SENSORY INTEGRATION For ASD

CONTINUING EDUCATION
for Occupational Therapists

SENSORY INTEGRATION AND
AUTISM SPECTRUM DISORDER
PDH Academy Course #OT-1706 | 3 CE HOURS
This course is offered for 0.3 CEUs (Intermediate level; Category 2 – Occupational Therapy
Process: Evaluation; Category 2 – Occupational Therapy Process: Intervention; Category 2 –
Occupational Therapy Process: Outcomes).
The assignment of AOTA CEUs does not imply endorsement of specific course content, products,
or clinical procedures by AOTA.
Course Abstract
This course focuses on the theory of Ayres Sensory Integration (ASI) and its application to Autism
Spectrum Disorder (ASD). It opens with an overview of ASD and the central nervous system,
reviews ASI, and discusses relevant Occupational Therapy assessment and intervention strategies.
Case studies are provided.
Target audience: Occupational Therapists, Occupational Therapy Assistants.
NOTE: Links provided within the course material are for informational purposes only. No endorsement of
processes or products is intended or implied.
Learning Objectives
By the end of this course, learners will be able to:
❏ Recognize elements of autism spectrum disorder and the central nervous system
❏ Differentiate between key sensory systems
❏ Identify components of Ayres Sensory Integration
❏ Differentiate between types of sensory integration dysfunction
❏ Recall assessment methods and intervention strategies pertaining to sensory integration
function in children with Autism Spectrum Disorder
OCCUPATIONAL THERAPISTS Sensory Integration and Autism Spectrum Disorder | 1
Timed Topic Outline
I. Autism Spectrum Disorder (5 minutes)
II. Overview of the Central Nervous System (5 minutes)
III. Key Sensory Systems: Identification, Definitions, and Function (10 minutes)
Vestibular System, Proprioceptive System, Tactile System, Somatosensory System, Other Sensory Systems
IV. Ayres Sensory Integration Theory (5 minutes)
V. Types of Sensory Integration Dysfunction (25 minutes)
Sensory Modulation Dysfunction, Sensory Discrimination and Perception Problems,
Vestibular-Bilateral Problems, Praxis Problems, Sensory Seeking Behaviors
VI. Sensory Processing and Participation (5 minutes)
VII. Assessment of Sensory Integration Function in Children with Autism (20 minutes)
VIII. Sensory Integration (SI) Intervention Strategies for Children with Autism (45 minutes)
Tactile Defensiveness, Gravitational Insecurity, Tactile Discrimination, Proprioception, Visual Perceptual,
Praxis; Using Sensory Equipment
IX. Case Studies (45 minutes)
X. Conclusion, Additional Resources, References, and Exam (15 minutes)
Delivery & Instructional Method

Distance Learning – Independent. Correspondence/internet text-based self-study, including a provider-graded
multiple choice final exam. To earn continuing education credit for this course, you must achieve a passing score of
80% on the final exam.
Registration & Cancellation

Visit www.pdhtherapy.com to register for online courses and/or request correspondence courses.
As PDH Academy offers self-study courses only, provider cancellations due to inclement weather, instructor
no-shows, and/or insufficient enrollment are not concerns. In the unlikely event that a self-study course is
temporarily unavailable, already-enrolled participants will be notified by email. A notification will also be
posted on the relevant pages of our website.
Customers who cancel orders within five business days of the order date receive a full refund. Cancellations
can be made by phone at (888)564-9098 or email at [email protected].
Accessibility and/or Special Needs Concerns?

Contact Customer Service by phone at (888)564-9098 or email at [email protected].
Course Author Bio & Disclosure

Jeryl D. Benson, EdD, OTR/L, earned a BS in Occupational Therapy and a MS in Motor Development from
the University of Pittsburgh. She earned her doctorate in Education from Duquesne University. She has
over 25 years of clinical experience in the area of pediatrics and school based occupational therapy practice.
She has worked with a variety of disabilities including autism/PDD, cerebral palsy, learning disabilities, and
intellectual developmental disabilities in both public and private schools, as well as outpatient practice.
She has advanced training in the Neurodevelopmental Treatment Approach, certification to administer the
Sensory Integration & Praxis Test, is a certified infant massage instructor, is TEACCH trained, and has been
Board Certified in Pediatrics through AOTA.
DISCLOSURES: Financial – Jeryl D. Benson received a stipend as the author of this course.
Nonfinancial – No relevant nonfinancial relationship exists.
2 | Sensory Integration and Autism Spectrum Disorder OCCUPATIONAL THERAPISTS

I. Autism Spectrum Disorder The following behaviors related to sensory processing
may be present in children with a diagnosis of
According to the American Psychiatric Association autism: difficulty with social interactions/developing
(APA) as indicated in the Diagnostic and Statistical friendships, difficulty with communication
Manual-5th edition (DSM-5), Autism Spectrum including delayed verbal communication and trouble
Disorder (ASD) is classified as a neurodevelopmental understanding body language such as posturing and/
disorder (APA, 2013). or facial expressions, repetitive play behaviors, self-
This new edition of the DSM made changes to the stimulatory behaviors, difficulty regulating arousal
criteria used for an ASD diagnosis. The changes in levels, and a decreased understanding of the result of
criteria have resulted in the elimination of Asperger’s their actions and behaviors.
disorder and Pervasive Developmental Disorder This supports the increased role of occupational
(PDD) and now present one diagnosis, ASD, with two therapy in interventions for ASD, as the occupational
primary categories: 1. Social Communication and therapy profession has traditionally played a large role
Interaction (SCI) and 2. Restrictive, repetitive behaviors in the promotion of sensory development.
(RRP). The diagnostic criteria for ASD include social
and communication difficulties, stereotype and/or
repetitive behaviors, sensory issues, and in some cases, II. O
verview of the
a cognitive delay (APA, 2013).
Central Nervous System
To receive a diagnosis of ASD a child must meet four
criteria with specific distinctions related to each The nervous system has two parts: the central nervous
criterion. 1. Deficits in social communication and system (CNS) and the peripheral nervous system (PNS).
interaction (SCI) has three distinctions that must be The CNS is a complex system that, in part, makes up
met, such as deficits in social-emotional reciprocity, the communication network in the human body. The
nonverbal communication, and deficits in developing, CNS is thought to be a hierarchical system, albeit a
maintaining, and understanding relationships. 2. very complex hierarchy that often has heterarchical
Restrictive, repetitive behaviors (RRP): the child must interactions (Bear, Connors, Paradiso, 2016).
meet two out of four of the distinctions which include The CNS is the processor of information as a stimulus
stereotyped or repetitive movements, inflexible is introduced: a stimulus from the environment
adherence to routines, highly fixated interests that are presents itself, the sensory receptors respond to the
abnormal in intensity, and hyper- or hyporeactivity stimulus and convey the message to the CNS, and the
to sensory input. 3. Symptoms must be present in information is processed (Bear, Connors, Paradiso,
the early stages of development. 4. Symptoms cause 2016).
impairment in “social, occupational or other important
areas” of function. (An intellectual developmental In the simplest form, the CNS is comprised of
disability is not a criterion for an ASD diagnosis but the spinal cord and the brain. The brain can be
can co-occur.) broken down into the cerebrum, the cerebellum,
the brainstem, and the spinal cord (Bear, Connors,
Children are also diagnosed with a severity level from Paradiso, 2016).
level 1 to level 3, with level 3 being the most severe.
With symptoms ranging from mild to severe, the The brainstem is responsible for delivering messages
behaviors associated with autism can be very different between the cerebrum and the cerebellum. It controls
among the different children who share the same basic functions such as heart rate, breathing, and
diagnosis. Even the same child may present somewhat consciousness; in addition, it is responsible for the
differently day to day, as the context and sensory sensory pathways (Bear, Connors, Paradiso, 2016).
information from the environment can alter their The cerebellum is the receiver of information from the
behaviors and responses. brain stem, spinal cord and various parts of the brain.
The addition of response to “sensory input” as an The cerebellum takes in the information and uses it to
indicator for an ASD diagnosis recognizes the role of regulate movement such as posture and coordination
sensory processing within this population: current (Bear, Connors, Paradiso, 2016).
evidence reports that 80-90% of children with an The cerebrum is a large part of the brain that contains
ASD diagnosis also have an abnormal response to the two cerebral hemispheres as well as several smaller
sensory stimuli (Tomchek & Dunn, 2007). It has been structures. The left hemisphere controls the right side
suggested that 62% of children with Autism have poor of the body and the right hemisphere controls the
registration of sensory input (Watling, Dietz, & White, left side of the body. The cerebrum is also divided
2001). In addition, Williamson & Anzalone (2001) into four lobes which each have a different function:
found that children with autism often present with the frontal lobe, the parietal lobe, the occipital lobe,
mixed patterns of sensory responsivity: for example, and the temporal lobe. The frontal lobe is where we
a child may be hyper-responsive to tactile stimuli and do our thinking and problem solving. It also controls
hypo-responsive to vestibular stimuli.

our movement. The parietal lobe supports sensation The ANS serves to control the unconscious functions of
and feeling. It plays a role in helping us determine the our body by such as breathing and heart rate. The ANS
safety of a situation. The occipital lobe processes visual has two systems, the sympathetic and parasympathetic
information. And lastly, the temporal lobes (there is systems. The sympathetic system protects us from
one in each hemisphere) support auditory processing, injury: it is responsible for the “fight or flight
language, learning, and emotions (Bear, Connors, response.” The parasympathetic system balances
Paradiso, 2016). the sympathetic system by doing the opposite. The
sympathetic system increases our heart rate and blood
pressure, and the parasympathetic system lowers our
heart rate and blood pressure (Bear, Connors, Paradiso,
2016).
The CNS seeks sensory stimulation needed for
organization and development (Schaaf & Mailloux,
2015). To help us understand the neural system’s
maturity and needs, we can observe the behaviors of
the child as they interact with the environment. To
better understand the observations, we need to better
understand the sensory systems and their functions.
III. K
ey Sensory Systems:
Identification, Definitions,
and Function
Cerebral Hemispheres When you think of the sensory systems most people
can name the typical five: sight, sound, touch, taste,
and smell. As therapists we identify those five senses
as vision, auditory, tactile, gustatory, and olfactory.
In addition to the typical five senses, therapists also
consider the “special senses” of the vestibular and
proprioceptive systems. To understand intervention
related to the SI approach the therapist must have an
understanding of each system and their impact on
performance.
The special or hidden senses, vestibular and
proprioception, and the more common tactile
system are often considered the building blocks
of development. Each system has characteristics
important to performance.
The Vestibular System

Lobes
The receptors for the vestibular system are located in
Information from the environment is transmitted the inner ear and consist of the semicircular canals and
to the CNS for processing via the peripheral nervous the utricle and saccule. The semicircular canals consist
system (PNS) and the autonomic nervous system of three circular tubes that contain fluid. Movement
(ANS), which is a subsystem of the PNS (Bear, Connors, of the head causes the fluid in the canal to move. The
Paradiso, 2016). direction of movement of the body will cause fluid
The role of the PNS is to transmit information to the in the coordinating canal to move. One canal detects
CNS to support movement and reactions. The PNS vertical movement, one detects horizontal movement,
has receptors and neurons which send information and one detects angular movement. The utricle and
to the CNS from our peripheral structures (i.e. saccule are near the semicircular canals and house the
muscles). Included in the peripheral nervous system hair cells. As the fluid moves through the semicircular
are the cranial and spinal nerves. These nerves offer canal it then moves over the hair cells providing more
information about motor and sensory input (Bear, information about the speed and direction of the
Connors, Paradiso, 2016). movement (Bear, Connors, Paradiso, 2016).

A child with poor proprioceptive function doesn’t
get enough information from the muscles and joints.
Going back to the pebble example, if you have a
pebble in your shoe you can feel the pressure of the
pebble digging into your muscle. Your proprioceptive
system detects the stimulus (the pebble), alerts to it,
and responds. Children with decreased proprioceptive
function would remain unaware of the pebble, not
noticing it until they removed their shoe and saw the
impression it left.
These children may have limited awareness of
where their body parts are in relationship to the
environment. They may present as uncoordinated
and stiff or they may be clumsy and report frequent
falls. They seek proprioceptive information so they
can function, but with a decrease in reception of the
stimulus they seek increased amounts of information.
The Vestibular Receptors: This presents itself clinically as being very heavy
Semicircular Canals, Utricle, and Saccule handed or footed. In another example, when you are
using a pencil to write you can feel the resistance of
the pencil against the paper. The resistance gives you
information about the direction of the pencil. You are
The function of the vestibular system is to provide
aware of what letter you have produced even without
the CNS with information about where our body is in
looking. A child with poor proprioception may need to
space. The vestibular system plays a role in attention,
press the pencil to the paper very hard to get the same
balance, muscle tone, bilateral integration, ocular
feedback. This often results in broken pencil points,
motor control and visual perception.
holes in the paper, or sloppy written work.
Disrupted vestibular processing can impact the person’s
Proprioception is a large contributor to gross motor
performance in typical occupations. For example, a
movement also. When you are walking your body
child with poor balance and bilateral integration may
continually makes adjustments to your pattern of
have difficulty riding a bike. Challenges with muscle
movement based on the proprioceptive information
tone and bilateral integration may impact the child’s
detected from the soles of the feet – the pressure of the
ability to participate in typical childhood occupations
foot on the surface. If the surface changes, for example
such as using scissors to cut, managing fasteners on
you walk from a room with carpeting into a room
clothing, or crossing the monkey bars.
with hardwood floors, your proprioceptive system
Because of the spatial role of the vestibular system, will detect the change and send a signal to the CNS to
visual perceptual skills are often impacted by a modify your movement patterns for continued success.
vestibular processing problem. Visual perceptual Under the same circumstances a child with poor
outcomes can be used as a clinical indicator of proprioception may fall, appearing clumsy.
vestibular processing. Visual perception is required
The role of the proprioceptive system in regulation
in most daily living tasks and has a large role in the
and arousal appears to support organization of the
school skills of a student. The spatial component of
overall system (Bundy, Lane, & Murray, 2002). For
this function has a contribution to our organization
example, when a newborn is crying we will swaddle
of self in space in daily life. For example, sizing and
them and hold them: here the proprioceptive input
spacing of letters, avoiding reversals and orientation
appears to support regulation (in this case a decrease)
errors during handwriting, left/right discrimination,
in arousal level, and the response of the newborn is
directionality, and fine motor tasks that have a spatial
to calm down. In addition, the proprioceptive system
component such as cutting and pasting all rely on
appears to support regulation of both the tactile and
spatial awareness.
vestibular system. Use of proprioceptive input prior to
or in combination with tactile input for a child who is
The Proprioceptive System sensitive may help the child accept the tactile input.
The receptors for the proprioceptive system are located The proprioceptive system also supports our ability to
in our muscles and joints. Our muscles detect pressure regulate the amount of force we use when interacting
and we receive proprioceptive information from the with our environment (Cronin, 2016). For example,
position of our joints: for example, if you have a when small children hold a pet, if they are unable to
pebble in your shoe, the proprioceptive system makes use discriminative proprioception, they may squeeze
you aware of it (Bear, Connors, Paradiso, 2016). the pet too tightly. As their system matures, the
proprioceptive system will contribute to their ability to

