Earn .
1 AOTA CEU
Education Article
Using Sensory Integration and Sensory-Based
Occupational Therapy Interventions Across
Pediatric Practice Settings
RENEE WATLING, PHD, OTR/L, FAOTA
Clinical Assistant Professor, Division of Occupational Therapy,
University of Washington
Seattle, Washington
Adjunct Faculty, School of Occupational and Physical Therapy,
University of Puget Sound
Tacoma, Washington
GLORIA FROLEK CLARK, PHD, OTR/L, BCP, FAOTA
Private Practice
Adel, Iowa
This CE Article was developed in collaboration with
AOTA’s Sensory Integration Special Interest Section.
ABSTRACT
Difficulties in processing and integrating sensory informa-
tion can have an effect on occupational performance and
behavior in the daily lives of children and youth. Services for
pediatric clients are influenced by a range of legislative and
funding policies. Occupational therapy practitioners working
in various pediatric practice settings need knowledge of the
differences between these approaches and the provisions
of the funding resources in order to best meet the sensory
processing and integration needs of their clients in various
contexts.
LEARNING OBJECTIVES
After reading this article, you should be able to:
1. Identify the differences between Ayres’ sensory integra-
tion intervention and sensory-based strategies.
2. Recognize provisions of legislative and funding policies for
pediatric occupational therapy services.
3. Recognize differences between supporting pediatric
clients with sensory needs in educational versus clinical
contexts.
INTRODUCTION
Difficulties in processing and integrating sensory information
can have an effect on occupational performance and behav-
ior in the daily lives of children and youth. Occupational
therapy practitioners working in various pediatric practice
settings need to be aware of sensory processing, the possible
impact of sensory processing difficulties across behavior and
performance areas, and the contextual factors that influence
provision of services to address these needs. This article
SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911
(one contact hour and
1.25 NBCOT PDU).
See page CE-7 for details.
presents a brief historical perspective of the sensory integra-
tion theory and a description of intervention strategies based
on the principles of sensory processing, followed by a discus-
sion of the regulatory and contextual factors that influence
service provision addressing sensory needs across pediatric
practice settings.
A HISTORICAL PERSPECTIVE
OF SENSORY INTEGRATION THEORY
A. J. Ayres developed the sensory integration theory in the
1960s and 1970s. Ayres (1972) posited that sensory infor-
mation was nourishment for the nervous system and that
the nervous system responded to sensory information with
alterations in function, structure, and output. Thus, sensa-
tion could both inhibit and facilitate brain function and
occupational behavior. She integrated findings from human
and animal neuroscience, psychology, education, and human
development to better understand and delineate the relation-
ship between brain functions, behavior, emotion, and learn-
ing (Ayres, 1972, 1979). She consulted studies examining the
effects of sensory deprivation and sensory-enriched environ-
ments on physical and emotional behavior. She used this
information to generate hypotheses about the nature of the
relationship between sensation and typical development, the
way development could be affected if physiological process-
ing of sensation was disrupted, and how sensory experiences
could then be used to remediate dysfunction and support
development (Bundy, Lane, & Murray, 2002).
Ayres tested her hypotheses through research studies and
developed measurement tools to help identify the presence
and nature of sensory dysfunction in children. Her work
generated the theory of sensory integration, which describes
the relationships between sensation, brain function, and
behavior; methods for measuring observable manifestations
of sensory integration processes; and principles for designing
interventions to address breakdowns in sensory processing
and integration. Since Ayres’ death in 1989, many research-
ers and theorists have continued her work, both directly
and indirectly. Present-day understanding of neuroscience,
psychology, and development supports many of her original
conceptualizations of brain-behavior relationships (Lane &
Schaaf, 2010).
Sensory Processing and Integration
Sensory information arises from multiple sources, both
within and outside of the body. Sensory information from
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within the body informs the individual of pain, hunger, or
other conditions reflecting the state of the physical body.
