Sensory Integration parte 06

 

508 ■ PART V Complementing and Extending Theory and Application

Sensory Integration

and Associated

Occupation-Based Challenges

 There is a signifi cant amount of literature supporting the presence of SI and processing disorders in adults within clinical groups ( Crane,

Goddard, & Pring, 2009 ; Davidson, 2010, Lyoo

et al., 2006 ; Yeap, Kelly, Reilly, Thakore, &

Foxe, 2009 ), as well as in individuals without

any clinical diagnoses ( Kinnealey & Fuiek, 1999 ;

 Kinnealey et al., 1995 ). One of the fi rst explorations of sensory processing disorders in adults

was a qualitative, phenomenological study with

non-clinical adults ( Kinnealey et al., 1995 ). The

authors described the subjective reality of fi ve

adults with defensive responses to environmental

stimuli and their coping strategies and then proposed a conceptual framework for understanding

this population. From this work, assessment tools

were developed, including the Adult Sensory

Questionnaire (ASQ), a screening tool, and the

Adult Sensory Interview (ADULT-SI), a 75-item,

open-ended, scored interview ( Kinnealey &

Oliver, 1999 ) for examining behaviors associated

with sensory processing in adults.

 The validity of sensory processing defi cits as

being a condition that may be present in some

adults was also addressed by examining the neurophysiological basis of the disorder in adults

with and without sensory defensiveness ( Kinnealey & Smith, 2002 ). These researchers found

differences between adults who are sensory

defensive and non-sensory defensive on the variables of heart rate variance and skin conductance

reactivity.

 In addition to existing in adults without other

known disorders, sensory processing and integration disorders may coexist with some conditions

that are known to occur throughout the life span,

such as intellectual impairment, ASD, and ADHD.

For example, sensory processing differences in

adults with ASD have been described by Crane,

Goddard, and Pring ( 2009 ); Davidson ( 2010 );

 Leekam and colleagues ( 2007 ); and W. Perry

and colleagues ( 2007 ). Several adult-onset

mental health conditions, such as schizophrenia

(see Jahshan et al., 2012 ), bipolar disorder (see

 Lyoo et al., 2006 ; Yeap et al., 2009 ), and conditions associated with anxiety (see Ludewig et al.,

 2005 ), have also been associated with sensory

processing problems. It can also be associated

with PTSD, traumatic brain injury, or sequelae to

violence, such as torture, abuse, or deprivation.

 Researchers have begun to explore and

describe the impact of SI and processing disorders in the lives of adults. Kinnealey and Fuiek

 ( 1999 ), for example, identifi ed differences in

anxiety, depression, and psychological adjustment between adults with and without sensory

defensiveness. May-Benson and Patane ( 2010 ),

in a retrospective review of medical records,

found social-emotional diffi culties, anxiety and

over-arousal, and functional motor and organization problems as being common problems associated with sensory processing defi cits in adults. A

case study report by Pfeiffer ( 2002 ) explored the

impact of SI and processing disorder on occupations in childhood through adulthood; she found

that many of the occupational roles and choices

of the individual were infl uenced by SI and processing disorder. She concluded that meaningful

interventions must address not only the primary

sensory disorder but also the secondary impact

on the person ’ s occupations. Kinnealey, Koenig,

and Smith ( 2011 ) explored the relationship

between sensory modulation, social supports,

and health-related quality of life in adult volunteers matched for age and gender and grouped

by sensory over-responsiveness or non-overresponsiveness. Results indicated that sensory

response style is signifi cantly and differentially

related to symptoms of mental functioning and

quality of life, including social participation.

Evaluation and Intervention

 The process for evaluating adults should

uncover specifi c sensory processing defi cits,

as well as any other physical, cognitive, and

social-emotional problems affecting the adult ’ s

participation in daily life and quality of life

(May-Benson & Kinnealey, 2002). There are

a few tools developed specifi cally to assess

sensory processing disorders in the adult population, although they all focus primarily on sensory

modulation. They include the Adolescent/Adult

SP and the ADULT-SI. The Adolescent/Adult SP

( Brown & Dunn, 2002 ) measures sensory modulation through a self-report format standardized

for individuals between 11 and 65 years of age.

Scores are provided in four quadrants—low registration, sensation seeking, sensory sensitivity,

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 509

HERE ’ S THE EVIDENCE

Kinnealey and colleagues compared 14 adults

with SOR with a typical group of adults, all

between 18 and 60 years of age, wanting to

understand the relationships between SOR,

anxiety, depression, perceived social supports,

and quality of life. Tools used included the ASQ

( Kinnealey et al., 1995 ) and the Adolescent/Adult

Sensory Profi le ( Brown & Dunn, 2002 ) to gather

information on sensory processing, the Medical

Outcomes Social Support Survey ( Sherbourne &

Stewart, 1991 ) for perceived social support,

the Short Form-36 Health Survey, version 2

( Ware, Snow, Kosinski, & Gandek, 1993 ) to

obtain information on health and well-being,

the Beck Depression Inventory-II ( Beck & Steer,

 1987 ), and the Beck Anxiety Inventory ( Beck &

Steer, 1990 ). The two groups of adults differed

signifi cantly on sensory processing ( p = .0001),

depression ( p = .009), anxiety ( p = .000), and

aspects of health and well-being (bodily pain,

p = .012; general health, p = .017; vitality, p =

.009; social functioning, p = .042). Among other

fi ndings, investigators identifi ed signifi cant correlations between SOR and anxiety ( r = .66,

p = .001), and, to a lesser extent, between SOR

and depression ( r = .37, p = .001). Scores on the

Adolescent/Adult Sensory Profi le (SP) quadrants

indicated that sensory sensitivity and sensory

avoiding were related to increased anxiety,

depression, bodily pain, and decreased general

health, vitality, and social functioning. In contrast, sensory seeking was signifi cantly correlated

with the quality of life indicators of vitality and

general health, and it may serve as a protective

factor in reducing the risk of mental and physical health disorders. Investigators suggested that

these results could guide therapists toward a

focus on health-related quality of life for adults

with sensory processing concerns that interfere

with occupational performance.

and sensation avoiding—refl ecting the combination of a person ’ s neurological threshold

(low and high) and behavioral response patterns (active versus passive) to sensory stimuli.

The ADULT-SI is administered in an interview

format to identify sensory defensiveness and

related social-emotional issues, coping strategies,

and the extent to which these impact on daily

living ( Kinnealey & Oliver, 1999 ).

 As with any thorough evaluation, extensive

sensory histories and clinical observations are

essential to the process. The evaluation process

should also include tools that assess performance skills commonly impacted by disorders

of sensory processing, including sensory perception, praxis, motor skills, and postural control.

Some valuable tools appropriate for use with the

adult population include the Quick Neurological

Screening Test—3rd Edition (QNST-3; Mutti,

Martin, Sterling, & Spalding, 1999 ), the Development Test of Visual Perception Adolescent/

Adult (DTVP-A; C. R. Reynolds, Pearson,

Voress, & Frostig, 2002 ), and the Sensorimotor

Performance Analysis ( Richter & Montgomery,

 1989 ). There are also tools that assess the adaptive behavior and functional skills that may be

negatively impacted by sensory processing defi -

cits, such as the Vineland Adaptive Behavioral

Scales II ( Sparrow, Cicchetti, & Balla, 2005 ) and

the Adaptive Behavioral Assessment System II

( Harrison & Oakland, 2003 ). Additionally, measures that address self-effi cacy and self-identifi ed

outcomes, such as the Canadian Occupational

Performance Measure ( Law et al., 2005 ) and

Goal Attainment Scaling ( Kiresuk, Smith, &

Cardillo, 1994 ), are extremely valuable tools

when working with adults who are able to identify the most relevant and meaningful outcomes

for their quality of life.

 Adults benefi t from information and tools that

they can apply to their lives within their natural

environments and everyday routines. Therefore,

intervention for adults is more commonly implemented within their natural contexts, as opposed

to treatment activities for children, which are

often implemented in clinic settings. Sensory

activities providing enhanced tactile, vestibular, and proprioceptive input to address specifi c

sensory-based problems that are identifi ed may

be provided. However, education to assist adults

in understanding the impact of their SI and processing issues on performance of their daily occupations is emphasized. Consultative models of

occupational therapy service delivery are commonly used and may focus on the identifi cation

of activities that provide the type of sensory

stimuli that would help the adult successfully

perform his or her daily occupations. Active participation of the adult in all aspects of the intervention planning and implementation process

is essential as the adult is viewed as the expert

regarding his or her needs, and what is relevant

and meaningful in his or her life.

510 ■ PART V Complementing and Extending Theory and Application

 For adults with sensory modulation defi cits,

direct intervention often includes providing

information, resources, and strategies to help

compensate for sensory processing challenges

by modifying the environment or activities to

increase comfort, and to enhance the ability to

perform necessary and desired daily activities in

the home, workplace, or community. It is helpful

for adults to be able to explain how their sensory

processing differences affect their behavior and

performance, so others can better understand

what they are experiencing. This understanding

enables adults to advocate effectively for adaptations to the sensory features of their environments (for example, at work) for supporting

their performance. For adults who are not able

to self-advocate, caregivers may participate in

the education process, which will enable them to

serve as advocates on behalf of the client.

 Sensory-based motor disorders, including

dyspraxia, and postural disorders can occur with

or without sensory modulation disorders. In

complex cases, one-to-one clinic-based intervention may be recommended over a consultation

model. When treating adults, it is important for

clients to understand not only the nature of their

diffi culties but also the principles of intervention, which positively infl uences their motivation

to participate in treatment, and to follow through

with strategies outside of intervention sessions,

including home programs. Adult clients can be

taught to identify the type of sensory input, combination of sensory inputs, and the frequency and

duration of inputs that work toward improving

their SI functions. This knowledge helps adults

determine the types of activities that would be

of benefi t to them, as well as those that they

would most likely succeed at doing and would

enjoy. For example, an adult ’ s postural and sensorimotor problems, including balance, motor

coordination, and oculo-motor control, might

be addressed by a martial arts program in the

community. Weight training, gym activities, and

swimming strengthen core muscles and improve

other basic motor foundations that support SI

functions. Engaging in a regularly scheduled

gross motor activity that the adult fi nds enjoyable, supplemented with an individualized home

program, can be effective.

 Somatosensory-based dyspraxia can be

addressed by encouraging the adult to engage

in heavy work activities that provide increased

somatosensory and proprioceptive input and that

enhance body awareness. Problem-solving strategies, modeling, or assisting to plan and sequence

the steps involved in a challenging task may be

helpful. Providing more cortical approaches,

such as problem-solving, and suggesting daily

organizational tools may be used in combination

with SI intervention approaches.

 Facilitating adaptive responses is a key

feature of SI intervention for both children and

adults, and adaptive responses can be achieved

by embedding challenging and novel activities

into activity routines, given optimal sensory

input or supports. Avoidance is frequently used

as a coping strategy by adults with sensory-based

motor disorders to decrease the risk of experiencing and having to deal with uncomfortable and

challenging motor situations. Avoidance behaviors often reduce one ’ s ability to fulfi ll roles and

develop skills, as well as social participation,

leading to social isolation and social-emotional

problems. Intervention should, therefore, include

replacing avoiding strategies with more adaptive strategies that support participation and

engagement.

 A treatment model largely based on the

Person-Environment-Occupation model (PEO;

 Brown, 2014 ) was developed for working with

adults with sensory processing disorders. This

model applies principles of SI to help guide

the evaluation and treatment process, including

the identifi cation of appropriate therapy outcomes. This model begins with an evaluation

process to identify which sensory systems are

impacted and how the person ’ s unique sensory

processing styles and abilities impact his or her

daily self-care and other maintenance activities,

emotional functioning, work, sleep, and leisure

pursuits. In addition, the client ’ s social supports, social participation, and quality of life are

addressed. A scored open-ended interview such

as the ADULT-SI ( Kinnealey & Oliver, 1999 )

might be used to gather detailed information

describing patterns of behavioral responses to

sensory stimuli throughout daily life for developing an intervention plan. The interview may

be supplemented by other standardized assessments depending on the individual needs of

the person and contextual factors, and clinical

observations can also be made during sensorimotor and other physical activities. The process

is designed to help the person or his or her

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 511

family and caregivers achieve insight and knowledge about the adult ’ s sensory makeup, as well

as principles of SI that he or she can employ as

needed. Intervention activities are then identifi ed

and designed through a collaborative process and

embedded throughout the adult ’ s day or week

in a manner that supports self-regulation and

enables the cadre of activities to be performed.

A problem-solving process is implemented to

achieve a comfortable fi t between the individual ’ s sensory styles and needs, as well as the

occupations that he or she engages in at home,

at work, and during leisure and social activities.

Through a collaborative process, the individual

and therapist identify activities that are easily

integrated into the meaningful occupations of

the person.

 Effectiveness of the adult intervention model

based on the PEO model ( Brown, 2014 ) was

supported by a study using a pre- and posttest

comparison design of adults with sensory modulation disorder. Results indicated a signifi cant

reduction of sensory defensiveness and anxiety

from pre- to post-intervention ( Pfeiffer & Kinnealey, 2003 ). The consultative treatment model

guided the collaborative development of a protocol that provided insight into sensory defensiveness, regular and daily sensory input, and

engagement in meaningful activities providing

proprioceptive, vestibular, and tactile sensory

input. Participants engaged in the self-treatment

protocol for a month.

 Kinnealey, Koenig, and Smith ( 2011 ) theorized

that adults who seek out sensory input frequently

engage in active and challenging activities, which

may promote fi tness and social engagement. It is

proposed that this sensory-based predisposition

is a protective factor for reducing the chances of

illness, whereas the sensory modulation patterns

of over-responsiveness and under-responsiveness

tend to be associated more often with social

emotional problems, such as anxiety, depression,

social isolation, and non-participation ( Kinnealey et al., 2011 ; Liss, Timmel, Baxley, & Killingsworth, 2005 ). The concept of sensory seeking

as a protective factor was further supported in a

study examining the relationships among adults

with different sensory processing patterns, participation in common home and community-based

activities, and recovery-oriented outcomes in

95 adults with severe mental illness ( Pfeiffer,

Brusilovskiy, Bauer, & Salzer, 2014 ). The adults

who had more sensory-seeking behavior, as indicated on the Adolescent/Adult SP, had higher

levels of participation and recovery than their

peers. Furthermore, adults identifi ed with low

sensory registration and higher sensory sensitivity reported less participation and lower levels of

recovery than their peers.

CASE STUDY ■ GEORGE

 George was an adult who was self-referred

for an evaluation after learning about occupational therapy through a colleague at work. He

recently graduated from college with a degree

in Business and obtained a job in a new area

of the country. George had been working only

3 months at the time of his occupational therapy

evaluation. He reported that he had a diffi cult

time adapting to his new environment, both at

home and at work. He was easily overwhelmed

by the noise in the offi ce and his apartment was

so disorganized that he was losing important

items. His clothing was often disheveled and he

was unaware of his appearance to others until

someone made a comment at work. Before

his recent move, he always lived with family

or roommates who helped him with many of

these issues. George received learning supports

in school when he was younger and received

accommodations in college, but he never

received occupational therapy services.

 George was evaluated using the Adolescent/

Adult SP and the QNST-3. He reported his

primary concerns as his ability to attend and

complete tasks at work, and the lack of organization in his apartment. Results of the evaluation

revealed signifi cant auditory over-responsivity,

decreased proprioceptive awareness, reduced

tactile discrimination, and dyspraxia. This

impacted his ability to complete many novel

daily activities. For example, his apartment was

extremely disorganized as he was not able to

perform basic cleaning and straightening up

tasks that were new to him. His clothing was

often disheveled and, at times, buttons were

not aligned properly. This contributed to concerns with his appearance socially and at work.

His distractibility impacting work performance

seemed most signifi cantly impacted by the level

of noise in the environment.

 Intervention focused on educating George

on his condition and possible SI strategies.

512 ■ PART V Complementing and Extending Theory and Application

were still in his apartment 3 months later. When

he learned how to complete this task, the clutter

and disorganization was signifi cantly reduced,

which allowed George to focus on more specifi c home care tasks. After 3 months of occupational therapy using an SI approach, George

was able to maintain the organization and

cleanliness of his home, increase his work productivity, and improve his personal appearance

for work and social events.

HERE ’ S THE POINT

• Research studies support the idea that sensory

processing problems commonly occur in adult

populations with and without coexisting

disorders, and that sensory modulation

disorders have received the most attention.

• Assessment tools and sensory-based

interventions have been designed specifi cally

for use with adults.

• A consultative approach to intervention,

designed to minimize exposure to sensory

sensitivities and to identify or provide activities

and strategies for meeting individualized

sensory needs and preferences, as well as for

enhancing performance in daily life, may be

useful.

• Although there is some relevant research

available, there is a dearth of studies specifi cally

examining the effectiveness of SI interventions

designed for adults.

Where Can I Find More?

 American Occupational Therapy Association.

(2011). Occupational therapy using a sensory

integration approach with adult populations,

fact sheet. Bethesda, MD: AOTA.

 Blanche, E. I., Parham, D., & Chang, M. (2014).

Development of an Adult Sensory Processing

Scale (ASPS). American Journal of Occupational Therapy, 68, 531–538. doi:10.5014/

ajot.2014.012484

 May-Benson, T. (2009, June). Occupational

therapy for adults with sensory processing

disorders, OT practice. Bethesda, MD: AOTA.

FIGURE 19-15 George added weightlifting to his

everyday routines as a way to meet his sensory

needs. Photo courtesy of Chris Cline.

This helped him engage more actively in the

intervention process and identify strategies

that were acceptable and meaningful for him.

Simple environmental adaptations were identifi ed to help George in his work environment.

He used noise-attenuating earbuds to block out

extraneous auditory stimuli. Additionally, he

advocated to have his desk moved to a quieter

location in his offi ce. George reported that his

work performance, as reported by his peers and

supervisors, improved signifi cantly after these

small adaptations. George participated in individual occupational therapy sessions to improve

overall body awareness, tactile discrimination,

and praxis for functional motor tasks. Sessions

were provided in both the clinical and home settings. Together with the therapist, he identifi ed

activities that provided deep pressure tactile,

proprioceptive, and vestibular sensory input

for implementation throughout his daily routines. These included activities such as biking

and weightlifting at the gym ( Fig. 19-15 ), as

these were preferred activities for George. The

occupational therapist worked with George in

his home settings to instruct him in how to

complete novel home care tasks that required

advanced praxis skills. They worked together

to break down the tasks and added additional

sensory feedback as necessary during the performance of the task. For example, although

George unpacked the majority of items from

his initial move, he was not able to fi gure out

how to break down the moving boxes, which

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 513

Section 6 : Sensory Integration

Approaches with Adults with Mental

Health Disorders

 Tina Champagne, OTD, OTR/L ■ Beth Pfeiffer, PhD, OTR/L, BCP

Background and Rationale

for Applying Sensory Integration

and the Impact on Occupation

 During the past decade, SI theory, assessment,

and intervention have expanded in scope and

application, and are being utilized increasingly

with adults with mental health symptoms, disorders, and related behaviors. This section

addresses applications with adults with schizophrenia, anxiety disorders, stress-related disorders including PTSD, and mood disorders. First,

there is discussion of the types of SI symptoms

and associated occupation-based problems characteristic of each of these mental disorders.

