Earn .

1 AOTA CEU
(one contact hour and
Education Article 1.25 NBCOT PDU).
See page CE-7 for details.

Using Sensory Integration and Sensory-Based

Occupational Therapy Interventions Across
Pediatric Practice Settings
RENEE WATLING, PHD, OTR/L, FAOTA presents a brief historical perspective of the sensory integra-
Clinical Assistant Professor, Division of Occupational Therapy, tion theory and a description of intervention strategies based
University of Washington on the principles of sensory processing, followed by a discus-
Seattle, Washington sion of the regulatory and contextual factors that influence
Adjunct Faculty, School of Occupational and Physical Therapy, service provision addressing sensory needs across pediatric
University of Puget Sound practice settings.
Tacoma, Washington
A HISTORICAL PERSPECTIVE
GLORIA FROLEK CLARK, PHD, OTR/L, BCP, FAOTA OF SENSORY INTEGRATION THEORY
Private Practice A. J. Ayres developed the sensory integration theory in the
Adel, Iowa 1960s and 1970s. Ayres (1972) posited that sensory infor-
mation was nourishment for the nervous system and that
This CE Article was developed in collaboration with the nervous system responded to sensory information with
AOTA’s Sensory Integration Special Interest Section. alterations in function, structure, and output. Thus, sensa-
tion could both inhibit and facilitate brain function and
ABSTRACT occupational behavior. She integrated findings from human
Difficulties in processing and integrating sensory informa- and animal neuroscience, psychology, education, and human
tion can have an effect on occupational performance and development to better understand and delineate the relation-
behavior in the daily lives of children and youth. Services for ship between brain functions, behavior, emotion, and learn-
pediatric clients are influenced by a range of legislative and ing (Ayres, 1972, 1979). She consulted studies examining the
funding policies. Occupational therapy practitioners working effects of sensory deprivation and sensory-enriched environ-
in various pediatric practice settings need knowledge of the ments on physical and emotional behavior. She used this
differences between these approaches and the provisions information to generate hypotheses about the nature of the
of the funding resources in order to best meet the sensory relationship between sensation and typical development, the
processing and integration needs of their clients in various way development could be affected if physiological process-
contexts. ing of sensation was disrupted, and how sensory experiences
could then be used to remediate dysfunction and support
LEARNING OBJECTIVES development (Bundy, Lane, & Murray, 2002).
After reading this article, you should be able to: Ayres tested her hypotheses through research studies and
1. Identify the differences between Ayres’ sensory integra- developed measurement tools to help identify the presence
tion intervention and sensory-based strategies. and nature of sensory dysfunction in children. Her work
2. Recognize provisions of legislative and funding policies for generated the theory of sensory integration, which describes
pediatric occupational therapy services. the relationships between sensation, brain function, and
3. Recognize differences between supporting pediatric behavior; methods for measuring observable manifestations
clients with sensory needs in educational versus clinical of sensory integration processes; and principles for designing
contexts. interventions to address breakdowns in sensory processing
and integration. Since Ayres’ death in 1989, many research-
INTRODUCTION ers and theorists have continued her work, both directly
Difficulties in processing and integrating sensory information and indirectly. Present-day understanding of neuroscience,
can have an effect on occupational performance and behav- psychology, and development supports many of her original
ior in the daily lives of children and youth. Occupational conceptualizations of brain-behavior relationships (Lane &
therapy practitioners working in various pediatric practice Schaaf, 2010).
settings need to be aware of sensory processing, the possible
impact of sensory processing difficulties across behavior and Sensory Processing and Integration
performance areas, and the contextual factors that influence Sensory information arises from multiple sources, both
provision of services to address these needs. This article within and outside of the body. Sensory information from

SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911 CE-1

 AOTA Continuing Education Article
CE Article, exam, and certificate are also available ONLINE.
Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

within the body informs the individual of pain, hunger, or sleep and wake states, and an inability to manage behavioral
other conditions reflecting the state of the physical body. responses. Often, the individual with dysfunction in sensory
Sensory information from external sources yields informa- processing and integration displays behavior that is out of
tion about the characteristics of objects, spatial relationships proportion to a sensory event or experience. For example,
between objects including the body, and movement of the the client may cover his or her ears and cry at the sound of
body or part of the body through space. There are seven a flushing toilet; react with aggression or as if in pain when
forms of sensory input: taste, smell, sight, sound, touch, accidentally bumped; appear to not notice sensory events
movement, and force. These must be registered, processed, noticed by others; or have difficulty grading the amount
and interpreted within the central nervous system in order of force used when interacting with other people, pets, or
for the individual to gain a reference for the body’s rela- objects.
tionship to itself, gravity, and people and objects in the
environment, as well as to perceive the spatial relationships INTERVENTIONS BASED ON
between other people and objects (Ayres, 1972). All sensa- PRINCIPLES OF SENSORY PROCESSING
tion is essential for the individual to develop an awareness of Based on her work with varied clinical populations, Ayres
himself or herself as an integrated whole, and sensation helps posited that sensation could be used intentionally and stra-
build a foundation for learning and developing skills. When tegically to enhance an individual’s ability to detect, register,
an individual effectively processes and integrates sensory perceive, and respond adaptively to stimuli in an organized
information, responses to sensation are purposeful and goal and appropriate manner with regard to cognitive, motor,
directed. The individual is able to register and perceive a social, and emotional responses. She researched and devel-
stimulus, formulate and execute a response to the stimulus, oped strategies for using sensory experiences and environ-
and learn from the success or failure of his or her response. mental modifications to create a foundation for successful
Over time, responses become more mature and complex, occupational engagement and functional performance.
effective and adaptive, and are “efficient, creative, and satis- Sensory integration intervention as described by Ayres
fying” (Ayres, 1979, p. 7). Occupational therapy practitioners (1972, 1979) is characterized by active engagement of the
are concerned with an individual’s ability to engage in occu- client in a range of sensory-based activities that challenge
pational activities that are desired by and meaningful to the the client to respond to environmental cues; register, per-
individual. When a disruption in occupational engagement ceive, and integrate sensation; and produce appropriate and
and performance is noted, it is important that the occupa- adaptive cognitive, emotional, physical, and social responses
tional therapy practitioner consider the possibility that dis- (Ayres, 1972, 1979; Parham et al., 2011; Smith Roley, Mail-
ordered sensory processing or integration is an influencing loux, Miller Kuhaneck, & Glennon, 2007). Ayres (1972, 1979)
factor. Accurate and thorough understanding of how disor- advocated that intervention activities emphasize active
dered sensory processing and integration can affect function engagement with tactile (touch), proprioceptive (pressure
and the manifestations of such dysfunction are crucial for or force), and vestibular (movement) sensations. Other
making these determinations. For further information on sensations (smell, taste, sound, and vision) are also incor-
sensory processing and integration, please see Ayres (1972, porated as they are useful to the individual client. Activities
1979, 2005); Bundy et al. (2002); Smith Roley, Blanche, & range from simple interactions with sensory materials, such
Schaaf (2001); and Schaaf & Davies (2010b). as scooping and pouring dry beans, to complex multisensory
activities, such as planning and navigating obstacle courses
Sensory Integrative Dysfunction of suspended and grounded equipment that challenge adap-
Ayres (1979) described dysfunction in sensory integra- tive occupational behavior in cognitive, motor, regulatory,
tion as a condition in which “the brain is not processing or and social domains. As such, sensory integration interven-
organizing the flow of sensory impulses in a manner that tion requires specialized equipment and environments that
gives the individual good, precise sensory input well...[and] afford a range of dynamic sensory experiences. For example,
is not directing behavior effectively” (p. 51). Thus, ineffec- suspended equipment such as swings, trapeze bars, rope
tive sensory processing interferes with the individual’s ability ladders, and other climbing materials allows engagement
to use sensation as a foundation for function and behavioral in movement activities that challenge balance, equilibrium,
organization. Sensory integration dysfunction is multifaceted, ideation, motor execution, problem solving, and a host of
with individuals displaying clusters of signs and symptoms in other adaptive responses. Equipment and environmental
cognitive, motor, emotional, and social behavior. For exam- modifications are part of the dynamic interplay between the
ple, dysfunction in sensory integration can be the source of occupational therapist, client, and environment in which
ineffective performance in school tasks or social situations, the therapist employs clinical reasoning, critical thinking,
poor use of the body to move through space or interact and therapeutic use of self to intentionally and strategically
with physical objects, an inability to regulate emotional and create opportunities for the client to actively experience

CE-2 ARTICLE CODE CEA0911 SEPTEMBER 2011 n OT PRACTICE, 16(17)

