the needs of children with

sensory integrative dysfunction.

 Another important part of coaching was

that the therapist-coach and teacher continued

to meet regularly to identify and solve several

diffi culties that Duncan had in the classroom.

As the teacher gained a greater understanding of Duncan ’ s diffi culties formulating new

motor programs, she began to devise her own

alternative teaching strategies. Initially, she liked

to discuss her plans with the therapist-coach.

However, the more she succeeded, the less

input she needed. During one of their sessions,

a couple of months into coaching, the teacher

remarked, “You know, this all was once so new

to me; now it seems so logical. I know that I

will look at other students’ problems differently

from now on.”

 The therapist did similar coaching with the

physical education (PE) teacher that was also

highly successful. Duncan ’ s PE class focused

on fi tness. The students spent the majority of their time doing basic skills: jumping

jacks, push-ups, sit-ups, and running in place.

Although the exercises were always the same,

the teacher varied the order. If Duncan concentrated intensely, he could perform the exercises

passably. But because this required inordinate

effort, he often chose simply to stand and

watch. When the therapist talked with the PE

teacher, she learned that it was the “standing

around” that bothered him.

 In coaching the PE teacher, the therapist

recommended some very simple adaptations to

increase Duncan ’ s participation. The therapist

explained that Duncan would fi nd the exercises

easier if there were set routines that he could

memorize. Furthermore, because Duncan ’ s

strongest channel for learning was auditory, she

suggested it might be helpful if the PE teacher

always called out the next exercise shortly before

it changed and again at the time of the change.

The PE teacher decided to stand relatively near

Duncan to ensure that he could hear the instructions. He also decided to perform the exercises

with the class, providing a visual model.

 The therapist-coach used her knowledge

of SI theory to help both teachers understand

Duncan ’ s diffi culties with motor planning. In

reframing, she helped them develop new strategies that worked. When the classroom teacher

combined her knowledge of proper letter formation with the therapist ’ s explanation of Duncan ’ s motor planning defi cits, the resulting

strategies allowed Duncan to write legibly. Initially, Duncan did not participate in PE class.

With a few simple modifi cations, however,

Duncan became an active member of the class.

 Pinpointing and refi ning the problem are particularly important. There might have been any

number of reasons why Duncan ’ s PE teacher

404 ■ PART V Complementing and Extending Theory and Application

sought the occupational therapist ’ s assistance.

However, what was really bothering Duncan ’ s

teacher was Duncan ’ s failure to participate in

class. The approach to solving the problem

would have been entirely different if the PE

teacher had been most bothered by Duncan ’ s

poor coordination. When refi ning the problem,

we use caution not to assume that we already

know what the problem is ( Schein, 1999 ). We

are mindful of the fact that the coaching partner

is the expert on the problem.

decades (e.g., Bulkeley et al., 2016 ; Davies &

Gavin, 1994 ; Dreiling & Bundy, 2003 ; Dunn,

 1990 ; Graham, Rodger, & Ziviani, 2009, 2010,

2013, 2014 ; Kientz & Dunn, 2012 ; Scott, 1997 ;

 Simpson, 2015 ). However, the body of evidence

examining SBIs commonly employed in coaching fails to provide such clear direction ( CaseSmith, Weaver, & Fristad, 2015 ; Watling &

Hauer, 2015 ). Several problems contribute to the

confusion surrounding these interventions. Chief

among the problems is inconsistent terminology

and methodological limitations in studies.

 In the remainder of this chapter, we critique

research about SBIs for preschool-aged children

with autism spectrum disorders (ASDs). We

decided to focus on research pertaining to children with ASDs because sensory challenges are

a core feature of ASDs, and many occupational

therapy interventions fall within a general category of SBIs. However, many of the strategies

examined in this research are also used commonly in practice with older children and children who do not have an ASD.

 In this section, we review and critique 16 studies

employing SBIs that may be offered as strategies

to coaching partners working with young children

with autism ( Table 17-2 ). We break those studies

into fi ve categories 2

 ( Table 17-3 ) described by

 Ashburner and colleagues ( 2014 ) according to the

primary strategy employed. Within Table 17-2 ,

we further consider two main groupings of SBIs:

(1) prescriptive interventions and (2) responsive

interventions. Prescriptive interventions have

dominated the SBI research to date.

 Generally prescriptive SBIs are characterized

by passive application of sensation at a time

and in a manner determined by the therapist or

researcher. In contrast, responsive SBIs provide

sensory experiences and opportunities in an individualized way to assist children to manage daily

routines and challenges ( Tomchek & Case-Smith,

 2009 ). Figure 17-1 illustrates the relationships

between ASI and two types of SBIs (prescriptive

and responsive).

 Although responsive strategies are more compatible with coaching interventions, and with

PRACTICE WISDOM

Time spent to build strong coaching partnerships

is well worth the effort. Mutual respect for one

another ’ s knowledge, skills, and previous experiences is essential in building those relationships.

2

 In addition to the fi ve categories listed in the table, Ashburner and

colleagues ( 2014 ) described a sixth category: behavioral strategies

to manage sensory challenges. We have not included this sixth

category because, although therapists commonly use behavioral

approaches with children with autism, the studies we located

employed desensitization, a behavioral approach with underlying

assumptions in direct confl ict with the assumptions of SI theory.

HERE ’ S THE POINT

• Children with sensory integrative dysfunction

confront many diffi culties in everyday life.

Their actions may be confusing to parents

and teachers who, in turn, fi nd it diffi cult to

assume their own roles effectively.

• The combined diffi culties of children and those

seeking to interact effectively with them often

lead to a child ’ s referral to occupational therapy.

• Thus, SI theory is an important tool for working

in schools and homes.

• Coaching enables parents and teachers to

reframe children ’ s behaviors and develop more

effective strategies for teaching and parenting.

• Because children spend the majority of the

day with parents and teachers, we argue that

coaching should be a primary type of service

delivery for children with sensory integrative

dysfunction.

Research Evidence

for Coaching- and Sensory-Based

Interventions Used Commonly

in Coaching with Families

of Young Children with Autism

 The benefi ts of coaching and collaborative consultation in occupational therapy have been fairly

well established during the past two or more

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 405

TABLE 17-2 Summary of SBI Research Including Preschool Children with Autism

PRIMARY

CATEGORY

FIRST

AUTHORS N DESIGN STRATEGY LOCATION

RESPONSIVE/

 PRESCRIPTIVE FINDINGS

Mutual

information

sharing and

support

Dunn,

2012

20 Group Coaching Home Responsive Signifi cant

improvements on

goals, parent stress,

parent feelings of

competence

Mutual

information

sharing and

support

Dunstan,

2008

1 Qualitative Sensory

diet/

Wilbarger

Home Responsive Positive impact on

family routines;

however, burden

of implementation

noted

Mutual

information

sharing and

support

Bulkeley,

2016

3 Single case Coaching/

sensory

Home Responsive Degree of change

and maintenance

of the intervention

effect varied among

participants

Embed

sensory input

to modulate

arousal

Bonggat,

2010

3 Single case Sensory

diet

School Prescriptive No difference in

time-on-task with

a sensory diet

compared with

attention control

Embed

sensory input

to modulate

arousal

Carter,

2005

1 Single case Weighted

vest

School Prescriptive No reduction in

self-injury from a

weighted vest

Embed

sensory input

to modulate

arousal

Davis,

2011

1 Single case Wilbarger/

brushing

Home Prescriptive Brushing had no

signifi cant effect on

stereotypy

Embed

sensory input

to modulate

arousal

Fertel-Daly,

2001

5 Single case Weighted

vest

School Prescriptive Decreased negative

behavior; increased

positive behaviors

Embed

sensory input

to modulate

arousal

Hodgetts,

2011a

10 Single case Weighted

vest

School Prescriptive On-task behavior

improved; in-seat

behavior unchanged;

mixed responses

across participants

Embed

sensory input

to modulate

arousal

Hodgetts,

2011b

6 Single case Weighted

vest

School Prescriptive Stereotypy not

reduced by weighted

vest

Continued

ASI, some techniques described as prescriptive

in Table 17-2 also can be used in responsive

ways. Thus, we include research utilizing prescriptive interventions in this section. Following Table 17-3 , we summarize and critique the

studies in each of the fi ve categories.

Mutual Information Sharing

and Support (Category 1)

 Mutual information sharing and support, along

with the responsive strategies employed in the

research described here, are integral parts of

coaching ( Rush & Shelden, 2011 ). In fact, the

406 ■ PART V Complementing and Extending Theory and Application

PRIMARY

CATEGORY

FIRST

AUTHORS N DESIGN STRATEGY LOCATION

RESPONSIVE/

 PRESCRIPTIVE FINDINGS

Embed

sensory input

to modulate

arousal

Leew,

2010

4 Single case Weighted

vest

Home Prescriptive No decrease in

negative behaviors

or increase in

joint attention;

parent feelings

of competence

increased

Embed

sensory input

to modulate

arousal

Murdock,

2014

30 Group Platform

swing

Clinic Prescriptive No signifi cant

difference on-task;

engaged; stereotypy

or out-ofseat behaviors

immediately after

swing

Embed

sensory input

to modulate

arousal

Quigley,

2011

3 Single case Weighted

vest

Clinic Prescriptive No decrease in

target behaviors with

weighted vest

Embed

sensory input

to modulate

arousal

Reichow,

2010

3 Single case Weighted

vest

School Prescriptive No difference

between intervention

and control

conditions for

weighted vest

Embed

sensory input

to modulate

arousal

Schilling,

2004

4 Single case Therapy

ball seat

School Prescriptive Increased

engagement and

in-seat behavior with

therapy ball seat

Embed

sensory input

to modulate

arousal

Sniezyk,

2015

3 Single case Sensory

diet

 School Prescriptive No causal relationship

between intervention

and behavior change

Self-regulatory

strategies

Thompson,

2013

3 Single case Social

story of

sensory

strategies

 School Prescriptive Desired behaviors

increased; change in

use of self-regulation

strategies variable

TABLE 17-2 Summary of SBI Research Including Preschool Children with Autism—cont’d

TABLE 17-3 Categories for Ameliorating

Sensory Challenges (Adapted from Ashburner

et al., 2014 )

MAJOR STRATEGY

 1. Mutual information sharing and support

 2. Adapting tasks or environment

3. Embedding sensory input into everyday activity to

modulate arousal

 4. Self-regulatory strategies

 5. Universal design

Note: Categories 1 to 4 can be applied in a sequential manner;

Category 5 is applied to benefi t all children, potentially

alongside individual interventions.

three studies in this category ( Bulkeley et al.,

 2016 ; Dunn, Cox, Foster, Mische-Lawson, &

Tanquary, 2012 ; Dunstan & Griffi ths, 2008 )

might be considered in a general way as studies

of coaching effectiveness. They provide promising evidence in support of coaching for managing the sensory challenges of children with

autism and make important contributions to

service delivery and future research ( Tomlin &

Swinth, 2015 ). We highlight the details of the

studies in Here ’ s the Evidence boxes.

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 407

FIGURE 17-1 ASI, SBIs, and subtypes.

Interventions with

Enhanced Sensation

Ayres Sensory

Integration®

Sensory based

interventions (SBIs)

Prescriptive

strategies

Responsive

strategies

Types

Subtypes

HERE ’ S THE EVIDENCE

Dunn and colleagues ( 2012 ) provided ten 1-hour

coaching sessions to parents. Together, parents

and researchers identifi ed goals to promote participation in family routines and develop parental

competence. They measured outcomes using the

Canadian Occupational Performance Measure,

goal attainment scaling, the Parenting Stress Index,

and the Parenting Sense of Competence Scale. To

ensure fi delity to the intervention, the therapist

recorded the sessions, maintained coaching logs,

and engaged in mentoring and team discussions.

Goals, parent perceptions of competence, and

perceived stress all improved because of the intervention. However, parents completed all outcome

measures together with the therapist who provided

the intervention, imposing some limitations on the

independence of these ratings.

HERE ’ S THE EVIDENCE

Dunstan and Griffi ths ( 2008 ) reported the results of

a coaching intervention in an in-depth case study

of a 4-year-old boy with autism. During a 5-week

period, they provided education about sensory

issues and support for the family and prescribed a

sensory diet and the Wilbarger brushing protocol.

Observation sessions and interviews with family

members yielded positive views on the impact of

the intervention. The mother highlighted the value

of knowledge and reframing of behavior:

The result of the assessment, it was just like light

bulbs going off . . . and it was so obvious once

they had pointed it out. . . . If you kind of understand why he ’ s feeling the way he ’ s feeling, or why

he ’ s doing what he ’ s doing then it tends to be a lot

easier. ( Dunstan & Griffi ths, 2008 , p. 10)

Despite the benefi ts, family members noted a need

for ongoing support to avoid being overwhelmed

by too much information and too many demands.

408 ■ PART V Complementing and Extending Theory and Application

HERE ’ S THE EVIDENCE

Bulkeley and colleagues ( 2016 ) explored the

effectiveness of a sensory-based, family-centered

coaching approach to changing problematic

routines for young children with autism. Three

mothers of young children with autism, atypical

sensory processing, and global developmental

delay each participated in a single-case experimental ABA-design study. Mothers selected a

problematic daily routine linked to sensory challenges as the focus of four intervention sessions

provided at home. Changes in the mothers’

perceptions of the children ’ s behavior were the

primary outcome, measured daily on a visual

analog scale. Bulkeley and colleagues analyzed

the data visually and descriptively. The degree

and maintenance of the intervention effect

varied among participants.

Adapting Tasks

or the Environment (Category 2)

 Occupational therapy practice models and guidelines for children with autism are replete with

the importance of adaptations to the task and

environment ( Rodger, Ashburner, Cartmill, &

Bourke-Taylor, 2010 ; Tomchek & Case-Smith,

 2009 ). Such adaptations are often the hallmark of

coaching interventions. Many occupational therapists working with individuals with autism use

adaptations to manage sensory challenges ( Ashburner et al., 2014 ; Kadar, McDonald, & Lentin,

 2012 ). However, as Baranek ( 2002 ) pointed out,

their effectiveness is rarely examined empirically. Dunstan and Griffi ths ( 2008 ) briefl y mentioned environmental modifi cations in their case

study, described previously. Dunn and colleagues

 ( 2012 ) provided examples of adaptation: a timer

to assist with task completion, including music

in morning routines, and arranging alternative

activities when siblings were playing soccer.

 Bulkeley and colleagues ( 2016 ) offered ways of

minimizing the noise associated with a hair dryer

as well as adaptations of a mealtime routine.

Embedding Sensory Input

into Everyday Activity to Modulate

Arousal (Category 3)

 Therapists commonly use sensory diets and

approaches such as the Alert Program ® (see

Chapter 18, Complementary Programs for Intervention) in coaching interventions as a way of

embedding sensory input into everyday activities. Very often coaches suggest embedding

enhanced sensation into daily activity in order

to help a child modulate arousal. Most of the

16 SBI studies reported here examined strategies for using enhanced sensory input to modulate arousal: weighted vests, alternative seating,

sensory diets, the Wilbarger protocol, and platform swings. However, with the exception of

 Dunn and colleagues ( 2012 ), Dunstan and Griffi ths ( 2008 ), and Bulkeley and colleagues ( 2016 ),

who embedded sensory input into everyday

activity as needed, all of the research in this category involved prescribed strategies done at set

times and in a standard manner.

 Given discrepancies between the ways that

therapists use the prescriptive strategies described

here in practice and the ways researchers employ

them in studies, it is not surprising that there is

little consensus on their effectiveness. Mixed

fi ndings reveal a need to target sensory interventions more effectively but do not support their

hasty dismissal, as critics often conclude. We

discuss existing research on each of these prescribed strategies next, recognizing that clearly

there is a need for further research.

Weighted Vests

 Weighted vests exert deep pressure, hypothesized

to be calming and organizing, with the intent of

facilitating increased attention, in-seat behavior, upright posture, and length of time on task.

 Olson and Moulton ( 2004b ) used weighted vests

to reduce stereotypy and self-injury. Most occupational therapists working with children with

autism report prescribing weighted vests ( Olson

& Moulton, 2004a, 2004b ). However, unlike in

practice, where weighted vests are generally a

part of a responsive intervention framework, in

the research described here, weighted vests are

a stand-alone prescribed intervention. Duration

of wear and amount of weight vary markedly

among studies. Only one study reported positive outcomes for all participants ( Fertel-Daly,

Bedell, & Hinojosa, 2001 ); two reported mixed

fi ndings ( Hodgetts, Magill-Evans, & Misiaszek,

 2011a ; Leew, Stein, & Gibbard, 2010 ); the

remaining four found no positive effects ( Carter,

 2005 ; Hodgetts, Magill-Evans, & Misiaszek,

 2011b ; Quigley, Peterson, Frieder, & Peterson,

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 409

 2011 ; Reichow, Barton, Sewell, Good, & Wolery,

 2010 ). See the Here ’ s the Evidence box for more

details on studies of the effectiveness of weighted

vests.

Alternative Seating

 Sitting on a therapy ball is thought to provide

opportunities to move and enhance sensation in

acceptable ways in a classroom. In turn, movement encourages a calm, alert state for focused

work. Schilling and Schwartz ( 2004 ) reported

increased engagement and in-seat behavior for

four preschool boys who, for a span of 3 weeks,

sat on therapy balls for 5 to 10 minutes during

class activities. Classroom staff and some families endorsed the therapy balls. Although there

has been only one study of the balls with preschoolers, and they were used in a prescribed

way, the positive fi ndings suggest that therapy

balls as alternative seating are worthy of further

investigation.

Sensory Diets

 Sensory diets are a mechanism for harnessing

the sensory features of activities to promote

function in natural environments (J. Wilbarger &

Wilbarger, 2002a ; see also Chapter 18, Complementary Programs for Intervention). Wilbarger

and Wilbarger described sensory diets as responsive and individually constructed and scheduled

according to the context, the sensory needs of

a child, and the demands of a chosen activity.

Thus, sensory diets are often part of coaching

interventions. Nonetheless, fi ndings from two

studies with preschool-aged children with ASD

( Bonggat & Hall, 2010 ; Sniezyk & Zane, 2015 )

yielded mixed evidence on their effectiveness.

However, the sensory diets were not necessarily

used in responsive ways (see the Here ’ s the Evidence box).

Wilbarger Approach

 The Wilbarger approach (J. Wilbarger & Wilbarger, 2002b ; see also Chapter 18, Complementary Programs for Intervention) is a professionally

guided program for managing sensory defensiveness that includes: mutual information sharing

and support, a sensory diet embedded in daily

routines, and an optional guided program that

involves applying deep pressure (brushing using

a specifi c brush) and joint compression at regular

intervals. See the Here ’ s the Evidence box.

HERE ’ S THE EVIDENCE

Researchers report a variety of durations for

wearing weighted vests: 4 minutes ( Quigley

et al., 2011 ), 5 minutes ( Carter, 2005 ),

10 minutes ( Reichow et al., 2010 ), 20 minutes

( Hodgetts et al., 2011a, 2011b ), 30 minutes

( Leew et al., 2010 ), and 2 hours ( Fertel-Daly

et al., 2001 ). Fertel-Daly and colleagues provided a rationale for length of wear time based

on anecdotal reports and an early animal study

proposing an initial surge in arousal before

calming when deep pressure was applied for

2 hours. Researchers generally prescribe the vest

once a day, but total duration of the intervention

ranged from two sessions ( Leew et al., 2010 )

to 2 years ( Reichow et al., 2010 ). Amount of

weight is another variable, ranging from 5% of

the child ’ s body weight ( Hodgetts et al., 2011a,

2011b ; Leew et al., 2010 ; Quigley et al., 2011 ;

Reichow et al., 2010 ) to 7.5% ( Carter, 2005 )

and up to 10% ( Hodgetts et al., 2011a, 2011b ;

Quigley et al., 2011 ) or a standard weight of

1 pound ( Fertel-Daly et al., 2001 ). Researchers

reported anecdotal evidence or common practice as the primary rationale for determining

weight.

HERE ’ S THE EVIDENCE

Sniezyk and Zane ( 2015 ) individually prescribed

sensory activities to three children to reduce stereotypy that interfered with classroom participation. The researchers described an ABA single

case design; however, one participant completed

only very brief baseline and intervention phases

(AB design) because the child ’ s stereotypy

increased on introduction of the intervention.

Although the other two participants’ problem

behaviors decreased during the intervention, the

behaviors did not return to baseline levels when

the intervention was withdrawn. Therefore, the

researchers concluded that the intervention was

not linked to behavior change; however, an

alternative interpretation is that the intervention

had positive long-term effects.

410 ■ PART V Complementing and Extending Theory and Application

Platform Swing

 Platform swings are a means of providing movement and vestibular input without making significant postural demands. The type of movement

(i.e., slow vs. fast; angular vs. linear) determines whether the input is calming or alerting.

We found only one study ( Murdock, Dantzler,

Walker, & Wood, 2014 ) of the effectiveness

of platform swings with children with autism.

In this study, the platform swing was used

as a stand-alone intervention for a relatively

short time immediately before a focused task.

 Murdock and colleagues ( 2014 ) investigated the

prescribed use of a platform swing with 30 preschoolers with autism for increasing engagement

and on-task behaviors and reducing stereotypy

and time out-of-seat. Children randomly received

5 minutes on a platform swing (intervention) or

5 minutes watching a movie (control) as a break

from table-top activities. The researchers found

no signifi cant differences between intervention

and control groups. They, therefore, did not recommend the platform swing, although their conclusion applies only to a restricted context and

not usual practice.

Self-Regulatory Strategies (Category 4)

 Ashburner and colleagues ( 2014 ) reported

that about half of occupational therapists use

self-management strategies, including social

stories, to help children with autism manage

sensory challenges ( Tomchek & Case-Smith,

 2009 ). In Chapter 18 (Complementary Programs

for Intervention), we include the Alert Program ®

( Williams & Shellenberger, 1996 ) that therapists

use commonly in the context of coaching interventions to help with self-regulation. However,

we found only one study of self-regulatory strategies with young children with autism. Thompson

and Johnston ( 2013 ) identifi ed individual goals

for three preschoolers and read social stories to

each child before a targeted activity. All three

children increased the target behaviors and two

increased their use of self-regulation strategies.

The preschool staff noted increased participation

in activities and a reduction in required support.

Universal Design (Category 5)

 Principles of universal design to increase

person-environment fi t for individuals with

ASDs have emerging support ( Ashburner et al.,

 2014 ; Rodger, Ashburner, & Hinder, 2012 ;

 Tomchek & Case-Smith, 2009 ). They are recommended in online media about autism-friendly

environments (e.g., https://www.theatlantic.com/

HERE ’ S THE EVIDENCE

Bonggat and Hall ( 2010 ) compared sensory diets

(brushing and joint compression, rolling on a

therapy ball, and swinging in a hammock) with

an attention-control treatment. They prescribed

different activities for each of the three children

but administered the activities at the same time

daily rather than following the recommended

responsive procedure for sensory diets ( CaseSmith et al., 2015 ; J. Wilbarger & Wilbarger,

 2002a ). The researchers reported increases in

on-task behavior for all participants but no difference between intervention and control conditions. Although they concluded that sensory

diets are ineffective, one might cautiously

(given problems with study design) conclude

that both sensory diet activities and one-on-one

attention-control activities are viable options for

improving attention to task.

HERE ’ S THE EVIDENCE

Davis, Durand, and Chan ( 2011 ) reported the

results of a single case design study using brushing and joint compression to reduce stereotypy in

a 4-year-old boy with autism. The child ’ s mother

or a behavior therapist administered the protocol seven times a day for 6 weeks. Although the

Wilbarger protocol is not commonly applied to

reduce stereotypy and the deep pressure and

joint compression techniques are not recommended for use in isolation from other sensory

strategies, these researchers hypothesized that

the intervention would provide a similar level of

sensory stimulation to that received from stereotypic movements. However, they found no

change, providing no support for brushing and

joint compression to reduce stereotypy. Because

they employed brushing for a different outcome

than that for which it is intended, their conclusion that the approach is ineffective must be

considered with caution.

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 411

health/archive/2015/04/making-theater-autism

-friendly/388348/ ), on websites about Universal

Design for Learning (e.g., http://www.udlcenter

.org/aboutudl ), and in textbooks ( Woronko &

Killoran, 2011 ). Although we found no research

of the effectiveness of universal design principles, such research clearly is warranted ( Ashby,

 2011 ; Rodger et al., 2010 ).

HERE ’ S THE POINT

• Studies embedding sensory input into daily

activity to modulate arousal and change

behavior yielded mixed findings and were often

fraught with methodological limitations.

• Thus, although some of the strategies have

promise, the evidence does not allow us to

conclude definitively that they either are or are

not effective.

• Studies of mutual information sharing and

support ( Bulkeley et al., 2016 ; Dunn et al.,

 2012 ; Dunstan & Griffi ths, 2008 ) most

closely refl ect the characteristics inherent to

coaching listed at the beginning of this chapter.

They also yielded some of the most positive

results.

• Collaboration between a therapist-coach

and coaching partners (i.e., families and

teachers) helps to ensure that interventions are

individualized and responsive.

Summary and Conclusions

 In coaching, we offer partners (e.g., parents,

teachers) access to SI (and other) theory as a way

of understanding behavior. Based on a new frame,

the therapist-coach assists a coaching partner to

understand the behavior differently and develop

new strategies for addressing it. The expected

short-term outcomes of coaching are a coaching

partner who feels, and is, more effective in his

or her own roles and a child who participates

more fully because of an improved fi t between

the child ’ s needs, the tasks he or she must do, and

the supportiveness of the environment. In other

words, coaching enables children with sensory

integrative dysfunction to succeed despite their

limitations. The long-term outcomes of coaching are that coaching partners learn a process for

identifying and refi ning problems and for developing strategies to ameliorate those problems and

can apply those in different situations.

 Coaching is a powerful means of delivering occupational therapy to individuals with

sensory integrative dysfunction. The overall goal

of coaching is to help coaching partners (e.g.,

parents, teachers) be, and feel, more effective in

their own roles. Coaching involves joint planning, observation, action, refl ection, feedback,

and reframing . The evidence for the success of

coaching as an intervention to improve children ’ s participation in everyday life and parents’

and teachers’ feelings of effectiveness in their

own roles is growing. However, more research

is needed.

 Coaching is, by defi nition, a collaborative

process. We note, however, that even when therapists collaborate with families, the interventions

they develop together do not always turn out to

be manageable from the families’ perspective.

When families simply agree to participate in a

particular intervention or study, rather than collaborating on its development, the danger of

imposition is even greater. The intensity of some

interventions places signifi cant demands on families, which may not be sustainable. Davis and

colleagues ( 2011 ) studied the Wilbarger brushing

protocol with the participant potentially receiving 294 occasions of intervention (if administered as proposed). Can such an intervention fi nd

a place in the busy schedules of families? The

amount of intervention required to achieve particular outcomes is unclear and requires research.

 The preponderance of evidence regarding the

effectiveness of strategies commonly offered

to coaching partners for managing the sensory

challenges of young children with autism falls

into two categories: embedding sensory input in

everyday activity and mutual information sharing

and support. Overall the research is limited,

results are mixed, and, as previously noted, the

research is fraught with methodological concerns. Further, a lack of Fidelity Measurement in

most studies means uncertainty about the delivery of the intervention and raises questions about

conclusions.

 Finally, some authors of the studies that we

reviewed here ( Leew et al., 2010 ; Quigley et al.,

 2011 ; Sniezyk & Zane, 2015 ) referred to their

interventions as “SI therapy.” However, in no

412 ■ PART V Complementing and Extending Theory and Application

case did the intervention comply with criteria

specifi ed in Parham and colleagues’ ( 2007 ) Fidelity Measure for ASI. As noted earlier, Parham

and colleagues’ Fidelity Measure applies to direct

intervention, and, therefore, it does not refl ect the

characteristics of coaching interventions.

Where Can I Find More?

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416

 APPENDIX 17-A

Part I: Strategies and Activities

for Addressing Common

School Problems

 The following pages contain several activities

and strategies that may be offered in the context

of coaching interventions at school to address

problems commonly experienced by children

with sensory integrative dysfunction. These

activities by no means represent an exhaustive

list. In each case, a problem is listed along with

its possible relationship to SI theory. Of course,

all the diffi culties that children with SI dysfunction experience are not caused by the sensory

integration dysfunction.

 We grouped the problems in Part I into categories. The categories, in the order in which they

appear, are as follows:

• Writing

• Art and Construction

• Homework

• Distractibility

• Social Behavior

• Lockers and Desks

• Posture

• Miscellaneous

PROBLEM

POSSIBLE RELATION TO

SENSORY INTEGRATION

THEORY POSSIBLE STRATEGIES

 WRITING

Child has a “death

grip” on pencil.

Poor proprioception

resulting in poor

modulation of force

 • Wrap the pencil or pen in stiff clay, which provides

feedback to the child; if the clay is misshapen after the

child uses it, the child ’ s grip is too fi rm.

Poor posture, which

encourages forceful

use of hands and arms

 • Tilt the writing surface to help the child maintain a

more upright posture, while also making it easier for

the child to use appropriate force.

Child uses so little

pressure on pen that

writing is almost

illegible.

Poor proprioceptive

processing resulting

in poor modulation of

force

 • Have the child place paper atop a magic slate and press

hard enough that the writing appears on the slate.

 • Have the child use a pencil with very soft lead or a

felt-tip marker.

Child can ’ t copy

accurately from

board onto paper.

Poor oculomotor

control resulting in

diffi culty switching

from vertical to

horizontal plane when

copying

 • Have the child copy from a book or paper to another

paper in the same plane instead of from the board to

the paper.

 • Have the child write on a slant-top surface, which

reduces the change in angle from one surface to

another.

Child can ’ t keep

columns lined on

arithmetic papers, so

he or she always gets

the wrong answer.

This problem may have

many causes, including

poor oculomotor

control.

 • Provide the child with grid or graph paper in which only

one digit is allowed per space.

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 417

PROBLEM

POSSIBLE RELATION TO

SENSORY INTEGRATION

THEORY POSSIBLE STRATEGIES

WRITING

Child has diffi culty

forming letters or

shapes.

Poor visual motor

coordination

 • Place a piece of clear plexiglass in a stand; someone

sitting behind the plexiglass can draw letters backward

for tracing on the other side; when the child is fi nished

tracing, erase the lines on the other side, leaving only

the child ’ s work. A Magnadoodle can be used in a

similar way; after the child traces the outline, erase the

adult ’ s markings.

Letters vary markedly

in size.

Poor visual motor

coordination

 • Use paper with raised lines (often available for children

who are partially sighted).

ART AND CONSTRUCTION

Child refuses to use

paste because he or

she can ’ t stand the

feel of it drying on

his or her skin.

Tactile defensiveness • Have the child use a glue stick, glue in a bottle, a

stapler, or Scotch tape instead of paste.

 • Have the child use a Popsicle stick instead of his or her

fi ngers to spread the paste.

 • Place a container of wipes on the desk for the child to

wipe off his or her fi ngers right away.

 • If the task is to glue the correct answer to the

paper, allow the child to use another method of

demonstrating knowledge (e.g., writing the correct

answer).

Child cannot cut with

regular scissors.

Poor bilateral

integration

 • Fasten loop scissors to a small board and then fasten

that to the top of the child ’ s desk; the child can cut

by pushing down with one hand and then turning

and moving the paper with the other; this signifi cantly

reduces the bilateral demand.

 HOMEWORK

Child forgets to take

home the books or

information needed

for homework.

Poor organization • As assignments are given, have the child place needed

supplies into his or her backpack. Alternatively, create

magnets or other manipulatives with words or pictures

of needed books; as an assignment is given, have the

child place the relevant icon in the same place; at the

end of the day, the magnets remind the child which

books to take home.

 • Have the student keep a second full set of books at

home.

 • The teacher or a designated student creates an ongoing

assignment list on the chalkboard, which includes the

necessary books and materials.

 DISTRACTIBILITY

Child follows

instructions given

to every child in the

classroom because he

or she is unable to

screen out stimuli.

Distractibility

secondary to sensory

defensiveness (of

course, there are

many other causes of

distractibility)

 • Have the child sit in the least distracting area of the

classroom, probably in a back corner.

 • Provide the child with written directions as well as

verbal; make him or her responsible for checking the

instructions himself or herself.

 • Provide an area in the classroom, such as a loft or quiet

space (e.g., refrigerator box lined with carpet), where

children can go when they feel they need a quiet place

to work.

 • Some children fi nd that wearing headsets helps cut

down the amount of auditory stimulation coming in;

also, some children fi nd the weight of the headset to

be calming.

Continued

418 ■ PART V Complementing and Extending Theory and Application

PROBLEM

POSSIBLE RELATION TO

SENSORY INTEGRATION

THEORY POSSIBLE STRATEGIES

DISTRACTIBILITY

Child wanders

around and disrupts

classmates when

he or she gets

overstimulated or

tired.

Distractibility

secondary to poor

sensory modulation

(of course, there are

many other causes

of distractibility—see

another explanation in

the row that follows).

 • Reduce the amount of stimuli.

 • Have the child sit in the least distracting area of the

classroom, usually a back corner.

 • Help the child organize his or her workspace so he or she

does not have to expend a lot of energy fi nding things.

 • Decrease bright lights and clutter, and provide a “cove”

for the child ’ s desk or a quiet space where the child can

go to regroup.

Child wanders

around and disrupts

classmates when

he or she gets

overstimulated or

tired.

Some children who

have motor planning

problems fatigue

easily with the motor

demands of school;

they also may wander

aimlessly when tired.

 • Build in many opportunities for the child to get up and

move around during the day.

 • Have the child help out with “chores” around the

classroom; if these provide increased proprioception

through resistance to movement, all the better (e.g.,

banging erasers, washing the blackboard, carrying

books to the offi ce).

 • Provide the child with clay or “fi dget toys” to use at his

or her desk; this will give the child something to do but

help keep him or her from disrupting others.

SOCIAL BEHAVIOR

Child pushes other

children who come

too close to his or

her desk.

Fight-or-fl ight reaction

secondary to sensory

defensiveness

 • Put the child ’ s desk in the area of the classroom where

there is the least amount of activity (usually a back

corner), and provide a quiet space in the classroom

where all children can go when they need to be alone

(e.g., refrigerator box, loft).

 • At the appropriate time, discuss the problem with the

child; help the child understand that he or she reacts

differently than other kids to touch and noise; ask

for the child ’ s ideas and solutions and give alternative

explanations for the other children ’ s behavior (e.g.,

“Other children often come very close to you because

they are your friends and feel comfortable with you”).

 • Help the child develop strategies for acceptable

replacement behaviors to be used when he or she

wants to hit (e.g., pull on a bungee cord attached to a

belt loop or the desk).

 • Teach the whole class about the importance of

respecting others’ personal space and individual

differences about comfort level in being close to others.

Child gets too close

to other children

when he or she is

playing and during

circle time.

This problem, which

sometimes seems

related to knowledge

of the boundaries of

the body, is not usually

seen in children with

sensory integrative

dysfunction; however,

it is a complicated

problem and not

clearly associated

with any aspect of SI

theory.

 • Because the problem seems related to a lack of internal

sense of boundaries, provide the child with external

guides to help him or her stay out of others’ personal

space.

 • During circle time, allow the child to choose a stuffed

animal that he or she is responsible for; the animal

requires being held fi rmly throughout the circle time

activity.

 • Begin circle time by explaining that everyone needs

to be at arm ’ s length away from each other; after the

correct distance is established, provide carpet squares or

hula hoops for children to sit on or in; the hook side of

Velcro also can be used to form a stationary, but readily

removed, square.

 • During playtime, engage the child in games that

promote being in contact with other classmates, such

as steamroller; point out that this game is intended for

being close but that most other games are not.

CHAPTER 17 Using Sensory Integration Theory in Coaching ■ 419

PROBLEM

POSSIBLE RELATION TO

SENSORY INTEGRATION

THEORY POSSIBLE STRATEGIES

LOCKERS AND DESKS

Child ’ s desk is so

disorganized that he

or she cannot fi nd

anything.

Disorganization is

commonly associated

with dyspraxia.

 • Line the child ’ s desk with butcher paper; outline and

label the places where the folders, pens, books, and so

on, should go.

 • Attach small boxes to the desk fl oor for various objects.

 • Give the child a colored folder for each subject; require

that the child take time after a subject is completed to

put supplies away before the next subject is started.