calibrate the correct amount of pressure on the pet so The Other Sensory Systems
they can hold the pet comfortably.
Our visual system supports the identification of visual
The proprioceptive system works very closely with the stimuli in our environment. The eyes help us to
tactile and vestibular systems, and these three systems interpret the properties of objects (shape, color, etc),
will often be considered together. For example, the facial expressions, body language, and guides social
tactile system (discussed next) provides information interaction. The information regarding the properties
about the external environment as we touch and of objects contributes to our perceptual understanding
feel things. The proprioceptive system responds to of the environment. We use our visual system and our
information that is internal from our muscles and cognitive system to interpret the stimulus and assign a
joints. Together the proprioceptive and tactile systems perceptual meaning.
are often referred to as the somatosensory system.
A child with an over-responsive visual system may
become easily distracted by visual input such as too
The Tactile System many words or pictures on a page or a very busy
The receptors for the tactile system are located in our bulletin board.
skin, with the majority in the palms of our hands The auditory system supports the functions of hearing,
and the soles of our feet. The tactile system has speech, and language. In addition, auditory perception
two functions: protection and discrimination (Bear, also is an important function of this system. Children
Connors, Paradiso, 2016). The protective function of may have under- or over responsive auditory systems,
the tactile system alerts us to danger. For example, which may impact behavior.
you may touch an object, immediately detect that the
temperature is high, and withdraw your hand so you A child with an over-responsive auditory system may
don’t get burned. The discrimination function of the be very sensitive to sound. They may have difficulty
tactile system provides us with information about the participating in environments with many different
property of an object. For example, when you reach in noises or loud noises, such as an assembly in school.
your bag for your keys, you can detect the size, weight, They may also be sensitive to background noises that
and texture of the objects inside, and find your keys we typically don’t attend to, such as water dripping or
without using your vision. the motor of a fan.
A child with tactile issues typically falls into one of The gustatory and olfactory systems provide us
two categories: a child with diminished sensitivity or a with information about tastes and smells in the
child who is very sensitive to touch. environment. They can give us information about
what to expect from our interactions. For example,
A child with diminished sensitivity may have a when we go to the movies, we may smell the popcorn
decreased awareness of being touched. They may before we enter the theater.
recognize that they have been touched but not know
where. Children with diminished sensitivity to touch When a child presents with hyper or hypo responsivity
often have poor body awareness and are unable to to sensory stimuli it often emerges as an atypical
recognize objects by touch. These are the children behavior, and may be misinterpreted by others. A child
who, when carrying their school supplies, drop items who is under/hypo responsive may appear to be spacey
along the way and don’t realize it. and others may interpret them as a loner or anti-
social. A child who is over responsive may react with
On the other end of the spectrum, a child who is very crying or aggression and others may interpret them
sensitive to touch may dislike unanticipated contact, as difficult and hard to be around. In both cases the
messy activities such as finger painting or using paste. child is reacting or not reacting to sensory input from
These children may be picky about the fabrics and tags the environment and not always the people around
in clothes. They are often misinterpreted as having a them. But people interpret what they see and often
behavior problem. They are not good at standing in inaccurately label the child.
line and when bumped or touched they may respond
with aggression toward the other child(ren).
IV. Ayres Sensory Integration Theory
The Somatosensory System
Overview
The somatosensory system is a combination of
the tactile and proprioceptive systems. At times Ayres Sensory Integration (ASI) is a trademarked
information that comes into our bodies initially approach to occupational therapy intervention that
may be detected by the tactile system and as the was developed by A. Jean Ayres. The process developed
pressure of the object increases the proprioceptive by Ayres outlines the relationship among the various
system is engaged. When working together they are sensory systems. Input into the systems (vestibular,
often referred to as the somatosensory system (Bear, proprioceptive, tactile, auditory and visual) provides
Connors, & Paradiso, 2016). information to support participation. The systems

work together to advance development: for example, V. Types of Sensory
as the vestibular system matures it provides support for
maturation of the tactile system. Maturation of each Integration Dysfunction
system then contributes to the development of various
performance components (i.e. eye hand coordination, Sensory Modulation Dysfunction
bilateral coordination, etc.) that support engagement
Our ability to modulate or regulate our sensory systems
in occupation.
means that we are able to manage the sensory stimuli
coming in from the environment and generate an
History appropriate response. Sensory modulation dysfunction
occurs when a child is over or under responsive to the
A. Jean Ayres was an occupational therapist and a stimuli. A large number of children with a diagnosis
psychologist who used her observations during clinical of autism present with sensory modulation difficulties
practice to develop a research agenda that has had (Schaaf & Roley, 2006). When trying to determine
a profound effect on occupational therapy practice the underlying sensory issue the therapist needs to
(Parham & Mailloux, 2015). Ayres introduced a novel consider the behaviors that occur in daily life that are
way of understanding children and their development. consistent with different types of sensory modulation
Over time, ASI came to include the theory of sensory difficulties.
integration, assessment methods, sensory & behavioral
patterns, and the concepts to guide the intervention Under-responsive
process. Currently occupational therapy that is based The child who presents with sensory modulation
on a sensory approach to intervention is referred to as difficulties that are characterized as under-responsive
SI (sensory integration) or OT-SI (occupational therapy has a decreased attention to incoming sensory stimuli
using a sensory integration basis). or poor sensory registration. The child does not attend
to or register the stimuli and therefore is unable
to generate the appropriate response. The clinical
Foundational Concepts
presentation of a child who is under-responsive may be
When we think of sensory development in terms of a child who appears unaware of the environment. The
laying the foundation for overall development, we under-responsiveness to stimuli may be subtle, such
must acknowledge the contribution of the sensory as not registering another person’s facial expression
systems as the building block in the foundation. and therefore responding with a socially inappropriate
Learning and behavior are built upon the base response: for example, laughing when someone is
provided by our sensory systems as they are modulated crying. In contrast, the under-responsiveness may
via these systems. Solid sensory development – sound also be to a greater degree, where large amounts of
vestibular, proprioceptive and tactile systems – become information are coming in and the child is unaware,
the base for higher level skill development. Response such as a child walking into a heavy traffic area.
to and subsequent integration of sensory information
Many children with autism who are under-responsive
from the environment provides the opportunity for
move through life without noticing the details around
development of motor experiences, learning, cognitive
them. This often presents as a child who is not
and emotional skills (Parham & Mailloux, 2015; Schaaf
connected to life experiences, is indifferent, or lacks
& Mailloux, 2015).
enthusiasm.
Over-responsive
The child who presents with sensory modulation
difficulties that are considered over-responsive has
an increased awareness or attention to the incoming
sensory stimuli, and the information coming in is too
much for the child to regulate. This is often referred
to as sensory defensiveness. These children respond
with heightened reactions such as when a light touch
is interpreted as an aggressive touch and the response
is to hit the other person. Similarly, children may cover
their ears and/or cry when they are in an activity (such
as a school assembly) that has an increased noise level.
A child may be over-responsive to many different types
of sensory stimuli, or it may be associated with just one
system.
Contributions of the Sensory Systems to Development

Tactile Defensiveness for the child. Because many social situations are
tied to sounds, children with auditory defensiveness
Tactile defensiveness can be described as the child’s
may find themselves unable to participate in typical
over-reaction to typical tactile stimuli from the
social activities such as attending a birthday party.
environment. Children with tactile defensiveness
often appear to be in distress or discomfort when MINI CASE STUDY
they come into contact with certain sensations: for
Marty is an 8 year 7-month old boy with a diagnosis
example, a child who refuses to wear jeans because
they are stiff and have heavy seams and a snap, or a of autism. When interacting with his peers he is slow
child who expresses a dislike for finger painting or to respond to requests and jokes, frequently doesn’t
pasting. respond to their facial expressions, and doesn’t engage
in physical exchanges such as “high fives.” The kids
When working with a child with tactile think Marty is nice but a little “out of it” most of the
defensiveness, the OT must determine the types of time. The teacher reports that his attention during
tactile input that is difficult for the child to regulate. class is not great and she is concerned about his
Light touch is often the most difficult, such as that learning.
produced by sand and some clothing. Wet textures,
such as soap and water, are often more difficult to Read the case again and think about what clinical signs
process than dry textures. Many self-care activities may provide information about Marty and his sensory
require tactile processing of sensory stimuli and modulation.
can therefore be an area of difficulty for families. The fact that Marty does not pick up on the nuances
Brushing hair, selecting clothing and shoes, washing of social language (slow to respond to requests and
hands and face can all pose a challenge and become jokes) could indicate that Marty is not attending to
a stressor. By identifying the details of the tactile auditory details during conversation.
processing the OT can then determine how to best
address the underlying issue. The fact that Marty does not interpret facial and
body cues embedded within a social context
Gravitational Insecurity (frequently doesn’t respond to their facial
Gravitational insecurity can be described as expressions and doesn’t engage in physical
the child’s over-reaction to vestibular stimuli. exchanges such as “high fives”) could indicate
Children with gravitational insecurity have a that he is not attending to the visual cues of body
fear of movement and falling. The exaggerated language and facial expression and/or connecting
response is often elicited by movement of the meaning to what he sees.
head. These children may present as someone who The fact that the teacher reports decreased attention
is very cautious of movement. They may move during class and decreased educational outcomes
slowly and wish to stay away from crowds. They could indicate that he needs more stimulation to
will often prefer to keep their feet firmly planted maintain his attention during class activities, as
on the ground and to sit on a stable surface. Their
typical movement during the school day is not
exaggerated response will often preset as fear or
supporting his attention.
anxiety. This child may cling to an adult when
encouraged to play on a swing set, or they may All three of these concerns point to an under-
refuse to participate in the tumbling unit during responsive system. Marty is not attending to and using
physical education class. sensory information from his environment.
When working with a child with gravitational
insecurity it is important to develop a trusting Sensory Discrimination and
relationship. The children need to feel secure Perception Problems
as they engage in movement activities that are
uncomfortable for them. Sensory discrimination is our ability to discriminate
between the properties of objects in our environment
Other Sensory Systems or the sensory stimuli coming in. As sensory stimuli
Just as the tactile and vestibular system can be come in from the environment we are able to interpret
over-responsive to sensory stimuli, so can our the details of the stimuli and organize our response.
other senses. Children may have an adverse For example, we are looking for our keys and see
reaction to smells, sights, tastes, or sounds from the part of the key chain sticking out from under the
environment. Auditory defensiveness is a frequent newspaper. We are able to interpret the sensory stimuli
concern for children with autism. When a child as “seeing part of the key chain means that the rest of
presents with auditory defensiveness they may the key chain and our keys are hidden.” Or we see an
have a negative response to sounds: for example, old friend and greet them with a hug: we are able to
the excitement at a fair, with lots of people making identify both of their arms in contact with our body,
noise and laughing, may cause distress or anxiety and differentiate them from our body.

Any of our sensory systems may present with Other Perceptual Problems (i.e. auditory)
discrimination difficulties.
Auditory processing problems may present as difficulty
Tactile Discrimination & Perception Problems with attending to auditory stimuli or discriminating
details of sounds. Many children with auditory
Tactile discrimination problems may present as having
processing issues also have sensory processing issues
difficulty interpreting touch information or stimulus.
in other systems. Auditory processing disorders are
A child may not be able to differentiate the difference
typically addressed by a speech language pathologist
between a quarter or a nickel by touch alone. It is not and/or an audiologist.
unusual for children with tactile discrimination issues
to rely on their visual system to support function. MINI CASE STUDY
When reaching in their pocket for a coin they may Sally is a 12-year-old girl with a diagnosis of autism.
look at the coin to determine if it is correct. Sally and her parents have come to an outpatient
Because we receive so much tactile information about clinic for occupational therapy services to address her
the properties of objects through our hands, many difficulties with coordination. Sally is transitioning
children with tactile discrimination problems will also to her local middle school next year, and although
present with fine motor delays. As children are picking she will spend the majority of her time in the autism
up toys and objects in the environment they may be support classroom she will need to transition from her
receiving less information about the object and the classroom to other select classes such as social studies,
possibilities for manipulation. This in turn decreases physical education, art, and music. Sally reports that
the opportunity to interact with the environment in a she falls frequently and the occupational therapist
meaningful way. noticed she has bruising on her legs. Sally reports that
she has recently learned how to tie her shoes and upon
Visual Perception Problems observation it is noted that she looks at her hands
Visual perception problems may present in many when tying.
different ways as we use our eyes to take in visual Read the case again and think about what clinical signs
stimuli and then use our perceptual system to interpret may provide information about Sally and her sensory
the information. We may use our visual perceptual discrimination.
system to determine the size of an object, the position
of an object, or the location of an object. For example, The fact that Sally is clumsy and falls frequently
when a child is looking for a toy in the toy box, they throughout the day could indicate that she has
must be able to visually locate the target (toy) amongst proprioceptive processing problems.
many other toys. Or a child may have to recognize The fact that Sally has more than usual bruising on
their shoe even though it has been turned upside her legs could be from her bumping into furniture
down. and indicate proprioceptive processing problems.
Proprioception Problems The fact that Sally is unable to tie her shoes without
looking could indicate tactile discrimination
Proprioceptive problems may present as difficulty
problems and she is compensating by using her
interpreting where the body is in space. A child with
visual system.
proprioceptive problems may appear to be clumsy
and awkward. Because the information registered All three of these concerns point to poor sensory
by the proprioceptive systems comes in through our discrimination. Sally is not detecting sensory
muscles and joints, these kids often need increased information and therefore unable to make the postural
sensory input to be able to identify a stimulus: for and motor adjustments needed for function.
example, to get a feel for the surface being walked
on, the child may appear to be stomping, seeking the
sensory input you and I get while walking. These are Vestibular-Bilateral Problems
also the children who may press very hard during Vestibular bilateral problems may present as difficulty
writing tasks, frequently breaking their pencils. with balance, equilibrium, or poor coordination
When moving through a crowd the child with between the two sides of the body (Parham &
proprioceptive problems may be unaware of others, Mailloux, 2015). A child with vestibular bilateral
therefore bumping into them or stepping on their problems may have difficulty participating in
toes. Although the child with problems is unaware, childhood activities such as riding a bike or playing
the child on the receiving end is aware – and typically cooperative hand games with a partner such as doing
unhappy about the interaction, assuming the first child a clapping pattern associated with a rhyme. Children
is rude or mean. with vestibular bilateral issues may also present with
postural challenges (laying their head on the desk) and
difficulties with attention to task during instruction,
and/or completion of schoolwork.

