Documente Academic
Documente Profesional
Documente Cultură
by
Kristen Renee Klyczek
May 4, 2009
Doctor of Philosophy
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______________________________________________________________
UMI Microform 3356047
Copyright 2009 by ProQuest LLC
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
_______________________________________________________________
ProQuest LLC
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P.O. Box 1346
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Copyright by
Kristen Renee Klyczek
2009
ii
iii
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iii
v
viii
ix
x
xi
I. INTRODUCTION
Hypothesis....
Conceptual Framework
Neuropathophysiology of Aspergers Syndrome and Pervasive
Developmental Disorder Not Otherwise Specified.
Sensory Integration.....
Sensory Dysfunction...
Sensory Integration Therapy..
Summary..
4
5
5
14
20
23
25
27
36
43
48
III. METHODS.............................
51
Introduction.....
Setting..
Participants..
Human Subject Protection...
Study Design
Instrumentation
Pre-Study Questionnaire.
The Asperger Syndrome Diagnostic Scale.
The Sensory Profile....
Perceived Efficacy and Goal Setting System.....
Clinical Observations.
The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition...
Sensory Integration and Praxis Tests..........
51
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54
56
56
56
57
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60
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27
31
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74
IV. RESULTS...
75
Introduction.
Recruitment.....
Demographics......
Services
Attrition...
Pre-Intervention Findings
The Asperger Syndrome Diagnostic Scale.....
Sensory Profile...
Perceived Efficacy and Goal Setting System.....
Clinical Observations.....
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition......
Sensory Integration and Praxis Tests..........
Post-Intervention Findings..
Interrater Reliability...
The Asperger Syndrome Diagnostic Scale.....
Sensory Processing.
Sensory Integration and Praxis Tests......
Motor Skill Performance
Clinical Observations.
Treatment Fidelity...............
Summary of Results.
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105
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115
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V. DISCUSSION..
119
Introduction.
Relationship of the Results to the Stated Hypotheses.
Relationship of the Results to the Conceptual Framework.
Summary of Conceptual Framework...
Relationship of the Results to the Literature...
Recruitment.
Sensory Processing..
Motor Skill Performance.
The Efficacy of Sensory Integration Therapy.
Additional Findings....
Behavioral Changes
Findings Related to The Asperger Syndrome Diagnostic Scale.
Findings Related to The Perceived Efficacy and Goal Setting System..
Findings Related to Clinical Observations.....................
Strengths and Limitations............
Implications for Practice..
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199
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.
Table 8.
Table 9.
Table 10.
Table 11.
Table 12.
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viii
List of Figures
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
80
86
86
89
105
ix
199
Appendix B:
201
Appendix C:
203
Appendix D:
207
Appendix E:
210
Appendix F:
212
Appendix G:
217
Appendix H:
Pre-Study Questionnaire..
220
Appendix I:
224
Appendix J:
226
Appendix K:
228
Appendix L:
230
234
Appendix N:
238
241
244
Appendix Q:
247
Appendix R:
Treatment Manual
249
Appendix S:
264
Appendix O:
Appendix P:
Abstract
This research study evaluated the sensory and motor skills of a group of children with
Aspergers Syndrome (AS) and Pervasive Developmental Disorder Not Otherwise
Specified (PDD-NOS). It also examined the efficacy of a 10-week intervention using
sensory integration therapy. In a one-group, pretest-posttest design with a delayed
treatment approach, nine children were assessed using the Asperger Syndrome
Diagnostic Scale, the Perceived Efficacy and Goal Setting System, Clinical Observations,
the Sensory Profile, the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition
and the Sensory Integration and Praxis Tests. Testing was repeated after a five-week
baseline phase during which children and families followed their normal daily routines.
Next, sensory integration therapy was provided twice a week for 10 weeks. A treatment
manual provided treatment options that could be used based on individual client needs.