 • If the child feels rushed and then stuffs things into

the desk, give the child a timer to set or give verbal

reminders so he or she can anticipate when an activity

will end and can put things away properly.

 POSTURE

Child slouches in seat

or falls out of seat.

Decreased postural

control secondary to

poor processing of

vestibularproprioceptive

information; this

problem is often

accompanied by poor

ability to cross the

midline while doing

desk work; child

moves nearer to the

edge of the chair and

is at risk for falling,

especially if he or she

does not have a good

sense of the vertical.

 • Allow the child or class to lie or sit on the fl oor during

some activities; wedges, pillows, and beanbag chairs

can make this more appealing. Slanting the table

surface makes it easier for the child to maintain good

posture and may decrease incidences of falling.

 • Some therapists have been successful having children

sit on t-stools; they believe that the children must pay

closer attention to their posture and, therefore, remain

more erect.

 • Make sure the child ’ s feet touch the fl oor; if they do

not, a footrest slanted toward the child may help.

 • Apply a nonslip surface to the seat of the chair (e.g.,

Dycem, bathtub decals).

 MISCELLANEOUS

Student misses

recess because he or

she can ’ t complete

assignments on time;

the child really needs

recess to “let off

steam.”

There are many

reasons why a child

may fail to fi nish work

on time; two that are

related to SI theory

are distractibility

secondary to sensory

defensiveness (which

makes it diffi cult to

focus) and poor motor

planning (which makes

it diffi cult to get large

quantities of work

done); in either case,

periodic opportunities

to be active can help

the child get more

done.

 • Provide as many opportunities as possible for active

work during the day; for example, instead of sitting at

his or her desk while doing math, have the child do

math problems on the board.

 • If the problem is with the quantity of work, see if the

teacher would consider shortening in-class assignments;

for example, how many problems does the child have

to do correctly to demonstrate that he or she has

mastered the concept of adding two-place numbers?

 • Break assignments into two parts, and allow the child

to work on them in smaller segments.

Continued

420 ■ PART V Complementing and Extending Theory and Application

PROBLEM

POSSIBLE RELATION TO

SENSORY INTEGRATION

THEORY POSSIBLE STRATEGIES

MISCELLANEOUS

Child chews collars

of clothing or hair

when stressed, which

is frequently; he or

she is ruining clothes

and smells bad much

of the time.

Stress is not

unusual among

children who have

sensory integrative

dysfunction, both

children with dyspraxia

and with modulation

disorders.

 • Teach stress-reduction strategies to the whole class

(e.g., pet a stuffed animal, listen to rain on a personal

stereo, fi nd a safe space to regroup).

 • Provide replacements for hair or clothing (e.g., a length

of knotted tubing, an object at the end of a pencil,

sugar-free gum); some children seem to thrive on oral

stimulation; rather than (or in addition to) chewing,

they might enjoy blowing on whistles (with the noise

maker removed) or blowing into Theraband © stretched

tight across the face to produce a “raspberry” noise.

Student gets lost

going from the

classroom to other

destinations in

school.

A poor sense of real

space is common

to many children

who have sensory

integrative dysfunction.

Neuroscience literature

links poor vestibular

processing with poor

spatial navigation

by way of vestibular

projections to the

hippocampus.

 • Have the child take a buddy with him or her.

 • Create colored lines along the walls going to common

destinations (e.g., offi ce, bathroom, lunchroom).

421

 APPENDIX 17-A

Part II: Selected Activities to

Address Underlying Aspects of

Sensory Integrative Dysfunction

 Note: The activities listed in the text that follows

are different from those in Part I in that they

are meant to address aspects of the underlying

problem that prevents a child from accomplishing certain school tasks. This is by no means an

exhaustive list of activities. Be aware that the

more the activity clearly seems related to a particular school problem, the more likely a teacher

is to incorporate it into the day ’ s routine.

Activities that Provide

Enhanced Proprioception

 • Use a vibrating pen that changes oscillations

as the pressure on the pen changes.

 • Do graphite or crayon “rubbings” of

three-dimensional objects (e.g., leaves).

 • Use media that encourage the child to pull

and work his or her hands and fi ngers, such

as putty, play dough, clay, or rubber bands.

 • Use activities that encourage the child to

push, pull, or carry heavy loads, such as

stacking chairs, carrying books to the offi ce,

or collecting all the blocks on the fl oor into a

large box.

 • Allow the child to lie supine under a small

table and write against the underneath

surface of the table. Some children even

enjoy bracing their feet against the bottom

of the table surface. Of course, that probably

means someone will have to sit on the table

to keep it from going up in the air.

 • Provide the child with a balloon fi lled with

fl our or gel to fi dget with as he or she listens.

Hearthsong of California (1-800-325-2502)

makes stress balls shaped to resemble

animals for squeezing.

Activities that Provide

Enhanced Tactile Sensation

(Especially Deep Pressure)

 • Fill the tub with beans or rice, and hide

familiar objects in the beans or rice. Have the

child search for the objects by touch.

 • Fasten a textured substance (e.g., carpet

square or object such as a surgical brush)

on top of or underneath a desk surface.

Encourage the child to rub his or her

hands briskly across it before engaging

in activity.

 • Techniques such as wrapping the child tightly

in a blanket and also rocking or sitting on the

teacher ’ s lap during story time (as tolerated)

can provide deep pressure under certain

circumstances.

Activities that Provide Enhanced

Vestibular Sensation

 • Use movement activities, especially activities

that involve swinging or jumping, and many

playground activities.

 • Encourage the child to rock in a rocking

chair before a new activity is started or

during the activity.

422 ■ PART V Complementing and Extending Theory and Application

 • Some children work well sitting on a

gymnastic ball or other surface on which

they can bounce and move around. Stabilize

the ball in a cardboard box or small square

wooden frame.

Activities that Require

Modulation of Force

 • Use the Hungry-Hippo game. This requires

the correct amount of pressure to shoot the

hippos into the correct spot.

 • Play the Operation game or simply pick

up any small objects with tweezers; this

requires deft prehension and modulation of

force. Do the egg, water balloon, or shaving

cream ball toss. Catching, especially, requires

modulation of force so as not to break the

object.

Suggestions for Tactile

Defensiveness

 • Do activities that provide light, unexpected,

or noxious touch when a child is relatively

calm.

 • Provide a quiet place for the child to engage

in tactile activities.

 • Create loft areas or refrigerator boxes placed

in a corner of the room where any child can

go when he or she feels a need to be in a

quiet place.

 • Have a child prepare for an activity by

having a little quiet time.

 • Provide a child with a box to sit on his or her

desk into which he or she can insert his or

her head. The box is painted a dark color on

the inside and the outside and has a curtain

across the open side. Glow-in-the-dark stars

can be attached to the inside walls of the

box. The child uses a fl ashlight to illuminate

the stars and is then allowed to stay in the

box until the stars stop glowing.

 • Any activity that provides deep pressure

input may be useful before engaging in an

activity that may “aggravate” a child ’ s tactile

defensiveness.

423

CHAPTER

18

Complementary Programs

for Intervention

 Julia Wilbarger , PhD, OTR/L ■ Patricia Wilbarger , MED, OTR/L, FAOTA ■ MarySue Williams , OTR/L ■

 Sherry Shellenberger , OTR/L ■ Molly McEwen , MHS, OTR/L ■ Gudrun Gjesing ■

 Beth Osten , MS, OTR/L ■ Mary Kawar , MS, OT/L ■ Sheila Frick , OTR/L ■

 Patricia Oetter , MA, OTR/L, FAOTA ■ Eileen W. Richter , MOH, OTR/L, FAOTA

 Chapter 18

 If something is complementary, then it somehow completes

or enhances the qualities of something else.

 — https://www.vocabulary.com/dictionary/complementary

Upon completion of this chapter, the reader will be able to:

✔ Have a broad understanding of the background

and basis of several sensory-based therapeutic

approaches currently used to complement

sensory integration (SI) intervention.

✔ Understand suggested links between SI and

these complementary approaches.

✔ Describe expected therapeutic benefi ts in

application of these approaches.

✔ Be able to appraise the application of these

approaches based on characteristics of children

and adults for whom these approaches are

intended.

LEARNING OUTCOMES

Introduction

 SI theory has inspired several occupational therapists to develop or adopt intervention programs

and applications that complement the theory in

some way. Such programs and applications are

often used alongside interventions drawn directly

from the theory. We invited several occupational

therapists who are well known for their contributions to professional development and the

creation or implementation of innovative complementary programs to contribute to this chapter.

Aspects of SI theory, most commonly enhanced

sensation, are inherent to all these programs

and applications. However, each differs in some

important way from “pure” sensory integrative

therapy. Giving voice and venue to these professionals offers readers an opportunity to learn

about and evaluate complementary programs and

applications commonly used with children and

adults who have sensory integrative dysfunction.

Readers should be aware that, although these are

in common usage, all are in need of empirical

research to examine their effectiveness, appropriateness, and feasibility.

 Based on Ayres’ teaching and writing, we

defi ne intervention based on the principles of

SI as:

 thoughtful provision of opportunities to actively

(1) take in enhanced tactile, vestibular and

proprioception sensations in the context of

(2) engagement in meaningful activity (generally play) that promotes postural development,

praxis, sensory modulation, and self-regulation.

 Both components must be present for an intervention to be considered SI. The relative importance of particular sensations and outcomes for

424 ■ PART V Complementing and Extending Theory and Application

any given child is determined through comprehensive assessment.

Three Areas of Sensory Integration

 We used the defi nition of SI in the preceding

section to set the context for evaluating each of

the programs in terms of the extent to which each

overlapped with, or complemented, intervention

based on the principles of SI. In the table that

precedes each section, we analyzed the program

in three areas:

 1. Sensation(s) emphasized—Is the sensation

embedded within the program uni-modal or

multi-modal? Does the program emphasize

integration of sensations? Does the child take

in sensation actively or passively?

 2. Approach—Is program implementation

varied (i.e., responsive to the child ’ s

needs at the time) or prescribed (i.e.,

standardized)?

 3. Setting—In what setting is the intervention

typically administered (i.e., traditional

[clinic] vs. nontraditional [home, school,

community])?

 Sensation

 Providing opportunities to actively integrate sensation in the context of a demand for an adaptive

response is a principle tenet of SI theory. “Integration is achieved by organizing and emitting an

adaptive response, and therapy is achieved when

that response represents more complex organization than previously accomplished” ( Ayres,

 1972 , p. 36). Although some of the programs and

applications described in this chapter adhere to

this principle, others focus on receiving, rather

than actively taking in, sensation. This is done

through passive application of sensation, seemingly to ensure ample stimulation and control the

characteristics of the stimulation (e.g., intensity

and duration).

 In her teaching and writing, Ayres ( 1972,

1979 ) emphasized the integration of three types

of sensation: vestibular, tactile, and proprioceptive. These proximal senses develop early in life

and seem to serve as points of reference for the

distal senses of vision and hearing, which develop

later. Perhaps Ayres would have examined the

distal senses more fully had she lived longer.

Certainly, she never excluded, or downplayed the

importance of, any sensation. (See also Chapter 1 ,

Sensory Integration: A. Jean Ayres’ Theory

Revisited.) Many of the programs described here

emphasize senses other than vestibular, tactile,

and proprioception. Some emphasize integration,

whereas others focus on particular sensations.

 Approach

 Ayres described therapy in much the same way

that many authors describe play: as constantly

evolving and determined by the “player” (i.e.,

the recipient of the services, as described in

 Chapter 12 , The Art of Therapy). Nonetheless,

in an attempt to make intervention “systematic,” some of the interventions described in this

chapter involve prescribing the type, application,

and dosage of sensation; they appear to lack

the spontaneity that Ayres described. Others are

more varied and responsive to a child ’ s needs at

the time. Clearly there are both advantages and

disadvantages to each approach.

 Setting

 Ayres wrote solely about therapy implemented in

clinic settings. Perhaps this was simply a refl ection of the time during which she was practicing

and writing: at that time, intervention occurred

in the clinic. Or perhaps, the clinic represented

a space where numerous opportunities for taking

in sensation and acting on challenges were

presented reliably. Times have changed and,

although the clinic remains an important site for

therapy, the press for family-centered interventions means that an increasing number of interventions are integrated into everyday activity at

home, in school, and in other community settings. (See also Chapter 17 , Using Sensory Integration Theory in Coaching.) The authors in this

chapter present interventions that take place in

the whole gamut of sites, from the clinic to the

swimming pool.

Purpose and Scope

 Readers will learn about a range of programs and

applications in this chapter. We introduce each

section with a table summarizing Sensations

Prioritized, Approach, and Setting. In examining programs from these three perspectives, we

seek only to inform, not to present conclusions

regarding effectiveness, appropriateness, or feasibility. Readers should decide which of these

CHAPTER 18 Complementary Programs for Intervention ■ 425

approaches fi ts their practice and the children

and families they serve.

 Although none of the programs discussed

here meets all the requirements for intervention

based on the principles of SI theory, as outlined

previously, individuals with sensory integrative

dysfunction may benefi t from any of them, when

used judiciously. In an effort to keep this chapter

manageable in scope, we have included only

eight of a myriad of complementary interventions. The programs and applications reviewed

in this chapter are:

• Section 1 : The Wilbarger Approach to

Treating Sensory Defensiveness (by Julia

Wilbarger & Patricia Wilbarger)

• Section 2 : The Alert Program ® for SelfRegulation (by MarySue Williams, Sherry

Shellenberger, & Molly McEwen)

• Section 3 : Aquatic Therapy (by Gudrun

Gjesing)

• Section 4 : Interactive Metronome ® (by Beth

Osten)

• Section 5 : Astronaut Training Program (by

Mary Kawar)

• Section 6 : Infi nity Walk Training (by Mary

Kawar)

• Section 7 : Therapeutic Listening® (by Sheila

Frick)

• Section 8 : Applying Suck/Swallow/Breathe

Synchrony Strategies to Sensory Integration

Therapy (by Patricia Oetter & Eileen Richter)

 For each complementary program, authors

described the following:

• The background to the program

• The rationale for why the program is thought

to work and the associated evidence—both as

it exists and what is needed

• Description of program components, and the

way it is carried out

• The relationship of the program to SI theory

and occupation

• Benefits expected and most commonly

attained, based in research and clinical

experience

• Populations for whom the approach is

appropriate

• Training recommended or required

• A case example or short vignettes of

individual(s) who benefi tted from the

approach

Each author provided references related to the

individual programs discussed; the references

appear by section at the end of the chapter. In

some cases, the rationale provided or terminology used by the authors is different from the

information or terminology used elsewhere in

this book. To provide the most accurate description, whenever possible, we have preserved the

authors’ terminology.

 Readers are asked to consider carefully the

evidence for each program and evaluate what is

most useful for individual children. SI represents

a theory; the theory will expand only because of

discussion among knowledgeable clinicians and

theorists. Certainly, Ayres would have wanted

her theory to grow.

426 ■ PART V Complementing and Extending Theory and Application

Section 1 : The Wilbarger Approach

to Treating Sensory Defensiveness

 Julia Wilbarger, PhD, OTR/L ■ Patricia Wilbarger, MED, OTR/L, FAOTA

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. multi- vs. single system

• Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional or both

Wilbarger Approach (Three Components)

 1. Education

 2. Sensory diet

 3. Therapressure

NA NA NA

 • Integrated

 • Active

 • Prescribed • Nontraditional

 • Multisystem

 • Passive

 • Prescribed • Both

Background

 Sensory defensiveness is a constellation of symptoms that involve negative, aversive, or avoidant responses to non-noxious sensation across

all sensory modalities ( Wilbarger & Wilbarger,

 1991 ). Sensory defensiveness can constrain function and adaptation in all areas of occupational

performance and throughout the entire life span.

Wilbarger and Wilbarger ( 1991 ) argued that

sensory defensiveness is so disruptive to an individual ’ s life that it should be a primary concern

in intervention. At the core, sensory defensiveness is a disruption in the ability to modulate responses to sensation not only in terms of

increased reactivity ( Reynolds & Lane, 2008 )

but also in the production of negative affect

( Ayres, 1972 ); thus, it cannot be thought of as

simply an over-responsiveness to sensation (see

 Chapter 6 , Sensory Modulation Functions and

Disorders).

 The Wilbarger approach to treating sensory

defensiveness is a comprehensive, intensive, and

individualized program to reduce sensory defensive symptoms ( Wilbarger & Wilbarger, 1991 ).

The approach involves prescribed sensory experiences repeated frequently during a short period

of time. Wilbarger was strongly infl uenced by

 Ayres ( 1972, 1979 ), but the Wilbarger approach

has evolved during the past fi ve decades, guided

by the study of functional neurology, collaboration with colleagues, and experience in clinical

practice.

Rationale

 Many of the symptoms of sensory defensiveness

suggest a disruption in a central nervous system

(CNS) process that evaluates incoming stimuli

for positive or negative valence ( LeDoux, 1996,

2014 ; Pribram, 1991 ; Rolls, 2014 ). This process

has been referred to, or described as, the protocritic system by Pribram ( 1991 ), low route

processing by LeDoux ( 1996 ), and the evaluative system by Rolls ( 2014 ). In general, this

evaluative system is responsible for the rapid,

automatic, and subconscious evaluation of the

affective qualities of stimuli. The evaluative

process also affects and is affected by CNS structures related to emotions, memory, autonomic

arousal, and adaptation to stress. One function of

this evaluative system is to alert the individual to

potential danger in the environment and initiate

CHAPTER 18 Complementary Programs for Intervention ■ 427

the appropriate behavioral and physiological

defensive responses, including changes to the

autonomic nervous system.

 Sensory defensiveness is believed to be a

disruption in the evaluation of sensory stimuli

that results in defense responses. In fact, the

behavioral and physiological responses of individuals with sensory defensiveness to certain

kinds of sensation are nearly identical to those

produced by fear or stress stimuli, including,

but not limited to, increased levels of sympathetic arousal and poor habituation ( Reynolds &

Lane, 2008 ). Stimuli that are most likely to

produce sensory defensive responses have features in common with stimuli that naturally

trigger general defensive responses ( LeDoux,

 2014 ). For example, light tactile input and high

frequency noises share sensory features with a

spider crawling on the skin and a distress cry

of an infant or an animal in pain. A person with

sensory defensiveness may be more sensitive to

sensations with these types of alarming features.

Therefore, sensory defensive responses may

lead to changes in arousal, affective tone, and

stress and produce a wide range of functional

diffi culties.

 The rationale for Wilbarger ’ s intervention approach is based on the assumption that

certain types of sensory experiences are thought

to be effective for reducing sensory defensive

responses ( Ayres, 1972, 1979 ; Wilbarger &

Wilbarger, 1991 ). These include deep pressure,

proprioception (i.e., muscle resistance, joint

traction, and compression), and vestibular input

( Ayres, 1972, 1979 ). These types of sensation

are believed to infl uence the adaptation to and

modulation of environmental sensory input along

with resultant physiological responses ( Field,

 2010 ; Ornstien & Sobel, 1987 ; Pribram, 1991 ).

Presumably, the ultimate effectiveness is mediated by the global integrative effects these inputs

have on the CNS.

 Somatosensory input is a powerful agent for

improving well-being and reducing stress and

pain ( Field, 2011 ; Hertenstein & Weiss, 2011 ).

Repeated application of sensory input is believed

to facilitate homeostasis and regulation of behavior in much the same way that massage and

other intense somatosensory-based interventions

(e.g., transcutaneous electrical nerve stimulation

[TENS] and acupuncture) reduce chronic pain

( Deer & Leong, 2012 ). Long-term adaptation

likely takes place at the biochemical, cellular,

and behavioral levels ( Field, 2010 ; Pert, 1997 ).

Program Description

 Sensory defensiveness is a diffi cult condition to

treat. Individuals with sensory defensiveness are

often resistant to novelty and change and accept

only a narrow range of sensory experiences.

The introduction of sensory-based interventions

needs to be carefully considered and planned.

The Wilbarger approach to treating sensory

defensiveness involves a specifi c, individualized

intervention program. The approach incorporates

three essential components:

 1. Education of the child and caregivers

to promote awareness of the presence

and impact of symptoms of sensory

defensiveness

 2. A sensory diet that incorporates

sensory-based activities into daily routines

 3. A professionally guided intervention program

that involves very specifi c, individualized

intervention with careful monitoring

 Professionally guided intervention may or may

not include the Therapressure Program TM , sometimes called the Wilbarger protocol. (This procedure also has been referred to as “brushing,” but

this term does not accurately convey the intent

of the technique and is misleading.) Although the

scope of this section does not allow for a complete description of this program, we will highlight key features below.

 Education

 Educating children and their caregivers or family

to understand the impact of sensory defensiveness on everyday life is, by itself, therapeutic.

Education can provide an explanation for and

awareness of previously incomprehensible reactions and feelings. Awareness allows children

and their caregivers to reinterpret sensory defensive behaviors and recognize how they disrupt

everyday life. Both knowledge and awareness

emerge from the evaluation process. The evaluation process should result in a relatively comprehensive and prioritized list of behaviors related

to sensory defensiveness, including (1) primary

defensive responses to sensation in daily life,

428 ■ PART V Complementing and Extending Theory and Application

(2) behaviors or disruptions secondary to sensory

defensiveness, and (3) coping strategies ( Kinnealey, Oliver, & Wilbarger, 1995 ). The “problem

list” is the basis for intervention planning,

monitoring, and assessment of outcomes. The

primary assessment tool is a structured clinical

interview. The use of standardized self-report or

parent-report questionnaires such as the Sensory

Profi le-2 ( Dunn, 2014 ) or Sensory Processing

Measure ( Parham, Ecker, Miller-Kuhaneck,

Henry, & Glennon, 2007 ) can be helpful in identifying some behaviors related to sensory defensiveness but rarely provide a full profi le of life

disruptions.

Sensory Diet

 The second aspect of intervention is a sensory

diet. A sensory diet is a strategy for developing

individualized home programs that are practical,

carefully scheduled, and based on the concept

that controlled sensory input can affect functional

abilities. The sensory diet therapy plan involves

the therapeutic use of sensation in the context of

daily activities ( Wilbarger, 1993 ) and is used to

address sensory defensiveness in two different

ways: (1) Activities with sensory qualities that

are most likely to reduce defensive behaviors are

identifi ed and implemented in the course of daily

life routines; and (2) Adaptations are made to the

environment to promote optimum functioning

and reduce disruption.

 Sensory-based activities provided at regular

intervals are the cornerstone of the sensory diet.

The activities are chosen to emphasize sensory

inputs such as deep pressure, proprioception,

and movement ( Ayres, 1972, 1979 ; Wilbarger &

Wilbarger, 1991 ). Other strategies (e.g., oral

and respiratory) also can be used, particularly for gaining and maintaining regulation of

arousal states ( Oetter, Richter, & Frick, 1995 ,

 Section 8 ; Williams & Shellenberger, 1994 ). In

this program, it is important to keep in mind the

power of a particular activity to produce adaptation and how long it may be expected to infl uence

behavior. Activities can be brief and provide a

specifi c type of sensory input, or adaptation can

be achieved by engaging in play, leisure, or work

activities.

 The sensory diet also includes adaptations

to the environment to promote optimum functioning and reduce disruption. For example,

adaptations frequently are made to daily routines (e.g., dressing, bathing, and transitions)

to reduce the distress and discomfort that often

accompany them; these suggestions may include

preparatory sensory activities or simply altering

the routines in which these activities are done. In

addition, caregivers are informed about ways to

reduce sources of sensation in the environment

(e.g., sounds, smells, and visual distraction) and

develop consistent routines and predictability.

These suggestions must be customized to match

the challenges unique to each individual.

Professionally Guided Intervention

 Professionally guided intervention involves

assessment, development of goals and objectives, and formation of an intervention plan in

collaboration with children and their caregivers.

The professionally guided intervention program

may include the therapeutic use of deep pressure

and proprioception (Therapressure Program),

but often includes recommendations for other

advanced strategies. Strategies include but are

not limited to direct individual intervention using

a traditional sensory integrative approach or other

complementary approaches such as sound-based

therapies (e.g., Therapeutic Listening®, Frick &

Young, 2009 [See Section 7 ]) and body work

(e.g., Craniosacral Therapy [ Upledger & Vredevoogd, 1983 ]). A variety of intervention strategies can be used to address certain complications

or other conditions: overload or shutdown, oral

defensiveness, postural problems, or disruptions

in the suck-swallow-breathe synchrony (see

 Section 8 ). Referrals to other professionals, such

as a psychologist, may be necessary to address

social and emotional issues related to sensory

defensiveness.

 The Therapressure Program involves the use

of a specifi c densely bristled brush, which, when

used correctly, can deliver deep pressure evenly

without friction, tickle, or scratch. The authors

recommend only one brush for this program:

the Therapressure Brush TM manufactured specifi cally for this purpose by Clipper Mills (San

Bruno, CA). The Therapressure Brush is available through multiple vendors of SI materials

and equipment.

 Deep pressure is applied to the child ’ s hands,

arms, back, legs, and feet. The tactile input is

never applied to the stomach, groin, buttocks,

CHAPTER 18 Complementary Programs for Intervention ■ 429

head, or face. Deep pressure is always followed

by compression of several joints in the trunk,

arms, and legs (see Fig. 18-1 ). The provision of

deep pressure and proprioception seems deceptively simple. However, the procedure cannot

be conveyed adequately in written form. The

authors’ experience with training professionals

and caregivers in this technique has revealed

many misinterpretations of its application, particularly in the amount of pressure needed. Anyone

executing the deep pressure and proprioceptive

procedure described by Wilbarger should have

specialized training or direct supervision from

someone with such training.

 This procedure must be repeated frequently.

Ideally, deep pressure and joint compression

are administered every 90 minutes to 2 hours.

However, frequency and timing depend on the

daily routines and unique needs of the child.

Clinical experience has shown that lack of

appropriate pressure or less frequent application

not only reduces effi cacy but may be detrimental.

The duration and modifi cation of the intervention

plan is based on the child ’ s progress. Furthermore, the program requires frequent (sometimes

daily) evaluation of effectiveness. Modifi cation

and continuation of the plan are informed by the

changing needs of the child. There is no specifi c

time frame for the duration of intervention. Intervention continues until the child ’ s goals are met.

 Individuals with sensory defensiveness

exhibit unique behaviors that complicate the

use of sensory-based interventions. Because of

sensory defensiveness, these individuals often

avoid sensory experiences in general and novel

activities in particular. Involving a child in a

novel sensory experience (such as the Wilbarger protocol) requires skill and sound clinical reasoning. One must approach a child with

sensory defensiveness positively and create as

little anticipatory anxiety as possible; this might

include describing what to expect using words or

pictures or modeling the techniques on a doll or

other person. Care must be taken to use the procedures correctly and appropriately.

Relationship to Sensory

Integration and Occupation

 The three parts of the Wilbarger approach to

intervention with individuals with sensory defensiveness all draw, to varying degrees, on principles of SI theory and occupational therapy.

Education, as previously described, is a way

of using SI theory to reframe problematic

FIGURE 18-1 Brushes, textured mitts, and joint compression. Photo courtesy of Shay McAtee, printed with

permission.

430 ■ PART V Complementing and Extending Theory and Application

behaviors associated with sensory defensiveness.

Sensory diets, which include active engagement

in self-selected or preferred sensory activities

embedded in daily routines, represent a subset of

the principles of SI theory ( Parham, Cohn, et al.,

 2007 ). All professionally guided interventions

must be evaluated individually for their relationship to SI theory. The Therapressure Program

described previously involves enhanced sensation but does not demand an active response.

Thus, it overlaps with some but not all principles

of SI. All aspects of the Wilbarger approach are

directed toward helping children achieve internal

adaptation in order to improve the quality and

effectiveness of overt adaptive responses. The

ultimate aim is to contribute to improved occupational and role performance.

Expected Benefi ts

 Clinical reports suggest the Wilbarger approach

is successful for reducing sensory defensive

responses in some people. The majority of evidence for the benefi ts of the approach comes

from professional opinion or clinical reports.

Published empirical research to date is limited

and consists mainly of single case or small

sample multiple case study designs ( Weeks,

Boshoff, & Stewart, 2012 ). Additionally, some

research has been reported in conference presentations or in master ’ s or doctoral theses (c.f.,

 Chapparo & Mora, 2011 ; Sudore, 2001 ). Most of

the studies report some positive outcomes. Informal surveys to therapists trained in the Wilbarger

approach conducted by the authors indicate that

about two-thirds of children are rated as making

“very good” to “some” improvement in function.

Similar fi ndings are reported in an unpublished

master ’ s thesis ( Sudore, 2001 ).

 Various functional goals may be established

when using the Wilbarger approach in research

or practice, although the primary goal of the

approach is to reduce sensory defensiveness.

The positive outcomes reported in the published

research include decreased sensory defensiveness, lowered stress or anxiety, reductions in

the stress hormone cortisol, reduced stereotypical behavior, improved social engagement, and

better breastfeeding ( Bhopti & Brown, 2013 ;

 Davis, Durand, & Chan, 2011 ; Kimball et al.,

 2007 ; Weiss-Salinas & Williams, 2001 ).

 With a few exceptions, the currently published research is methodologically weak, consisting of small samples, lacking control groups,

and poorly adhering to intervention protocols in

terms of including all components, frequency,

and duration of application. As with any intervention, practitioners deciding whether to use the

Wilbarger approach with children should consider evidence as part of their decision-making

process; however, there are ways in which the

approach should be conducted in order to achieve

maximal short- and long-term benefi ts. For

example, intervention to reduce sensory defensiveness must always occur within the context of

a comprehensive intervention plan that considers

all aspects of the individual ’ s life. Intervention

must be appropriate to the child ’ s age, level of

disability, context, and available social support.

When these considerations are made, individuals

with sensory defensiveness, without other signifi cant problem areas, who are treated with the

comprehensive application of all three components of the Wilbarger approach and consistently

adhere to the program, are most likely to show

improvement.

 The Wilbarger approach, similar to all other

programs or interventions, is not effective for all

people. Research is needed to determine the population(s) for whom the approach will be most

effective, including children and adults who have

sensory defensiveness that co-occurs with other

disorders or medical complications. Furthermore,

intervention to reduce sensory defensiveness is

not limited to the Wilbarger approach. Occupational therapists have been treating sensory

defensiveness for decades using the principles

of SI theory ( Ayres, 1972, 1979 ). In general,

expectations for effectiveness depend on the

complexity of the individual ’ s clinical picture,

confounding problems, adequacy of the program,

and faithful adherence to the program.

Target Populations

 The Wilbarger approach was developed specifically to address sensory defensiveness, which

appears to be present in many clinical conditions. The populations in the current research on

the Wilbarger approach include not just children

and adults with sensory processing disorders

but also individuals with autism, developmental

CHAPTER 18 Complementary Programs for Intervention ■ 431

disabilities, and adults and adolescents with psychiatric disorders ( Bhopti & Brown, 2013 ; Davis,

Durand, & Chan, 2011 ; Moore & Henry, 2002 ;

 Pfeiffer & Kinnealey, 2003 ; Stratton & Gailfus,

 1998 ; Withersty, Stout, Mogge, Nesland, & Allen,

 2005 ). In most cases, it is not appropriate for use

with individuals who have behavioral or health

problems not accompanied by sensory defensiveness. The Therapressure Program should not be

used on infants younger than 2 months of age

(when age has been corrected for prematurity) or

on individuals with autonomic, physiologic, or

CNS instability. Medical histories, psychological status, and appropriate individual precautions

should be considered in all cases.

Training Recommended

or Required

 Intervention for and management of sensory

defensiveness require expertise gained by specifi c training through continuing education,

mentoring, and advanced knowledge of sensory

processing and sensory integrative theories. The

Therapressure Program described here should not

be used without direct training. The authors offer

continuing education courses on intervention

for sensory defensiveness using this approach.

These courses are commonly advertised through

occupational therapy newsletters and magazines.

It is also recommended that therapists complete

courses in SI theory.

CASE STUDY ■ DANIELLE

 Danielle ’ s mother began to suspect that

9-year-old Danielle might have problems with

sensory processing after a cousin was diagnosed with a sensory processing disorder. Interviews with Danielle and her mother revealed

behaviors suggestive of signifi cant defensiveness to tactile, auditory, visual, and olfactory

sensations. Danielle ’ s mother rated most of

Danielle ’ s problematic behaviors as moderately

severe or disruptive and occurring daily. Danielle did not want anyone to help (touch) her

with any self-care activities. She cried every

time she had her hair brushed or cut. Danielle

also complained frequently about the smells

of self-care and cleaning products such as

shampoo and laundry soap and reported these

gave her headaches. She chose only soft cotton

clothing and did not like elastic waist bands.

She was a very picky eater, refusing some textures of food and, again, complaining about the

smell of many foods. Danielle was affectionate

with her parents but did not want anyone else

to hug or kiss her. Her younger brother was

particularly irritating because he would try to

grab Danielle and would screech with laughter when she got upset. Danielle loved to play

and particularly liked to swing and swim, but

when playing outside she complained of the

bright sunlight. This also gave her a headache,

so she would not go out on bright days. She

had trouble sleeping and only slept in a sleeping bag on the fl oor of her parents’ room. No

medical reason for the headaches could be

identifi ed and the occupational therapist evaluating Danielle suspected that they might be

secondary to the sensory defensiveness.

 After educating Danielle and her family

about sensory defensiveness, Danielle was

given an intervention program that consisted of

the Therapressure Program administered eight

times a day, approximately every 2 waking

hours, and a sensory diet. As the program began

in the summer, all activities were done by her

parents. The Therapressure Program was scheduled to match the family ’ s schedule, but generally took place at wake-up, after breakfast,

mid-morning, before lunch, mid-afternoon, late

afternoon, after dinner, and before bedtime. The

main components of the sensory diet consisted

of swinging on the family swing set and play

wrestling with her parents. The swing set was

adapted so that Danielle could swing in prone

and pull a rope to propel herself. The swing set

also had a set of rings. Hanging from the rings,

she would swing to kick a beach ball with her

mother. The play wrestling consisted of safe

rough and tumble play with her parents. In this

case, the emphasis was to be on all fours on

the ground and push and roll over each other

without using hands to maximize deep tactile

pressure and proprioception. Before beginning,

everyone needed to say “Start,” and if anyone

said “Stop,” everyone needed to stop. These

activities were to occur for at least 10 minutes

at least four times a day. Other suggestions

included using a straw to drink and manipulating a squishy stress ball in the car.

432 ■ PART V Complementing and Extending Theory and Application

 The family was asked to log the application

of Therapressure as well as the occurrence of

sensory defensive reactions daily and provide a

note about daily behavior. During the fi rst few

weeks, the Therapressure was provided inconsistently, only two to three times a day. Danielle

loved the sensory diet activities and these were

done frequently and consistently. Nonetheless,

little progress was noted. On the third week, the

frequency of the Therapressure increased to at

least six times a day, and progress was evident

immediately. The fi rst change was a dramatic

decrease in the severity and frequency of the

headaches, followed by a decrease in tactile

symptoms. By the fourth week, she was trying

new foods and allowing her mother to help

her with her hair. She continued to improve

during the next few weeks with the last area

to diminish being sensitivity to smells. At the

end of 6 weeks, Danielle ’ s mother rated most

of the symptoms as mild or of no concern and

happening less than once a week. Danielle ’ s

mother noted the biggest accomplishment was

that Danielle was able to sleep at a friend ’ s

house for the fi rst time.

Section 2 : The Alert Program ®

for Self-Regulation

 MarySue Williams, OTR/L ■ Sherry Shellenberger, OTR/L ■ Molly McEwen, MHS, OTR/L, FAOTA

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional

The Alert

Program ®

 • Integrated

 • Active

Prescribed, but varies

among children

Nontraditional

Background

 For decades, the Alert Program ® has provided an

organizing framework and process for addressing issues of self-regulation for both children

and adults. This approach is grounded in Ayres’

 ( 1972, 1979 ) theory of SI regarding issues of

CNS arousal. The theory underlying the Alert

Program ® is that arousal “can be considered a

state of the nervous system, describing how alert

one feels,” and self-regulation is “the ability to

attain, maintain, and change one ’ s arousal appropriately for a task or situation” ( Williams &

Shellenberger, 1996 , pp. 1–5). The Alert

Program ® promotes awareness of the importance

of self-regulation and encourages the use of sensorimotor strategies to manage arousal states to

support optimal functioning. It has been utilized

in more than 40 countries of the world.