Sensory information from external sources yields informa-
tion about the characteristics of objects, spatial relationships
between objects including the body, and movement of the
body or part of the body through space. There are seven
forms of sensory input: taste, smell, sight, sound, touch,
movement, and force. These must be registered, processed,
and interpreted within the central nervous system in order
for the individual to gain a reference for the body’s rela-
tionship to itself, gravity, and people and objects in the
environment, as well as to perceive the spatial relationships
between other people and objects (Ayres, 1972). All sensa-
tion is essential for the individual to develop an awareness of
himself or herself as an integrated whole, and sensation helps
build a foundation for learning and developing skills. When
an individual effectively processes and integrates sensory
information, responses to sensation are purposeful and goal
directed. The individual is able to register and perceive a
stimulus, formulate and execute a response to the stimulus,
and learn from the success or failure of his or her response.
Over time, responses become more mature and complex,
effective and adaptive, and are “efficient, creative, and satis-
fying” (Ayres, 1979, p. 7). Occupational therapy practitioners
are concerned with an individual’s ability to engage in occu-
pational activities that are desired by and meaningful to the
individual. When a disruption in occupational engagement
and performance is noted, it is important that the occupa-
tional therapy practitioner consider the possibility that dis-
ordered sensory processing or integration is an influencing
factor. Accurate and thorough understanding of how disor-
dered sensory processing and integration can affect function
and the manifestations of such dysfunction are crucial for
making these determinations. For further information on
sensory processing and integration, please see Ayres (1972,
1979, 2005); Bundy et al. (2002); Smith Roley, Blanche, &
Schaaf (2001); and Schaaf & Davies (2010b).
Sensory Integrative Dysfunction
Ayres (1979) described dysfunction in sensory integra-
tion as a condition in which “the brain is not processing or
organizing the flow of sensory impulses in a manner that
gives the individual good, precise sensory input well...[and]
is not directing behavior effectively” (p. 51). Thus, ineffec-
tive sensory processing interferes with the individual’s ability
to use sensation as a foundation for function and behavioral
organization. Sensory integration dysfunction is multifaceted,
with individuals displaying clusters of signs and symptoms in
cognitive, motor, emotional, and social behavior. For exam-
ple, dysfunction in sensory integration can be the source of
ineffective performance in school tasks or social situations,
poor use of the body to move through space or interact
with physical objects, an inability to regulate emotional and
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sleep and wake states, and an inability to manage behavioral
responses. Often, the individual with dysfunction in sensory
processing and integration displays behavior that is out of
proportion to a sensory event or experience. For example,
the client may cover his or her ears and cry at the sound of
a flushing toilet; react with aggression or as if in pain when
accidentally bumped; appear to not notice sensory events
noticed by others; or have difficulty grading the amount
of force used when interacting with other people, pets, or
objects.
INTERVENTIONS BASED ON
PRINCIPLES OF SENSORY PROCESSING
Based on her work with varied clinical populations, Ayres
posited that sensation could be used intentionally and stra-
tegically to enhance an individual’s ability to detect, register,
perceive, and respond adaptively to stimuli in an organized
and appropriate manner with regard to cognitive, motor,
social, and emotional responses. She researched and devel-
oped strategies for using sensory experiences and environ-
mental modifications to create a foundation for successful
occupational engagement and functional performance.