The tests were repeated after the intervention period and results were analyzed using
repeated measures ANOVA. Prior to intervention, all children were identified as having
sensory and motor impairments that were greater than typically developing children,
particularly in the areas of sensory processing, inattention, distractibility, sensory
modulation, emotional and behavioral responses to sensory input, coordination, praxis
and standing and walking balance. Six children completed the study. Following
intervention, significant improvements were identified in sensory processing, modulation
of sensory input, praxis and balance compared to pre-intervention findings. This
provides preliminary quantitative evidence that sensory integration therapy may be a
useful strategy to improve the sensory and motor skills that are identified in children with
AS and PDD-NOS.
xi
120%
Percentage (%)
100%
80%
60%
Pretest
Midtest
40%
20%
SQ
Se
ns
or
im
tiv
gn
i
Co
ot
or
e
M
al
ad
ap
t
iv
ia
l
So
c
La
ng
ua
ge
0%
Subtest
Figure 1. Percentage of Participants Whose ASDS Scores Were Above the 50th
Percentile.
Mean
Pretest
Midtest
(N=17)
(N=9)
(N=8)
Pragmatics)
6.8
6 = 67%
4 = 50%
9.1
5 = 56%
5 = 63%
behaviors)
8.2
8 = 89%
8 = 100%
8.2
6 = 67%
6 = 75%
3.6
6 = 67%
3 = 38%
106.3
7 = 78%
7 = 88%
Table 2
Percentage of Participants Scoring in the Probably Different or Definitely Different
Categories on Sensory Profile Factors Indicating Impaired Sensory Processing
Subtest
Pretest
Midtest
(N=9)
(N=8)
8 = 89%
8 = 100%
9 = 100% 8 = 100%
6 = 75%a
5 = 63%
mouth)
6 = 67%
5 = 63%
9 = 100% 8 = 100%
8 = 89%
8 = 100%
3 = 33%
3 = 38%
4 = 44%
3 = 38%
6 = 67%
5 = 71%b
Complete data available for eight participants due to a missing response. bComplete
Pretest
Midtest
(N=9)
(N=8)
9 = 100%
7 = 88%
7 = 78%
7 = 88%
9 = 100%
7 = 88%
Touch Processing
9 = 100%
6 = 75%
experiences)
8 = 89%
7 = 88%
6 = 67%
6 = 75%
6 = 75%a
5 = 63%
6 = 67%
6 = 75%
9 = 100%
6 = 75%
9 = 100%
8 = 100%
9 = 100%
7 = 88%
9 = 100%
8 = 100%
Pretest
Midtest
(N=9)
(N=8)
9 = 100% 7 = 100%b
9 = 100% 8 = 100%
Complete data available for eight participants due to a missing response. bComplete data
nt
ar
y
Fi
n
eM
ot
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de
iti
v.
en
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g.
Re
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ns
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at
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ns
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ra
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O
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d
/T
on
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ct
.
Lo
w
.R
ot
Em
Se
ns
.S
Midtest
or
/P
er
ce
p
Pretest
120
100
80
60
40
20
0
ee
k
Percentage (%)
Factor Category
Midtest
.P
ro
c
V
is. .
P
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es roc.
tib
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ro
To
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uc
h
Pr
oc
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oc
oc
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ra
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o
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M
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od
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f I Af..
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np
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I
ot
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t
o
Be
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v.
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sp
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.
re
ut
sh
co
ol
m
ds
es
fo
rR
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p.
100
80
60
40
20
0
ud
Percentage (%)
Pretest
Section Category
120%
Percentage (%)
100%
80%
Pretest
60%
Midtest
40%
20%
os
e
Fi
ng
er
/N
t.