 The core of the Alert Program ® was taught to

Williams (co-author) by one of her “instructors,”

an 11-year-old child. The young girl entered the

therapy clinic in a low state of alertness and

appeared to be lethargic, disinterested, and resistant to activities or interactions. After a short

period of active play using sensory integrative

CHAPTER 18 Complementary Programs for Intervention ■ 433

techniques, she became alert, communicative,

confi dent, and energetic (i.e., in an optimal state

of alertness for the given tasks).

 The child struggled to fi nd words to describe

her inner experience of self-regulation and,

therefore, was unable to generalize her therapeutic experience to home or school. Williams

introduced an engine analogy by explaining

to the child, “If your body is like a car engine,

sometimes it runs on high, sometimes it runs

on low, and sometimes it runs just right.” Her

states of alertness were observed and identifi ed

using the engine analogy, “Hmmm, it looks like

your engine is low right now. I can tell because

you look a little droopy and are having trouble

playing.” And when Williams observed a high

state of alertness, she explained to the girl in a

neutral tone of voice, “Looks like your engine is

running pretty high right now. I can tell because

you are talking and moving fast, and it ’ s getting

hard for you to share your ideas so we can play

together.”

 Not only did Williams comment frequently

about the child ’ s engine level, but she talked

about her own adult “engine.” For example, she

demonstrated a lethargic posture at the start of an

early morning therapy session and said, “Gosh,

my engine sure is in low this morning. I know

I need to get up and get moving. Let ’ s go play

into the therapy room together.” By modeling to

the child, she reinforced how to identify “engine

speeds” and began teaching the fi ve ways to

change alert levels: mouth, move, touch, look,

and listen.

 With Williams’ verbal refl ections and observations, the child learned about her own unique

nervous system and developed a repertoire of

effective “engine strategies.” Together, they

developed sensory routines and problem-solved

how to insert more “engine strategies” throughout her day. This helped her self-regulate so she

could demonstrate her knowledge at school,

complete her homework, make friends, and be

a more integrated part of her family. With the

many children and adults that followed, success

was observed using these simple terms to explain

to children and adults the basic SI concepts as

the foundation for self-regulation. Williams

and Shellenberger refi ned their approach until

the program “How Does Your Engine Run? ® ”

was born and subsequently renamed “The Alert

Program ® .”

Rationale

 To attend, concentrate, and perform tasks in a

manner suitable to the situation, one must be

in an optimal state of arousal for the particular

task ( Mercer & Snell, 1977 ). When diffi culties

in self-regulation occur, individuals have trouble

changing their levels of alertness, which in turn

compromises their ability to engage competently

in their chosen tasks ( Williams & Shellenberger,

 1996 ). Ayres ( 1979 ) suggested that a variety of

sensory inputs is necessary to keep the nervous

system organized and regulated, thereby supporting engagement in meaningful occupational

roles. The Alert Program ® works to expand

individuals’ awareness, repertoire, and use of

these sensory inputs to improve their ability to

self-regulate.

 Research, particularly from the fi elds of education and psychology, is beginning to recognize

multiple levels of self-regulation as being critical for laying the foundation for higher metacognitive functions ( Baumeister & Vohs, 2011 ).

During the past decade, the fi eld of education

has grown to recognize that student success in

school is largely dependent upon how well students self-regulate ( McClelland, Acock, Piccinin, Rhea, & Stallings, 2013 ). A growing body

of literature has examined the various types of

self-regulation and the related neurobiological foundations for each. As the brain matures,

more complex levels of self-regulation emerge,

with neurobiological and functional interrelationships existing among the multiple levels

of regulation ( Shanker, 2012 ). Sensorimotor

self-regulation, which Shanker ( 2012 ) refers to

as biological self-regulation, is the most basic,

foundational level and the focus of the Alert

Program ® .

 Neurobiological literature has considerable

evidence to support the notion that sensorimotor engagement enhances the development of

underlying neural substrates and thus supports

the ability to develop higher cognitive function

( Kandel, Schwartz, Jessell, Siegelbaum, & Hudspeth, 2012 ). Sensorimotor self-regulation occurs

at lower levels of the nervous system and supports the emergence of higher cognitive functioning, including regulation on emotional and

social levels. In turn, higher cognitive functioning supports new learning that integrates lower

sensorimotor functioning for more sophisticated

434 ■ PART V Complementing and Extending Theory and Application

processing of information. The Alert Program ®

capitalizes on higher cognitive functioning, using

the cortex for thinking about self-regulation to

help individuals recognize problems with lower

level functioning (i.e., a “top-down approach”).

They learn to select from and implement a range

of strategies to change sensorimotor regulation

(i.e., a “bottom-up” approach). In turn, improved

sensorimotor regulation contributes to improved

emotional, social, and behavioral regulation. By

using sensorimotor strategies from the mouth,

move, touch, look, and listen categories, the

Alert Program ® supports both “bottom-up” and

“top-down” sensory-motor-cognitive developmental interactions and integrations.

Program Description

 The Alert Program ® is a framework that takes

complex sensory processing information related

to modulation and self-regulation and makes it

accessible for the layperson. People who struggle with self-regulation frequently have diffi -

culty transitioning between activities, coping

with changes in routines, and generally adapting

to the challenges of life. The Alert Program ®

 was developed so that individuals can learn

to be independent in self-regulation and team

members can learn to support those individuals

who cannot be independent in self-regulation. It

is a low-budget, practical approach that supports

the development of a sensory diet, a term coined

by Patricia Wilbarger ( 1984 ).

 The simple vocabulary and step-by-step

process inherent in the Alert Program ® promote

learning about and enhancing one ’ s own ability to

self-regulate. Knowledge of self-regulation and

a repertoire of sensorimotor strategies enhance

one ’ s abilities to learn, interact with others, and

work or play within varied environments, in

addition to building self-esteem, self-confi dence,

and self-monitoring skills.

 Designed to supplement and strengthen established intervention programs, individuals wishing

to use the Alert Program ® are advised to determine the underlying causes of self-regulation

diffi culties through a comprehensive assessment.

Most individuals with self-regulation diffi culties

will need occupational therapy with sensory integrative emphasis, in addition to using the Alert

Program ® .

 There are process and structural elements that

are critical for optimal success in implementing

the Alert Program ® . The process for implementation requires several elements or strategies,

including an “inside-out” approach to learning,

collaborative “detective work,” critical reasoning and creative problem-solving, modeling of

one ’ s own levels of alertness and strategies, a

jargon-free vocabulary, and supportive coaching

through the developmental stages. The structural

elements include qualifi ed leadership, evidence

of support team collaboration, adherence to core

stages of learning, and appropriate space and

equipment.

 Anyone can be a leader of the Alert Program ®

(parent, teacher, family member, mental health

provider, community support personnel, etc.);

however, to expertly guide implementation, it is

critical that an occupational therapist (or other

related professional, knowledgeable and skilled

in the theory of SI and the Alert Program ® ) be

on the team in the role as leader or consultant to

the leader. Adults who support a child ’ s learning

process need to be actively engaged in the learning process. These individuals act as a “support

team.” The make-up of the team varies depending upon the age and occupational contexts of

the individual. The occupational therapist provides team members with information and experiences to help understand the key concepts of

the program.

 All team members need to be “detectives”

in collaboration with the occupational therapist. Detective work encompasses observing

states of alertness (see Fig. 18-2 ), identifying

potential sensory strategies, and then applying

sensory strategies while observing and asking,

“Is it working?” Team members learn to interpret problematic behaviors from a sensorimotor

perspective and teach children and adults how

to help “set up the nervous system for success”

using positive feedback and coaching.

 The Alert Program ® involves a developmental process for learning based on the idea that a

greater understanding of “self” leads to greater

understanding of others and, ultimately, to greater

problem-solving—an inside-out approach. One

of the methods to bring more awareness of “self”

to team members is to ask them to complete the

Sensory-Motor Preference Checklist ( Williams &

Shellenberger, 1992 ). This self-learning process

is congruent with the three core stages that guide

CHAPTER 18 Complementary Programs for Intervention ■ 435

FIGURE 18-2 The Alert Program ® helps children and adults to monitor how alert they feel (on charts similar to

the above or on speedometers).

learning about self-regulation through the Alert

Program ® :

 1. Identifying one ’ s own “engine speed” or alert

levels

 2. Experimenting with methods to change alert

levels

 3. Regulating one ’ s own alert level:

independent self-regulation in varied

situations and contexts

 Invariably, adults fi nd that they use socially

acceptable strategies as well as strategies that

may be labeled “idiosyncratic.” However, the

same self-regulation strategies in children are

often inaccurately labeled “inappropriate” or

“problematic.” Consistent with the inside-out

approach, team members ultimately learn about

their own nervous system needs, sensory-motor

preferences, and patterns of self-regulatory strategies in an effort to better support adults and

children.

Relationship to Sensory

Integration and Occupation

 Occupational therapists have long recognized

the multiple factors that contribute to successful

participation in occupation. The dynamic interactions among the individual, environment, and

chosen occupation form a complex transactional

relationship. The ability to self-regulate affects,

436 ■ PART V Complementing and Extending Theory and Application

and is affected by, the individual ’ s performance

skills, patterns, activity demands, and by contextual and environmental factors (American

Occupational Therapy Association [AOTA],

2014). The Alert Program ® infl uences individuals’ intrinsic sensory function by assisting them

in understanding how to become effi cient and

effective in changing arousal in response to the

occupational context, thereby establishing or

enhancing skill. To support this enhanced understanding and skill, the program also promotes

fi nding ways to modify the environment or activity demands. The resultant outcome is enhancement of health and participation in life.

 SI theory helps the practitioner understand

the relationship between behaviors and ability to

process sensory information. The Alert Program ®

was drawn directly from SI theory; it is a unique

adaptation of the theory specifi cally addressing self-regulation. To assist individuals with

self-regulatory and attention defi cits, the Alert

Program ® applies basic principles of SI theory

related to arousal states. Intervention strategies

are embedded in day-to-day occupational tasks

and routines. A child or adult is expertly guided

to identify sensorimotor preferences, determining what fosters self-regulation skill development and enhancing occupational performance

and participation in life.

Expected Benefi ts

 The Alert Program ® benefi ts the person who is

learning to be independent in self-regulation.

Additionally, those individuals who have yet

to achieve or may not achieve independent

self-regulation (such as infants or young children, those who are nonverbal with autism, those

with developmental disabilities or cognitive

challenges, those with psychiatric conditions,

adults who have experienced trauma, or elders

with dementia) may benefi t through continual

and individualized team member support.

 The program is designed to (1) teach how

to recognize states of alertness as they relate

to attention, learning, and behavior; and

(2) help recognize and expand the number of

self-regulation strategies used in a variety of

tasks and settings. Increased awareness of one ’ s

own self-regulatory needs and strategies typically results in the enhanced ability to focus,

attend, and concentrate, resulting in more successful participation in everyday life. Individuals

feel more effi cient and effective in relationships

and performance in daily occupations, leading to

a more satisfying sense of well-being.

 The goal of the Alert Program ® is not to teach

children or adults how to get “engines to run just

right” and remain there throughout the day, but

rather to learn how to change levels of alertness to meet situational demands. For example,

parents and caregivers can support infants and

young children (who are not developmentally

able to self-regulate independently) by learning

how to help the child ’ s nervous system change

from a disorganized, agitated state to one that

is more organized and focused. A preschooler

may need a parent ’ s assistance to know how to

self-regulate to change from a high state to a low

state of alertness for sleep. A school-aged student

can learn what to do before homework time to

attain an optimal state of alertness for attending

and concentrating. A college student needs to

know how to self-regulate to stay alert for studying and maintain an optimal state while taking

the examination to demonstrate her knowledge.

An adult with autism who is nonverbal may need

guidance from a knowledgeable support team

to help him stay alert at work in a community

setting. Adults learn what they can do after lunch

when their nervous systems are in a low alert

state yet they need to be productive at work.

Elders with dementia can be skillfully directed

to use self-regulation strategies that decrease

anxiety and agitation to help them participate

in meaningful activities. The program has been

successful with both children and adults (who

are developing typically or atypically, verbal or

nonverbal), suggesting that all individuals can

benefi t from greater awareness of self-regulation.

 Research and literature related to

self-regulation and the Alert Program ® are

growing and provide evidence related to the benefi ts of the program ’ s use. Barnes and colleagues

 ( 2008 ) found the Alert Program ® to be effective

in helping children with emotional disturbances

to change tasks, organize themselves, cope

with sensory challenges, and focus on tasks in

the classroom. Bertrand ( 2009 ), Wells and colleagues ( 2012 ), and Nash and colleagues ( 2015 )

found signifi cant improvements in emotional and

executive functioning of individuals with fetal

alcohol spectrum disorders (FASD). Currently,

CHAPTER 18 Complementary Programs for Intervention ■ 437

there are large, ongoing government-funded

studies in both Australia and Canada focusing on

self-regulation issues with individuals with FASD

and the use of the Alert Program ® as an intervention. Mac Cobb and colleagues ( Mac Cobb,

Fitzgerald, & Lanigan-O’Keefe, 2014 ; Mac

Cobb, Fitzgerald, Lanigan-O’Keefe, Irwin, &

Mellerick, 2014 ), studying the use of the Alert

Program ® with socially disadvantaged students

in Ireland, found that students demonstrated

enhanced self-management skills resulting in

greater self-effi cacy in students with a history

of low achievement in school. A whole school

approach is being considered.

 Unpublished graduate studies also provide

important data for review. When applying the

program in a self-contained language-learning

disability classroom, Chiodo ( 2010 ) found an

increase in attention to task and a decrease in

the need for redirection during activities. The

Alert Program ® was found to be the main contributing factor to improving communication

and interaction skills of adults with severe and

persistent mental illness ( Clark, Pritchett, &

Vandiver, 2011 ).

 Less rigorous research studies published in

professional magazines also provide important evidence. Through a case-study format,

 Feldman ( 2012 ) found the Alert Program ® to be

successful in helping a pre-adolescent with an

anxiety disorder to gain critical self-knowledge

and skills related to self-regulation. Schoonover

 ( 2002 ) provided another case example demonstrating improved social skills of children in a

school-based program. Additional citations to

support evidence-based practice and extensive

review of literature related to the program can

be found in the document titled “Alert Program ®

Literature and Research,” at AlertProgram.com .

Target Populations

 Individuals of all ages need the ability to

self-regulate for successful occupational engagement in the world. Although the Alert Program ®

 was originally developed for children with learning disabilities, 8 to 12 years of age, it has been

adapted successfully for use with individuals

across the age span. The program is often used

with individuals (1:1), but it is also effective and

has been used with groups and on a system-wide

basis, such as an entire school district, corrections facility, or mental health facility.

 The authors have implemented adaptations of

the Alert Program ® concepts for all ages, from

infants to elders, for a wide variety of populations, including individuals with autism, attention

defi cit disorder, FASD, developmental disabilities, medical fragility, physical impairments,

social skill challenges, and mental health issues.

They have provided Alert Program ® consultation

in schools (public and charter at all levels and

around the world), homes (home schools and

family consultations), therapy clinics, college

classrooms, skilled nursing facilities, chronic

pain clinics, aquatic therapy programs, and camp

settings. They have assisted preschool, Head

Start, elementary, middle, high school, and university staff and administrators; foster care providers; adoptive families; and camp counselors

to successfully adapt the Alert Program ® to the

needs of children and adults.

Training Recommended

or Required

 Although formal training is not required, it is

recommended that anyone who facilitates the

Alert Program ® with children or adults complete a 2-day program, which is available live

or online. This is particularly critical for those

researchers and others implementing the program

system-wide or to large groups of individuals.

 The Alert Program ® publications and materials were developed to guide the implementation of the program. The theoretical foundations

(grounded in SI concepts) and conceptual framework for the Alert Program ® are documented

in four books and in an online course. Since

the early 1990s, a variety of publications and

free resources have been developed, including self-regulation activities, songs, and games,

as well as workshops and distance learning

opportunities.

CASE STUDY: ALERT PROGRAM ® IN A PUBLIC

SCHOOL SYSTEM

 The following case example provides a brief

description and selected results of a system-wide

implementation of the Alert Program ® within

438 ■ PART V Complementing and Extending Theory and Application

a public school district including more than

30 elementary schools. It demonstrates that

occupational therapists can obtain stronger and

more successful outcomes when they include

support team members. Implementation on

a larger scale provides evidence of the Alert

Program ® success and school-wide infl uence in

helping school-aged students develop skills in

self-regulation and subsequent learning.

 Throughout much of the past decade, this

school district documented steady increases in

general education kindergarten enrollments of

children with poorly developed social-emotional

readiness for learning. Teachers requested tools

to help students who were developmentally not

ready to learn. Occupational therapy referrals

increased beyond available resources, prompting the therapists to examine the issues more

carefully and consider solutions for such pervasive performance skill concerns. In analyzing

the trend, it became evident that many of these

children were lacking the ability to self-regulate,

a core competency that is foundational to

social-emotional development and ultimately

to academic success. The Alert Program ® was

identifi ed as a viable and practical framework

for addressing such a large-scale problem, and

a strategic plan for gaining support of its use

system-wide by administrative decision-makers

was initiated.

 First, occupational therapists provided

opportunities to allow administrators to

observe therapists collaborating with teachers

in the classroom using the Alert Program ® ,

learn about their own personal self-regulation

needs and strategies, foster an understanding

of the underlying theory behind the approach,

and gain a clear understanding of potential

short-term and long-term outcomes. Ultimately,

the administrative leaders identifi ed sensorimotor self-regulation as a core competency

and provided necessary resources to support a

district-wide program focusing on the development of self-regulation as a competency initially for all K–2 children (and later expanded

to older students).

 Occupational therapists designed a comprehensive plan for implementing the Alert

Program ® and the therapists, acting as consultants, guided its implementation. Teachers

were trained in the core concepts and principles of the Alert Program ® . Multiple resources,

activities, and strategies for implementing the

program were put into place in an effort to

support teachers in integrating the concepts

into day-to-day teaching routines. The teachers

became the “leaders,” and the therapists were

highly involved consultants. All students in

general education classes participated, and any

students whose special needs were not met by

the consultation model obtained direct occupational therapy services, as needed.

 “Tracking Success” ( McEwen, 2009 ), a

strategy to assist with evaluating the effi ciency

and effectiveness of the district-wide program,

was used to identify gains in three distinct

aspects of the program: (1) student learning,

(2) professional practice and learning, and

(3) school culture and climate. The results are

too extensive for complete discussion here;

however, select outcomes pertaining to teacher

perceptions, confi dence, and application are

described next.

 In an annual teacher survey, 74% of the

participating teachers responded to questions

related to their perceptions and use of the Alert

Program ® . Use of sensorimotor self-regulation

strategies in the classroom was reported by

97% of the teachers who had received the Alert

Program ® 2-day training. Of those teachers,

82% found the approach to be highly valuable

and compatible with their teaching practices.

A majority of these teachers (78%) reported

applying the approach to the entire class. Most

(93%) of the teachers reported observing and

understanding student behavior from a different

perspective, with 84% having gained knowledge about how to change the structure and

routine of their classroom to support learning.

More than one-half (57%) observed improved

student levels of alertness and attention in the

classroom.

 These and other more extensive data refl ect

the value and benefi t of the Alert Program ®

 when implemented system-wide. Not only did

individual children gain self-regulation skills,

but teachers found an effective tool and necessary support for classroom implementation

in their efforts to support the development of

self-regulation skills with their students.

CHAPTER 18 Complementary Programs for Intervention ■ 439

Section 3 : Aquatic Therapy

 Gudrun Gjesing, Occupational Therapist, Specialist in Children ’ s Health & Swimming, Coach and Lecturer

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional

Aquatic therapy • Integrated

 • Active

 • Responsive • Nontraditional

Background

 Throughout history, water has been associated

with life and health. People throughout time

have fl ocked to places with healing springs. In

ancient times Romans, Greeks, and Incas, among

others, built baths both for cleaning their bodies

and purifying their souls and minds. Today we

relax in bathtubs, hot tubs, and SPAs. (SPA is an

acronym for sane per aqua, which means “health

through water.”)

 One can think of aquatic therapy as a means

of radically changing the environment such that

the new environment provides many new possibilities for stimulation. In water, you create a

situation in which children are submerged in an

ever-changing environment where the force of

gravity is not dominant as it is on land. Water acts

on the body in accord with the laws of physics:

buoyancy, pressure, turbulence, and current.

Therapists who work with children in the water

need to learn both the theory and practical application of these laws, including hydromechanics.

They also must learn appropriate skill acquisition in the water; how to analyze activities, toys,

and equipment used in water; and how to handle

children in ways that turn water activities into

therapy.

Rationale

 All of us began life in water. Before birth, we

grow and play in “aqua vitae” (the water of

life) in our mother ’ s womb. In this element, the

embryo moves naturally, and its sensory systems

are stimulated by its own movements and its

mother ’ s movements. Because of the buoyancy

of the water, the embryo moves freely in three

dimensions without the need of a fi rm base.

That freedom of movement in water will always

be present. Nobody is born with fear of water;

quite the opposite is true. Unfortunately, some

people learn to fear water, often because of an

anxiety-producing experience and sometimes

the result of poor instruction. Those people must

re-master moving in water if swimming and

other water activities are to be fun.

 Water stimulates the tactile system over the

entire surface of the body, and the input changes

constantly as both the water and the child move

and different body parts break the surface intermittently. Because of constantly changing stimulation, the tactile receptors cannot habituate.

Hydrostatic pressure yields deep pressure on the

whole body and, when lying supine in the water,

individuals feel grounded through the tactile

sensations received along the whole back. They

seldom experience tactile defensiveness when

submerged. Children also receive tactile input in

the changing room and shower from the running

water in the shower, washing the whole body

with soap, drying with a towel, and applying

body lotion.

 The vestibular system similarly receives

enhanced input throughout aquatic therapy sessions. Water invites moving in both the vertical and horizontal planes and in all planes in

440 ■ PART V Complementing and Extending Theory and Application

between, offering much greater variety of position and movement than is possible on land.

Diving, swimming, and fl oating activities in this

ever-changing environment give rise to constant starts and stops, and changes of direction

and position. Balance is constantly challenged

by currents and water turbulence, and the body

rotates in water as soon as it is not symmetrical

in shape. Therefore, children must pay a lot of

attention to balance control. They learn to use

head position to control the whole body, to initiate desired movements, or to prevent undesired

movements. All of these postural adjustments

give rise to vestibular input. Because most of the

body is submerged, children cannot see the body

well; thus, they cannot compensate for poor processing of vestibular information through vision.

 The changing room and shower also yield

substantial vestibular input because of changes

in head position and challenges to balance. Some

examples include tilting the head backward

with eyes closed to wash hair, bending the head

forward to wash feet, bending down to remove

or put on socks and shoes, balancing on one leg

when putting on trousers, putting on pullover

garments that occlude vision, and navigating the

changing base of support that comes with a wet

fl oor.

 Aquatic therapy also yields enhanced proprioception . Without a fi rm support surface, one

can move freely in water, and the sensation of

movement is experienced strongly because of

resistance felt from the water. However, because

of buoyancy, one gets less proprioceptive input

from the legs and trunk when standing upright

in shoulder-deep water than when standing in the

same position on land. The resulting decrease in

pressure to joints and resistance to muscles means

there is a need to pay greater attention to body

positions when stationary in water. Although

proprioception may be decreased when a child

is stationary, water is nearly always moving and,

to maintain a position, children must counteract

the force of the water, which in turn generates

proprioceptive input.

 In addition to the tactile, vestibular, and

proprioceptive systems, other sensory systems

also receive different input in water compared

with on land. Some can be unpleasant, causing

children to not want to get their head under, or

near the surface of, the water. Water in the ears

and eyes can cause feelings of discomfort and

insecurity, as well as affect hearing and vision.

Water in the mouth and nose can taste and smell

unpleasant. Nonetheless, children usually learn

that the fun of being in water compensates for

any discomfort.

Program Description

 The section author has conducted aquatic therapy

groups weekly in a local public swimming pool

for more than 30 years with children ranging

from 8 weeks to 12 years of age. (Note: Although

this author works primarily with children, the

description also applies to adults.) Babies and

children who are not yet able to be free in water

are accompanied in the water by an aide. The

aide may be a parent, a grandparent, other relative, or a caregiver—someone the child knows

well, and the same aide each time.

 Before going into the water, the aide must be

trained in the theory and practice of water activities, including appropriate support of a child in

the water. Aides give children both physical and

psychological support. They use their hands to

facilitate balance reactions in different positions

during different tasks, so it is essential that they

know the appropriate techniques for handling a

person in the water. This may be quite different

from the appropriate handling of the same person

on land.

 To avoid disturbing the child ’ s own balance

reactions, the aide provides support at the body ’ s

center of balance, about waist level. Foam and

infl atable fl oatation aids are used as infrequently

as possible because they are static and may

disturb the child ’ s learning of balance reactions.

In contrast, hands are sensitive and dynamic, and

they can adapt to the just right support and challenge, according to the child ’ s position in water,

the tasks, and the child ’ s actual ability and needs.

This is science and art in combination.

 Group size is optimal with six to eight children. Groups are formed according to the

individuals’ abilities in the water rather than

diagnosis, age, or challenges on land. The most

appropriate water temperature and depth also

are important considerations in forming groups.

Water temperature is approximately 84°F (or

28°C), although it should be some degrees

warmer for young babies, as they have not yet

learned to regulate body temperature properly. If

CHAPTER 18 Complementary Programs for Intervention ■ 441

water temperature is higher than skin temperature (approximately 92°F or 33°C), the water

will heat the body, resulting in decreased activity.

When water temperature is lower than skin temperature, it promotes being active and moving

around, in order to keep the body warm.

 The depth of the water varies from 3 to 12 feet

(1 to 4 meters). When you are standing upright

with the water just below waist level, balance

reactions will be similar to those on land because

gravity is the dominant force. When the body is

submerged to shoulder level, buoyancy dominates, and balance reactions are controlled by the

head and shoulders. The phrase “No shoulders

out of the water,” referring to both children and

aides, is an attempt to draw on the special attributes of the water as much as possible.

 As with intervention on land, the instructor (therapist) often motivates children through

playful interactions ( Fig. 18-3 ). We use objects

that are easily seen in water to promote understanding of the tasks and sometimes just for fun.

We use both objects that fl oat and those that sink

(e.g., small and big balls, balloons, clothes-pegs,

small rings, hula-hoops, water pistols, umbrellas, and buckets). With children, we use a lot

of well-known action songs and rhymes. The

instructor and the aides are often included in

the activities, which provide useful feedback,

both internal (i.e., knowledge of the body) and

external (i.e., knowledge of the results of their

actions).

 Games need groups, and groups need games!

The instructor designs group games and learning

situations with every child in mind. For example,

children anticipate movement patterns associated

with songs, rhymes, and objects. In addition to

planning movements, the activities also engage

attention and prompt social interactions. Later,

the same movement patterns are incorporated

into purposeful “water skills” (e.g., automatic

inhaling only when nose and mouth are out of

the water; body stability; rotational control;

mobility; and, for some, swimming strokes).

 Some activities have goals that are specifi c to

particular individuals. Instructors can create “stations” at the edge of the pool, using pool markers.

Each station contains objects and instruction with

written clues, photos, or drawings for children to

decide how to solve the challenge, using imagination. The instructor gives individualized suggestions to children to make activities simpler,

ensuring success, or more challenging, increasing engagement. One important desired outcome

FIGURE 18-3 Using a water pistol in the swimming pool increases the fun. Photo courtesy of Gudrun Gjesing.

442 ■ PART V Complementing and Extending Theory and Application

is that all children are open to new goals. One

example of a station would be placement of

clothes pins and textured dish rags at the edge

of the pool, with a weighted string hanging off

the edge and traveling down into the water. One

task goal would be to attach the dish rags to the

string with the clothes pins as far down to the

bottom of the pool as they can. The tasks could

be modifi ed so that one child may put the dish

rags on the string without submerging, whereas

another child would do the task having to fully

submerge. The task goal could also be modifi ed

using the same materials; for example, a goal

could be for a child to pick the clothes pins off

the bottom of the pool fl oor with their toes or

hand the clothes pins to another child who then

attaches them to the string.

 Each water session should include both

activities tailored by the instructor and time for

engagement in self-selected, self-initiated, and

self-organized activities. The latter are more

likely to be meaningful to children while, at the

same time, promoting adaptive responses.

Relationship to Sensory

Integration and Occupation

 Aquatic therapy provides opportunities to

actively take in enhanced tactile, vestibular, and

proprioceptive sensations, and it demands adaptive responses. Thus, aquatic therapy promotes

SI, and, although it looks very different from

traditional sensory integrative therapy and is

delivered in a markedly different environment,

the overlap of principles is apparent. Carefully

designed aquatic therapy programs promote

praxis, sensory modulation, and successful

engagement in occupation—in water and on

land.

 With regard to occupation, aquatic therapy

programs may lead to children becoming

members of swimming clubs, going with family

or friends to public swimming pools, and going

on holidays near bodies of water. Such recreation is fun for the whole family and capitalizes

on children ’ s abilities rather than emphasizing

their disabilities. In addition, aquatic therapy

programs facilitate numerous occupation-based

gains: planning (e.g., packing the things needed

at the pool), undressing and dressing, showering,

washing hair, toileting, and perhaps even using

public transportation. Therapy is apparent in the

changing room as much as the pool. Aides are

taught not to help children with tasks they can

do themselves, to assist with tasks the children

are practicing, and to do only what a child is not

yet able to do. Children readily understand the

need for performing these skills in the context

for which they are required.

Expected Benefi ts

 Water can be a powerful and highly motivating

therapeutic medium. Several physical benefi ts

can be realized, including improved respiration

and breath control, stability and control of movement, rhythmicity, coordination, and fi tness.

Psychosocial and learning benefi ts also are

described, including improved skills for working

in groups (e.g., paying attention to, waiting for,

and supporting others); learning by imitation;

self-assessment; self-esteem; comfort with being

close to, and dependent on, others; and developing new friendships.

 When one considers all these potential gains

together, the possibility for improved quality of

life does not seem a big stretch. Many skilled

therapists with years of practical experience

describe the benefi ts they have seen repeatedly.

They believe strongly in the enduring effects

of aquatic therapy on everyday functioning.

And although there is research supporting the

benefi ts of aquatic therapy for children with

autism ( Vonder Hulls, Walker, & Powell, 2006 ;

 Yilmaz, Yanardag, Birkan, & Bumin, 2004 ),

cerebral palsy and other neuromotor conditions

( Dellaratta, 2002 ; Getz, Hutzler, & Vermeer,

 2006 ; Maynard, 2004 ; Sterba, Safar-Riessen, &

DeForest, 2004), juvenile rheumatoid arthritis

( Epps et al., 2005 ), and other conditions, research

concerning the effects of aquatic therapy for children with SI dysfunction is not yet available.

Target Populations

 People of all ages and with all types of challenges

may benefi t from intervention in water. The goals

that the therapist sets together with children or

caregivers and the way the therapist designs and

implements programs will vary according to

each child ’ s specifi c needs. This section focused

CHAPTER 18 Complementary Programs for Intervention ■ 443

on aquatic therapy for individuals with sensory

integrative dysfunction, with whom it can be

used to address challenges with maintaining

optimal arousal, alertness, self-regulation, and

modulation, as well as with praxis and gravitational insecurity.

 Some children with sensory integrative dysfunction as a primary or secondary diagnosis

also have other diffi culties that may respond

to aquatic therapy, such as neuromotor disabilities (e.g., cerebral palsy), emotional disorders

(e.g., because of sexual abuse, neglect, or other

trauma), behavior disorders, learning defi cits,

speech defi cits, and visual and hearing impairments. Aquatic therapy also provides a natural

context for working with babies and their parents

or caregivers to promote attachment, playfulness,

resilience, self-confi dence, body awareness, respiration, head control, and control of movement

patterns.

Training Recommended

or Required

 Learning to provide aquatic therapy involves

experiential learning. An instructor must be

trained in three areas: hydromechanics, water

safety instruction, and the art of therapy (i.e.,

making therapy motivating and matching it to

the needs of children; see Chapter 12 , The Art of

Therapy). Instruction in hydromechanics as well

as the technical expertise of teaching water skills

(i.e., what we do in water, why, and how we do

it) may be learned through study of the Halliwick Concept (Halliwick Association of Swimming Therapy National Education Committee,

2010). Instructors must be trained to do continuous qualitative assessment of children ’ s abilities

in water, to adjust goals and plans appropriately

as abilities change. They must also continually

assess activities and playthings (i.e., how to

make activities simpler or more challenging) so

they match each child ’ s needs. This principle of

“grading” helps to make activities tempting and

obviate the need to resort to manipulation or

demands when instructing. Aquatic instructors

are not always therapists; in that case, a therapist should serve as a consultant to the program,

assisting with assessment, tailoring goals, and

helping to analyze playthings and activities.

[Note: In the United States, swimming instructors

must be certifi ed in water safety instruction. This

certifi cation is available from the American Red

Cross.]

CASE STUDY: “THE ALARM CLOCK”

 “Come on, now we are going to do the Alarm

Clock!” the instructor says. All the children and

their aides immediately know exactly what is

going to happen, and they begin to prepare. The

children form a circle in an upright position

facing the instructor. Their aides support them

from behind according to each child ’ s needs,

so all get the just right support and challenge.

The instructor then says: “Now you are going

to sleep, all of you, with your eyes closed!” The

children move to a supine position by bending

their head backwards into the water and letting

their legs fl oat upwards ( Fig. 18-4 ). The children receive vestibular stimulation by changing

their head position without using vision and

tactile stimulation from movement of water and

from the hands of the aides. Goals of this part

of the activity could include participation in a

social activity, maintaining appropriate levels

of alertness and attention, and preparing for and

moving from one stable position into another.

 Then the instructor moves around the circle,

touching each child ’ s feet when saying his

or her name. “Now I can see you are all fast

asleep!” The children take in tactile, proprioceptive, and vestibular sensation. New goals of

this part of the activity could include holding a

position in an ever-changing environment and

remaining calm and relaxed when lying supine

with eyes closed.

 “Ding-a-ling-a-ling!” the instructor yells

until all children have moved as quickly as

possible from supine into a vertical position

again by fl exing the neck and hips and stretching the arms forward. As they move into the

vertical position, the mouth may go under

water, and they must either close the mouth or

blow bubbles. The children take in tactile, proprioceptive, and vestibular sensation. Goals of

this part of the activity could include changing

head position quickly, changing body position

without using vision as the body is submerged

in the water, and having controlled mouth

closure or making bubbles.

 The instructor continues making the alarm

sound until all children have placed one hand

444 ■ PART V Complementing and Extending Theory and Application

FIGURE 18-4 “Now you are going to sleep, all of you.” Photo courtesy of Gudrun Gjesing.

FIGURE 18-5 All of the children place one hand on the “alarm button.” Photo courtesy of Gudrun Gjesing.

on “the alarm button” (the instructor ’ s head)

and they start pressing her down into the water

( Fig. 18-5 ). Again, the children take in tactile,

proprioceptive, and vestibular sensation. Goals

of this part of the activity include the ability

to bend the head forward while stretching

the arms and keeping the trunk stable while

exerting resistance and working together. The

instructor stays submerged as long as possible.

As she emerges, all the children yell: “Let ’ s do

it again!” ( Fig. 18-6 ).

 Learning really goes swimmingly. . . .

CHAPTER 18 Complementary Programs for Intervention ■ 445

Section 4 : Interactive Metronome ®

 Beth Osten, MS, OTR/L

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional

Interactive

Metronome ®

 • Single system

 • Passive application

 • Prescribed • Traditional

Background

 Interactive Metronome ® (IM) is an evidencebased computer technology that can be a useful

adjunct to sensory integrative intervention. This

program is designed to improve timing and rhythmicity, which are necessary to perform several

functional skills and play tasks and that are commonly problematic for children with sensory

integrative dysfunction, especially dyspraxia.

The original metronome that has been used for

centuries to help musicians improve their timing

and rhythmicity inspired the IM program. The

developer, James Cassily, worked for many years

as a sound engineer in the recording industry,

and in 1992 he initially devised the IM for use by

musicians. This newer IM technology improves

on the original metronome by adding an auditory

feedback component that is linked to the timing

of movement patterns used to activate a switch.