 Schizophrenia

 Schizophrenia is a mental health disorder characterized by psychosis that may include delusions,

hallucinations, disorganized speech, or grossly

disorganized or catatonic behavior. In order to

be diagnosed with schizophrenia, behaviors must

persist and signifi cantly interfere with occupational performance and participation, and cannot

be accounted for by other mental disorders, such

as a mood disorder ( APA, 2013a ). In recent years,

there has been an increase in research related to

understanding sensory processing in individuals with schizophrenia ( Champagne & Frederick, 2011 ; Javitt, 2009a ; Mouchet-Mages et al.,

 2007 ). Individuals with schizophrenia show poor

sensory gating, or diffi culty with sensory fi ltering, resulting in a diminished ability to inhibit

response to irrelevant sensory stimuli (Arnfred &

Chen, 2004; Micoulaud-Franchi et al., 2016 ;

 Patterson et al., 2008 ; Vlcek, Bob, & Raboch,

 2014 ). It has been suggested that inadequate

gating leads to sensory overload and contributes

to diffi culties with cognitive process in individuals with schizophrenia. Keil, Roa Romero,

Balz, Henjes, and Senkowski ( 2016 ) have also

suggested that differences in auditory gating correspond to subtypes of schizophrenia, something

that may impact treatment approaches. In addition, some researchers have suggested that, given

the complexity of schizophrenia, rather than

simply a “mental health disorder,” it should be

considered a neurodevelopmental, biobehavioral,

and cognitive disorder with psychiatric symptoms; they indicated that sensory processing

defi cits contribute substantially to the cognitive

concerns ( Twamley, Salva, Zurhellen, Heaton, &

Jeste, 2008 ). This later point supports an earlier

statement that sensory processing defi cits in

childhood “may contribute greatly to defi cits in

higher-order cognition” ( Leitman et al., 2005 ,

p. 56). Phillips and Seidman ( 2008 ) proposed

that diffi culties with sensory processing and emotional and behavioral regulation are evident in

some individuals before the onset of symptoms

associated with schizophrenia. Subsequently,

these diffi culties may serve as early biomarkers

of the disorder.

 Defi cits in visual processing among individuals with schizophrenia are well documented

( Kantrowitz, Butler, Schecter, Silipo, & Javitt,

 2009 ; Silverstein & Keane, 2008 ). For example,

problems with visually decoding facial information and a reduced capacity for recognizing and

identifying emotions in others has been demonstrated consistently by Butler and colleagues

( Butler et al., 2005 ; Butler et al., 2007 ; Butler

et al., 2009 ). Such challenges have been shown

to negatively infl uence the quality of social interactions and social participation in individuals

514 ■ PART V Complementing and Extending Theory and Application

with schizophrenia ( Butler et al., 2009 ; Javitt,

 2009a, 2009b ). Problems integrating sensory

information from the vestibular and visual

systems to execute skills such as coordinating

eye movement to visually scan and track objects,

and to read, have also been identifi ed in people

with schizophrenia ( Chen, 2011 ; D. Kim, Wylie,

Pasternak, Butler, & Javitt, 2006 ).

 Olfactory discrimination problems were

reported by Atanasova, Graux, El Hage,

Hommet, Camus, and Belzung ( 2008 ) as well as

 Moberg and colleagues ( 1999 ), who suggested

that atypicalities in processing odors may be a

potential biomarker of schizophrenia. Diffi culty

with auditory discrimination, such as the ability

to match tones, was found to lead to impairments in the processing of phonological information and auditory emotion recognition in adults

in schizophrenia ( Javitt, 2009a ; Leitman et al.,

 2008 ; Turetsky, Bilker, Siegel, Kohler, & Gur,

 2009 ; Vinogradov & Nagarajan, 2017 ). Finally,

diffi culty with somatosensory processing, including under-responsivity to pain sensations, was

reported by Arnfred and Chen ( 2004 ) and Chang

and Lenzenweger ( 2005 ).

 Movement-based interventions have been

shown to decrease negative symptoms of schizophrenia ( Rohricht & Priebe, 2006 ), suggesting

that there is a possible link between vestibular

and proprioceptive processing and the underlying processes involved in schizophrenia. Using

Dunn ’ s Model of Sensory Processing ( Brown &

Dunn, 2002 ), people with schizophrenia were

found to have a high neurological threshold for

stimulation and exhibit fewer sensation-seeking

patterns than most neuro-typical adults in the same

age range ( Brown, Cromwell, Filion, Dunn, &

Tollefson, 2002 ). Although more research is

necessary, this growing body of evidence strongly

supports the idea that people with schizophrenia have a variety of sensory processingrelated challenges that often interfere with

their daily functioning and occupational performance, supporting sensory-based intervention

approaches with this population.

Anxiety Disorders

 Anxiety disorders refer to a family of disorders characterized by excessive feelings of fear,

worry, concern, or apprehension that interfere

with one ’ s ability to function. Anxiety disorders

include several more specifi c disorders, such as

separation anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, generalized

anxiety disorder, and selective mutism ( APA,

 2013a ). Engel-Yeger and Dunn ( 2011 ) found that

in Western cultures, adults with a high threshold

for stimulation (SUR) often experience symptoms of anxiety, shame, guilt, hostility, and irritability. These researchers also found that a pattern

of sensory sensitivity was correlated with trait

anxiety, which is a general level of anxiety that

is related to personality and that results in an

individual becoming easily stressed and anxious.

In contrast, the sensation-avoiding pattern was

correlated with state anxiety or a state of heightened emotions that develops in response to a

fear or danger of a particular situation. Signifi -

cant correlations have been found between SOR,

high anxiety, and diffi culty coping with everyday

situations ( Bakker & Moulding, 2012 ). Hoffman

and Bitran ( 2007 ) explored correlations between

SOR and social anxiety disorder and revealed that

SOR appears to be separate from social anxiety,

although it is highly correlated with agoraphobic and harm-avoidance patterns. Although more

research is needed, these investigators indicated

that individuals with the generalized subtype of

social anxiety disorder tended to report higher

levels of SOR than study participants with a

non-generalized subtype.

 Although many studies have supported a

relationship between SOR and anxiety, it has

also been shown that some people (especially

males) with SUR patterns or low sensory registration have a higher probability of trait anxiety,

somatization, high levels of distress, feelings

of fear and guilt, and preoccupation with body

image ( Ben-Avi, Almagor, & Engel-Yeger,

 2012 ; Engel-Yeger & Dunn, 2011 ). According

to Jerome and Liss ( 2005 ), adults with SUR

may be separated into two groups: those who

tend to be under-aroused, and those who tend

to be hyper-aroused or extremely overwhelmed

and then shut down or “tune-out,” perhaps as

a coping mechanism. Engel-Yeger and Dunn

 ( 2011 ) found that individuals with SUR patterns

have diffi culty with recognizing and appraising

sensory stimuli, which can result in increased

anxiety and over-reactivity or a denial of distress

and shut down ( Engel-Yeger & Dunn, 2011 ).

 For many years, problems with vestibular functioning have been linked to anxiety

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 515

disorders ( Balaban & Jacob, 2001 ; Jacob,

Whitney, Detweiler-Shostak, & Furman, 2001 ;

 Simon, Pollack, Tuby, & Stern, 1998 ; Staab,

 2017 ). Balaban ( 2002 ) created a complex model

demonstrating the neurological basis linking

anxiety and balance. He cited evidence that a

vestibulo-recipient region of the parabrachial

nucleus (PBN) of the brain contains cells that

respond to body rotation and position relative

to gravity. He further explained that this area

assists in integrating vestibular, somatic, and visceral information, helping to mediate avoidance

anxiety and fear responses. Perna and colleagues

 ( 2001 ) also described balance problems as measured by posturography in individuals with panic

disorder and agoraphobia.

Trauma and Stress-Related Disorders

 Trauma and stress-related disorders, such as

PTSD, acute stress disorder, and adjustment

and attachment disorders, also are characterized

by feelings of anxiety, although they have their

own diagnostic category and unique set of criteria ( APA, 2013a ). Trauma is defi ned as an individual ’ s experience of circumstances or events

that are threatening or harmful, emotionally or

physically, and have an adverse infl uence on a

person ’ s physical, emotional, social, or spiritual

functioning and well-being ( Substance Abuse

and Mental Health Services Administration

[SAMHSA], 2014 ). Circumstances and events

that are traumatic may be single, repeated, or

chronic, and the emotional or physical threat

may be actual, witnessed, or perceived. Neglect

is also considered a form of trauma (SAMHSA,

2014). The degree of traumatic stress that an

individual experiences after traumatic circumstances or events depends upon many variables,

such as the amount of control an individual has

regarding the experience, the amount and type

of supports available, the predictability of the

events, and the degree of adaptability intrinsic to

the individual ( APA, 2013a ).

 The pervasive infl uence of trauma across the

lifespan and its infl uence on affect regulation,

attachment formation, and other medical, integrative, and developmental capacities are well documented ( Briere, Kaltman, & Green, 2008 ; Feletti

et al., 1998 ; Porges, 2008 ; Schore, 1994 ; van der

Kolk, 2006 ). Some of the symptoms of individuals who have experienced multiple or prolonged

trauma include diffi culty with arousal regulation,

re-experiencing of the traumatic stressors or

events (e.g., nightmares, fl ashbacks), avoidance

of trauma-related triggers, hypervigilance, dissociation, and being easily startled. These symptoms often result in diffi culties with participating

in meaningful life roles and activities. There is

an abundance of research that has shown how

trauma impacts the structure and function of

the brain and why such trauma has a pervasive

infl uence on an individual ’ s life ( De Bellis et al.,

 2002 ; De Bellis & Kuchibhatla, 2006 ).

 Stewart and White ( 2008 ) revealed that people

with PTSD have diffi culty fi ltering out unwanted

sensory stimuli, demonstrating patterns of SOR.

Research also has shown that people with SOR,

being more aware of sensory stimuli, have a

higher risk and probability of developing PTSD

if exposed to trauma ( Hendler et al., 2003 ).

Symptoms and behaviors seen in individuals

with PTSD and in those with sensory processing

problems may be viewed as adaptive responses,

as these individuals may need to be able to identify risks and threats within the environment in

order to protect themselves from potential danger.

Hence, low sensory registration behaviors have

been proposed as an example of a neurologically

based, protective, adaptive response sometimes

used to tune out or shut down the processing of

sensory stimuli perceived as traumatic ( Jerome &

Liss, 2005 ). Through time, these nervous system

responses may become dominating, habitual patterns that continue throughout adulthood when

not addressed ( Cloitre et al., 2009 ).

 Using functional Magnetic Resonance

Imaging (fMRI), Croy, Schellong, Joraschky,

and Hummel ( 2010 ) examined how women with

a history of childhood maltreatment process

non-threatening and non-trauma-related olfactory

stimuli as compared with control subjects. Individuals who had experienced childhood maltreatment showed enhanced activation in multiple,

mainly neocortical, areas, such as the precentral frontal lobe, posterior parietal lobe, occipital lobe, and the posterior cingulate cortex. The

results suggested there was a pattern of enhanced

activation in associative and emotional brain

regions. This indicates that following trauma,

hypervigilance is often present, resulting in the

central nervous system (CNS) being on constant

alert. Because the CNS prioritizes the processing

of danger and noxious sensory stimuli and is

516 ■ PART V Complementing and Extending Theory and Application

constantly assessing for threat(s), the individual ’ s

capacity to attend to other aspects of the environment is likely reduced. Research on trauma and

stress reveals that these experiences often compromise one ’ s ability to regulate, fi lter, organize,

and process sensations (internal and external).

Mood Disorders

 Mood disorders are the most common mental

health disorders and include depressive disorders

as well as bipolar disorder. Depression involves

feelings of extreme sadness; being unmotivated;

feeling worthless, helpless, or suicidal; and

having little or no interest in typical pleasurable

activities ( APA, 2013a ). People with depression

also often have diffi culties sleeping or eating.

Bipolar disorder involves depressive episodes

with periods of extreme excitement and irritability or mania. Symptoms of mania include feelings of extreme irritability; infl ated self-esteem;

and having racing thoughts, poor judgment, and

the urge to engage in extremely risky behaviors

( APA, 2013a ). People with mood disorders often

have diffi culty successfully engaging in their

daily occupations, such as completing tasks at

work, managing a household, participating in

leisure activities, and maintaining healthy relationships with family and friends.

 Similar to what has been documented in individuals with schizophrenia, adults with bipolar

disorder show electrophysiological defi cits in

the auditory domain and visual processing ( Yeap

et al., 2009 ). Auditory sensory gating is also

problematic in individuals with bipolar disorder;

for those with a history of psychosis sensory

gating worsens ( Cheng, Chan, Liu, & Hsu, 2016 ).

 Yeap and colleagues ( 2009 ) compared a sample

of adults with bipolar disorder with age-matched

healthy controls and, using electroencephalography, showed markedly different visual processing

neurophysiology, suggestive of a dysfunction in

visual processing. Lyoo and colleagues ( 2006 )

compared brain magnetic resonance images from

a sample of subjects with and without bipolar

disorder. They discovered that those with bipolar

disorder exhibited signifi cantly decreased cortical thickness in multiple prefrontal cortical areas

and cortical thinning in sensory and sensory

association cortices. These researchers concluded

that such differences may account for some of

the emotional, cognitive, and sensory processing

impairments seen in adults with bipolar disorder. Newer research, using MRI technology to

examine intracortical myelin in individuals with

schizophrenia and those with bipolar disorder,

found parallels between these disorders. Reduced

intracortical myelin was identifi ed in sensory and

motor regions of the brain, leading investigators

to hypothesize that inhibition of sensory input

was reduced, leading to distortions in perceptual

processing. Investigators emphasized that these

results are preliminary ( Jorgensen et al., 2016 ).

Finally, the dysregulation of energy and arousal

level that characterizes mood disorders appear

quite similarly in individuals with sensory modulation disorders. Adults with depression may

appear as having low levels of sensory registration or exhibit sensory-avoiding behaviors,

whereas adults with mania appear as sensory

seeking.

Evaluation and Intervention

 The overwhelming evidence relating specifi c

kinds of sensory processing dysfunction in adults

with psychiatric or mental health disorders supports the application of SI theory and principles

as part of comprehensive occupational therapy

services in mental and behavioral health settings. Sensory-based assessments help to identify and describe some of the diffi culties people

with mental health disorders may have that signifi cantly impact their ability to participate in

their daily occupations. Assessment tools, such

as the Adolescent/Adult SP ( Brown & Dunn,

 2002 ), the Adult/Adolescent Sensory History

(May-Benson & Teasdale, 2015), Ayres’ formal

clinical observations, interviews focusing on

detailed sensory histories, and informal observations of occupational performance (at home,

community, work, or in the context of therapeutic groups), can provide valuable information

about how sensory processing defi cits are contributing to one ’ s behavior, symptoms, and areas

of occupational performance.

 Among other intervention strategies, adults

with mental health needs and goals can be taught

to recognize their sensory differences and preferences and how they usually respond to certain

sensory features of environments and activities.

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 517

This increased self-awareness can then be used to

modify, reduce, or enhance the kinds of sensory

input they experience on a daily basis to support

their ability to function, increase comfort sensations, decrease undesirable or unsafe behaviors,

and promote engagement in meaningful roles,

routines, and occupations ( Champagne & Frederick, 2011 ). The identifi cation of individualized, sensory strategies to use as part of personal

self-care plans, for grounding and self-soothing

purposes, or mindfulness practice is often helpful

with this population.

 Sensory diets (see Chapter 18, Complementary Programs for Intervention, for more information) are routines that are collaboratively

designed to ensure that individuals regularly and

strategically schedule sensory-based activities

that will help them self-regulate and perform to

the best of their abilities throughout the day. The

creation of predictable routines and adding structure to daily tasks also gives individuals more

control regarding the amount and type of sensory

input they experience. Personal safety plans can

also be developed that include sensory-based

strategies that are easily accessible to the individual ( Chalmers, Harrison, Mollison, Molloy, &

Gray, 2012 ).

 Interventions for adults with mental health

concerns largely focus on making environmental or activity modifi cations that consider sensory

processing needs and preferences so that the

person can more easily and successfully participate in his or her daily occupations. Environmental modifi cations might include setting up

quiet, uncluttered work areas to minimize visual

and auditory stimulation and eliminating fl uorescent lighting. 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 focus and organization. Sensory

supportive spaces and portable sensory carts

may be used in a variety of settings (e.g., home,

residential, school, forensic) so that individuals

can readily use and explore different stimuli as

needed. Similar to therapeutic applications with

youth, sensory approaches are also used to help

individuals change their sensory processing patterns in order to support participation, and are

not solely for coping, stress management, or

regulatory purposes. Providing education and

resources for individuals with mental illness and

their family members regarding the symptoms

and behaviors experienced, and how sensory

processing abilities and challenges affect safety,

behavior, and occupational participation, often

provides a new and useful perspective.

 Sensory-based interventions are provided as

part of individual and group sessions. Chalmers

and colleagues ( 2012 ) also researched the effectiveness of a group intervention for adults with

mental illness, for improving awareness of the

effects of different sensations on thoughts, behavior, and functioning. The sensory group provided

an opportunity for clients to discuss, share, and

explore their own sensory diets and preferences

and to experiment with different sensory strategies ( Chalmers et al., 2012 ). Finally, in some

cases, more traditional sensory-based clinic

interventions involving therapeutic activities or

exercise that are heavily loaded with tactile, proprioceptive, and vestibular sensory input may be

appropriate. Such interventions are best designed

in accordance with the adult ’ s specifi c sensory

needs in mind and following the same basic principles of ASI, including being client-driven and

incorporating challenging activities. Specifi c SI

problems, such as dyspraxia, visual perceptual

and visual motor defi cits, sensory modulation

challenges, or postural, praxis, and motor coordination problems, might be addressed using a

more traditional ASI approach.

 Chalmers and colleagues ( 2012 ) also looked

at the effectiveness of various sensory strategies within one of their mental health facilities,

including environment modifi cations, personal

safety plans, sensory groups, a sensory room,

and staff education on sensory-related issues.

The results showed that 93% of patients believed

the sensory room and the personal safety plans

were most effective in stress reduction and for

helping to control their symptoms. Sensory

rooms were found to create a “safe space” within

the unit where patients felt supported and comfortable. Similarly, the use of sensory strategies

and creation of a sensory space for self-soothing

purposes was shown to promote the ability to

decrease agitation and better regulate autonomic

arousal levels across four inpatient mental health

units in New Zealand ( Sutton, Wilson, Van

Kessel, & Vanderpyl, 2013 ). Champagne and

Stromberg ( 2004 ) had earlier demonstrated that

518 ■ PART V Complementing and Extending Theory and Application

staff training and the skilled use of a sensory

modulation-style room with adults during an

acute inpatient admission helped to reduce the

use of seclusion and restraint by three standard

deviations during the course of 1 year.

Sensory rooms are sometimes created in

mental health-care and other types of settings

serving adult populations, and they are geared

primarily toward offering sensory strategies to

promote self-nurturance, comfort, stress prevention, decreased patient distress or agitation, and

for de-escalation of diffi cult behaviors ( Chalmers et al., 2012 ; Champagne & Stromberg, 2004 ;

 Sutton et al., 2013 ; Wiglesworth & Farnworth,

 2016 ). Sensory rooms are often described as

being quiet spaces commonly found in an acute

or long-term care mental health setting equipped

with sensory modalities, such as massage chairs,

beanbags, music, weighted blankets, light and

visual features such as colored fi sh tanks, stress

balls, water and fountain features, and lollipops

or other candy ( Chalmers et al., 2012 ; Champagne & Stromberg, 2004 ). Although there is

limited research relative to their effectiveness,

one recent study examining use of a sensory

room in a forensic mental facility suggested

that both staff and patients felt use of the room

resulted in stress reduction ( Wiglesworth &

Farnworth, 2016 ).

Snoezelen™ rooms, often referred to as multisensory environments, are a type of sensory

room that provides a variety of sensory experiences and that are generally used with individuals

with moderate to severe cognitive impairments,

such as dementia or psychosis. These rooms

aim to promote relaxation and social interaction.

Sensory rooms vary from setting to setting and

can be tailored and modifi ed to meet the needs of

the clients they serve. Staff training is necessary

to ensure the skilled and safe use of all items and

equipment when creating and implementing the

use of sensory rooms in different contexts.

Case Studies

 Two case studies are presented in this section to

demonstrate how occupational therapy using SI

techniques may be applied to adults with mental

health disorders. The fi rst case, Janelle, is an

adult with schizophrenia, and the second case

describes a woman, Amy, with bipolar disorder.