Sensory integration intervention as described by Ayres
(1972, 1979) is characterized by active engagement of the
client in a range of sensory-based activities that challenge
the client to respond to environmental cues; register, per-
ceive, and integrate sensation; and produce appropriate and
adaptive cognitive, emotional, physical, and social responses
(Ayres, 1972, 1979; Parham et al., 2011; Smith Roley, Mail-
loux, Miller Kuhaneck, & Glennon, 2007). Ayres (1972, 1979)
advocated that intervention activities emphasize active
engagement with tactile (touch), proprioceptive (pressure
or force), and vestibular (movement) sensations. Other
sensations (smell, taste, sound, and vision) are also incor-
porated as they are useful to the individual client. Activities
range from simple interactions with sensory materials, such
as scooping and pouring dry beans, to complex multisensory
activities, such as planning and navigating obstacle courses
of suspended and grounded equipment that challenge adap-
tive occupational behavior in cognitive, motor, regulatory,
and social domains. As such, sensory integration interven-
tion requires specialized equipment and environments that
afford a range of dynamic sensory experiences. For example,
suspended equipment such as swings, trapeze bars, rope
ladders, and other climbing materials allows engagement
in movement activities that challenge balance, equilibrium,
ideation, motor execution, problem solving, and a host of
other adaptive responses. Equipment and environmental
modifications are part of the dynamic interplay between the
occupational therapist, client, and environment in which
the therapist employs clinical reasoning, critical thinking,
and therapeutic use of self to intentionally and strategically
create opportunities for the client to actively experience
SEPTEMBER 2011 n OT PRACTICE, 16(17)
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and engage with sensations, ultimately leading to produc-
tion of adaptive responses. Sensory integration intervention
is designed to address the underlying neurophysiological
processing of sensation as the foundation for function and
requires advanced theoretical knowledge and practical skills.
Due to the complexity of Ayres’ sensory integration interven-
tion, specialized postprofessional training and mentorship
are highly recommended (Watling, Koenig, Schaaf, & Davies,
2011).
Sensory-Based Intervention
At times, occupational therapy practitioners may not have
access to the equipment or environments essential for pro-
viding sensory integration intervention, or may be working
in contexts in which this approach is not supported. In these
cases, the sensory needs of clients may be at least partially
addressed through sensory-based interventions. Sensory-
based interventions use discrete sensory experiences or envi-
ronmental modifications to support regulation of behavior,
address specific difficulties in sensory modulation or sensory
discrimination, prepare the client for engagement, support
the ability to focus on learning activities, and regulate client
behavior as task demands change (Tomchek & Case-Smith,
2009; Watling et al., 2011). For example, sensory-based
strategies include providing a quiet enclosed space for a child
to retreat to when feeling overwhelmed in a busy or noisy
environment, providing compressible or resistive materials
for manipulation to help decrease distraction and increase
focused attention on a task, and providing nontraditional
seating options such as air-filled cushions or ball chairs
that offer movement opportunities while allowing a child to
remain seated during desk work. Sensory-based interven-
tions often aim to focus a child’s attention and promote orga-
nized behavior in everyday contexts such as school, home, or
the community (Watling et al., 2011). Sensory-based inter-
ventions are often an integral part of occupational therapy in
early intervention and school-based practices.
CURRENT CONCEPTS
Ayres’ work spurred recognition by many professions of the
critical role that sensation plays in behavior and function.
Over the past 40 years, many other theorists and practition-
ers developed sensory-based methods that are quite different
from what Ayres developed and described. However, in most
instances, there was little to no discriminant discussion or
examination of these methods, and many were referred to
erroneously as sensory integration methods. This resulted in
widespread and often inappropriate use of the term sen-
sory integration in the literature, with many publications
inaccurately being identified as descriptions or examinations
of sensory integration intervention. This led to confusion
about what sensory integration intervention is and is not, as
well as inaccurate conclusions about the effectiveness of the
SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911
approach described by Ayres. (See Schaaf & Davies, 2010a,
2010b for a more thorough description of the confusion
regarding terminology and the current state of the science of
sensory integration theory and intervention.) Recent reviews
of evidence-based literature have helped to discriminate
among the published examinations of sensory integration and
sensory-based interventions and provide evaluations of the
efficacy of both (see Schaaf & Davies, 2010b).
Fidelity to Sensory Integration Theory
Because of the confusion around terminology and the
growing use of the phrase sensory integration to refer to
approaches very different from the intervention Ayres devel-
oped, efforts were made to re-establish the term sensory
integration and to trademark the phrase Ayres Sensory
Integration® (ASI®). Scholars, scientists, and researchers
recognized as experts in sensory integration theory and
practice used systematic procedures to identify the features
of the sensory integration intervention process (see Parham
et al., 2007, for a description of the procedures used). This
work identified and defined core structural and procedural
elements of sensory integration intervention (see Table 1).