 Early in the development of the IM, a physician suggested that it might be useful for

children with severe movement problems. As

clinical trials progressed, observations indicated

FIGURE 18-6 “Let ’ s do it again!” Photo courtesy of Gudrun Gjesing.

446 ■ PART V Complementing and Extending Theory and Application

improvements not only in the timing of movements but also an impact on a broader range

of functions. The program drew the attention of

Dr. Stanley Greenspan, who, in 1997, became

the director of IM research. In 1999, the program

was made available to trained health-care professionals, and, in 2001, a version was released for

use in mainstream settings, including academic

settings and athletic training venues.

 Importantly, structured movement activities

such as the standard IM program are not considered sensory integrative therapy, as described by

Ayres. Rather, IM can be a useful adjunct to an

SI therapy plan.

Rationale

 Rhythmicity, or timing, is inherent to the human

organism and is the foundation of many human

functions. Neural rhythmicity is refl ected in

brain waves that can be measured by sophisticated brain scanning and EEG monitoring technology to tell us how complex neural networks

fi re in synchrony to produce coordinated perceptual and behavioral responses ( Bear, Conners, &

Paradiso, 2015 ).

 Within the human brain, synchronous rhythmic activity appears to be coordinated by two

types of neural processes. The fi rst is a pacemaker process, whereby a small group of cells

acts as the timekeeper for other functions. Within

the thalamus, internal cellular activity occurs,

in which single cells fi re rhythmically without

external infl uence and in turn synchronize with

other thalamic cells. Connections between excitatory and inhibitory thalamic cells generate

coordinated rhythmic activity, which is then sent

to the cortex to act as a pacemaker for a larger

group of cortical cells ( Bear et al., 2015 ).

 The second source of rhythmic activity is

generated by the collective behavior of cortical

circuits, or brain networks, which coordinate into

synchronous patterns of activity that can be either

localized or spread to larger areas of the cortex.

This synchronized rhythmic activity may serve to

increase the speed and effi ciency of information

processing during complex functional activities

and aspects of executive functioning ( Bear et al.,

 2015 ). Although there are several theories to

explain various classes of neural timing, teasing

apart the neural mechanisms has proven diffi cult

( Lewis & Walsh, 2005 ). Many areas of the brain,

which are interconnected in complex neural networks, appear to be involved. The cerebellum,

basal ganglia, anterior cingulate cortex, dorsolateral prefrontal cortex, right parietal area, motor

cortex, and frontal-striatal loop have all been

identifi ed as playing a role in timing ( Buhusi &

Meck, 2005 ; Lewis & Miall, 2006 ).

 McGrew ( 2013 ) proposed a three-tiered model

based on current neuroscience research to explain

the positive effects seen in a broad range of functional areas following IM training. He proposed

that IM training impacts precise timing mechanisms that occur at millisecond intervals and

that, although there are domain-specifi c effects

(such as the improvement of the movements

being trained), there are also domain-general

effects. Domain-general effects refer to the

broad range of functional improvements noted in

areas that have not been the specifi c focus of the

training.

 The outcome of this rhythmic brain activity

can be observed through a wide variety of human

behaviors that occur within an individual, from

sleep-wake cycles and respiration to dance performance and athletic ability. Timing and rhythmicity are key factors in coordination, motor

planning, and motor execution. Individuals

with motor defi cits may display any number of

timing-related issues, including diffi culty timing

the initiation of movement (which may occur too

soon or too late for successful execution of a task)

or the pace of movement (which may be either

too fast or too slow). Inability to time the termination of movement, as well as poor anticipatory timing, can also impact success. Aspects of

movement, which may be additionally impacted

by movement disorders, can include coordination

of movements and sustaining rhythmic patterns

of movement, as well as timing and coordinating the use of force ( Cermak & Larkin, 2002 ;

 Shumway-Cook & Woollacott, 2007 ).

 Rhythmic activity is also highly interpersonal. Motor timing and rhythmicity fi rst appear

functionally in early infancy within the contexts of feeding and interactive synchrony with

the caregiver and are infl uenced by the maturation of timing mechanisms that organize before

birth at around 30 to 34 weeks gestational age

( Doussard-Roosevelt, McClenny, & Porges,

 2001 ; Feldman, 2006 ; Mirmiran & Lunshof,

 1996 ). In studies of premature infants, Feldman

CHAPTER 18 Complementary Programs for Intervention ■ 447

 ( 2006, 2007 ) found that the organization of

physiological oscillators appears to lay the foundation for an infant ’ s ability to participate in

rhythmic parent-infant interactions. Parent-infant

interactions have measurable, developmentally determined, temporal patterns that predict

later developmental capacities for attention

and regulation; and affect attunement, interactive reciprocity, and early preverbal and verbal

communication ( Beebe et al., 2010 ; Papoušek,

 2008 ; Porges, 2009 ; Schore, 1996, 1997 ; Stern,

 1984 ; Tronick, 2007 ). Even complex, high-level

functions, such as symbolic play ( Feldman &

Greenbaum, 1997 ); self-regulation at 2, 4, and

6 years of age ( Feldman, Greenbaum, & Yirmiya,

 1999 ); and the capacity for empathy in adolescence ( Feldman, 2005 ) have been linked to the

timing and rhythmicity of early parent-infant

interactions.

 Because of the pervasive infl uences of timing

and rhythmicity on human functioning, it is

understandable that the development of effective

intervention methodologies is desirable. From its

initial inception, IM has offered promise as an

intervention for children with functional defi cits

that are founded in timing errors. Clinical reports

suggest a broad spectrum of positive effects, but

controlled, peer-reviewed research on IM effectiveness remains sparse. In addition, research

has been conducted on a range of populations

varying in age and the nature of physical and

developmental status. Selected published studies

are reviewed in the Expected Benefi ts section of

this chapter.

Program Description

 IM is a computer-based software program that

can be used in a wide variety of ways on either

Macs or PCs. Different versions of the IM software are available for either desktop or laptop

computers; these computers are purchased separately. The IM program also comes with headphones and triggers. Two contact triggers, or

switches, are standard: a hand trigger, which

comes in two sizes and connects by Velcro to

a glove; and a foot trigger (approximately 6 by

12 inch), which is a thin pad that can be placed

on the fl oor and is activated by the child ’ s foot.

Both the hand and foot triggers are available in

wireless models. In addition to these standard

triggers, the “In Motion” heel strike-activated

sensor is available for use in assessing and training gait. Other commercial switches can be used

instead to tailor the program to the needs of each

child. Any two switches can be used at one time.

Speakers can be used instead of headphones for

individuals who might not be able to tolerate

headphones, but the auditory input will be less

specifi cally localized.

 When in use, the IM software generates a

steady beat through the headphones, and the

user is asked to respond by producing continuous rhythmic movements of the hands or feet

in response to the metronome beat. The triggers register the contact, and the software analyzes the timing relative to the beat. Guide

sounds, delivered via the headphones to one or

both sides, indicate whether the movement is

early, late, or on target to the auditory stimuli.

The response time is measured in milliseconds,

and scores are given for accuracy, variability,

and number of consecutive on-target beats. An

in-a-row threshold can be set to increase the diffi culty for consistency of performance. Visual

feedback is provided on the computer screen

to allow users to adjust rhythm and timing in

order to synchronize movements to the metronome beat. The visual stimuli include animated images with game-like features that give

feedback on accuracy and make the program

more appealing, especially to children and

adolescents.

 The standard protocol consists of 13 different movement patterns that involve the upper

and lower extremities and are performed bilaterally, ipsilaterally, contralaterally, or reciprocally. Some of the movement patterns include

clapping the hands together in midline, clapping

one hand at a time against the side of the body,

alternating toe tapping between each foot, and

alternating toe tapping and hand tapping. The

standard movements are described in the IM

manual ( Interactive Metronome®, 2007 ). The

standard IM training program consists of 12 to

15 sessions with predetermined objectives and

specifi c instructions for the session, including the

duration of each exercise. The protocol involves

training the timing and accuracy of the movement patterns and training the user to increase

focus and attention on the coordination of the

movements with the metronome beat. A certifi ed

trainer must administer the program.

448 ■ PART V Complementing and Extending Theory and Application

Relationship to Sensory

Integration and Occupation

 IM is a structured, therapist-driven program

that addresses attention, timing, rhythmicity,

and motor coordination, which support effi cient

motor planning and sequencing that, in turn,

contribute to functional skills and support occupational performance. The IM program is considered to be a sensory-based approach because

the auditory and visual feedback provided by

the program allow for the timing of movement

patterns to be adjusted. It is further theorized

that moving to the repetitive auditory beat trains

anticipation of movement that is characteristic

of feedforward actions. Anticipatory preparation is necessary to perform complex movement

sequences in a timely and automatic manner.

 IM technology can be used in ways other than

the standard protocol to make IM fun and engaging. For example, IM technology can be incorporated into SI therapy activities to strengthen

multisensory processing and sensory feedback.

Variations of movement patterns, positioning,

incorporation of other movement modalities, and

adjustments in timing can be used to adjust diffi culty and to accommodate to the needs of the

user. Principles of motor learning theory also

apply to the IM.

 Upon completion of the standard program,

users will have completed up to 35,000 repetitions. This accounts for the gains in timing and

rhythmicity seen in the program activities but

does not account for broader gains that do not

refl ect the direct practice of the timed movements

within the protocol. These broader changes may

refl ect shifts in the internal organization of timed

functions, which would be more in keeping with

dynamic systems theory. IM has been described

as a top-down approach, but the impact of the

program appears to affect bottom-up processes.

Expected Benefi ts

 Many benefi ts from IM training have been

reported in children and adults with a broad spectrum of clinical conditions, including improvements in attention and focus; motor control,

as seen in improved accuracy and timing of

movements; improved coordination; and faster

reaction times. Several authors ( Bartscherer

& Dole, 2005 ; Cosper, Lee, Peters, & Bishop,

 2009 ; Shaffer et al., 2001 ) reported improvements in regulation of aggression and impulsivity. Cosper and colleagues ( 2009 ) noted trends

toward improvement in balance, response speed,

visual motor coordination, upper limb coordination, and upper limb speed and dexterity scores

on the Bruininks-Oseretsky Test of Motor Profi ciency. Johansson, Domellöf, and Rönnqvist

 ( 2012 ) noted signifi cant improvements in the

speed of movement, quality of movement, and

effi ciency of movement following IM training in

two adolescents with cerebral palsy. Improved

athletic performance in typical adults has also

been reported ( Libkuman, Otani, & Steger, 2002 ;

 Sommer & Rönnqvist, 2009 ).

 Anecdotally, many therapists have noted

improvements in children ’ s balance, fl uidity of

handwriting, keyboarding, and visual pursuits.

Many families and clinicians report positive

changes in behavior and attention, decreases in

anxiety, and improvements in organization and

self-initiation. Interestingly, improvements have

also been noted with regard to aspects of language processing, speech production, and reading

( Sabado & Fuller, 2008 ; Taub & Lazarus, 2013 ;

 Tierney & Kraus, 2013 ).

 With any clinical tool of this nature, differences in intervention outcomes can be expected

in individuals with different clinical conditions

and comorbidities. Because each child presents

with his or her own unique profi le and issues,

each individual will respond somewhat differently to any type of intervention. What is statistically signifi cant for a large group will not

necessarily be true for each individual. For this

reason, the use of IM training should be part

of a comprehensive intervention plan based on

thoughtful clinical reasoning.

Target Populations

 IM is currently used with a wide population of

individuals, including children and adults with

learning disabilities, attention defi cit disorder/

attention defi cit-hyperactivity disorder (ADD/

ADHD), autism spectrum disorders (ASDs), and

cerebral palsy. IM has been used with individuals with balance problems; motor coordination

disorders; functional gross and fi ne motor defi -

cits, including diffi culties with handwriting and

CHAPTER 18 Complementary Programs for Intervention ■ 449

keyboarding; and more complex motor planning

and sequencing diffi culties (dyspraxia). IM is

also used for executive functioning disorders,

including issues with attention and focus, poor

organizational skills, memory defi cits, and regulatory issues. Research has supported the use

of IM with individuals with language defi cits,

including diffi culties with listening comprehension, verbal expression, reading comprehension,

and diffi culties with the motor and sequencing

aspects of language ( Sabado & Fuller, 2008 ;

 Taub & Lazarus, 2013 ; Tierney & Kraus, 2013 ).

 More recently, IM has been used in the treatment of individuals with traumatic brain injury,

stroke, multiple sclerosis, and Parkinson disease.

IM is gaining popularity among the typically

developing population for athletic training, academic skills enhancement, and musical and

dance training.

 Generally, IM is recommended for use with

individuals with a developmental level of 6 years

or older, but clinicians are beginning to use

adapted versions of IM with younger children

and with more involved populations. As with

any intervention, appropriateness is a clinical

decision, and the varying degrees of severity will

indicate appropriateness.

Training Recommended

or Required

 Certifi cation and continuing education in the

use of IM is available electronically through the

IM website ( http://www.interactivemetronome.

com/ ). In-person training is also offered throughout the United States and internationally. A certifi cate for using the IM program can be obtained

in one day via approved training courses. IM

equipment is only available to trained administrators. A home version is available for use under

the supervision of a trained therapist or administrator. The home version can be monitored and

the program adjusted by the trainer via an Internet connection.

Case Examples

 Two short case vignettes presented here provide

a summary of the use of IM with children; different models of practice are used in each. For these

two children, IM was combined with other interventions, as has been noted to be appropriate. A

third, more descriptive case study is presented

following the vignettes, which includes some

greater detail on the IM intervention.

CASE STUDY ■ LARS

 Lars is an 11-year-old boy who lives in Europe.

He has a diagnosis of high-functioning autism.

He initially presented with signifi cant sensory

processing and motor involvement. He had

very low muscle tone, poor postural control,

and severe dyspraxia. He was hypersensitive

to many types of sensory input, was extremely

anxious, and became dysregulated easily. His

family had done intensive bouts of therapy

and sought consolation from a large SI and

fl oortime therapy practice in the Chicago area.

Occupational therapy service providers in their

area were diffi cult to fi nd, and the models of

intervention used were not fully what the

family wanted for their son. The family set

up a small SI gym in their home. Lars made

excellent gains in response to consultative

therapy with follow-up at home by the parents.

He was receiving speech therapy through

his school, and the family eventually found a

therapist to do SI work with Lars with input

from the occupational therapy consultant from

Chicago.

 Following a short visit to Chicago, it was

decided that Lars might benefi t from adding

IM to his SI therapy. The consultant suggested

the IM Home program with oversight by the

local therapist and monitoring via Internet by

the consulting therapist. Lars did the standard

protocol during about 4 months, making nice

improvements on his timing. Functional gains

in motor skills, fl uidity of handwriting, and

improved attention were noted by the family

and Lars’ school team. The greatest benefi t,

however, was in the area of regulation. Lars

found the IM exercises very relaxing and, after

completion of the protocol, he spontaneously

requested time on the IM program. He made

up his own “moves” and used some of the old

ones. He would work on the program for 10 to

15 minutes when he came home from school.

This lasted for more than a year until he gradually stopped using the program.

450 ■ PART V Complementing and Extending Theory and Application

 On follow-up, many of the initial gains in

attention continued to improve, and changes in

his vocal prosody were noted. As a high school

freshman at a competitive private school, Lars

has done well academically. He has a small

circle of friends and is generally well liked.

He continues to have diffi culty with postural

control, athletics, and handwriting, but he has

become profi cient at keyboarding. It is anticipated that he will be able to attend college.

CASE STUDY ■ GEORGE

 George is a 9-year-old boy who lives with his

family in a small rural Oklahoma town. The

family originally lived in Chicago and, when

developmental delays became apparent when

George was a toddler, the family established

connections with a team of therapists. George

was never formally diagnosed but had features of autism. He made excellent progress in

therapy, especially in his ability to be socially

engaged and reciprocal. Although language was

late to emerge, he eventually became verbal.

 When George was 6, his family relocated

because of his father ’ s job, and access to services was more diffi cult. When George entered

school, he was placed in a regular classroom

with support. The family maintained connections in Chicago and periodically went to

Chicago for intensive interventions lasting

1 to 3 weeks. When the family returned

home, follow-up intervention suggestions

were offered, and his local therapists followed

through and consulted with his Chicago team.

 When George was 9, he went to Chicago

for a 3-week combined SI and IM therapy. He

received IM in the morning and SI for an hour

in the afternoon, as well as speech therapy for

an hour every day. At the time, George continued to display quite low muscle tone, diffi culty

with postural control, poor body awareness,

motor planning defi cits, and signifi cant diffi -

culty with visual-spatial problem-solving. His

language processing was still impaired, with

a very slow response speed, diffi culty with

verbal formation, and halting prosody. Because

of the time constraints of the 3-week intervention, a standard IM protocol was administered

during 15 one-hour sessions. George started

with scores that ranged from 160 milliseconds

off the beat to up to 250 milliseconds off the

beat for the more diffi cult IM movement patterns (40 to 60 ms is more typical of a child

his age). Following the IM training, his

scores went down to within the range of 60

to 90 ms.

 During this time, George learned to ride a

bicycle, which in the past had been very frightening and diffi cult for him to attempt. He made

reasonable gains, and his parents continued to

report gradual changes during the next year.

Language gains were noted with regard to

timing and speed of vocal output. His prosody

improved but continued to be “a bit off.” His

handwriting and keyboarding improved in

both speed and accuracy. His motor planning

improved signifi cantly, especially for sports

skills. He was better with novel motor tasks but

still had some diffi culty.

 At age 11, George returned for an assessment

and intervention update. He was reassessed on

the IM long form test, and his scores remained

in the same range as when he had fi nished the

IM program 2 years prior. George had been

taking karate and was progressing well. He was

discharged from his occupational therapy at

home, although he still needed some work on

postural control and balance. Neuropsychological testing identifi ed challenges within the area

of processing speed, and executive function

issues were thought to contribute to diffi culties

in new learning and memory, as well as social

problem-solving. He was given the diagnosis

of social (pragmatic) communication disorder.

Timing and rhythmicity in his vocal output,

although improved, continued to be a problem.

This is something that may be revisited in the

future using IM adaptively in an individualized

program that incorporates movement and some

type of language demand or executive functioning demand.

CASE STUDY ■ MARTIN

 Martin, who is 19 years of age, has received

several services through many years, starting

with Early Intervention at 2 years of age. He

has a diagnosis of cognitive disability and has

some autistic features. He has been seen for

many years in an SI clinic. When he was 14

and had just started high school, his therapist

CHAPTER 18 Complementary Programs for Intervention ■ 451

started the IM program with him. At the time,

he was anxious, impulsive, extremely rigid, had

diffi culty with problem-solving, and was slow

to respond when asked a question or when confronted with a problem. He also had signifi cant

diffi culty with postural control and motor planning as well as diffi culty initiating familiar routines and actions such as getting dressed in the

morning and packing his bag for school. Attention was a signifi cant issue at school.

 Martin started slowly in weekly sessions

by learning the basic IM movement patterns,

such as clapping with both hands at midline,

tapping one hand on the thigh of the same side.

As he learned the moves, the time on task was

increased until he was able to consistently complete 2,000 repetitive sessions during approximately 45 to 55 minutes. Five years later, his

therapist continues to use IM as part of his

sessions but in unique and creative ways as

part of a larger occupational therapy program.

About every other week, 20 to 35 minutes of

the occupational therapy session involves some

form of IM. Most of the activities are done

using a wireless trigger and a speaker instead

of headphones.

 One of his current activities involves

walking backward on a treadmill, using the

wireless hand trigger, alternating fi ve hits on

the opposite shoulder and then fi ve hits on the

opposite hip while doing visually presented

math problems placed in different locations

around the room (both numeric and short story

word problems targeting addition or subtraction

and money concepts). The target areas of this

activity are mental endurance, focus and concentration, processing speed, postural adjustments and righting reactions, simultaneous

intake and prioritizing of input, overall physical

endurance, crossing midline, full body coordination, functional math, and timing.

 Another activity involves standing on a

Bosu in front of a table with Velcro cards with

letters face down and a vertical Velcro surface

behind. Using the wireless hand trigger to hit

the opposite shoulder, Martin fl ips over all the

cards with the other hand, and then puts them

in alphabetical order (upper then lower case) on

the board behind (trunk rotation). This requires

visual discrimination and sequencing. Once the

letter cards are in order, rapid recall cards are

presented. For example, if a visually presented

card reads “type of vegetable,” Martin must

think of a vegetable and use the letters to spell

it out. Also, he is encouraged to problem-solve

if he runs into diffi culty, such as asking how

to spell a word or what to do if he needs two

of the same letter to spell a word. This activity is meant to address mental endurance, focus

and concentration, processing speed, postural

adjustments and righting reactions, overall

physical endurance, crossing midline, full body

coordination, timing, visual discrimination,

recall, and problem-solving.

 Martin enjoys opportunities to test his skills

using the IM program and he is a motivated

and eager participant. The point of the various

IM activities is to access or activate different

parts of the brain simultaneously with incoming information, and then integrate that information in order to produce the appropriate

output actions (shift balance, calculate quantities, recall, fi nd and sequence letters, all while

maintaining his trigger beat). Throughout these

types of activities, he typically scores within

the range of 40 to 50 ms with 3 to 10 in-a-row

(IARs) beats, hitting a target level of three in a

row (a burst) 10 to 15 times during the duration of the activity, which is about 16 minutes

in length. At times, he is given verbal cues to

“stay off the reds” (indicating that he is very off

beat) when he becomes distracted.

 The school team, Martin ’ s parents, and his

therapist have noted overall improvements in

processing speed, problem-solving, social interactions, reading fl uency, fl uidity of writing and

keyboarding, speed and accuracy of writing,

and better overall regulation. They also note

that Martin learns from mistakes more quickly,

is better at anticipating problems, has more confi dence and success with novel motor actions,

makes more spontaneous comments, and is less

anxious. During the course of therapy, Martin

also showed specifi c gains in timing, body

awareness, visual-spatial awareness, left and

right discrimination, multitasking, and bilateral

coordination. When Martin started high school,

he was enrolled in a life skill program in anticipation of eventually needing an adult day-care

setting or at best a sheltered workshop. Now his

school team feels that Martin will be able to

work in a community setting with a job coach.

 Concrete examples of the functional

improvements seen include recognizing and

452 ■ PART V Complementing and Extending Theory and Application

anticipating the need to hold the door for somebody coming, waiting for someone to stop

speaking before starting to speak, and anticipating what to bring to an outing without explicit

instruction to change to boots, bring a wallet,

and so on. Also, he is organizing himself so that

it is done in a timely manner. Improved organization has increased his access to resources

with improved ability to navigate the Internet

(e.g., double clicking, using mouse or touch

pad mouse). He is able to manage school materials more readily and use maps and reference

points when moving about the community.

 In addition to his IM activities, Martin continues to engage in open-ended, self-selected

movement activities in a large SI gym and to

engage in life skills and recreational and prevocational activities with his therapist. (Case

study of Martin provided by Rose Heredia, MS,

OTR/L.)

Section 5 : Astronaut Training Program

 Mary Kawar, MS, OT/L

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional

Astronaut

Training Program

 • Integrated

 • Active and passive components

 • Prescribed with some

responsive components

 • Traditional

Background

 Beginning in the 1970s, Ayres developed clinical strategies for ameliorating vestibular dysfunction ( Ayres, 1972 ). In more recent years,

pediatric vestibular rehabilitation programs have

addressed balance and vision stability issues

intensively ( Braswell & Rine, 2006 ; Casselbrant, Villardo, & Mandel, 2008 ; Cronin & Rine,

 2010 ; Rine, 2009 ; Weiss & Phillips, 2006 ). The

Astronaut Training Program (ATP) was built

upon many years of mentorship by Dr. Ayres and

Dr. Josephine Moore, years of clinical practice,

and an increased awareness of the effectiveness

of pediatric vestibular rehabilitation strategies. An

expansion of the vestibular component of Ayres’

original work, the ATP is a rotary and linear acceleration program that integrates sound-activated

vestibular-visual processing for moving, looking,

and listening. The ATP offers a systematic way to

address vestibular-based issues.

 The U.S. space program provided a real-world

context for framing the ATP, because the training

program to prepare astronauts for space travel

closely parallels ATP therapeutic activities. The

metaphor of climbing onto a space ship often

captures children ’ s imagination and helps dispel

anxiety about the therapeutic activities. After the

therapist does a “countdown,” the child “blasts

off into space” on an astronaut board (available

from www.astronautboards.com ) or on a suspended platform swing in order to bring back

treasures from imagined visits to Mars or the

moon. (Note: A scooter board does not work

because the therapist cannot achieve precise rotation, and it is too short for side-lying.)

CHAPTER 18 Complementary Programs for Intervention ■ 453

Rationale

 The ATP refl ects the neuroanatomical design

and function of the inner ear, including all six

peripheral vestibulo-cochlear receptors bilaterally and their connection, through the eighth

cranial nerve, with CNS structures and pathways. A primary focus on the vestibular system,

with secondary focus on the visual, somatosensory, and auditory systems (i.e., multisensory inputs), sets the ATP apart from most

interventions that incorporate vestibular inputs

( Schaaf & Lane, 2009 ), not placing specifi c

emphasis on precise vestibular activation as a

foundation for SI.

 As a gravity receptor, the vestibular system

instantaneously senses changes in head position in order to maintain stable visual images

on the fovea of the retina and dynamic postural

orientation and control of the body. Typically,

the vestibular system is fully formed in the fi rst

trimester, able to elicit the expression of tonic

vestibular refl exes in utero, and capable of supporting orientation of the head in space shortly

after birth ( Jeffery & Spoor, 2004 ; Rine, 2009 ;

 Weiss & Phillips, 2006 ). However, its infl uence on balance does not fully mature until

late adolescence, whereas somatosensory and

visual contributions to balance mature much

earlier ( Peterson, Christou, & Rosengren, 2006 ,

Rine online vestibular course; Rine, Rubish, &

Feeney, 1998 ). Some children who present with

poor postural control or gravitational insecurity

have underdeveloped or compromised vestibular function ( Cronin & Rine, 2010 ). To maintain

balance, they may rely on less effi cient and more

cognitively demanding compensatory strategies

involving vision.

 The ATP addresses vestibular connections at

all levels, beginning with the profound interaction between sound and movement that starts

at the receptor level, and including vestibular

integration with all of the other sensory systems

at multiple levels of the CNS. The vestibular

receptors are afferently and efferently connected

with the brainstem vestibular nuclei and with the

archi-cerebellum that is exclusively devoted to

vestibular processing. From the vestibular nuclei,

there is two-way communication with many subcortical and cortical structures ( Goldberg et al.,

 2012 ). See Chapter 4 (Structure and Function of

the Sensory Systems).

Program Description

 There are three distinct components to the ATP:

(1) preparatory; (2) sound-activated, rotary; and

(3) linear acceleration.

 The preparatory component of the ATP

can be considered an expansion of a sensory

integration-occupational therapy (SI-OT) intervention because the child engages in fun,

goal-directed movements that spontaneously

orient the head in many different planes while

executing a combination of rotary and linear

head and body movements, at varying speeds, to

activate as many receptors of the entire vestibular

system as possible. These self-generated movements provide proprioceptive input to help modulate a potential vestibular overload. Participants

are not coached for precision while engaged in

these activities. Rather, they are encouraged to

have fun and discover the joy of engaging in

playful movements while accomplishing simple,

purposeful acts, such as “rocking the bears”

(see Figs. 18-7 and 18-8 ). To keep the activities dynamic and compelling, participants select

their favorite music and create additional moves

to complement those incorporated initially into

the program. The preparatory protocol is a good

starting point for vestibular activation as part of

home, school, and clinic programs.

 The second component of the protocol is

the rotary program that incorporates focal and

ambient sounds to keep individuals continuously

informed that they are “here” in this “space.”

Note that for this to occur, the sound source must

be positioned near the child.

 The individual maintains a specifi c orientation of the head while sitting or side-lying and

being rotated by the therapist at a speed of one

revolution every 2 seconds for up to 10 revolutions. Responses are carefully monitored so

as to provide only as many revolutions as the

individual can tolerate (with quick recovery)

before proceeding with the next set. A full complement of rotations, if tolerated, includes three

different head positions while rotating both

counter-clockwise (CCW) and clockwise (CW):

 1. Sitting with the head tilted forward 30

degrees (see Fig. 18-9 ) to activate the

horizontal canals bilaterally

 2. Side-lying on the right side with the head in

line with the spine and tilted forward

454 ■ PART V Complementing and Extending Theory and Application

30 degrees and turned 45 degrees to the

right of midline, toward the support surface

( Fig. 18-10 ) to activate the right superior and

left posterior canals

 3. Side-lying on the left side with the head

in line with the spine and tilted 30 degrees

forward and turned 45 degrees to the left

of midline, toward the support surface to

activate the left superior and right posterior

canals.

 Rotation in the sitting position induces refl exive horizontal perirotary nystagmus and postrotary nystagmus (PRN) responses, which are

alternating rapid, resetting eye movements (saccadic refl exes) and slow following eye movements (smooth pursuit refl exes) involving the

medial and lateral rectus muscles. Immediately

after the PRN has stopped, the child does the

same eye movements voluntarily while viewing

a penlight that the therapist moves in conjunction with a soundtrack, thus coordinating vision

and sound. Rotation in the side-lying positions

induces refl exive vertical peri- and post-rotary

nystagmus responses involving the superior and

inferior rectus muscles and the superior and

inferior oblique eye muscles. Volitional vertical

saccades and smooth pursuit movements timed

to music are elicited following the refl exive eye

movements.

 In the rotary protocol component of the ATP,

an astronaut board, which does not require a

suspension system, is used for rotation. The

board can be easily carried from one setting to

another, is close to the fl oor for safety, and emulates the “blasting off into space” theme. This

FIGURES 18-7 and 18-8 Therapist and child rock the

bear back and forth to spontaneously and repeatedly

alter the orientation of head in space. Photos

courtesy of Mary Kawar.

FIGURE 18-9 Head vertically aligned with spine and

tilted in 30 degrees of fl exion. Photo courtesy of

Mary Kawar.

FIGURE 18-10 Head in line with spine with

30 degrees of neck fl exion and turned 45 degrees to

the right of midline. Photo courtesy of Mary Kawar.

CHAPTER 18 Complementary Programs for Intervention ■ 455

component is therapist directed, although it does

spark the child ’ s imagination. Activation of the

vestibular-ocular refl ex during and following

rotation is thought to provide a foundation for

the child to subsequently generate volitional saccadic and smooth pursuit eye movements.

 Once all rotations have been completed, the

child sits up and does a brief oculomotor “wrap

up.” This includes volitional saccades and pursuits in all directions, near-far convergence and

divergence, stabilizing eye focus on the visual

target while moving the head, and sustaining

visual focus on a stationary midline target while

monitoring the peripheral visual fi eld for moving

visual targets. Compelling visual objects are used

as visual targets, and a lively soundtrack helps

integrate the vestibular, somatosensory (support

for head and trunk alignment and stability),

visual, and auditory aspects of performance.

 The most important guideline for rotary activation is to avoid overloading the system. The

objective is to provide the just right amount of

rotary stimulation to allow quick recovery and

lay a comprehensive vestibular-somatosensory

foundation for subsequent adaptive engagement

with people, objects, and events. Individuals who

are hypo-responsive to vestibular activation can

usually tolerate a signifi cant amount of intense

acceleration. Even so, they may be overly sensitive because of lack of exposure to vestibular acceleration in side lying. When vestibular

function has been permanently compromised

(for example, because of congenital anomalies:

refer to case 4) other sensory systems need to be

trained to take over the compromised vestibular

function.

 Individuals who are hypersensitive to vestibular activation have been found to increase tolerance most successfully by frequent exposure

to small, gradually increasing amounts of rotary

movement. When an individual person experiences an adverse response to rotation (e.g., dizziness, nausea, pallor), the therapist immediately

engages the child in rigorous proprioceptive activation through resistive activities (e.g., wall push

up) to help inhibit vestibular overload. The rotary

protocol should always be done at the beginning

of a session, followed by inviting linear activities

with scooter boards, gymnastic balls, or a variety

of suspension equipment that entails emphasis on

proprioceptive activation to modulate vestibular

activation.

 The third component of the ATP focuses on

linear movements. The ATP includes a wide

variety of linear acceleration activities that,

together with strategic placement of visual

and auditory targets, encourages spontaneous

changes in head position. Facilitating several different head positions supports awareness of head

position in space under all conditions. These

linear activities are often supported by music

that matches the timing and rhythmicity of the

requisite movements. Research has documented

that sound-enhanced movement increases muscle

strength and endurance and improves timing and

rhythmicity ( Thaut, 2007 ).

 (Note: This program is described in greater

detail in a booklet/CD combination by Kawar

and Frick [ 2005 ] and in a chapter by Kawar

 [ 2005 ].)

Relationship to Sensory

Integration and Occupation

 Aspects of the preparatory (fi rst component) and

linear acceleration (third component) protocols

of ATP are closely related to SI-OT intervention. They involve active engagement in specifi c,

whole-body, goal-directed activities that provide

enhanced vestibular-auditory-visual inputs.

Many of the suggested activities are typical of

those seen in SI-OT clinics. The rotary protocol

(component 2) departs from SI-OT because the

therapist rotates the child. However, although the

input is provided passively, the child is actively

stabilizing the body, listening to the focal and

ambient soundtrack, and responding visually to

stationary and moving targets. Some children

enjoy learning how to spin themselves independently with optimal head positioning. The

therapist also directs the follow-up volitional

eye movements that are a part of all ATP protocols, setting these aspects apart from SI-OT

interventions.

Expected Benefi ts

 The ATP utilizes several strategies designed

to ameliorate vestibular challenges through

adaptation (to reset the system for improved

gaze stability and postural control), habituation

(to diminish or alleviate motion sickness and

456 ■ PART V Complementing and Extending Theory and Application

dizziness), and substitution (to compensate for

vestibular anomalies or loss). Precise vestibular

activation provides a solid foundation for supporting, integrating, and enhancing the combined contribution of all the sensory systems to

optimal engagement in life occupations. Cronin

and Rine ( 2010 ) emphasized how a comprehensively designed vestibular activation program

can signifi cantly enhance a child ’ s performance

in terms of development, learning, postural

alignment and control, and confi dence in achieving age-appropriate skills. Anecdotal results

consistent with Cronin and Rine ’ s statement are

reported from using the ATP in conjunction with

an SI therapy program. No research has investigated ATP directly, and rigorously designed

studies are needed to document its effectiveness.

Target Populations

 The ATP may be used with children and adults

throughout the lifespan, starting as young as

1 month of age. These individuals may demonstrate diffi culties with vestibular-somatosensory,

vestibular-visual, and vestibular-auditory integration associated with movement deprivation, emotional trauma, gravitational insecurity, dizziness,

car sickness, and aversion to head movement,

among others.

Training Recommended

or Required

 Therapists using the ATP must be competent

in essential clinical assessment, reasoning, and

application skills related to SI, vestibular-visual

functioning, and the ATP in order to be able to

adapt the program to meet the unique needs of

each individual. It is recommended that occupational therapy practitioners have at least 1 year of

clinical practice before becoming trained in the

ATP. Certifi cation in the Sensory Integration and

Praxis Tests ( Ayres, 1989 ), including in-depth

theory, is also recommended to provide a foundation in SI assessment and intervention before

taking formal training in this program.

 Formal training in the ATP is best achieved

by taking the 2-day continuing education course

entitled Astronaut Training: A Sound Activated

Vestibular-Visual Protocol ( https://vitallinks.com/

course/astronaut-training/ ) through Vital Links.

This experiential training workshop includes the

Astronaut Training booklet and CD. Advanced

ATP training to become a preferred provider is

being developed to further ensure that the ATP

is being utilized competently and responsibly.

Individuals desiring to use the ATP also should

consider the “Eyesight to Insight” continuing

education course ( https://vitallinks.com/course/

eyesight-to-insight/ ) sponsored by Vital Links to

develop profi ciency in visual-vestibular assessment, integration, and intervention techniques.

Pediatric vestibular rehabilitation courses are

another related avenue for continuing education.

Case Examples

 Next are four short case vignettes describing the

use of the ATP for different presenting concerns.

It is important to keep in mind that each child

is unique, and this program lends itself to individual adaptation based on needs, tolerance, and

goals.