CASE STUDY ■ JANELLE

 Janelle was a 28-year-old single mother diagnosed with schizophrenia, who was referred for

occupational therapy at an outpatient community health clinic. During the initial interview,

she reported that many sounds outside and

groups of people made it hard for her to leave

the house. She reported feeling uncomfortable

running errands, such as going grocery shopping, attending groups at her day program, and

going to meetings or events at her daughter ’ s

school. She stated that, “I no longer go out of

the house much, and I do not spend time with

any of my friends.” She also reported discomfort with intimate relationships and with completing some self-care, home maintenance, and

child-care tasks. She reported that she often

did not feel comfortable in her own skin and

found it diffi cult to navigate in the environment

because of a fear of elevators, escalators, and

even going up and down stairs. She stated that

she bumps into things and falls down easily.

She also reported that she struggles with symptoms of schizophrenia, including feelings of

paranoia and experiencing hallucinations.

 As part of the evaluation process, the

occupational therapist helped Janelle identify

her strengths and challenges, what was most

important to her, and what she wanted to work

on. Assessment tools, in addition to the interview, included the QNST-3 ( Mutti et al., 1999 ),

Clinical Observations of Sensory Integration

( Blanche, 2002 ), Adolescent/Adult SP ( Brown &

Dunn, 2002 ), and the Sensory Modulation

Screening Tool ( Champagne, 2011b ). Janelle ’ s

assessment results were consistent with the

types of sensory processing concerns that she

shared during the initial interview. Her sensory

processing suggested sensory modulation concerns, with scores much higher than others in

low registration, sensory sensitivity, and avoiding patterns. Sensory discrimination problems,

including somatosensory, auditory, and visual

discrimination challenges, were identifi ed, as

well as a sensory-based motor disorder characterized by low muscle tone, poor bilateral

coordination, and poor praxis or motor planning skills. The therapist and Janelle discussed

how Janelle ’ s sensory processing challenges

were impacting her ability to carry out her daily

occupations and contributing to her feelings of

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 519

discomfort in her own skin and when going

outside the home. Intervention goals were

developed collaboratively with Janelle, who

wanted to address her sensory modulation problems, diffi culty with balance and visual-spatial

perception, and fi ne and gross motor coordination as she felt these were barriers to recovery

and to successful occupational participation.

 Janelle was interested in using some of

the equipment in the occupational therapy

gym, such as suspended equipment to address

balance, coordination, and motor planning.

Visual tracking and aiming activities were

also incorporated; she sometimes planned, set

up, and completed physical challenge obstacle

courses that involved climbing and balancing

activities, and she did some arts and crafts activities using a variety of different textured materials and media. Janelle was taught how to carry

over the skills she was learning in the clinic at

home and how she could incorporate some of

the activities she was doing in the clinic space

into her daily routines. A home program was

created with the support of her outreach worker

and included the use of graded activities of

daily living and leisure activities. She created

a sensory kit ( Fig. 19-16 ) where she kept some

sensory tools organized and readily available

for use as part of a sensory diet to prevent her

from becoming overstimulated or agitated or

for calming when necessary. She modifi ed a

corner in her bedroom and living room where

she could use sensory modulation strategies as

needed, and she used a daily self-rating scale to

monitor her behavior and to track her progress.

 After 6 months of weekly occupational

therapy services and follow through with her

home program, Janelle demonstrated signifi cant

gains. The skills that she had learned helped

her perform more competently and comfortably

the everyday self-care, child care, leisure, and

home management activities that she wanted,

and was expected, to do. She increased her participation in meaningful life roles (e.g., parent,

friend, day program participant), and, through

time, she began to feel more comfortable going

out into the community. For example, she

signed herself and her daughter up for swimming lessons at the local YMCA, she enrolled

in a small yoga class, and she more regularly

took her daughter to a park with a playground.

CASE STUDY ■ AMY

 Amy was a graduate student completing

her fi nal school counseling internship at her

local high school. She had been diagnosed

with bipolar disorder in her freshman year of

college. Amy self-referred for an occupational

therapy evaluation after learning about SI from

the occupational therapist at her internship site.

Amy reported that she always knew she was

different and could never understand why so

many things bothered her that did not bother

others. She remembered feeling this way from

a very young age.

 Amy was evaluated using an interview,

and the QNST-3 ( Mutti et al., 1999 ) and

Adolescent/Adult SP ( Brown & Dunn, 2002 )

were administered. She reported her primary

concerns as her ability to complete her internship successfully and maintain successful

employment in a school setting as a school

counselor. She reported feeling traumatized in

her internship environment every day, as she

was overwhelmed by the amount and intensity

of sensory stimuli at work. Results of the evaluation revealed moderate tactile hypersensitivity, impacting the types of clothing she would

wear and causing feelings of discomfort with

unexpected touch from others. She described

feeling pain when wearing certain types of

work clothes and also having intense feelings

of wanting to hit people throughout the day

FIGURE 19-16 Janelle developed a kit with sensory

tools to support strategies she used as part of her

sensory diet. Photo courtesy of Carissa Reinbein.

520 ■ PART V Complementing and Extending Theory and Application

when they bumped into her in the halls or came

up from behind and touched her. The noise of

the school environment was overwhelming her,

and she had diffi culty interacting with others in

many of the classrooms because of the noise

and brightness of the fl uorescent lighting. She

reported that she very much enjoyed working

with the students and her colleagues but that

she often left work with headaches and completely exhausted. Previously she had been able

to cope with her sensory differences by avoiding stimulating environments or by making

sure that activities and environments were at

least predictable for her. However, these coping

strategies were not effective in her new work

environment. Amy reported that as a child she

was clumsy and had a diffi cult time keeping

up with her peers in motor activities. However,

this was no longer a concern because the activities she chose to participate in now suited her

motor skills.

 Intervention began with providing education on SI and processing so Amy could

better understand her own behaviors and feelings. This knowledge helped her become more

self-aware regarding how her sensory issues

impacted her participation and performance

throughout her daily activities. Although she

was unable to make adaptations to her school

environment to decrease the amount of sensory

stimuli in the classrooms or hallways, she did

have an offi ce area where she could make adaptations to minimize the noise and lighting. The

therapist also suggested that she retreat to her

offi ce for short time periods during the day

in order to implement activities that provided

modulating sensory input and to recuperate

after being in very stimulating environments.

Together with her therapist, she identifi ed

activities that provided deep pressure as well

as tactile, proprioceptive, and calming vestibular sensory input for implementation throughout her daily routines. Some of these included

a rigorous hike before work in the morning

( Fig. 19-17 ) and doing a short yoga workout

in the school gym during her lunchtime, which

also allowed her to avoid the school cafeteria

area. She used a weighted lap beanbag or did

chair pushups when sitting at her desk, which

provided deep pressure and proprioceptive

input. As Amy developed a better understanding of SI, she expanded the types and amounts

of modulating sensory activities both at home

and in the school environment. For instance,

she began practicing yoga at home as a way

of lowering her arousal level at the end of the

day ( Fig. 19-18 ). Intervention was discontinued

FIGURE 19-18 Amy used yoga at home, providing

her with proprioceptive input, to reduce stress at the

end of the day. Photo courtesy of Melissa Tucker.

FIGURE 19-17 Amy began engaging in morning

hikes whenever possible, providing proprioception,

tactile, and vestibular inputs, to prepare for the day

ahead. Photo courtesy of Melissa Tucker.

CHAPTER 19 Application of Sensory Integration with Specifi c Populations ■ 521

after six weekly sessions that were collaborative and more consultative in nature. Amy did

well with intervention and was happy to report

to her therapist that she not only successfully

completed her internship but that she was hired

on as a school counselor at the school.

HERE ’ S THE POINT

• There is a solid research base linking SI and

processing problems with many mental

disorders.

• Common sensory-based approaches include

providing activity and environmental

modifications, providing education on how

sensory processing differences associated with

certain mental disorders impact one ’ s behavior

and functioning, use of sensory rooms,

developing and implementing sensory diets,

and providing traditional ASI.

Where Can I Find More?

 Bar-Shalita, T., & Cermak, S. A. (2016). Atypical sensory modulation and psychological

distress in the general population. American

Journal of Occupational Therapy, 70, 1–9.

 Bar-Shalita, T., Vatine, J., Parush, S., Deutsch,

L., & Seltzer, Z. (2012). Psychophysical correlates in adults with sensory modulation disorder. Disability and Rehabilitation, 34 (11),

943–950.

 Ben-Avi, N., Almagor, M., & Engel-Yeger, B.

(2012). Sensory processing diffi culties and

interpersonal relationships in adults: An

exploratory study. Psychology, 3, 70–77.

 Champagne, T. (2011c). The infl uence of posttraumatic stress disorder, depression, and

sensory processing patterns on occupational

engagement: A case study. WORK: A Journal

of Prevention, Assessment, & Rehabilitation,

38 (1), 67–75.

Summary and Conclusions

 In Chapter 1 (Sensory Integration: A. Jean Ayres’

Theory Revisited), we indicated that there were

boundaries in the application of SI theory. More

importantly, we indicated that when therapists

work outside the boundaries of the initial theory,

they must proceed with caution. The sections

in this chapter refl ect the cautious thinking of

therapists and experts on the application of theoretical constructs outside these original boundaries. Bigsby provides support for the application

of sensory integrative theory and practice for

high-risk infants, and she indicates that applying these ideas as part of a family-centered

intervention approach is important. Considering

childhood disorders, Mulligan, as well as Benevides and colleagues, indicated that both ADHD

and ASD have a more substantive history of

disorders in modulation and praxis, and there

is increasing support for the use of a sensory

integrative approach as a component of intervention. An additional application of sensory

integrative constructs is described by Kennedy,

relative to disorders of trauma and attachment,

where increasingly we are seeing references to

diffi culties with sensory processing as part of

the overall concerns. She further explained that

blending a sensory integrative foundation with

an approach that emphasizes regulation and relationship building is showing promise for TIC.

Pfeiffer indicated that adults with and without

other diagnoses can be identifi ed as having disorders of sensory modulation, and that a consultative approach to treatment is useful in supporting

occupational participation. Expanding on this,

Champagne and Pfeiffer stated that individuals

with mental health disorders, across the age spectrum, also experience disorders of SI, suggesting

that intervention should give consideration to the

use of SI constructs. Each of these sections was

carefully considered and supported by available

research. Thus, increasingly there is a research

basis for expanding the original boundaries of SI

theory and practice. However, as has been stated

in other chapters in this book, more research is

needed.

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PART

VI

CASES

532

CHAPTER

20

Planning and Implementing

Intervention Using Sensory

Integration Theory

 Anita C. Bundy , ScD, OT/L, FAOTA ■ Susanne Smith Roley , OTD, OTR/L, FAOTA

 Chapter 20

 “Would you tell me, please,” [asked Alice,] “which way I ought to walk from

here?” “That depends a good deal on where you want to get to,” said the

Cat. “I don ’ t much care where,” said Alice. “Then it doesn ’ t matter which

way you walk,” said the Cat. “—so long as I get somewhere,”

Alice added as an explanation. “Oh, you ’ re sure to do

that,” said the Cat, “if you only walk long enough.”

 — Carroll, 1923 , p. 69

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

✔ Utilize a process of goal setting and

intervention planning with particular

children.

✔ Understand the systematic application of

clinical reasoning as it pertains to Ayres Sensory

Integration ® (ASI).

LEARNING OUTCOMES

Purpose and Scope

 In this chapter, we provide a brief overview

of goal setting and intervention planning,

based on assessment fi ndings. We illustrate

decision-making associated with Ayres Sensory

Integration ® (ASI) methods with Kyle, one of the

children whose evaluation data we had presented

in Chapter 11 (Interpreting and Explaining Evaluation Data). We discuss not only aspects of the

intervention that went “according to plan” but

also some of the diffi culties we encountered.

Introduction

 Intervention consists of two phases: planning

and implementation. Each depends on the other.

That is, unless implementation is preceded by

well-constructed plans, intervention becomes

haphazard at best. Similarly, unless planning is

followed by skillful implementation, the plan

dies. The plan has three parts:

 1. Setting goals and objectives as guided by

the assessment data; we predict how a child

will act or interact differently because of

intervention.

 2. Determining intensity, duration, location, and

type of service delivery.

 3. Developing ideas about intervention that

refl ect sensory integration (SI) theory

and other practice approaches as needed;

furthermore, we develop a general idea

about activities to meet the goals as well as

optimal characteristics of the intervention

environment.

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 533

 Certain goals are best met through direct service,

whereas others are met through coaching ( Hinojosa & Segal, 2012 ). If, for example, a child has

low postural muscle tone and decreased postural

stability, we may propose direct intervention

characterized by activities that provide enhanced

vestibular and proprioceptive input. If the same

child is also distractible and gets into trouble at

school, we may propose to coach the teacher to

help alter tasks and the school environment to

accommodate the child ’ s needs.

 A plan helps ensure that intervention is

mutually agreeable to children, caregivers, signifi cant others, and the therapist. The plan also

ensures that intervention is conducted as effi -

ciently and effectively as possible and contributes to enhanced participation in everyday life.

Evidence on effectiveness, along with available

resources and constraints, guides the plan.

Kyle Revisited

 Kyle was 6½ years old. He lived with his

parents, brother, and two sisters. Kyle ’ s parents,

Mr. and Mrs. P., described him as bright, active,

and loving. They reported that he is sensitive to

the fact that he is less coordinated than his siblings. Despite their best attempts at being patient,

they fi nd that Kyle is often the child who is

reprimanded for being too active or not paying

attention, which is eroding his self-esteem.

Mrs. P. ’ s greatest concerns were Kyle ’ s lack

of friends and negative self-concept, even

more than his incoordination or diffi culty with

handwriting.

Conducting the

Comprehensive Evaluation

 When evaluating Kyle, we interviewed his

parents and teacher; observed him at school; and

administered a variety of assessments, including structured and unstructured observations in

the clinic; the Sensory Profi le2 (SP2) ( Dunn,

 2014 ), a questionnaire completed by the teacher

and parents; and performance testing using the

Sensory Integration and Praxis Tests (SIPT;

 Ayres, 1989 ). See Chapter 11 (Interpreting and

Explaining Evaluation Data) for an additional

description of Kyle ’ s evaluation.

Generating Hypotheses

 We concluded that Kyle ’ s diffi culties were based,

at least in part, on sensory integrative dysfunction. More specifi cally, Kyle appeared to have a

vestibular and proprioceptive processing disorder

that was manifested in postural diffi culties. His

poor vestibular and proprioceptive processing

appeared to have resulted in bilateral integration and sequencing (BIS) defi cits and likely

contributed to poor visuomotor skills, constructional abilities, and form and space perception.

Furthermore, Kyle showed sensory modulation

dysfunction in the form of tactile defensiveness and, to some extent, with the modulation

of auditory input. The SP2 also identifi ed the

presence of behavioral and emotional issues

(i.e., lowered self-esteem and poor frustration

tolerance) related to diffi culties with sensory

modulation. Both the SP2 and clinical observations indicated that Kyle was highly distractible

and overly active. We explained our fi ndings to

Mrs. P. and interpreted her concerns in light of

these fi ndings.

HERE ’ S THE EVIDENCE

Recent research conducted with children diagnosed with autism spectrum disorders (ASDs;

Bulkeley, Bundy, Roberts, & Einfeld, 2016 ;

Dunn, Cox, Foster, Mische-Lawson, & Tanquary,

 2012 ; Dunstan & Griffi ths, 2008 ; Schaaf et al.,

 2013 ) suggested that both classic ASI and

coaching interventions are promising but that

sensory-based interventions (SBIs) of the type

often included in coaching were variably successful. (See also Chapter 17 , Using Sensory

Integration Theory in Coaching, and Chapter 21 ,

Planning and Implementing Intervention: A Case

Example of a Child with Autism.)

Intervention proceeds in the manner suggested by the plan. Although this idea seems

rather simplistic, translating a plan into action

requires a different kind of reasoning than planning itself. The logic of the planning process is

fairly linear, but the logic used when conducting

intervention is more dialogic, a kind of ongoing

“conversation” between a therapist and a child

( Dunkerley, Tickle-Degnen, & Coster, 1997 ; Mattingly & Fleming, 1994 ) or a coaching partner

( Rush & Shelden, 2011 ).

534 ■ PART VI CASES

HERE ’ S THE POINT

• Challenges to a child ’ s participation lay

the foundation for the evaluation process,

providing insights into areas of concern.

• A comprehensive evaluation includes

standardized tools, observations, and

interviews. The therapists’ frame of reference

guides the choice of assessments.

• Based on assessment results, the therapist

generates hypotheses, making way for

establishment of goals.

Developing and Setting Goals

and Objectives

 We began by asking Mr. and Mrs. P. how they

wanted occupational therapy services to benefi t

their family. We used SI theory to offer explanations for Kyle ’ s test results and their concerns.

We discussed ways in which Kyle ’ s challenges

affected participation and the people around him.

We asked for confi rmation, clarifi cation, and correction of our perceptions. Together with Mr. and

Mrs. P., we formulated four important goals to

guide intervention.

 With regard to Mrs. P. ’ s primary concerns, we

speculated that two things contributed to Kyle ’ s

negative beliefs about himself and the diffi culties

he had interacting with peers. These were:

 1. Poor motor coordination, which interfered

with his ability to perform the same kinds

of skilled activities that his peers easily

performed

 2. Distractibility and increased activity, which

resulted in Kyle ’ s being reprimanded more

frequently than peers or siblings

 Mr. and Mrs. P. agreed with this assessment. We

determined that our goals should refl ect each

of these major areas of concern. In addition to

setting goals to address contributors to his poor

self-esteem, we also decided to set goals that

directly refl ected the parent ’ s primary concerns.

Modifying Kyle ’ s Beliefs About Himself

 Kyle ’ s expectations that he would fail seemed to

be both a cause of some of his diffi culties and

a result of others. Because he knew he lacked

skills, he avoided certain activities. In avoiding them, he became more sedentary, which,

given his underactive vestibular-proprioceptive

processing, increased anxiety and created diffi -

culty regulating arousal and activity levels. Additionally, he deprived himself of opportunities to

practice skills. He fell further and further behind

his peers and came to believe, even more fi rmly,

that he was “no good.” When he was forced to

do activities that he knew he could not do well

(e.g., handwriting), he became anxious, and

his performance deteriorated. When he became

anxious, he also became overly active and overwhelmed. His behavior further deteriorated, and

he was reprimanded for bad behavior. Therefore,

he had more reason to believe he was “bad” and

that others also viewed him that way. He often

indicated that no one wanted to play with him

and that he had no friends aside from his siblings.

 Mr. and Mrs. P. concurred with this line of

reasoning. They punctuated our conversation

with examples that illustrated our developing

“theory” of Kyle ’ s beliefs and behavior. Based

on our jointly held perceptions, we proposed that

one general goal for our intervention would be to

help Kyle develop a belief that he would succeed

at activities that he valued (i.e., self-effi cacy) and

that were appropriate for his age. Kyle ’ s parents

thought this was an important goal. However, we

wanted to be sure that we could evaluate Kyle ’ s

progress toward meeting that goal at the end of

6 months’ time. Thus, we needed to formulate

specifi c objectives.

 We asked Mr. and Mrs. P. what kinds of things

they thought Kyle would do that would tell them

that he had changed his beliefs about himself.

How would Kyle act differently if he believed

that he would succeed? What activities were both

important to him and refl ected skills appropriate

to his age? We were unable to answer these questions by ourselves; only Mr. and Mrs. P. could

fi ll in the details that would make the goal meaningful and measurable. Mrs. P. indicated that she

would know that Kyle felt better about himself

when, at least once a week, he willingly went

off to play with other children in the neighborhood who are about his age. She felt that would

mean he saw himself as a desirable friend and

playmate.

 We all recognized this objective might be diffi cult to meet, but it exemplifi ed how Kyle would

act as he began to feel better about himself.