 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

and engage with sensations, ultimately leading to produc- approach described by Ayres. (See Schaaf & Davies, 2010a,
tion of adaptive responses. Sensory integration intervention 2010b for a more thorough description of the confusion
is designed to address the underlying neurophysiological regarding terminology and the current state of the science of
processing of sensation as the foundation for function and sensory integration theory and intervention.) Recent reviews
requires advanced theoretical knowledge and practical skills. of evidence-based literature have helped to discriminate
Due to the complexity of Ayres’ sensory integration interven- among the published examinations of sensory integration and
tion, specialized postprofessional training and mentorship sensory-based interventions and provide evaluations of the
are highly recommended (Watling, Koenig, Schaaf, & Davies, efficacy of both (see Schaaf & Davies, 2010b).
2011).
Fidelity to Sensory Integration Theory
Sensory-Based Intervention Because of the confusion around terminology and the
At times, occupational therapy practitioners may not have growing use of the phrase sensory integration to refer to
access to the equipment or environments essential for pro- approaches very different from the intervention Ayres devel-
viding sensory integration intervention, or may be working oped, efforts were made to re-establish the term sensory
in contexts in which this approach is not supported. In these integration and to trademark the phrase Ayres Sensory
cases, the sensory needs of clients may be at least partially Integration® (ASI®). Scholars, scientists, and researchers
addressed through sensory-based interventions. Sensory- recognized as experts in sensory integration theory and
based interventions use discrete sensory experiences or envi- practice used systematic procedures to identify the features
ronmental modifications to support regulation of behavior, of the sensory integration intervention process (see Parham
address specific difficulties in sensory modulation or sensory et al., 2007, for a description of the procedures used). This
discrimination, prepare the client for engagement, support work identified and defined core structural and procedural
the ability to focus on learning activities, and regulate client elements of sensory integration intervention (see Table 1).
behavior as task demands change (Tomchek & Case-Smith, These same core elements are the foundation of a fidelity-to-
2009; Watling et al., 2011). For example, sensory-based treatment measurement tool (see Parham et al., 2007, 2011)
strategies include providing a quiet enclosed space for a child that can be used to determine whether an intervention meets
to retreat to when feeling overwhelmed in a busy or noisy
environment, providing compressible or resistive materials
for manipulation to help decrease distraction and increase Table 1. Process and Structural Elements of Ayres’
focused attention on a task, and providing nontraditional Sensory Integration Interventions
seating options such as air-filled cushions or ball chairs Process Elements
that offer movement opportunities while allowing a child to Key therapeutic strategies of an ASI intervention
remain seated during desk work. Sensory-based interven- • Ensures physical safety
tions often aim to focus a child’s attention and promote orga- • Presents sensory opportunities
nized behavior in everyday contexts such as school, home, or • Helps the child attain and maintain appropriate levels of alertness
the community (Watling et al., 2011). Sensory-based inter- • Challenges postural, oral, ocular, or bilateral motor control
ventions are often an integral part of occupational therapy in • Challenges praxis and organization of behavior
early intervention and school-based practices. • Collaborates with the child on activity choices
• Tailors activities to present the just-right challenge
CURRENT CONCEPTS • Ensures that activities are successful
Ayres’ work spurred recognition by many professions of the • Supports the child’s intrinsic motivation to play
critical role that sensation plays in behavior and function. • Establishes a therapeutic alliance with the child
Over the past 40 years, many other theorists and practition-
Structural Elements
ers developed sensory-based methods that are quite different
Commonly documented features of an ASI intervention
from what Ayres developed and described. However, in most
• Therapist qualifications in sensory integration include
instances, there was little to no discriminant discussion or
postprofessional training and mentorship
examination of these methods, and many were referred to
• Record review, including thorough occupational therapy
erroneously as sensory integration methods. This resulted in
evaluation results
widespread and often inappropriate use of the term sen-
• Physical space and equipment affordances, including space
sory integration in the literature, with many publications
for vigorous activity and a variety of suspended equipment
inaccurately being identified as descriptions or examinations
• Ongoing communication with team members, including
of sensory integration intervention. This led to confusion
evidence of parent–therapist collaboration on goal setting
about what sensory integration intervention is and is not, as
well as inaccurate conclusions about the effectiveness of the Note: From Parham et al., 2011

SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911 CE-3

 AOTA Continuing Education Article
CE Article, exam, and certificate are also available ONLINE.
Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

the criteria for being an ASI intervention (Smith Roley et al.,

2007). Table 2. Characteristics of Ayres Sensory Integration and
Sensory-Based Intervention Approaches
Professional Responsibility Ayres Sensory Integration Sensory-Based
Given the confusion around terminology and intervention Intervention Intervention
strategies, it is critical for occupational therapy practitioners
to understand the difference between sensory integration Aims to have a lasting Aims to modify regulatory
and sensory-based strategies and to accurately identify and impact on neurophysiological state or behavior quickly
describe the approach being used in their services. Doing processing of sensation without a lasting effect
so demonstrates personal professionalism as well as the Adheres to core process and Uses sensation to support
scientific rigor of our field. In addition, by understanding the structural elements identified function but does not meet
difference between sensory integration and sensory-based in fidelity-to-treatment fidelity criteria
interventions, the theoretical conceptualizations of each, instrument
and the evidence around each, we are equipped to enter into
dialogue with others and bring clarity of these issues to those Requires active engagement Sensation may be experienced
outside our field. and an adaptive response passively with or without an
As other professions use, advertise, and publish informa- adaptive response
tion about sensory-based approaches, we must understand Requires specialized equipment Minimal equipment needed
and be able to articulate the similarities and differences
between these approaches, ASI, and occupational therapy Requires specialized environ- Easily implemented in
using sensory-based approaches. The different interven- mental affordances everyday environments
tions can produce different outcomes, and expectations
Provided in the context of play May or may not be playful
should be adjusted accordingly. When occupational therapy
practitioners understand the realistic expectations of a Provided in a one-on-one May be administered in
given intervention, we can advocate for and provide the context that allows individual- individual or group contexts
intervention most appropriate for a client and help others to ization and responsive modifi-
understand and appreciate the affordances and limitations of cation of the intervention
each approach. Table 2 identifies some of the key differences
between ASI and sensory-based approaches. Practitioner has advanced Advanced training
training recommended
MAJOR LAWS AND FUNDING SOURCES INFLUENCING Certification recommended
SERVICE PROVISION
Consistent with Ayres Sensory
Providing services that adequately and effectively meet
Integration theory
the sensory needs of pediatric clients with challenges in
processing and integrating sensory information requires
advanced knowledge and skills in this area of practice as well
as knowledge of the various contextual factors that influ- dlers, birth to 3 years of age (Part C), as well as children and
ence provision of services to children. Occupational therapy young adults ages 3 to 21 years who have disabilities (Part
practitioners may provide services for children at home, in B). Part C emphasizes services to children in the natural
school, and in myriad community environments. However, environments, and Part B emphasizes the least restrictive
current legislation and reimbursement regulations often environments. Other differences between Part C and Part B
stipulate parameters within which occupational therapy are delineated below. Funding sources for IDEA services may
services are funded. The next section of this article describes include federal, state, and local special education dollars as
the relevant legislation and corresponding public and private well as Medicaid and private insurance (primarily for Part C
funding resources that influence provision of occupational programs).
therapy services to children in the United States. To advocate IDEA Part C. Part C, also known as early intervention or
for and ethically provide appropriate services, occupational the Infant & Toddler Program, focuses on children and
therapy practitioners must understand the affordances and their families. Early intervention is a 12-month program
limitations of these various resources. that serves children and families throughout the traditional
school year as well as during the summer months. One of the
Educational Legislation and Publically Funded Services primary purposes of Part C programs is to build the capacity
The Individuals with Disabilities Education Improvement of families to care for their infants or toddlers. Because the
Act of 2004 (IDEA) addresses services to infants and tod- law does not mandate states to provide these services, states

CE-4 ARTICLE CODE CEA0911 SEPTEMBER 2011 n OT PRACTICE, 16(17)

