and mental health, daily life functioning, and participation in desired daily life .... a model for treating adults with sensory modulation disorder, and Champagne.
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(one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.
An Approach to Assessment of and Intervention for Adults With Sensory Processing Disorders TERESA A. MAY-BENSON,
sen. OTR/L,
FAOTA
home-based intervention. However, this model does not address the full range of sensory and motor dysfunction seen in SPDs such as sensory discrimination, postural-ocular skills, or praxis needs. Thus, a more comprehensive framework of practice that encompasses all aspects of OT-SI practice is needed for adults with SPD.
Director of Research and Education The Spiral Foundation, Newton, MA
MOYA KINNEALEY, PHD, OTR, FAOTA Faculty Emeritus, Temple University, Philadelphia, PA
ABSTRACT Occupational therapists using a sensory integrative frame of reference routinely assess and treat children with sensory processing disorders (SPDs). However, similar services for adults with SPDs are less available, perhaps in part because therapists feel unqualified or unprepared to work with this population. This article presents a conceptual framework for guiding occupational therapists in assessing, intervening with, and setting priorities for adults with an SPD, whether the focus is on specific body function difficulties, activities of daily living, or full participation in daily life.
LEARNING OBJECTIVES After reading this article, you should be able to: l. Identify four areas of assessment important for comprehensively evaluating adults with SPDs. 2. Identify the two major areas of intervention for adults withSPDs. 3. List the subcomponents of each area of intervention for adults with SPDs. 4. Recognize four coping strategies used by adults with SPDs.
INTRODUCTION Occupational therapy practitioners using a sensory integration frame of reference have become increasingly aware in recent years of the need to address the sensory concerns of adults as well as children. Adults with sensory processing disorder (SPD) are increasingly seeking sensory integrationbased occupational therapy (OT-SI) services and frequently report they are not able to locate occupational therapy practitioners who are willing or able to treat them. This is particularly true for adults with co-morbid mental health issues and adults with developmental disabilities, such as autism. Occupational therapy practitioners are often educated in using a sensory integration frame of reference with children; however, formal education on applying sensory integration principles with adults is lacking. Thus, therapists may not be sure how to approach assessment and intervention of older clients. For adults with sensory modulation difficulties, Kinnealey (2012) and Pfeiffer (2012) articulated a model of intervention focused on self-advocacy, sensory diets, and SEPTEMBER 2012 • OT PRACTICE. 17(17)
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UNDERLYING ASSUMPTIONS REGARDING INTERVENTION WITH ADULTS Occupational therapy practitioners must first understand and appreciate several important facts when working with adults with SPDs. First, recent studies suggest that sensory modulation problems, especially for tactile and auditory defensiveness, are partly hereditary (Van Hulle, Lemery-Chalfant, & Goldsmith, 2007), supporting SPD as a unique diagnosis and not just an aspect of some other disorder, such as anxiety. Further, adolescents and young adults do not "grow out" of their sensory and motor difficulties. Research on motor skills demonstrates that children with motor problems do not grow out of their clumsiness (Cermak, Trimble, Coryell, & Drake, 1991; Cousins & Smyth, 2003) but continue to demonstrate difficulties in these areas into adulthood. Similarly, May-Benson and Patane (2010) found adults seeking OT-SI services for the first time reported remarkably little change in their signs and symptoms of sensory and motor dysfunctions from childhood to adulthood. Kinnealey, Oliver, and Wilbarger (1995) found that although adults reported they developed coping mechanisms to manage their sensory problems, thus making symptoms appear less severe over time, the problems persisted, resulting in deleterious effects on emotional and mental health, daily life functioning, and participation in desired daily life activities. In addition, adults with SPDs frequently are not aware that their perceptions differ from others. Their sensory and motor problems are lifelong difficulties that are their lived experience and the only reality they know. For example, when discussing with an adult that the evaluation finding of double vision was a sign of oculomotor difficulty, she remarked, "You mean everyone does not see double?" Thus, occupational therapy practitioners must appreciate the lifelong nature of sensory integration and processing problems for adults with SPDs and the profound impact these difficulties have on these individuals. Further, the effect of managing these lifelong sensory difficulties on quality of life is well documented. Kinnealey et al. (1995) and Kinnealey, Koenig, and Smith (2011) reported adults with sensory modulation problems may manage their sensory symptoms to the detriment of their quality of life. Heufner, Cohn, and Koomar (in press) found mothers of