Kyle ’ s going off to play with neighborhood

children was something that his family cared

about. Furthermore, objectives are a way of

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 535

organizing actions; they are predictions, not contracts. If Kyle did not accomplish this objective,

we would re-examine it to determine whether it

was our predictions that were out of line or our

methodology that was ineffective. Because the

objective was readily observable by those closest

to him, Kyle ’ s family would be the ones to determine whether it had been met. They needed only

to attend carefully to the evidence that he was or

was not playing more with his peers.

Improving Kyle ’ s Posture and Motor Skills

 Both of Kyle ’ s parents expressed a desire that

Kyle develop increased stamina and the postural ability to sit comfortably in his chair and

complete his schoolwork more easily. They

also wanted him to enjoy playing some of the

games and activities his peers loved—not to tire

so quickly. We agreed that improving Kyle ’ s

posture and motor skills were important general

goals. However, once again, we were at a loss

to create specifi c objectives without knowing

from the parents what he was currently able to

do. That is, what specifi c skills did Kyle most

need to develop? What should Kyle be able to

do better in 6 months that would enable all of

us to recognize that he had made progress? And

how would it look if he performed a particular

skill better?

 We discussed this area for some time. His

parents focused on riding his bicycle, pumping a

swing, throwing a ball, catching a ball, handwriting, and buttoning. We talked about what seemed

to be preventing him from doing each one. We

reiterated that we were interested in selecting

only the one or two skills that everyone (most

importantly, Kyle) thought were most important.

We felt certain that if Kyle changed in the ways

that we specifi ed, he would also develop additional skills simultaneously—ones not specifi ed

explicitly in objectives. These would be equally

important, but we viewed them as an added

bonus.

 Mr. and Mrs. P. indicated that Kyle had, on

numerous occasions, expressed a desire to be

able to make the swing go by himself. That way,

he could play on it as long as he wanted, rather

than having to stop because his parents were

tired of pushing him or had something else to

do. Furthermore, Kyle loved swinging, but he

was acutely aware that his 5-year-old sister had

learned some time ago to pump the swing by

herself and his 4-year-old brother could nearly

do so. Thus, we decided that our objective would

be that:

Kyle will independently pump the swing. PRACTICE WISDOM

Two points regarding objectives cannot be

emphasized strongly enough. First, objectives

belong to caregivers and children. Unless they

are meaningful, they are pointless. Second, intervention is “driven” by objectives.

Objectives that defi ne achievement of a goal

established by a team need not be agreeable

to people who are not members of that team.

However, all team members must agree that

the objectives refl ect the goals, and all team

members should know whether or not a child

has met the objectives ( Mager, 1975 ).

We need not write objectives for every behavior related to a particular goal. Rather, targeting

a few really meaningful objectives and working

toward those collectively is much more critical.

We then measure improvement in those areas as

representative of the larger goal of improving his

beliefs about his skills. A child might well make

other gains in a particular area, and those gains

may be equally important, but they would not

have objectives attached to them.

PRACTICE WISDOM: SPECIFYING

CRITERIA FOR OBJECTIVES

Readers familiar with the parts of an objective

(i.e., learner, behavior, condition, and criterion)

( Mager, 1975 ) will notice that we have not

defi ned a criterion for measuring this objective.

That is, we have not specifi ed how well Kyle will

have to pump his swing in order for us to say

that he has met this objective. In our experience,

the issue with pumping a swing is simply learning to do it. After children know how it feels to

work with the swing, they can swing until they

are ready to quit. Thus, we did not believe that

the specifi cation of a criterion was necessary.

Because no criterion is specifi ed, we assumed

that Kyle would be able to do it whenever he

wanted. Because that really was our intent, the

lack of a criterion did not present a problem.

536 ■ PART VI CASES

Improve Handwriting

 Mrs. P. also expressed particular concern about

Kyle ’ s poor handwriting. She believed that the

inordinate diffi culty that he had with writing

caused him to be slow and messy in school. This,

in turn, resulted in his having to repeat his work

or receiving negative feedback from his teacher.

Many times, he brought home papers with the

word messy scrawled across the top, which he

was embarrassed to show his parents. We related

his poor handwriting to the identifi ed diffi culties

with visuomotor skills and form and space perception, and possibly also to his postural control

challenges.

 We agreed that improved handwriting was

an appropriate goal for Kyle. Again, we began

the process of discovering what exactly Mrs. P.

meant by this goal. Should Kyle be able to write

faster? If so, how fast? Should he be able to form

letters more legibly? And, if so, what would constitute legibility? After discussing this, it became

clear that Mrs. P. actually hoped that Kyle would

improve in both areas; however, she recognized

that he could probably not accomplish both

within 6 months’ time. We told her that, in our

experience, children who wrote quickly could

learn to write more legibly. However, children

who became overly concerned with legibility

often had a particularly diffi cult time learning

to write more quickly. We agreed that the more

important immediate objective was that:

Kyle will complete at least three of four written

assignments within the allotted class time.

Improving Kyle ’ s Behavior

 Kyle ’ s behavior (i.e., distractibility, increased

activity, and tendency to lash out at children who

bumped into him) was a major concern for his

parents and teacher. Kyle ’ s behavior “got in his

way” more obviously than anything else; it was

probably the greatest single reason for the negative feedback that he got from those around him.

Thus, we all agreed that improved behavior was

an appropriate general goal.

 We explored this diffi culty more fully with

Mr. and Mrs. P. so that we could formulate relevant objectives. We asked Mr. and Mrs. P. to tell

us about circumstances when Kyle ’ s behavior

was most problematic (i.e., occurred frequently,

was unavoidable, or in which his behavior was

especially intolerable). Again, we asked how Kyle

would behave differently in the next 6 months if

he were making progress. Mr. and Mrs. P. talked

about Kyle ’ s behavior at some length. They mentioned the diffi culties that they had taking him

to restaurants, shopping malls, and their friends’

homes. In the end, they concluded that, although

all these created diffi culties, they had learned to

manage. When they anticipated that the situation

would be particularly loud or crowded (e.g., a

shopping mall during a holiday season), one of

them either stayed home with Kyle (and often

one or more of the other children) or they left

some or all the children with a babysitter. They

tried to take whole family outings to places

where they knew Kyle would not be overstimulated or overwhelmed; they knew many such

places. While this was not an ideal solution

for optimal participation, Mr. and Mrs. P. were

content, for the time being, with continuing this

approach. However, Kyle ’ s parents were quite

concerned about his behavior at school. Nearly

every week, his teacher called or sent a note

home about Kyle ’ s fi ghting or not paying attention to his work. Thus, we created one objective:

Kyle would not hit classmates who bumped into

him accidentally.

 We knew this might be a diffi cult objective for

Kyle to meet through sensory integrative intervention alone. Thus, we used a sensory strategy

based on SI theory and recommended that Kyle

have frequent activity or stretch breaks, particularly before a sedentary task or when waiting

in line. The objective was written with the provision that the parent and teacher would allow

Kyle access to sensory-regulatory strategies and

the occupational therapist would teach everyone their appropriate use. With that in mind, we

reframed the goal:

Given suffi cient breaks and sensory-regulatory

strategies, Kyle will not hit classmates who

bumped into him accidentally.

 Besides fi ghting, the other signifi cant aspect of

Kyle ’ s behavior at school was inattention to his

work. When questioned about what exactly that

meant, the parents indicated that Kyle rarely got

his work fi nished on time. We hypothesized that

this was related, at least in part, to the motor and

postural concerns noted earlier. We decided that

the objective (already specifi ed under the goal to

improve his motor skills) also pertained equally

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 537

well to the goal of improving his behavior. Thus,

we also listed it under this goal:

Kyle will complete at least three of four written

assignments within the allotted class time.

Summary of the Intervention Plan

 Although this process was diffi cult and time

consuming, it was worth the effort. We all clarifi ed our thinking and made explicit the most

desirable outcomes of the intervention. Mr. and

Mrs. P. said that the process helped them decide

which things to focus on during the next several

months. Before our discussion, they had felt

guilty if they did not try to teach Kyle each time

they interacted with him. Yet, they also felt that

he needed time to “just be a kid.” They were

relieved to talk with someone who understood

Kyle and could help them plan.

 We then went on to recommend types of

service delivery (e.g., coaching, direct intervention) that we would use to meet each objective.

We recommended that Kyle obtain direct intervention in a clinic (private practice) setting and

that his parents engage in coaching with the

clinic-based therapist. We encouraged Mrs. P.

to seek coaching services for the teacher from

the occupational therapist at Kyle ’ s school. We

explained that direct service meant that a therapist intervened directly with Kyle in order to

improve his skills (see also Chapter 13 , The

Science of Intervention: Creating Direct Intervention from Theory). Coaching meant that a

therapist collaborated with the parents and the

teacher to help each understand Kyle ’ s behavior

and needs better and to develop more effective

strategies for working with him. Coaching could

involve teaching parents and the teacher a simple

procedure that they, in turn, would conduct with

Kyle. (See also Chapter 17 , Using Sensory Integration Theory in Coaching.)

 Mr. and Mrs. P. agreed. Kyle ’ s Individualized

Education Program (IEP) team meeting was in

another week, and Kyle ’ s parents were glad to

have had an opportunity to participate in goal

setting before that meeting. They planned to take

the goals that we had established to the meeting

and incorporate them into Kyle ’ s IEP. Kyle

was fortunate to be eligible to receive occupational therapy services at school. Within the IEP

meeting, we recommended school-based occupational therapy services via coaching. Kyle would

receive direct intervention outside of school and,

therefore, it did not appear in his IEP. However,

we recommended that the clinic-based therapist and the school-based therapist touch base

periodically. The suggestions we presented to

Mr. and Mrs. P. and the team are summarized in

 Table 20-1 .

HERE ’ S THE POINT

• Goals are established in conjunction with the

major stakeholders in the child ’ s life (e.g.,

parents, teachers) and are based on the outcome

of the comprehensive evaluation process.

• Objectives help defi ne goal achievement;

they are predictions of change and refl ect

measurable outcomes.

• Once goals are established, approaches to

intervention can be identifi ed.

Setting the Stage for Intervention

 The occupational therapist seeing Kyle in

the clinic had taken special courses in the

PRACTICE WISDOM: MORE

ON CREATING CRITERIA

Astute readers will note that the previous Practice Wisdom box pertaining to lack of a specifi ed criterion applies here also. Because we have

not specifi ed a criterion, we assume that when

Kyle meets the objective and is given reasonable

accommodation, he will never hit a classmate

who accidentally jostles him. This is precisely

the criterion we have in mind. Although Mager

 ( 1975 ) indicated that perfect performance is

rarely achievable, we believe that, in this case, it

would be nonsensical to write an objective that

said that Kyle would only hit a classmate once

a month or once a year. Hitting other children

because they accidentally bump into you is never

acceptable. Furthermore, Kyle does not have

a serious problem with violent outbursts; his

mother indicated that his fi ghting occurs about

twice a month and is triggered by very predictable occurrences (especially lack of suffi cient

breaks). Therefore, we believe that the objective,

as specifi ed, was attainable. We expected that

Kyle, similar to most children, might occasionally

“backslide.” However, our objective is that he

not respond to accidental touch by hitting.

538 ■ PART VI CASES

implementation of ASI intervention and was a

reliable intervener in this method. The therapist

wanted to maximize Kyle ’ s participation in the

intervention process. In preparation for the fi rst

session, the therapist, as she always did, thought

about three things:

 1. The physical layout and activities and

materials in the clinic

 2. Types of activities that the child would enjoy

 3. Types of interactions that the therapist hoped

to promote as well as playful themes and

games that the child might enjoy

 Although these aspects of direct intervention

become inextricably intertwined in a session,

each has slightly different purposes and is, therefore, important enough to consider separately.

Therefore, we discuss each briefl y before illustrating how they came together in intervention.

Physical Layout of the Clinic

 The therapist fi rst considered the physical layout

of the clinic. She knew that Kyle was easily overstimulated and found it diffi cult to maintain his

attention when there were a lot of distractions.

TABLE 20-1 Contributions of Private Practice and School Occupational Therapists to Meet

Kyle ’ s Objectives

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

Work on proximal goals: 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

Work on proximal goals: 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

the 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.

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 539

She also knew that Kyle was exceedingly

curious. If a lot of equipment was visible, he

might run from item to item rather than choose

one piece of equipment. Providing a visual chart

to use in thinking about activities initially might

help his focus as long as there was enough fl exibility built into its use.

 In choosing equipment, the therapist wanted

to have some swings that could be suspended by

two points because her plan was to incorporate

linear movement. She kept out the glider, the

bolster swing, the net hammock, and the trapeze

for Kyle ’ s fi rst visit.

 Anticipating that she might need activities

that would help Kyle organize himself to stay

focused, the therapist wanted to arrange the room

so that it would be easy to create “small spaces”

where distractions were minimized. Thus, she

made available a barrel and a tent with cozy

pillows. She also left out the Lycra swing, which

could be suspended by two points for gentle

swinging or by a single point to provide a cozy

small space. She thought about some activities

that he might enjoy in a confi ned space that also

could help him increase his focus. The therapist

thought of blowing and breaking bubbles, fi shing

with a Velcro fi shing rod for Velcro fi sh, and

locating and using a large pair of plastic tweezers

to pick up plastic “bedbugs” (i.e., ½-inch diameter, brightly colored, bug-shaped plastic objects

that belong to another game).

Selecting Activities

 In thinking about activities, the therapist considered ways to engage Kyle and, at the same time,

scaffold his ability to modulate and discriminate

sensation, utilize effective postural responses,

and plan and implement actions. The therapist

planned to address four primary proximal objectives ( Schaaf & Mailloux, 2015 ):

• Postural stability

• Bilateral coordination

• Visuomotor skills

• More typical responsivity to sensations

 She hoped these would contribute to meeting the

distal objectives of pumping the swing, completing assignments, and improved behavior. See

 Table 20-1 for the relationship between proximal

and distal objectives in the column that describes

the contributions of the private practice therapist.

 SI theory suggests that Kyle ’ s poor posture

and BIS are linked to diffi culties processing vestibular, proprioceptive, and visual sensations and

would, therefore, be addressed through activities that provide multi-sensory sensation in the

context of motivating activities. Activities that

provide enhanced linear vestibular sensation and

proprioception support the development of postural control and coordinated use of both sides

of the body.

 Although diffi culties with visuomotor skill

may stem from many sources, Kyle ’ s evaluation suggested that his visual-motor diffi culties

resulted, at least in part, from poor processing

of vestibular and proprioceptive sensations.

Thus, the therapist planned to build visuomotor challenges into activities that provided enhanced vestibular proprioceptive sensation. (See

 Chapter 13 , The Science of Intervention: Creating Direct Intervention from Theory.)

 Kyle ’ s over-responsivity to tactile and auditory sensations yielded defensive responses at

home and school. Although the “best solution”

for improving sensory modulation has not been

determined, SI theory suggests that activities that

promote calming and organization (e.g., swinging gently back and forth in a Lycra swing or

wearing compression garments) support the

acquisition of a regulated state and reduced

defensiveness. An atmosphere of trust and safety

in which the child controls important aspects of

the activities (e.g., amount and type of sensation) is critical to modulating arousal and ensuring engagement. Therefore, while guiding the

direction of the session, the therapist must guard

against imposing sensation.

 Based on what she knew of Kyle and her experience with other clients with similar problems,

the therapist developed a working hypothesis

PRACTICE WISDOM

Schaaf and Mailloux ( 2015 ) described both proximal and distal objectives. They used the term

proximal to refer to objectives targeting sensorimotor abilities and distal to refer to objectives

targeting participation in everyday life. These

terms assist therapists with practical reasoning

by helping to clarify the relationship between the

ultimate objectives of intervention (i.e., everyday

activities) and the sensorimotor components

hypothesized to underlie those activities.

540 ■ PART VI CASES

and created ideas for activities that refl ected her

hypothesis. She would observe Kyle ’ s behavior

and seek information from his parents to determine whether her strategies were successful. If

she did not have visible evidence within a few

sessions that Kyle ’ s defensiveness was decreasing, she would develop an alternative hypothesis

and plan.

 The therapist ’ s “hunch” about Kyle ’ s sensory

defensiveness was that it was a major contributor

to his heightened arousal. If this was the case,

introduction of inhibitory vestibular, proprioceptive, or deep pressure sensation as well as the

reduction of visual and auditory input should

help to lower his arousal when necessary. She

considered natural lighting, speaking in a quiet

voice, and encouraging Kyle to spend time in

quiet spaces.

Thinking About Interactions

and Playful Themes

 The therapist wanted to be sure that her

actions and interactions with Kyle served to

“co-regulate” him. That is, through therapeutic

use of self and the repertoire of materials and

activities that she made available, she created an

environment that supported Kyle ’ s ability to regulate himself.

 The therapist thought fi rst about providing

choices to give Kyle a sense of control. She knew

he liked pirates so together they could create a

pirate story complete with boats, ropes, and treasure. The therapist ’ s role would be to steer him

toward equipment that would be organizing yet

challenging. She had begun to consider this issue

already in deciding which swings to leave in the

room. For example, having left out the glider and

the bolster swings, she could ask Kyle to select

the swing that would be the boat. Realizing

they might need paddles for the boat, the therapist also decided to leave out a bat and a ball

and some swim noodles. She would ask Kyle

to identify the paddles they would need to go to

“Treasure Island.”

 The therapist thought about ways to build-in

discussions of challenges that Kyle might experience and ways that he could overcome them. She

wanted to develop strategies for him to use when

things got diffi cult. For example, the pirates need

a rest; where should they go? While they rested,

they could make other plans for Kyle to use

outside of therapy at times or in places, such as

school, when he felt overwhelmed. The therapist

knew that it might take many such conversations

before he could actually use this information and

that she would have to “check out” any strategies

with his parents (and perhaps his teacher). She

also thought about engaging Kyle in similar discussions about his poor motor coordination when

the opportunities presented themselves.

 The therapist recognized that asking a

6-year-old boy to engage in meaningful conversations about sensory integrative dysfunction

was likely to be diffi cult and the play narratives

were a safe way to engage in these discussions.

However, she believed that a very important part

of her intervention was to help him understand

why he was unable to do some things and that

made him neither “bad” nor “dumb” (words he

frequently used to refer to himself). Furthermore,

she believed that he must develop strategies for

dealing with his own diffi culties and that these

strategies also were an important part of her

intervention with him. The therapist knew that

Mr. and Mrs. P. planned to spend time talking

with Kyle in a similar fashion. She planned to

touch base with them frequently so that their

efforts would be complementary.

HERE ’ S THE POINT

• Treatment planning is multifaceted, requiring

consideration of the physical environment,

available equipment, planned activities, and

anticipated therapist-child interactions.

Providing Intervention

 Now that all the pieces were in place, the therapist was ready to begin. We describe several

“snapshots” taken during the fi rst 3 months of

intervention. In so doing, we illustrate how the

plan was translated into action and how the therapist resolved some of the diffi culties that she

encountered. We demonstrate how the therapist

refl ected, both in the moment and afterward.

The First Intervention Session

 During their initial session together, the therapist

gave Kyle a tour of the therapy room, pointing

out several things that she thought might interest him. After the tour, she suggested that Kyle

might want to try “fl ying” in the hammock (see

 Fig. 20-1 ). She kept several thoughts in mind.

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 541

First, she knew that Kyle, similar to many boys

his age, was really into superheroes. The therapist showed him how he could do tricks the

way a superhero does, such as rolling out of the

hammock onto pillows on the fl oor. Second, the

therapist saw the hammock as a way of providing

enhanced vestibular and proprioceptive sensation

and also requiring him to use postural responses

against gravity. She knew that it would be easy

to create activities in the hammock that required

visual-motor skill, bilateral coordination, and

projected action sequences.

 Kyle was excited about trying the hammock.

Anticipating that he might have diffi culty getting

into it, the therapist suggested they build a superhero house using the soft stairs to “enter” the

house (hammock). Even so, on his fi rst attempt

to get into the hammock, Kyle ended up rolling

out instead, landing on the pillow. Kyle was startled, but they laughed and tried again, the therapist silently guiding him, this time more slowly.

