Sensory Integration Education

Aimee Piller, PhD, OTR/L is a paediatric occupational therapist with more than 13 years experience. She owns and operates Piller Child Development, LLC, a multidisciplinary paediatric therapy practice located in Phoenix, Arizona, USA. She completed her masters in occupational therapy at Temple University in Philadelphia, Pennsylvania, USA and her PhD in occupational therapy from Texas Woman’s University in Denton, Texas, USA. Dr. Piller is the author of the Participation and Sensory Environment Questionnaire–Teacher Version. She has published and presented at a national level on a sensory environment, interdisciplinary practice with a speech-language pathologist using sensory strategies to support language development, and the importance and application of practice-based research. She is passionate about the field of occupational therapy and continues to practice paediatric occupational therapy with expertise in sensory integration, feeding therapy, and motor development.

Sensory integration is an evidence-based intervention that is designed to influence children and adults with sensory processing differences to remediate sensory processing difficulties with the goal of increasing participation. Sensory processing differences may occur in any of the sensory systems, in all of the systems, or in how the sensory systems integrate and process together. Sensory processing consists of registration, modulation, and the habituation of sensory input. Traditional sensory integration treatment was designed to address the difficulties in how Assessing the Sensory Environment the sensory systems processes input. Interventions provide enhanced sensory experiences to illicit an adaptive response with the result of improved adaptation, sensory processing, and in turn, participation (Bundy, Lane, Murray, 2002). 

Sensory integration is an effective treatment for children with various sensory processing needs. Although evidence is still emerging, current research demonstrates the effectiveness of the intervention in improving motor skills, participation in structured tasks, sleep, social participation, and reducing caregiver burden (Watling & Hauer, 2015). Sensory integration is implemented by skilled occupational therapists to improve sensory processing of the person and increase participation within various environments and activities. Working from an SI perspective involves eliciting an adaptive response and building upon these adaptive responses which will ultimately change routines and habits thus increasing participation. The sensory environment is an often-overlooked aspect of the physical environment, but can greatly impact participation, especially for individuals with sensory processing differences.

Occupational therapists function under the assumption that participation is a result of the interaction of the person and the environment (Law, Cooper, Strong, Steward, Riby, & Letts, 1996). Participation increases when there is a greater fit between these two elements. For a child with sensory processing differences, the fit between the person and the environment is frequently poor, resulting in decreased participation. Occupational therapists may utilize sensory integration treatment to remediate sensory processing differences and increase the fit between the person and environment with a result of increased participation. Direct sensory integration intervention is an effective treatment that utilizes the environment to facilitate the internal adaptive process of the child. Consideration of the sensory environment in treatment can influence participation and allow therapists to design interventions that can increase participation within chosen occupations.

Participation is a key goal in occupational therapy principles and sensory integration treatment is a tool used by occupational therapists to increase participation of the child or adult in chosen occupations. Participation and the environment are linked together with one consistently influencing the other. The result of the interaction of the person and the environment is participation (Law et al., 1996). When the fit between the environment and the person is poor, participation is negatively impacted. The better the fit between the person and the environment, the more the person has successful participation in occupations. If the person is experiencing sensory processing difficulties, and the components of the sensory environment are a poor fit for that individual’s sensory processing, then the person may have decreased participation. For example, a child with hyper reactivity to auditory input may have poor participation in a room that is next to a construction zone that has excess background noises.

The child may be so overcome with sensory input within the environment, that the child is unable to participate to his or her fullest ability simply because of the poor fit between the person and the environment. Instead of participating in play and school tasks, the child may run from the room, stay away from the group, cover his or her ears, thus impacting the ability to engage in play and social activities, etc. Conversely, the same child with auditory sensitivities in a quiet room, absent of background noise may experience no difficulties in participation, and perform all activities and tasks as the other children. This example indicates the impact of the sensory environment.

Under sensory integration theory, therapists typically evaluate the sensory processing patterns of the person. They do not necessarily formally examine the sensory aspects of the environment. By including an assessment of the sensory environment, the therapist is able to intervene at the level of the environment to increase participation more immediately. The Participation and Sensory Environment Questionnaire– Teacher Version (PSEQ–TV) (Piller, 2017) is an assessment designed to examine the sensory environment, specifically the school environment and how it impacts participation for young children. Because of the unique aspects of each environment, it is important to examine specific environments, in this case the preschool environment, and participation within one assessment. By examining these two concepts in a single assessment, therapists can design specific environmental interventions that target increased participation in specific tasks.