These same core elements are the foundation of a fidelity-to-
treatment measurement tool (see Parham et al., 2007, 2011)
that can be used to determine whether an intervention meets
Table 1. Process and Structural Elements of Ayres’
Sensory Integration Interventions
Process Elements
Key therapeutic strategies of an ASI intervention
• Ensures physical safety
• Presents sensory opportunities
• Helps the child attain and maintain appropriate levels of alertness
• Challenges postural, oral, ocular, or bilateral motor control
• Challenges praxis and organization of behavior
• Collaborates with the child on activity choices
• Tailors activities to present the just-right challenge
• Ensures that activities are successful
• Supports the child’s intrinsic motivation to play
• Establishes a therapeutic alliance with the child
Structural Elements
Commonly documented features of an ASI intervention
• Therapist qualifications in sensory integration include
postprofessional training and mentorship
• Record review, including thorough occupational therapy
evaluation results
• Physical space and equipment affordances, including space
for vigorous activity and a variety of suspended equipment
• Ongoing communication with team members, including
evidence of parent–therapist collaboration on goal setting
Note: From Parham et al., 2011
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the criteria for being an ASI intervention (Smith Roley et al.,

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

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

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choose whether to participate in this federal program and
receive funds. There is wide variability among states regard-
ing the agency that oversees this program, the person provid-
ing service coordination, and the professionals providing the
services. The definition of developmental disability is set
by each state, so a child could be eligible for this program in
one state, but not in another. Even funding varies from state
to state. Some states provide services at no cost to the family,
whereas other states use private insurance and Medicaid as
funding sources.
Teams have 45 calendar days after receiving a referral to
complete assessments and to develop the individualized fam-
ily service plan (IFSP). Under Part C, assessments include
both family and child measures. Family-directed assessments
often include interviews to identify the family’s concerns, pri-
orities, and resources (such as informal or formal supports).
Families may decline to participate in this assessment and
still receive early intervention services. Evaluation/assess-
ment information is used in determining whether the child
meets the state’s eligibility for this Part C program. Children
must be evaluated in five domains: adaptive, cognitive,
communication, physical, and social development. Physi-
cal evaluation may include fine motor, gross motor, hearing,
vision, and sensory processing skills. In addition, a review of
the child’s health and nutrition is typically included. In young
children, concerns related to sensory processing and integra-
tion may include the child having difficulty with feeding and
eating; calming and state regulation; frequent or intense
tantrums; or rigid behaviors that interfere with outings, social
interaction, or transitions (Watling, Bodison, Henry, & Miller-
Kuhaneck, 2006).
At the IFSP meeting, parents and other members of the
early intervention team identify family and child outcomes
as well as services. IDEA requires the IFSP to a include
a statement of early intervention services based on peer-
reviewed research, to the extent practicable, necessary to
meet the unique needs of the infant or toddler and the fam-
ily. To assist with transitioning out of the early intervention
program, an individualized transition plan must be in place at
least 90 days before the child’s third birthday. Some children
will transition out of all services; others may transition to
community-based programs or be referred for an evaluation
to determine eligibility for Part B services. Occupational
therapy is considered a primary service under this law,
meaning occupational therapy could be the only service on
a child’s IFSP. Under Part C, occupational therapists may act
as service coordinators, participate in the evaluation process
through multi- or transdisciplinary team evaluation, or con-
duct a separate occupational therapy evaluation of the child.
IDEA Part B. Under IDEA Part B, eligible children ages 3 to
21 years are entitled to a free appropriate public education
(FAPE), including academic instruction and related service
provision. In most cases, if a student’s educational perfor-
SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911
mance consistently falls below state standards, typical physi-
cal development, behavioral expectations, or grade level; and
educational performance is unique when compared to others
in that setting; and there are no more plausible explana-
tions, a disability may be suspected and a referral for a full
and individual evaluation (FIE) is made. Lack of instruction
or access to instruction, poor attendance, and language or
cultural differences need to be ruled out as possible reasons
for the delay because these do not constitute a disability. An
independent medical or mental health diagnosis may be suffi-
cient for suspecting a disability; however, the impact of such
a diagnosis on educational performance must be established
in order for the child to receive special education services.