The second time, Kyle succeeded. He immediately began to pull the handle that made the

hammock bounce, and the therapist encouraged

him to see how high he could go. Kyle called

out, “I ’ m fl ying like Superman!” He seemed

delighted with his accomplishment and yelled

for his mother (who was observing from behind

a one-way mirror) to watch.

 The therapist noted that, as Kyle pulled on

the ropes to propel himself, he tended to lose

his grasp on the handles, so she recognized that

she must adapt the activity. She grabbed a long

dowel rod from the shelf behind her, held it at

either end between her two outstretched arms,

and entered into Kyle ’ s game. “Hey, Superman!”

she yelled. “Grab onto this branch and look in

this window. I think there ’ s someone who needs

your help!” Kyle reached up and grabbed the bar

with his arms outstretched. “Hold on,” yelled

the therapist. “Pull hard so you can come a little

closer.” As Kyle began to fl ex his arms, the therapist watched closely to make sure that his body

and head remained extended. At the fi rst sign of

neck, hip, or knee fl exion, she lowered the bar a

little to reduce the amount of resistance.

 “What do you see?” asked the therapist. Kyle

replied, “There ’ s a whole bunch of bad guys in

there.” The therapist suggested that maybe he

had better fl y for help because there were too

many bad guys to take on alone. Kyle let go of

the bar and swung back and forth several times,

calling for Batman and Superwoman to come

and help him.

FIGURE 20-1 Many young boys enjoy swinging prone in the net hammock. Photo by Shay McAtee, printed

with permission.

542 ■ PART VI CASES

 Meanwhile, the therapist had pulled a cushion

underneath Kyle and laid several beanbags on

top of the cushion. She hoped to arrange the

beanbags so they were high enough for Kyle to

grab them as he fl ew by and so that he would do

so without using total body fl exion. After several

more “peeks through the window,” the therapist

suggested that the superheroes might want to

throw the beanbags into the hiding place to “take

out” the bad guys.

 The game continued with the therapist gradually altering the demands and watching Kyle ’ s

responses. By the time it was fi nished, Kyle

was pushing himself with both hands, grabbing

a beanbag or two on the way by, and throwing

them at a target identifi ed as the secret place. The

therapist was impressed with the accuracy of his

throw and with the amount of extension he was

able to maintain. She cheered as he hit the target.

The therapist told Kyle that this game would help

him have stronger muscles and that throwing the

beanbags was good practice for throwing a ball.

 As Kyle grew tired, his throwing accuracy

decreased, and he began to fall into fl exion. He

complained that his neck hurt and that he wanted

to sit up to throw the beanbags. The therapist

helped him out of the hammock. It was nearly

time for the session to end anyway, but the therapist wanted to be sure his level of arousal was

not too high before he left the clinic. Together

they found fl ashlights, and the therapist hung

the Lycra swing from a single point; she also

lowered the lights in the room. Kyle sat in the

swing and he and the therapist played a game

of “I Spy,” using the fl ashlights to point out the

objects once the other person guessed what they

were. Within a few minutes, Kyle was ready to

put his shoes and socks back on. As they were

leaving, the therapist spoke briefl y with Mrs. P.

Kyle was very excited to tell his mother about

everything he had done, not knowing that she

had seen it through the mirror.

One Week Later

 Having had such a successful fi rst session with

Kyle, the therapist looked forward to repeating the same activity in the second session.

However, Kyle announced, upon arriving for his

second session, that he did not want to lie down

to do anything; he only wanted to sit on the

swing because lying down hurt his neck. Mrs. P.

concurred that Kyle had complained about sore

neck muscles for 2 days. However, she also said

that she had told Kyle that his muscles were sore

because they were getting stronger.

 The therapist had to think quickly. Although

she had planned to create activities for Kyle to

do while sitting, she was afraid to create a lot of

those activities at this point because it might be

diffi cult to get him to go back to the prone position. The therapist had probably demanded too

much of Kyle in the fi rst session, and she should

have had him spend less time in the prone position. However, she believed that he needed to

work in the prone position because that was the

best position to encourage maintained extension

against gravity.

 The therapist could have insisted that Kyle lie

prone in the net if he wanted to do the activity.

She could have explained to him that it would

not work as well while sitting. She also could

have helped him to create an activity while

sitting, using a different swing, that probably

would have been successful. However, the therapist believed it was important to give Kyle an

active decision-making role. She wanted him to

learn that he could adapt situations to make them

turn out better. The therapist knew that Kyle

probably would learn on his own that using the

prone position was better for doing this particular activity. Although the prone position was,

in general, more diffi cult, the therapist believed

that he would choose it because he had enjoyed

the activity and the feelings he had when he

succeeded.

 The therapist also knew that when children try

throwing from a sitting position in the hammock,

they often come to realize on their own that

the prone position is easier. Thus, the therapist

decided to follow Kyle ’ s lead. She and Kyle set

up the hammock swing, the cushion with the

beanbags, the target, and the pillows, in much the

same way she had set them up the week before.

Kyle sat in the swing and began pushing it with

his feet. He soon found that it was diffi cult to

reach the beanbags, and his throwing was very

inaccurate because he had to throw around the

sides of the hammock and hold on at the same

time. After a few minutes, Kyle told the therapist that he thought it worked better when he was

lying down.

 Hoping that this would happen, the therapist agreed immediately. Kyle got out of the

hammock and, this time, using soft bolsters

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 543

and stairs, was able to climb in with very little

assistance from the therapist. He seemed pleased

with his accomplishment and quickly engaged in

fi nding the beanbags and throwing them into the

hiding place.

 The therapist watched the time and his reactions closely. After about 10 minutes, and well

before Kyle began to appear fatigued, she suggested that they “fi nd another secret hiding place”

from a different swing. This time she helped him

to create an activity that he could do well while

sitting on the glider.

 As the therapist refl ected on her sessions with

Kyle, she was surprised and pleased by some

things. Kyle had been able to focus his attention remarkably well. He did not exhibit much

of the distractibility that she had observed during

testing and heard about at school. Thus, the therapist learned that, with the undivided attention of

an adult and activities he found highly motivating, Kyle was able to pay attention to relevant

stimuli. The therapist had set up the therapy room

such that she kept distractions to a minimum, and

Kyle successfully screened out those that were

present. Although the therapist was pleased, she

was not fooled into believing that Kyle would

necessarily be able to focus his attention in more

diffi cult situations, such as when he had less

adult attention or there were more distractions.

The therapist recognized the implications for the

way she had structured the environment. She felt

it might be benefi cial not to be so careful that

only certain swings remained in the room at subsequent sessions.

 The therapist also knew that she was probably “buying time” with regard to Kyle ’ s willingness to work in a prone position. She hoped

she would be able to develop activities that are

best done in the prone position that were highly

motivating for at least a few more sessions. By

then, Kyle might begin to fi nd the prone position

easier and be less resistant to it. However, she

knew that if he balked, she probably would have

to work primarily in sitting for a time and go

back to the prone position as his postural stability

improved.

Six Weeks Later

 After working with Kyle weekly for 6 weeks, as

the therapist anticipated, Kyle had become familiar with the activities and tried to “steer clear”

of those that required a prone position. She had

been able to bargain with him a little; at the

current appointment, the therapist had created

an activity to work on the timing of limb movements and on his ability to fl ex his neck and

upper trunk against gravity. She hoped that this

activity would carry over into his being able to

pump the swing independently.

 Kyle was standing on a pile of mats, the net

swing slung around him. He was holding on

with both hands. The therapist stood on the fl oor

opposite him, far enough away that she would

not get hit as he swung. She was holding a large

hula hoop between her outstretched arms. On

cue, Kyle jumped off the mats and extended his

legs. The goal of the task was to lean back and

fl ex his knees around the hoop. The therapist

yelled, “Now!” a fraction of a second before he

should bend his knees. After Kyle had successfully “grabbed” the hoop, the therapist pulled

him up a little higher, watching to see how far

she could move him without his losing control of

his head and neck. After she had attained the best

possible position, the therapist moved the hoop

from side to side and back and forth, making

“roaring” noises.

 “Let go! Let go!” the therapist said again and

again. “You ’ ll never capture me, you mean old

monster!” Kyle, fully involved in the activity, did

let go after a few seconds, saying, “Okay, just

one more chance to be good. But, if you do anything else bad, I ’ ll be back to get you!” As soon

as Kyle landed back on his mats, the therapist

did something to make Kyle “attack” her again,

and the game went on.

 After a time, the therapist stopped telling

Kyle when to fl ex his legs in order to grab the

hoop because Kyle seemed no longer to require

assistance. He continued to be successful at the

activity. In fact, the therapist thought that Kyle

was doing so well he might be able to shift to

pumping the swing. The therapist feigned tiredness. She said to Kyle, “I need a break. Why

don ’ t you just swing by yourself for a few

minutes?”

 He continued to push off the mats, catching

himself after each swing. The therapist watched

for a while and then suggested he not stop so frequently. “You know,” she said, “when your sister

pumps the swing, it ’ s like she ’ s leaning back and

reaching out with her legs to catch an imaginary hoop. After she catches it, she pulls it back

with her. Then she reaches out for a new hoop.

544 ■ PART VI CASES

And it just keeps going. Why don ’ t you try that?

Pretend I ’ m still standing there with that hoop.”

 Kyle thought for a while. Then he tried it once.

He leaned back as he had when catching the

hoop, but he fl exed his knees too fast. Knowing

that it had not worked, he caught himself on the

mats. “Try again,” the therapist urged. “But wait

until I say ‘now’ to bend your legs.”

 Kyle jumped off the mats, and the therapist

began to say quietly, “Now,” just before he

reached the full arc of the swing. At fi rst, Kyle

had trouble coordinating his leg and body movements, but gradually he began to coordinate the

fl exion and extension of his body with the fl exion

and extension of his legs. He did it very forcefully, and his swinging was jerky, but his timing

seemed to be better. “See if I can do it without

you telling me when,” Kyle said. The therapist

followed his lead and Kyle was able to pump the

swing himself, although a little awkwardly. He

practiced for a few minutes until it was time for

the session to end.

 Mrs. P. had been watching from behind the

one-way mirror. She was beaming at Kyle as

he entered the observation room. “We ’ ll have

to hurry home so you can practice before it gets

dark. Your father will be very excited when he

sees what you ’ ve learned,” Mrs. P. said.

 Two days later, Mrs. P. called to say that

Kyle had mastered his fi rst objective. “He ’ s so

excited,” she said. “He spends every minute on

the swing, practicing. His teacher sent a note

home yesterday saying that he tried the swing at

school for the fi rst time. That ’ s the fi rst positive

note we ’ ve gotten all year.”

 The therapist was also excited. She talked for

several minutes with Mrs. P., and they decided

that the next week, Kyle ’ s individual session

would be half as long. Mrs. P. requested that she

spend the other half of the session with the therapist so they could begin working out a home

program to address Kyle ’ s handwriting problem.

The therapist made a note to call the occupational therapist seeing Kyle at school.

Scaffolding Measurable Outcomes

 In the context of the objective for Kyle to pump

the swing independently, it would not be enough

for the therapist to create activities to improve

Kyle ’ s fl exion and bilateral coordination in a

general way. Rather, she needed also to create

activities that mimicked the actual process of

pumping a playground swing, scaffolding his

skills through intervention activities that “mimicked” the demands of a stated objective.

 Another child might have an objective to go

up and down stairs quickly and reciprocally.

Similar to Kyle ’ s, that child ’ s intervention might

also include activities to improve his BIS abilities. However, activities created for this client

should involve bilateral movement and projected

action sequences using his feet (e.g., sitting in

the net hammock and pushing off a wall with his

feet). At least a portion of those activities should

be done in a vertical position, similar to actually climbing stairs. We provide an example of

intervention for a child with needs and objectives

similar to these in Chapter 22 (Viewing Intervention Through Different Lenses).

Developing a Home Program

 When Mrs. P. and the therapist sat down together

the next week, Mrs. P. mentioned that she

thought she could already see progress in Kyle ’ s

handwriting. She had had only one note in the

past month from Kyle ’ s teacher indicating that

he failed to get his work done on time. Nonetheless, Mrs. P. felt that a home program focusing

specifi cally on handwriting would be helpful.

 The therapist explained that the occupational

therapist at school was coaching the teacher and

that they had decided to adapt Kyle ’ s assignments so that he had less written work. The

school-based therapist had provided a device to

put on Kyle ’ s pencil to encourage a better grasp

and a slant-top surface to promote better posture.

Also, because of coaching, the teacher had

decided to move Kyle ’ s desk to a rear corner of

the classroom, where his classmates rarely went.

Both the school-based therapist and teacher

were encouraged by the results. However, they

too believed that a home program could be

benefi cial.

 The therapist reminded Mrs. P. that Kyle ’ s

objective was to get his schoolwork done on

time, which required writing more quickly.

Thus, the home program would concentrate on

speed rather than letter formation. She also told

Mrs. P. that a home program should not be just

“exercises” that they had to “cram” into their

already busy schedules. Mrs. P. agreed. With

three other active children, she did not have

time to make sure Kyle did his home program.

She continued to express the need to facilitate

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 545

positive interactions with Kyle rather than setting

up situations in which he might need to be reprimanded for his performance.

 The therapist wanted Kyle to write without

worrying about forming perfect letters. One idea

she had was that Kyle could practice quickly

writing simple phrases while he was watching

a video or television ( Benbow, 1982 ). Mrs. P.

thought Kyle would love that idea. Kyle and

his brother and sisters were allowed a minimum

of screen time; they often protested this rule. If

Kyle ’ s home program called for half an hour of

television or a video each night, all the children

would be delighted.

 From the school-based therapist, the private

therapist obtained lists of the letters that Kyle

should already know, those that Kyle was currently working on, and letters he would be

working on in the near future. She and Mrs. P.

constructed silly phrases such as “the duck

barked” and “the cat fl ew.” The plan was that

Kyle would select one of those phrases each night

and write it as many times as he could while he

watched television. The therapist asked Mrs. P.

to remind Kyle that he should “just write” and

not pay attention to each letter. He should only

need to look down at his paper when he started a

new line. It did not matter if he made a mistake;

he should just keep going. When they told Kyle

of the plan, he thought it was a “great idea.” He

wanted to know if he could start that very night.

He promised to bring his “homework” in each

week to show the therapist.

 In selecting this idea, the therapist considered

that writing phrases without looking involved

writing with reduced feedback. The therapist

hoped Kyle would develop a better “feel” for

the way to make each letter and that his speed

would improve as he did so. Furthermore, she

believed that the procedure should be fun and

that it should increase the ease with which he

wrote. That all the children in the family would

be delighted with the “requirements” of Kyle ’ s

intervention was an added bonus.

 Both Mrs. P. and the therapist believed that

the home program was an important part of

intervention. Thus, there was no question that

they should use some of Kyle ’ s intervention time

to develop their ideas for it. In fact, they scheduled a similar time for a month later when they

planned to develop strategies for helping Kyle to

enter a group of children. They would also talk

about having a friend join Kyle and the therapist

in some of their sessions.

 Although the home program that the therapist

created for Kyle was guided by SI theory, it was

a type of skills training. The therapist created the

most effective intervention for Kyle by drawing

from several compatible occupational therapy

practice models.

After 4 Months

 Our fi nal “snapshot” of Kyle and the therapist

was taken about 4 months after Kyle began intervention. Kyle had, in fact, made a new friend

named Jason. Jason had recently moved next

door to Kyle and was in his class at school. Kyle

had invited Jason to join him at his “special gym

class.” This was Jason ’ s fi rst visit to the clinic,

and the boys were very excited. Kyle had just

completed giving Jason a tour of all the swings.

The therapist had asked Kyle what he and Jason

would like to do fi rst. Kyle responded that they

would like to “fl y” in the nets. “It ’ s really cool.

You ’ re gonna like it,” he told Jason. “It ’ s just

like being Superman.”

 In response to Kyle ’ s request, the therapist

hung two nets from single suspension points

8 feet apart. She asked Kyle if he would like to

play the “hockey” game that she and Kyle had

devised together. Kyle agreed.

 The game consisted of both boys swinging

prone in the nets. Each had a long stick that

he held at both ends. Off to each side, slightly

behind each boy, was a stack of cardboard

blocks. The object of the game was to use the

sticks to hit a large ball that was centered in a

small hula-hoop on the fl oor between them. Each

boy tried to use the ball to knock over the other ’ s

stacks of blocks. The game continued until one

boy ’ s blocks were completely knocked over.

 Kyle had played this game with the therapist.

She saw it as a means of providing Kyle with

enhanced vestibular and proprioceptive sensation while demanding bilateral projected actions.

Kyle had gotten to be fairly good at this activity,

and he took the lead with Jason, teaching him

the rules and showing him how to get the ball

into the net.

 The two boys were engaged for several

minutes in the activity. However, with the competition, Kyle got very excited. He began to

swing the stick with one hand and accidentally

hit Jason quite hard. Jason was clearly upset and

546 ■ PART VI CASES

yelled at Kyle, “Hey, that ’ s too hard. We ’ re just

playing.”

 The therapist intervened. She suggested

that the boys get out of the nets and get into a

medium-sized box fi lled with dried lentils. They

climbed in. Meanwhile, the therapist turned off

the overhead lights and put fl ashlights in her

pockets for each boy. Kyle was still overstimulated. He immediately began to throw lentils. The

therapist intervened again before a full-blown

lentil fi ght could develop. “Kyle,” she said, “lie

down in the corner here, and Jason and I will

bury you, all but your head.” The therapist knew,

from past experience, that this was an activity

that Kyle found calming.

 The therapist and Jason began dumping containers full of the lentils on top of Kyle. When

Kyle moved too much, uncovering a limb, Jason

reminded him to be very still. After Kyle was

completely covered, the therapist suggested that

Jason lie down beside him, and she buried Jason.

She talked to the boys in hushed tones, and Kyle

calmed down noticeably. The therapist gave each

boy a fl ashlight, and they played a modifi ed

game of “I Spy” for a while.

 The therapist noticed Kyle ’ s proximity to

Jason in the lentil box; his tactile defensiveness was somewhat reduced. Mrs. P. had also

observed this. In one of their conversations,

Mrs. P. told the therapist that Kyle ’ s fi ghting at

school had been nearly eliminated.

 The therapist recognized that being in the

lentil box provided a good opportunity to talk

with Kyle about developing strategies to use

when he felt out of control. She began a discussion with the two boys about how it felt to be

buried under all those lentils. Jason indicated

that it made him feel calm, kind of the way he

felt after he had just taken a bath. The therapist

skillfully guided the conversation so that both

boys contributed and so Kyle could see that even

Jason sometimes felt overwhelmed by “too much

stuff going on around him.” Seeing that Kyle

was very intrigued by this knowledge, the therapist probed a little more. “What do you do when

you feel like that?” she asked. Jason answered

that sometimes he went to his room to be alone

and sometimes he just put his head down on his

desk. Kyle did not contribute much to that part of

the conversation, but he listened intently.

 After a time, the therapist turned the lights

back on and dumped some small plastic

“bedbugs” into the lentil mixture. The boys spent

the last few minutes of the session busily searching for them and picking them up with large

plastic tweezers. The therapist had scattered the

bedbugs so that they were closer to Kyle. By

the end of the session, both boys had found an

equal number of bedbugs. They climbed out of

the box and got ready to go home, chatting about

what they would do together the next time Jason

accompanied Kyle to the clinic. They planned

that date for 3 weeks later.

HERE ’ S THE POINT

• Therapy using ASI is both planned and fl exible;

clinical reasoning and problem-solving are skills

crucial to the success of each session.

• Therapy activities are designed to capitalize on

existing abilities and scaffold the development

of more complex adaptive responses as

progress is made toward established goals.

• Intervention may include a variety of service

delivery options to meet the needs of the child

and the family.