MINI CASE STUDY the person. Because we are unable to see the process
occurring in the brain the occupational therapist
Jonathon is a 4 year 4-month old boy with a diagnosis
uses the clinical observation of motor behavior and
of autism. He and his family frequently go to the
interaction with the environment as the measure of a
local playground. The mother noticed that Jonathon
child’s practic abilities.
struggles to climb the ladder to the slide. Once on the
slide he is unable to remain upright, and he will slide MINI CASE STUDY
down in a supine position. The mother reports that
Alex is a 3-year-old boy with a diagnosis of autism.
she also has to push him on the swing – he is unable to
He just received a play farm set for his birthday. The
initiate or maintain the pumping action to move the
toy includes a barn that opens up to show various
swing himself.
animals in different stalls or areas of the barn. The barn
Read the case again and think about what clinical unhooks to open and the compartments inside have
signs may provide information about Jonathon and his gates that open out or lift up for access to the animals.
vestibular bilateral problems. Alex gets excited when her sees the barn and he
immediately wants to play with it. He shakes the barn
The fact that Jonathon is unable to climb the ladder to try to open it. His mother shows him the hook and
demonstrates poor coordination and use of both he pulls at the hook still unable to open it. She opens
sides of his body. the barn. Alex is again excited but is unable to open
The fact that Jonathon is unable to maintain an the various stalls for access to the animals. With help
upright posture while sliding could indicate postural to open the gates he is able to play with the toy.
challenges and issues with balance. Read the case again and think about what clinical signs
The fact that Jonathon is unable to initiate or may provide information about Alex and his praxis
support maintenance of movement of the swing problems.
could indicate issues with use of both sides of his The fact that Alex is excited when he sees the barn
body. (It could also indicate issues with praxis, indicates that he has ideation: the ability to develop
discussed below.) the idea of what he wants to do with the toy.
All three of these concerns point to poor vestibular The fact that Alex tries to open the toy and the
bilateral processing. Jonathon is unable to coordinate gates inside the barn indicates that he has a motor
use of both sides of his body or stabilize his trunk to plan: he wants to open the different parts of the toy.
successfully interact with his environment.
The fact that Alex is unable to actually open the
parts of the toy indicates that he has difficulty with
Praxis Problems execution of his plan. He is unable to execute the
motor task of interacting with something new in his
Praxis is our ability to come up with an idea, develop
environment.
a plan, and then execute a novel motor task. A praxis
problem may be referred to as dyspraxia. When a child
first sees an object or opportunity in the environment Sensory Seeking Behaviors
(i.e. a bike) they develop an idea of what to do with
the bike (i.e. I can ride that!). Next they develop a A child who presents with sensory seeking behaviors
plan for how to ride the bike (i.e. I should get on seeks increased sensory stimulation from the
and put my feet on the pedals). Finally, they initiate environment. Sensory seeking behavior can occur
the movement required to carry out or execute the within any of the sensory systems. For example, a child
plan (i.e. they propel the bike forward). A child with who is seeking tactile input may excessively touch
dyspraxia may have difficulty with any stages of the things in their environment. If a person is nearby,
process, appearing to be awkward and clumsy and have they may touch their hair inappropriately. If a child
difficulty participating in a new game with peers. For is seeking vestibular stimulation when playing on the
swing set, they may continually wind and unwind the
example, they may see something in the environment
chains to spin the swing.
(i.e. the bike, a swing, a toy) and may not know how to
interact with it (problems with ideation) or they may Although the reasons for sensory seeking remain
see the bike and know they want to ride it but may not unclear, some theories suggest that sensory seeking
know how to plan for making that happen (planning) may occur because the child is not getting the amount
or they may know they want to ride it, know they of information they need to interpret the incoming
must get on it to make it move but they may not stimuli and therefore they seek to increase the stimuli
know how to initiate the movement to propel the coming in so they can attend and respond to it. For
bike (execution). You may have noticed that at each example, if their tactile system isn’t giving them the
phase the description includes the statement “They information they need to interpret an object they may
may not know.…” That is because praxis is a cognitive touch it repeatedly to try and gather the information.
process that ends when the movement is initiated by Another theory is that the child may be using the

sensory stimulation to regulate arousal levels, or maybe • May not easily settle down at the end of the day:
they find pleasure in the outcome of the stimulation. they can’t fall asleep and/or they wake up very
early. (Rest/Sleep; ADL’s)
As discussed earlier, the sensory systems are the
VI. S
ensory Processing building blocks to overall development. If the
and Participation functions of our sensory systems are impaired, we
often see a decrease in typical childhood interactions.
The Occupational Therapy Practice Framework (OTPF-
3) identifies the areas of occupation as Activities of In turn, the child may experience limitations in skill
Daily Living (ADL’s), Instrumental Activities of Daily development. For example, a child who presents with
Living (IADL’s), Play, Leisure, Work, Education, Social tactile defensiveness (over-responsive tactile system)
Participation and Rest/Sleep (AOTA, 2014). Difficulties has decreased interaction with the environment
processing sensory information can lead to challenges via touch. This decreased interaction with the
participating in all areas of occupation. Let’s consider environment leads to delayed development of fine
some examples of how sensory processing dysfunction motor skills. Likewise, the child who presents with
can impact engagement in occupations: gravitational insecurity (over-responsive vestibular
system), and is afraid to move, doesn’t develop the
Children with an over-responsive tactile system (the gross motor skills typically acquired during movement.
behavioral manifestation is extreme sensitivity to These limitations in turn create a cycle of delay.
textures)
In addition, sensory processing difficulties can raise
• May be unable to participate in dance class the stress level of the family unit. A child with light
because they are unable to wear the leotard or the sensitivities (visual processing) may be unable to go to
tights. (Social Participation; Leisure; ADL’s) a grocery store that has high ceilings and fluorescent
• May refuse to wear a Halloween costume. (Social lights without having a meltdown, but the family
Participation) can’t afford a babysitter every time they grocery shop.
Another child may have a negative behavioral response
• May not keep their socks and shoes on, limiting to background noises such as a fan motor or lights
community outings. (Play; Leisure; Education; humming (auditory processing), and be unable to
Social Participation) comfortably attend church or go to a dance recital with
Children with an under-responsive tactile system the family. Limitations in participation affect the entire
family unit, not just the impacted child.
• May be unable to complete fasteners such as shoe
tying or buttoning. (ADL’s)
• May be unable to retrieve an item from their VII. A
ssessment of Sensory
book bag without looking. (IADL’s) Integration Function in
Children with a diminished proprioceptive system Children with Autism
• May be very heavy-handed when writing, During the assessment process the occupational
pressing so hard on their pencil they rip the therapist is looking for a clustering of behaviors
paper. (Education; IADL’s) within a category to provide insight into the child’s
• May be like a “bull in a china shop,” stepping on occupational performance. The clinical indicators
or bumping into other children in the play area/ should come from a variety of sources such as parent
playground without acknowledging the contact. report, observation in a natural setting, clinical
The other kids don’t like it and think these observation, and structured assessment measures such
children are bullies. (Social Participation, Leisure, as a questionnaire. Once an area of sensory processing
Play) emerges from the data, the therapist must determine
if the child’s sensory challenges interfere with
Children with an over-responsive vestibular system
performance and participation. (Many individuals have
• May refuse to participate in the “gymnastics “quirky” behaviors that may be noticeable to others,
unit” during physical education class. (Education; but those behaviors only become a problem when
Social Participation; Leisure) occupational performance and participation are limited
due to the sensory challenges.)
•
May not enjoy the rides and games at the summer
festival. (Social Participation; Leisure; Play) Identifying the root of a sensory processing disorder
is often like trying to complete a puzzle or solve a
Children with an under-responsive vestibular system
mystery. The occupational therapist must sort through
• May demonstrate out-of-seat behaviors during the clues (behavior patterns, work samples, parent and/
class, falling behind in schoolwork. (Education; or teacher report) and organize them into clusters and
IADL’s) then clinically reason through the possibilities.

Typically, the first set of data comes to the OT via resources for the COP can be found here: http://
a referral: a teacher requests a screening because a sensorymetrics.net/COPForm
child is having difficulty completing schoolwork, or
For a more detailed examination of standardized
a parent reports that the morning routine is difficult
assessment options, please see the handout “Common
as the child struggles with getting dressed and
Sensory Assessments,” pages 28-29.
completing grooming in the morning before school.
Following a referral, the occupational therapist will Ideally used in combination with data collection,
often gather additional information from the team informal observation of the child allows the
(parents, teachers, child) via one or more methods. The occupational therapist to gather data about the
occupational therapist works to create an occupational child’s participation in daily life. If possible, the
profile of the child that includes information about child should be observed in the day care setting, the
what they want and need to do, how they do it, where classroom, home, and/or the community. During the
they do it, and with what supports. observation, the OT will interpret the child’s observed
Because the children we are discussing have a diagnosis behaviors such as laying his head on the desk during
of autism, use of traditional standardized testing tools classwork (vestibular-bilateral problems) or walking
may be a challenge. Many children with ASD perform around the perimeter of the playground during recess
poorly on traditional standardized tests that are (gravitational insecurity). These informal observations
criterion or norm referenced due to the characteristics support the outcomes of the more formal testing.
of autism, such as poor sensory processing, poor For example, when the results of the Sensory Profile
attention, or poor language skills. Because standardized indicate an issue with touch processing, it is important
tools require specific procedures during administration to also observe how these difficulties impact typical
and the child may not be able to comply, the results day to day interaction. If an assessment indicates a
are often skewed and not reflective of the child’s actual problem area, but the problem area does not interfere
ability. Therefore, the occupational therapist must with participation, then it does not become a priority
rely more heavily on clinical observations as discussed for intervention.
below. In addition to observation of the child within their
There are also other, non-standardized, options to environment, the occupational therapist will also
gather data. One such tool, a sensory history, is a gather data via the use of clinical observations,
non-standardized questionnaire that asks the parent or developed by Ayres, which can reveal information
teacher to identify behaviors such as “is bothered by about the function of the neurological system of the
tags in their shirt” or “only eats crunchy food.” The OT child. These clinical observations are not standardized,
will review the sensory history to determine if there is and due to the nature of the procedures are often
a pattern to the behaviors. administered differently with different children, so
normative information may not be available; that
Other, standardized, assessments include the Sensory said, they allow the OT a means of supplementing
Profile and the Sensory Processing Measure (SPM). the information already gathered via traditional
The Sensory Profile, developed by Winnie Dunn assessment measures.
(1999), is a questionnaire that has been norm Depending on the severity of the autism diagnosis,
referenced. The questionnaire consists of a series clinical observations may be particularly helpful in
of statements, and the parent/caregiver rates each understanding the nature of the problem: if children
statement. It comes in four versions: the Infant/ are unable to understand the specific directions to
Toddler Sensory Profile, The Sensory Profile, the participate in the data gathering, the occupational
Adolescent/Adult Sensory Profile and the Sensory therapist may instead choose to observe the behavior
Profile-School Companion. The results of each will (or modified behavior) occurring naturally in the
organize the reported behaviors into categories
environment. For example, if a child is unable to
related to sensory processing.
understand the requirements of “prone extension,”
The Sensory Processing Measure (SPM) is also norm the occupational therapist may choose to observe
referenced. It offers forms for the Home, the Main and document their response to being prone on a
Classroom, and the School Environments, as well swing. Although not the clinical observation of “prone
as a preschool edition (Glennon, Miller-Kuhaneck, extension,” this data can offer insight into the child’s
Henry, Parham, & Ecker, 2007). Online resources for systems and needs. Is the child able to maintain
the SPM are available here: Western Psychological extension of the upper trunk, neck, and upper
Services, http://bit.ly/1RG7dz3 extremities without movement? With movement? If
so, for how long? When recording the information,
The Comprehensive Observations of Proprioception
the occupational therapist must clearly note the
(COP) developed by Blanche, Bodison, Chang, &
circumstances of the data collection.
Reinso (2014) is a scale that measures proprioceptive
processing via therapist observation. Online

