Participation and Sensory Environment Questionnaire (P-SEQ) © 2017 Beth Pfeiffer This questionnaire measures the amount of effort needed to help your child to participate in common activities in both home and community environments AND if the sensory features of the environment or the activity impact on your child's participation. Participation is your child's involvement in an activity. Your child may or may not have the skills necessary to complete the activity by them self, but can still participate (i.e. putting his arms out to help with dressing, sitting and being fed while at a restaurant). Sensory Features refer to the type of sensory stimuli that is in the environment or present when participating in the activity. This could include: the way something feels to the touch or the texture (tactile); the amount or type of noise (auditory); the amount or type of visual information or light; the amount of movement (vestibular); the way something smelis or taste: the amount of heavy muscle work (proprioception). Your child's responses to the sensory features of the ‘environment may include sensory seeking (Le. jumping, running, crashing into things, touching things more than usual), typical responses, and hypersensitive responses (overly sensitive or reactive). r We are also interested in the strategies that are used to support (or help) your child's participation in activities. The following are a list of possible strategy choices and descriptions of the strategies: 1. Keeping or developing Following an already established predictable routine or developing a new routines predictable routine, ‘Sensory features that are naturally part of the environment or the activity (Le. 2. Presence of certain sensory | movement on the swings at the park; deep touch input from the foam at features in the activity ‘gymnastics: the feel and resistance of the water when swimming: darkness in the movie theater) that support or enable participation for your child 3. Child having control of the _| The child feels in control of how the activity is completed or the environment in situation which itis completed. ‘Anticipating the unique needs of your child to participate in the activity and preparing the child or other materials and strategies that are necessary for more successful participation (i.e. using a social _ story to prepare the child, bringing ‘snacks or favorite toys/objects, developing alternate plan or environment if necessary), 4, Preparing and planning for participation in the activity ‘These are adaptations or modifications to the actual sensory features that are 5. Changing the sensory naturally occurring in the environment or the activity (Le. reducing the noise in features of activity the environment, turning off the sound on a toy, taking the tags out of the child's clothing, turning down the lights) ‘These involve providing sensory input or techniques to block out sensory input that are implemented with the child (ie. firms hugs, wearing noise reducing headphones, use of fidget or oral motor toys). 6, Use of sensory strategies during the activityHOME ENVIRONMENT How much do your child's responses (hypersensitivity and/or sensory seeking) to the sensory features of the environment or activity impact on participation in the following activities that take place at Home? Definitions: Hypersensitivity: overly sensitive or reactive to sensory stimuli (i.e. not liking to be touched or not liking loud noises) Sensory Seeking: responds with intense searching for more or stronger sensory stimuli, (ce. jumping, running, crashing into things, or touching things more than usual) Instructions: Please select the response that best represents the impact your child's responses have on participation, and then indicate if the impact is due to Hypersensitivity Responses, Sensory Seeking Responses or Both. On) ey crud Sree SC Cd PEN a NE sotieelp Q Hypersensitivity Dressing (excluding shoes, (ill erates aren e@}]oa]o}o ° Sensory Seeking 2 Both O Hypersensitivity 2 | Putting on Socks and Shoes | 9 | 9 | O | 0 ° Q Sensory Seeking © Both Q Hypersensitivity 3 | peming ca Coat by Sekocby a) |e) io. || a ° Q Sensory Seeking Another 2 Both © Hypersensitivity 4 | Tooth Brushing eo }o/o0]}o0 ° Q Sensory Seeking 2 Both . ; | Q Hypersensitivity 5 or ean ° ° ° ° ° Q Sensory Seeking © Both Q Hypersensitivity 6 | Washing Hair a2 }a/o0]}0 ° Q Sensory Seeking 2 Both Brushing Hair/Hair Care Q Hypersensitivity 7 | (combing, fixing, puttinghair | 2 | 9 | 0 | O ° Q Sensory Seeking in ponytail holder) © Both Q Hypersensitivity g | Cutting Fingemails andor a lololo 3 © Sensory Seeking Toenails O pon * choose this answer if your child does not participate in this activity due to the sensory features of the environment.Cy (eC) Cee end RCo ea ee RTT Toileting (diaper changes or Hypersensitivity 9 | going tothe bathroomonthe | © | 9 | 9 | oO ° © Sensory Seeking toilet) 2 Both Hypersensitivity 10 | Falling Asteep eo }|o}o)}oa o ° ° O Hypersensitivity Staying Asleep or Sleeping : 11.