Summary and Conclusions

 In this chapter, we demonstrated how one expert

therapist took information that she gathered in

evaluation, put it together with SI theory and

other occupational therapy practice models, and

developed and implemented an effective intervention plan. We emphasized the importance of

working with caregivers to formulate objectives,

and we described a therapist ’ s refl ections in

action ( Schön, 1983, 1987 ) as well as the resulting modifi cations.

 We highlighted the reasoning of a clinic-based

practitioner performing direct intervention.

We referred only briefl y to the coaching role

of the clinic-based therapist and roles of the

school-based therapist. We have done so partly

because we emphasized coaching in Chapter 17

(Using Sensory Integration Theory in Coaching).

We have not done so because we believe that

the direct service role of the clinic-based therapist is any more important than the role of the

school-based therapist.

 Direct intervention, conducted by a skilled

therapist, is a powerful approach to intervention

for individuals who have sensory integrative

CHAPTER 20 Planning and Implementing Intervention Using Sensory Integration Theory ■ 547

dysfunction. However, it is only one avenue by

which to address the diffi culties that individuals

encounter in daily life. Furthermore, intervention

based on SI theory alone often is not enough to

eliminate these diffi culties. We believe that the

greatest benefi ts are attained when a team of

individuals pools its skills and knowledge, sets

meaningful and achievable objectives, and implements an integrated approach to intervention.

Where Can I Find More?

 Fisher, A., & Marterella, A. (2019). Powerful

Practice: Fort Collins, CO: Center for Innovative OT Solutions.

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

guide for implementing Ayres Sensory Integration: Promoting participation for children

with autism. Bethesda, MD: AOTA Press.

 References

 Ayres , A. J. ( 1989 ). Sensory Integration and Praxis

Tests . Los Angeles, CA : Western Psychological

Services.

 Benbow , M. ( 1982, March ). Problems with

handwriting. Paper presented at Eunice Kennedy

Shriver Center, Waltham, MA .

 Bulkeley , K. , Bundy , A. , Roberts , J. , & Einfeld , S.

( 2016 ). Family-centered management of sensory

challenges of children with autism: A single-case

experimental design. American Journal of

Occupational Therapy, 70, 7005220040 .

 doi:10.5014/ajot.2016.017822

 Carroll , L. ( 1923 ). Alice in Wonderland and Through

the Looking Glass . London, UK : John C. Winston .

 Dunkerley , E. , Tickle-Degnen , L. , & Coster , W.

( 1997 ). Therapist-child interaction in the middle

minutes of sensory integration treatment.

American Journal of Occupational Therapy, 51,

 799 – 805 .

 Dunn , W. ( 2014 ). Sensory Profi le2 . Bloomington,

MN : Psych Corp .

 Dunn , W. , Cox , J. , Foster , L. , Mische-Lawson , L. , &

 Tanquary , J. ( 2012 ). Impact of a contextual

intervention on child participation and parent

competence among children with autism spectrum

disorders: A pretest-posttest repeated-measures

design . American Journal of Occupational

Therapy, 66 ( 5 ), 520 – 528 . doi:10.5014/

ajot.2012.004119

 Dunstan , E. , & Griffi ths , S. ( 2008 ). Sensory

strategies: Practical support to empower families.

New Zealand Journal of Occupational Therapy,

55 ( 1 ), 5 – 13 .

 Hinojosa , J. , & Segal , R. ( 2012 ). Building

intervention from theory . In S. J. Lane &

 A. C. Bundy ( Eds .), Kids can be kids: A

childhood occupations approach ( pp . 161 – 179 ).

 Philadelphia, PA : F. A. Davis .

 Mager , R. ( 1975 ). Preparing instructional objectives .

 Belmont, CA : Fearon .

 Mattingly , C. F. , & Fleming , M. H. ( 1994 ). Clinical

reasoning: Forms of inquiry in a therapeutic

practice . Philadelphia, PA : F. A. Davis .

 Rush , D. D. , & Shelden , M. L. ( 2011 ). The early

childhood coaching handbook . Baltimore, MD :

 Paul H. Brookes .

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

 P. , Hunt , J. , van Hooydonk , E. , . . . Kendra , D.

( 2013 ). An intervention for sensory diffi culties in

children with autism: A randomized trial . Journal

of Autism and Developmental Disorders, 44 ( 7 )

 1493 – 1506 . doi:10.1007/s10803-013-1983-8

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

guide for implementing Ayres Sensory Integration:

Promoting participation for children with autism .

 Bethesda, MD : AOTA Press .

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

professionals think in action . New York, NY :

 Basic .

 Schön , D. A. ( 1987 ). Educating the refl ective

practitioner . San Francisco, CA : Jossey-Bass .

548

CHAPTER

21

Planning and Implementing

Intervention: A Case Example

of a Child with Autism

 Roseann C. Schaaf , PhD, OTR/L, FAOTA ■ Joanne Hunt , OTD, OTR/L ■ Elke van Hooydonk , OTD, OTR/L ■

 Patricia Faller , OTD, OTR/L ■ Teal W. Benevides , PhD, OTR/L ■ Rachel Dumont , OTR/L, MS

 Chapter 21

 Autism is neither a gift nor a curse. It just is what it is.

Focus on the person. They ’ re the true gift.

 —Stuart Duncan

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

✔ Understand and apply sensory integration (SI)

principles for a child with autism spectrum

disorder.

✔ Explain relevant research evidence that has

guided intervention using SI for a child with

autism spectrum disorder.

✔ Demonstrate how systematic, evidence-based,

clinical reasoning is used for interpreting

assessment data and identifying specifi c

patterns of SI dysfunction, goal setting,

intervention planning and implementation, and

outcome measurement.

✔ Describe occupational therapy using an Ayres

Sensory Integration ® (ASI) approach for a child

with autism whose participation challenges

relate to diffi culty processing and integrating

sensation.

LEARNING OUTCOMES

Purpose and Scope

 In this chapter, we present Kendra, a child with

autism spectrum disorder (ASD) experiencing

diffi culty with participation across many developmental areas. As we interpreted her participation

concerns to be, at least in part, linked to inadequate sensory integration (SI), we describe our

evaluation process to identify related strengths

and needs. Determining that there are sensory

integrative concerns, we then discuss goal setting

and intervention planning. We present a sample

treatment session in detail along with the therapist ’ s clinical reasoning process throughout the

session and Kendra ’ s gains after 10 weeks of

treatment.

Introduction

 As was noted in earlier chapters, children with

ASD show a high incidence of diffi culties with

sensory responsiveness and praxis. Consequently, many children with ASD have participation challenges that are impacted by these

diffi culties ( Bar-Shalita, Vatine, & Parush, 2008 ;

 Bundy, Shia, Qi, & Miller, 2007 ; Schaaf &

Case-Smith, 2014 ; Smith, Press, Koenig, &

Kinnealey, 2005 ). The sensory integrative

approach specifi cally targets the sensory motor

diffi culties impacting the child ’ s participation in

learning, social, daily living, and other activities.

The therapist uses individually tailored sensory

motor activities contextualized within a playful,

CHAPTER 21 Planning and Implementing Intervention: A Case Example of a Child with Autism ■ 549

child-centered approach that fosters adaptive

responses to sensory motor challenges at the

just-right challenge . Importantly, activities utilized in the therapeutic interaction are based on

the child ’ s specifi c sensory and motor needs that

are identifi ed through a comprehensive evaluation of sensory integrative functions. The therapist analyzes the fi ndings from the assessment

data to design individually tailored sensory motor

activities that target the identifi ed sensory motor

defi cits impacting the child ’ s daily functioning.

The therapist collaborates with the family and

the child to identify goals and areas of priority

along with a plan for intervention.

 When direct therapy is warranted, the therapist follows the principles and practices of the

Ayres Sensory Integration ® (ASI) approach and

sets up the environment to target the child ’ s specifi c areas of need while allowing for collaborative, therapeutic interactions. The therapist then

engages with the child to foster the child ’ s participation with a keen eye on observation of the

child ’ s response to activities and spontaneously

grades the activities to target the just right challenge. Some goals may be best met by adaptations to the environment or to the daily routines.

For example, a child may experience diffi culty

attending to learning activities in the classroom

because of decreased vestibular functioning,

resulting in poor postural control. This child

may benefi t from a change in seating such as

a movable chair or having his seat moved to a

quiet spot. Environmental adaptations are made

on an individual basis and must be monitored

regularly to ensure they continue to target the

child ’ s needs. Further, when making environmental adaptations, it is important to consider

the perspectives of both the teacher and the

child and assure that they are acceptable and

appropriate.

 ASDs are among the most frequently occurring neurodevelopmental disorders, affecting

one in every 59 children (Baio et al., 2018). As

a lifelong condition, ASD often causes individuals to experience diffi culty functioning in daily

living activities, and this diffi culty impacts their

ability to participate fully in educational, leisure,

social, and daily living activities while also

impairing quality of life for themselves and their

family ( Bagby, Dickie, & Baranek, 2012 ; Schaaf,

Toth-Cohen, Johnson, Outten, & Benevides,

 2011 ). Hence, there is a need for evidence-based

treatments for children with ASD that address

these functional limitations. Parents reported

that their children ’ s sensory diffi culties impact

their ability to participate in everyday activities,

and research has found that they are predictive of maladaptive behaviors in ASD ( Jasmin,

Couture, McKinley, Frombonne, & Gisel, 2009 ).

Hence, it is important to consider whether and

how diffi culty processing and integrating sensory

information is affecting the child ’ s ability

to function effectively in his or her various

environments.

 In this chapter, we present Kendra, a young

girl with ASD, and describe the ways that her SI

defi cits impacted her own daily life as well as her

family ’ s routines. Following the evidence-based

intervention protocol described by Schaaf and

Mailloux ( 2015 ), we will describe Kendra ’ s

strengths, needs, and interests; the process of

assessment and goal setting; and the course of

her occupational therapy intervention using the

SI frame of reference. Throughout the chapter,

we will emphasize the reasoning associated with

interpreting assessment data to design an intervention, and we will describe the intervention

specifi cally tailored to achieve meaningful outcomes for Kendra.

Kendra Revisited

Identifying Participation Challenges

 Kendra, age 4 years, 5 months, lives with her

parents. She is their only child. Kendra was born

full-term with no complications. Her mother is a

self-described homemaker, and her father works

in the fi eld of marketing. Kendra was diagnosed

with autism at 2 years 8 months of age and has

been enrolled in a special education preschool

class since she was 3 years of age. Her parents

report that Kendra has challenges in daily activities at home—including refusal to try new foods,

which impacts her participation in mealtime—

and she requires maximal assistance for dressing, including needing help fi guring out how to

put on clothing and manage fasteners. Kendra

also has diffi culty participating in community

outings, such as eating dinner with her family in

a restaurant or going shopping in a store, because

she becomes overwhelmed and distracted by the

noise and people. She also has diffi culty playing

with other children, often running aimlessly

550 ■ PART VI CASES

around the playground and engaging in unsafe

behaviors, such as jumping off playground

equipment. Kendra ’ s parents report that she

has diffi culty at school participating in learning

activities and in playing with other children. She

has diffi culty participating in lunch time with the

other children as she is very particular about the

food she will eat. During lunch time, she also

becomes overstimulated by the noise and activity

in the lunchroom.

 After observing Kendra at home and at school,

the therapist noted that Kendra demonstrated diffi culty organizing her behavior for learning in

the classroom. Her learning space was disorganized and messy, and she had diffi culty following simple classroom routines. She also appeared

to be bothered by the feel of various classroom

materials, such as clay and other tactile modalities, used during learning activities. At recess she

generally ran about the playground and resisted

any of her peers’ attempts to engage her in play.

Conducting the Comprehensive

Evaluation

 The information derived from interviewing her

parents, and from observations of Kendra in

the clinic and school setting, led the therapist

to suspect that some of Kendra ’ s diffi culties

could be explained by diffi culty processing and

integrating sensory information. The therapist

hypothesized that Kendra ’ s unsafe behaviors on

the playground and her constant running around

may be associated with poor praxis ; specifi -

cally, that she may be unable to generate plans

for engaging in play. Further, the therapist proposed that Kendra ’ s diffi culties with organization

of behavior for learning activities may also be

related to poor praxis and an inability to make

appropriate motor plans to organize her approach

to learning tasks. The behavior of pushing away

children who attempt to play with her seems

likely because of her inability to tolerate the

tactile input of other children. Kendra ’ s diffi -

culty generating plans to engage in play with

others (i.e., poor praxis) also may contribute to

this behavior. These clinical hypotheses led the

therapist to conduct a comprehensive assessment of Kendra ’ s ability to process and integrate sensations. To assess whether Kendra ’ s

participation challenges and goals were related

to poor processing and integration of sensory

information, the occupational therapy evaluation

included the Sensory Integration and Praxis Test

(SIPT; Ayres, 1989 ) and the Sensory Processing Measure (SPM) Home and School ( Parham,

Ecker, Kuhaneck, Henry, & Glennon, 2007 ).

 The SIPT ( Ayres, 1989 ) was administered to

examine Kendra ’ s ability to discriminate, integrate, and utilize visual, tactile, proprioceptive,

and vestibular sensations as well as motor abilities, such as balance, bilateral coordination,

motor imitation, and sequencing of actions. The

SPM Home and School forms ( Parham et al.,

 2007 ) also were administered to examine sensory

modulation and processing behaviors and how

such behaviors may be playing a role in Kendra ’ s

participation challenges. This assessment tool

involves acquiring information and observations

from parents and teachers on a child ’ s behavior

and participation in both the home and school

environments. Observations of performance were

made throughout the evaluation process.

 As shown in Table 21-1 , Kendra was able

to complete only nine out of the 17 SIPT tests.

She showed high tactile responsivity during the

tactile tests and thus was unable to complete

Manual Form Perception, Localization of Tactile

Stimuli, Finger Identifi cation, Graphesthesia, or

Kinesthesia. She was unable to initiate useful

strategies during the Constructional Praxis tests

and threw the blocks across the room. She also

refused to participate in the tests for Bilateral

Motor Coordination and Motor Accuracy. Of the

tests she did complete, her scores were very low

on Praxis on Verbal Command, Postural Praxis,

Oral Praxis, Standing and Walking Balance, and

Post-Rotary Nystagmus, all of which can be seen

in Table 21-1 . She scored in the low average

range on both tests of non-motor visual-spatial

perception, Space Visualization, and FigureGround Perception, and her score on Design

Copying, a visual motor test, was low.

 Because almost half of the SIPT tests were

not administered, drawing conclusions regarding specifi c patterns of SI dysfunction was not

possible based solely on the results of the SIPT.

However, there was some evidence for dyspraxia

based on low scores on several praxis tests that

she did complete. Poor tactile perception was

also evident while attempting to administer items

on the Finger Identifi cation and Localization of

Tactile Stimuli tests. This fi nding led the therapist

to conclude that poor somatosensory processing

CHAPTER 21 Planning and Implementing Intervention: A Case Example of a Child with Autism ■ 551

underlies the diffi culties with praxis. Average

scores on the vestibular and visual-spatial tests

suggest adequate abilities in these areas.

 On the SPM, Kendra scored in the defi nite

dysfunction range in the areas of tactile responsivity, praxis, and social participation. These

fi ndings provided further evidence that Kendra ’ s behaviors associated with selective eating

and participating in learning activities that used

a tactile medium as well as her diffi culty tolerating other children ’ s touch may be related

to over-responsivity to sensation. Further, her

low score on the praxis subscale supported the

fi ndings of poor praxis on the SIPT and support

the therapist ’ s reasoning that many of her diffi -

culties with play and organization of behavior for

learning in the classroom may be related to poor

praxis.

HERE ’ S THE POINT

• The evaluation process begins by investigating

a child ’ s challenges with participating in his or

her daily activities at home and school.

• Difficulties that are hypothesized to be

related to poor SI or praxis indicate the need

for examining functions such as sensory

perception and discrimination, praxis,

postural control, bilateral integration, and

sensory responsivity .

• A combination of evaluation methods is

recommended, including a standardized

performance-based assessment of SI such as

the SIPT, a caregiver questionnaire of sensory

processing functioning and behavior such

as the SPM, and Ayres Clinical Observations

of postural control and motor coordination.

Interviews with those who know the child well,

such as parents and teachers, and a measure of

occupational performance are also important.

• Synthesis of assessment data from multiple

sources is necessary to identify the specifi c

sensorimotor factors that are impacting

the child ’ s participation in his or her daily

occupations and to begin the intervention

planning process.

Generating Hypotheses

 Assessment data from the SIPT and SPM were

synthesized and analyzed in relation to common

patterns of sensory integrative dysfunction defi ned

in the literature ( Mailloux et al., 2011 ; Mulligan,

 1998 ). Kendra ’ s assessment results indicated

poor praxis (low score on SIPT Praxis tests and

Praxis subscale of SPM). Poor tactile perception

was also evident. Diffi culty with sensory responsivity (also called poor sensory modulation) was

apparent, specifi cally over-responsivity to tactile

sensations. Many of the behavioral consequences

of SI defi cits, as depicted in Figure 1-6 presented

in Chapter 1 (Sensory Integration: A. Jean Ayres’

Theory Revisited), are consistent with Kendra ’ s

presentation, such as tactile over-responsivity,

decreased ability to regulate her behavior,

TABLE 21-1 Kendra ’ s SIPT Z Score at Pretest

SIPT TESTS

PRE-TREATMENT

SCORE

Tactile Perception Tests

Manual Form Perception (MFP) Not administered

Finger Identifi cation (FI) Not administered

Graphesthesia (GRA) Not administered

Kinesthesia (Kin) Not administered

Localization of Tactile Stimuli

(LTS)

Not administered

Praxis Tests

Constructional Praxis (CPr) Not administered

Postural Praxis (PPr) –3.00

Praxis on Verbal Command –3.00

Oral Praxis (OPr) –3.00

Sequencing Praxis (SPr) –3.00

Tests of Posture, Balance, Bilateral Integration, and

Vestibular Functions

Bilateral Motor Coordination

(BMC)

Not administered

Standing and Walking Balance

(SWB)

–0.80

Post-Rotary Nystagmus (PRN) –0.50

Visual Perception and Visual Motor Tests

Motor Accuracy (Mac) Not administered

Space Visualization (SV) –0.85

Figure-Ground Perception (FG) –0.05

Design Copying –1.74

552 ■ PART VI CASES

diffi culty organizing her approach to learning,

and diffi culty playing with others.

 Next, specifi c hypotheses were formulated to

link assessment fi ndings to the participation challenges noted. For example, diffi culty at mealtime

was linked to tactile sensitivity that included

the oral area (noted on the SPM). Diffi culty

dressing was hypothesized to be related to poor

praxis, whereas her diffi culty participating in

community activities, such as eating at a restaurant, was hypothesized as being related to tactile

over-responsivity (SPM) and poor praxis. Kendra ’ s diffi culty participating in play with peers in

the community or at school was hypothesized to

be related to both poor praxis, resulting in diffi -

culty creating strategies for engaging in play with

others, as well as tactile hyper-reactivity, which

impacted her acceptance of other children into

her play space. Finally, Kendra ’ s diffi culty participating in learning activities in the classroom

was hypothesized to be related to poor praxis ,

resulting in diffi culty organizing motor plans for

following the classroom routines during learning.

Further, tactile over-responsivity was hypothesized to be limiting her participation in learning activities when materials with a lot of tactile

input were used. In summary, the evaluation data

revealed that Kendra ’ s participation in home,

community, and school activities was affected

by poor praxis and tactile over-responsivity. The

evaluation process ends with the initiation of the

intervention planning process.

HERE ’ S THE POINT

• Analysis of assessment data provides the basis

for identifying how sensory processing and

integration deficits are affecting the child ’ s

behavior, participation challenges, and ability to

perform daily tasks.

• Analysis is essential for guiding the intervention

process, for developing meaningful therapy

goals, and for assuring that intervention

activities are targeted appropriately.