Examples of commonly-used clinical observations whose trajectory cannot be anticipated, kicking a
(Bundy, 2002; Blanche, 2010) are: rolling ball, and running, jumping, or stepping over
a rolling object. Projected action sequences can also
Prone Extension: The ability to simultaneously
be observed during a variety of treatment activities.
lift the head, flexed arms, upper trunk, and
Demands are greatest when both the client and
extended legs up against gravity from the prone-
the object are moving; demands are minimal when
lying position. Poor prone extension often is
both the client and the object are still. A critical
associated with inadequate processing of vestibular-
component of the quality of performance is that the
proprioceptive inputs. The presence of tight hip
client performs the demanded action without need
flexors should be ruled out before interpreting the to hesitate, stop, or correct the planned action once
results of this observation. it is initiated.
Supine Flexion: Simultaneous flexion against Sequential Finger Touching: The ability to
gravity of the knees, hips, trunk, and neck from a sequentially oppose the thumb to each of the other
supine-lying position; the top of the head should fingers, index to little finger and back. Considered
approximate the knees. The ability to assume this a test of cerebellar function, also used to assess
position has been related to somatosensory function somatosensory processing.
and praxis.
Weight Bearing and Proximal Joint Stability: The
Crossing Midline: The ability to cross the body ability to stabilize proximal joints. Can be observed
midline with one or both hands to manipulate by having the client assume a quadruped position,
objects in contralateral space. Deficits in this making sure that they understand the desired
area may be associated with inadequate bilateral position. Observe for inability to maintain position
integration or poor trunk rotation and may also be without locking elbows, winging of the scapula, or
indicative of deficits in the development of hand lordosis of the trunk. Poor postural stability may
preference. be associated with poor vestibular-proprioceptive
Equilibrium Reactions/Righting Reactions: processing and poor extensor muscle tone. In the
Equilibrium reactions are compensatory movements past, the ability to stabilize joints has erroneously
of body parts that serve to MAINTAIN the center been equated with cocontraction or simultaneous
of gravity over the base of support when either the contraction of antagonistic muscles around a joint.
center of gravity or support surface is displaced. While the ability to cocontract muscles may be an
Righting reactions are used to ATTAIN or REGAIN element of postural stability, cocontraction often
such postures. These reactions are related primarily does not occur under normal conditions of joint
to visual and vestibular-proprioceptive function. stabilization.
Deficits in vestibular-proprioceptive functioning Reciprocal Stride Jumps and Jumping Jacks:
are most apparent when balance deficits occur or Reciprocal stride jumps and jumping jacks involve
increase under conditions where vision is occluded. bilateral reciprocal, alternating, or symmetrical
Protective Extension: A protective reaction limb movements. The client is asked to perform the
that results from loss of balance that involves actions in imitation of the examiner. The inability
extension of the non-weight bearing “downhill” to perform these tasks after demonstration by the
limbs, or those on the side toward which the fall examiner and a practice trial has been associated with
would occur. A support reaction is characterized deficits in bilateral integration and sequencing praxis.
by extension of weight bearing downhill limbs. The overall assessment process should culminate in
Immature or poor responses may contribute to the an occupational profile that includes past medical
identification of decreased vestibular-proprioceptive and developmental history; a narrative of the child
function. However, protective extension and including social history, play history, activity of
support reactions develop early in life and may daily living skills and daily routines and community
not be impaired in clients with sensory integrative engagement; identification of strengths, needs and
dysfunction. barriers; priorities of the child/family/team; and a
recommendation for services.
Projected Action Sequences: The ability to plan and
produce anticipatory action sequences. Anticipatory While developing the narrative of the child, keep
or projected action sequences are those in which the autism diagnosis and the child’s sensory
the goal must be formulated and the plan of action processing challenges in mind, considering the
developed before movement is initiated. This ability, following:
especially when it involves bilateral movement
• Does the child have a preference/avoidance for a
patterns, is related to vestibular-proprioceptive
certain type of sensory input?
processing and sequencing praxis. Examples of tasks
that assess this function include jumping in a series • What kind of sensory input results in organized/
of squares or circles on the floor, catching a ball disorganized behaviors?

• What behaviors does this child demonstrate consultation, and/or development of considerations for
when disorganized? home will be provided.
• Is the child over- or under-responsive to sensory The foundation of OT-SI, or occupational therapy
stimuli? If so, which ones? using a sensory integration basis, is that “neural system
• How do these issues impact participation? functions” can be changed via the engagement in
a sensory rich environment. Thus, a sensory based
The identification of the needs and barriers will intervention relies on the occupational therapist to
include evaluation of performance skills and support exploration of the environment by offering
patterns. For children with autism, as performance activities for engagement to promote development
skills are evaluated, the therapist should continue – bearing in mind that sensory based intervention is
to gather information regarding the role of sensory more effective when more than one sensory system is
processing, considering the following: engaged (Parham and Mailloux, 2015).
•
How does the child register sensory information? The use of sensory input during intervention requires
• What is the child’s arousal level? the active engagement of the child. As the sensory
• How does the child regulate/modulate sensory input is available the child must then process the
information? information and organize it to support participation.
The goal is to elicit an adaptive response, or
• Is the child able to discriminate or interpret organization of “a successful, goal-directed action
sensory information? on the environment” (Parham & Mailloux, 2015, p.
• Is the child able to demonstrate ideation, 259). In simpler terms, an adaptive response is when
planning and execution of the movements? the child successfully responds to an environmental
• How does the child organize his/her behavior challenge. A basic adaptive response may occur, for
during participation? example, when a child gets on a swing but doesn’t
hold on, the occupational therapist moves the swing,
(Schaaf & Roley, 2006). and the child grabs the ropes of the swing to stabilize
The occupational profile is then used to develop the (the adaptive response). As the movement of the
intervention plan to address the needs of the child swing gets bigger, the child is required to increase
and family. When developing goals with the family their stabilization by making postural adjustments and
it is important to remember that the goals should be holding tighter (a higher level adaptive response).
occupation based. Although the occupational therapist Evaluation is the guide to intervention, answering such
uses many of the clinical observations discussed above, questions as “Which sensory systems are impacting
the goals should not be a reflection of the clinical occupational performance?” and “What are the
observations. For example, the clinical observation priorities for the child/family?” The occupational
of sequential finger touching provides insight into therapist uses evaluation findings and data to develop
the child’s ability to dissociate fingers and the child’s a plan for intervention, based on the sensory needs of
understanding of where their body is in space (how the child coupled with the interests of the child. The
the fingers relate to one another). An example of an occupational therapist creates an environment that
occupation that may be related to poor performance is inviting to the child, and provides opportunities
with sequential finger touching is difficulty with for the child to actively explore the environment
fasteners such as buttons, difficulty opening small within the boundaries of what is needed to promote
containers such as the toothpaste cap, or difficulty development.
using a writing utensil such as a crayon or pencil. The
clinical observations are used to better understand the For a child with autism, intervention can pose an
child’s needs and can be used to track developmental additional challenge. Many children with autism
change over time. present with a decreased interest in participation,
and therefore decreased motivation to engage. So, in
VIII. S
ensory Integration (SI) addition to creating sensory opportunities to promote
development, the occupational therapist must also
Intervention Strategies for find ways to motivate the child to engage, such as
Children with Autism discovering the child’s interests and passions and
incorporating them into the intervention plan. Armed
Intervention will require the occupational therapist
with the assessment data and child specific preferences,
to assume multiple roles: direct intervention provided
the occupational therapist designs each individual
to the child, education and support of the family,
session to meet the child’s needs.
consultation to the team (family, teachers, aides,
other professionals), and home programs to support Finally, the occupational therapist should have a
performance. Ideas for the development of direct keen awareness of the significant impact sensory
intervention approaches will be addressed below. stimulation can have on the state of the nervous
In addition, suggestions/examples of education, system: autonomic nervous system responses that can

result from misuse of sensory stimulation are nausea, Due to difficulty regulating responses to sensory input,
sweating, drowsiness, etc. The occupational therapist Person C will stay at a high level of arousal throughout
has a responsibility to monitor and make observations the day. Therefore, Person C will not process incoming
about the child’s response to any sensory input, in sensory information effectively, and behavior and
relationship to their arousal level and their autonomic performance will be impacted.
nervous system response, during the entire session,
As we can see, arousal level is influenced by sensory
and adjustments should be made based on these
input from the environment. For example, attending
observations.
a child’s birthday party may include lots of young
At the start of each session, the occupational therapist children laughing and playing. The noise level is
must also determine the child’s arousal level, or probably high. There are decorations all around.
the level of alertness of the child’s CNS. Typically, a The auditory (laughing, squealing, music playing),
person’s arousal fluctuates within a range: for example, visual (balloons, decorations, lots of people),
in the morning a child’s arousal state may be low; by vestibular (chasing kids, jumping in a bounce house),
the end of the school day, however, their arousal level proprioceptive (bumping into to others, hugging,
is high. Humans are at their best when arousal level is clapping), and tactile (eating sticky ice cream and
within the expected range. At that time, we are able cake, handling toys) input, plus the smells and tastes,
to attend to environmental stimuli, process it, and comprise an increased amount of sensory input that
respond to it. But in a circumstance where a person’s is not typical. Based on this additional sensory input,
system is very stressed, their arousal level may increase a child’s arousal level will likely begin to increase, and
or decrease to a level outside of the typical range. may reach a high level outside of the typical range. The
result for a typically developing child may be a “melt
down,” which is the child’s way of coping with the
sensory overload.
Arousal levels for some children with autism may
routinely run high or low. Other children may have a
fluctuating arousal level, high at times, low at times, or
somewhere in between. To maximize therapy sessions,
the occupational therapist should determine the child’s
arousal level at the start of the session, then sensory
input can be used to regulate the arousal level and
bring it into the mid-range. For example, if a child
Arousal Levels comes to occupational therapy and appears sluggish,
For example, Person A above wakes up at a low arousal the therapist may determine that the child is currently
level; after a shower and caffeine, the person’s arousal in a state of low arousal: therefore, their ability to
level increases, and continues to increase throughout attend to relevant stimuli will be decreased. The
the day as Person A faces stimuli from the environment occupational therapist would then use sensory input to
(traffic, work demands, etc.). The arousal level begins increase the child’s arousal level prior to engaging them
to decline as the day comes to an end and Person A in occupation, which could be accomplished by using
listens to the radio during the drive home. Although vestibular input such as a scooter or swing to “wake up”
it presents with some ups and downs throughout the the system and prepare it to work. In contrast, if a child
day, Person A’s arousal level remained with the range of comes to occupational therapy and they are at a state
normal. of very high arousal, they will be unable to attend to
relevant stimuli in a meaningful way. The occupational
Person B wakes up with a little more energy than therapist would then use sensory input to decrease
Person A, and starts the day in much the same way. the child’s level of arousal: this could be accomplished
Then, on the way to work, Person B is in stop and go by turning down the lights, playing soft music, and
traffic and gets in a minor fender bender: this incident using slow, predictable movement on a swing. The goal
immediately increases Person B’s arousal level, sending of both of these interactions is to bring the arousal
it outside of the normal range. While there were level into the typical range, where registration of
no injuries and all parties continued on their way, sensory stimuli is accurate and response to the stimuli
Person B is still shaken up; the arousal level, although is functional. Once the child’s system is ready to
gradually decreasing, remains high for a period of time. accurately take in sensory input and process it for use,
the occupational therapist can then engage the child in
Person C is a child with autism who has difficulty
an interaction that requires them to interact with the
processing sensory information, who begins the day
environmental challenges.
with an arousal level within the range of normal,
but already high. Any disturbance, such as a change To reiterate: each session should be planned for each
in routine, a loud noise, or unexpected touch, may individual child to address the specific needs of the
increase the arousal level to outside the normal range. child and to monitor the response of the child.

Tactile Defensiveness of the child’s choice, or painting the train a variety
of different colors using different dry paint brushes.
Let’s consider a child with tactile defensiveness. The
child has an interest in trains. The occupational ❍ As participation with the imaginative play task
therapist may want to consider a few of the following increases the tools or brushes can be located in
concepts when planning the intervention: texture bins of rice, macaroni. The child must
retrieve the desired object (tool or brush) from
• Tactile defensiveness means the child’s tactile system the bin to complete the “job.”
is ____?____ reactive to incoming tactile stimuli.
(hyper) • The occupational therapist will continue to offer
opportunity for active exploration of a variety
• The goal is to engage the child in sensory of textures using the child’s interests to support
opportunities to facilitate development of the neural participation.
systems. To have direct access to the tactile system
in which the receptors are located _____?_____ (on
the surface of the skin, with most receptors in the Gravitational Insecurity
hands and feet) the occupational therapist would
Let’s consider a child with gravitational insecurity. This
ask the child to remove their shoes and socks.
child enjoys arts and crafts.
• Then knowing that stimulation of multiple sensory
• Gravitational insecurity means that the child’s
systems has a more positive effect on development
vestibular system is ___?___ reactive to a change
AND to develop a relationship based on trust and
in position of the head or center of gravity
fun, the occupational therapist may use the child’s
(hyper). This indicates an issue with vestibular-
love of trains and choose a “bolster swing” (see
proprioceptive processing.
Using Sensory Equipment, below) to begin the
session. The child and the occupational therapist • The goal is to engage the child in sensory
can both go for a ride on the “bolster swing/train.” opportunities to facilitate development of the
neural systems. To have direct access to the
• As the child participates in play on the “train” the
vestibular system in which the receptors are located
occupational therapist can change the speed and/or
_____?_____ (inner ear) the occupational therapist
direction of the swing to elicit an adaptive response.
could ask the child to sit at a table on a small ball
The child may have initially been straddling the
(one that allows their feet to be firmly on the
bolster swing with his hands placed in front of him
ground).
on the smooth swing. As the therapist-guided speed
and direction change (as the train races down the • Then knowing that stimulation of multiple sensory
track and around the bends) the child will need systems has a more positive effect on development
to make postural adjustments (adaptive response). AND to develop a relationship based on trust and
When the movement of the swing increases still fun the occupational therapist may use the child’s
more, or changes directions more often, the postural love of arts and crafts and choose to make jewelry
adjustments may not be enough and the child must at the table. Trust between the child and the
reach for the ropes (adaptive response). The ropes occupational therapist is key to this intervention.
are a different texture than the smooth surface of The child must be confidant that they are safe
the swing, increasing the active sensory input into and that the occupational therapist respects their
the hands. movement limitations boundaries.
Because of the child’s interest in trains, the child