CASE STUDY ■ RITA

 An adaptation frame of reference to enhance the

effi ciency of bilateral vestibular processing was

used with Rita, a 7-year-old girl with a history

of chronic right ear infections and right-sided

vestibular hypo-responsivity. Rita demonstrated

asymmetrical vestibular processing as seen by

an 18-second PRN response when rotated to

the left and no observable PRN when rotated

to the right. She presented with poor balance

as well as handwriting and reading diffi culties.

Rita could not maintain visual clarity when an

object came within 6 inches of her eyes.

 Rita was started on two 60-minute weekly

outpatient occupational therapy sessions and a

daily preparatory ATP home program, incorporating Rita ’ s music choices to accompany the

movements, which she referred to as dancing.

The rotation protocol of the ATP, including

volitional eye movements and the soundtracks,

was completed at the start of each session.

For the remainder of these sessions, Rita

selected various linear acceleration activities

that incorporated interaction with visual and

auditory targets that she strategically placed

CHAPTER 18 Complementary Programs for Intervention ■ 457

to facilitate spontaneous changes in head position while moving through space on equipment

(e.g., scooter board, carpet skates, suspended

hammock).

 After the fi rst 2 weeks, the rotation protocol

of the ATP replaced the preparatory program

at home. Within 3 months, Rita no longer

demonstrated the right-side hypo-responsivity

and had a right PRN of 13 seconds’ duration,

consistent with her left-side PRN response,

suggesting symmetrical vestibular processing.

Moreover, Rita ’ s handwriting was increasingly legible, reading fl uency was beginning to

emerge, and her parents reported that she had

fi nally achieved her goal of being able to ride

a bicycle. At this point, they pursued a vision

assessment.

CASE STUDY ■ ROBBIE

 Adaptation strategies were also used with

Robbie, a 5-year-old boy with autism whose

favorite activities were standing and spinning to

his right and spinning objects. After a thorough

evaluation, it was hypothesized that Robbie

was trying to provide himself with suffi cient

vestibular-visual activation to meet his sensory

needs because his self-regulation appeared

better after spinning himself or objects. In addition to his once weekly clinic sessions, a daily

home program utilizing rotary and linear activities with the astronaut board and the scooter

board was initiated to activate all vestibular

receptors precisely.

 Within 1 week, Robbie ’ s perseverative spinning was markedly reduced. Within 5 weeks, he

had ceased spinning behaviors, provided that he

maintained a movement-rich sensory diet.

CASE STUDY ■ GEORGE

 Habituation strategies were incorporated into

10-year-old George ’ s intervention program.

George was referred to occupational therapy

because of severe carsickness, which limited

him to riding in a car for only a few blocks before

vomiting. Initially, in clinic-based occupational

therapy, he could tolerate and quickly recover

from a preparatory movement activity that

involved standing and quickly turning himself

around for one revolution CW, followed by

touching the wall and visually fi xing on a target

and then rotating CCW and again touching and

looking. All other attempts at rotary movement

activities resulted in nausea. However, he could

tolerate linear movements on a scooter board.

 After 2 weeks of twice-daily self-spinning at

home, he had increased his tolerance for rotary

movement to 10 revolutions each way with

quick recovery and was able to begin the ATP

astronaut board rotational protocol. During a

6-week period of doing the rotary protocol two

to three times weekly at home and twice weekly

in the clinic, George could achieve quick recovery following rotation in all positions (upright

and side lying). He was able to enjoy participating in movement activities that were of interest

to him and no longer experienced carsickness,

even while reading in the car.

CASE STUDY ■ PAGE

 Page was a 4-year-old with a congenital

anomaly of the vestibular receptors manifested

by the presence of only fragments of semicircular canals bilaterally. When fi rst seen, she had

received occupational and physical therapy for

more than 3 years, but she was unable to walk

independently. A substitution strategy was initiated by adapting the ATP rotary protocol to

focus on enhancing somatosensory, visual, and

auditory inputs to compensate for her lack of

vestibular processing capability.

 Page loved spinning and quickly learned

how to spin herself by pushing on a vertical

pole that was positioned close to the astronaut board and stabilized by the therapist. The

astronaut CD was also positioned close to the

board so that the sounds could enhance auditory awareness of her place in space as well

as her sense of the space that she was spinning in. She was able to tolerate a twice daily,

self-administered rotary acceleration program

with eyes open at the rate of 1 to 2 revolutions

per second for at least 10 repetitions both CW

and CCW with no adverse effects. The therapist or the mother held the penlights so that she

could do the visual wrap-up program after she

completed the rotations.

 Page ’ s self-spinning seemed to heighten her

proprioceptive awareness in order to maintain

her balance on the board (increasing extension

458 ■ PART V Complementing and Extending Theory and Application

of the left side of the body when turning to her

left and increasing right-sided extensor activation when turning to her right). Increased

tactile awareness facilitated weight shifting on

the board. Peripheral visual fl ow was activated

by the fast movement on the board with her

eyes open, and focal vision was enhanced by

repeatedly sighting the pole to push on it and by

performing the oculo-motor wrap-up activities.

 One month after initiating the ATP, Page

took her fi rst steps, suggesting increased effi -

ciency of somatosensory, visual, and auditory

processing to compensate for a lack of vestibular function.

Section 6 : Infi nity Walk Training

 Mary Kawar, MS, OT/L

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional

Infi nity Walk Training • Integrated

 • Active

Prescribed Traditional

Background

 Infi nity Walk (IW) training was fi rst developed

by Deborah Sunbeck, PhD, in 1991 for use primarily in special education. Sunbeck ’ s books

(1996, 2002) and workshops have helped to introduce the application of the IW program to other

professions, including occupational and physical therapy. The IW program includes several

strategies, with varying degrees of complexity

that have emerged through time. The basic IW

program is the focus of this section.

 The IW contributes to a repertoire of novel,

compelling, versatile therapeutic strategies. It

can be utilized in any environment with minimal

props and expense. An imaginative therapist will

discover that it affords unlimited options for

adaptation. One of its great advantages is that

many physical, cognitive, and social experiences

can be incorporated through time to sustain interest. The IW lends itself to group participation as

well, so that it can be used with family members

and classmates for home and school-based

programming.

Rationale

 IW is a strategy for enhancing multisensory

processing and bilateral motor coordination.

IW activates the upper and lower extremities

in conjunction with simultaneous rotation or

counter-rotation of the shoulder girdle and pelvis

while simultaneously eliciting continuous head

movements from side to side so as to engage the

eyes and ears with a stationary target.

Program Description

 The IW involves walking continuously fi rst CW,

then CCW, around a fi gure eight (i.e., infi nity

CHAPTER 18 Complementary Programs for Intervention ■ 459

symbol) pattern. Simultaneously, the participant

looks at, listens to, or interacts with a strategically placed stationary target (e.g., person, TV,

video, or other object). The target is positioned

perpendicular to the crossover point between

the two circles of the fi gure eight pattern and

at an optimal distance for effective interaction

between the participant and the target. Refer to

 Figures 18-11 and 18-12 for an activity example

of a child playing darts while walking along the

infi nity pattern.

 The participant selects the target so that it

appeals to his or her interests. It may be helpful

to change the target during the walk to extend the

walking time and thereby enhance the benefi ts.

 Several aspects of function should be considered when implementing the IW:

• The therapist may need to guide the

participant from behind to keep him or her

on the path. It is not recommended to mark

a line on the fl oor, because then participants

are tempted to watch the line rather than

focusing on the stationary target while

walking. Looking at the path also keeps

the body in midline and symmetrical and

precludes the unfolding of the many other

desired movements.

• Walking the IW promotes continuous

recalibration of the relationship of the

head, neck, and body to keep the eyes and

ears oriented on the focal target. Each step

along the path requires a slight shift in head

position in order to sustain focal attention

on the target. These movements of the head

create an opportunity for the individual to

process information continuously with the

eyes and ears all the way from the extreme

left visual and auditory fi eld through the

midfi eld and on to the extreme right visual

FIGURES 18-11 and 18-12 The dartboard visual target and the recorded music are positioned perpendicular

to the crossover point of the two circles at an appropriate distance from the path. A fanny pack is used to

transport the darts so that both arms are free. The tape on the fl oor is only used to illustrate the path for the

reader. It is not used with the activity.

460 ■ PART V Complementing and Extending Theory and Application

and auditory fi eld. The thought is that

the eyes and ears become integrated with

dynamic head movements for effi cient visual

and auditory orientation and processing in all

life tasks.

• Walking the IW involves subliminal

processing of sights and sounds in the

surroundings to promote orientation in space.

This frees the individual to sustain focal

cognitive engagement without needing to

consciously attend to where the body is

in space.

• Changing between walking the CW circle

and the CCW circle involves a reversal of

the direction of rotation between the shoulder

girdle and pelvis and a gradual transition into

and out of symmetry at the midpoint of the

circles. This dynamic interplay between the

upper and lower trunk enhances body scheme

and supports bilateral integration and praxis.

• When walking around the CW circle, the

left leg must take longer strides, followed

by even stride length at the midpoint

and then longer strides with the right leg

when negotiating the CCW circle. These

constant, subtle changes in stride length,

in conjunction with weight shift demands,

provide somatosensory input to enhance

body scheme and balance and support the

development of praxis.

• Swinging the arms in conjunction with

shoulder movement and opposite pelvic

movements helps elicit trunk rotation and

establish a foundation for functional bilateral

skill development.

• All hand activities are placed at the crossover

point and at an optimal location. Activities

that have proven to be appealing include

dropping coins in a piggy bank, eating a

snack by picking up pieces of food from

a plate, putting a piece in a puzzle, and

stacking cones.

 Special considerations and modifi cations of the

IW include:

• Keeping the activity demands realistic

to ensure success. Simply walking along

the path can take one ’ s full concentration

initially. The more interesting the focal

target, the more compelling it will be for the

child to attempt to attend to and engage with

it while walking.

• Positioning a CD player at the focal point to

provide music when the chosen activity does

not include sound.

• Changing the placement of the focal target

(e.g., high-low and near-far) to alter focal

orientation and visual demands.

• Using “infi nity riding” to enable

non-ambulatory individuals to be transported

along the path. A caregiver can carry an

infant face forward or place the infant in

a stroller. One child can pull another in a

wagon. A child can be in a wheelchair, riding

a tricycle, or using a scooter board.

• Guiding participants to negotiate the path in

different ways, such as walking backward,

jumping, hopping, crawling, skipping, or

doing animal walks. Many of these variations

can be accomplished while the child is

multitasking with fl ashcards being held by

the therapist at the focal point or having a

dialogue with the therapist about a movie,

what happened at the playground, and so on.

Relationship to Sensory

Integration and Occupation

 The IW can fi t into the SI frame of reference

when a therapist implements it in a manner consistent with the theory and principles of OT-SI

intervention. As such, IW has an indirect relationship with occupation.

Expected Benefi ts

 IW directly addresses the development of

bilateral integration and postural control. The

repetitive nature of IW lends itself to developing automaticity in basic movements. Effi cacy

studies are needed to document the favorable

anecdotal evidence reported by therapists who

have utilized IW as an integral component of

OT-SI intervention.

Target Populations

 IW is a self-paced method that is appropriate

for children and adults of all ages. When children are too young or are physically incapable of

CHAPTER 18 Complementary Programs for Intervention ■ 461

walking, they can do infi nity riding while turning

their head and trunk as well as incorporating

their upper extremities with the visual and auditory activity that is serving as the point of focus.

Higher functioning participants can do multitasking with high-level cognitive processing and

simultaneous, adaptive management of the body

in space.

Training Recommended

or Required

 No training is required to use the IW program;

however, there are several helpful resources.

 Sunbeck ’ s ( 1996, 2002 ) two books describe the

theoretical rationale and creative process that culminated in developing and implementing the IW

program. She currently offers a webinar entitled

“The Infi nity Walk Method: A Developmentally

Progressive and Integrative Systems Approach to

Clinical Treatment” ( Sunbeck, 2013 ).

CASE STUDY ■ KEVIN

 Kevin, an intelligent 9-year-old boy with a

2-year delay in reading ability, immature bilateral motor coordination, and poor self-esteem,

came very reluctantly for OT-SI intervention at

the request of his parents. He was being pulled

out of class for a reading resource program.

Before his initial occupational therapy visit,

he had received 6 months of developmental

optometry for correction of right exotropic

strabismus as well as a year of private tutoring

with a reading specialist. He described himself

as a “klutz” and stated that he hated to read.

Although vision therapy had recently improved

his binocular control, he had spent several

years avoiding sports, socializing with peers,

and reading.

 Kevin took a liking to the IW after the therapist introduced him to the idea of using a

water pistol with a bull ’ s eye target painted on

a plastic apron worn by the therapist. It allowed

him to channel his frustrations and detracted

him from thinking about how challenging it

was for him to walk the path. He often resorted

to side-stepping because he seemed stuck in

symmetrical movements and had minimal body

scheme awareness. Trunk stiffness impeded

lower extremity mobility and the ability to keep

his feet aligned and pointed in the direction of

the path ’ s CW and CCW curves. He sometimes

missed crossing over at the mid-position but

never missed an opportunity to squirt the water

gun, sometimes hitting the therapist instead

of the apron. He was encouraged to alternate

hands with the water pistol to free his head and

trunk movement and gain further arm movement and eye-hand coordination.

 After two sessions, Kevin could stay on

the path through the crossover point, although

his performance was still immature. He began

choosing a wider range of IW activities

with increased sensory, motor, and cognitive

demands. An IW home program was started for

10 minutes twice daily while watching television. This was very rewarding for him, because

TV time was rarely permitted.

 Each week, Kevin demonstrated further

reduction in postural rigidity and greater rotation and counter-rotation of the trunk accompanied by rhythmic extremity movements. He

consistently stayed closer to the path. Frequent

engagement in the IW home program was

largely responsible for the gains. He became

eager to engage in cognitive IW activities,

including reading words from fl ashcards he

made. The therapist manipulated the cards

while they discussed defi nitions, putting the

words into sentences, and so on. As his bilateral coordination and praxis improved, he also

became more fl uid and quick in his reasoning

and communication skills.

 After approximately 2 months of occupational therapy using IW, Kevin reported that he

had begun to read for pleasure before going to

sleep and that his resource teacher had moved

him up one grade level in reading. He chose

to join a therapeutic sports-oriented group

with two other boys to start building his ball

skills. Through the IW he had found his path to

increasing self-esteem and rewarding achievement of goals that he had previously thought

were beyond his reach.

462 ■ PART V Complementing and Extending Theory and Application

Section 7 : Therapeutic Listening®

 Sheila Frick, OTR/L

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

nontraditional

Therapeutic Listening® • Single system

 • Passive

Prescribed Traditional

Background

 The use of sound-based interventions emerged in

the 1950s when Dr. Alfred Tomatis created the

Electronic Ear, the basis for the Tomatis Method

( Tomatis, 1996 ). Initially, Dr. Tomatis treated

patients with auditory processing and learning

diffi culties and, later, children with autism. Other

sound-based techniques, such as Auditory Integration Training, developed from the Tomatis

Method.

 In the early 1990s, a small group of occupational therapists trained in SI began incorporating

sound-based approaches into 2-week intensive

intervention protocols based on an SI frame of

reference. The fi rst published case studies using

this approach ( Frick & Lawton-Shirley, 1994 )

showed promising results in many areas typically

addressed in SI therapy (e.g., sensory defensiveness, gravitational insecurity, and praxis).

Although participants appeared to benefi t from

the interventions, there were several barriers.

Participation required extensive time and fi nancial resources and necessitated intervention in a

clinic setting. To minimize the barriers, Therapeutic Listening® was developed based on extensive clinical experience with SI and auditory

interventions specifi cally for use in a variety of

settings and with a large population ( Frick &

Hacker, 2001 ).

Rationale

 Ayres ( 1972 , p. 123) described the vestibular

system as providing a “unifying and coordinating

role in relation to all other sensory input” and

acting as a key integrator in sensory processing. Because of the interaction of the vestibular, visual, and auditory systems, we are able

to move, explore, and engage with people and

objects in the three-dimensional environment.

When individuals experience SI challenges, the

vestibular system—which has direct connections to the auditory system—is often a target of

intervention.

 The vestibular and auditory systems are intimately connected, both anatomically and neurologically. Both systems are housed within the

bony structure of the inner ear and function via

hair-like receptors moving in fl uid-fi lled canals.

Both systems share the eighth cranial nerve,

which sends neurological impulses to the CNS—

crossing paths and exchanging information at

multiple junctures in the cerebellum, brainstem,

and cortex. Research conducted by Emami

and colleagues ( 2013 ) identifi ed the stimulation of the saccule in response to high-intensity

low-frequency sounds. Furthermore, the saccule

can support the cochlea in hearing in noisy environments ( Emami et al., 2013 ). Because of these

intimate connections, auditory interventions such

as Therapeutic Listening® are thought to support

the sensory processing that underlies occupational performance and function.

 A key component of Therapeutic Listening®

is specialized electronic modifi cation of specifi cally recorded music, designed to highlight

aspects of the sound spectrum and initiate an

orienting response to salient features of the

environment (see Fig. 18-13 ). Orienting is a

subcortical action in response to novelty in the

CHAPTER 18 Complementary Programs for Intervention ■ 463

environment. When individuals detect and orient

to novelty, they display characteristic behavioral

patterns: stilling of the body, head turning, and

visual search ( Siddle, 1983 ). They also experience physiological changes in heart rate, respiration, and pupillary dilation ( Frick & Young,

 2012 ). Orienting responses ultimately infl uence

the autonomic nervous system (ANS) through

neural pathways in the limbic system, reticular

formation, and other subcortical areas.

 Orienting precedes adaptive behavior. In

asserting that orienting is a pre-adaptive response,

 Ayres ( 1972 ) paved the way for an underlying

assumption of Therapeutic Listening®: facilitating orienting may “prime” the approach behaviors that precede adaptive responses ( Wilbarger

& Frick, 2011 ).

 Another cornerstone of Therapeutic Listening®, rhythm, also appears to have far-reaching

infl uences on the nervous system—especially

motor networks ( Bengtsson et al., 2009 ). Thaut

and colleagues ( 1992 ) have extensively investigated the relationship between music, rhythm, and

motor output. In one study, they found that auditory rhythms immediately improved gait patterns

in individuals with neurological injury ( Thaut,

Kenyon, Schauer, & McIntosh, 1999 ). Using

electromyography (EMG), Thaut and colleagues

 ( 1992 ) demonstrated that rhythmic input facilitates motor unit recruitment patterns—ultimately

infl uencing motor control, coordination, and

performance. Type and quality of rhythm infl uence the motor system through entrainment

with motor responses ( Thaut & Abiru, 2010 ).

The musical rhythms in Therapeutic Listening® are specifi cally selected to match individuals’ needs and support targeted therapeutic

outcomes.

Program Description

 Therapeutic Listening® is a sound-based intervention often embedded into a therapeutic approach

based on the principles of SI (see Fig. 18-14 ).

Therapeutic Listening® involves an individualized intervention progression in which recorded

music is selected based on an individual ’ s unique

clinical picture and used within a variety of intervention settings. Therapeutic Listening® includes

a wide range of music, precisely engineered to

utilize rhythm, facilitate orienting response, and

support adaptive behaviors. During a Therapeutic Listening® progression, children listen for

30 minutes, twice per day, and rotate through an

assortment of music. Because Therapeutic Listening® is highly individualized, length of participation varies, on average, from 3 to 6 months.

However, many individuals continue using

Therapeutic Listening® as a part of an ongoing

sensory diet.

Relationship to Sensory

Integration and Occupation

 Therapeutic Listening® is thought to ‘prime’ an

individual for adaptive responses; therefore, it is

FIGURE 18-13 A key component of Therapeutic

Listening® is specialized electronic modifi cation

designed to highlight aspects of the sound spectrum

that initiate an orienting response to salient features

of the environment. Photo courtesy of Sheila Frick.

FIGURE 18-14 Therapeutic Listening® is a

sound-based intervention often embedded into

intervention based on the principles of sensory

integration. Photo courtesy of Sheila Frick.

464 ■ PART V Complementing and Extending Theory and Application

often utilized within a therapeutic approach utilizing interventions based upon the principles of

SI theory. This joint interaction is meant to facilitate organization and dynamic engagement with

the environment as a foundation for occupational

participation.

 In her early work, Ayres ( 1972 ) addressed the

relationship between the auditory and vestibular

systems. Although she never directly discussed

the use of enhanced auditory input, we think of

Therapeutic Listening® as an expansion of Ayres’

original theory. However, when Therapeutic Listening® is used in the absence of any demand for

adaptive interaction, it represents pure sensory

stimulation and falls outside the construct of SI.

Therapists commonly report changes in child

factors and performance skills that infl uence

activities of daily living, instrumental activities

of daily living, school and work, and other occupational domains.

Expected Benefi ts

 Therapeutic Listening® used within an SI therapy

perspective can increase effectiveness for individuals with sensory integrative dysfunction. A

wide range of functional improvements associated with Therapeutic Listening® has been

documented in research. In 2005, Vital Links

conducted an international survey of 1,343 practitioners trained in Therapeutic Listening® ( Frick

& Young, 2012 ). Practitioners reported improvements in attention, self-regulation, sensory modulation, sound sensitivities, sensory defensiveness,

focus, energy level, ease with transitions, and

mood. In addition to supporting specifi c functional gains, practitioners reported that Therapeutic Listening® appeared to speed up the rate

of improvement in overall (general) goals.

 Empirical results are consistent with gains

observed by practitioners. Researchers examining

the effectiveness of Therapeutic Listening® have

employed several designs: repeated measures,

pretest and posttest, case study, and qualitative

phenomenological approach. Most participants

have been preschool or elementary-aged children identifi ed with developmental disabilities

or sensory processing challenges. Outcome measures include both parent and teacher report and

standardized assessments. Studies have taken

place at home and at school.

 Hall and Case-Smith ( 2007 ) investigated

the effects of Therapeutic Listening® and a

sensory diet for elementary-aged children with

developmental disabilities. They wrote, “participants demonstrated remarkable improvement in behaviors that refl ected [poor] sensory

processing” as measured by the Sensory Profi le

(p. 214). They demonstrated signifi cant gains

in the Visual Perception subtest of the BeeryBuktenica Developmental Test of Visual-Motor

Integration (Beery-VMI), and in handwriting

(measured by the Evaluation Tool of Children ’ s

Handwriting). Parents also reported improvements in attention, social interaction, ease with

transitions, self-awareness, sleeping, and listening to and following directions.

 Studying a preschool population, Bazyk and

colleagues ( 2010 ) assessed the effectiveness of

Therapeutic Listening® on a variety of school

performance domains.

 Results from pre- and post-test assessments

showed signifi cant improvements in visual

motor, fi ne motor, language, nonverbal intelligence, and social skills. In addition, parents and

teachers reported signifi cant progress in attention and communication skills, ability to follow

directions, participate in group activities, and

complete activities of daily living.

 Wink, McKeown, and Casey ( 2017 ) conducted a qualitative study examining parents’

experiences and impressions of use of Therapeutic Listening® as part of a home program

for their children with sensory processing diffi culties. The fi ndings from parent interviews

were transcribed and analyzed for key themes.

Researchers identifi ed critical subthemes following Therapeutic Listening®, including: reductions

in their child ’ s level of anxiety and distress; all

parents acknowledged their child was “calmer,”

and noted subsequent improvements in family

life and participation in activities of daily living

and social interactions. Current research provides preliminary support for Therapeutic Listening®. However, rigorous studies are required

to validate its effectiveness and support its use

with broader populations. Future research should

include control groups and larger samples that

vary in age and diagnoses or diffi culties. As

 Hall and Case Smith ( 2007 , pp. 214–215) wrote,

“Given the robust effects [of Therapeutic Listening® on behavior], additional measures should be

incorporated in future studies.”

CHAPTER 18 Complementary Programs for Intervention ■ 465

Target Populations

 Therapeutic Listening® is most often utilized

with children older than 2 years of age. However,

when monitored by a trained provider who uses

an adapted protocol (i.e., modulated music is

not played through headphones), Therapeutic

Listening® can be appropriate for children under

2 years of age.

 Individuals with a variety of diffi culties or

diagnoses may benefi t from Therapeutic Listening®. Most often children display abnormal

responses to sensation (e.g., sounds, touch), poor

attention and modulation of arousal, diffi culty

following directions, poor ability to transition

or deal with changes in routine, poor timing and

sequencing of movements, and diffi culty interacting with peers. Common clinical diagnoses

include sensory integrative dysfunction, ASD,

and ADHD. Therapeutic Listening® is contraindicated for individuals with auditory evoked seizures or schizophrenia.

Training Recommended

or Required

 Before implementing Therapeutic Listening®,

therapists are required to complete a basic training course entitled “Listening with the Whole

Body” offered through Vital Links, a continuing

education company (Vital Links, 608-270-5424,

 www.vitallinks.com ). Continued mentorship and

training beyond the 2-day basic course is encouraged. The modulated music and specialized

headphones required for Therapeutic Listening®

may be purchased through Vital Sounds, following completion of the 2-day basic training (Vital

Sounds, 6613 Seybold Rd., Suite E, Madison,

Wisconsin 53719, www.vitalsounds.com ).

CASE STUDY ■ CHRISTOPHER

 At 5 years of age, Christopher displayed

sensory processing diffi culties that seemed

to underlie diffi culties with participation at

home and in the community. These diffi culties

included poor emotional regulation, anxiety

around movement and gravitational insecurity,

and defensive responses to sensory input.

 Christopher displayed extraordinary diffi -

culties with emotional regulation. His mother

described his “meltdowns” as lasting for hours

and occurring up to three times daily. Once

Christopher reached an elevated emotional

state, it was extremely diffi cult to calm him.

These regulation challenges infl uenced Christopher ’ s life and prevented him from attending

social activities.

 Christopher also demonstrated gravitational

insecurity, which resulted in signifi cant anxiety

around activities where his feet were off the

ground or that required changing levels (e.g.,

stairs, escalators, and playground climbing

equipment). Once at a birthday party, Christopher followed a friend up a slide ladder. After

climbing three rungs, he began screaming at the

top of his lungs. He was so frozen with fear that

his mother had to physically assist him off the

ladder—one limb at a time.

 Christopher also displayed tactile defensiveness, which infl uenced dressing, bathing, and

eating. He did not enjoy having his hair or face

washed and demanded that his clothing be “just

right.” Christopher was very particular about

textures. He avoided touching grass or sand,

could only tolerate certain shoes, and would

only wear one brand of socks. Christopher was

also a very picky eater and had an extremely

limited diet. One evening, when Christopher

did not enjoy the dinner being served, he

erupted into tears and ran to his room. He was

inconsolable for hours.

 Christopher ’ s sensory defensiveness was

also evidenced in response to sounds. When

riding in the car, he could only tolerate increasing the radio volume if he controlled the dial.

If his mother adjusted the volume, Christopher

would erupt in a tantrum. Because the family

lived near an airport, they often heard planes

fl ying above. When this occurred, Christopher

became extremely upset and quickly covered

his ears to dampen the sound. He also became

distressed by low frequency sounds, such as

lawnmowers.

 In addition to reported functional challenges,

clinical observation revealed diffi culties with

sensory processing. Initially, Christopher ’ s postural and ocular skills appeared within normal

limits. However, he held his breath and stiffened his body in response to motor challenges,

suggesting some diffi culty.

466 ■ PART V Complementing and Extending Theory and Application

 Therapeutic Listening® proved essential to

reducing anxiety associated with gravitational

insecurity and sensory defensiveness. During

his fi rst experience with Therapeutic Listening®, Christopher demonstrated a strong orienting response. His body became very quiet and

still, and his breath deepened. This orienting

reaction appeared to prepare Christopher for

activities that followed in the clinic because

he conquered previously challenging activities

and was better able to modulate his arousal to

meet the physical and emotional demands of

the activities.

 Christopher was treated biweekly during

his 3 months in the clinic and at home. Initially, Therapeutic Listening® comprised his

home program; after a time, the Wilbarger

Therapressure Program TM and precise vestibular activities were added. At his fi nal session,

Christopher excitedly announced how he had

recently “fl own” down a huge slide at a local

water park and was able to climb a giant ladder

at the local hardware store. Christopher ’ s

explosive tantrums ceased. When talking about

his time in the clinic, Christopher described his

experiences as “magical.”

Section 8 : Applying Suck/Swallow/

Breathe Synchrony Strategies

to Sensory Integration Therapy

 Patricia Oetter, MA, OTR/L, FAOTA ■ Eileen W. Richter, MOH, OTR/L, FAOTA

PROGRAM SENSATION APPROACH SETTING

 • Integrated vs. single system

 • Application: active vs. passive

 • Responsive vs.

prescribed

 • Traditional vs.

Nontraditional

Suck, Swallow, Breathe • Integrated

 • Active

Prescribed Both

Background

 In the late 1970s, Patti Oetter ’ s practice included

Phillip, a 3-year-old boy with Down syndrome.

Similar to many of the other children on her

caseload, Phillip presented with vestibular, postural, and ocular-based issues; oral motor issues;

and irregularities in depth, rate, and rhythm

of his respiratory patterns. Phillip engaged in

compensatory strategies to support his function,

such as using respiration (blowing) to change

vestibular and postural outcomes and sucking,

biting, and chewing during vestibular-based

activities. Patti discussed these intriguing behaviors with Dr. Ayres at one point and Ayres told

Patti to continue to study the suck/swallow/

breathe synchrony (SSB) because it was “the seat

of sensory integration” (Ayres, A. J., personal

CHAPTER 18 Complementary Programs for Intervention ■ 467

communication). Patti took that advice and in

collaboration with several colleagues has seen

improvements.

Rationale

 Because of the survival nature of the SSB

synchrony and the prodigious display of SSB

synergistic behavior in infancy, SSB has been

studied extensively, from embryonic development throughout the lifespan. The signifi cance

of SSB synergistic development has also been

studied extensively, including:

• The use of nonnutritive sucking to

self-regulate ( Pickler, Frankel, Walsh, &

Thompson, 1996 )

• The bonding for social development that

is established during feeding ( Montegue,

1986 )

• Ocular-motor coordination ( Kalnins &

Bruner, 1973 ); refi nement of sound through

trigeminal and facial nerve to the stapedius

and tensor tympani muscles of the inner ear;

neck and head control that develops as use

of the SSB synergy integrates with brainstem

functions ( Barlow, 2009 )

• Mouth and hand function ( Gentilucci &

Campione, 2011 ; Rochat, 1993 ).

 The face and mouth are some of the most

sensory-rich areas of the body. The evidence

for SSB infl uence throughout development may

be inferred through observation and neuroanatomical research showing that the components

of sucking, swallowing, and breathing operate

synchronously, rhythmically, and independently.

Half of the cranial nerves are directly related to

oral sensorimotor and respiratory functions (CN

V, VII, IX, X, XI, XII). Complex information

traveling on these cranial nerves connects with

numerous structures throughout the nervous

system. These include cranial and spinal nerves,

medulla, pons, brainstem, cerebellum, thalamus,

and, in turn, cerebral hemispheres. These neurological connections underpin SSB and many

aspects of development (see the SSB Model;

 Fig. 18-15 ).

 Anatomically, neurologically, and biomechanically, the functions of the SSB synchrony,

which evolve to a muscle synergy through functional use, have direct and indirect infl uences

on many aspects of life and human development. As Figure 18-15 illustrates, the infl uences are neither linear nor mutually exclusive.

The interrelationships also indicate that we can

infl uence the outer rings by addressing the SSB

or its specifi c components. Bringing arousal

into optimal range, for example, by using SSB

strategies for self-regulation (i.e., sucking on a

straw or chewing a pen top) may also infl uence

engagement, postural and motor organization,

voice, and articulation (i.e., fi rst ring—postural

or psychosocial functions; second ring—vision

or communication; third ring—attention, postural mechanism, social emotional development,

speech).

 As each component develops and refi nes, that

refi nement contributes to the development and

elaboration of other components. Early in development, suck and gnaw, cry, and voice on breath

are the only oral motor or respiratory skills that

can infl uence the synergy. Later, bite, crunch,

chew, and lick, followed by suck, seal, vacuum,

and swallow, become additional ways to access

and activate the synergy.

 Dr. Ayres wrote, “Any major neural structure

receiving sensory input from many sources is

apt to have widespread infl uence over the rest

of the brain. Multiplicity of input also usually

means convergence of input and thereby integration of input. The brain stem and thalamus are

good examples of these principles” ( Ayres, 1973 ,

p. 82). The infl uence of the SSB is an excellent example of Ayres’ statement. Consider this

action: When a nursing infant looks up from the

breast, the muscles of the inner ear contract to

prepare for the sound of the human voice. This

seemingly simple act requires massive integration of all 12 cranial nerves ( Brownlee &

Watson, 1997 ).

 Because the SSB synergy is so broadly integrated throughout the brain and spinal cord

architecture, our model suggests that it impacts

many areas common in children with sensory

integrative dysfunction, including modulation,

postural control, praxis, and so on. On the postural side of function, any defi cit in posture is

associated with a concurrent defi cit in respiration (and vice versa), because the neurology,

muscles, and structures are the same for both.

This provides a strong indication that SSB

should be considered in children with postural

dysfunction.

468 ■ PART V Complementing and Extending Theory and Application

FIGURE 18-15 The Suck/Swallow/Breathe Model. From: MORE: Integrating the Mouth with Sensory and

Postural Functions by Oetter, Richter, & Frick (1993).

Relationship of Development to the

Suck/Swallow/Breathe Synchrony

Suck–

seal, vacuum,

synchrony, muscles

Swallow–

muscles, synchrony

Breathe–synchrony,

grading, vital capacity,

strength, muscles

Speech

Articulation, Nonverbal

aspects of speech, Loudness,

Pitch, Intonation

Eating

Biting, Munching,

Chewing, Licking,

Oral motor coordination

Soc ai l E/ mot oi nal

Self concept, Jo ni t of cus, Awareness

of

others, Self express oi n– al ugh ni g, cry ni g, e ct .,

Purposeful com

mun ci at oi n, nI et grat oi n of emot oi ns

yE H/ e na d

Deve ol mp

en ot

hf na d cr a seh pyT,

, psar gf o se

Mechan ci s f o ot l o su

V, e ausi no ml gnir oti

and d ri e t c ni , g r P do t cu l oot f o esu

oP t s r u l a

dA

pa

at t oi

n

i kS sll ni

na d r a ound m di l ni e

gir( /t h el tf , ot / p bot ot m, f or nt/

cab ,) k r G da t a oi n E, quil bi r ui m

V si ual A/

udi ot ry Percept oi n

Temporal and

sequent ai l

p or cess ni g

Praxis

dI eat oi n/Conceptualization

P al nn ni g and Choosing

Eva ul ation and Execution

Language

Breath support

Nonverbal communication

Social interaction, Pragmatics

Attention

Postural

Visual

Auditory

N

Communication

onverbal communication

Graded air

Vocal

flow

play

Self Regulation

Movement

Oral

Hand Fo mr ni a/ nd

Space

Oral of mr /space, Grasp

of mr s/ pace

Visual fo mr /space, D si at nt of mr s/ pace seyE noi si V/

i L hg er t

, sucoF, noit al ug

r T ca ni k gi F, g uor g/ er u dn ,

pS ait a acol l t azil noi

Pos ut

ar Ml echan

si ms

Ba al nced s at bili yt m/

obility

S rt eng ht r gi ht ni g/ro

at t oi n

M di l ni e s at bili yt

Ears/Hearing

Sound regulation, Focus,

Tracking, Figure/ground,

Spatial localization

Feeding

Bottle, Breast,

Oral motor

coordination

Postural Development

muscle tone, joint mobility,

muscle elongation/activation

Psychosoc

ai l Deve ol

mp

ne t

bond ni g, ni et ar ct oi , n

sense of se

A

fl

rousal

el s

pe

w/

ake, er ward p/ un si hment

el a nr ni g

m/ emory

Eyes and Ears

Dental

Gastrointestina

R

l

espiratory

Health

Program Description

 Originally M.O.R.E. was the name applied to

therapeutic principles used to guide the grading

of oral motor activities to address defi cits in

SSB. Each letter in the acronym refl ects an area

addressed in therapy: M for motor, O for oral,

R for respiratory, and E for eyes (i.e., visual).

We now refer to these therapeutic principles as

the suck/swallow/breathe synchrony, although

M.O.R.E. is still widely used.

 Research and clinical observations of both

typical and atypical SSB function have given

rise to discreet strategies to include in intervention. These strategies are based on the following

principles:

• Sucking requires the ability to create an

oral seal and vacuum to activate the muscle

synergies for use in supporting development.