After the family formally consents to an FIE of their child,
the team has 60 calendar days to complete evaluations, hold
a meeting with the parents, and write the individualized
education program (IEP). Team members, including occupa-
tional therapists, who participate in the FIE are required to
use a variety of evaluation tools and strategies. These could
include observations, interviews, record reviews, and formal
and informal evaluation tools. When difficulties processing
and integrating sensory information are suspected, data
should be gathered using a range of tools as well as across a
range of school environments and contexts.
Federal provisions state that services to help students
with IEPs transition out of the educational system must
occur by the time they are 16 years of age. At a minimum,
the first IEP in effect when the child turns 16 must include
measurable postsecondary goals, based on age-appropriate
transition assessments and transition services needed to
assist the child in reaching those goals. For students with
challenges processing and integrating sensory information,
transition planning should include strategies for managing
sensory needs in postsecondary settings and contexts. Occu-
pational therapy has a critical role in addressing life skills for
many students with special needs and should be included in
the transition planning.
Early Intervening Services
IDEA 2004 also included early intervening services. Local
education agencies may use up to 15% of their Part B monies
to identify children who are at risk for academic and behavior
challenges and to provide support for these students to suc-
ceed in the general education environment. IDEA uses the
term early intervening services (EIS) to identify services
to general education students and professional develop-
ment for teachers delivered under this provision. Response
to Intervention (RtI) is the framework used by many states
for providing services under EIS. Under EIS/RtI, occupational
therapy practitioners provide services primarily to popula-
tions or groups. For example, occupational therapists may
train teachers in how sensory processing and integration
challenges can interfere with learning and behavior and how
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sensory-based strategies can support the diverse needs of
many such students. Some children who have mild to moder-
ate difficulties processing and integrating sensory informa-
tion may display learning challenges or behaviors that lead
to RtI services; these children may simply need additional
assistance but never require an FIE.
Section 504
The Rehabilitation Act Amendments of 2004, otherwise
known as Section 504, stipulates that if an agency, such
as a school, receives federal financial assistance, it cannot
discriminate against a person with a disability. Discrimina-
tion could result in revocation of the agency’s federal monies.
There is no additional funding to agencies for 504 activities.
Section 504 requires school districts to provide a FAPE to
students who have been determined to (1) have a physical
or mental impairment that substantially limits one or more
major life activities, (2) have a record of such an impairment,
or (3) be regarded as having such an impairment.
Major life activities, as defined by Section 504, include
“functions such as caring for one’s self, performing manual
tasks, walking, seeing, hearing, speaking, breathing, learn-
ing, and working. This list is not exhaustive. Other functions
can be major life activities for purposes of Section 504” (34
C.F.R. 104.3(j)(2)(ii)). Children and youth with challenges
in processing and integrating sensory information who are
not eligible for IDEA may be eligible for accommodations or
modifications under this law if the impairment limits daily
life activities. The school may require documentation from
a health care provider (e.g., the child’s physician) stating
the necessity of these modifications or accommodations.
Occupational therapists should consider using Section 504
provisions for students who require activity or environmental
modifications due to sensory-based needs that affect their
daily life skills.
Individually Funded Services
In addition to services provided through the public school
system, children also can receive services in settings such
as outpatient clinics; hospital-affiliated programs; private
offices; their home; or other environments funded through
private health insurance, Medicaid, accounts such as trusts
or adoption support, out-of-pocket payments, or other
sources. When providing services outside of the educational
system, the occupational therapist can design and imple-
ment these services to address a range of needs without the
requirement to demonstrate an impact on educational per-
formance. Thus, the occupational therapy practitioner can
address the neurophysiological functions that underlie sen-
sory processing and integration challenges and their impact
on a child’s occupational performance in home and commu-
nity contexts. For example, auditory sensitivities may cause
a child to dislike or avoid noisy or crowded spaces and events
CE-6 ARTICLE CODE CEA0911
such as birthday parties; challenges with tactile, vestibular,
and proprioceptive processing can impact praxis and limit a
child’s success in maneuvering through the environment or
learning to ride a bicycle; and poor processing of tactile input
can result in feeding difficulties due to poor awareness and
localization of food in the mouth. The ASI approach is often
provided in clinical contexts to meet sensory needs such as
these for clients receiving services funded through individual
sources such as health insurance.