❍ • Because of the child’s interest in arts and crafts they
is more likely to be an active participant in the are likely to be an active participant in the play
play process, and be less focused on the tactile process, and be less focused on the vestibular input.
input. • By having the child sit on a ball the opportunity for
• After racing down the tracks, the child can pull movement is built in to the session. The movements
the train into the station for a tune up. The are small and controlled by the child. The therapist
occupational therapist has carefully selected can then set up the work space to facilitate larger
“tools” available for tuning up the train. The tools movements on the ball.
can be different weights, sizes, and textures. The
occupational therapist and the child proceed in the
Tactile Discrimination
imaginative play process, facilitating engagement
with a variety of textures in the environment. Let’s consider a child with tactile discrimination
problems. This child has an interest in animals. The
• To increase the opportunity for tactile engagement,
occupational therapist may want to consider a few of
the occupational therapist can expand the
the following concepts when planning intervention:
interaction to include cleaning/scrubbing the train
with a variety of different brushes or cloth textures • Tactile discrimination problems means the child’s

tactile system is ___?____ reactive to incoming Proprioception
stimuli. (hypo)
Let’s consider a child with proprioceptive problems.
• The goal is to engage the child in sensory This child has an interest in sports. The occupational
opportunities to facilitate development of the neural therapist may want to consider a few of the following
systems. To have direct access to the tactile system concepts when planning intervention:
in which the receptors are located _____?_____ (on
the surface of the skin, with most receptors in the • Proprioceptive discrimination problems means the
hands and feet) the occupational therapist would child’s proprioceptive system is ___?____ reactive to
ask the child to remove their shoes and socks. incoming stimuli. (hypo)
• To directly stimulate the skin surface, the • The goal is to engage the child in sensory
occupational therapist can use a brush to “scrub” opportunities to facilitate development of the
the child’s hands. The therapist can utilize any neural systems. To have direct access to the
brush that adequately impacts the child’s system in proprioceptive system in which the receptors are
a positive way (i.e. no pain). located _____?_____ (in the muscles and joints) the
occupational therapist should consider activities
❍ A common brush utilized by many occupational that include joint compression, pressure and
therapists is a surgical scrub brush (see below). vibration.
The soft, yet stiff, bristles stimulate the receptors
(skin) and increase the child’s awareness of their • To directly stimulate the proprioceptive system,
hand. the occupational therapist can place the child
prone on a therapy ball. The key point of control,
or where the therapist provides physical support
on the child’s body, can be proximal (i.e. pelvis) or
distal (i.e. ankles). The therapist can ask the child to
“walk” on extended arms.
❍ The child can be encouraged to bend their
extended arms and push themselves back. The
therapist can then shift them towards the floor
again and the child “catches” themselves on
Surgical Scrub Brush & Nail Brush extended arms.
❍ The therapist can brush the palmar surface of the • Remaining on the therapy ball, the child can be
hand and then brush each finger as an isolated asked to retrieve the small soft balls a little bigger
unit. Finally, the therapist can brush the tips of than their hand by weight shifting onto one upper
the fingers. extremity and reaching for the ball with the other
upper extremity.
• Now that the tactile system is “awake” and ready,
the occupational therapist can hide small zoo
animals in a bin of rice or macaroni. The hard
texture of the dried food will provide more tactile
input than a soft texture. The hidden animals
should have distinct differences that can be
identified by touch. For example, an elephant with
a long trunk, a lion with a mane, a crocodile with a
long nose and teeth, a monkey with a curly tail, a
bear with a big body.
❍ The occupational therapist can ask the child to
locate a specific animal via touch: for example,
“find the monkey.” The child reaches into the bin
to feel around and locate the monkey. Therapy Ball: Prone Weight Bearing & Weight Shifting
❍ The occupational therapist continues to ask the • The child can then “slam dunk” the ball into a
child to locate all of the animals, making sure the trash can basketball hoop. This should be repeated
child is not relying on the visual system. multiple times with both arms with the therapist
maintaining control of the child’s lower extremities
❍ This activity should be expanded to include and therefore changing the upper extremity
typical objects the child uses throughout the requirements and positions. The joint compression
day, such as a key, a paperclip, a pencil, an eraser, into the shoulder and the “heavy work” of
coins, etc. weight bearing and weight shifting will increase
proprioceptive awareness in the arms.

Visual Perceptual Praxis
Let’s consider a child with visual perceptual problems. Let’s consider a child with praxis problems. This child
This child has an interest in fish. The occupational has an interest in dinosaurs. The occupational therapist
therapist may want to consider a few of the following may want to consider a few of the following concepts
concepts when planning intervention: when planning intervention:
• Visual perceptual issues may present themselves as • Praxis is difficulty figuring out how to do a novel
problems with visual attention, visual memory, or task. So intervention should be focused on activities
visual discrimination. The visual system is __?___ that are ___?___ to the child. (novel)
reactive to the visual stimulus. (under)
• The occupational therapist should use sensory
• The goal is to engage the child in sensory activities to create a context where the child is
opportunities to facilitate development of the neural motivated to problem solve and come up with ideas
systems. To have direct access to the visual system and plans.
receptors (the eyes), the occupational therapist
• To directly encourage the child to use his sensory
should consider activities that are visually appealing
systems to participate in a novel task, the
and of interest to the child.
occupational therapist can build an obstacle course.
• Stimulating multiple sensory systems is more The course can be a dinosaur dig. The child will be
effective and provides the opportunity for overflow required to climb up a ramp, trapeze swing over
between systems: the relationship between the the “lava pit” (foam pieces in a large sack), crawl
vestibular system and the visual system make them through a tunnel and climb over a barrel, all in
a good match for this intervention. The child can search of dinosaurs, which are small plastic toys
be sitting a large air pillow (see below) that is now a hidden in a theraputty at the end of the gross motor
fishing boat. portion of the obstacle course.
As the child goes through the obstacle course the
❍
occupational therapist will encourage the child

to “figure out” the various challenges without
giving the answer. For example, as the child
unsuccessfully attempts to cross the “lava pit”
on the trapeze swing the occupational therapist
can offer cues to support performance but not
solve the problem. Cues may be related to the
performance that is interfering with success, such
as “Your feet are touching the lava.” This cue
provides the child with some information, but
also requires the child to problem solve. After
hearing the verbal cue the child may go through
a series of thoughts leading him to a solution:
“Why are my feet touching the lava? Oh, because
my arms and legs are hanging straight. So I need
Air Pillow
to bend my knees and maybe my elbows while I
The child will have a “fishing rod” weighted with am swinging.”
a magnet on the end of the rope. The occupational
• Once the child has made it through the gross motor
therapist has placed various (paper) fish (with a
portion of the obstacle course the child can be asked
paper clip attached) on the floor.
to help “hatch” the dinosaur eggs by manipulating
The child will have to stay on the boat while
❍ the putty to reveal the dinosaur inside.
fishing. The therapist/waves will move the boat
• After all of the dinosaurs have been “hatched”
up/down and side/side in the water as the child
the child can be encouraged to sort the dinosaurs
fishes, stimulating the vestibular system.
into categories. The complexity of the categories
The therapist will ask the child to retrieve a fish
❍ can be dependent on the child’s cognitive level.
(visual attention: find a fish!”), or to retrieve a For example, a child with high interest and
specific fish (visual discrimination: “find all of the understanding of dinosaurs may use categories such
red fish”, “find all of the fish with a black tail”) as carnivores, herbivores and omnivores. A child
or specific fish in a specific order (visual memory: with lower cognitive functioning or a younger child
“find the red, blue, and then the green fish in may sort the dinosaurs by colors, such as yellow,
that order”). blue and red.

Using Sensory Equipment SCOOTERS: When using a scooter, consider the type
and size of the scooter and the needs of the child.
Vestibular equipment is any equipment that allows the
opportunity for movement, such as swings, scooters, If the occupational therapist is working on prone
riding toys, etc. extension, the scooter should be smaller: this
provides a smaller weight bearing surface and
SWINGS: Some swings can be hung from one therefore requires a higher level of prone extension.
suspension point, allowing for rotational, linear, Children can use a scooter in prone on a level
orbital, or vertical stimulation (vertical stimulation surface, propelling themselves with alternating
can be achieved by using a vertical stimulation upper extremity movements or simultaneous upper
device to suspend the swing, which allows for an extremity movements, or they can pull themselves
up/down or vertical movement of the swing). Other along a rope that has been attached to a door.
swings can be hung from two suspension points,
which limits them to primarily linear movements. If the occupational therapist is working on supine
flexion, the child can assume a prone position on
the scooter with the rope overhead. The child can
be asked to propel the scooter using reciprocating
upper extremity movements to pull along the rope
while they keep their lower extremities lifted off the
floor. Another option for addressing supine flexion
is to position the child in sitting and ask them to
propel the scooter using simultaneous movements
of the lower extremities to move forward. This will
require the child to “pull” themselves forward with
their legs.
Bolster Swing: One & Two Suspension Points Ramps work well with scooters: the child can
assume a prone position to fly down the ramp and
Most therapists typically use a prone or sitting crash into a crash pad or a wall of cardboard bricks
position on a swing, but other positions, such as or soft foam pieces. Next. the child can rebuild the
kneeling and standing, also have benefit. Moving wall, propel back to the ramp, and pull themselves
the child into a higher position with a smaller base up the ramp using bilateral upper extremities. They
of support against gravity will increase the challenge can then turn around and repeat the activity.
and require a more mature adaptive response. To add additional resistance, the therapist can sit
When using a swing with a base (platform, net, on the scooter or on a wheeled therapy stool and
bolster, frog, etc.) the therapist can ask the child the child can be asked to push the therapist along
to reach for/pick up toys while in prone, sitting or a path. The therapist can adjust the amount of
kneeling; catch/throw a ball or bean bags to the resistance by dragging their foot.
therapist or a target; propel the swing using upper Typical equipment to support proprioceptive
extremities while in prone, considering the height input may provide resistance or pressure, such as
of the swing and the amount of weight bearing a trampoline, “steamroller,” therabands/tubing,
desired; pump the swing while in sitting; move the weighted vests and blankets, medicine balls, body
swing by pulling on a rope/inner tube/hoop. The socks, massagers/vibrators, etc.
therapist can also consider tilting the surface of
the swing: for example, when a child is sitting on a The therapist should create a context that requires
platform swing, tilting the base requires an adaptive the child to participate in resistive activities, such
response that includes both postural and upper as crawling through tunnels/barrels/tubes and
extremity engagement and adjustments. crawling under foam blocks/bolsters/weighted
blankets. The therapist can also use ramps/ladders/
steps for climbing up/down. Ropes/theraband/inner
tubes can be used to support the climbing and add
extra resistance or used to play tug-o-war.
Children may enjoy playing “Simon Says” or
dancing while in a body sock. Jumping on a
trampoline, catching a medicine ball, and then
diving into a crash pad is a great proprioceptive and
fun activity. “Squishing” or providing deep pressure
is a great activity for lowering arousal levels: the
child can lay on the mat in prone and the therapist
can roll a therapy ball or air pillow over the child;
Platform Swing: In Sitting & In Prone
alternately, make a “sandwich” with the child on environment. Does intervention occur in a room with
the bottom or in the middle, sandwiched between bright lights? Lots of decorations? High ceilings? Poor
mats, foam pads, blankets, etc. Massagers and acoustics? An air conditioning vent? If so, consider
vibrators are also a great tool for addressing the how this context will impact the child’s behavior, and
proprioceptive system: large electric massagers what can be changed. Lights can be dimmed, music
can be used all over the body, or small, toy like can be played and bulletin boards can be emptied.
massagers can be used in the hands. Similarly, some things will need to be managed: the
air vent system and the “hum” that accompanies it
cannot be changed, but sound dampening headphones
may help to reduce the impact of the noise. Finally,
what should be added to the existing context? For
example, the therapist can facilitate visual skills by
using visual targets during play: flashlights, bean bags,
looking for items placed around the room, and aiming
at a target during the movement activities will support
ocular motor and visual development.
As we’ve discussed, regulating arousal level can be
a very important part of preparing the child for
intervention and participation. When children present
with a low arousal level, the occupational therapist
will need to increase it. This can be accomplished by
incorporating quick, unpredictable movements (such
as on a swing, trampoline, therapy ball, or air pillow),
Body Sock using bright lighting in the room, or playing fast, loud
music. Many therapists also consider using food, such
Tactile input is offered by anything in our environment
as sour candy or spicy chips, to increase arousal level
that we touch.
(the therapist should always check with the family
To provide options of items with interesting first about allergies, cultural guidelines, preferences/
textures, occupational therapists will often create aversions, etc.). To decrease arousal levels, providing
“texture bins” holding reusable items such as a closed in space (laying under a pile of pillows, in a
macaroni, sand, rice, beans, etc. A variety of tent, under a weighted blanket, etc.), sandwiching or
brushes, such as paint brushes, hair brushes, nail squishing the child, rolling a therapy ball over them,
brushes, etc. can be used. There are many toys on decreasing the lighting in the room, playing soft
the market such as bumpy balls and animals, soft music, or just keeping the room very quiet all work
and squishy toys filled with liquid or sand, and well, as does using controlled, regular movements on
stretchy toys that can be squeezed and pulled. a trampoline or swing, Oral motor activities also can
Theraputty, finger paint, clay, and dough are be very calming: sucking or blowing can help a child
great resistive and tactile toys: small items (coins, focus, such as sucking through a straw or blowing the
buttons, etc.) can be hidden in them, and the child whistle of a musical toy.
can locate the items using their tactile system.
The therapist can use “wet” textures such as shave IX. Case Studies
cream, finger paint, pudding, slime, etc., and also
consider combining wet and dry textures to create CASE STUDY #1:
something novel and unpredictable such as sand/ Samuel is a 5 year 7 month old boy with a diagnosis of
water, paint/rice, pudding/crushed cereal. autism.
As stated earlier, using a multisensory approach is He is the oldest of three boys. He lives with both
recommended to create change to the CNS. Most parents: his dad is a pilot and is away from home for
of the items identified above offer the opportunity days at a time; his mother, a former teacher, is now a
to provide stimulation to a primary sensory system, stay at home mom due to Samuel’s diagnosis.
and a secondary sensory system as well. For example,
many swings are carpeted, so they offer both vestibular Samuel is verbal and ambulatory. He likes trains and
and tactile input; if you add the vertical stimulation the color blue. He is able to follow 2-3 step directions.
device, you also add proprioception to the mix. The
Samuel is currently enrolled in full day kindergarten
occupational therapist is seldom able to isolate a
at his local public school. Samuel rides the bus to
sensory input.
and from school daily. He is in a classroom with 16
When designing an intervention, the occupational other children. There are two other children in the
therapist should also consider the visual, olfactory, class receiving special education services. There is one
and auditory stimulation occurring naturally from the teacher and one aide.