A
ss
oc
.M
vm
Fi
ng
er
/T
hu
m
rS
ki
lls
M
ot
o
A
ct
iv
ity
Le
ve
l
Pr
on
eE
xt
en
sio
n
0%
Pretest
Midtest
(N=9)
(N=8)
5 = 56%
5 = 63%
Coordination)
6 = 67%
4 = 50%
8 = 89%
7 = 88%
4 = 44%
3 = 38%
Sensory Integration and Praxis Tests (SIPT). The SIPT was completed by each
participant in order to obtain quantitative data regarding his or her sensory skills. This
test utilizes a computer-based scoring system which provides subtest scores up to three
standard deviations above or below the mean. A score of one standard deviation below
the mean was used to identify an impairment that was greater than that of a typically
developing child. At both the pretest and the midtest phases of the study which were
completed prior to initiation of intervention, participants demonstrated scores below one
standard deviation from the mean on all 17 subtests of the SIPT. There was a wide
variability in the frequencies of children performing below one standard deviation on
Pretest
Midtest
(N=9)
(N=8)
Space Visualization
1 = 11%
2 = 29%
Figure Ground
1 = 11%
2 = 29%
4 = 44%
1 = 14%
Kinesthesia
2 = 22%
5 = 71%
Finger Identification
4 = 44%
2 = 29%
Graphesthesia
4 = 44%
4 = 57%
5 = 56%
3 = 43%
5 = 56%
3 = 43%
Design Copying
5 = 56%
2 = 29%
Constructional Praxis
3 = 33%
2 = 29%
Postural Praxis
6 = 67%
4 = 57%
Oral Praxis
7 = 78%
6 = 86%
Sequencing Praxis
4 = 44%
2 = 29%
2 = 22%
1 = 17%
9 = 100%
7 = 100%
Motor Accuracy
4 = 44%
2 = 29%
Postrotary Nystagmus
3 = 33%
2 = 29%
Pretest
Midtest
Posttest
-1
-2
-3
SIPT Subtests
Constr.
Praxis
Postural
Praxis
Oral
Praxis
Stand/Walk
Balance
Kinesthesia Graphesthesia
Figure 5. Mean Scores on Selected SIPT Items at Pretest, Midtest and Posttest
Behaviors or Functions
Inattention/Distractibility
Impairments
Improvements
Prior to
Following
Intervention
Intervention
Instrumentation Used
Emotional/Social
Responses
Clinical Observations
Sensory Profile
Input
Sensory Profile
Balance
SIPT, BOT-2
Sensory Seeking
Sensory Processing
Modulation of Sensory
Observations
SIPT, BOT-2, Clinical
Coordination
Observations
BOT-2
Appendix A
Approval from the Institutional Review Board
Appendix B
Sample Request for Support in Recruitment Procedures
Sincerely,
Kristen Klyczek, PT
PhD Student
Department of Rehabilitation Science
Enclosure
Appendix C
Letters of Support for Recruitment Procedures
Appendix D
Radio and Written Advertisements
A study is being conducted at the University at Buffalo for children with Aspergers
Syndrome, to determine if children with this disorder benefit from Sensory Integration
Therapy. To be eligible for the study, children must be between the ages of 5 and 9 years
at the time the study is being conducted. Participants will receive 10 weeks of free
therapy sessions under the direction of a qualified physical or occupational therapist that
include fun activities which incorporate movement and the senses of the body. Both
participants and their parents will be required to complete pre-, mid- and post-study
testing which involves both sensory and motor questionnaires and tests. The testing and
intervention will take place on UBs South Campus at 3435 Main Street. For more
information, please contact Kristen Klyczek at (716) 639-9201, or by email at
krarent@buffalo.edu.
Appendix E
Parent Information Letter and Invitation
Kristen Klyczek, PT
PhD Student
Department of Rehabilitation Science
Enclosure
Appendix F
Parent Informed Consent Form
The purpose of this consent is to provide you with enough information to make an
informed decision as to whether you will agree to have your child be a subject in research
that take place during the 2007 calendar year. You and your child have been invited to
participate in this study because your child was identified by his or her clinician as
having Aspergers Syndrome, being between 5 and 9 years of age, and being free of any
other neurological diagnoses.
