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education & therapies 

A Practical Look
at the Theory
and Model for
By Megan Carrick, MOTR/L

Introduction and emotional homeostasis that we call

How are we able to react so quickly, regulation. While the environment can often
unconsciously for that matter, when we start inundate us with sensory stimuli, we learn
to experience a fall? Why is it that we can ride what sensory inputs help us feel good, what
a bike without much thought of what our feet, sensory information to tune into, and what
hands, eyes, and ears are doing or how they sensory information to filter out. This process
work together? How is it that we can learn is necessary to reach and sustain the state
new dance steps just by watching others and of arousal that is organizing, calming and,
following their lead? When our nervous system therefore, regulating, (Greenspan & Wieder,
and brain work together, we can engage in 1998). No two people experience sensory
a dialogue with our environment. It is the information the same way; rather, each person
function of the brain and nervous system has a unique sensory profile. Therefore, by
working together that allows us to experience providing our nervous system with the right
and communicate with our world, for example, types of sensory stimuli, we can become calm Megan Carrick, MOTR/L, is working
as clinical director of her private
engaging in things as simple as a smile or and stay that way, for the most part. When we practice in the north suburbs of
as complex as a double backflip off a diving are calm and regulated, we can attend to the Chicago, Illinois. She provides services
board. This concept of a body-environment world around us and take interest in people, for children ranging in age from
dialogue is best known as the theory of sensory objects, and experiences. Sensory and motor infancy up to 15 years old. Megan
provides services through the Illinois
integration. It is the unconscious process by experience, or lack thereof, can cause us to Early Intervention Program, therapy
which we “organize sensation for use” (Ayres, become dysregulated. If we experience too groups, and school consultations.
2005). Effective sensory integration gives much sensory stimuli or too little, we may She holds a master’s degree in
meaning to our experiences by tuning into become overly excited or shut down. These occupational therapy from Midwestern
University, is Sensory Integration and
the important information and dismissing or arousal states, overly excited and shutdown, Praxis test (SIPT) certified, and recently
filtering out the unimportant. It allows us to are forms of dysregulation. When we are in received her DIR® certification through
respond to the world around us both purposely these states, we need to nourish our arousal the Interdisciplinary Council on
and successfully with what is referred to as an via sensory information and sensory motor Developmental and Learning Disorders
(ICDL). Megan is pursuing a doctorate
adaptive response (Ayres, 2005). experiences. Children and adults who suffer in infant and early childhood mental
Efficient sensory integration allows us to from sensory integration challenges lack the health and development disorders. See
reach and sustain a state of physiological efficient processing of sensory information, also REPRINTED WITH PERMISSION © THE AUTISM FILE THE AUTISM FILE USA 34 2010 • 57
 education & therapies

struggle in their ability to adaptively respond late 1970s and published a great deal of research
to their environment, and experience difficulty throughout her career (Ayres, 2005). The theory
shifting their arousal back to a state of of sensory integration has been a staple in
Children and regulation. pediatric occupational therapy evaluation and
Because we all have a unique sensory profile, intervention for many years and continues to be
adults who suffer from our perceptions truly are our own. While a much researched and implemented model.
we may experience many similarities in our
sensory integration perceptions, when comparing them to others, Sensory integration at work
challenges lack the we will never experience a situation in the Sara is a 3-year-old girl attending her first ballet
exact same manner as any other person. This class. She is eager to dance and has been
efficient processing of is important to remember as we think about practicing ballet for several months as her
people with challenges in processing and mother has been teaching her some of the
sensory information, integrating sensory information. What feels basic concepts per Sara’s request. She enters
struggle in their ability good to us does not feel good to everyone; the class, a drop off class with a window for her
what bothers us will not necessarily bother mother to watch from, and is greeted by her
to adaptively respond others; and what helps us become regulated teacher. The teacher, Miss Mary, reaches out to
will not work for all. Essentially, it is impossible touch Sara on the shoulder as she introduces
to their environment, to experience the world like any other person. herself. She asks Sara why she is taking ballet,
and experience Therefore, as professionals and family members while still placing a gentle hand on her
working with children, it is imperative that shoulder. Sara looks to her mother and sees in
difficulty shifting their we gain a true sense of these differences to her mother’s face and eyes that it is safe and
promote the most effective supports and the quite expected to respond to Miss Mary. Sara (in
arousal back to a state highest quality of care for each child. her very big girl voice) replies, “I want to dance
of regulation. like the ballerinas in my book!”
History Miss Mary smiles and responds quite pleased,
In the 1950s, Dr. A. Jean Ayers began her work “That is good news because here we learn how
defining the model of sensory integration to dance like real ballerinas.” Miss Mary then
theory, evaluation, and intervention. She gently leads Sara into the classroom with the
published Sensory Integration and the Child in the hand placed on her shoulder, and Sara turns to
education & therapies 
wave at her mother through the observation
In this example, Sara relies on her visual,
tactile, auditory, vestibular, and proprioceptive
systems to support her adaptive responses. She
first relies on the visual and auditory systems
to take in the setting, the words of her teacher,
and the expression on her teacher’s face. She
listens for tone of voice and volume, and she
looks for affective cues in the teacher and
her mother’s facial expressions as she works
to gain a sense of the new adult’s intentions
based on how she is communicating to Sara.
Sara relies on her tactile system to perceive,
discriminate, and accurately interpret the
hand on her shoulder. She then relies on her
proprioceptive (sensations of the muscles and
joints) and vestibular (sensation of head and