Samuel is currently working at grade level, although During the classroom observation the therapist should look
he requires verbal prompts to stay on task. He is easily at Samuel’s posture and position at his desk, as well as his
distracted and frequently plays with his clothing. He attention to task during academic tasks and less structured
completes any unfinished classroom work with the activities.
special education teacher.
Does he sit upright? Lay his head on the desk? Wrap his
Samuel started the school year off fine, but as the feet around the legs of the chair? Tug at his clothing?
structure of school becomes more defined Samuel Wiggle in his seat?
appears to be having some behavioral challenges.
Is he able to complete his work within the allotted time? If
Samuel has some behavioral outbursts and occasional
not, why? Is his pace slow? Does he lose attention? How
hitting during transition times, most notably, when
long does he attend? How does his attention differ during
they leave the classroom to attend a special class
preferred and non-preferred tasks, manipulative and paper/
such as physical education or art. He has hit a few
pencil tasks? What are the environmental distractors (for
of peers reporting that they hit him first. He is also example, noises or movement outside of the classroom) that
having difficulty during large school assemblies and impact his attention? When Samuel loses attention, is he
music class, covering his ears and at times crying. He able to come back to the task or does he require redirection?
was initially making friends, but the other children
in the classroom are including him less. The teacher What is his arousal level? How does the environment
is concerned about his social progress and also impact his arousal level? What strategies, if any, does
the impact of his new behaviors on his classroom Samuel use to regulate his arousal? For example, does he get
performance. out of his seat frequently? Does he chew on his pencil? If
Samuel has a behavioral issue, what preceded it?
The teacher has requested an OT screening and
the parents have agreed. Although Samuel as never What classroom skills does Samuel demonstrate? Document
received OT services before, they are friendly with a his fine motor skills, visual motor and visual perceptual
few other parents of children with autism so they have skills, bilateral skills, postural skills, gross motor skills such
heard OT. as finger use, grasp, and pinch. Handwriting? Keyboarding?
Cutting with scissors? Turning pages of a book? Movement
You’re the OT on the educational team! transitions from the floor to standing to floor, standing to
• Where do you start? sitting in a chair, etc.? Is he able to gather/manage/organize
the classwork materials such as notebooks, textbooks,
• What assessment tool will you use? papers, pencils, etc.?
• What observations do you note from the case? The therapist should also observe the teacher’s style of
• In what sensory systems do you see a clustering of interaction with Samuel and the class. Does the teacher use
behaviors? How will identification of the system(s) primarily verbal instruction? Project based instruction? How
inform your next step? does Samuel respond to his teacher and his peers?
• What type of service delivery model will you use What assessment tool will you use?
with Samuel? Why? The Sensory Processing Measure (SPM) – the Home,
• What intervention strategies will you use with the Main Classroom, and the School Environments.
Samuel? Why? The SPM is appropriate for a child Samuel’s age
and provides the therapist specific, school related
• How might the multisensory approach impact direct information from a sensory perspective.
intervention during occupational therapy sessions?
What observations do you note from the case?
• How will you determine if your strategies are
Verbal, ambulatory, the oldest of three, mom is stay
working?
at home and often acts as a single parent due to dad’s
• What will you share with the educational team? travel schedule; likes trains and the color blue
• What will you share with the family? In what sensory systems do you see a clustering of
behaviors? How will identification of the system(s)
Take some time to consider each question and jot down your
inform your next step?
thoughts before reading on. Space is provided at the end of
the course. • Tugs at clothing (tactile)
Where do you start? • Hitting other kids while in line (tactile)
Complete an observation in the classroom, request work • Easily distracted, maybe by clothing (tactile,
samples, interview the teacher and the aide, interview the attention)
parent(s), spend time with Samuel. (The time spent with
• Overwhelmed by loud noises (auditory)
Samuel should be therapist directed, for the purpose of
gathering data.)

Samuel appears to have a clustering of behaviors that are The OT can also suggest to the parents a home program
rooted in the tactile system. that includes “scrubbing” with a rough wash cloth prior
to getting dressed in the morning or during daily hygiene
The OT should take a closer look at his classroom context
tasks.
and social context (playground). The results from the
sensory profile should be used to corroborate the observation GOAL: Successful transitions with his class
results. The OT should also have a more detailed
Unanticipated contact during transitions may be causing
conversation with the mother asking probing questions to
Samuel’s response of aggression towards the peers that
gather data about Samuel’s sensory history.
“hit” him.
What type of service delivery model will you use
The OT should recommend to the teacher that Samuel
with Samuel? Why?
be at the back of the line when transitioning to activities
The overall goal is to support Samuel’s school participation. outside of the classroom, so that the typical bumping
Therefore, the OT should provide direct services to Samuel and jostling among the kids is more under his control.
within the context of the classroom.
How might the multisensory approach impact
By providing services in the natural environment, the direct intervention during occupational therapy
OT can better understand the sensory inputs from that sessions?
environment and how they impact Samuel. Strategies Prior to the intervention, the occupational therapist should
can then be developed to support his participation in the consider the primary goal: attention to and participation
classroom, cafeteria, at recess, etc. during classwork. What are the barriers that are preventing
Often, to address a specific sensory need, the therapist must Samuel from accomplishing this goal?
provide a 1:1 intervention in addition to the services in the To answer this question, the therapist must consider the
natural environment. task itself. What is required to participate in class? Being a
In addition, the occupational therapist must work with student is a complicated role and involves many cognitive,
the team to help them understand Samuel’s needs in the motor, and sensory systems to support the outcome.
classroom. A quick task analysis offers some insight: For Samuel
What intervention strategies will you use with to participate in class he will need to attend to the task,
Samuel? Why? he will need the postural tone to support his posture and
movement, he will need to make postural adjustments, he
Goals should be developed with the teacher and the parents. will need to have grasp to use typical classroom tools such
The OT intervention will then focus on the goal areas. as a pencil and scissors, he will need to be able to follow
GOAL: Participation in classroom tasks directions, and he will need to engage with his teacher and
peers in reciprocal interactions.
The OT should explore Samuel’s response to various
textures in the environment to develop an understanding The occupational therapist should identify the barriers that
of preferences and sensitivities. The OT can explore are unique to Samuel: of the requirements to classroom
various textures with Samuel, beginning with preferences participation identified above, what can and can’t he do?
and working into non-preferred textures. The occupational therapist then needs to design a session to
address Samuel’s barriers. Samuel’s barriers to performance
The OT can provide a “sensory bin” in the classroom can be identified as attention, tactile processing, postural
with a variety of brushes and textured small toys, and control and adjustments, pencil grasp and control, following
encourage Samuel to “get his hands ready” before non- directions, and social participation.
preferred activities. For example, Samuel may scrub his
hands with the brush of choice prior to school work that The first step to determining Samuel’s needs is to evaluate
requires contact with a non-preferred texture such as his level of arousal at the beginning of the session. Samuel
paste or clay. presents with a slightly elevated arousal level, so the
occupational therapist needs to lower his arousal level for
GOAL: Attention to task during work time optimal engagement – for example, having Samuel lay
down on a mat while the therapist rolls a therapy ball
The OT has observed that during work time, Samuel gets
over him to provide pressure/proprioceptive input. The
distracted and will begin tugging at his clothing.
occupational therapist should observe Samuel’s response
The OT should call the parents and explore Samuel’s to the input. As it is determined that he has “relaxed” or
preferences and non-preferences for various textures. lowered his arousal level, the session can move towards goal
When selecting his clothing for the day, they should attainment.
consider his preferences and make suggestions to support
The direct intervention should begin with Samuel taking
respecting his preferences; other modifications may
off his shoes and socks. This will offer the opportunity for
include tagless shirts, fleece sweatpants with an elastic
increased tactile input throughout the session.
waist, and socks without seams or turned inside out so
the seams are on the outside. Since Samuel is a student in a public school, the

occupational therapist probably won’t have access to the the wall, each with a picture of one of the objects from his
suspended equipment, but there are options for stimulating sight words – for example, the first paper will have a picture
the vestibular system that don’t require a swing. A nice, of an “engine car” Samuel will be asked to stand at the wall
portable piece of equipment that provides a movement and paint the “engine,” either by finger painting or painting
experience is a “vestibular disc,” which can be used to with a brush. After he has filled in the object with paint, he
provide rotary vestibular input. Samuel can be asked to will be asked to paint the word under the picture. Standing
assume a prone at the wall will require Samuel to maintain his upper
position on extremity against gravity and use the proximal stability he
the vestibular was working on while weight bearing and weight shifting
disc which into his upper extremities earlier. The paint is yet another
is positioned opportunity for tactile input, although now a wet texture
on a carpeted is introduced. The carpeting as he stands barefoot at the
floor. The prone picture is also an additional opportunity to tactile input.
position will
require Samuel After Samuel has painted the pictures and the words, the
to assume and occupational therapist can transition Samuel to the sink so
maintain this he can wash up. The sink may be down the hall, requiring
position against Samuel to walk on a smooth, cool surface in his bare feet.
gravity; the Samuel will be encouraged to use soap and water to clean
movement of the his hands and/or the brushes. He will be encouraged to
vestibular disc dry his hand using a cloth towel instead of a paper towel.
will increase The occupational therapist and Samuel will return to the
his muscle tone area they were working and put on his socks and shoes.
and support his Incorporating “clean up” into the session provides another
engagement in opportunity for wet tactile input, the soap and water. The
this task; the carpet will provide tactile input into his hands use of paint put the wet texture in context for Samuel and
and feet. also provides a reason to wash his hands. The opportunity
to don/doff his shoes offers multiple benefits from increased
The occupational therapist has gathered a list of words
sensory input to practicing his ADL’s.
associated with trains, and written each word on an index
card. These can be placed in a circle around Samuel, and he As Samuel progresses academically, the therapist can
can be asked to locate specific words: “Find ____.” Samuel exchange the train words for his sight word vocabulary or
will then move the disc in a circle, visually scanning the spelling words.
words and trying to locate the correct one. When Samuel
How will you determine if your strategies are
finds the correct word, he is offered praise and asked to
working?
place the card on an “x” to make a pile of the words. If this
task is easy for Samuel, it can be graded up by asking him A data collection system should be developed to gather
to “Find ____ and _____ and ____.” He will now have to outcome data to inform the clinical reasoning process. Has
retain three items in his short term memory and locate them attention to task and work completion improved? Has the
on the floor around him. As he locates the correct words he number of physical incidents with his peers decreased?
adds them to the pile.
Factors specific to the intervention strategies used during
Once all of the words have been found, Samuel can occupational therapy include:
transition to heel sitting on the floor. The vestibular input
will increase Samuel’s attention so he is better able to •
How long was Samuel able to maintain a position of
participate in a school task. The occupational therapist has prone extension against gravity during the session?
prepared several pieces of paper that have one short sentence •
How long was Samuel able to attend to the academic
on each: “The first car is called the_____,” or “Trains task?
drive on a _____.” The occupational therapist will read the
sentence to Samuel and ask him to find the word that fills •
Was Samuel able to visually scan the environment and
in the blank. He can then be encouraged to occasionally locate the words?
weight bear on one hand while he manipulates the cards •
How long was Samuel able to maintain his upper
to find the correct word to complete the sentence. Once the extremities against gravity at the wall to paint?
word is located, Samuel will place it on the paper and go
to the next sentence. The intermittent weight bearing on •
What was Samuel’s reaction to the tactile input? What
the carpeting will provide an opportunity for tactile input were his responses to the textures? Was there a difference
into his hands and proprioceptive input into his upper in his response to the wet vs. dry textures?
extremities.
•
Was Samuel able to complete the ADL tasks of hand
After all of the sentence are complete Samuel can be washing/drying and donning/doffing his socks and
encouraged to stand in front of large pieces of paper taped to shoes?

What will you share with the educational team? Although Mary attends her local public school she is
currently working in the life skills curriculum at school
The educational team should be given information
in a self-contained classroom. Her Individualized
regarding sensory processing and how sensory processing
Educational Program (IEP) goals are focused on
impacts participation. Examples should be provided
participation in basic ADL’s such as toileting, hygiene,
that included over/under stimulation and the potential
self-feeding after set up, donning/doffing her coat.
behavioral responses.
Team members should be encouraged to inform the Mary continues to make slow but steady progress with
occupational therapist about concerning behaviors that her IEP goals. But the parents report increased stress
occur during the school day. The occupational therapist in during the morning routine, primarily related to
can further investigate the behavior to determine the dressing on school days. Mom is often on the night
underlying cause and if appropriate, suggest strategies to hospital shift and dad is responsible for getting all four
support performance. The strategies may include developing kids ready for school. Mary is reluctant to participate
a “sensory diet” or use of sensory input to regulate arousal in her self-care activities and often demonstrates
in support of positive behaviors. (A sensory diet provides behaviors such as hitting and crying during the
sensory opportunities offered throughout the child’s day morning routine, making it difficult to manage.
to proactively support regulation. For example, if the Specific behaviors include:
occupational therapist knows that the child responds Refuses to wear certain clothing
•
positively to somatosensory input, the use of “squishing”
paired with the opportunity to use a “fidget toy” such as Has difficulty getting her arms and legs into the
•
a bead necklace prior to art class may support the child’s openings
participation in a class that is typically a challenge.)
Hitting and crying during dressing
•
The therapist will share Samuel’s response to the
Overwhelmed by loud noises
•
intervention and outcomes. For example:
Rocking forward and backward with one foot
•
• Did his attention to task increase post vestibular input?
slightly in front of the other when she is staying in
If so, share with the teacher the outcome and suggest
one place
the opportunity to build movement into his day as his
attention decreases during class time. Will clap her hands and squeal when excited
•
• Share with the teacher Samuel’s ability to visually The parents need Mary to increase her independence
scan his environment and participate in an academic with dressing so that morning routine is less stressful
task. If he was overwhelmed by the visual input, the for the entire family.
occupational therapist can suggest simplifying some of
his worksheets by reducing the amount of visual stimuli The parents are seeking outpatient occupational
per page. therapy services to support Mary’s activities of daily
living (ADL’s).
• Share Samuel’s response to the wet and dry tactile input.
If Samuel was challenged by the wet texture, suggest You’re the outpatient OT!
options during classroom tasks that involved wet textures Where do you start?
•
such as painting or pasting.
What assessment tool will you use?
•
What will you share with the family?
•
The family should be an integral part of the team. As
options are being explored and developed, parental input In what sensory systems do you see of clustering of
•
is essential. If the family is unable to be present during behaviors? How will identification of the system(s)
team meetings and informal exchanges of information, the inform your next step?
parents should be part of the communication mode used to
•
share information.
with Mary? Why?
CASE STUDY #2: What intervention strategies will you use with
•
Mary? Why?
Mary is a 10 year 5-month old girl with a diagnosis of
autism. How might the multisensory approach impact direct
•
intervention during occupational therapy sessions?
She is the second of four children. Her dad is an auto
mechanic and her mom is a nurse. How will you determine is your strategies are
•
working?
Mary is ambulatory and non-verbal. She has a simple
augmentative communication system/picture board Take some time to consider each question and jot down your
using picture symbols to indicate her basic needs: yes/ thoughts before reading on. Space is provided at the end of
no, hungry/thirsty, potty, hurt, tired, happy/sad. the course.