• Control progresses from proximal to distal

and from center ring on the model to the

outer rings ( Fig. 18-15 ).

• During a therapy activity, children seek oral

input and demonstrate improved skill in

area(s) in the outer rings. Children will need

to return periodically to the SSB strategies

(center) to support and maintain their activity

in the outer rings. This means that quality

and endurance in performance increases

during a single session, and, through time,

quality and endurance will improve with less

intensity and frequency of return to center.

CHAPTER 18 Complementary Programs for Intervention ■ 469

• Manual intervention may be necessary to

release fi xed muscles and activate stability

or mobility in the jaw, tongue, cheeks, lips,

neck, shoulder girdle, and diaphragm.

• SSB strategies should be integrated with

functional outcomes such as eating,

self-regulation, exploration, facial expression,

and vocalization (refer to outer rings).

• Sucking, biting, and chewing should also be

addressed to activate facial musculature and

promote self-regulation through tongue, jaw,

and cheek proprioception.

• Respiration is automatic but can also be

controlled. It is easy to change, but changes

require repetitive, functional use to maintain.

The objective is to ensure that the lungs and

ribcage are capable of three-dimensional

expansion and the diaphragm is able to grade

breath appropriate to the demands of a given

task ( Massery, 2012 ).

 Typical activities to engage sucking or chewing

might include:

• Use of various-sized straws, tubing, bottle

nipples, or sports bottles ( Fig. 18-16 ).

• Suck or explore objects of different sizes,

shapes, tastes, or textures (e.g., red hots,

sweet tarts, lemon drops, sour drinks, and

carbonation).

• Promote bite or crunch with things such as

pretzels, ice chips, or popcorn.

• Bite or tug opportunities that can engage

the jaw and neck musculature (e.g., licorice,

tubing, oral chewies, jerky, or fruit rollups).

• Gum (fresh or stale) can be offered for

resistance. Note that regular (i.e., with sugar)

gum offers initial resistance, then softens,

allowing the muscles to activate initially.

Sugar-free gum works in the reverse; it

is initially soft with added resistance as

chewing continues.

 Typical intervention strategies to support optimal

respiratory function (and therefore posture)

might include:

• Blowing or inhaling—straws, tubing, novelty

blow toys, or bubbles

• Vocalizing through sound play—humming,

animal sounds

• Manual techniques to release fi xed muscles

of the jaw, tongue, cheeks, trunk, shoulder

girdle, and diaphragm

 SSB concepts and strategies are meant to be

incorporated into the child ’ s therapy program

along with many other techniques for improving

sensory and motor processing and development.

Oral motor activity can be incorporated into

meals and snacks, as well as play with the toys

and items that children and adults frequently put

in the mouth for oral motor self-regulation.

Relationship to Sensory

Integration and Occupation

 Children with SSB diffi culties often have

sensory integrative, particularly postural, dysfunction. The intervention principles are therefore often embedded in sensory integrative

therapy. Working on SSB synchrony involves

child-directed oral exploration of taste, texture,

and temperature; shapes; and play with breath

(whistles and blowing). Supplementary hands-on

facilitation of respiratory functions related to

depth, rate, and use of breath (postural musculature) may also be used. Additional therapy

targets may include oral motor or eating skills,

self-regulation, and articulation.

FIGURE 18-16 Blowing bubbles through a long

straw. Photo courtesy of Shay McAtee.

470 ■ PART V Complementing and Extending Theory and Application

Expected Benefi ts

 The benefi ts of using SSB strategies are based

on the authors’ longstanding experience. Rigorous research to test the effects of SSB strategies

is needed to validate clinical reports.

 SSB synergies support regulation, increase

or maintain alertness, focus attention, support

posture, enhance communication, perform skilled

movement, and promote stability to enable

“power” tasks ( Frick, Frick, Oetter, & Richter,

 1996 ). Therefore, some benefi ts of SSB activities

include:

• Resistive sucking can improve visual focus

for close work, and may also be organizing;

strengthening the musculature improves

eating, speech production (articulation), and

facial expression.

• Chewing can increase alertness and attention

to a task ( Allen & Smith, 2012 ), head and

neck fl exor strength and core activation, and

shoulder and pelvic stability for distal control

(i.e., for hand function, climbing, kicking a

soccer ball, etc.).

• Ability to change depth and rate of

breath according to the task; graded

breathing supports typical sleep patterns,

physical activity, verbal and nonverbal

communication, alertness, self-regulation,

and attention.

• Sucking and blowing can support visual

tracking and accommodation, improve

binocular focus at varying focal lengths,

activate facial musculature for articulation

and emotional expression, increase core

muscle strength for posture, and so on ( Kolar

et al., 2012 ; Massery, 2012 ).

• Suck, blow, bite, crunch, munch, and chew

facilitate better control and function of the

extraocular muscles and the muscles of the

inner ear; these muscles are striated and

therefore can be treated using the same

principles of muscle development as used

throughout the body.

Target Populations

 SSB strategies are a normal part of daily life, and

most of us use some variation of them to support

a range of functional tasks (see Fig. 18-17 ; Frick

et al., 1996 ). In addition, children and adults who

have diffi culty with SSB function, commonly

those with developmental, sensory integrative,

musculoskeletal, or frank neurological dysfunction, can benefi t from this intervention.

Training Recommended

or Required

 Importantly, because oral motor and respiratory functions depend on cranial nerve function,

knowledge of cranial nerve structure, related

pathways, and integration with other areas of

the CNS is critical to understanding the complex

interactions that affect sensorimotor development

and SI processing ( Moore, 1990 ; Oetter, Richter,

& Frick, 1993 ; Saladin, 2018 ).

 Although no formal training is required for

using the M.O.R.E. program and SSB synchrony

strategies, therapists may need continuing education in SSB to develop an understanding of

the intervention principles and skills to target

and implement effective intervention. The book

MORE: Integrating the Mouth with Sensory and

Postural Functions ( Oetter, Richter, & Frick,

 1993 ) and MORE: The DVD (Oetter & Richter,

2004) provide extensive suggestions for identifying and ameliorating SSB dysfunction. These

materials may be found at https://www.allmusic.com/artist/pileated-press-mn0003010174 .

Whistles and blow toys used to promote graded

breathing can be acquired from www.sensorytools.net and other pediatric therapy suppliers.

Information on courses may be found at www

.eileenrichter.com and www.patriciaoetter.com .

CASE STUDY ■ ELISHA

 Elisha is a girl who is 6 years and 9 months

old. We chose this case because the presenting issues are familiar to many occupational

therapists and also because intervention using

activities to promote SSB synchrony resulted

in decreased sensory defensiveness, increased

language, improved praxis, and increased occupational performance, especially in play.

 Elisha ’ s mom reported that Elisha was delivered at term following an unremarkable pregnancy. Early on, Elisha had diffi culty attaching

to and remaining attached to the breast, and

that diffi culty continued until she weaned

CHAPTER 18 Complementary Programs for Intervention ■ 471

FIGURE 18-17 Relationships among SSB functions in typical development. From: Out of the Mouths of Babes:

Discovering the Developmental Signifi cance of the Mouth by Frick, Frick, Oetter, & Richter (1996). Pileated Press,

LLC, Stillwater, MN.

Support Behaviors Chart

(Typical SSB Related Behaviors That Support Function and Skill)

Infant Toddler Preschool Childhood Adolescence Adulthood

Sucking a pacifier

Sucking fingers, fist, thumb

Mouthing faces, chins, shoulders, objects

Biting Biting/teething

Slurping

Clothing, collars, cuffs Hair Necklaces, chains

Sipping soups, beverages (hot/cold, thick/thin, etc.)

Tasting foods Paste, playdoh, sweet

Mouthing, chewing, sucking-hair, straws

Hands/fingers (touching, pressing) to face lips, cheeks, chin, jaw

Biting/chewing

 Strings

 Gum

 Candy

Erasers

Pencils

Fingernails

Straws

Ice

Pens

Tobacco

Hanging things from

chin or bottom teethshirts, necklaces

Teeth grinding

Jaw clenching

Soap bubbles

Voicing, whining

Yelling Screaming

Yawning, stretching Panting from exercise,

or to dampen pain

Sighing, moaning, groaning

Burping

Singsong, chanting, singing

Bathroom noises

Munching, crunching, chewing junk food

Whistling

Gum bubbles

Tongue clucking

Blowing drool bubbles

Crying, laughing

Cooing

Babbling

Screeching

Raspberries Spitting

 Humming

Spit balls

Animal noises

Breath holding

Coffee stirrer,

toothpicks, paper

clips, rubber bands

Carbonated beverages Spicy, hot, sour, salty tastes

Sucking candy, etc

Sucking on tongue, cheeks, lip

Sucking food, candy objects/smoking

Deep breathing

(relaxation exercises)

herself at 8 months and switched to a sippee

cup. Once Elisha got into preschool and fi rst

grade, her teachers had concerns about language organization and speech. In addition, her

motor skills were a bit awkward, and often she

avoided the slide, climber, and swings on the

playground. For Elisha, peer interaction was

minimal.

 Primary concerns that were uncovered

include severe sensory defensiveness as well as

a very high palate and very weak and arrhythmic suck. In addition, Elisha had a poor SSB

synchrony and synergy. Her jaw was retracted

and fi xed, limiting excursion. Elisha had

cheek retraction, resulting in an ever-present

“smile” and inability to get lip closure to suck

the contents off a spoon or to produce labial

sounds (p,b,m). Elisha ’ s food preferences

were limited.

 Elisha had low normal muscle tone. Additional postural concerns ranged from poor

head and neck alignment (head forward and

extended), to a fi xed shoulder girdle that did

not support hand development, to a rib cage

that was high and tight, resulting in a rapid and

shallow breathing pattern regardless of activity

level, and a “fi xed” trunk and diaphragm that

were noted during gross motor activity and

activity requiring skilled eye-hand coordination. Elisha had issues with binocular vision,

making it diffi cult to view objects both near

and far.

 Regarding oral, fi ne, and gross motor activities, Elisha avoided all activities requiring

problem-solving or praxis, head down or backward space, as well as swings or climbers of

any kind.

 Through an integrated occupational therapy

program, we worked with Elisha in an intensive block: 2½-hour sessions during 5 consecutive days, employing a multipronged

approach. Although SSB synchrony strategies

were an important part of intervention, we also

employed Wilbarger ’ s Therapressure TM Protocol

472 ■ PART V Complementing and Extending Theory and Application

(every 2 hours), Therapeutic Listening®, and the

ATP (see more description in this chapter). We

chose to address the sensory defensiveness and

SSB issues fi rst, believing that lessening these

problems would enable other therapy to have a

more profound effect on Elisha ’ s postural and

practic development.

 We implemented SSB activities to address

core tone; breathing patterns and breath support

for all activities; sucking, mouth, and eating

issues; and diaphragm, rib, and shoulder girdle

fi xation. We also included activities more traditionally associated with sensory integrative

intervention and other programs as noted. We

describe our SSB strategies and SI activities

by day.

Day One

• SSB activities to release the connective

tissue around the jaw, neck, shoulder girdle,

spine, diaphragm, and pelvic girdle; for

example, bite and tug to elongate the neck

and align the jaw, suck a sour or cold, thick

smoothie to generate more organized tongue

movement and upper trunk co-contraction,

or blow darts to increase the depth and rate

options for breath.

Day Two

• Continued connective tissue releases occur.

• SSB activities with emphasis on bite or tug,

resistive suck, and soft chew; for example,

bite or tug on chewy tubes, exercise

tubing, or a “chewy necklace,” and sucking

thickened, intense-tasting liquids through a

straw (thickened with applesauce, banana,

or yogurt). All activities were chosen with

the intensity of taste she preferred; for

example, lemon, cranberry, and grapefruit

gums or juices.

• The last portion of Day Two, following

SSB activities, Elisha chose climbing

the ramp to jump into the cloud swing

(six layers of 5’ x 9’ sheets of four-way

stretch Lycra). In the Lycra, she wanted to

be intensely swung and bounced. As she

repeated this activity many times, she began

laughing and talking about the experience.

 Following the Day Two intervention, Elisha ’ s

parents reported that she chatted all the way

home and asked many questions about what

she was seeing out the window. These were

new behaviors as Elisha never talked in the car,

and neither Mom nor Grandma could remember Elisha ever asking a question. They also

reported a noticeable improvement in her articulation and organization of language.

Day Three

• We introduced the ATP (see Section 5 of

this chapter).

• Sensory diet continued and expanded to

include:

• Suck, blow, and bite (e.g., with, for

example, whistles, bubbles, and straws).

• During snack time, we provided foods

that had intense fl avor and various

textures and degrees of resistance.

• Mouth and cheek massages to help with the

tightness in her jaw, cheeks, and lips.

Days Four and Five

• Elisha created her own activities that

challenged posture and praxis. She

incorporated activities that involved SSB

(e.g., whistles, kazoos, and singing).

 Elisha ’ s comment following the Day Four

intervention said it all. With a full, natural

smile, she said, “The fog has lifted!” Her dad

remarked that he had never seen her really play

with such joy.

 With phone consultation weekly and then

monthly, Elisha ’ s family implemented a daily

home program involving SSB oral and breath

activities and cheek massages, as well as Therapeutic Listening® and the Astronaut Training

Program. We also coached her school speech

and language pathologist (SLP). Elisha engaged

in two 2-day “tune ups” at 3 and 6 months,

which completed her occupational therapy.

Summary and Conclusions

 The eight programs described in this chapter

represent a sample of the breadth of tools used

by occupational therapy practitioners to supplement intervention based on the principles of SI

theory. All are complementary to SI theory; some

are more closely allied with it than others. This

chapter does not represent an endorsement of any

of these programs. Our intent is to alert readers

CHAPTER 18 Complementary Programs for Intervention ■ 473

to some of the available programs, provide

information for learning more about them, and

instill in readers an interest in pursuing empirical

research in these areas.

Where Can I Find More?

 Dimitrijevi ć , L., Aleksandrovi ć , M., Madi ć ,

D., Oki č i ć , T., Radovanovi ć , D., & Daly, D.

(2012). The effect of aquatic intervention on

the gross motor function and aquatic skills

in children with cerebral palsy. Journal of

Human Kinetics, 32, 167–174. doi:10.2478/

v10078-012-0033-5

 Gjesing, G. (1997, autumn). Water activities:

Purposeful therapy for children with special

educational needs. Newsletter of the National

Association of Paediatric Occupational Therapists. London, UK: Oxford Information.

 Gjesing, G. (1998, spring). Water activities as an

OT intervention for children (and adults) with

physical and/or mental disabilities. Newsletter

of the Aquatic Therapy Network for Occupational Therapists. Available from A.T.N., 2424

Hirst Terrace, Haverton, PA 19083-1417.

 Gjesing, G. (2013). Refl ections on promoting activity, participation, playfulness and

sensory integration through water-based

intervention—a contribution to water-based

intervention from an occupational therapist

perspective (2nd ed.). Unpublished paper, see

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479

CHAPTER

19

Application of Sensory

Integration with

Specifi c Populations

 Teal W. Benevides , PhD, OTR/L ■ Rosemary Bigsby , ScD, OTR/L, FAOTA ■ Tina Champagne , OTD, OTR/L ■

Rachel Dumont , OTR/L, MS ■ JoAnn Kennedy , OTD, MS, OTR/L ■ Shelley Mulligan , PhD, OTR/L, FAOTA ■

Beth Pfeiffer , PhD, OTR/L, BCP ■ Roseann C. Schaaf , PhD, OTR/L, FAOTA

 Chapter 19

 By autistic standards, the “normal” brain is easily distractible, is obsessively social,

and suffers from a defi cit of attention to detail and routine. Thus people

on the spectrum experience the neurotypical world as relentlessly

unpredictable and chaotic, perpetually turned up too loud, and

full of people who have little respect for personal space.

― Steve Silberman, NeuroTribes: The Legacy of Autism

and the Future of Neurodiversity (p. 471)

Upon completion of this chapter, the reader will be able to:

✔ Describe sensory-based concerns for infants

who have been in neonatal intensive care units.

✔ Describe common patterns of sensory

integrative dysfunction in individuals with

attention defi cit-hyperactivity disorder (ADHD)

and autism spectrum disorder (ASD).

✔ Apply principles of sensory integration (SI) for

evaluating and intervening with children with

ADHD and ASD, and discuss research supporting

SI approaches with these populations.

✔ Apply principles of SI for evaluating and

intervening with children with disorders of

trauma and attachment, and discuss research

supporting sensory-based approaches with this

population.

✔ Apply principles of SI for evaluating and

intervening with adults with and without

mental health disorders, and discuss research

supporting SI approaches in the context of

occupational therapy with adults.

✔ Describe common patterns of SI dysfunction

occurring in adults with disorders of mental

health, and in adults with no other identifi able

diagnosis.

LEARNING OUTCOMES

Introduction

 Sensory integration (SI) theory, evaluation, and

intervention principles can be applied to children

and adults with a wide variety of diagnostic conditions. Application across a wide variety of populations makes perfect sense because SI defi cits

often coexist with, or are characteristic of, many

different conditions, and they can occur throughout the life span. For example, atypicalities in

sensory processing are cited as diagnostic criteria

for autism spectrum disorder (ASD; American

Psychiatric Association [APA], 2013a ). An abundance of literature has been published during

the past 10 years describing the types of sensory

processing and integration defi cits typically seen

480 ■ PART V Complementing and Extending Theory and Application

in individuals who fall within various diagnostic

groups. For example, Wells, Chasnoff, Schmidt,

Telford, and Schwartz ( 2012 ) described the types

of SI challenges commonly seen in children with

fetal alcohol syndrome; Mouchet-Mages, Canceil,

Willard, and Krebs ( 2007 ) described sensory

differences seen in patients with schizophrenia;

and Parush, Sohmer, Steinberg, and Kaitz ( 2007 )

described sensory modulation concerns of boys

with attention defi cit-hyperactivity disorder

(ADHD). Here we describe the application of SI

constructs across commonly served diagnostic

groups.

 This chapter is divided into six sections by

population or condition. The rationale for using

SI, and information describing how SI as a frame

of reference can be applied for guiding evaluation and intervention, is included for the following populations:

• Section 1 : Sensory Integration Applications

with Infants in Neonatal Intensive Care and

Early Intervention (by Rosemarie Bigsby)

• Section 2 : Sensory Integration Approaches

with Individuals with Attention Defi citHyperactivity Disorder (by Shelley Mulligan)

• Section 3 : Applying Sensory Integration

Principles for Children with Autism

Spectrum Disorder (by Teal W. Benevides,

Rachel Dumont, & Roseann C. Schaaf)

• Section 4 : Sensory Integration and Children

with Disorders of Trauma and Attachment

(by JoAnn Kennedy)

• Section 5 : Sensory Integration Applications

with Adults (by Beth Pfeiffer)

• Section 6 : Sensory Integration Approaches

with Adults with Mental Health Disorders

(by Tina Champagne & Beth Pfeiffer)

 Research explaining the relationship between

sensory processing patterns and each condition

is highlighted, along with research describing the potential benefi ts of using SI strategies

with each population. Ideas for evaluation and

intervention using an SI approach are shared,

and case studies are presented to illustrate how

SI has been practically applied in the context

of occupational therapy services. This chapter

was written by multiple authors to take advantage of the expertise of those with experience working within each of the populations

addressed.

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 481

Section 1 : Sensory Integration

Applications with Infants in Neonatal

Intensive Care and Early Intervention

 Rosemarie Bigsby, ScD, OTR/L, FAOTA

Background and Rationale

for Applying Sensory Integration

 Human behavior is inextricably tied to the

senses. At every age and stage of development,

our thoughts, emotions, and actions are shaped

by our experiences. Sensation is registered and

processed, amplifi ed, attenuated, or ignored,

constructing our experience of the world. Recognizing the impact of sensory experiences on

the developing brain, clinicians aim to enhance

infant development by intervening when infants

present with atypical responses to sensory experiences. Furthermore, it is imperative that interventions are respectful of the family ’ s primary

role in the lives of their children, and decisions

regarding intervention practices are made in consideration of the best available evidence of the

potential effects of specifi c interventions ( Dunst,

Bruder, & Espe-Shervindt, 2014 ).

 Infants and young children sometimes present

with atypical responses to sensory experiences

within the context of daily routines, limiting

active participation in many of the necessary

developmental tasks and skills of infancy. These

include exhibiting optimal levels of arousal and

affect for given contexts, developing positive

interactions with their caregivers, and progressing within and across all areas of development

( Cohn & Tronick, 1987 ). For decades, therapists

have adapted the vocabulary, defi nitions, and

interventions characteristic of SI treatment for

applications in their work with infants and toddlers and their families ( Williamson & Anzalone,

 2001 ). Yet the question of whether it is appropriate to apply an approach that was conceived

for school-aged children ( Ayres, 1972 ) to a much

younger population has not been adequately

addressed. The existing research on the effi cacy

of SI theory and treatment has predominantly

focused on school-aged children, and the evidence that is available has been criticized for

methodological limitations such as small sample

sizes, lack of controls and of blinded assessment, and absence of fi delity to the components

of intervention that are considered essential to

SI treatment ( Parham et al., 2011 ). A review of

research examining the effectiveness of SI intervention appears in Chapter 15 (Advances in

Sensory Integration Research: Clinically Based

Research). Some recommendations that can be

made based on previous research that are useful

for guiding further research with children of all

ages including infants are as follows: (1) examining the effectiveness of child (infant)-directed

activity (i.e., modifying treatment according

to individual preferences and responses of the

child); (2) comparing the effects of sensory-based

interventions experienced in the home setting

with parents guiding the intervention versus

therapist-directed sessions in community-based

or clinic settings; and (3) examination of the relations among physiological measures (autonomic

stability [e.g., vagal tone, galvanic skin response]

and regulation of arousal, attention, and behavior

in infancy including preterm infants).

Sensory Integration in Early

Infancy and Associated

Occupation-Based Challenges

 This section provides an overview of how sensory

experiences may impact the developing fetus

through infancy. The human fetus encounters

482 ■ PART V Complementing and Extending Theory and Application

multiple, simultaneous sensory inputs throughout gestation, and the intrauterine environment

has a buffering effect, limiting the intensity of

exposure to these multisensory experiences

( Lickliter, 2011 ). In contrast, preterm infants

born as early as 23 weeks post-conception, and

who are cared for in medical care environments

such as neonatal intensive care units (NICU),

experience sensory stimuli often in ways that

bear little resemblance to what would be experienced in the natural, intrauterine environment.

For example, the timing, intensity, types, and

duration of exposure may differ signifi cantly

and have little relationship to the infants’ level

of maturation, sensory needs, or individual tolerances. Depending on the timing of exposure,

sensory experiences in the NICU have the potential to undermine development of the infants’

ability to regulate states of arousal, to attend to

and process sensory information, and, ultimately,

to develop age-appropriate social-emotional

responses ( Weisman, Magori-Cohen, Louzoun,

Eidelman, & Feldman, 2011 ).

 Although the senses function in concert from

early infancy, individual sensory systems become

functional in the fetus in the following invariant

order: tactile, vestibular, auditory, and fi nally

visual. Because of this sequence, the sensory

modalities have “markedly different developmental histories at the time of birth” ( Lickliter,

 2011 , p. 594). Depending on the timing of introduction of stimuli from one sensory system,

sensory responsiveness in another sensory

modality may be inhibited or enhanced. In the

case of preterm infants, the intensity and type of

sensory stimuli within the NICU environment, as

well as the timing of and context for stimulation,

are dramatically different from the experience of

infants born at term, and these experiences could

have implications for later sensory functioning.

For example, Rahkonen and colleagues ( 2015 )

conducted a prospective study of 44 infants born

at fewer than 28 weeks gestation, and assessed at

2 years corrected age, using the Infant/Toddler SP

( Dunn, 2002 ) as well as cognitive scales. They

demonstrated that half the sample had at least

one atypical area of sensory processing, with

low registration being the most common atypical sensory processing pattern. Chorna and colleagues ( 2014 ) prospectively studied 72 infants

born weighing at least 1,500 grams using the

Test of Sensory Function in Infants ( DeGangi &

Greenspan, 1989 ); the researchers demonstrated

that at 4 to 12 months corrected age, 82% of the

infants had at least one atypical score. The lower

the gestational age at birth, the greater the association with atypical responses to deep pressure

and vestibular activity. Although these studies

have small sample sizes, their effect sizes are

suffi ciently large to suggest the need for further

exploration of these relationships and for consideration of approaches to early infant intervention

that could reduce the risk of sensory issues in the

low birthweight preterm population.

 The infant ’ s ability to transition from one

state of arousal to another is one of the most

reliable expressions of an infant ’ s tolerance for

a particular sensory experience. Holditch-Davis

and Thoman ( 1987 ) and Weisman and colleagues

 ( 2011 ) proposed that transitions between different sleep states among preterm infants may be

predictive of cognitive, neurobehavioral, and

emotional developmental outcomes. There is evidence that slow wave (deep sleep) in particular

is characterized by an increased balance between

excitatory and inhibitory signaling and of protein

synthesis, suggesting that deep sleep may have

a singular role in brain plasticity ( Aton, 2013 ).

Infants may show that an experience is tolerated by sustaining a particular state of arousal,

whether a particular sleep state or a particular

level and quality of alertness. Infants also may

demonstrate tolerance by transitioning gradually to a new state of arousal, such as awakening slowly from a sleep state. However, sensory

stimuli that are perceived as stressful may contribute to increasing arousal toward an irritable

state or may produce inhibition—a pulling down

toward a drowsier state to effectively “tune

out” continued interaction. These behavioral

responses may represent an adaptive, protective

response on the part of the infant, whose behavioral expression of his or her unique threshold

for stimulation may not be easily recognized by

the caregiver. A recent meta-analysis of studies

incorporating sensory modulation abilities of

preterm infants demonstrated relationships

between these sensory modulation challenges

and length of stay in the NICU, degree of white

matter injury, and later cognitive and behavioral

outcomes ( Bröring, Oostrom, Lafeber, Jansma, &

Oosterlaan, 2017 ).

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 483

Evaluation and Intervention

in the NICU

 Both the physical environment for NICUs and

care practices have been studied for their impact

on developmental outcomes, and there is little

doubt that sensory factors involved within each

contribute to the quality of life experienced by

NICU survivors. Two overarching principles of

NICU care that have achieved broad acceptance

are: (1) providing care that is modifi ed to the

individual sensory thresholds of the infant, offering not only protection from unnecessary stress

but also enhancement of the infant ’ s unique

capacities for physiological and behavioral organization, and (2) integrating the infant ’ s family

into all aspects of care, thus supporting the role

of the family as the constant in the infant ’ s life.

These principles are grounded in transactional

developmental theory ( Sameroff & Chandler,

 1975 ), a systems theory that acknowledges the

impact of three main components: the infant, the

caregiver, and the environment. This systems

theory emphasizes how each of the three components interacts and affects one another, as well

as how the transactions among these components

contribute to developmental outcome. Transactional developmental theory fi ts into the broader

framework of dynamic systems theory in which

characteristics of the individual, in concert with

affordances within the environment and timing

of sensory experiences and activities, have the

potential to move the individual forward in

development ( Smith & Thelen, 2003 ). Synactive theory ( Als, 1982 ) is a dynamic systems

theory that is specifi c to NICU care. In synactive theory, the self-regulatory capacities of the

infant represent the maturation of and interplay

between the infant ’ s autonomic, state, motor, and

attentional or interactive subsystems. Inherent in

the application of synactive theory to developmental support in the NICU is the importance

of: (1) assessing the infant ’ s individual capacity

for self-regulation within the context of NICU

care, and (2) working with caregivers to modify

aspects of care on an ongoing basis in order to

achieve a better fi t between the infant ’ s tolerances or needs and the care that is provided.

 These child-directed approaches involve

modifying care practices and the environment

according to an infant ’ s individual thresholds

for managing sensory input and capacity for

self-regulation. This same principle is essential

to SI treatment when it is practiced optimally—

providing the “just right” challenge and constantly assessing child responses in order to adapt

the sensory experiences and demands for achieving an adaptive response from the child. Also,

these systems approaches underscore the importance of parent and caregiver participation, which

has been shown to be very effective in the context

of sensory-based interventions ( Case-Smith,

Weaver, & Fristad, 2014 ; Dunst et al., 2014 ).

These principles of NICU care, with a particular focus on providing guidance for enhancing

parent sensitivity to infant behavior, parent participation in care, and collaboration with NICU

therapists, have been shown to produce positive

outcomes in infant brain structure and function,

pain reduction and reduced medical morbidity,

and weight gain ( Als et al., 2004 ; Lester et al.,

 2014 ). Yet, wide variations in care practices

and standards of care continue to exist among

different NICUs across the country and internationally. Subsequently, there are potentially large

numbers of infants vulnerable to atypical or suboptimal sensory experiences who may be at risk

for developing sensory-related dysfunction as a

consequence of NICU care.

Neuroprotective care is another recommended standard care practice for NICU providers. This approach emphasizes stress and pain

reduction, position and handling techniques,

partnering with families, and the regulation of

sleep and states of arousal in order to promote

a more stable, well-regulated infant ( Altimier,

Kenner, & Damus, 2015 ). Neuroprotective care

can be practiced within the dynamic systems

approaches discussed previously. From birth,

the NICU patient is assessed in terms of arousal

and spontaneous activity and exposure to stress.

Necessary yet stressful interventions may be

modifi ed by providing positive touch and soothing containment, such as skin-to-skin holding,

hand swaddling or facilitated tucking, sucking

on a pacifi er sweetened with mother ’ s expressed

breast milk or sucrose, or by implementing a

combination of these interventions ( Liaw et al.,

 2013 ). These sensory techniques may enhance

infant tolerance for painful procedures, and they

may be helpful for preserving sleep. Unnecessary

stressors can be largely reduced by modifying

484 ■ PART V Complementing and Extending Theory and Application

the NICU environment, such as providing single

family room care whenever possible, targeting

sources of excessive noise, and using adjustable,

cycled lighting to help establish diurnal rhythms.

 Sensory-based, environmental interventions are incorporated into care in many NICU

settings. However, to achieve widespread

improvements in developmental outcomes and

to optimize long-term effects, particularly with

extremely low birthweight (ELBW; fewer than

1,000 grams) infants, NICU practitioners also

need to consider the conditions under which these

interventions are being implemented, including

consideration of the timing of intervention and

parental participation. The importance of utilizing appropriate sensory-based input, provided

by parents with considerations given to timing,

was emphasized in a recent follow-up study by

 Feldman and colleagues ( 2014 ) (see Here ’ s the

Evidence box). On the strength of these fi ndings,

as well as other long-term follow-up studies and

meta-analyses ( Boundy et al., 2016 ; Charpak

et al., 2017 ; Conde-Agudelo & Diaz-Rossello,

 2016 ), skin-to-skin care (kangaroo mother care)

is now recommended for universal use for low

birthweight infants. The data supporting infant

massage in the NICU is not as strong. A recent

meta-analysis points to many potential benefi ts

of this sensory-based intervention for preterm

infants, but also concedes that more study is

needed before it can be recommended without

reservation ( Niemi, 2017 ).

 It is important to acknowledge that the

responses of NICU patients to their care are particularly nuanced and individualized. Preterm

infants are not only immature but may differ

PRACTICE WISDOM: BUILDING A FOUNDATION FOR POSITIVE

SENSORY EXPERIENCES THROUGHOUT INFANCY

Educate families about evidence-based approaches

to supporting early sensory experience and demonstrate sensitivity to infant behavioral communication.

• Attention to infant behavior and arousal

 • Babies communicate availability for

interaction or stress through their posture,

movement, facial expressions, and level of

arousal

 • There is an expected range of infant

crying, sleep, and arousal patterns ( https://

www.cdph.ca.gov/Programs/CFH/DWICSN/

CDPH%20Document%20Library/Families/

FeedingMyBaby/970027-Getting-To-Know

.pdf )

• Supports to enhance early caregiving

interactions

 • “Asking permission”—approaching the baby

with adult presence fi rst, then introducing

soft voice and resting hands

 • Postural containment (swaddling, holding

close) to soothe and organize

 • Skin-to-skin holding (kangaroo mother care)

throughout early infancy

 • Nuzzling at the breast as preparation for

breastfeeding ( http://www.breastcrawl.org/

video.shtml )

 • Slow position changes to minimize startles

 • Swaddled bathing

 • Use of a wrap or baby carrier to keep baby

close (in vertical position on chest for safety)

• Modulated sensory experiences—following the

baby ’ s lead

 • Softtalking and “Parentese” to capture the

baby ’ s auditory attention

 • Slow movement in baby ’ s view to entice the

baby to visually attend

 • Watching and waiting—pausing and

observing the baby ’ s response to talk, touch,

and movement-play before continuing

 • Floor-play and contingent responses—

allowing the baby some space to explore

on his or her own, and “being there” to

respond when the baby communicates his

or her needs and wants

 • “Taking turns”—building reciprocity in vocal

and motor responses

 • Joint attention—looking where the baby

looks or points, and picking up on the

baby ’ s interest with descriptive talk and

demonstration

 • Gradual introduction of new sensory

experiences—massage, swing, wind and

rain, new sounds, and talking through the

experience

 • Respecting the baby ’ s need to pull

back from something that may seem

overwhelming

 • Demonstrating delight when the baby has a

positive response to something new

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 485

dramatically in their ability to register sensations

and to process them. By virtue of their immature

neurological pathways, thresholds for tolerating

sensory experiences vary signifi cantly among

low birth weight preterm infants. Although they

are often exquisitely sensitive to sensory stimuli,

they also are not mature enough to produce an

organized response that is easily recognized by

caregivers. This may leave infants susceptible

to painful, uncomfortable, or excessive sensory

input, which has the potential to negatively affect

brain development ( Vinall & Grunau, 2014 ). On

the other hand, protective factors in the life of

the infant have the potential to mediate those

negative infl uences. Parent involvement in NICU

care, caregiver sensitivity to the infant ’ s behavioral and physiological responses to care, and

sensory experiences that are appropriately timed

and modulated to the infants’ tolerances have

been demonstrated to mediate those negative

infl uences, and to result in improved behavioral,

developmental, and even neurological outcomes

( Lester et al., 2016 ; Milgrom et al., 2010 ; Wolke,

Jaekel, Hall, & Baumann, 2013 ).

Evaluation and Intervention

in Early Intervention Programs

 It is well established that early and intensive

intervention for young children (before 3 years

of age, and the earlier the better) with neurodevelopmental problems, such as sensory processing disorders and autism, results in signifi cant

improvements in adaptive functioning and promotes development across multiple domains

( Bailey et al., 2005 ; Dawson & Bernier, 2013 ).

Therefore, the identifi cation of sensory processing challenges and initiation of therapeutic

services as early as possible is very important.

The emphasis on early diagnosis and intervention

for infants and toddlers with neurodevelopmental problems that may result from prematurity,

or because of conditions such as autism, has

resulted in more young children being served by

Part C of the Individuals with Disabilities Education Act (IDEA; U.S. Department of Education,

Offi ce of Special Education and Rehabilitative

Services, Offi ce of Special Education Programs,

 2014 ). This program provides federal funding

and mandates interdisciplinary, family-centered

early supports and services for children under

3 years of age who qualify for services, based on

a developmental disability or risk for developmental problems.

 In order to develop the most appropriate Individual Family Service Plan (IFSP) for

infants receiving early intervention services,

initial and ongoing assessment must include

a semi-structured or structured parent interview and observation of infant behavior and

HERE ’ S THE EVIDENCE

Feldman and colleagues ( 2014 ) conducted a

10-year follow-up of a randomized controlled

study of very low birth weight (fewer than

1,500 grams) preterm infants, matched on

gestational age at birth, birth weight, illness

severity, sex, socio-economic status, and demographics, with 73 infants in each group. The

intervention group received skin-to-skin holding

during a 2-week period while in the NICU.

During the 10-year period, improved respiratory

sinus arrhythmia (vagal tone), infant-caregiver

interaction, and performance scores related to

language, cognitive, motor, and externalizing

behaviors have persisted among the children in

the intervention group. Feldman and colleagues

 ( 2014 ) attribute these lasting effects not only

to the specifi c benefi ts of skin-to-skin holding

as an early intervention but also to the conditions under which it was administered and the

positive effect on infant-caregiver relationships.