Sensory Processing Disorder (SPD)

The ability to
meet environmental
Sensory Modulation Sensory-Based Motor Sensory Discrimination
Disorder (SMD) Disorder (SBMD) Disorder (SD) expectations and
demands may be
Visual compromised by
SOR SUR SS Dyspraxia Postural Disorders Auditory
poor processing and
poor integration; this
SOR = sensory overresponsivity. Vestibular
SUR = sensory underresponsivity. Proprioception leads to maladaptive
SS = sensory seeking/craving.
Taste/Smell responses to many
daily situations – even
neck movement in any direction) systems in Diagnosis those that are quite
concert with her visual, tactile, and auditory The theory of sensory integration has led to
systems to allow her to move across the room the use of assessment tools and intervention routine.
given a subtle tactile cue from her teacher. to promote qualitative changes in a child’s
Sara’s nervous system sends rapid electrical regulatory capacities and observable behaviors
impulses to the brain where many centers in their daily life. Recent literature suggests
are involved in quickly distributing, sharing, a new system for classification of sensory
and essentially integrating the multitude of processing disorders (SPD) to help provide greater
information. Because Sara can gain an accurate diagnostic specificity (Miller, Anzalene, Lane,
read on her environment quickly, she is able to Cermak, & Osten, 2007).
respond adaptively by engaging in a way that Miller and colleagues have proposed a new
demonstrates her intention while meeting the nosology for diagnosing sensory processing
demands of the immediate situation. disorders as illustrated in figure 1 above.
If in fact Sara were a child with a sensory
processing disorder, she would likely have a Nosology Definitions
very different experience. The ability to meet The proposed nosology suggests three patterns
environmental expectations and demands may including sensory modulation disorders,
be compromised by poor processing and poor sensory-based motor disorders and sensory
integration; this leads to maladaptive responses discrimination disorders. Each pattern then
to many daily situations – even those that are has greater definition in varying subtypes. It
quite routine. is often the case that many of these subtypes REPRINTED WITH PERMISSION © THE AUTISM FILE THE AUTISM FILE USA 34 2010 • 59
 education & therapies
are concomitant with other subtypes, further  Experience difficulty responding to stimuli
evidence of the unique sensory profile in changing environments.
differences among individuals (Miller et al.,  Demonstrate lack of awareness of sensory
2007). stimuli, which may then lead to a lack
of interest or the ability to initiate motor
Pattern 1 – Sensory Modulation exploration and interactions with others.
Disorders (SMD)  Have a tendency to be withdrawn,
This pattern is intended to help us better apathetic, and difficult to engage
identify children who struggle with a difficulty or disinterested in their immediate
responding to sensory input with adequately environment.
graded responses in relation to the stimulus.  Have limited reaction or response to pain,
Children with modulation disorders will often temperature, or other intense stimuli.
respond inconsistently and demonstrate
some inflexibility adapting to their immediate Pattern 1, Subtype 3: Sensory Seeking (SS)
environment (Miller et al., 2007). Miller and colleagues suggest these children
Pattern 1, Subtype 1: Sensory  Crave a great deal of sensory stimuli across
Overresponsivity (SOR) environments.
Miller and colleagues suggest these children  Have intense preferences (e.g., movement,
may: food, auditory, visual, etc.).
 Be faster than peers.  Engage in an inappropriate social
 Demonstrate an overall greater intensity. mannerisms and sometimes demonstrate
 Sustain intensity for longer periods of time. poor safety awareness across environments.
Children with  Struggle with modulation in one or more  Struggle completing expected tasks,
systems. especially those that are not of his/her own
modulation disorders  Struggle in novel situations or with volition.
will often respond transitions.  Appear impulsive and disorganized.
 Exhibit more intense responses to stimuli;
inconsistently and this may occur when unexpected stimuli is Pattern 2 – Sensory Discrimination
presented. Disorder (SDD)
demonstrate some  Experience sensory input as having a SDD highlights patterns of sensory processing
inflexibility adapting summative effect; responses are linked to that are disrupted in the interpretation of the
accumulated events of the day. quality of sensory stimuli. Sensory discrimination
to their immediate  Demonstrate behaviors that include a wide challenges may occur in one or more than
range from active and intense to more one system. In addition, the discrimination
environment. passive and withdrawn. challenges impair the ability to identify the
similarities and differences among stimuli. When
Pattern 1, Subtype 2: Sensory someone struggles with discrimination, they
underresponsivity (SUR) may experience difficulty in identifying the
Miller and colleagues suggest these children what and where of the stimuli. Their response
may: time may be slower as they require more time
to make sense of the meaning, and this then
leads to often slower planning and sequencing.
Children with SDD can demonstrate awkward
motor planning and praxis abilities (learning
a new motor plan or sequence, such as riding
a bike, skiing, dancing etc.), challenges with
learning, compromised self-confidence and
poor body scheme. It is important to keep in
mind that this may also be concomitant with
one or more sensory processing disorders, as
well (Miller et al., 2007).