| Through the Night e2}o}o/}o ° Sensory Seeking Both Hypersensitivity 12 | Eating eo }o}o)}o o Sensory Seek Both ame wit : 2 Hypersensitivity Mealtime with Family ‘ 43) emcee eo }1o0};o0 /}0o ° Sensory Seeking Both Hypersensitivity Play with Siblings or Other id | Cohcbar ii the tome e2}o}o/}o0 ° Sensory Seeking Both ° 16 | Play with Toys/Objects eo }o}o/}o ° ° ° * choose this answer if your child does not participate in this activity due to the sensory features of the environment.How important is it for your child to participate in these activities? eC nae us Need Peery Rnd Cider eee ee Dressing (excluding shoes, socks, 1 | and coat) ° ° ° 2. | Putting on Socks and Shoes ° ° ° 3. | Putting on Goat by Self or by Another 9 9 Q 4 | Tooth Brushing ° ° ° 5 | Bathing (excluding washing hair) 9 a 9 6 | Washing Hair ° ° ° Brushing Hair/Hair Care (combing, 7” | fixing, putting hair in ponytail holder) 2 2 2 8 | Cutting Fingernails and/or Toenails ° ° ° Toileting (diaper changes or going to 8 | the bathroom on the toilet) 2 9 2 10 | Falling Asleep ° ° ° Staying Asleep or Sleeping Through 11 | the Night a o a 12 | Eating Q a 9 43 | Mealtime with Family Members ° ° ° 14 | Play with Siblings or Other Children 3 3 3 in the Home 45 | Play with Toys/Objects o ° °Rank up to three strategies that help your child participate in home activities: (1 = Most Helpful, 2 = 2nd Most Helpful, 3 = 3rd Most Helpful) Rating Strategy Keeping or developing routines: Following an already established predictable routine or developing a new predictable routine. Presence of certain sensory features in the activity: Sensory features that are naturally part of the environment or the activity (i.e. movement on the swings at the park; deep touch input from the foam at gymnastics; the feel and resistance of the water when swimming; darkness in the movie theater) that support or enable participation for your child. Child having control of the situation: The child feels in control of how the activity is completed or the environment in which it is completed. Preparing and planning for participation in the activity: Anticipating the unique needs of your child to participate in the activity and preparing the child or other materials and strategies that are necessary for more successful participation (i.e. using a social story to prepare the child, bringing snacks or favorite toys/objects, developing alternate plan or environment if necessary). Changing the sensory features of activity: These are adaptations or modifications to the actual sensory features that are naturally occurring in the environment or the activity (i.e. reducing the noise in the environment, turning off the sound on a toy, taking the tags out of the child's. clothing, turning down the lights). Use of sensory strategies during the activity: These involve providing sensory input or techniques to block out sensory input that are implemented with the child (ie. firms hugs, wearing noise reducing headphones, use of fidget or oral motor toys).COMMUNITY ENVIRONMENT How much do your child's responses (hypersensitivity and/or sensory seeking) to the sensory features of the environment or activity impact on participation in the following activities in the Community? Definitions: Hypersensitivity: overly sensitive or reactive to sensory stimuli (ie. not liking to be touched or not liking loud noises) Sensory Seeking: responds with intense searching for more or stronger sensory stimuli (i.e. jumping, running, crashing into things, or touching things more than usual) Instructions: Please select the response that best represents the impact your child's responses have on participation, and then indicate if the impact is due to Hypersensitivity Responses, Sensory Seeking Responses or Both. ics Ny OCOD eee) Much to Coed Fe cal . O Hypersensitivity a) || Earby Haris at Ancinat 2 Jo Jo jo ° 2 Sensory Seeking 2 Both Parties for Another Child in the Hypersensitivity 2. | Community or at Another's eo Jo Jo fo ° 2 Sensory Seeking Home 3. Beth Q Hypersensitivity 3 | Eating at a Restaurant eo Jo Jo fo ° 2 Sensory Seeking 2 Both . O Hypersensitivity a; | Mgala at Family or Extent ° ° ° ° ° © Sensory Seeking 2 Both Hypersensitivity 5. | Movies/Theaters o Jo Jo