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children with SPDs who had sensory problems themselves reported that their own sensory issues negatively affected their ability to mother and actively engage with their children, especially if a child's sensory needs were different than their own. In addition, Koomar (2012) interviewed adults with SPDs and found sensory processing issues negatively affected their quality of life. They felt constantly overwhelmed or exhausted from managing and coping with sensory experiences, under constant stress and anxiety from sensory experiences, and unable to do or enjoy many daily life activities. Thus adults with SPDs experience a lifetime of living with adverse sensory and motor functioning, which shapes their perceptions of the world and forms a foundation for possible problems with their emotional and mental health. Recent publications have described the sensory and motor needs and patterns of function and dysfunction of adults with SPDs and highlighted the high frequency of co-morbid mental health diagnoses, especially trauma, anxiety, and depression (Kinnealey et al., 1995; May-Benson, 2011; Pfeiffer, 2012). Problems in mental health are one reason adults seek OT-SI services. May-Benson and Patane (2010) examined the clinical records of adults seeking OT-SI therapy services and identified three major reasons for referral: (1) socialemotional and interpersonal difficulties, especially with significant others; (2) anxiety, over-arousal, and a desire to be calm and relaxed; and (3) functional motor and organization problems interfering with participation in desired daily life and leisure activities. Many adults, because they had never heard of OT-SI or did not think it applied to them, indicated that OT-SI services were their last resort after seeking other medical or mental health services with no relief. An approach for assessment and intervention that addresses the unique complexity of needs of adults with SPD is needed to assist occupational therapists in navigating the assessment and intervention process for this particular population. Based upon the World Health Organization's International Classification of Function, the framework presented in this article articulates specific areas of assessment and intervention to be addressed, and it provides a roadmap to guide therapists through the assessment and intervention process for adults with SPD, including effective intervention tools and activities.
EVALUATION Assessment of adults with SPD should be as comprehensive as possible, although adults often want to spend their resources on intervention and not on an extensive, potentially costly evaluation. Comprehensive OT-SI assessments encompass physical, cognitive, and social-emotional functions in order to determine factors that both facilitate and inhibit clients' participation in occupations and quality of life. These areas later guide prioritization and selection of intervention activities. CE-2
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Performance skills that should be addressed in a comprehensive assessment include sensory perceptual, motor and praxis, emotional regulation, cognitive, and social skills. Specific areas may include sensory processing of both modulation and discrimination of inputs, postural control, ocular motor and functional vision skills, motor control and praxis, and cognitive functions such as memory and attention. To directly evaluate these areas, May-Benson (2009) described a process and materials that may be used in conjunction with structured self-report sensory histories such as the Adult Sensory Profile (Brown, Tollefson, Dunn, Cromwell, & Filion, 2001) or therapist-directed sensory interviews such as the ADDLT-SI (Kinnealey & Oliver, 1999). Further, Champagne and Koomar (2012) and Champagne, Koomar, and Olson (2010) described sensory integration-based assessment processes and tools specifically for adults with mental health concerns. Additional assessments of body-level functions that may be useful for adults with and without mental health concerns include the Quick Neurological Screening-S (Mutti, Martin, Sterling, & Spalding, 1999), the Motor-Free Visual Perceptual Test (Colarusso & Hammill, 2003), the Dynamic Loewenstein Occupational Therapy Cognitive Assessment (Katz, Livni, Bar-Haim Erez, & Averbuch, 2011), and the Allen Cognitive Scale (Allen, 1990). Social-emotional concerns, including clients' beliefs, desires, self-esteem, and emotional state, are best assessed through a comprehensive semi-structured interview such as the ADDLT-SI (Kinnealey & Oliver, 1999). Goal-setting tools such as Goal Attainment Scaling (Kiresuk, Smith, & Cardillo, 1994) or the Canadian Occupational Performance Measure (Law et al., 2005) are recommended to gather relevant information and establish intervention goals. Occupational therapists may wish to use tools such as Beck's Anxiety Scale (Beck & Steer, 1990) or Beck's Depression Scale (Beck, Steer, & Brown, 1996) to screen for mental health issues such as anxiety or depression and identify areas of emotional health that they may need to support during intervention. In addition, re-assessment using both of the Beck scales after a period of intervention may help therapists and clients identify whether these emotional issues are improved by the sensory integration intervention or whether more direct mental health intervention is needed. Adults with SPDs may have difficulties with eating, sleeping, working, and participating in leisure and social activities. This information may be obtained during the interview process and from sensory histories such as the Adult Sensory History (Koomar, Hurwitz, Kahler-Reis, & Szklut, 1996). The Kohlman Evaluation of Living Skills (Thomson, 1992) or the Adaptive Behavior Assessment System (Harrison & Oakland, 2003) may help identify difficulties in specific areas of occupational performance. During assessment, therapists should identify what affects occupational performance the most. For instance, if a client does not dress appropriately for work, is CODE CEA0912