PURPOSE
Kristen Klyczek, hereafter referred to as the researcher, is conducting this study to
determine if children with Aspergers Syndrome have any difficulty with sensory
integration, which is the ability to process information from the senses. Another purpose
is to see if sensory integration therapy is an effective treatment for children with
Aspergers Syndrome. To conduct the study, your child will take part in a therapy
program designed around his or her specific needs, in order to improve his or her ability
to take in information from his or her senses, process that information and then use it to
complete play skills and daily activities. The body has many sensory systems including
touch, vision, movement and an awareness of where the body is in space. Sometimes,
when these systems overreact or do not react enough, people have difficulty behaving or
moving in ways that are considered typical. Sensory integration therapy may help these
systems to work together more easily, in order for your child to behave and perform daily
skills without difficulty.
PROCEDURES
This study will be conducted at the University at Buffalo, in a room designed to provide
sensory integration therapy. Since the procedures can be done at a time convenient for
you and your child, there will be no interruption to your childs school day. With your
consent, you will be asked to complete a short questionnaire. It will provide information
about your child, such as his or her age, gender and the services he or she is receiving.
You will also be asked to complete the Sensory Profile, and the Aspergers Syndrome
Diagnostic Scale, caregiver questionnaires which will provide additional information
about your childs diagnosis and his or her sensory systems. Together, these
questionnaires will determine whether or not your child is eligible for the study. If your
child is identified as being eligible to participate, and if you provide consent, and your
child agrees, he or she will participate in three tests to measure how he or she uses his or
her sensory and motor skills. These tests include: Clinical Observations, the Perceived
SUBJECT STATEMENT
I have read the explanation provided to me. I have had all my questions answered to my
satisfaction, and voluntarily agree to allow my child to participate in the study.
I HAVE BEEN GIVEN A COPY OF THIS CONSENT FORM.
SIGNATURE OF PARENT/GUARDIAN
DATE
I certify that I obtained the consent of the subject whose signature is above. I understand
that I must give a signed copy of the informed consent form to the subject, and keep the
original copy in my files for 3 years after the completion of the research project.
SIGNATURE OF INVESTIGATOR
(OR PERSON OBTAINING CONSENT)
DATE
SIGNATURE OF WITNESS
DATE
Appendix G
Childs Assent Form
(716) 639-9201
(716) 829-3141 extension 129
If you would like to be in my study, please sign or print your name on the line below:
Appendix H
Pre-Study Questionnaire
Private / Public
Regular Classroom / Special Education Classroom / Inclusion Classroom
Other
_________________________________________________________
Language delays
Academic delays
Accident Prone
Clumsy or poorly coordinated
Please comment on any noteworthy or unusual ways in which your child responds to:
Taste: ________________________________________________________________________
Sound: _______________________________________________________________________
Touch: _______________________________________________________________________
Sight: ________________________________________________________________________
Movement: ___________________________________________________________________
Appendix I
Asperger Syndrome Diagnostic Scale
Sample Items
Observed
Not Observed
Selected From: Myles, B. S., Bock, S., & Simpson, R. (2001). Asperger Syndrome
Diagnostic Scale Examiners Manual. Texas: Pro-Ed, Inc.
Appendix J
Sensory Profile Caregiver Questionnaire
Sample Items
Always
Responds negatively to
unexpected or loud noises
Covers eyes or squints to
protect eyes from light
Seeks all kinds of movement
and this interferes with daily
routines (for example, cant
sit still, fidgets)
Reacts emotionally or
aggressively to touch
Has difficulty paying
attention
Picky eater, especially
regarding food textures
Modulation:
Poor endurance/tires easily
Seems accident-prone
Takes excessive risks during
play
Is overly affectionate
Behavior and Emotion
Responses:
Is sensitive to criticisms
Has temper tantrums
Poor frustration tolerance
Doesnt express emotions
Selected From: Dunn, W. (1999). Sensory Profile: Users Manual San Antonio:
Psychological Corporation.
Never
Appendix K
Perceived Efficacy and Goal Setting System
Sample Items
Item
A Lot
A Little
A Little
A Lot
Selected From: Missiuna, C., Pollock, N., & Law, M. (2004). The Perceived Efficacy and
Goal Setting System Manual. San Antonio: Psych Corp; Harcourt Assessment.