Developing and Setting Goals

and Objectives

 Intervention planning involved operationalizing each one of Kendra ’ s identifi ed problems or

daily life challenges into a goal and then identifying desired outcomes. This step was followed

by making decisions regarding the selection of

intervention type and context, setting a schedule

for intervention, and identifying specifi c intervention activities. Therapists engage in a process

of clinical reasoning to make all these decisions,

with consideration of the synthesis and interpretation of assessment data, child and parent priorities, contextual elements, the research evidence

available on potential intervention approaches

and strategies, as well as pragmatics such as the

therapist ’ s resources.

 The goals set for Kendra were established

based on the primary concerns of the parents and

the teacher (e.g., participation in mealtime, community activities, dressing, learning activities,

and play with other children) as well as a review

of her occupational profi le data. There was also

clear evidence from multiple sources of evaluation data suggesting that these participation

goals were at least partially caused by underlying

defi cits in SI and processing. Her goals focused

on functional, participation-based outcomes:

participation in mealtime, dressing, community

activities such as eating at a restaurant with her

family, learning activities at school, and play

with her peers on the school playground.

 Once goals were identifi ed, Goal Attainment

Scaling (GAS) ( Kiresuk, Smith, & Cardillo,

 1994 ; Mailloux et al., 2007 ) was used to identify

the expected or desired outcome for each goal

following 10 weeks of intervention. Then goals

were scaled so that changes in outcome could be

measured ( Table 21-2 ). Each goal identifi ed the

underlying SI defi cit or factor(s) hypothesized

to be impacting Kendra ’ s ability to perform an

occupation-based activity or to participate in a

meaningful area of occupation. All goals were

broken down further into measurable components and scaled as follows: –2 = much less

than expected outcome; –1 = less than expected

outcome; 0 = expected level of performance;

+ 1 = better than expected outcome; and + 2 =

much better than expected outcome ( Kiresuk

et al., 1994 ; Mailloux et al., 2007 ).

 For instructional purposes, we focus on two

specifi c goals related to improving Kendra ’ s

dressing and eating skills. These examples are

used to illustrate how goals may be scaled and

written, how progress toward goal achievement

can be measured, and how the planning and

implementation of intervention relates to these

goals.

CHAPTER 21 Planning and Implementing Intervention: A Case Example of a Child with Autism ■ 553

Context and Schedule

for Service Delivery

 Kendra demonstrated signifi cant diffi culty processing and integrating sensation, and, therefore, clinic-based intervention was believed to

provide the level and intensity of services that

she needed to address her goals. This environment provided opportunities for participation

in active, sensory motor activities that were in

keeping with Kendra ’ s level of need and with

therapy equipment that afforded varied opportunities for experiencing sensation and developing praxis. Individual sessions of clinic-based

TABLE 21-2 Sample of Kendra ’ s Intervention Goals Written Using Goal Attainment Scaling

Kendra will decrease oral-tactile over-responsivity as a basis for trying new foods and mealtime participation.

Current level: When presented with new foods, Kendra will push them away and leave the table; if prompted to

come back to the table, Kendra will have a tantrum.

–2

Kendra will taste

one new food

with no tantrum

behaviors within

the 10-week

intervention period.

–1

Kendra will taste

two new foods

with no tantrum

behaviors within

the 10-week

intervention period.

0 (expected outcome)

Kendra will taste

three new foods with

no tantrum behaviors

within the 10-week

intervention period.

+ 1

Kendra will taste

four new foods

with no tantrum

behaviors within

the 10-week

intervention period.

+ 2

Kendra will taste

fi ve new foods

with no tantrum

behaviors within

the 10-week

intervention period.

Kendra will show improved praxis as a basis for increased participation in dressing.

Current level: Kendra requires frequent verbal directions and physical cues to don a shirt.

–2

Kendra will

put on a t-shirt

independently

given four or more

verbal re-directions.

–1

Kendra will

put on a t-shirt

independently

given three verbal

re-directions.

0 (expected outcome)

Kendra will put on a

t-shirt independently

given two verbal

re-directions.

+ 1

Kendra will

put on a t-shirt

independently

given one verbal

re-direction.

+ 2

Kendra will

put on a t-shirt

independently

with no verbal

re-directions.

PRACTICE WISDOM

GAS methodology has been applied most often

for research purposes, although it is also effective for clinical purposes. GAS is a quantifi able

alternative to the way in which occupational

therapy goals and objectives are traditionally

measured and provides a means of measuring

individualized progress in functional areas. Using

GAS methodology, expected level of performance for each goal can be set and then scaled

with equal intervals between levels. An important part of writing, scaling, and measuring goals

is describing the child ’ s current level in each

area. Further, when using the SI approach, it is

helpful to identify the sensory motor factors that

are hypothesized to be impacting each goal, as

this information communicates the underlying

sensory motor skills that are being addressed in

treatment.

HERE ’ S THE EVIDENCE

GAS has been shown to be an effective strategy

for identifi cation and measurement of individual

goals and a valid outcome measure for psychosocial interventions for autism ( Ruble, McGrew, &

Toland, 2012 ). GAS has been used in three

randomized controlled trials (RCTs) of SI ( Miller,

Coll, & Schoen, 2007 ; Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011 ; Schaaf et al.,

 2013 ). Signifi cant gains in GAS scores for the SI

group were reported from a study of 24 children

with sensory modulation diffi culties by Miller and

colleagues ( 2007 ). In a study of 37 children with

ASD, Pfeiffer and colleagues ( 2011 ) reported

the SI treatment group had signifi cantly greater

gains in GAS scores than the group receiving

fi ne motor intervention. Using a manualized

protocol, Schaaf and colleagues ( 2013 ) also

reported signifi cant gains in the SI group in comparison to the usual care group of a study with

32 children. These studies have found GAS to be

a useful tool for documenting change in children

with ASD, as it is sensitive, objective, and provides an individualized, and thus very relevant,

outcome measure.

554 ■ PART VI CASES

occupational therapy intervention using the SI

approach were provided three times per week

for 10 weeks or a total of 30 sessions during the

10-week period. This intervention was supplemented with environmental adaptations in the

classroom to support her sensory motor needs

and to enable her to participate more effectively

in learning, play, and lunchroom activities. In

addition, frequent interaction with her parents

was accomplished during the individual therapy

sessions (before or following each session), and

these focused on increasing parental knowledge

and understanding of how Kendra ’ s sensory

motor diffi culties were impacting her ability to

carry out her daily activities and routines. The

therapist also reached out to Kendra ’ s teacher to

collaborate on problem-solving strategies to aid

Kendra in addressing her challenges in school,

and weekly check-in with the teacher was accomplished via e-mail, phone, or on-site visits. Intervention outcomes would be measured at both the

proximal level (changes in sensory motor skills

and abilities forming proximal objectives ) and

distal levels (change in her participation in dressing and mealtime forming distal objectives ) as

measured by GAS and daily charting.

Setting the Stage for Intervention

 Treatment activities based on the principles of

ASI were chosen, as the assessment results indicated diffi culty processing and integrating sensation were impacting Kendra ’ s performance in the

areas refl ected in her goals. The therapist considered the following questions when identifying

preliminary ideas for intervention:

 1. What were the specifi c sensory motor areas

being targeted for Kendra?

 a. The assessment data revealed that

tactile over-responsivity and poor

praxis were primary factors impacting

Kendra ’ s participation in dressing,

mealtime, community activities, learning

activities, and play with other children.

Therefore, activities heavily loaded with

somatosensory (tactile and proprioceptive)

input and that challenge her

motor-planning abilities were emphasized.

 2. What specifi c goals are being addressed?

 a. Participation in mealtime, participation

in dressing, participation in community

activities such as eating at a restaurant

with her family, participation in learning

activities at school, and participation in

play with her peers on the playground

at school were identifi ed as goals

for Kendra. Therefore, her therapist

incorporated activities associated with

these goals into the intervention whenever

possible and selected therapeutic activities

with these goals in mind.

 3. What are Kendra ’ s interests and strengths?

 a. Kendra enjoys puzzles and stuffed

animals, and she likes active play, so

these interests were incorporated into

therapy sessions.

 4. How might the clinic and specifi c activities

be organized so that Kendra participates in

sensory motor activities that address her

areas of need and so that they provide her

with the just right challenge?

 a. The intervention included opportunities

for rich total-body tactile input combined

with opportunities for moving her body

in new and novel ways. This included

access to a large ball pit, large mats, a

climbing wall, and suspended Lycra fabric

layers that Kendra could crawl through

and around. Also, there were opportunities

for oral-tactile activities, such as blowing

bubbles or eating a tactile-rich food such

as peanut butter.

 In the previous chapter, we went through the

reasoning process for setting up a treatment

session with Kyle, and we provided snapshots

and clinical reasoning from a series of therapy

sessions. We also looked at gains made after

4 months of therapy. Here we provide a more

detailed example of a single treatment session

with Kendra, the reasoning used by the therapist

as the session unfolded, and Kendra ’ s outcomes

after a 10-week treatment program. Additional

treatment approaches and ideas can be found in

Chapter 12 (The Art of Therapy) and Chapter 13

(The Science of Intervention: Creating Direct

Intervention from Theory), respectively.

Providing Intervention

A Typical Treatment Session with Kendra

 The therapist used the steps described previously

to set up the treatment area with activities that

might entice Kendra to play. Keeping in mind

the goal of dressing, the therapist set up a small

CHAPTER 21 Planning and Implementing Intervention: A Case Example of a Child with Autism ■ 555

area with a bench where Kendra ’ s shorts and

t-shirt were laid out (each child has a spare pair

at the clinic). Here Kendra could change into her

shorts and t-shirt, allowing more of her skin to

be exposed to the many tactile sensations that

Kendra would hopefully engage with during the

treatment session. This activity also gave her the

opportunity to practice dressing. Further, in consideration of Kendra ’ s tactile over-responsivity

but need for somatosensory (tactile and proprioceptive) sensations to improve body awareness and praxis, the therapist had the large ball

pit available. Access to the ball pit included a

couple of options: Kendra could drag over the

large foam wedge and place it next to the ball

pit, or Kendra could climb into the ball pit by

lifting her body over the edges. The therapist had

a puzzle nearby because she recalled that doing

puzzles was an activity that Kendra enjoyed. The

therapist thought she and Kendra might play a

game of fi nding puzzle pieces in the ball pit. As a

second option, the therapist had the bolster swing

hanging up with some small stuffed animals laid

out around it. The therapist anticipated initiating functional play, such as “get on your horse

and ride through the forest.” In addition, an area

for oral motor play and snack time was set up.

This area had bubbles, whistles, and other mouth

toys in a small container on the table, and there

were some preferred and non-preferred snacks

and drinks nearby. The entire therapy area had

mats, and all equipment was checked routinely

for safety.

 As Kendra entered the therapy room, the

therapist noticed that she seemed agitated. Her

mother indicated that Kendra was fi ghting with

her in the waiting area because she did not want

to leave her stuffed animal toy, “Stuffy,” behind.

Kendra wanted to bring it into the therapy

session. The therapist, seeing an opportunity to

build rapport with Kendra, fi rst reassured Mom

that it was fi ne to bring Stuffy into the therapy

session. She then asked Kendra if she wanted

Stuffy to play with them today also. Kendra

was excited by this idea and ran off to retrieve

Stuffy. In order to continue building rapport and

to engage Kendra in functional play, the therapist

pretended that Stuffy was whispering in her ear

and stated: “Oh—Stuffy wants to go swimming

today. Let ’ s get into our swim gear.” The therapist used this opportunity to encourage Kendra to

work with her to remove her shoes and change

into the t-shirt and shorts. With additional supportive whispers from Stuffy, and some assistance from the therapist, Kendra was willing

and able to change clothes. The therapist gently

guided Kendra toward the ball pit and pretended

that Stuffy was trying to get into the ball pit but

was not able to climb over the side because she

is too short. “Stuffy is struggling. Can you think

of a way to help Stuffy climb into the pool?” The

therapist might have placed her hand on the large

foam wedge as a suggestion. If Kendra picked

up on the cue, she would begin to drag the foam

wedge over to the ball pit. If not, the therapist

might use Stuffy to begin to push the wedge over

and (struggling) note, “Stuffy wants to use the

wedge to help her get in the pool. Can you help?”

The hope was that Kendra would help push the

large (and heavy) foam wedge to the ball pit.

The therapist noted that this activity was providing good proprioceptive sensations for Kendra

(i.e., working muscles against resistance), which

she anticipated would help decrease Kendra ’ s

tactile over-responsivity in preparation for play

in the ball pit. Once the wedge was in place,

the therapist asked Kendra to show Stuffy how

to climb the wedge to enter the ball pit. Kendra

jumped in and then Stuffy followed. Once in the

ball pit, Kendra and Stuffy “swam” around and

took turns covering each other up with balls in a

“hide-and-seek” game for about 10 minutes. The

therapist continued expanding the play schemes

as she was able.

 The therapist was vigilant in attending to

Kendra ’ s mood, attention, and responses to the

sensations of the ball pit, and the therapist was

prepared to adjust the activity in order to maintain the just right challenge for Kendra. When

Kendra showed signs of disorganization, the

therapist encouraged Kendra and Stuffy to come

out of the pool and dry off with a big fl uffy

towel, providing fi rm tactile input. To ensure

that Kendra stayed regulated, the therapist was

prepared to wrap Kendra in the towel and hold

Kendra (and Stuffy) against the therapist ’ s body

with fi rm pressure. This was not necessary during

this session. Here the therapist was using knowledge that deep pressure touch may help regulate Kendra ’ s tactile over-responsivity and also

provide additional input to improve tactile perception and body awareness. Once Kendra was

ready, they returned to the ball pit, and the therapist and Kendra expanded the playful activities

556 ■ PART VI CASES

and motor plans. This modifi cation of activities

allowed Kendra to be constantly challenged at

the “just right” level to encourage praxis, acceptance of tactile sensations, and opportunities for

tactile and proprioceptive perception to build

body awareness. The therapist also might have

suggested that Kendra show Stuffy different ways

to jump into the ball pit (e.g., jump and twist

around; go in backward, etc.) to facilitate praxis.

In the ball pit, the hide-and-seek play scheme

might have been expanded to just body parts

(“let ’ s fi nd Kendra ’ s foot”) to foster tactile perception, or Kendra and Stuffy might have shown

each other different ways to “swim through the

‘pool’” (back stroke, side stroke, etc.). If going

well, the therapist might introduce some of the

oral motor mouth toys from the snack table into

the activities in the ball pit. For example, the

therapist might encourage Kendra to bury herself

in the ball pit and then blow on the whistles for

Stuffy to fi nd her or blow bubbles so that Stuffy

can pop them. The therapist continued to expand

the play activities and schemes to create more

challenging praxis schemes and play themes until

Kendra showed signs of wanting to move on.

 Once the therapist felt that the ball pit activity had exhausted its therapeutic value, the therapist pretended that she was hungry. “Wow, that

swimming really made me hungry! I ’ m wishing

for a snack.” This suggestion was to encourage

Kendra to go to the snack table. Here Kendra

was encouraged to make Stuffy a peanut butter

sandwich (a non-preferred food for Kendra)

with two slices of bread and peanut butter that

was set out prior. Next, the therapist encouraged

Kendra to show Stuffy how to bite the sandwich.

As expected, Kendra did not comply, and the

therapist suggested that blowing on whistles and

other mouth toys might help Stuffy and Kendra

be more willing to accept the food. As there was

still no success, the therapist reconsidered Kendra ’ s interests; recalling that Kendra liked to play

with her mother ’ s makeup, the therapist brought

out some play makeup and a mirror. They put

on lipstick and rouge. The therapist reasoned that

Kendra ’ s resistance to try non-preferred foods

was related to oral-tactile over-responsivity. As

the makeup play required tolerance of tactile sensations in and around the oral area, this helped

Kendra accept oral sensations more readily.

After a few minutes of play, the therapist showed

Kendra that biting into the sandwich while

wearing lipstick left a funny mark on the bread.

Curious to try this herself, Kendra bit the sandwich to make the lipstick imprint!

 After several minutes of snack time, the therapist recognized that it was time to transition back

to the waiting room and let Kendra know that she

and Stuffy must change out of their “swimsuits”

and back into their regular clothes. The therapist

took advantage of the sensory motor experiences

during therapy that were used to build Kendra ’ s

body awareness as a basis for praxis and worked

with Kendra to don her shirt. The therapist might

have tapped Kendra ’ s arm and pointed to the

shirt sleeve as cues for Kendra to motor plan

the placement of her arm in the sleeve. At each

future session, the therapist will provide less

cueing and encourage Kendra to complete more

of the steps to dressing independently.

 Kendra ’ s mom had been sitting in the treatment room during this session. As they walked

together back to the waiting area, the therapist

talked with Kendra ’ s mom about the reasons

for playing in the ball pit and using makeup to

encourage Kendra to try non-preferred foods.

They discussed similar strategies that could be

used at home to help Kendra with her motor

planning and to expand her food repertoire. The

therapist suggested they make a peanut butter

sandwich at home tomorrow and include Stuffy

in the lunch time activity. In addition, the therapist talked with Kendra ’ s mom about how to set

up Kendra ’ s daily dressing tasks, suggesting that

they work on dressing in the evenings when they

are not rushed and have fewer time constraints.

 Communication and collaboration with Kendra ’ s parents were integral to the occupational

therapy intervention. In addition, environmental adaptations were also incorporated into the

treatment program. The effects of environmental

stimuli on Kendra ’ s ability to focus and attend

were discussed, and strategies were identifi ed to

decrease environmental stimuli. For example,

when dining in a restaurant, her parents were

advised to choose a seating location that was

away from highly traffi cked areas. When eating

dinner at home, parents were advised to turn

off the TV and reduce other unnecessary auditory, visual, and tactile sensations. To minimize

demands on motor organization and planning,

her parents were encouraged to provide Kendra

with simple one- or two-step directions when

asking her to perform daily living tasks.

CHAPTER 21 Planning and Implementing Intervention: A Case Example of a Child with Autism ■ 557

Ongoing Clinical Reasoning

 Tailoring intervention is done mostly by carefully observing the child and considering the

child ’ s behavioral responses during intervention. Observations were made and recorded

throughout Kendra ’ s intervention sessions. Her

behavior during the fi rst two treatment sessions

was quite disorganized, and she required physical and frequent verbal prompts to engage in

therapeutic activities. She tended to run around

the room, shifting from task to task with little

sustained, productive play. With guidance and

structure from the therapist, Kendra began to

become more organized in her approach to the

therapeutic activities. A possible explanation

for this is that as Kendra became better able to

manage sensation, her behavior became more

organized. As this shift occurred, the therapist

engaged Kendra with more and more challenging

activities that required increasingly sophisticated

adaptive responses.

 Another important component to the intervention is that the therapist followed Kendra ’ s lead in

the sample session described previously. Recall

that although the therapist set out a puzzle with

the intent to use it in the ball pit activity, the therapist instead adapted to a swimming play theme.

This theme seems to fl ow nicely with Kendra ’ s

interest in having Stuffy join in the activity and

shows that the therapist followed Kendra ’ s lead

and read her cues to adjust the treatment accordingly. Treatment in SI is more focused on the

types of experiences that the child needs rather

than the activity itself. A successful treatment

session is one where the child is engaged in

active, individually tailored sensory motor activities in a playful context. The activity itself is

only the catalyst for this experience.

HERE ’ S THE POINT

• Skilled occupational therapists working in

clinical settings use their clinical reasoning

by considering the child ’ s needs, goals, and

interests, along with the available research

evidence, for guiding their service delivery

decisions and for orchestrating intervention

sessions.

• Effective sessions using SI are playful. They

are filled with social interactions that foster a

strong therapeutic alliance between the child

and therapist, while engaging the child in

activities providing the just right challenge and

resulting in adaptive responses.