 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

choose whether to participate in this federal program and mance consistently falls below state standards, typical physi-
receive funds. There is wide variability among states regard- cal development, behavioral expectations, or grade level; and
ing the agency that oversees this program, the person provid- educational performance is unique when compared to others
ing service coordination, and the professionals providing the in that setting; and there are no more plausible explana-
services. The definition of developmental disability is set tions, a disability may be suspected and a referral for a full
by each state, so a child could be eligible for this program in and individual evaluation (FIE) is made. Lack of instruction
one state, but not in another. Even funding varies from state or access to instruction, poor attendance, and language or
to state. Some states provide services at no cost to the family, cultural differences need to be ruled out as possible reasons
whereas other states use private insurance and Medicaid as for the delay because these do not constitute a disability. An
funding sources. independent medical or mental health diagnosis may be suffi-
Teams have 45 calendar days after receiving a referral to cient for suspecting a disability; however, the impact of such
complete assessments and to develop the individualized fam- a diagnosis on educational performance must be established
ily service plan (IFSP). Under Part C, assessments include in order for the child to receive special education services.
both family and child measures. Family-directed assessments After the family formally consents to an FIE of their child,
often include interviews to identify the family’s concerns, pri- the team has 60 calendar days to complete evaluations, hold
orities, and resources (such as informal or formal supports). a meeting with the parents, and write the individualized
Families may decline to participate in this assessment and education program (IEP). Team members, including occupa-
still receive early intervention services. Evaluation/assess- tional therapists, who participate in the FIE are required to
ment information is used in determining whether the child use a variety of evaluation tools and strategies. These could
meets the state’s eligibility for this Part C program. Children include observations, interviews, record reviews, and formal
must be evaluated in five domains: adaptive, cognitive, and informal evaluation tools. When difficulties processing
communication, physical, and social development. Physi- and integrating sensory information are suspected, data
cal evaluation may include fine motor, gross motor, hearing, should be gathered using a range of tools as well as across a
vision, and sensory processing skills. In addition, a review of range of school environments and contexts.
the child’s health and nutrition is typically included. In young Federal provisions state that services to help students
children, concerns related to sensory processing and integra- with IEPs transition out of the educational system must
tion may include the child having difficulty with feeding and occur by the time they are 16 years of age. At a minimum,
eating; calming and state regulation; frequent or intense the first IEP in effect when the child turns 16 must include
tantrums; or rigid behaviors that interfere with outings, social measurable postsecondary goals, based on age-appropriate
interaction, or transitions (Watling, Bodison, Henry, & Miller- transition assessments and transition services needed to
Kuhaneck, 2006). assist the child in reaching those goals. For students with
At the IFSP meeting, parents and other members of the challenges processing and integrating sensory information,
early intervention team identify family and child outcomes transition planning should include strategies for managing
as well as services. IDEA requires the IFSP to a include sensory needs in postsecondary settings and contexts. Occu-
a statement of early intervention services based on peer- pational therapy has a critical role in addressing life skills for
reviewed research, to the extent practicable, necessary to many students with special needs and should be included in
meet the unique needs of the infant or toddler and the fam- the transition planning.
ily. To assist with transitioning out of the early intervention
program, an individualized transition plan must be in place at Early Intervening Services
least 90 days before the child’s third birthday. Some children IDEA 2004 also included early intervening services. Local
will transition out of all services; others may transition to education agencies may use up to 15% of their Part B monies
community-based programs or be referred for an evaluation to identify children who are at risk for academic and behavior
to determine eligibility for Part B services. Occupational challenges and to provide support for these students to suc-
therapy is considered a primary service under this law, ceed in the general education environment. IDEA uses the
meaning occupational therapy could be the only service on term early intervening services (EIS) to identify services
a child’s IFSP. Under Part C, occupational therapists may act to general education students and professional develop-
as service coordinators, participate in the evaluation process ment for teachers delivered under this provision. Response
through multi- or transdisciplinary team evaluation, or con- to Intervention (RtI) is the framework used by many states
duct a separate occupational therapy evaluation of the child. for providing services under EIS. Under EIS/RtI, occupational
IDEA Part B. Under IDEA Part B, eligible children ages 3 to therapy practitioners provide services primarily to popula-
21 years are entitled to a free appropriate public education tions or groups. For example, occupational therapists may
(FAPE), including academic instruction and related service train teachers in how sensory processing and integration
provision. In most cases, if a student’s educational perfor- challenges can interfere with learning and behavior and how

SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911 CE-5

 AOTA Continuing Education Article
CE Article, exam, and certificate are also available ONLINE.
Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

sensory-based strategies can support the diverse needs of such as birthday parties; challenges with tactile, vestibular,
many such students. Some children who have mild to moder- and proprioceptive processing can impact praxis and limit a
ate difficulties processing and integrating sensory informa- child’s success in maneuvering through the environment or
tion may display learning challenges or behaviors that lead learning to ride a bicycle; and poor processing of tactile input
to RtI services; these children may simply need additional can result in feeding difficulties due to poor awareness and
assistance but never require an FIE. localization of food in the mouth. The ASI approach is often
provided in clinical contexts to meet sensory needs such as
Section 504 these for clients receiving services funded through individual
The Rehabilitation Act Amendments of 2004, otherwise sources such as health insurance.
known as Section 504, stipulates that if an agency, such Clinic-based occupational therapists use standardized
as a school, receives federal financial assistance, it cannot assessments, skilled clinical observations, and caregiver
discriminate against a person with a disability. Discrimina- reports rather than direct peer comparison, school standards,
tion could result in revocation of the agency’s federal monies. or teacher expectations to document the child’s perfor-
There is no additional funding to agencies for 504 activities. mance. This provides therapists and families with individual
Section 504 requires school districts to provide a FAPE to performance data that can be analyzed and used to develop
students who have been determined to (1) have a physical treatment plans. Information about the child’s performance
or mental impairment that substantially limits one or more in the school context can be acquired by interviewing care-
major life activities, (2) have a record of such an impairment, givers, teachers, or other school-based personnel. In addi-
or (3) be regarded as having such an impairment. tion, clinic-based occupational therapists can use the clinic
Major life activities, as defined by Section 504, include environment and equipment to create strategic contexts that
“functions such as caring for one’s self, performing manual elicit engagement of the child in activities the therapists want
tasks, walking, seeing, hearing, speaking, breathing, learn- to observe. The therapist can infer how skills and behaviors
ing, and working. This list is not exhaustive. Other functions observed in the clinic may affect the child in educational or
can be major life activities for purposes of Section 504” (34 other natural settings. A collaborative relationship between
C.F.R. 104.3(j)(2)(ii)). Children and youth with challenges the occupational therapist in the clinic and the child’s educa-
in processing and integrating sensory information who are tional occupational therapist is ideal in order to best support
not eligible for IDEA may be eligible for accommodations or the child and enhance his or her ability to generalize perfor-
modifications under this law if the impairment limits daily mance across these settings.
life activities. The school may require documentation from
a health care provider (e.g., the child’s physician) stating Private Health Insurance
the necessity of these modifications or accommodations. Private health insurance traditionally has been a major
Occupational therapists should consider using Section 504 source of funding for clinically based occupational therapy
provisions for students who require activity or environmental services in the United States. Insurance companies issue
modifications due to sensory-based needs that affect their many different policies, so coverage for services varies widely
daily life skills. and there may be restrictions based on client age, location
of service delivery, specific type of service provided, or other
Individually Funded Services factors. Occupational therapy services funded through pri-
In addition to services provided through the public school vate health insurance typically are considered medically rel-
system, children also can receive services in settings such evant and often require a physician’s referral. The physician
as outpatient clinics; hospital-affiliated programs; private referral may or may not identify the child’s diagnostic condi-
offices; their home; or other environments funded through tion and specify the frequency and duration of therapy being
private health insurance, Medicaid, accounts such as trusts prescribed. Occupational therapy practitioners can affect
or adoption support, out-of-pocket payments, or other these decisions by communicating with the referring physi-
sources. When providing services outside of the educational cian regarding the client’s occupational performance, evalu-
system, the occupational therapist can design and imple- ation results, response to intervention, and evidence in the
ment these services to address a range of needs without the literature related to the recommended strategy or duration
requirement to demonstrate an impact on educational per- of services. Observations and performance on assessments of
formance. Thus, the occupational therapy practitioner can sensory processing and integration can be especially helpful
address the neurophysiological functions that underlie sen- when considering diagnosis of a sensory processing disorder.
sory processing and integration challenges and their impact Reimbursement for occupational therapy services through
on a child’s occupational performance in home and commu- privately funded insurance is influenced by many factors.
nity contexts. For example, auditory sensitivities may cause Among these is whether a provider is recognized on the
a child to dislike or avoid noisy or crowded spaces and events company’s preferred provider register, the insurance compa-

CE-6 ARTICLE CODE CEA0911 SEPTEMBER 2011 n OT PRACTICE, 16(17)

 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See below for details.