Where do you start? Will clap her hands and squeal when excited
(proprioceptive/sensory seeking)
Interview the parent(s), spend time with Mary. (The time
spent with Mary should be therapist directed, for the Mary appears to have a clustering of behaviors that are rooted
purpose of gathering data.) in the sensory defensiveness and sensory seeking behaviors.
To gather information about her sensory systems, The OT should gather additional data about the home
Mary should be encouraged to interact with the sensory context. The results from the sensory profile should be used
equipment such as swings, barrels, trampolines, climbing to corroborate the observation results. The OT should have a
equipment, scooter, etc. The occupational therapist should more detailed conversation with the parents asking probing
use clinical observations and document Mary’s response to questions to gather data about Mary’s sensory history.
the environment. For example:
What swing does she prefer? (solid surface vs. soft surface, with Mary? Why?
one suspension point vs. two suspension points, etc.) What
The overall goal is to support Mary and the family during
position on the swing does she prefer? (sitting, prone,
the morning routine. Therefore, the OT should provide direct
supine, etc.) What type of movement does she prefer?
services to Mary within the clinical context.
(rotation, linear, orbital, etc.) Is her movement self-directed
(she is able to move the swing or able to communicate that In addition, the OT should use Parent Coaching – defined
she wants the therapist to move the swing) or therapist as a verbal interaction where “therapists engage parents
directed? in collaborative, goal specific conversations to identify
what works to further enable child, parent and family
What is her arousal level? How does her arousal level
performance within the home, and community” (Graham,
change in response to the environment?
Rodger, & Ziviani, 2010, p.5) – strategies to support the
How does she use her fine and gross motor skills to interact parent’s interaction with Mary during dressing. Strategies
with the environment? can then be developed to support her participation in the
home.
How does she use cognition (such as attention, memory,
problem solving, sequencing, etc.) to support her What intervention strategies will you use with
performance? Mary? Why?
What assessment tool will you use? Goals should be developed with the parents. The OT
intervention will then focus on the goal areas.
The Sensory Profile. The SP is a good choice to use with
Mary because it is a caregiver questionnaire that provides GOAL: Complete evening hygiene routine
information related to all of the sensory systems. The
The OT should explore Mary’s response to various
results will help to identify how Mary processes sensory
textures in the environment to develop an understanding
information. It will also facilitate a dialogue with the
of preferences and sensitivities. The outcomes should be
parents.
discussed with the family.
The OT can explore various textures with Mary,
Non-verbal, ambulatory, the second of four kids, mom beginning with preferences and working into non-
works shifts so dad is often solely responsible for the kids preferred textures as Mary tolerates them.
care.
The OT can suggest using a bath mitt with a preferred
Mary is generally compliant but when she is upset she cries texture during bathing, and having a variety of different
loudly and hits. She is frequently upset when in a hectic textured towels for drying off, introducing the different
context. textures as Mary tolerates them.
In what sensory systems do you see of clustering of In addition, the parents should try to vary the amount of
behaviors? How will identification of the system(s) pressure provided during the drying. This can be a great
inform your next step? opportunity to offer tactile input.
Refuses to wear certain clothing (tactile) After bathing, the OT can suggest the use of a body
lotion, asking the parents to take into account the scent
Has difficulty getting her arms and legs into the openings
of the lotion: since it is bedtime, the scent should be one
(proprioceptive)
that Mary finds calming. Rubbing down the skin surface
Hitting and crying during dressing (tactile, proprioceptive) with lotion is an additional opportunity to provide
tactile input.
Overwhelmed by loud noises (auditory)
GOAL: Complete Upper Body and Lower Body Dressing
Rocking forward and backward with one foot slightly
in front of the other when she is staying in one place The therapist can complete a task analysis of upper
(vestibular/sensory seeking) body and then lower body dressing. This should be
followed by an observation of Mary during these tasks.

The therapist can then break the task into steps and The first step to determining Mary’s needs is to evaluate
introduce each step using a picture schedule, like the one her level of arousal at the beginning of the session. Mary
above, depicting each step and provide verbal and/or presents with a highly elevated arousal level, so the
physical cues as needed. The parents can be taught how occupational therapist needs to lower her arousal level
to provide cues and supports. for optimal engagement. For example, the occupational
therapist may choose to begin by altering the visual and
The OT can suggest that the parents work on dressing
auditory input from the environment by providing therapy
following the newly established evening hygiene routine,
in a private room, turning down the lights, and playing
to allow for more time and reduce the possibility of
soft music. The therapist may then want to use a swing to
stress due to time constraints (other children needing
provide vestibular input
assistance, the bus coming, etc.).
to Mary: this can be
As Mary increases her skills, her parents can begin to accomplished by placing
transfer the skills into the morning routine. a tube on a small
platform swing that
How might the multisensory approach impact
is suspended from one
direct intervention during occupational therapy
suspension point and
sessions?
having Mary lay down
In addition to the support provided to the parents for carry inside, then covering
over in the home, the direct intervention session may her with a blanket and
include using a multi sensory approach. Since intervention moving the swing in a
is taking place in an outpatient clinic, the resources to slow, predictable, orbital
support sensory based intervention will be more readily movement, limiting
available. verbalizations to what
is necessary. The
Prior to the intervention, the occupational therapist should occupational therapist
consider the goal: getting dressed in the morning. What are should observe Mary’s
the barriers that are preventing Mary from accomplishing response to the input.
this goal? As it is determined that she has “relaxed” or lowered her
To answer this question, the therapist must consider the arousal level the session can move towards goal attainment.
task itself. What is required to get dressed? Getting dressed Once Mary is able to attend and participate, the
is a complicated task and involves many cognitive, motor, occupational therapist will transition Mary from the swing
and sensory systems to support the outcome. to the trampoline, which will have a “crash pad,” or a bag
A quick task analysis offers some insight: If Mary gets
dressed in sitting she will need to attend to the task, be able
to have postural tone to support her posture and movement,
she will need to make postural adjustments, she will need
to know where her body is in space, she will need to have
grasp and sustained grasp of the clothing, she will need to
understand the sequence of putting on her clothes.
The occupational therapist should identify the barriers
that are unique to Mary: of the requirements to dressing
identified above, what can and can’t she do? The filled with foam pieces, placed beside it. The occupational
occupational therapist then needs to design a session to therapist will ask Mary to step onto the trampoline and –
address Mary’s barriers. Mary’s barriers to performance can standing in front of Mary and holding both of her hands
be identified as attention, postural control/adjustments, – will ask Mary to jump 10 times, then jump off the
awareness of position of her limbs, eye hand coordination, trampoline and crash land on the crash pad. The therapist
sustained grasp, and cognitive sequencing. will encourage the jumping by providing physical cues
while holding Mary’s hands, and will count the jumping
up/down. The structured jumping on the trampoline will

Mary can be directed to sit on the swing holding on to
the ropes on both sides. The occupational therapist can
propel the swing forward towards the wall. Mary can be
asked to lift her legs and push off of the wall to propel the
swing backwards. As Mary is swinging back and forth the
therapist can hold up pieces of oversized clothing and ask
Mary to release her grasp on one rope, reach for the clothing
and to toss it in a laundry bin. This will be repeated
multiple times and on both sides. The number of repetitions
should not be predetermined, but based instead on Mary’s
response to the input. The linear swinging will increase
Mary’s postural tone, and the movement of the swing will
require postural adjustments. The vestibular input from
the swing will also support Mary’s attention. Mary will
be required to lift her lower extremities up against gravity
provide vertical vestibular input and strong proprioceptive and to maintain them in that position while swinging.
input. The vestibular input will be motivating to Mary This position will further engage her core musculature.
as she is a sensory seeker, and it will also support her The pushing off of the wall with her lower extremities will
attention. Mary is also a proprioceptive seeker and has provide proprioceptive input into her lower body. The ropes
decreased proprioceptive awareness; the heavy jumping on will provide tactile input into her hands and the opportunity
the trampoline will increase her proprioceptive awareness for maintaining a sustained grasp.
and provide her with information about where her body Mary will then be directed to transition from the swing to
is in space, and the final crash into the crash pad is an a small bench where she can sit with her feet on the floor.
additional reinforcer about her body in space. After Mary Mary will be told she is going to practice getting dressed.
crashes into the pad, she will be asked to repeat the jumping She will be offered a choice of oversized clothing (for
on the trampoline and the crash pad. The occupational example, “Do you want the blue shirt or the red shirt?”).
therapist will observe Mary’s response to the sensory input, After Mary indicates her choice she will be instructed to
paying close attention to her arousal level, attention to task, put on the shirt using backward chaining, an approach
and her adaptive responses. used to scaffold learning to support cognitive processing
After Mary is ready to move on from the trampoline, and promote success (Shepard, 2015). The parents will
she will climb a “mountain” – a large foam wedge that be invited to join the session so that they can observe the
has a rope down the middle. Mary will be asked to hold structure and cues provided to support her performance.
the rope in both hands and use it to pull herself up the The parents will be offered tips on how to cue Mary, how to
mountain. At the top, the occupational therapist has placed encourage her, and how to reward her performance.
some oversized clothing and a small laundry bin. Once How will you determine if your strategies are working?
Mary arrives at the top, she is asked to gather the clothes
and place them in the basket. The heavy, proprioceptive A data collection system should be developed to gather
work of pulling her body up the incline will increase her outcome data to inform the clinical reasoning process. Has
proprioceptive awareness of her upper and lower body and her self-dressing improved? What is she able to do? What
require her to sustain her grasp. In addition, the tactile and is the efficiency of her abilities? Do the parents report a
proprioceptive input into her hands will help prepare them decrease in behaviors related to the self-care routine? Do the
for task engagement. Picking up and placing the clothing in parents report a decrease in family stress as a result in the
the laundry basket will require eye hand coordination. The changes in performance?
occupational therapist then directs Mary to slide down a
ramp and land in a foam pit.
After Mary figures out how to get up and out of the pit,
she is directed onto a large bolster swing hung from two
suspension points. The occupational therapist will use
clinical observations to determine Mary’s current arousal
level If needed, the swing can be used to decrease Mary’s
arousal level in the same way it was accomplished at the
start of the session: slow, predictable movements with a
decrease in sensory input from the environment. If Mary’s
response to the heavy, proprioceptive work has been to
maintain her arousal level in an optimal state, then
the swing can be used to continue to work towards goal
attainment.

X. Conclusion
On a final note: although occupational therapists have and family dealing with autism, the therapist must be
a basic understanding of sensory based intervention, aware of the multifaceted needs of the child and the
advanced training is highly recommended to develop the family. Providing direct services to influence the state
clinical skills to support the use of OT-SI with a variety and development of the sensory systems is vital. Direct
of diagnoses. There are multiple advanced training services can target specific developmental needs and
opportunities available. facilitate maturity of the CNS. But it is important to
remember that providing intervention 1-2 times per week,
Caution is always required when using sensory based
although important, is going to promote a limited change
intervention techniques. Sensory input has a very
in development. The role of the child’s occupational
powerful impact on our CNS, and should be used with
therapist is to create a supportive environment that will
caution and a keen clinical eye, based on client need as
maximize the child potential. Therefore, in addition to
determined by evaluation. The occupational therapist
direct intervention, the occupational therapist must also
should always closely monitor the child’s ANS reaction to
assume the role of an educator and an advocate.
the input and the child’s emotional response to the input,
using both to determine the next steps of the process. When used correctly, rooted in a theoretical
understanding of how the brain works, sensory based
The occupational therapist plays a central role on the
intervention can be a powerful tool to engagement and
team, filling in the gap for understanding the sensory
participation of those with autism who present with an
systems and how they impact function. To maximize
abnormal response to sensory stimuli.
the influence of occupational therapy services for a child
Notes

Common Sensory Assessments
Assessment Ages Format Time to Subscales
Administer/
Scoring
Infant Toddler Birth-3 ·Criterion-referenced; judgment-based questionnaire 15 min. Birth to 6 mos.:
Sensory Profile measuring infant/toddlers’ reactions to sensory General Processing
Dunn (2002) experiences completed by primary caregiver. Auditory Processing
·Yields scores on frequency of observed behaviors Visual Processing
rated on a Likert scale of 1-5 from “Almost Never” to Tactile Processing
“Almost Always.” Scores summed into 4 quadrants Vestibular Processing
(Low Registration, Sensation Seeking, Sensory
Sensitivity, and Sensation Avoiding) and/or sensory
systems. 7 to 36 mos.:
·Scores given in relation to distance above and below General Processing
the mean (Typical Performance) Auditory Processing
Visual Processing
Tactile Processing
Vestibular Processing
Oral Sensory
Processing
Sensory Profile Ages ·Criterion-referenced, judgment-based questionnaire 20-30 Sensory Processing
Dunn (1999) 3-10 of 125 items completed by a primary caregiver minutes Modulation Behavior
years and Emotional
·Standardized on children with Autism
Responses
·Scores fall in range of Typical Performance, Probable
Difference (1 sd <mean), or Definite Difference (2
sd < mean). SP Supplement provides an updated
scoring system with expanded cut scores for easier
interpretation
·Scoring software and Spanish versions available
·Yields scores on frequency of observed behaviors
rated on a Likert scale of 1-5 from “Almost Never” to
“Almost Always”
Adolescent/ Ages 11+ ·Criterion-referenced, judgment based self-report 15-20 Taste/ Smell
Adult Sensory questionnaire of 60 items minutes Sensitivity
Profile Dunn Movement Processing
·Yields scores on frequency of exhibited behaviors
(2002)
based on a Likert scale of 1-5, from “Almost Never” Visual Processing
to “Almost Always.” Scores are summed according to Touch Processing
four sensory quadrants (Low Registration, Sensation
Seeking, Sensory Sensitivity, and Sensation Avoiding). Activity Level
Scores given in relation to distance above and below Auditory Processing
the mean

Sensory Ages ·Criterion-referenced, judgment-based questionnaire 15 minutes to Environmental
Profile-School 3-12 completed by the child’s primary teacher administer Sensations:
Companion
·Yields scores on frequency of observed behaviors 15 minutes to ·Auditory
Dunn (2006)
rated on a Likert scale of 1-5 from “Almost Never” to score ·Visual
“Almost Always.” Three types of scores are derived: Body Sensations:
(a) Sensory Quadrant Scores, (b) School Factor Scores,
and (c) Section Scores. Scores given in relation to ·Movement
distance above and be-low the mean ·Touch
Classroom Behaviors:
·Behaviors
Sensory Ages ·Norm-referenced, judgment-based questionnaires 20 minutes Higher-level
Processing 5-11 completed by primary caregiver, main teacher, and for the Home integrative functions:
Measure (SPM) years school personnel familiar with child. and Main Praxis
Glennon, Classroom
·Three forms: Home Form, Main Classroom Form, Social participation
Miller- Forms, 5
and School Environments Form (art class, music class,
Kuhaneck, minutes
physical education class, recess/playground, cafeteria,
Henry, Parham, for each Sensory systems:
and school bus)
& Ecker (2007) additional
Visual
·Four-point Likert scale. Home and Main Classroom School
Forms yield standard scores (social participation, Environments Auditory
vision, hearing, touch, body awareness, balance and form Tactile
motion, planning and ideas, total sensory systems).
Proprioceptive
Environmental difference score shows the difference
in sensory processing across environments Vestibular
SPM-P Glennon, Ages 2-5 ·Norm-referenced, judgment-based questionnaires 15-20 Higher-level
Miller- years completed by primary caregiver, daycare provider, or minutes for integrative functions:
Kuhaneck, preschool teacher the Home Praxis
Henry, Parham, and Main
Social participation
& Ecker (2010) Classroom
Forms, 5
minutes Sensory systems:
for each
Visual
additional
School Auditory
Environments Tactile
form
Proprioceptive
Vestibular