Jo ° Q Sensory Seeking 2 Both Religious Service, Evert, or Hypersensitivity 6 | Education (ie. church, eo Jo Jo fo ° Q Sensory Seeking synagogue, mosque) 2 Both Library Activities (ie. choosing a O Hypersensitivity 7 | book at the library, attending | 0 | 0 | 0 |o ° Q Sensory Seeking reading times) © Both ental ‘ Q Hypersensitivity 6. | Dartal Appolriments an ° ° ° ° ° © Sensory Seeking 2 Both * choose this answer if your child does not participate in this activity due to the sensory features of the environment.Onc (Ny OT am ares _ od Pea O Hypersensitivity 8. | Decor Ampaiimenss end eo Jo Jo Jo ° Q Sensory Seeking 2 Both Q Hypersensitivity 10 | Vacations eo Jo Jo fo ° © Sensory Seeking 2 Both Hypersensitivity Play at the PlayaroundiPark or y Cl eareeny eee eo Jo Jo Jo ° O Sensory Seeking 2 Both play with other hie O Hypersensitivity lay with Other Children : 12) Outside of ome and School | 2 | 2 | 9 | 2 ° Q Sensory Seeking 2 Both Sporting Event of Another (i.e. Hypersensitivity 13 | professional game, sibling's eo Jo Jo fo ° 2 Sensory Seeking event) © Both Sporting Event of the Child ( ee porting Event of the Child (Le. . 1 | See tavocon teal ea Jo Jo fo o Q Sensory Seeking 2 Both Hypersensitivity 15 | Swimming eo Jo Jo Jo ° Q Sensory Seeking 2 Both O Hypersensitivity 16 | Amusement ParkWaterPak | 0 | 0 |o |o ° Q Sensory Seeking 2 Both Q Hypersensitivity 17 | Using a Public Bathroom o Jo Jo Jo ° Q Sensory Seeking 2 Both community Events (eta © Hypersensitivity community Events (Le. fairs, 18 | orn eworne, arate) eo Jo Jo fo ° Q Sensory Seeking 2 Both Q Hypersensitivity 19 | Taking Public Transportation | 9 | a | 0 | o ° Q Sensory Seeking 2 Both * choose this answer if your child does not participate in this activity due to the sensory features of the environment.How important is it for your child to participate i ON encoes fois TOM ise , ern , De ene ee re) 1 | Family Parties at Another's Home a Oo oO Parties for Another Child in the 2 | Community or at Another's Home ° ° ° 3. | Eating at a Restaurant a Qo o 4 | Meals at Family or Friend's Home ao QO o 5 | Movies/Theaters Q Q ° Religious Service, Event, or 6 | Education (ie. church, synagogue, ° ° ° mosque) Library Activities (Le. choosing a 7 | book at the library, attending a Qo ° reading times) Dental Appointments and 8 | Procedures ° o 8 Doctor Appointments and ® | Procedures 2 ° ° 10 | Vacations 2 ° ° Play at the Playground/Park or ** | indoor Play Place iS 2 2 Play with Other Children Outside of "2 | Home and Schoo! 8. o 9. Sporting Event of Another (i. wv professional game, sibling's event) 2 2 2 ‘Sporting Event of the Child (i.e. 14 | gymnastics, soccer, t-ball) 9 o 9 15 | Swimming °o ° ° 16 | Amusement Park/Water Park ° ° ° 17 | Using a Public Bathroom Qo oO fo} ‘Community Events (Le. fairs, 18 | concerts, fireworks, parade) 2 o °. 19 | Taking Public Transportation o ° °Rank up to three strategies that help your child participate in community activities: (1 = Most Helpful, 2 = 2nd Most Helpful, 3 = 3rd Most Helpful) Rating Strategy Keeping or developing routines: Following an already established predictable routine or developing a new predictable routine. Presence of certain sensory features in the activity: Sensory features that are naturally part of the environment or the activity (.e. movement on the swings at the park; deep touch input from the foam at gymnastics; the feel and resistance of the water when swimming; darkness in the movie theater) that support or enable participation for your child. Child having control of the situation: The child feels in control of how the activity is completed or the environment in which it is completed Preparing and planning for participation in the activity: Anticipating the unique needs of your child to participate in the activity and preparing the child or other materials and strategies that are necessary for more successful participation (i.e. using a social story to prepare the child, bringing snacks or favorite toys/objects, developing alternate plan or environment if necessary). Changing the sensory features of activity: These are adaptations or modifications to the actual sensory features that are naturally occurring in the environment or the activity (i.e. reducing the Noise in the environment, turning off the sound on a toy, taking the tags out of the child's clothing, tuming down the lights). Use of sensory strategies during the activity: These involve providing sensory input or techniques to block out sensory input that are implemented with the child (ie. firms hugs, wearing noise reducing headphones, use of fidget or oral motor toys).