ny’s approval of the specific service provided by the practi-

tioner, or the specific location in which services are provided.
Thus, the provisions of each client’s individual policy should
be reviewed carefully and any limitations that may affect How To Apply for
service delivery discussed with the child’s family prior to
beginning services. When limitations in coverage are encoun-
Continuing Education Credit
A. After reading the article Using Sensory Integration and Sensory-
tered, occupational therapy practitioners can work with Based Occupational Therapy Interventions Across Pediatric Practice
insurance companies to advocate for expanded coverage for Settings, register to take the exam online by either going to
their clients. This may include providing education of general www.aota.org/cea or calling toll-free (877) 404-2682.
occupational therapy concepts, interpreting the evidence B. Once registered you will receive your personal access informa-
in the literature related to sensory integration methods, or tion within 2 business days and can log on to www.aota-learn
ing.org to take the exam online. You will also receive a PDF
providing clinical evidence of the client’s positive response
version of the article that may be printed for personal use.
to intervention. Such negotiations can lead to extension of
C. Answer the questions to the final exam found on p. CE-8 by
services that can maximize client progress and outcomes. September 30, 2013.
D. Upon successful completion of the exam (a score of 75% or
SUMMARY more), you will immediately receive your printable certificate.
The funding sources, environments, child’s age, and frame-
work chosen for the intervention all influence occupational
therapy service delivery for children with difficulty process-
ing and integrating sensory information. Providing early
Bundy, A. C., Lane, S. J., & Murray, E. A. (2002). Sensory integration: Theory and
intervention in the home may include teaching the family practice (2nd ed.). Philadelphia: F. A. Davis.
ways to feed, bathe, hold, position, or play with the child. Individuals with Disabilities Education Improvement Act of 2004. Pub. L. 108-446,
Occupational therapy practitioners are in the child’s and 20 U.S.C. §1400 et seq.
family’s natural environment, so they can observe family Lane, S. J., & Schaaf, R. C. (2010). Examining the neuroscience evidence for
sensory-driven neuroplasticity: Implications for sensory-based occupational
routines and activities. In the educational setting, occupa- therapy for children and adolescents. American Journal of Occupational
tional therapy practitioners focus on the skills, environmen- Therapy, 64, 375–390. doi:10.5014/ajot.2010.09069
tal adaptations, and teacher supports that a child needs to No Child Left Behind Act of 2001. Pub. L. 107-110, 116 Stat. 3071.
benefit from his or her educational program. In the medical Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J. A., Miller, L. J., Burke, J. P, et
al. (2007). Fidelity in sensory integration intervention research. American
or community setting, occupational therapy pratitioners Journal of Occupational Therapy, 61, 216–227.
focus primarily on the child and the functional limitations Parham, L. D., Smith Roley, S., May-Benson, T. A., Koomar, J., Brett-Green, B.,
secondary to the medical condition(s). The emphasis is on Burke, J. P., et al. (2011). Development of a fidelity measure for research on
the effectiveness of the Ayres Sensory Integration® intervention. American
remediating underlying problems in the child, implementing Journal of Occupational Therapy, 65, 133–142. doi:10.5014/ajot.2011.000745
environmental adaptations, and building a broad founda- Rehabilitation Act Amendments of 2004. 29 U.S.C. §794.
tion of skills that the child can draw upon for success in Schaaf, R. C., & Davies, P. (2010a). From the desk of the guest editors: Evolution
various contexts and situations. Across all of these settings, of the sensory integration frame of reference. American Journal of Occupa-
tional Therapy, 64, 363–367.
knowledge of the brain-behavior relationships that underlie
Schaaf, R. C., & Davies, P. (Guest Eds.). (2010b). Special issue on sensory integra-
sensory processing and integration and the principles guiding tion [Special issue]. American Journal of Occupational Therapy, 64(3).
intervention to address related deficits is an essential first Smith Roley, S., Blanche, E. I., & Schaaf, R. C. (2001). The nature of sensory inte-
step in providing relevant and effective services that promote gration with diverse populations. Tucson, AZ: Psychological Corporation.
and enhance our clients’ occupational engagement. n Smith Roley, S., Mailloux, Z., Miller Kuhaneck, H., & Glennon, T. (2007). Under-
standing Ayres Sensory Integration®. OT Practice, 12(17), CE-1–CE-8.
Tomchek, S. D., & Case-Smith, J. (2009). Occupational therapy practice guide-
REFERENCES lines for children and adolescents with autism. Bethesda, MD: AOTA Press.
Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles:
Watling, R., Bodison, S., Henry, D. A., & Miller-Kuhaneck, H. (2006, December).
Western Psychological Services.
Sensory integration: It’s not just for children. Sensory Integration Special
Ayres, A. J. (1979). Sensory integration and the child. Los Angeles: Western Interest Section Quarterly, 29(4), 1–4.
Psychological Services.
Watling, R., Koenig, K. P., Schaaf, R. C., & Davies, P. (2011). Occupational therapy
Ayres, A. J. (2005). Sensory integration and the child: Understanding hidden practice guidelines for children and adolescents with challenges in sensory
sensory challenges. Los Angeles: Western Psychological Services. processing and integration. Bethesda, MD: AOTA Press.