Outcomes Following 10 Weeks

of Intervention

 The therapist had a systematic plan for measuring outcomes, namely changes in participation

in mealtime and dressing measured by GAS and

daily charting of behavior. In keeping with the

goals, the therapist asked the parents to keep a

daily log of new foods tried and the number of

verbal directions Kendra required during dressing. To facilitate data collection, the therapist

provided two charts—one for the refrigerator in

the kitchen so the parents could mark new foods

tried daily, and one posted in Kendra ’ s bedroom

where dressing generally took place. After

10 weeks of intervention, the therapist evaluated

Kendra ’ s progress. The data from the charts was

entered into a spreadsheet, and charts were made

to show change through time. The therapists also

asked the parents to view the GAS and circle

the level of attainment. Kendra ’ s parents marked

her goal attainment for trying new foods as + 2

(far exceeds expected outcome) and for dressing as + 1 (exceeds expected outcome), showing

that she made notable progress on both goals. A

semi-structured interview was also conducted

with the parents, which provided additional

information about how Kendra was doing in her

daily activities. Qualitative data from the interview with Kendra ’ s parents further informed the

HERE ’ S THE EVIDENCE

Evidence for the effectiveness of ASI characteristic of the intervention approach used with

Kendra is available from several studies, including Schaaf and colleagues ( 2013 ). The study by

Schaaf and colleagues included children with

autism, ages 4 to 8 years old, and used a randomized controlled research design. The results

showed that the children in the treatment group

( n = 17) who received 30 sessions of the intervention scored signifi cantly higher ( p < .01) on

GAS, and they also did signifi cantly better on

measures of caregiver assistance in self-care

( p = 0.008) and socialization ( p = 0.04) than the

usual care control group ( n = 15).

558 ■ PART VI CASES

therapist of outcomes indicating that Kendra participated in dinner at a restaurant and is better

able to regulate her behavior when out in the

community, such as eating in a restaurant.

 Although it is not generally recommended

that the SIPT be re-administered in a time

frame that is fewer than 6 months, Kendra was

re-administered the SIPT as an exploratory

measure. The therapist wanted to see if Kendra

would be able to complete more of the tests

than were attempted at her initial assessment,

and the therapist wanted to compare pre- and

post-treatment z-scores. Kendra had completed

eight SIPT tests at pretest, and she completed all

17 tests at posttest. Positive changes were noted

on the following tests:

• Oral Praxis (pre: –3.00 to post: –2.18)

• Standing and Walking Balance (pre: –3.00 to

post: –1.85)

• Figure-Ground (pre: –0.05 to post: 1.03)

• Sequencing Praxis (pre: –3.00 to post: –1.00)

• Postural Praxis (pre: –3.00 to post: –1.00)

 These improvements were refl ected in her ability

to participate in multi-step sensory motor activities in the clinic (e.g., climbing onto a foam

pillow, holding onto a trapeze, and swinging into

a ball pit fi lled with large pillows) as well as her

ability to participate in multi-step tasks at home

(e.g., the ability to get dressed by herself, excluding fasteners). Furthermore, these improvements

in sensory motor abilities were likely key factors

contributing to the positive gains she obtained

toward achieving her intervention goals.

Summary and Conclusions

 This chapter described a child with ASD who

was experiencing participation challenges in

daily living and learning activities that were

hypothesized to be related to poor SI. Following

a detailed history and occupational profi le, Kendra ’ s participation challenges were identifi ed, as

were her strengths and interests. Assessment of

the sensory motor factors affecting these participation challenges was accomplished using the

SIPT, select clinical observations, and by administrating the SPM. Data from these assessments

were analyzed and interpreted, and hypotheses

about the specifi c sensory motor factors affecting

Kendra ’ s participation challenges were identifi ed.

Intervention activities that targeted these factors

were implemented with Kendra following the

key principles of the SI approach. In addition,

her parents were educated about the impact of

Kendra ’ s diffi culty processing and integrating

sensation on her behavior, and specifi c environmental adaptations were recommended and

implemented. After 10 weeks (30 sessions) of

occupational therapy using SI, Kendra achieved

her goals, and her ability to participate in her

daily activities had improved signifi cantly.

 As autism is a complex condition, it is

important to consider that standard care typically involves a multifaceted approach. In addition to receiving occupational therapy, children

with ASD typically have additional professionals

involved in their care. This chapter demonstrated

how Kendra ’ s occupational therapist, as a valued

team member, used SI theory and techniques as a

powerful approach for addressing Kendra ’ s participation challenges.

Where Can I Find More?

 Miller-Kuhaneck, H. (2004). Autism: A comprehensive occupational therapy approach (2nd

ed.). Bethesda, MD: American Occupational

Therapy Association.

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

guide for implementing Ayres Sensory Integration: Promoting participation for children

with autism. Bethesda, MD: AOTA Press.

 Websites:

 Autism Speaks: www.autismspeaks.org

 Autism Research Institute: www.autism.com

 SPD Foundation: www.spdfoundation.net

 References

 Ayres , A. J. ( 1989 ). The Sensory Integration

and Praxis Tests . Los Angeles, CA : Western

Psychological Services.

 Bagby , M. S. , Dickie , V. A. , & Baranek , G. T.

( 2012 ). How sensory experiences of children with

and without autism affect family occupations .

American Journal of Occupational Therapy ,

66 ( 1 ), 78 – 86 .

 Baio , J. , Wiggins , L. , Christensen , D. L. , Maenner ,

 M. J. , Daniels , J. , Zachary , W. , Kurzius-Spencer ,

 M. , . . . Dowling , N. ( 2018 ). Prevalence of

Autism Spectrum Disorder Among Children

Aged 8 Years – Autism and Developmental

Disabilities Monitoring Network, 11 Sites,

United States, 2014 . MMWR Surveill Summ ,

67 ( No. SS-6 ), 1 – 23 . DOI: http://dx.doi.org/

10.15585/mmwr.ss6706a1

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 Bar-Shalita , T. , Vatine , J. , & Parush , S. ( 2008 ).

 Sensory modulation disorder: A risk factor for

participation in daily life activities. Developmental

Medicine & Child Neurology , 50 ( 12 ), 932 – 937 .

 doi:10.1111/j.1469-8749.2008.03095.x

 Bundy , A. C. , Shia , S. , Qi , L. , & Miller , L. J. ( 2007 ).

 How does sensory processing dysfunction affect

play? American Journal of Occupational Therapy ,

61 ( 2 ), 201 – 208 .

 Jasmin , E. , Couture , M. , McKinley , P. ,

 Frombonne , E. , & Gisel , E. ( 2009 ). Sensori-motor

and daily living skills of preschool children with

autism spectrum disorders. Journal of Autism and

Developmental Disorders , 39 ( 2 ), 231 – 241 .

 Kiresuk , T. J. , Smith , A. E. , & Cardillo , J. E. ( 1994 ).

Goal attainment scaling: Applications, theory, and

measurement . Mahwah, NJ : Lawrence Erlbaum

Associates, Inc .

 Mailloux , Z. , May-Benson , T. A. , Summers , C. A. ,

 Miller , L. J. , Brett-Green , B. , Burke , J. P. , . . .

 Schoen , S. A. ( 2007 ). Goal Attainment Scaling as

a measure of meaningful outcomes for children

with sensory integration disorders. American

Journal of Occupational Therapy , 61 ( 2 ),

 254 – 259 .

 Mailloux , Z. , Mulligan , S. , Roley , S. S. , Blanche ,

 E. , Cermak , S. , Coleman , G. G. , . . . Lane , C. J.

( 2011 ). Verifi cation and clarifi cation of patterns

of sensory integrative dysfunction. American

Journal of Occupational Therapy , 65 ( 2 ), 143 – 151 .

 doi:10.5014/ajot.2011.000752

 Miller , L. J. , Coll , J. R. , & Schoen , S. A. ( 2007 ).

 A randomized controlled pilot study of the

effectiveness of occupational therapy for children

with sensory processing disorder . American

Journal of Occupational Therapy , 61 ( 2 ),

 228 – 238 .

 Mulligan , S. ( 1998 ). Patterns of sensory integration

dysfunction: A confi rmatory factor analysis .

American Journal of Occupational Therapy ,

52 ( 10 ), 819 – 828 .

 Parham , L. D. , Ecker , C. , Kuhaneck , H. M. ,

 Henry , D. A. , & Glennon , T. J. ( 2007 ). Sensory

Processing Measure manual . Los Angeles, CA :

 Western Psychological Services .

 Pfeiffer , B. A. , Koenig , K. , Kinnealey , M. , Sheppard ,

 M. , & Henderson , L. ( 2011 ). Effectiveness of

sensory integration interventions in children

with autism spectrum disorders: A pilot study .

American Journal of Occupational Therapy ,

65 ( 1 ), 76 – 85 . doi:10.5014/ajot.2011.09205

 Ruble , L. , McGrew , J. H. , & Toland , M. D. ( 2012 ).

 Goal Attainment Scaling as an outcome measure

in randomized controlled trials of psychosocial

interventions in autism . Journal of Autism and

Developmental Disorders , 42 ( 9 ), 1974 – 1983 .

 doi:10.1007/s10803-012-1446-7

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

 P. , Hunt , J. , van Hooydonk , E. , . . . Kendra , D.

( 2013 ). An intervention for sensory diffi culties in

children with autism: A randomized trial . Journal

of Autism and Developmental Disorders , 44 ( 7 ),

 1493 – 1506 . doi:10.1007/s10803-013-1983-8

 Schaaf , R. C. , & Case-Smith , J. ( 2014 ). Sensory

interventions for children with autism. Journal

of Comparative Effectiveness Research , 3 ( 3 ),

 225 – 227 .

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

guide for implementing Ayres Sensory Integration:

Promoting participation for children with autism .

 Bethesda, MD : AOTA Press .

 Schaaf , R. C. , Toth-Cohen , S. , Johnson , S. L. , Outten ,

 G. , & Benevides , T. W. ( 2011 ). The everyday

routines of families of children with autism:

Examining the impact of sensory processing

diffi culties on the family . Autism , 15 ( 3 ), 373 – 389 .

 Smith , S. A. , Press , B. , Koenig , K. P. , & Kinnealey ,

 M. ( 2005 ). Effects of sensory integration

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Therapy , 59 ( 4 ), 418 – 425 .

560

CHAPTER

22

Viewing Intervention Through

Different Lenses

 Anita C. Bundy , ScD, OT/L, FAOTA ■ Dido Green , PhD, MSc, DipCOT

 Chapter 22

 In all affairs it ’ s a healthy thing now and then to hang a question

mark on the things you have long taken for granted.

 —Bertrand Russell

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

✔ Describe how clinical reasoning and evaluation

and intervention decisions are shaped by the

selection of a guiding frame of reference or

theory.

✔ Consider that there is more than one approach

that may be effective in intervention for

children with sensory-integrative-based

dyspraxia.

✔ Describe how the Cognitive Orientation to daily

Occupational Performance (CO-OP) model may

be applied to a child with sensory integration

(SI) dysfunction.

LEARNING OUTCOMES

Purpose and Scope

 The lens through which a therapist views a child

determines the look of the intervention. Similarly, the principles of a particular approach

dictate the focus of the therapist ’ s critical reasoning. Within the broad context of occupational

therapy, there are multiple ways of thinking

about children, conceptualizing their diffi culties, and minimizing the effects of those diffi culties. Although there may be approaches that are

“wrong”—that is, they are known to be ineffective or they are not appropriate or feasible in a

given situation—there are likely to be multiple

“right” approaches to intervention. In most chapters, we use sensory integration (SI) theory to

assess, interpret fi ndings, and plan intervention.

In this chapter, we view intervention for Lars, an

11-year-old boy referred for occupational therapy

because of substantial diffi culties performing

many complex motor tasks through two equally

plausible interventions. In the fi rst instance, we

describe Lars and his intervention using a modifi ed sensory integrative approach. Then we

change the frame and use the Cognitive Orientation to daily Occupational Performance

(CO-OP) model, which, as the name suggests, is

a cognitive problem-solving approach often used

with children who have a diagnosis of developmental coordination disorder (DCD).

 DCD is a neuromotor condition that, by defi nition, cannot be explained by intellectual disability or another neurological condition affecting

movement ( American Psychiatric Association,

 2013 ). The diffi culties of children with DCD are

very similar to those of children diagnosed with

dyspraxia. In fact, in cases where there is also

a somatosensory or vestibular-proprioceptive

processing disorder, a child might be diagnosed

with either DCD or sensory-integrative-based

dyspraxia, depending on the views and training

of the professional making the diagnosis. Several

CHAPTER 22 Viewing Intervention Through Different Lenses ■ 561

researchers ( Smits-Engelsman et al., 2013 ;

 Green, Chambers, & Sugden, 2008 ) have shown

the effectiveness of the CO-OP Approach TM .

Looking at Lars Through

a Modifi ed Sensory

Integrative Lens

 In this section, we view Lars through a sensory

integrative lens. However, for several reasons,

we modify some of the principles. Ayres ( 1972 )

proposed that sensory integrative therapy was a

means of changing the underlying function of

the central nervous system (CNS) in order to

promote processing of sensation, which in turn

led to improved body scheme and motor planning. In Ayres’ ( 1972 ) words, “The objective

is modifi cation of the neurological dysfunction

interfering with learning rather than attacking

the symptoms of that dysfunction” (p. 2). She

proposed that improved motor planning would

result in better abilities to learn new motor tasks.

But however powerful SI may be, it is neither

a miracle nor a cure. Ayres ( 1972 ) went on,

“This type of therapy . . . does not necessarily

eliminate the need for the more symptomatic

approach. Therapy is considered a supplement,

not a substitute, to formal classroom instruction

or tutoring. It reduces the severity of the diffi -

culty and allows specifi cs . . . to be learned more

rapidly” (p. 2). No doubt, the same could be said

about learning to rapidly descend an open stairwell or ride a bike.

 Because of the nature of Lars’ problems,

ascertained through testing and observation, we

believe that a sensory integrative approach can

be effective for ameliorating underlying diffi -

culties and ultimately making it easier for him

to learn new motor skills. But Lars is 11. He is

interested in a very rapid solution to his goals.

He is also enrolled in an intensive intervention

program that occurred during 1 week. Working

fi rmly within the philosophical base of occupational therapy, we set an explicit goal that we felt

he could master in the four sessions. In keeping

with sensory integrative therapy, we developed

activities that captured Lars’ intrinsic motivation

to play and we incorporated ample opportunities

for him to experience enhanced sensation, especially vestibular-proprioception, in the context

of active engagement in the therapy. We adapted

traditional sensory integrative therapy slightly to

emphasize activities that “mimicked” aspects of

the targeted goal.

 The results of testing suggested that Lars had

diffi culty processing vestibular-proprioception,

seen as poor postural-ocular control (i.e., diffi culties with prone extension, neck fl exion

against gravity, equilibrium). Poor processing

of vestibular-proprioception seemed to contribute to diffi culties with bilateral integration and

sequencing (BIS). Figure 22-1 shows the results

of Lars’ Sensory Integration and Praxis Test

(SIPT) testing and clinical observations. We

labeled his SI dysfunction as defi cits in Vestibular Bilateral Integration and Sequencing (VBIS),

a relatively mild form of dyspraxia. See also

 Chapter 5 (Praxis and Dyspraxia).

 The fi rst day of intervention, Lars and his

mother set a goal of “descending a fl ight of

open stairs reciprocally and without hesitation.”

The therapist then observed Lars going down

the stairs. As she watched, she engaged in task

analysis to develop specifi c hypotheses about the

reasons for Lars’ diffi culty with the stairs. She

videotaped his performance for comparison at the

end of the intensive intervention. Lars descended

the stairs slowly and in a step-tap fashion (i.e.,

without alternating feet). He looked downward,

carefully monitoring his feet and the stairs. He

held the railing securely, appearing fearful. Lars’

performance on the stairs suggested that his proprioceptive processing defi cits resulted in a poor

sense of where his feet were in space and contributed to diffi culties integrating the two sides

of his body.

 While Lars was still on the stairs, the therapist placed cuff weights around his ankles to test

the hypothesis. However, rather than improving,

Lars’ performance actually deteriorated. In one

more attempt to examine the theory of poor proprioception as a major contributor to impaired

stair climbing, the therapist moved the weights

to Lars’ shoulders. This time the improvement

was dramatic. Although he still held the handrail,

Lars walked reciprocally and much more quickly

down the stairs. We interpreted this “improved

performance” as suggesting that weights on the

shoulder provided resistance (i.e., proprioception) through the trunk and potentially all the

way to the feet as when he was weightbearing.

In contrast, weights on the feet yielded proprioception to a much more restricted area and were,

562 ■ PART VI CASES

Score Score Score Score

0.50

0.67

0.90

0.50

0.90

0.89

0.89

Visual Vestibular

2.70

Weak

Poor

Poor

Poor

Poor

Poor

Poor

Poor

1.63

1.80

2.80

0.99

0.90

1.10

0.50

Bilateral Integration Score

BMC

SPr

OPr

GRA

MFPII

MAC

Observations

 e.g., skipping,

 jump jacks

Low PRN

Ocular stability

Head/neck/eye

 coordination

Summary

Vestibular-Ocular

SWB

Prone extension

Stability

Righting

Equilibrium

Postural Control

3.00

2.70

0.50

0.90

1.20

1.26

1.07

1.06

1.20

2.80

1.80

Poor

Poor

esp.

neck/

head

Yes

Score

PPr

OPr

PRVC

(SPr)

(BMC)

Flexion

Praxis

Tactile

LTS

GRA

FI

MFP

Observations

KIN

SWB

Poor body scheme

Observations

 (e.g.,

 finger/nose,

 thumb/finger

 touching,

 diadokokinesis)

Proprioception

Somatosensory Interoception/

Sensory Modulation

 No concern

NA

OK

OK

OK

Can be poor

at times

OK

OK

OK

Sensory responses

 Over/Under

 fluctuating

SPM results

 Visual

 Hearing

 Touch (LTS)

 Body awareness

 Balance and motion

Observations

 Arousal

 Affect

 Activity level

 Attention

Home

OK

OK

OK

OK

OK

Scl

OK

OK

OK

OK

OK

DC

CPR

MAC

MFP

GRA

Observations

 Able to complete

 age-appropriate

 puzzles with help

 organizing

Haptic Form

and Space

Visual Praxis

SV

FG

Visual Spatial

SP2 results

FIGURE 22-1 Lars’ completed diagnostic worksheet.

therefore, not as effective for providing a sense

of where Lars’ body was in space.

 Lars participated in intervention for 1 hour

on each of the next 4 days. Intervention activities provided him with opportunities to take

in enhanced vestibular-proprioception, through

activities that provided resistance to movement

and demanded BIS. The therapist created activities involving Lars’ whole body but emphasizing

his trunk and lower extremities. For example,

while he was prone or supine in the net, Lars

kicked off a mat leaning against a wall. He did

the same thing on a scooter board. Lars also

kicked large balls while swinging supine in the

net. Because stair climbing is done in an upright

position, he also engaged in jumping activities

as well as challenging obstacle courses that he

moved through as quickly as possible.

 Lars co-created these activities with the therapist but she offered more context (e.g., emphasizing the lower extremities) than she might

have done in typical sensory integrative therapy.

 Table 22-1 details the principles of intervention,

drawn from Parham and colleagues’ ASI Fidelity Measure (ASIFM) and applied to the four

intervention sessions with Lars. As noted, the

therapists modifi ed sensory integrative therapy

slightly to fi t with the short, intensive intervention block. Although the therapist collaborated with Lars in activity choice (Principle 6 in

 Table 22-1 ), all activities involved enhanced proprioceptive input to the trunk and lower extremities, thus potentially restricting the available

choice of activities.

 At the end of the four sessions, the therapist

took Lars back to the stairwell and once again

videotaped his descent of the stairs, this time

with no weights on Lars’ shoulders. Just as

Lars began the descent, someone handed him a

cap, which he placed on his head. Then he ran

quickly down the stairs, his hands in his pockets,

looking toward, and smiling at, his mother, who

stood at the bottom.

 Discussion

 Lars made signifi cant gains in just 4 hours of

intervention that occurred during the course of

1 week. The activities in which Lars engaged

during intervention looked very similar to those 

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