Pattern 3 – Sensory-Based Motor Disorder

The two subtypes presented here, dyspraxia
and postural disorders, suggest difficulty with
planning, praxis, sequencing, fluidity, and
control of movement as a result of sensory
challenges (Miller et al., 2007).
education & therapies 
Pattern 3, Subtype 1: Postural Disorders (PD)
People with PD may prefer a more passive
sedentary lifestyle, avoiding movement, or a
more active lifestyle with a lack of postural
control leading to unsafe movements (Miller et
al., 2007). Miller and colleagues suggest these
children may exhibit:
 Difficulty maintaining postural stability
necessary to meet the demands of both
static and dynamic movement.
 Inappropriate muscle tone, either hypotonic
or hypertonic tone.
 Insufficient muscle activation. intervention of sensory integration and sensory
 Insufficient control during movement. processing disorders. This information can be
 Poor righting and equilibrium reactions. used to guide understanding of the individual
 Inefficient weight shifting and trunk rotation differences of the child as well as plans for
capacities. intervention.
 Insufficient balance between the flexion
and extension patterns of body parts. Case Illustration (this is the true story of a little
 May demonstrate inefficient execution of girl and her family; the names have been to
motor tasks. changed for the purpose of confidentiality)
Elle is a 4-year-old girl living with her parents
Pattern 3, Subtype 2: Dyspraxia and younger sister, Claire. Elle was diagnosed
Miller and colleagues suggest that these with 80% hearing loss in her right ear shortly
children may: after birth. At 33 months she was talking only
 Seem unsure of where they are in space. in one to two word utterances inconsistently, a child’s sensory
 Be accident prone. was difficult to engage, demonstrated a
 Experience difficulty with projected action preference to be alone, and did not show processing challenges
sequences that require timing. much interest or pleasure in her immediate
should be conducted
 Demonstrate difficulty grading force of surroundings. She was diagnosed with autism
movement at 35 months and her parents started working by a licensed
 Have challenges related to ideation of with an occupational therapist at 36 months.
movement. Elle demonstrated difficulty with ideation as well occupational
 Require more time and practice to learn a as planning and execution of motor actions,
therapist trained
new skill and struggle with their ability to and she required assistance with sequences of
generalize the new skills to other motor more than two steps. Elle was difficult to engage in the theory and
tasks. in her initial sessions and did not demonstrate
 Have difficulty with complex motor task good initiation necessary to engage in play intervention of sensory
execution, even those that are very familiar schemes or motor exploration. Her mother
integration and
and routine. reported that it was especially hard to parent
 Prefer fantasy games and activities to actual Elle because she felt rejected by her and did not sensory processing
doing and execution of activities. feel a strong bond with her. After a few sessions
 Prefer sedentary activities requiring only dedicated to clinical observations and getting disorders.
limited movement (however, some children to know the parents and Elle, the therapist
exhibit a preference for movement, though identified the following challenges:
it can be uncoordinated and unsafe).  Elle was unable to initiate sensory motor
play, including those inputs that felt good to
This nosology was presented in an effort to her.
provide homogeneity for sample selections  It was difficult for Elle to reinitiate a
in research and to support the planning of pleasurable sensory motor sequence a
intervention (Miller et al., 2007). It is important second time, but she was able to do so
to remember that these patterns may be given a cue such as “you can do it again.”
concomitant with other identified patterns  Elle was not able to use a strong social
as well as other related disorders such as cueing system to express her intentions or
attention deficit hyperactivity disorder, attention ideas. (She did not use gestures or affect
deficit disorder, autism spectrum disorder, cues consistently or robustly.)
anxiety disorder, and others (Miller et al.,  Elle appeared to maintain a state of