Clinic-based occupational therapists use standardized
assessments, skilled clinical observations, and caregiver
reports rather than direct peer comparison, school standards,
or teacher expectations to document the child’s perfor-
mance. This provides therapists and families with individual
performance data that can be analyzed and used to develop
treatment plans. Information about the child’s performance
in the school context can be acquired by interviewing care-
givers, teachers, or other school-based personnel. In addi-
tion, clinic-based occupational therapists can use the clinic
environment and equipment to create strategic contexts that
elicit engagement of the child in activities the therapists want
to observe. The therapist can infer how skills and behaviors
observed in the clinic may affect the child in educational or
other natural settings. A collaborative relationship between
the occupational therapist in the clinic and the child’s educa-
tional occupational therapist is ideal in order to best support
the child and enhance his or her ability to generalize perfor-
mance across these settings.
Private Health Insurance
Private health insurance traditionally has been a major
source of funding for clinically based occupational therapy
services in the United States. Insurance companies issue
many different policies, so coverage for services varies widely
and there may be restrictions based on client age, location
of service delivery, specific type of service provided, or other
factors. Occupational therapy services funded through pri-
vate health insurance typically are considered medically rel-
evant and often require a physician’s referral. The physician
referral may or may not identify the child’s diagnostic condi-
tion and specify the frequency and duration of therapy being
prescribed. Occupational therapy practitioners can affect
these decisions by communicating with the referring physi-
cian regarding the client’s occupational performance, evalu-
ation results, response to intervention, and evidence in the
literature related to the recommended strategy or duration
of services. Observations and performance on assessments of
sensory processing and integration can be especially helpful
when considering diagnosis of a sensory processing disorder.
Reimbursement for occupational therapy services through
privately funded insurance is influenced by many factors.
Among these is whether a provider is recognized on the
company’s preferred provider register, the insurance compa-
SEPTEMBER 2011 n OT PRACTICE, 16(17)
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ny’s approval of the specific service provided by the practi-
tioner, or the specific location in which services are provided.
Thus, the provisions of each client’s individual policy should
be reviewed carefully and any limitations that may affect
service delivery discussed with the child’s family prior to
beginning services. When limitations in coverage are encoun-
tered, occupational therapy practitioners can work with
insurance companies to advocate for expanded coverage for
their clients. This may include providing education of general
occupational therapy concepts, interpreting the evidence
in the literature related to sensory integration methods, or
providing clinical evidence of the client’s positive response
to intervention. Such negotiations can lead to extension of
services that can maximize client progress and outcomes.
SUMMARY
The funding sources, environments, child’s age, and frame-
work chosen for the intervention all influence occupational
therapy service delivery for children with difficulty process-
ing and integrating sensory information. Providing early
intervention in the home may include teaching the family
ways to feed, bathe, hold, position, or play with the child.
Occupational therapy practitioners are in the child’s and
family’s natural environment, so they can observe family
routines and activities. In the educational setting, occupa-
tional therapy practitioners focus on the skills, environmen-
tal adaptations, and teacher supports that a child needs to
benefit from his or her educational program. In the medical
or community setting, occupational therapy pratitioners
focus primarily on the child and the functional limitations
secondary to the medical condition(s). The emphasis is on
remediating underlying problems in the child, implementing
environmental adaptations, and building a broad founda-
tion of skills that the child can draw upon for success in
various contexts and situations. Across all of these settings,
knowledge of the brain-behavior relationships that underlie
sensory processing and integration and the principles guiding
intervention to address related deficits is an essential first
step in providing relevant and effective services that promote
and enhance our clients’ occupational engagement. n
REFERENCES
Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles:
Western Psychological Services.