References:
American Psychiatric Association (2013) Diagnostic Glennon, T., Miller-Kuhaneck, H., Henry, D. A.,
and statistical manual of mental disorders (5th ed.). Parham, L. D., & Ecker, C. (2010). Sensory Processing
Washington, DC Measure – Preschool manual. Los Angeles, CA: Western
Psychological Services.
American Journal of Occupational Therapy (2014)
Occupational Therapy Practice Framework: Domain Parham, L.D. & Mailloux, Z. (2015) Sensory
and Process, 3rd edition, The American Journal of Integration. In Case-Smith, J. & O’Brien, J (Eds)
Occupational Therapy, 68, S1-S48. Occupational Therapy for Children and Adolescents, (7th
edition), St Louis: Mosby.
Bear, M.F., Connors, B.W., and Paradiso, M.A.
(2016) Neuroscience: Exploring the brain (4th ed), Schaaf, R.C. & Mailloux, Z. (2015) Clinicians Guide for
Philadelphia: Wolters Kluwer Implementing Ayres Sensory Integration®: Promoting
participation for children with autism, Bethesda, MD:
Blanche, E.I. (2010) Observations based on sensory
AOTA Press
integration theory, Torrance, CA: Pediatric Therapy
Network. Schaaf, R.C. and Roley, S.S. (2006) Sensory Integration:
Applying clinical reasoning to practice with diverse
Blanche, E.I., Reinoso, G., Chang, M.C., & Bodison,
populations, Austin, TX: Pro-ed.
S. (2012). Brief Report- Proprioceptive processing
difficulties among children with autism spectrum Shepherd, J. (2015) Activities of Daily Living and
disorders and developmental disabilities. American Sleep and Rest. In Case-Smith, J. & O’Brien, J (Eds)
Journal of Occupational Therapy, 66, 621-624. Occupational Therapy for Children and Adolescents, (7th
edition), St Louis: Mosby.
Bundy, A.C. (2002) Assessing Sensory Integrative
Dysfunction. In Bundy, A.C., Lane, S.J. and Murray, Taylor & Trott (1991) How does your engine run?
E.A. (Eds) Sensory Integration Theory and Practice,
Tomchek, S. D. & Dunn, W. (2007). Sensory processing
Philadelphia, PA: FA Davis
in children with and without autism: A comparative
Cronin, A. (2016) Development in the Preschool study using the Short Sensory Profile. American Journal
Years. In Cronin, A. & Mandich, M.B.(Eds) Human of Occupational Therapy, 61, 190-2000.
Development and Performance throughout the Lifespan,
Watling, R.L., Deitz, J., & White, O. (2001).
Boston, MA: Cengage Learning.
Comparison of sensory profile scores of young children
Dunn, W.W. (1999) Sensory Profile: User’s Manual. San with and without autism spectrum disorders. American
Antonio, TX: Psychological Corporation. Journal of Occupational Therapy, 55 (4), 416-423.
Dunn, W.W. (2002) The Infant Toddler Sensory Profile Williamson, G.G., & Anzalone, M.E. (2001)
manual. San Antonio, TX: Psychological Corporation. Sensory integration and self-regulation in infants and
toddlers: Helping very young children interact with their
Dunn, W.W. (2006) Sensory Profile school companion
environment. Washington DC: Zero to Three.
manual. San Antonio, TX: Psychological Corporation.
Glennon, T., Miller-Kuhaneck, H., Henry, D. A.,
Parham, L. D., & Ecker, C. (2007). Sensory Processing
Measure manual. Los Angeles, CA: Western
Psychological Services.
Additional Resources:
Sensory Integration Topics by Zoe Mailloux AOTA
http://www.zoemailloux.com/sensory-integration- http://www.aota.org/Practice/Children-Youth/Autism.
topics.html aspx
Sensory Integration Network CDC
https://www.facebook.com/ http://www.cdc.gov/ncbddd/autism/index.html
SensoryIntegrationNetwork
Research Autism
Autism Speaks http://researchautism.net/
https://www.autismspeaks.org/
Autism Spectrum Disorder Fact Sheet
http://www.ninds.nih.gov/disorders/autism/detail_
autism.htm

Sensory Integration and Autism Spectrum Disorder
(3 CE Hours)
FINAL EXAM
1. To receive a diagnosis of Autism Spectrum Disorder 6. ________ may present as having difficulty
(ASD) a child must meet four criteria with specific interpreting touch information or stimulus: a child
distinctions related to each criterion. Which is may not be able to differentiate the difference
NOT a criterion for an ASD diagnosis? between a quarter or a nickel by touch alone.
a. An intellectual developmental disability a. Proprioceptive problems
b. Deficits in social communication and interaction b. Tactile defensiveness
(SCI) - three distinctions c. Tactile discrimination problems
c. Restrictive, repetitive behaviors (RRP) - two out of d. Vestibular bilateral problems
four distinctions
d. Symptoms cause impairment in “social,
7. Proprioceptive problems may present as difficulty
occupational or other important areas” of
interpreting where the body is in space. A child
function
with proprioceptive problems ________.
a. May appear to be stomping, seeking the sensory
2. The role of the peripheral nervous system (PNS) is input you and I get while walking
to ________. b. May appear unaware of the environment
a. Control basic functions such as heart rate, c. May not be able to recognize their shoe if it has
breathing, and consciousness been turned upside down.
b. Process information as a stimulus is introduced d. May refuse to wear jeans because they are stiff and
c. Receive information from the brain stem, spinal have heavy seams and a snap
cord and various parts of the brain
d. Transmit information to the central nervous
8. A child with a praxis problem (dyspraxia) who sees
system (CNS) to support movement and reactions.
an object or opportunity in the environment such
as a bike, and knows he wants to ride it but doesn’t
3. The receptors for the vestibular system are located know what to do, has difficulty with ________.
________. a. Any stage of the process
a. In our muscles and joints b. Execution: Making the bike move
b. In our skin, with the majority in the palms of our c. Ideation: I can ride the bike
hands and the soles of our feet d. Planning: How to ride the bike
c. In the inner ear
d. In the nose and tongue
9. Which of the following is NOT characteristic of
vestibular bilateral problems?
4. The ________ system has two functions: protection a. Difficulty participating in childhood activities
and discrimination. such as riding a bike or playing cooperative hand
a. Auditory games with a partner
b. Proprioceptive b. Difficulty with balance, equilibrium, or poor
c. Tactile coordination between the two sides of the body
d. Vestibular c. Negative response to sounds, tastes, and smells
d. Postural challenges and difficulties with attention
to task
5. According to Ayres Sensory Integration (ASI),
when we think of sensory development in terms of
laying the foundation for overall development, we 10. The ________ is norm referenced. It offers forms for
must acknowledge the contribution of the sensory the Home, the Main Classroom, and the School
systems as ________. Environments, as well as a preschool edition.
a. A crack in the foundation a. Comprehensive Observations of Proprioception
b. Contrary to higher level skill development (COP)
c. Detrimental to learning and behavior b. Sensory History
d. The building block in the foundation c. Sensory Processing Measure (SPM)
d. Sensory Profile

11. Clinical observations, developed by Jean Ayres, 16. During an intervention for a child with tactile
can reveal information about the function of the defensiveness, the occupational therapist may
neurological system of the child. For example, ________.
when looking at ________, immature or poor a. Ask the child to find and retrieve a desired object
responses may contribute to the identification of from a texture bin containing rice or macaroni
decreased vestibular-proprioceptive function. b. Ask the child to sit at a table on a small ball
a. Crossing Midline (The ability to cross the body c. Build an obstacle course
midline with one or both hands to manipulate d. Place the child prone on a therapy ball and ask
objects in contralateral space) the child to “walk” on extended arms
b. Protective Extension (A protective reaction
that results from loss of balance that involves
17. During an intervention for a child with praxis
extension of the non-weight bearing “downhill”
problems, the occupational therapist should
limbs, or those on the side toward which the fall
________.
would occur)
a. Consider activities that are visually appealing
c. Sequential Finger Touching (The ability to
b. Consider activities that include joint compression,
sequentially oppose the thumb to each of the
pressure and vibration
other fingers, index to little finger and back)
c. Use a brush to “scrub” the child’s hands
d. Supine Flexion (Simultaneous flexion against
d. Use sensory activities to create a context where
gravity of the knees, hips, trunk, and neck from a
the child is motivated to problem solve and come
supine-lying position)
up with ideas and plans
12. The overall assessment process should culminate in
an occupational profile that includes ________. 18. Which of the following typical equipment would
a. A narrative of the child provide the MOST proprioceptive input?
b. Past medical and developmental history a. Enjoyable textures: soft and squishy toys filled
c. Priorities of the child/family/team with liquid or sand
d. All of the above b. Novel textures: texture bins holding reusable
items such as macaroni, sand, rice, beans, etc.
13. A sensory based intervention relies on the
c. Resistance or pressure: therabands/tubing,
occupational therapist to support exploration
weighted vests and blankets, medicine balls, etc.
of the environment by offering activities for
d. The opportunity for movement: swings, scooters,
engagement to promote development – bearing
riding toys, etc.
in mind that sensory based intervention is more
effective ________.
a. When environmental challenges have been 19. Which of the following typical equipment would
eliminated provide the MOST vestibular input?
b. When only one sensory system is engaged a. Enjoyable textures: soft and squishy toys filled
c. When more than one sensory system is engaged with liquid or sand
d. When the child is not actively engaged b. Novel textures: texture bins holding reusable
items such as macaroni, sand, rice, beans, etc.
14. Many children with autism present with a
c. Resistance or pressure: therabands/tubing,
decreased interest in participation, and therefore
weighted vests and blankets, medicine balls, etc.
decreased motivation to engage. In addition
d. The opportunity for movement: swings, scooters,
to creating sensory opportunities to promote
riding toys, etc.
development, the occupational therapist must also
find ways to motivate the child to engage, such as
________. 20. When children present with a low arousal level,
a. Asking the child’s parents to sit in on sessions and the occupational therapist will need to increase it
enforce engagement prior to beginning the intervention. One way this can
b. Incorporating the child’s interests and passions be accomplished is by ________.
into the intervention plan a. Decreasing the lighting in the room
c. Using a system of penalties for failure to engage b. Incorporating controlled, regular movements on a
d. All of the above swing
c. Incorporating quick, unpredictable movements
15. At the start of each intervention session, the on a swing
occupational therapist must determine the child’s d. Keeping the room very quiet
_________, or the level of alertness of the child’s CNS.
a. Arousal level
b. Emotional mood
c. Physical anticipation
d. Sensory workload

ANSWER SHEET
First Name:_______________________________ Last Name: ______________________________ Date: ________________
Address: ________________________________________________________City: ___________________________________
State: ____________________________________ ZIP: ___________________Country_________________________________
Phone: __________________________________ Email: ________________________________________________________
NCBOT #:_______________________________________________________________________________________________
Other: License/certification # and issuing state/organization_________________________________________________
Clinical Fellow: Supervisor name and NCBOT account #____________________________________________________
Graduate Student: University name and expected graduation date___________________________________________

** See instructions on the cover page to submit your exams and pay for your course.
By submitting this final exam for grading, I hereby certify that I have spent the required time to study
this course material and that I have personally completed each module/session of instruction.
Sensory Integration and Autism Spectrum Disorder

Final Exam
1. A B C D 5. A B C D 9. A B C D 13. A B C D 17. A B C D
Accessibility and/or special needs concerns?

Contact customer service by phone at (888) 564-9098
or email at [email protected].
Refund and general policies are available online at

http://pdhacademy.com/policies/

SENSORY INTEGRATION AND
AUTISM SPECTRUM DISORDER
(3 CE HOURS)
COURSE EVALUATION
Learner Name:_____________________________________________ Completion Date: ______________________________
❑ PT ❑ PTA ❑ OT ❑ OTA ❑ SLP ❑ SLPA Other: _______________________________________
Disagree Agree
Orientation was thorough and clear 1 2 3 4 5
Instructional personnel disclosures were readily
available and clearly stated 1 2 3 4 5
Learning objectives were clearly stated 1 2 3 4 5
Completion requirements were clearly stated 1 2 3 4 5
Content was well-organized 1 2 3 4 5
Content was informative 1 2 3 4 5
Content reflected stated learning objectives 1 2 3 4 5
Exam assessed stated learning objectives 1 2 3 4 5
Exam was graded promptly 1 2 3 4 5
Satisfied with learning experience 1 2 3 4 5
Satisfied with customer service (if applicable) 1 2 3 4 5 n/a
What suggestions do you have to improve this program, if any?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
What educational needs do you currently have?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
What other courses or topics are of interest to you?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

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CONTINUING EDUCATION

for Occupational Therapists

Delivery & Instructional Method

Registration & Cancellation

Accessibility and/or Special Needs Concerns?

Course Author Bio & Disclosure

2 | Sensory Integration and Autism Spectrum Disorder OCCUPATIONAL THERAPISTS

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The Vestibular System

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Because of the child’s interest in trains, the child

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occupational therapist will encourage the child

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Address: ________________________________________________________City: ___________________________________

State: ____________________________________ ZIP: ___________________Country_________________________________

Phone: __________________________________ Email: ________________________________________________________

Other: License/certification # and issuing state/organization_________________________________________________

Clinical Fellow: Supervisor name and NCBOT account #____________________________________________________

Graduate Student: University name and expected graduation date___________________________________________

Sensory Integration and Autism Spectrum Disorder

Accessibility and/or special needs concerns?

Refund and general policies are available online at

34 | Sensory Integration and Autism Spectrum Disorder OCCUPATIONAL THERAPISTS

❑ PT ❑ PTA ❑ OT ❑ OTA ❑ SLP ❑ SLPA Other: _______________________________________

What suggestions do you have to improve this program, if any?

What educational needs do you currently have?

What other courses or topics are of interest to you?

OCCUPATIONAL THERAPISTS Sensory Integration and Autism Spectrum Disorder | 35

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Because of the child’s interest in trains, the child

Address: ______________________City: _

State: __________________________ ZIP: _Country_________________________

Phone: Email: ______________________