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 Continuing Education Article 6. Practitioners can rely on the literature to consistently
and accurately identify examinations of sensory integra-
CE Article, exam, and certificate are also
available ONLINE. Register at http://www.aota. tion and sensory-based strategies.
org/cea or call toll-free 877-404-AOTA (2682). A. True B. False

7. Which aspect of the Individuals with Disabilities Educa-

Final Exam CEA0911
tion Act (IDEA) requires states to provide services to
children with disabilities?
Using Sensory Integration and Sensory-Based Occupational A. Part C (birth to 3 years)
Therapy Interventions Across Pediatric Practice Settings B. Part B (3 years to graduation)
September 26, 2011 C. Part C and Part B
D. None of the above
To receive CE credit, exam must be completed by September 30,
2013. 8. Which should be ruled out before identifying a child as
Learning Level: Entry Level having a disability under IDEA Part B?
Target Audience: Occupational therapists and occupational A. Lack of instruction in that skill area
therapy assistants B. Poor attendance at school
Content Focus: Category 2: Occupational Therapy Process: C. Limited English proficiency
D. All of the above
Evaluation; Category 3: Legal, Legislative,
Regulatory, & Reimbursement Issues
9. IDEA allows states to use up to what percent of Part B
special education money for children in general educa-
1. Sensory integration theory is based on all of the following tion who are at risk for learning and behavior challenges?
except: A. 15%
A. Psychology B. 25%
B. Human development C. 45%
C. Animal neuroscience D. 55%
D. Exercise science
10. Which civil rights statute prohibits discrimination on
2. Sensory integration intervention involves: the basis of a disability by any program receiving fed-
A. Prescribed sensory-rich activities eral funds and has been used as the basis for providing
B. Passive application of sensory experiences to the accommodations and modifications for some children
client who have a disability but are not eligible for IDEA?
C. Active engagement in a wide range of sensory-based A. Individuals with Disabilities Education Act
activities B. Response to Intervention
D. Group activities in everyday environments C. Rehabilitation Act Amendments of 2004, Section 504
D. Positive Behavioral Interventions and Supports
3. Sensory integration intervention aims to directly address:
A. Gross motor performance deficits 11. Occupational therapy practitioners working in the clinical
B. Neurophysiological processing of sensation setting have the opportunity to:
C. Academic performance A. Observe a child’s performance during natural routines
D. Communication and activities
B. Remediate a child’s underlying deficits using a wide
4. Which of the following is true of sensory-based strategies? range of materials and equipment
A. They involve discrete sensory experiences or accom- C. Use physical space and a variety of suspended equip-
modations to support behavior ment for vigorous activities
B. They require advanced postprofessional training and D. B and C
mentoring
C. They involve monitoring the heart rate and stress 12. Occupational therapy practitioners working in home or
hormones school settings have the opportunity to:
D. They can be implemented without knowledge of sen- A. Observe and intervene with children in their natural
sory processing principles environment (e.g., bathrooms, classrooms, lunch-
rooms, playgrounds) while observing peer perfor-
5. Fidelity to sensory integration involves all of the following mance and teacher/family expectations
except: B. Observe and evaluate the environmental supports
A. Practitioner training and barriers that are present during the child’s
B. Environmental affordances performance
C. Process elements C. Facilitate the child’s performance in daily occupations
D. Consistency with the International Classification of by collaborating with the teacher
Function D. All of the above

CE-8 ARTICLE CODE CEA0911 SEPTEMBER 2011 n OT PRACTICE, 16(17)

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