The authors concluded that when parents learn

to be sensitive to their infant ’ s behavioral and

physiological cues very early on, this relationship provides a foundation for communicative

synchrony going forward. These researchers presented a systems model that is consistent with

dynamic systems theories, including synactive

theory, and, it could be argued, aspects of SI

intervention. Important concepts of their model

included: (1) specifi city—targeting of specifi c

processes shown to be linked with the expected

improvements; (2) sensitive periods—even small

inputs or minor changes have the potential to

have a major effect when delivered during critical periods; and (3) incorporation of individually

stable components—introducing an intervention

at a time when it is possible to build on the

natural stability of other functions.

Feldman, R., Rosenthal, Z., & Eidelman, A. (2014).

Maternal-preterm skin-to-skin contact enhances child physiologic

organization and cognitive control across the fi rst 10 years of

life. Biological Psychiatry, 75, 1, 56–64.

486 ■ PART V Complementing and Extending Theory and Application

developmental competencies within the infant ’ s

natural setting. When these observations take

place during familiar daily routines such as

playful interaction between parent and infant,

feeding, dressing, and bathing, they provide a

rich source of information for the early intervention therapist. These activities help the therapist

and parents to collaborate in identifying infant

thresholds for various sensory experiences, individual strengths, and potential concerns that may

require further evaluation. The Bayley Scales

of Infant and Toddler Development-III ( Bayley,

 2005 ) and the Mullen Scales of Early Learning

( Mullen, 1995 ) are assessment tools for measuring overall development (motor, perceptual,

communication, social-emotional, cognition,

and behavior, in terms of both “expressive” and

“receptive” abilities), which also provide some

useful information about sensory processing

abilities of young children. Administration of

the Infant-Toddler Sensory Profi le 2 (SP2; Dunn,

 2014 ) or the Test of Sensory Function in Infants

( DeGangi & Greenspan, 1989 ) provide more

specifi c information regarding sensitivities and

tolerance for various activities, interactions,

and environmental stimuli specifi c to individual

sensory systems (e.g., vestibular, tactile, auditory, visual, taste, and smell).

 Dunn ( 2002, 2014 ) developed a theoretical model for describing the sensory processing patterns of young children to assist in

identifying sensory processing diffi culties. The

patterns are conceptualized as resulting from

interaction between neurological threshold and

self-regulatory behaviors. Dunn described four

patterns (see Chapter 6, Sensory Modulation

Functions and Disorders), recognizing that children may exhibit a mixed sensory profi le (i.e.,

exhibiting behaviors in more than one category).

The fi rst pattern, registration, is refl ected by a

combination of high neurological threshold and

passive behavioral response. Dunn terms these

children “bystanders,” indicating that they tend

to respond too slowly to sensory stimuli and

miss more sensory information than do other

children. They may appear uninterested; have

low energy levels or low muscle tone; show

decreased awareness of people, objects, or

common dangers; or have a high tolerance to

pain. “Seeking” is another pattern that refl ects

high neurological threshold, this time coupled

with active self-regulation strategies. Children

characterized as seekers look excessively for

activities that provide them with specifi c types

of sensory input (e.g., tactile, movement, visual,

etc.). These children may be described by caregivers as overly active, impulsive, excitable, and

sometimes disruptive. The third pattern, “sensitivity,” characterizes children with low neurological

thresholds and passive self-regulation strategies.

These children are often “on alert,” making them

appear distractible and hyperactive. They may

be described as being easily upset when they

are overstimulated, may have a low tolerance

to pain, may not want to be cuddled, and may

be picky eaters. Finally, the “avoiding” pattern

is characterized by low neurological thresholds

coupled with active self-regulatory strategies.

Children with this pattern are very sensitive to

sensation and prefer order and sameness as a

way to avoid unexpected sensations. Children

who are “avoiders” tend to withdraw from situations they perceive as threatening. Infants and

toddlers exhibiting any of the previously noted

patterns may benefi t from an individualized therapeutic approach to optimize their comfort and

participation in age-appropriate developmental

activities. Thus, family-centered, early supports

and services administered through IDEA, Part C

are typically provided in the home or within

other natural contexts such as day-care settings.

 Therapists collaborate with parents and caregivers to identify sensory-related challenges

within these contexts and to develop strategies

for modifying the daily environment and activities to optimize comfort and active participation

for the infant or toddler. Everyday activities of

infants and toddlers provide important sensory

experiences that expand the child ’ s understanding of the world. SI theory can be applied with

infants and toddlers to help caregivers incorporate the appropriate types of activities into their

daily routines and to modify such aspects as the

timing and intensity of the activity to enhance

development of sensory integrative functioning.

Activities such as feeding; dressing and diaper

changing; splashing in the water while bathing;

exploring textured surfaces such as carpeting,

grass, and sand; and swinging and climbing at

the park can be modifi ed, according to the infant

or toddler ’ s tolerance, to ensure they are pleasurable for both the child and the caregiver. Play

experiences that provide an element of challenge

to the child, while remaining pleasurable, lay the

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 487

foundation for competence and confi dence, as

well as providing motivation for further exploration. Perhaps most importantly, activities that are

perceived as pleasurable by both members of the

interactive dyad support healthy social and emotional relationships between infants or toddlers

and their caregivers. Through early intervention services that incorporate education, modeling, collaboration, and, most importantly, active

problem-solving, parents and caregivers become

more astute observers of their child ’ s responses

to various experiences and improve their ability

to make their own modifi cations in sensory

aspects of day-to-day activities ( Dunst et al.,

 2014 ). These parent and caregiver competencies

ensure an optimal environment for infants who

might otherwise be at risk to explore and learn

from the world around them.

CASE STUDY ■ LILY

 From her fi rst days in the NICU, Lily, born

at 26 weeks gestation, was described as

“underaroused.” As she matured, NICU staff

frequently voiced concerns that she was

“under-responsive.” Her parents rejected that

interpretation. They participated in neurobehavioral assessments with the occupational

therapist and collaborated in developing the

neuroprotective care plan posted at her bedside:

offering containment, nested positioning

( Fig. 19-1 ), and slow changes in position;

FIGURE 19-1 Lily responded well to resting hands

at head and feet, for soothing, during care. She

is under phototherapy, with eye protection, which

makes her even more sensitive to caregiver touch.

Photo courtesy of Christina DiChiera.

holding her skin-to-skin for hours each day

( Fig. 19-2 ); softly talking, reading, and singing

to her; and allowing her to nuzzle at the breast,

and offering breast or bottle only for as long as

she was able to participate actively in feeding,

requesting the remainder be fed by gavage. At

31 weeks corrected age, her father began gentle

daily massage, modifi ed according to her tolerances. She “slept through” many of her care

times, sustaining quiet alertness only briefl y

before pulling down to a drowsy state, and

some nurses were concerned that her “low-key”

routine was keeping her too “sedate.” However,

both her parents and a strong primary nurse

advocated for staying with the plan. They gradually introduced more challenging care routines, such as bathing ( Figs. 19-3 and 19-4 ).

By 38 weeks corrected age, she was able to

sustain arousal for feeding and became more

easily engaged in interaction, and at 39 weeks,

still with short periods of visual alertness

( Fig. 19-5 ), but with good weight gain, she

was discharged home. Lily ’ s mother stayed

in contact with the NICU through a blog and

by e-mail, and it soon became clear that Lily

was blossoming at home. She began to have

longer periods of alertness, became increasingly active and responsive, and her parents

followed her lead, offering more opportunities

for sensory exploration, according to her cues.

By the end of her fi rst year, she was on target

developmentally, “babbling up a storm” and

demonstrating “creativity” in her explorations

(e.g., using whatever happened to be available

FIGURE 19-2 Lily and Mom began skin-to-skin

holding as soon as Lily had stable ventilator settings.

Photo courtesy of Christina DiChiera.

488 ■ PART V Complementing and Extending Theory and Application

as steps to climb up and peek out the window).

At age 6, Lily has emerged as a superstar—a

bright, socially interactive, curious kindergartner, with neonatal follow-up records that show

above-average cognitive, language, motor, and

social-emotional scores.

 Lily exemplifi es the infant who might be

described as “inhibited” or “avoiding” but

who is actually signaling her high reactivity

and her need for caregivers to accommodate

FIGURE 19-3 Lily ’ s parents were active participants

in her care and were delighted when she was able

to tolerate a tub bath. Photo courtesy of Christina

DiChiera.

FIGURE 19-4 Lily enjoys a warm cuddle with Mom

while drying off after her bath. Photo courtesy of

Christina DiChiera.

her by modulating levels of stimulation. Her

caregivers chose activities that were appropriate to her gestational age and stage of sensory

development—focusing, during her earlier

weeks in the NICU, on the tactile, vestibular,

and auditory systems, which are better prepared

to process input than the visual system. They

were responsive to her behavioral communication and provided increasing challenges as

she demonstrated readiness, motivation, and

self-directed exploration. Most importantly, her

care was predominantly provided by her parents,

leading to continuity after discharge, timed

to her readiness, and emphasized interactions

that integrated the sensory experiences within

an age-appropriate caregiving context rather

than focusing on specifi c sensory interventions.

This approach is similar to that recommended

by Case-Smith and colleagues ( 2014 )—

focusing on sensory integrative experiences

rather than on individual sensory-based interventions. Haith ( 1991 ) challenged his colleagues

in psychology to move in this direction in their

research on perceptual processes in infancy—

away from a focus on individual inputs to a

more integrated, dynamic systems approach

that is client-centered and that involves contextual and environmental elements, caregiver

involvement, and consideration of the infant ’ s

readiness and needs.

FIGURE 19-5 At 38 weeks, Lily was still easily

stressed by handling, but she tolerated vertical

rocking to increase her alertness for the photo.

Photo courtesy of Christina DiChiera.

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 489

HERE ’ S THE POINT

• SI and other sensory-based interventions have

important contributions to make in the care

of infants in NICU settings, as well as in early

intervention services.

• Interventions aim to accommodate the

individual sensory thresholds of infants

with sensory processing challenges to avoid

unnecessary stress and enhance the infant ’ s

unique capacities for physiological and

behavioral organization.

• Providing family-centered services within

the infant ’ s natural environment is essential

when working with infants and toddlers

to ensure that sensory aspects of the

environment are integrated into developmental

services, and to ensure that the role of the

family as the constant in the infant ’ s life is

optimized.

Where Can I Find More?

 Bröring, T., Oostrom, K. J., Lafeber, H. N.,

Jansma, E. P., & Oosterlaan, J. (2017).

Sensory modulation in preterm children: Theoretical perspective and systematic review.

PLOS ONE, 12 (2). doi:10.1371/journal.pone

.0170828

 Charpak, N., Tessier, R., Ruiz, J. G., Hernandez,

J. T., Uriza, F., Villegas, J., . . . Maldonado,

D. (2017). Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics, 139, 1, 1–10.

 Conde-Agudelo, A., Diaz-Rossello, J. L. (2016).

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.

Cochrane Database Systematic Reviews,

Aug 23 (8), CD002771. doi:10.1002/1465858.

CD002771.pub4

 Niemi, A. (2017). Review of randomized

controlled trials of massage in preterm

infants. Children, 4 (4), 21. doi:10.3390/

children4040021

Section 2 : Sensory

Integration Approaches

with Individuals with Attention

Defi cit-Hyperactivity Disorder

 Shelley Mulligan, PhD, OTR/L, FAOTA

Background and Rationale

for Applying Sensory Integration

 ADHD is the most common neurobiological disorder that manifests in childhood, and it often

continues into adolescence and adulthood ( Wolraich et al., 2012 ). ADHD is placed within the

section describing neurodevelopmental disorders

in the Diagnostic and Statistical Manual for

Mental Disorders, Fifth Edition ( DSM-5; APA,

 2013b ), and it is characterized by persistent and

maladaptive symptoms of inattention, hyperactivity, and impulsivity. The average age of onset

is 7 years, and boys are four times more likely

than girls to have the disorder. The prevalence

of ADHD has steadily increased during the

past 20 years, and it is now reported as affecting approximately 11% of children across the

United States ( APA, 2013b ) and from 4% to

6% of adults. According to the DSM-5, ADHD

490 ■ PART V Complementing and Extending Theory and Application

includes three clinical presentations: combined,

predominantly inattentive, and predominantly

hyperactive-impulsive. Behaviors characterizing inattention and hyperactivity-impulsivity

are listed in Table 19-1 . The label of ADHDcombined is given to adults and children who

exhibit symptoms from both the attention and

hyperactive-impulsive categories. An ADHD

diagnosis is made when several symptoms are

present before 12 years of age, and inattentive

or hyperactive-impulsive symptoms must be

observed in two or more settings (e.g., home and

school). There also must be clear evidence that

symptoms interfere with, or reduce the quality

of, the individual ’ s social functioning, academic

performance, or ability to perform the desired

and necessary occupations (APA, 2013b).

 It is important to keep in mind that normal

child behavior often includes having a high

activity level, being easily distracted, and acting

impulsively. All children mature at different

rates, and their personalities, sensory processing

abilities and preferences, and energy levels are

variable, which makes it challenging to discern

true ADHD from normal behavior ( Holmberg,

Sundelin, & Hjern, 2013 ). Also complicating

matters is that ADHD is often comorbid with

motor, sensory, learning, mood, anxiety, and disruptive behavior disorders in children and adults.

Sensory Integration

and Associated

Occupation-Based Challenges

 Kaplan and colleagues ( 2006 ) reported that as

many as 80% of children with ADHD are at

risk of having at least one other disorder, such

as a reading disability, developmental coordination disorder (DCD), oppositional behavior

disorder, or anxiety. Motor disorders have been

reported in as many as 40% to 60% of individuals representing all three subtypes of ADHD,

with slightly more representation in the combined clinical presentation ( Egeland, Ueland, &

Johansen, 2012 ; Piek & Dyck, 2004 ). Disorders

of attention and learning have also been associated with sensory processing disorders or SI

dysfunction ( Dunn & Bennett, 2002 ; S. J. Lane,

Reynolds, & Thacker, 2010 ; Mangeot et al.,

 2001 ; Mulligan, 1996 ; Pfeiffer, Daly, Nicholls, &

Gullo, 2015 ). Children with ADHD have an

increased risk of sensory modulation diffi culties (sensory over-responsivity [SOR] or sensory

under-responsivity [SUR]) as well as defi cits in

visual perception ( Miller, Neilson, & Schoen,

 2012 ; Yochman, Parush, & Ornoy, 2004 ). ADHD

and SOR may also be linked with anxiety in this

population (S. J. Lane et al., 2010 ; S. Reynolds &

Lane, 2009 ). In addition, studies have shown

that ADHD is associated with adverse reactions

to tactile stimuli and motor planning problems

( Parush, Sohmer, Steinberg, & Kaitz, 2007 ).

Mulligan also demonstrated postural control and

balance defi cits, sensory-based dyspraxia, and

visual-motor integration diffi culties in this group

of children ( Mulligan, 1996 ). More recently,

 Pfeiffer, Daly, Nicholls, and Gullo ( 2015 ) found

that children with ADHD were much more likely

to exhibit challenges in all areas of sensory processing than those of neuro-typical children and

to display problems with higher level functions

believed to be dependent in part on effi cient

sensory processing, including social participation and motor planning. The close association between attention defi cits and impairments

TABLE 19-1 Behaviors Associated with ADHD Symptoms

INATTENTIVE BEHAVIORS HYPERACTIVE-IMPULSIVE BEHAVIORS

 • Forgetfulness

 • Failing to give close attention to details

 • Making careless mistakes in schoolwork, work, or other activities

• Overlooking or missing details

 • Diffi culty sustaining attention in tasks or play activities

 • Appearing to not listen when spoken to directly (e.g., mind seems to

wander)

 • Diffi culty following through on instructions and with task completion

 • Poor organizational skills

 • Fidgety

 • Trouble sitting still or staying seated

 • Feeling restless

 • Talking excessively

 • Diffi culty waiting or taking turns

Adapted from the American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington,

VA: American Psychiatric Publishing.

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 491

with sensory, motor, and perceptual functions is

further supported by the work of Gillberg ( 2003 )

and Hellgren and colleagues ( 1994 ). These

investigators refer to this as a condition called

DAMP, or defi cits in attention, motor control,

and perception. Therefore, it is not surprising that Ayres Sensory Integration ® (ASI) and

other sensory-based approaches have commonly

been used by occupational therapists with this

population.

Evaluation and Intervention

 Comprehensive evaluations of children with

ADHD using an SI approach include administration of the Sensory Integration and Praxis

Test (SIPT; Ayres, 2005 ), a measure of sensory

modulation such as the SP ( Dunn, 2014 ), clinical

observations, as well as gathering information

through interviews and naturalistic observations

when possible. Other assessments may help

to explore the cognitive and executive functions that are characteristic of the disorder; for

instance, the Brief Rating Inventory of Executive

Functions ( Giolo, Isquith, Guy, & Kenworthy,

 2000 ), Dynamic Occupational Therapy Cognitive Assessment for Children ( DOTCA-Ch;

Katz, Parush, & Traub-Bar-Ilan, 2004 ), the

Leiter-3 International Performance Scale–

3rd edition ( Roid, Miller, Pomplun, & Koch,

 2004 ), the Executive Function Performance Test

( Baum et al., 2008 ), the Stroop Color and Word

Test ( Golden & Freshwater, 2002 ), and the Test

of Every Day Attention for Children ( Manly,

Robertson, Anderson, & Nimmo-Smith, 1998 ).

 There is no question that sorting out the underlying cause of challenging behaviors associated

with inattention, which may include SUR or

SOR, is diffi cult; such challenging behaviors may

be linked with the ADHD diagnosis, an underlying sensory processing disorder, or both. One of

the best ways to deal with this dilemma is to carefully attend to the client ’ s response to specifi c

interventions and then adjust intervention to meet

the individual ’ s needs. For example, if a child

starts a trial of stimulants for managing his or her

ADHD symptoms, and then the child ’ s sensory

processing problems diminish signifi cantly, using

an SI approach may not be indicated.

HERE ’ S THE EVIDENCE

Pfeiffer and colleagues ( 2014 ) collected data on

sensory processing (Sensory Processing Measure–

Home Form; Parham & Ecker, 2007 ) and child

behavior (Conners Manual 3rd Edition–Parent

Short Form; Conners, 2008 ) on 20 children with

ADHD and 27 children with no diagnosis, from 5 to

10 years of age. Their goal was to investigate

whether children with ADHD had more sensory

processing concerns than did typical children, to

characterize those concerns as they related to core

features of ADHD, and to examine differences that

might be linked with medication use. Using multivariate analysis and controlling for differences based

on age, they determined that children with ADHD

differed from typical children in sensory processing.

Through follow-up using univariate analyses and

adjusting for multiple comparisons, these investigators determined that children with ADHD had

higher mean scores on all subscales of the SPM,

with a small to medium effect size ( Š2

 ranging from

0.27 to 0.61). On further examination, they also

determined that there was no difference within

the group with ADHD for children taking or not

taking medication. Not surprisingly, investigators

also found that children with ADHD had higher

mean scores for Hyperactivity/Impulsivity [ F (1,44) =

104.88, p < .001] and Inattention [ F (1,44) = 99.90,

p < .001] subscales on the Conners; there were no

differences between groups based on medication.

Examining the correlation between the SPM and

Conners subscales, investigators found moderate

correlations between Hyperactivity/Impulsivity and

Social ( r = 0.50, p < .05) and Planning and Ideas

( r = 0.73, p < .01) subscales of the SPM. No links

between specifi c sensory systems and subscales on

the Conners were found. These fi ndings suggest

that sensory processing concerns in children with

ADHD are substantive, impacting occupational

performance and engagement. Further research

is needed to better understand the links between

ADHD core symptoms and praxis concerns, and to

further examine sensory-system-specifi c sensory

processing.

Pfeiffer, B., Daly, B. P., Nicholls, E. G., & Gullo, D. F. (2014). Assessing sensory processing problems in children with and without

attention defi cit hyperactivity disorder. Physical & Occupational Therapy in Pediatrics, 35(July 2013), 1–12. doi:10.3109/01942638.2014.

904471

492 ■ PART V Complementing and Extending Theory and Application

 Individuals with ADHD are typically

treated with a multi-modal, multi-disciplinary

approach. For example, interventions for children often include parental and child education

about ADHD; school-based, educational interventions; specialized therapies, such as occupational therapy using an SI approach; and

medication management for those choosing

medication. In addition, many adults and older

children benefi t from psychotherapies, such

as cognitive-behavioral therapy, and interventions to address daily life activities that may

be disrupted, such as work, leisure, driving, or

social relationships. Pharmacotherapy, however,

remains the cornerstone for ADHD intervention

for all age groups, with advances in long-lasting

stimulant medications being the most common

( DeSousa & Kalra, 2012 ). Research on treatment

effectiveness has largely focused on comparing

the relative gains in managing ADHD with medication versus the effects of behavior therapies

alone. Studies comparing medication with nonpharmacological interventions have consistently

shown stimulants to be superior to non-drug

treatments, according to the American Academy

of Pediatrics ( 2011 ) and DeSousa and Kalra

 ( 2012 ). However, the combination of medication

and behavioral interventions is more benefi cial

than medication alone ( Murray et al., 2008 ).

 ASI is a useful treatment approach for children

with ADHD if specifi c patterns of SI dysfunction have been identifi ed. During intervention

sessions, it is important to emphasize sensory

activities that aim to regulate the child ’ s level of

arousal throughout the session as well as those

aimed at addressing specifi c problems, such as

dyspraxia or visual motor integration defi cits.

Treatment spaces may be better able to meet the

child ’ s needs if they are free from clutter to minimize distractions and the potential for the child

to become overstimulated. Allowing the child to

choose those activities that he or she enjoys is

vital, as children with ADHD may only be able

to attend to tasks well when they are invested in

or interested in whatever they are doing. Recent

reviews and studies of the effectiveness of ASI

intervention with children with ASDs and other

conditions have shown the intervention to be

effective in occupational goal achievement and

for improving SI functions ( May-Benson &

Koomar, 2010 ; Pfeiffer, Koenig, Kinnealey,

Sheppard, & Henderson, 2011 ). Miller, Coll, and

Schoen ( 2007 ) found that in addition to being

effective for goal achievement, SI intervention

helped children improve more than control subjects on cognitive measures including attention.

 In addition to ASI, sensory-based approaches

have also been used with children with ADHD

to assist in behavior regulation and to address

more directly the undesirable behaviors associated with the disorder, such as hyperactivity and

inattention. Other studies have used tools such as

weighted vests for calming children and increasing

attention and on-task behavior, although success

has been mixed ( Collins & Dworkin, 2011 ; Lin,

Lee, Chang, & Hong, 2014 ; Olson & Moulton,

 2004b ; VandenBerg, 2001 ). Alternate classroom

seating, such as move and sit cushions or therapy

ball type seats, has also been used to enhance

on-task behavior, reduce undesirable behavior, and improve handwriting in children with

symptoms associated with ADHD ( Fedewa &

Erwin, 2011 ; Schilling, Washington, Billingsley,

& Deitz, 2003 ). Other sensory-based programs such as the Alert Program ( Williams &

Shellenberger, 1996 ) may be useful in assisting

children to maintain optimal levels of arousal

(see Chapter 18, Complementary Programs for

Intervention, for more detail). The Zones of Regulation ( Kuyper, 2011 ) program also addresses

behavior regulation, including the sensory

needs of the child. This program provides a

framework for educating children and adults

about behavioral regulation, and it is geared

toward helping students understand their emotions and gain skills in consciously regulating

their actions, which, in turn, leads to increased

control and problem-solving abilities. Students

engage in learning activities designed to help

them recognize states of arousal and emotion,

called “zones,” and learn how to use strategies

or tools, including sensory tools, to stay in a

zone or move from one zone to another. Students

develop their own toolbox of methods to use

to move between zones. For more information,

see zonesofregulation.com . Although there are

not any well-designed studies that evaluate its

effectiveness, Wells, Chasnoff, Schmidt, Telford,

and Schwartz ( 2012 ) conducted a randomized

controlled study of a neurocognitive group

therapy intervention that applied many aspects

of the Alert and the Zone programs. These

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 493

researchers used a sample of children with fetal

alcohol syndrome who exhibited many ADHD

symptoms, and they found that the intervention

improved executive functioning and emotional

problem-solving skills.

 The Interactive Metronome, a unique

approach that incorporates aspects of sensory

processing, has often been used with children

with ADHD (see Chapter 18, Complementary

Programs for Intervention). This approach aims

to increase attention span and the ability to focus

for extended periods, while addressing some SI

functions, such as motor planning and rhythmicity of movement. In a well-controlled study

with boys with ADHD from 6 to 12 years of

age, Shaffer and colleagues ( 2001 ) demonstrated

that the intervention was effective for improving several variables, including attention, motor

control, language processing, and reading, as

well as for reducing aggressive behavior.

 Sensory-based interventions are commonly

combined with ASI in addressing concerns. For

instance, Sahoo and Senapati ( 2014 ) examined

functional skills in home and school, comparing the effects of combining ASI with a sensory

diet using an outdoor playground to ASI alone.

Results suggested that both groups made functional gains in performance areas at home and

school as well as with life skills and social

behaviors. After 2 months of treatment, those

receiving the sensory diet in addition to SI treatment made signifi cantly more gains than those

receiving just the SI intervention. It was concluded that SI intervention along with a sensory

diet provided in the context of outdoor play is

effective for improving functional skills of children with ADHD.

 When applying SI as a frame of reference for

adults with attention disorders, sensory-based

strategies and SI techniques are commonly used

to modify tasks and environments, as opposed to

more traditional, clinic-based, ASI intervention.

For adults, instrumental activities of daily living,

social participation, and work are the types of

occupations that are most often impacted by

symptoms of ADHD and, therefore, addressed by

occupational therapists. Adults with ADHD, for

example, have been shown to have lower rates

of professional employment ( Cermak & Maeir,

 2011 ). Driving has also been an area that has

received attention in the ADHD population, as

teens and adults with ADHD have been shown

to be at a higher risk for accidents and violations

than control subjects ( Molina et al., 2009 ). The

Dynamic Interactional Model of Cognition

( Toglia, 2011 ) is an example of an approach

that has been used with adults with ADHD,

and this model can easily be combined with SI

techniques. In this model, cognitive function is

viewed as an ongoing product of the dynamic

interaction among the person, activity, and the

environment ( Toglia, 2011 ), and intervention can

target any of these three components. Adults are

taught to recognize the cognitive strategies they

use to process information, to recognize their

sensory preferences, how they typically process

sensory information, and how the sensory features of environments and activities may support

or hinder their functioning. Challenges with

behavior regulation that relate to sensory sensitivities, or a need for increased sensory stimuli to

maintain interest and focus during tasks, can be

addressed through the use of sensory diets. Environmental modifi cations might include setting

up quiet, uncluttered work areas to minimize

visual and auditory stimulation and distractions.

Simple highlighting or underlining of salient

written instructions may assist in visually focusing, and tools such as day planners and personal

electronic devices with reminders may assist

with organization. The creation and following

of predictable routines and adding structure to

routines and tasks may assist with compensating

for motor planning defi cits and give the individual more control over the amount and type

of sensory input that he or she experiences. As

with children, sensory strategies, such as using

a therapy ball as alternate seating, holding fi dget

toys, or using headphones to reduce sound, may

be effective strategies for adults. Sensory diets

that schedule time for physical activity, quiet

time, or for engaging in whatever type of activities provide the individual with kinds of sensory

input that help them self-regulate and perform

can also be developed and implemented.

 Important components of comprehensive

occupational therapy programming for adults

and children with ADHD to consider include:

(1) education about the disorder and how

one ’ s symptoms infl uence everyday functioning;

(2) techniques to remediate or compensate

for executive function defi cits and behavioral

494 ■ PART V Complementing and Extending Theory and Application

regulation; (3) techniques to remediate or compensate for coexisting conditions, such as motor

coordination, memory, or SI problems, when

they are identifi ed and impact occupational performance; (4) environmental and task modifi -

cations, including sensory strategies to reduce

distractions, increase structure and organization,

and to enhance attention to tasks in home, work,

or school settings; (5) behavioral interventions

to learn, monitor, and reward identifi ed desired

behaviors, to reduce undesirable behavior, and

to enhance motivation and task persistence; and

(6) implementation of cognitive processing strategies to improve task performance and generalization of skills in the context of daily life. The

application of SI theory and intervention techniques should be made with consideration of the

client ’ s own goals and priorities in mind and in

concert with any other medical, pharmacological, psychological, or educational interventions

that the client might be receiving.

CASE STUDY ■ MORGAN

 Morgan was referred by his pediatrician for

occupational therapy at a private outpatient

clinic specializing in SI to evaluate his sensorimotor abilities and fi ne and gross motor skills.

Morgan had been diagnosed with ADHD, combined presentation, when he was 6 years of age

and began to receive special education services

when he was in the fi rst grade. At the time he

was referred for occupational therapy, he was

in the third grade and receiving special education services to address diffi culties with math,

handwriting, and visual motor skills, as well

as to assist in managing behavioral concerns

in the classroom, including inattention and

emotional outbursts. All his services were provided within the regular classroom, and he also

received monthly classroom consult visits from

the occupational therapist.

 Morgan ’ s pediatrician had suggested medication for managing Morgan ’ s ADHD; however,

his parents opted to try and deal with his behaviors using behavioral strategies. His parents

had been through a parent training program to

help them implement strategies to help control

his behavior. His mother reported that he had

diffi culty making friends, was not involved in

any extracurricular activities outside of school,

and did not like school very much. Mom also

indicated that Morgan cried frequently at home

and was distressed by taking the bus to and

from school. At home he liked to play computer games and build with Legos and required

only minimal assistance to complete dressing,

grooming, and bathing activities. Although she

had set up a system of simple chores for him to

do at home, Mom stated that Morgan required

frequent reminders and assistance to complete

them.

 His occupational therapy evaluation included

parent and child informal interviews, observations of and interactions with Morgan during

several structured and unstructured gross and

fi ne motor play activities, completion of the SP

( Dunn, 1999 ), and administration of the SIPT

( Ayres, 1989 ). Morgan scored within the

average range on both of the SIPT tests examining non-motor visual space perception (Space

Visualization, Figure-Ground). However, visualspatial construction tasks involving motor

planning were challenging for Morgan, and he

scored below average on Constructional Praxis

and Design Copying; he also had signifi cant

diffi culty with Praxis on Verbal Command,

whereas Postural Praxis and Oral Praxis scores

were average. Morgan demonstrated some

diffi culties with tactile discrimination, and

vestibular defi cits were seen in low scores

for Standing and Walking Balance and PostRotary Nystagmus. His score on Bilateral Motor

Coordination was below average, whereas his

score on the Motor Accuracy Test was average.

These results suggested a sensory-based motor

disorder, including both dyspraxia and bilateral

integration and sequencing defi cits. In consideration of the cluster analyses provided by his

SIPT profi le, Morgan was most closely likened

to the visuo-somatodyspraxia grouping. Children likened to this group typically have problems with visual and space perception, most

areas of praxis, tactile and proprioceptive processing, balance, and motor coordination.

 The SP completed by his mother suggested

that Morgan was overly sensitive to auditory

stimulation and easily distracted by noise. There

was some indication of mild tactile hypersensitivity, and Morgan was a picky eater. He was

a child who sought out movement excessively

with an increased activity level and inattention.

He was described as an emotionally sensitive

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 495

child with low tolerance for frustration and frequent emotional outbursts.

 Clinical observations of Morgan indicated

minimally lowered muscle tone globally and

diffi culty assuming anti-gravity postures, such

as prone extension and supine fl exion indicative of low tone and generalized muscle weakness. He walked and ran without diffi culty,

although his running speed was slow, and he

did not demonstrate smooth reciprocal upper

and lower extremity movements. Morgan

experienced diffi culty with coordination tasks,

such as rapid alternating fi nger movements and

jumping jacks, demonstrating a weakness with

motor planning and sequencing.

 In summary, these fi ndings indicated that

Morgan had SI defi cits that were impacting his

behavior at home and at school, his learning,

and his development of fi ne and gross motor

skills. More specifi cally, he demonstrated

challenges with motor planning, balance, and

bilateral motor coordination, which seemed to

be related to poor tactile, proprioceptive, and

vestibular processing. He also demonstrated

some sensory modulation problems, including

tactile and auditory over-responsivity, and diffi -

culty modulating and processing vestibular and

proprioceptive sensory input. Despite his diffi -

culties, Morgan was a pleasant, well-mannered

child who was interested in his environment

and eager to please others.

 Morgan received occupational therapy services on a weekly basis at school in the classroom. Strategies were implemented to help him

compensate for his SOR to auditory and tactile

stimuli, such as avoiding spaces that were

crowded, loud, or unpredictable. He also began

to use a Move and Sit cushion on his classroom

chair, which gave him constant subtle movement, and this alternative seating signifi cantly

reduced his fi dgetiness. Because children with

motor planning problems typically experience

diffi culty in new situations and learning new

skills, it was important that pre-teaching was

conducted and more time and practice or repetition was allotted for Morgan to learn new skills.

A variety of approaches, such as hands-on learning, demonstration, and talking through steps of

tasks, were found to be helpful in facilitating

Morgan ’ s learning of new skills. The therapist

also suggested that he be provided with ample

opportunities to develop gross motor skills and

move about during the day (receive proprioceptive and vestibular input) such as doing seat

push-ups, using a rebounder in the classroom,

and being able to stand rather than sit to complete some classroom activities.

 In addition to school-based services, including occupational therapy, clinic-based occupational therapy using an SI approach was

implemented once per week for 4 months. ASI

was implemented to address Morgan ’ s motor

and postural responses, comfort with movement,

muscle strength and balance, somatosensory

processing, and motor planning and sequencing.

At home, his therapist suggested that Morgan

engage in play activities that help to develop

his fi ne and gross motor skills, such as play

with construction toys such as Legos and other

building blocks, using clay and playdough, and

engaging in any craft activities (cutting, gluing)

that he enjoys. Morgan was encouraged to do

functional tasks independently, such as dressing, brushing his hair and teeth, opening packages, and cutting meat, as well as complete

simple chores. Gross motor play suggestions

included riding his bike, playing ball games

such as basketball and soccer, swimming,

and playing on playground equipment such

as climbing and swinging. Heavy work-type

activities (pushing or pulling, carrying heavy

objects, rough-house play, jumping on a trampoline, etc.) were encouraged at home and at

school, and they were implemented frequently

during his treatment sessions.

 Morgan did well with intervention, and the

sessions using SI were particularly effective

for improving his motor planning skills and for

improving his self-regulation of behavior. He

continued to receive occupational therapy on

a consult basis throughout the school year to

address his behavior at school and to monitor

the effectiveness of sensory strategies that were

implemented to help him attend and focus.

HERE ’ S THE POINT

• ADHD is a complex condition, and many of

the behavioral indicators of ADHD that are

associated with poor behavior regulation mimic

those seen in children with sensory modulation

disorders.

496 ■ PART V Complementing and Extending Theory and Application

• Comprehensive programs for those with

ADHD are described as using an individually

tailored, multi-modal intervention approach

to meet the unique presentation of each

client.

• For many adults and children with ADHD,

occupational therapy services applying ASI

or implementing sensory-based strategies

to assist with behavior regulation as well

as to address co-occurring SI dysfunction are

often helpful.

Where Can I Find More?

 Ratey, N. (2008). The disorganized mind:

Coaching your ADHD brain to take control of

your time, tasks and talents. New York, NY:

St. Martin ’ s Press.

 Schmidt Neven, R., Anderson, V., & Godber,

T. (2002). Rethinking ADHD: Integrated

approaches to helping children at home and

at school. Crows Nest, NSW, Australia: Allen

& Unwin.

Background and Rationale

for Applying Sensory Integration

 ASD is one of the most frequently occurring

neurodevelopmental disorders in children, with

current prevalence estimates suggesting that 1 in

68 children have an ASD diagnosis ( Centers for

Disease Control and Prevention, 2014 ). Current

diagnostic criteria for ASD ( APA, 2013a ) include

consideration of four main areas: (1) Symptoms

of ASD must be present in early childhood;

(2) symptoms must limit functional abilities;

(3) symptoms must include defi cits related to

social-communication and social-interaction

skills; and (4) symptoms must include restricted,

repetitive behavior or interests that are related

to two or more of the following: stereotypy in

speech or motor actions, excessive routines or

patterns of behavior, intense and unusual interests, and hyper- or hypo-reactivity to sensation

or unusual sensory interests. Basic diagnostic

criteria are shown in Table 19-2 .