Appendix L
Clinical Observations Documentation Form
Eye Movements:
Visual Tracking
Follows small object with eyes across midline, along diagonals and in a circular
pattern
Unable to follow small object in a smooth and controlled pattern
Convergence or Divergence
Able to follow object with eyes when brought to the nose and then moved away
Unable to coordinate eye movements when an object is brought to the nose and
back again
Quick Localization
Appendix M
Clinical Observations Worksheet
DOB: __________________
Handedness:
1. Muscle Tone: Sitting in chair; forearm supination; 90 degree shldr flexion; thumb
in hand
Hypertonic
Normal
Slightly hypotonic
Hypotonic
Right/Left Differences:
2. Eye Dominance:
3. Eye Movements:
4. Ramp Movements:
R / L
R / L
R / L
Able / Unable
Across Midline:
Normal
Pursuits:
Normal
Convergence:
Normal
Quick Localization:
Normal
Smooth
5. Pronation/Supination:
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slightly Irregular
Jerky/Too Fast
Right: ___
Normal
Left: ___
Normal
Both: ___
Normal
6. Finger-Thumb Touching:
Hand: R / L
Hand: R / L
Hand: R / L
Right: ___
Normal
Left: ___
Normal
Both: ___
Normal
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Right: ___
Normal
Left: ___
Normal
Upper Lip:
Normal
Lower Lip:
Normal
Sides:
Normal
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
9. Cocontraction: (90 degrees shldr flexion, elbows slightly bent, hands fisted)
Elbow:
Normal
Slight Irregular
Poor
Neck: (rotation, downward pressure, sidebending)
Normal
Slight Irregular
Poor
Trunk: (rotation with examiners hands at shoulders)
Normal
Slight Irregular
Poor
10. Postural Insecurity:
Quadruped:
Normal
Long Sitting:
Normal
Kneeling:
Normal
Standing:
Normal
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Slight Irregular
Slight Irregular
Poor
Poor
Poor
(standing)
Eyes Open: Normal
Eyes Closed: Normal
Absent
Absent
______ seconds
_______effort
(quadruped)
No change in joint flexion or extension
Slight change in joint position
Definite change in joint position
_____ seconds
______ effort
Normal
Slight Irregular
Poor
Appendix N
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition
Sample Items
Appendix O
Sensory Integration and Praxis Tests
Descriptions and Examples
Description
Space
Visualization
Figure-Ground
Perception
Standing and
Walking Balance
Example
Offering an egg shape and a
diamond which fits the eggshaped hole?
Design Copying
Postural Praxis
Bilateral Motor
Coordination
Praxis on Verbal
Command
Constructional
Praxis
Postrotary
Nystagmus
Motor Accuracy
Sequencing
Praxis
Oral Praxis
Manual Form
Perception
Kinesthesia
Finger
Identification
The child is asked to identify which Left ring and left little fingers
fingers were touched when vision are touched simultaneously
was occluded
Graphesthesia
Location of
Tactile
Stimulation
Selected From: Ayres, A. J. (1989). Sensory Integration and Praxis Tests Manual. Los
Angeles: Western Psychological Services.
Appendix P
Description of the Sensory Integration and Praxis Tests for Parents
Appendix Q
Request For Assistance in Test Administration of Participants
Sincerely,
Kristen Klyczek
PhD Student
Department of Rehabilitation Science
Appendix R
Treatment Manual
Mode of Delivery:
The activities within this treatment manual are designed for a ten-week treatment
period using direct, one-on-one therapy. Sessions are designed to be provided for 45-60
minutes each. The provider, will be a licensed physical therapist who is trained and
certified in SI evaluation and intervention, and will conduct all treatment sessions. A
sensory integration frame of reference will be followed at all times.
Session activities will be child-directed whenever possible, however the types of
activities offered to the child will be based on the needs of the child, identified during
pretesting, previous sessions and that session itself. A list of treatment options has been
provided.