2007). Assessing a child’s sensory processing low arousal for most of the time, which
challenges should be conducted by a licensed compromised her motor and social
occupational therapist trained in the theory and development. REPRINTED WITH PERMISSION © THE AUTISM FILE THE AUTISM FILE USA 34 2010 • 61
 education & therapies
support her language development through
meaningful activities including those that she
demonstrated a preference for, and support her
regulation by limiting the amount of auditory
and visual stimuli. In addition, the following
recommendations were made to Elle’s parents
to support her development outside the
 In your play with her, move slowly to better
support her visual integration of your
actions and better anticipate what you
might do next.
 Make sure to follow her lead and be guided
by her preferences. The more emotionally
invested she is in the activity, the stronger
her efforts will be to share the activity with
 Identify and implement daily opportunities
for her to engage in organizing sensory
motor play that supports her arousal and,
therefore, her social-emotional and motor
 Use less language with her, model longer
utterances, and limit the questions that
are posed to her. This will help her more
spontaneously use what language she has
 Elle was not demonstrating good and build on her expressive language skills.
comprehension (understanding of much  Provide her with ideas for sensory motor
of the language that was being said to her) play and slowly remove supports that
and was unable to use expressive language are already in place so she can become
in a way that allowed her to sustain an more independent in the sensory
interaction. motor executions as her motivation and
 Elle was overresponsive to visual and integration improve.
auditory stimuli, often startling and
becoming upset when people or objects Elle made rapid progress. She started to talk
moved suddenly toward her or when more robustly, first at home and then in all
surprise noises were heard. settings, and she was able to engage in a wider
 Elle was underresponsive to vestibular input. variety of conversations and play schemes.
Because vestibular input is the primary This continues to expand to this day. Elle was
arousing system to support regulation, Elle able engage more robustly with others, and
would become very excited, engage more her social emotional development improved
References easily, use more language and reinitiate steadily and quickly. Most importantly, Elle and
Ayres, A.J. (2005) Sensory sensory motor play after engaging in a her parents fell head over heals in love with
Integration and the Child. fair amount of swinging, sliding, jumping, each other. Elle is now in a typical classroom, has
Los Angeles: Western etc. Participating in active vestibular- many friends, enjoys a wide variety of sensory
Psychological Services. proprioceptive activities supported her motor activities and play schemes, and is
Greenspan, S.I., Wieder, S. regulation, and, therefore, her attention and making steady gains all the time.
(1998) The Child With Special interest in her environment and others.
Needs, Massachusetts:  In general, life was not easy for Elle and Summary
Perseus Books. she struggled to find easy pleasure in The theory of sensory integration is often
Miller, L.J., Anzalene, M.E., play, interactions and relationships, and misunderstood, misinterpreted, and can be
Lane, S.J., Cermak, S.A., exploration of the world. quite difficult to understand. Understanding
Osten, E.T. (2007) Concept this theory is critical to inform the work that is
evolution in sensory Given the observations, the occupational done with children in their home and in other
integration: A proposed therapist recommended that the parents settings. This is not the job of occupational
nosology for diagnosis. come in twice a week to work with Elle, therapists alone, but also pediatricians, teachers,
The American Journal of and goals were identified according to the and other professionals who can truly help the
Occupational Therapy, 61, aforementioned areas of challenge. The sessions family better understand their child and his/her
135-139. were focused on helping Elle’s parents read individual differences by integrating the theory
her subtle cues, model clear cues for her, of sensory integration into their work.