 The recent change in diagnostic criteria for the

DSM-5 ( APA, 2013a ) for the fi rst time acknowledges and recognizes the frequency with which

sensory processing differences and challenges

are reported in people with ASD. However, such

differences in sensory processing have long been

documented in infants and children with ASD

(e.g., Ornitz & Ritvo, 1968 ). Accordingly, clinical practices to evaluate and treat sensory symptoms have received renewed interest.

Sensory Integration

and Occupation-Based Challenges

 Most children with ASD have some type of

sensory processing differences, although prevalence estimates vary. According to parent

responses using a variety of parent-report assessments, 45% to 90% of children with ASD are

identifi ed as displaying unusual responses to

sensory stimuli ( Baranek, David, Poe, Stone, &

Section 3 : Applying Sensory

Integration Principles for Children

with Autism Spectrum Disorder

 Teal W. Benevides, PhD, OTR/L ■ Rachel Dumont, OTR/L, MS ■ Roseann C. Schaaf, PhD, OTR/L, FAOTA

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 497

TABLE 19-2 DSM-5 Diagnostic Criteria for Autism Spectrum Disorder

PERSISTENT DEFICITS IN SOCIAL COMMUNICATION AND

SOCIAL INTERACTION ACROSS MULTIPLE CONTEXTS

RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR,

INTERESTS, OR ACTIVITIES

Manifestation, Current or by History, as Defi cits in Manifestation, Current or by History, as

 • Social-emotional reciprocity (e.g., failure to initiate

or respond to social cues)

 • Nonverbal communication used for social

interactions (e.g., defi cits in use or understanding

of gestures, lack of facial expression)

 • Developing, maintaining, and understanding

relationships (e.g., lack of interest in peers; diffi culty

sharing in play)

 • Stereotyped or repetitive movements, use of objects,

speech (e.g., lining up toys)

 • Insistence on sameness, infl exible adherence to

routines, or ritualized patterns or verbal and nonverbal

behavior (e.g., distress with small changes, diffi culties

with transitions)

 • Highly restricted, fi xated interests of abnormal intensity

or focus (e.g., preoccupation with unusual objects)

 • Hyper- or hyporeactivity to sensory input or unusual

interests in sensory aspects of the environment (e.g.,

adverse response to sound or touch; excessive smelling

or touching)

 • Symptoms must have been noted in early development but might not have been fully demonstrated until

demands from the social environment were increased.

 • Symptoms must impair current occupational, social, or other important areas of function.

 • Concerns must not be better explained by other diagnosis, although ASD can coexist with other diagnoses (e.g.,

ADHD, intellectual disability).

Adapted from the American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington,

VA: American Psychiatric Publishing.

Watson, 2006 ; Leekam, Nieto, Libby, Wing, &

Gould, 2007 ; Tomchek & Dunn, 2007 ; Watling,

Deitz, & White, 2001 ). Similarly, motor and

praxis symptoms are frequently reported and

have been studied ( Baranek, 2002 ; Dawson &

Watling, 2000 ; Smith Roley, Parham, Mailloux,

Schaaf, & Cermak, 2014 ).

 Although the majority of the literature identifi es sensory processing patterns along a continuum of over- or under-responsivity ( Ben-Sasson

et al., 2009 ; Rogers & Ozonoff, 2005 ), referred

to as “sensory modulation,” others have identifi ed patterns related to specifi c sensory modalities, such as taste-smell sensitivity (e.g., A. E.

 Lane, Young, Baker, & Angley, 2010 ) or auditory hypersensitivities. Others have noted diffi culties in sensory discrimination and praxis

( Smith-Roley et al., 2014 ), and poor or delayed

motor imitation (characteristic of dyspraxia) is

commonly cited as a problem seen in children

with ASD ( Fig. 19-6 ). Other lines of inquiry

have identifi ed postural and praxis-related differences in children with ASD, and that atypical

sensory processing and integration may underlie

fi ne motor, gross motor, and gait dysfunctions

seen in children with ASD (e.g., Bhat, Landa, &

Galloway, 2011 ). Occupational therapists focus

on occupational performance in daily life activities. In children with ASD, differences in sensory

FIGURE 19-6 Tasks such as walking over a block

require both postural control and praxis, which is

often problematic for children with ASD. Photo

courtesy of Meghan Hall.

498 ■ PART V Complementing and Extending Theory and Application

responsivity have been linked to reduced participation in a variety of occupational areas, such

as social participation, play, and performance of

self-care skills, such as bathing, dressing, and

feeding ( Ashburner, Ziviani, & Rodger, 2008 ;

 Baranek, 2002 ; Leekam et al., 2007 ; Rogers &

Ozonoff, 2005 ).

Evaluation and Intervention

 Assessment of sensory integrative function in

children with ASD can be accomplished using

the SIPT, tools addressing sensory modulation,

and clinical observations. These approaches are

presented in Chapter 9 (Using Clinical Observations within the Evaluation Process) and

Chapter 10 (Assessing Sensory Integrative Dysfunction without the SIPT), respectively. Additional information on assessing a child with

ASD can be found in Chapter 21 (Planning and

Implementing Intervention: A Case Example of a

Child with Autism), in which detailed information is presented on a child with ASD.

 One common approach to addressing sensory

symptoms in children with autism is using ASI.

 Ayres ( 1972 ) proposed that information from the

tactile, vestibular, and proprioceptive systems

were important substrates for adaptive responses

and that diffi culty processing and integrating

sensations from the body and environment contribute to disrupted or disorganized motor skills

and adaptive behaviors. Occupational therapy

using SI (OT/SI, also termed ASI) focuses on

improving sensory symptoms that impact behavior and addresses underlying sensory and motor

factors that may be affecting occupational performance. Practice patterns indicate that nearly

99% of occupational therapists treating children

with ASD use a sensory-integrative frame of

reference for evaluation or treatment ( Watling,

Deitz, Kanny, & McLaughlin, 1999 ), although

only 29% indicate that they use ASI specifi cally,

as opposed to other sensory approaches ( Ashburner, Rodger, Ziviani, & Jones, 2014 ).

 ASI is directed by a set of principles that

includes opportunities for safe, child-directed,

sensory-rich, playful interactions that are tailored to the child ’ s need; the art and science of

intervention are described in Chapter 12 (The

Art of Therapy) and Chapter 13 (The Science of

Intervention: Creating Direct Intervention from

Theory), respectively. Interventionists using SI

consider a child ’ s strengths and areas of need

based on a comprehensive evaluation, as well

as motivational interests and desired outcomes,

including long-term and short-term goals for

treatment. When working with a child with ASD,

therapists utilizing the ASI approach may initially have diffi culty when identifying motivating, playful opportunities for interaction within

the treatment environment given that diagnostic

criteria include restricted and repetitive interests

and challenges with social-communicative skills.

However, therapists are encouraged to use the

child ’ s specifi c interests in planning and implementing treatment. Similarly, some therapists

may use sensory-based interventions that are not

fully in line with accepted SI tenets. Such sensory

stimulation (or sensory-based) interventions may

include weighted vests ( Fertel-Daly, Bedell,

& Hinojosa, 2001 ; Olson & Moulton, 2004a,

2004b ; VandenBerg, 2001 ) and brushing ( Davis,

Durand, & Chan, 2011 ; Kimball et al., 2007 ).

Although these interventions are used to stimulate certain sensory systems, these interventions

do not focus on the active involvement of the

children in sensorimotor activities challenging

tactile, proprioceptive, and vestibular systems

that are essential to the SI approach ( Ayres, 1972,

1979 ). Although a complete review is outside the

scope of this chapter, therapists should recognize

the difference between sensory-based interventions relying on sensory stimulation with passive

application of sensation and OT/SI, which abides

by the elements of ASI, as described by Parham

and colleagues ( 2007, 2011 ). Understanding the

differences in these approaches and the specifi c evidence for these different approaches is

addressed in the text that follows.

 Research on the evidence supporting the use

of SI with children with ASD is available, and

readers are encouraged to seek systematic reviews

that fully examine published research on SI treatment and sensory-based treatment in children

(e.g., Case-Smith et al., 2014 ; May-Benson &

Koomar, 2010 ).

 Emerging evidence suggests that using a

sensory integrative approach and abiding by

tenets as proposed by Ayres ( 1979 ) and explicated by Parham and colleagues ( 2011 ) may

positively infl uence functional outcomes of children with ASD. Currently, two small randomized

controlled trials (higher level evidence) (Pfeiffer

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 499

et al., 2011; Schaaf et al., 2013 ) demonstrate signifi cant improvement on parent-identifi ed functional goals following OT/SI for children with

ASD compared with usual care ( Schaaf et al.,

 2013 ) or fi ne motor treatment (Pfeiffer et al.,

2002). Lower level evidence also supports the

use of OT/SI, as a recent observational cohort

study ( Iwanaga et al., 2013 ) found differences

in functional outcomes for the OT/SI group

compared with children receiving unspecifi ed

group therapy ( Iwanaga et al., 2013 ). In contrast, Watling and Dietz ( 2007 ) did not fi nd an

effect of SI on engagement in tasks or a reduction in undesired behaviors in young children

with ASD following short-term exposure to ASI

in a single-subject alternating treatment design.

Additional evidence from case studies using OT/

SI suggest that these approaches may impact

the participation of some children with ASD

( Linderman & Stewart, 1999 ; Schaaf, Hunt, &

Benevides, 2012 ; Schaaf & Nightlinger, 2007 ;

 Van Rie & Hefl in, 2009 ). One systematic

review has evaluated the evidence related to

sensory-based interventions and SI treatment for

children with ASD ( Case-Smith et al., 2014 ) and

reported that there is promising evidence for SI

treatment. Overall, fi ndings from both higher and

lower level evidence suggest positive effects for

OT/SI on functional, participation-based goals

for children with ASD. More information on SI

intervention and children with ASD can be found

in Chapter 15 (Advances in Sensory Integration Research: Clinically Based Research) and

Chapter 16 (Advances in Sensory Integration

Research: Basic Science Research), respectively.

 In contrast, research examining sensory-based

approaches that rely on passive application of

sensation to children, such as weighted vests,

brushing, or spinning protocols, have limited

evidence supporting their use ( Case-Smith et al.,

 2014 ). Typically, these approaches are used in

settings in which traditional OT/SI is not feasible (e.g., treatment occurring in a school). Therapists seeking to use sensory-based approaches

should consider whether these treatment choices

are justifi ed given their lack of supporting evidence, and therapists using these approaches

should carefully collect data on their intervention and child ’ s response and document objective

outcomes consistently. As with any occupational

therapy treatment, regular tracking of data on

outcomes will assist a therapist in modifying

or adjusting a treatment plan to better meet the

long-term goal(s) of the child and family.

CASE STUDY ■ MARTIN

 Martin, a young child diagnosed with autism at

18 months of age, was enrolled in early intervention from 9 months of age because of delays

in gross motor, communication, and socialization skills. At 20 months of age, Martin was

seen twice a week in his home with his mother

present. The home environment offered multiple opportunities for sensory-rich experiences in

tactile, vestibular, and proprioceptive activities

in keeping with ASI principles. The therapist,

upon referral, assessed the family ’ s routines

and areas of occupational need. For example,

Martin ’ s mother identifi ed that eating a wider

repertoire of foods, tolerating a toothbrush,

ability to go into the community, and playing

interactive games with the family were areas of

importance. To further assess whether diffi culty

processing and integrating sensory information

was a factor affecting these participation challenges, the Infant/Toddler SP ( Dunn & Daniels,

 2002 ) was used to identify possible areas of

sensory responsivity that were impacting daily

routines. Observation of the child in his natural

environments (e.g., home during mealtimes,

home during play, home during morning routines, backyard during outside play, at the playground, and in the grocery store) afforded the

therapist opportunities to observe the sensory

qualities of the environment and the parents’

reported dilemmas in caregiving and play.

Lastly, the therapist used playful opportunities,

such as play with food textures and outdoor

play equipment, to evaluate Martin ’ s responses

to tactile, proprioceptive, and vestibular input

within the natural environments and to assess

his praxis abilities and postural control.

 Assessment results were used to generate hypotheses regarding the specifi c sensorimotor factors affecting Martin ’ s occupational

performance problems. The therapist also

identifi ed child, family, and environmental

factors that appeared to be contributing to his

diffi culties, and importantly, identifi ed Martin ’ s strengths and areas of interest. Although

this case emphasizes specifi c child factors

assessed using a sensory integrative frame

500 ■ PART V Complementing and Extending Theory and Application

of reference, it is important that occupational

therapists also examine the intersection of the

child, environment, and his or her occupations

using other frames of reference that may be

appropriate ( Ashburner et al., 2014 ). Martin ’ s

interests and strengths at 20 months of age

included engaging with puzzles and animal

fi gurines, and Martin had a fascination with

bubbles and other repetitive visual stimuli

(e.g., ceiling fans). Assessment data revealed

that Martin had tactile hypersensitivity, especially around the hands and mouth; that he did

not like movement activities, preferring seated

activities (e.g., puzzles, animals); and he was

sensitive to environmental stimuli, especially

situations with a lot of visual stimuli and noise.

These sensory rich environments often resulted

in increased self-stimulation behaviors, crying,

or “meltdowns.” Additionally, similar to many

young children with ASD, Martin rarely made

eye contact, did not use words, and did not

use gestures to communicate his needs. Martin

displayed diffi culties with ideation and motor

planning and with delayed fi ne and gross motor

skills, which were particularly evident during

play and feeding.

 Intervention was targeted at enhancing the

home environment to provide needed sensory

experiences and develop self-regulation strategies and skills for use in community settings

that were challenging for Martin, such as the

playground and grocery store. For example,

upon recommendation from the therapist,

the family brought a Playskool ® toddler slide

from the basement up to the living room with

the dual goal of addressing the child ’ s sensory

and motor needs and the parents’ participation goals (social play). The therapist worked

with Martin ’ s mother using the Playskool ®

slide to engage Martin in motor challenges in

order to address motor planning skills (praxis)

and to work on vestibular processing and postural control. For example, the therapist and

parent team encouraged Martin to engage in

supported climbing onto the slide in search

of animals (or puzzle pieces) ( Fig. 19-7 ) and

to slide down (with support) ( Fig. 19-8 ) into

a pile of pillows with an immediate “squish”

(deep pressure touch input). Martin found this

to be challenging, but enjoyable, and this activity often resulted in brief periods of eye contact

with mom after coming out of the pillows. Such

FIGURE 19-7 Providing physical cues of the body in

space without “doing for” the child as he climbs.

Photo courtesy of Meghan Hall.

activities also provided Martin with opportunities to process proprioceptive and tactile

input. As his ability to successfully navigate

this sensorimotor challenge increased, and his

mother became comfortable with facilitating

her son ’ s sensorimotor skills, additional items

were added into the play situation, such as large

chair beanbags, a tunnel ( Fig. 19-9 ), and foam

blocks. These were incorporated as objects to

step on (challenging vestibular), to crawl over

(challenging proprioception), or to crash into

(challenging tactile), as well as to challenge

his motor planning abilities (e.g., navigating

through the tunnel connected to the playhouse).

At a participation level, Martin developed

reciprocal play interactions with his mother and

both Martin and his mother engaged in positive

affect, including smiling and physical touch

( Fig. 19-10 ).

 Intervention goals were developed collaboratively with Martin ’ s mother and the interdisciplinary team and included that Martin would

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 501

HERE ’ S THE POINT

• Most children with ASD have some SI

challenges. Several small randomized controlled

trials and a systematic review suggest there is

suffi cient evidence to support the use of an SI

approach to address sensory-based challenges,

FIGURE 19-8 Modeling trunk support with a

toy slide (vestibular challenge). Photo courtesy of

Meghan Hall.

FIGURE 19-9 Motor planning how to navigate the

tunnel. Photo courtesy of Meghan Hall.

FIGURE 19-10 Demonstrating positive affect and

engagement during the “squish” activity. Photo

courtesy of Meghan Hall.

eat a wider repertoire of foods, tolerate a toothbrush, be able to participate in the community

(e.g., playground, grocery), and play interactive games with the family. During the course

of twice-weekly sessions performed during an

18-month period, Martin progressively used

more spontaneous eye contact during preferred

sensory play and during activities that were

non-preferred, such as walking barefoot on an

indoor or outdoor mat to get to the slide. He

also began to spontaneously use signs and gestures that he was learning in speech therapy,

such as “more” to communicate with his mother

( Fig. 19-11 ). Additionally, Martin improved in

his ability to process and integrate sensations

for motor challenges that were introduced and

was more willing to try new activities requiring

motor play, such as using unfamiliar playground

equipment with novel climbing structures in the

community.

502 ■ PART V Complementing and Extending Theory and Application

although sensory-based approaches such as

weighted vests have not been supported by

research.

• Sensory modulation challenges, sensory

discrimination dysfunction, and sensory-based

motor problems including dyspraxia and

postural disorders are commonly seen in

children with ASD.

• Principles of SI, such as child-directed, playful

activities that incorporate rich opportunities

for tactile, proprioceptive, and vestibular

experiences, can be provided in home,

community, and clinic environments.

• Most of the research examining the

effectiveness of ASI has been done with

samples of children with ASDs, and the

evidence suggests that the treatment approach

is effective at addressing parent-related goals

in clinic-based settings, although more research

is needed on the use of this approach in home

and community environments.

Where Can I Find More?

 The following two articles provide a deeper

understanding of the sensory-related issues

in autism. They refl ect only a small bit of the

ongoing research in this area.

 Schauder, K. B., & Bennetto, L. (2016). Toward

an interdisciplinary understanding of sensory

dysfunction in autism spectrum disorder: An

integration of the neural and symptom literatures. Frontiers in Neuroscience, 10 (JUN),

1–18. doi:10.3389/fnins.2016.00268

 Tavassoli, T., Bellesheim, K., Siper, P. M.,

Wang, A. T., Halpern, D., Gorenstein, M.,

. . . Buxbaum, J. D. (2016). Measuring

sensory reactivity in autism spectrum disorder: Application and simplifi cation of a

clinician-administered sensory observation

scale. Journal of Autism and Developmental Disorders, 46 (1), 287–293. doi:10.1007/

s10803-015-2578-3

FIGURE 19-11 Fist bump for a job well done! Shared

affect and touch without eye contact is accepted.

Photo courtesy of Meghan Hall.

Section 4 : Sensory Integration

and Children with Disorders

of Trauma and Attachment

 JoAnn Kennedy, OTD, MS, OTR/L

Background and Rationale

for Applying Sensory Integration

 During recent decades, biological and clinical

evidence has shown that childhood trauma and

inadequate parent-child attachment profoundly

impact the health and function of individuals into

adulthood ( Bowlby, 1988 ; Karen, 1998 ; van der

Kolk, 2006 ). Koomar ( 2009 ) reported that occupational therapists using the SI model frequently

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 503

treat children who have experienced traumatic

events that impede healthy social attachments.

This situation is caused by the high prevalence

of childhood trauma in general ( National Child

Traumatic Stress Network, n.d. ) and also the

shared features of sensory modulation disorders

with disorders of trauma and attachment (DTA).

Although these same sensory features can

present similarly in children with sensory modulation disorders associated with other conditions,

those related to DTA require a different treatment approach termed trauma-informed care

(TIC). TIC is an approach used across many

health and education disciplines. In occupational

therapy, TIC requires therapists to be aware of,

and consider the signs of, DTA. This includes

conducting thorough evaluations to identify possible trauma in client histories, ongoing efforts

to avoid re-traumatization of the client, use of

techniques that support recovery from trauma,

and interventions to help develop secure relationships with attachment fi gures ( Champagne,

 2011a ). Direct involvement of caregivers in

therapy sessions, for example, is often a priority

in occupational therapy treatment using SI with

children with DTA.

 Under optimal conditions, infants and their

caregivers form strong social attachments as

parents accommodate to their baby ’ s fi rst needs

for sensory comfort and stimulation. When

infants sense discomfort or a need for stimulation, they signal those needs through vocalizations (fussing, crying, cooing) or gestures (eye

contact, reaching, head turning). When the caregiver satisfi es the infant ’ s need, both of them are

gratifi ed and gain trust in each other as individuals. With repeated experience, the dyad becomes

increasingly adept at signaling and meeting

one another ’ s needs. A positive attachment

cycle ( Fig. 19-12 ) develops, leading to a secure

attachment pattern. This provides a foundation

for healthy social and emotional functioning

throughout life. Animal research also indicates

that optimal attachment formation depends on

species-specifi c sensory inputs from the caregiver to the infant during sensitive periods

of development ( Kaffman & Meaney, 2007 ;

 Panksepp, 2004 ).

 Additional fi ndings from clinical and animal

research show that early trauma or insensitive

care often leads to anxious attachment patterns

( Karen, 1998 ). Anxious attachment patterns

can be ambivalent, causing a child to signal

dependence excessively, or avoidance, leading

to independence beyond the child ’ s overall

developmental readiness. Figure 19-13 depicts

how through time a negative attachment cycle

becomes short-circuited, eventually leading

to anxious attachment patterns. Children with

anxious attachments struggle to form satisfying friendships and positive relationships with

authority fi gures.

Infant experiences

needs for sensory

comfort and stimulation

Stronger infantcaregiver

relationship

Caregiver

responds to

needs

Infant expresses

needs

Need is met,

gratification for

both infant and

caregiver

FIGURE 19-12 A positive attachment cycle is the

foundation for a secure attachment pattern.

Anxious

infant-caregiver

attachment,

excessive

dependence,

or premature

independence

Infant experiences

sensory needs for

comfort and stimulation

Infant signals

needs

Infant signals

distress, then

despair and lack of

gratification

Need is

ignored,

cannot be

met, or is

mis-met

FIGURE 19-13 A negative attachment cycle (initial

infant signals do not lead to suffi cient care) is

short-circuited (red arrows), leading to excessive

dependence or independence.

504 ■ PART V Complementing and Extending Theory and Application

 Severe or ongoing trauma frequently results

in a disorganized attachment pattern characterized by contradictory, fearful behaviors ( Bowlby,

 1988 ); sometimes this leads to one of many

trauma- and stress-related disorders as defi ned

in the DSM-5 ( APA, 2013a ). One such disorder

is referred to as reactive attachment disorder

(RAD) , and it is very relevant to children with

DTA . The hallmark of this internalizing disorder is an inability to seek or be comforted by

adequate caregivers because of insuffi cient care

during infancy or early childhood. Disinhibited

social engagement disorder (DSED) also stems

from inadequate early care but results in externalizing behaviors characterized by overly familiar or indiscriminant socialization. Post-traumatic

stress disorder (PTSD) is another stress-related

disorder these children may face. There is a set of

diagnostic criteria for older children, adolescents,

and adults, and separate criteria for children

6 years of age and younger ( APA, 2013a ). Children

with PTSD often have tantrums, nightmares, episodes of staring or freezing, exaggerated startle

responses, reenactment of trauma during play, or

avoidance of reminders (including sensations) of

the trauma. Because sensory processing problems

often accompany or co-occur in children with

DTA, occupational therapists working with such

children should consider applying SI approaches.

Sensory Integration

and Associated

Occupation-Based Challenges

 Occupational therapists frequently treat children

who have DTA caused by neglect, abuse, inconsistency of caregivers, or comparable experiences

suffered during treatment for medical conditions

( Koomar, 2009 ). Several types of sensory disturbances are typical of DTA. Infants who do not

receive or benefi t from regular sensory stimulation that is responsive to their needs for emotional and physiological regulation often engage

in extensive rocking, pulling at objects or body

parts, or pounding on hard surfaces. These repetitive, sensory-seeking behaviors can continue as

self-regulatory mechanisms, even after the child

receives more supportive care. Sensory seeking

behavior is problematic when it interferes with

regulation through an attachment fi gure, is

destructive, or interferes with the child ’ s ability

to complete other desired or important tasks and

activities.

 Another sensory problem common among

individuals who have experienced severe traumatic events is hypervigilance—a continual monitoring of the environment to detect and avoid

additional trauma ( van der Kolk, 2006 ). Visual

and auditory hypervigilance can shift awareness

away from the individual ’ s own body, causing

functional impairments similar to somatosensory

under-responsivity of other origins. It can also

impede attention and focus on more important or

salient tasks, and, therefore, it must be differentiated from attention disorders of other etiologies.

Individuals who have DTA can experience trauma

triggers, which are specifi c sensations or reminders of past trauma that prompt periods of physiological or emotional dysregulation. Common

examples of trauma triggers are the odor of liquor,

angry facial expressions, and touch to body parts

that have been painfully injured. These behavioral

responses differ from SOR, which is associated

with a broader category of sensations ( Koomar,

 2009 ). Increasingly, leaders in the fi eld of trauma

recovery are recognizing these sensory features

of DTA and the need for sensory treatments

(B. D. Perry, 2009 ; van der Kolk, 2006 ).

 In humans, multisensory stimulation may

buffer babies from some inadequacies of institutional care (T. I. Kim, Shin, & White-Traut,

 2003 ). Laboratory animals that experience conditions analogous to inadequate infant care

or PTSD respond to enriched environments

with emotional, social, and cognitive recovery

( Hendriksen, Prins, Olivier, & Oosting, 2010 ;

 Kaffman & Meaney, 2007 ). These functional

improvements are attributed to neural plasticity,

especially in the hippocampus and amygdala of the

brain. Enriched animal environments share many

features with SI intervention, including varied,

novel, and complex sensory experiences; active,

enjoyable social engagement; and physical and

emotional safety (S. Reynolds, Lane, & Richards,

 2010 ). This basic research supports use of SI and

other sensory-based techniques as part of an occupational therapy program for children with DTA.

Evaluation and Intervention

 Because children with DTA and their families have complex needs, they often require

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 505

assessment and intervention from multiple perspectives. Assessment from a sensory integrative

perspective should address sensory modulation

and discrimination, as well as praxis; these children present with complex needs. Specifi c information on assessment of sensory integrative

concerns can be found in Chapter 9 (Using Clinical Observations within the Evaluation Process)

and Chapter 10 (Assessing Sensory Integrative

Dysfunction without the SIPT). Intervention

is often best when it combines approaches that

address sensory and regulatory needs, is relationship based, and includes caregiver education. For

instance, Wells and colleagues ( 2012 ) studied

78 children between 6 and 11 years of age

who were exposed to alcohol prenatally and

removed from their birth families. Treatment of

the experimental group was an adaptation of the

sensory-based Alert Program ® ( Williams & Shellenberger, 1996 ), with concurrent parent training

on effective management of children with executive dysfunction and sensory dysregulation.

Compared with controls, the experimental group

achieved signifi cantly greater improvements in

executive and emotional functioning.

 In her seminal work of 1975, Jean Ayres

briefl y addressed children with emotional problems and advised: “In this case a revised plan

with more direction and structure with considerable support may be required” (p. 265). Children

who have not experienced consistent physical

and emotional security or responsive care often

need support in choosing and safely engaging

in SI activities. For example, children who have

obtained adult attention mainly through negative or self-abusive behavior may take excessive

risks on suspended equipment, threatening their

own safety. A child with PTSD may use therapy

equipment to re-play themes from past trauma

in unproductive ways or may be inadvertently

triggered into traumatic fl ashbacks by sensations

during treatment. For children with insuffi cient

attachment, especially those who are indiscriminately affectionate, their caregivers or primary

attachment fi gures should participate in therapy

and they, rather than the therapist, should become

the primary source of positive sensory experiences. Finally, therapist self-care is essential

for working with this population. To empathize

with children who have DTA while maintaining their own emotional regulation, therapists

must have knowledgeable, sensitive support

from TIC-experienced mentors and colleagues

( Koomar, 2009 ). The following is a case study to

illustrate how SI principles may be applied to a

child who has experienced trauma.

CASE STUDY ■ TED

 Ted and his twin brother were born at 25 weeks

gestation. Sadly, his brother died a few days

later. Ted experienced considerable physical

pain caused by complex medical problems

and multiple surgeries. In addition, staff in the

NICU told his parents that touching Ted might

cause him discomfort. After spending his fi rst

6 months in the hospital, Ted continued to be fed

by a gastric tube at home and to receive daily

therapies supporting oral, sensory, motor, and

cognitive development. His parents were very

involved in this process. Ted walked at 3 years

of age, and he transitioned fully to oral feedings

at 5 years of age. Just before starting kindergarten, he became gradually more emotionally

dependent on his parents. He required several

hours of undivided attention to fall asleep. He

complained at length about minor injuries,

though he habitually picked at his hands and

surgical scars, sometimes causing bleeding. He

actively explored familiar places but insisted on

being carried when the family was out in the

community and would not attempt to use playground equipment independently.

 At this point, Ted ’ s parents sought occupational therapy intervention at a communitybased clinic. Their immediate goal was to

increase Ted ’ s independence at his new school

building and playground. They were also concerned about his dependence for self-feeding,

dressing, and at bedtime. Sue, his occupational

therapist, performed the initial occupational

therapy evaluation, which showed that Ted

was over-responsive to vestibular sensations.

He was stressed when asked to jump or climb,

and he lacked equilibrium responses when

on mobile therapy equipment. In addition, he

avoided textures and was not soothed when

held by his parents. Sue ’ s clinical reasoning led

her to the hypothesis that Ted ’ s needs for soothing and stimulation were not met satisfactorily

during his early infancy because of his medical

conditions. This situation, combined with his

over-responsivity to movement, led to emotional

dependence that limited his motor exploration.

506 ■ PART V Complementing and Extending Theory and Application

that Ted readily explored. Each time Sue

invited Ted to use a new swing or scooter

board, he protested extensively, although Sue

knew he had enjoyed almost identical sensory

experiences.

 His parents initiated mental health support,

including some counseling, and with guidance,

they told Ted about his brother. Gradually the

combination of mental health and occupational

therapy interventions seemed to be having the

desired effects. Ted began to trust his own sensorimotor abilities and his parents’ judgments

about trying new things. Slowly he began trying

equipment on playgrounds where he previously would not go, including pumping swings,

and he used the neighborhood pool. Sue also

worked with his mother, showing her how to

provide deep pressure massage to Ted ’ s back in

a consistent, rhythmic pattern at bedtime. After

this tactile input, his parents implemented their

counselor ’ s recommendations to sit next to his

bed without interacting while Ted fell asleep.

Through several months his parents gradually

sat farther away until they could stay in the

next room as he drifted to sleep. With improved

sensory processing and family relationships,

Ted became more adventurous and independent across all settings. Six months later, he

needed only occasional occupational therapy

consultations.

HERE ’ S THE POINT

• SI intervention techniques are a valuable part

of the recovery process for many children with

DTA.

• All professionals serving this population need

to be knowledgeable regarding normal sensory,

social, and emotional development as well as

the diffi culties trauma and poor attachment

pose.

• Professionals working in this area will need

collegial support on both technical and

emotional levels for this extremely challenging

work.

• Jean Ayres ( 1975 ) foresaw a time when the

fi elds of SI and mental health would join

forces. Scientifi c and clinical evidence now

affi rm the importance of sensory interventions

in trauma and attachment work.

FIGURE 19-14 Ted prone on the peanut ball as he

begins to feel secure enough with movement to lift

his feet from the mat and engage in play. Photo

courtesy of Tracey Hulen.

His parents also revealed that they had never

talked with Ted about his brother ’ s existence or

death. Sue explained how a history of neonatal pain, and limited tactile stimulation, along

with Ted ’ s vestibular over-responsivity, could

be hindering his current emotional and motor

development. She advised that a mental health

consultation would help the family process the

challenging emotional issues surrounding Ted ’ s

birth and the loss of his brother. His parents and

therapist agreed that an initial goal was to help

Ted modulate movement and tactile sensations

as a foundation for more mature motor and

emotional skills. Sue affi rmed Ted ’ s parents’

accomplishments in fostering his progress

during the past years.

 Initial occupational therapy sessions focused

on using different types of equipment for Ted to

explore and to expand the amount of movement

he could comfortably process. For example,

Ted enjoyed rolling prone over a peanut ball

wedged between large cushions, which allowed

him to experience lifting his feet from the fl oor

in a predictable and limited rocking motion

( Fig. 19-14 ). He asked to repeat variations

of this activity during a dozen sessions. Sue

coached his father to encourage this exploration and to intermittently provide fi rm touch in

rhythm with Ted ’ s rocking. She added tactile

materials near the barrel and other equipment

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 507

Where Can I Find More?

 Gaskill, R. L., Perry, B. D., Malchiodi, C., &

Crenshaw, D. A. (2013). The neurobiological power of play. In E. Cathy Malchiodi

& David A. Crenshaw (Eds.), Play and creative arts therapy for attachment trauma (pp.

2–22). New York, NY: Guilford Press.

 Ryan, K., Lane, S. J., & Powers, D. (2017). A

multidisciplinary model for treating complex

trauma in early childhood. International

Journal of Play Therapy, 26 (2), 111–123.

doi:10.1037/pla0000044

Section 5 : Sensory Integration

Applications with Adults

 Beth Pfeiffer, PhD, OTR/L, BCP

Background and Rationale

for Applying Sensory Integration

 Adults with SI and processing issues are an

underserved and underidentifi ed group despite an

emerging body of literature supporting the presence of sensory processing defi cits in adult populations. Some children identifi ed with sensory

processing disorder continue to exhibit sensory

processing and integration problems as adults,

although the idea of sensory processing disorder

as a lifelong condition has not been adequately

researched. Some individuals are only fi rst identifi ed with the disorder in adulthood, although

upon history taking, it is almost always the case

that adults share experiences suggesting that

sensory processing differences were also present

throughout their childhood. There has been some

work indicating that sensory processing problems

can occur in the general adult population among

adults with no known comorbid or co-occurring

mental or physical health conditions ( Kinnealey &

Fuiek, 1999 ; Kinnealey, Koenig, & Smith, 2011 ;

 Kinnealey, Oliver, & Wilbarger, 1995 ; Pfeiffer &

Kinnealey, 2003 ). In this section, evidence

suggesting the presence of sensory processing

disorders in adulthood is discussed, along with

some general ideas and principles for evaluating and intervening with adults following an

SI approach.

 The etiology of sensory processing disorder

is largely unknown, but it may be related to a

genetic predisposition or other medical conditions. In addition, some adults with sensory

processing disorders may view their symptoms

simply as part of their constitutional makeup,

or as an aspect of their behavior, personality,

or temperament. Such individuals often do not

understand how it is to live without SI and processing issues because they have no basis for

comparison, despite a feeling that they experience

sensations throughout their daily lives differently

from others. It is common for many adults with

sensory processing differences to experience a

sense of relief in learning that there is a name for

the discomfort or awkwardness they experience,

and that there are others who are challenged by

the same or similar sensory processing symptoms. Adults with sensory processing differences

often develop effective coping mechanisms such

as avoiding or preparing for situations that they

anticipate would be uncomfortable or challenging for them although these techniques are often

exhausting and time consuming ( Kinnealey et al.,

 1995 ; Koomar, 2012 ). Although some coping

mechanisms enable adults to “get through the

day” or recuperate from diffi cult situations more

quickly, these techniques do not entirely relieve

the problem, and often these sensory processing

differences continue to hinder quality of 

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ayres sensory integration and neuroscience

sensory integration olfactory activities

sensory integration outcome measures

sensory integration online course

sensory integration obstacle course

sensory processing occupational therapy

sensory processing overload

sensory processing over responsive

neural integration sensory input

sensory integration physical therapy

sensory integration pyramid of learning

sensory integration practitioner

sensory integration pyramid

sensory integration products

sensory integration premature babies

sensory integration programme

sensory integration process

sensory integration proprioceptive activities

sensory integration powerpoint

sensory integration pathway

sensory integration therapy room

sensory integration session

sensory integration strategies for the classroom

sensory integration screening

sensory integration senses

sensory integration smell

sensory integration sound sensitivity

sensory integration systematic review

sensory integration swing activities

sensory integration speech and language therapy

sensory processing sensitivity

sensory processing sensitivity (sps)

sensory integration therapy for cerebral palsy

sensory integration therapy for sound

sensory integration tactile

sensory integration therapy for autism in tamil

sensory integration therapy in hindi

sensory integration therapy for autism in hindi

sensory integration usmle

sensory integration ultrasound

sensory processing video

sensory integration xbox

sensory integration zen

sensory integration zoo

sensory integration zoom

sensory integration zen den

sensory integration zakir naik