Equipment Specifications:
The following equipment is available for use during the study:
Suspended equipment: New swing, Platform swing, disc swing
Therapy Balls: Assorted sizes and shapes
Mats and Landing Cushions: Six mats: 910x 6 x 3
Mat Tables: Two: 7x 5 raised 21 off the floor, and two: 6x 4, 18 off the floor
Panel Mats: Three: 4 panels each
Wedges: Assorted sizes and shapes
Bolsters: Assorted sizes and shapes
Scooter boards
Tilt boards
T-stools
Adjustable benches
Ramp: 22 wide, extending 57
Mirrors: full length
Mini-trampoline
Floor balance beam: 8 x 4 x 1 high
Elevated balance beam
Tunnels: Rigid, flexible, and resistive tunnels
Weighted equipment: vests, toys, cuff weights
Blankets, elastic fabrics and resistive vests
Activity
Calming
Alerting
Purpose
Activity
Prone activities on the ground
Rolling on the floor or mat
Rolling in a barrel
Proprioceptive activities
Linear activities such as swinging
on suspended equipment, or using a
scooter board (may have child knock
something over in the backwards
direction if he or she has a fear of
backwards movement)
Quadruped activities such as an
obstacle course
Poor Posture
Purpose
Activity
Often low tone, poor postural stability, poor equilibrium reactions, decreased prone
extension, poor supine flexion together, indicate vestibular and proprioceptive
processing deficits
Facilitating extension against gravity
(Cocontraction of extensor muscles)
257
258
259
Proprioceptive Input
Purpose
Calming
Activity
Slow, steady activities
Resistance activities
Slowly alternating pushing and
pulling
Firm, deep pressure: tight wraps,
blankets,
mats
Alerting
260
Activity
Warm temperatures
Deep touch pressure
Rolling balls, bolsters or other
objects over the child
Compression of the child with
mats, toys, hugging, wraps
Weight bearing activities
Smooth textures
Alerting
Rough textures
Cold temperatures
Light, inconsistent, unexpected or
pressure point touch
Touch in direction opposite of hair
growth
261
Deep pressure
Weighted vests, backpacks, hats
Large pillows and mats for
burrowing
Large therapy balls roll over
child or child pushes against w/
therapist
Activities requiring the child to
move heavy objects such as pulling
on end of rope, barrels, therapist on
equipment
Theraband wrapped on skin
Proprioceptive activities
Jumping, bouncing
Vibration to arms and legs
Textured coverings on equipment
Textured mitts on skin
Searching for objects in boxes of
tactile experiences (beans, rice)
Ball pits
Resistance activities for the mouth,
such as sucking through a straw
(sour = organizing)
262
Tactile experiences
Identifying unseen objects
Have child describe or discriminate
various textures
Activity
Ideation
263
References
Bundy, A. Lane, S. & Murray, E. (2002). Sensory Integration Theory and Practice (2nd
Edition). Philadelphia, PA: F.A. Davis Company.
Fisher, A.G., Murray, E. & Bundy, A. (1991). Sensory Integration Theory and Practice.
Philadelphia, PA: F.A. Davis Company.
Huebner, R.A. (1992). Autistic Disorder: a neuropsychological enigma. The American
Journal of Occupational Therapy, 46(6), 487-499.
Shriber, L. (2004). Sensory Integration and Neurodevelopmental Therapy Course.
University at Buffalo, Buffalo, NY.
Watling, R. (2004). The effect of sensory integration on behavior and engagement in
young children with autistic spectrum disorders. University of Washington.
Appendix S
Therapy Session Progress Note and Checklist
264
265
Subjective:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Objective:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Assessment:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Plan:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Additional Comments:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
266
Vestibular
Praxis
267
Comments:
_____________________________________________________________
12. Did the therapist work to connect with the child, build a sense of trust, convey a sense
of appreciation of the childs capabilities, respect the childs signs of distress and
assist in regaining a sense of comfort and competence?
Yes /
Somewhat / No
Comments:
_____________________________________________________________
This checklist has been adapted from work published in:
Watling, R. (2004). The effect of sensory integration on behavior and engagement in
young children with autistic spectrum disorders: University of Washington.