Ayres, A. J. (1979). Sensory integration and the child. Los Angeles: Western
Psychological Services.
Ayres, A. J. (2005). Sensory integration and the child: Understanding hidden
sensory challenges. Los Angeles: Western Psychological Services.
SEPTEMBER 2011 n OT PRACTICE, 16(17) ARTICLE CODE CEA0911
How To Apply for
Continuing Education Credit
A. After reading the article Using Sensory Integration and Sensory-
Based Occupational Therapy Interventions Across Pediatric Practice
Settings, register to take the exam online by either going to
www.aota.org/cea or calling toll-free (877) 404-2682.
B. Once registered you will receive your personal access informa-
tion within 2 business days and can log on to www.aota-learn
ing.org to take the exam online. You will also receive a PDF
version of the article that may be printed for personal use.
C. Answer the questions to the final exam found on p. CE-8 by
September 30, 2013.
D. Upon successful completion of the exam (a score of 75% or
more), you will immediately receive your printable certificate.
Bundy, A. C., Lane, S. J., & Murray, E. A. (2002). Sensory integration: Theory and
practice (2nd ed.). Philadelphia: F. A. Davis.
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. 108-446,
20 U.S.C. §1400 et seq.
Lane, S. J., & Schaaf, R. C. (2010). Examining the neuroscience evidence for
sensory-driven neuroplasticity: Implications for sensory-based occupational
therapy for children and adolescents. American Journal of Occupational
Therapy, 64, 375–390. doi:10.5014/ajot.2010.09069
No Child Left Behind Act of 2001. Pub. L. 107-110, 116 Stat. 3071.
Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J. A., Miller, L. J., Burke, J. P, et
al. (2007). Fidelity in sensory integration intervention research. American
Journal of Occupational Therapy, 61, 216–227.
Parham, L. D., Smith Roley, S., May-Benson, T. A., Koomar, J., Brett-Green, B.,
Burke, J. P., et al. (2011). Development of a fidelity measure for research on
the effectiveness of the Ayres Sensory Integration® intervention. American
Journal of Occupational Therapy, 65, 133–142. doi:10.5014/ajot.2011.000745
Rehabilitation Act Amendments of 2004. 29 U.S.C. §794.
Schaaf, R. C., & Davies, P. (2010a). From the desk of the guest editors: Evolution
of the sensory integration frame of reference. American Journal of Occupa-
tional Therapy, 64, 363–367.
Schaaf, R. C., & Davies, P. (Guest Eds.). (2010b). Special issue on sensory integra-
tion [Special issue]. American Journal of Occupational Therapy, 64(3).
Smith Roley, S., Blanche, E. I., & Schaaf, R. C. (2001). The nature of sensory inte-
gration with diverse populations. Tucson, AZ: Psychological Corporation.
Smith Roley, S., Mailloux, Z., Miller Kuhaneck, H., & Glennon, T. (2007). Under-
standing Ayres Sensory Integration®. OT Practice, 12(17), CE-1–CE-8.
Tomchek, S. D., & Case-Smith, J. (2009). Occupational therapy practice guide-
lines for children and adolescents with autism. Bethesda, MD: AOTA Press.
Watling, R., Bodison, S., Henry, D. A., & Miller-Kuhaneck, H. (2006, December).
Sensory integration: It’s not just for children. Sensory Integration Special
Interest Section Quarterly, 29(4), 1–4.
Watling, R., Koenig, K. P., Schaaf, R. C., & Davies, P. (2011). Occupational therapy
practice guidelines for children and adolescents with challenges in sensory
processing and integration. Bethesda, MD: AOTA Press.
CE-7
 Continuing Education Article
CE Article, exam, and certificate are also
available ONLINE. Register at http://www.aota.
org/cea or call toll-free 877-404-AOTA (2682).
6. Practitioners can rely on the literature to consistently
and accurately identify examinations of sensory integra-
tion and sensory-based strategies.
A. True B. False

7. Which aspect of the Individuals with Disabilities Educa-

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

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

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