The PSEQ–TV is a teacher report assessment that consists of three subtests designed to examine the impact of the sensory environment on participation. The first subtest explores specific activities and tasks that occur within the preschool setting. Activities include things such as circle time, snack or lunch time, classroom routines, instructional time, movement time, etc. Each activity is broken down into specific tasks a child may perform during the school day. The respondent is asked to indicate how much the sensory aspects of the environment impact participation for the child on a Likert scale from “none” to “too much to participate.” The second subtest explores the amount of support a child is provided to participate in an activity. Support may be physical, verbal, or visual. The third subtest examines modifications to the environment that support participation. Modifications include physical changes to the environment, changes to the task, or changing the timing of the activity. The assessment provides a baseline for identifying where the child may be having barriers in participation due to the sensory aspects of the environment as well as how much support and modifications are currently needed to support participation.

 Initial testing reveals that the PSEQ–TV is a reliable and valid assessment. Reliability was established via internal consistency of 0.98 and test-retest reliability of 0.70. Construct and content validity have also been established (Piller, Fletcher, Pfeiffer, Dunlap, & Pickens, 2017). Currently the assessment is available for free use from https://participationandsensoryenvironment.weebly.com/pseq---teacher-version.html. The PSEQ–TV is a companion assessment to the Participation and Sensory Environment Questionnaire (PSEQ) (Pfeiffer, 2017), a parent report tool that examines the impact of the sensory environment on activities and tasks within the home and community. The PSEQ and PSEQ–TV follow the same format for subtests and scoring, but are designed to examine three different environments, which are the school, home, and the community environment for young children.

The PSEQ also exhibits initially strong psychometric properties with reliability at 0.96-0.98 and test-retest at 0.62- 0.76. Evidence of construct, content, and concurrent validity have been established (Pfeiffer, Piller, Slug, & Shiu 2018; Pfieffer, Piller, Bevans, & Shiu, 2019). This assessment is available for free at https://participationandsensoryenvironment.weebly.com/view-pseq-tv. html.

The results of the PSEQ and PSEQ–TV provide therapists with unique information about how the sensory environment impacts participation within specific activities and tasks. When the results of this assessment are combined with other assessments that identify the sensory processing needs of the child, the therapist is able to tailor interventions within the environment to change the sensory features to better fit the sensory needs of the child. This in turn will increase participation. Assessments that identify sensory processing, specifically modulation and registration, that can be used in combination with the PSEQ–TV and PSEQ include assessments such as the Sensory Processing Measure (Parham, Ecker, Miller Kahaneck, Henry, & Glennon, 2007) and Sensory Profile 2 (Dunn, 2014). These assessments assess the sensory processing patterns of the person while the PSEQ and PSEQ–TV examine the sensory features of the environment and how those influence participation.

To combine the results of the assessment of sensory registration and modulation with the PSEQ or PSEQ–TV, the therapist needs to use skills to analyse the activities and tasks that are impacted by the sensory environment, the information gathered from using the PSEQ and PSEQ–TV. In addition, the therapist must also consider the results of the sensory registration and modulation profile of the child. The therapist should examine what aspects of the sensory environment influence participation based upon the child’s sensory processing. For example, if the child’s sensory registration and modulation profile indicates hyper reactivity to tactile and the child is experiencing great difficulties in circle time participation, the therapist may conclude that the tactile sensitivities of the child in combination with the tactile aspects of the environment (i.e. other children sitting near and unexpectedly touching the child) may be impeding participation. The therapist would then design an intervention to modify where the child is sitting to decrease unexpected tactile input of other children. The modification may be providing a separate area for the child to sit away from other children, sitting in a chair or modified chair to provide a physical boundary from unexpected touch of other children, or wrapping the child in a weighted blanket while he or she sitting in circle time.

Modifications to the sensory environment can increase and facilitate participation, but are not designed to take the place of sensory integration therapy, which is designed to remediate sensory processing differences. The PSEQ and PSEQ–TV is not only designed to identify barriers within the environment, but also facilitators within the environment. Often teachers and parents almost innately modify tasks and the environment or provide support to facilitate participation (Piller & Pfeiffer, 2016). By honing in on specific facilitators, the therapist can guide teachers and parents to provide the best support and modifications to increase participation of their children.

In summary, the sensory environment is often considered when addressing children with sensory processing difficulties, but not in a formal manner. Examination of the sensory environment through a formal assessment, such as the PSEQ and PSEQ–TV, provides a method to identify barriers and facilitators to participation within the sensory environment. In combination with identification of the sensory processing needs of the person, the PSEQ and PSEQ– TV provides guidance for the therapist to design interventions that modify the environment, thus increasing participation in a more immediate manner.

You can reach Aimee at: [email protected]