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Earn .1 AOTA CEU (one the problem related to clientfactors (e.g., she doesn't value dressing appropriately for work or there are body structures or functions that limit her) or e performamce skill, such as sensory perceptual or motor and praxis skills? If the latter, the client may be so tactilely defensive that she will only wear soft loose, shapeless clothing. Or she may have motor planning problems that make zips, snaps, and buttons just too challenging, so she opts to wear easy-pull-on clothing instead. Such knowledge guides therapists in clinical reasoning about aspects of intervention to focus on, and it also helps clients make changes in performance. Therapists can evaluate a client's participation in desired and valued activities (i.e., ability to engage in social roles and relationships) using intake information, sensory histories, and interviews. Therapists will need to clarify the specific nature of these various concerns, as it is often difficulties at the participation level of functioning that motivate clients to seek occupational therapy services. Therapists should examine the following when evaluating participation skills in adults with SPDs: • Work skills, including finding and keeping employment, successfully completing work responsibilities, and managing work-related social interactions. • Leisure (and play) skills, which are important for both sensory self-regulation and social connectedness. Concerns include identifying what physical, social, and leisure activities the client engages in as well as examining the frequency of participation and whether the leisure activities are solitary or with others. Often, adults seeking OT-SI services state they are not able to enjoy family activities because of sensory or motor issues that, in turn, affect the family social-emotional dynamic. These may be activities such as biking (because of poor balance and coordination), visiting a zoo (because of sensitivity to odors), or eating with others (because the sound of people chewing is too upsetting). • Educational activities, which adolescents and young adults may have difficulties participating in because of difficulty in tolerating crowded hallways or classroom noise, or in organizing themselves to complete coursework. • Social participation, which is a trigger for many adults seeking services because they have problems with intimacy and tolerating touch from their loved ones and partners. Some are over-stimulated by the sensory stimuli of social environments such as restaurants, bars, concerts, or parties. Further, participation in religious or spiritual activities such as attending crowded services can be problematic to some people. A common self-defeating coping strategy is to avoid these situations altogether. • Transportation issues, which affect many other areas of occupation. Difficulty with driving or the sensory aspects of public transportation may interfere with participation in work, leisure, social, and educational experiences. SEPTEMBER 2012 • OT PRACTICE, 17(17)
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Participation in social roles may also be influenced by the match or mismatch between the sensory styles of two or more individuals. Mismatches can lead to emotional difficulties in the relationship. For instance, one adult recalled that her father was a friendly, loud, active man who loved to play with her in a very active way when she was small, picking her up and tossing her in the air. Unfortunately, this woman was severely gravitationally insecure, so every time he did this she was terrified, and she hated having him come near her as she did not know when she would be tossed about. Her father felt rejected by her response and eventually gave up interacting with her, resulting in a significant emotional distance between them. She recalled one particular day when, in exasperation, her father told her, "You're just no fun at all." That rejection had a very negative effect on the client. Thus, person-person fit may impact not only interpersonal relationships, but also a client's sense of attachment and ability to bond with others and, ultimately, affect the development of a social support system. It is important to examine what social supports are available for the client, as the lack of a solid social support system is common in adults with SPDs. Trust and bonding with others may be difficult. Other adults report problems maintaining friendships as they are often perceived as being too difficult, fussy, or rigid by family and friends. In addition, they often do not want to engage with friends in social activities such as attending parties due to sensory overstimulation. Tools such as the Scaling Medical Outcomes Social Support Survey (Sherbourne & Stewart, 1991) or the Short Form 26 Health Survey (yVare & Sherbourne, 1992) may be useful in identifying strengths and weaknesses in social supports with adults. Research has shown that individuals with good social supports do better in intervention (Kinnealey et al., 2011). Lastly, quality-of-life questionnaires such as the World Health Organization Quality of Life-BREF (World Health Organization, 2004) may be useful in the assessment process to determine how these participation difficulties affect a client's quality of life or ability to live his or her life fully and happily.
INTERVENTION Sensory integration-based intervention for adults is multifaceted and must address not only adults' sensory and motor needs but also their social and emotional needs. Kinnealey (2012) and Pfeiffer (2012) proposed a model for treating adults with sensory modulation disorder, and Champagne (2010) has discussed a sensory-based model for treating sensory modulation in adults with mental health concerns. Kinnealey (2012) and Pfeiffer's (2012) model is based on the core assumptions that knowledge is power, people are experts on themselves, and people are the architects of their lives. They proposed that educating adults about the nature of their sensory and motor difficulties is key to helping them understand themselves. Further, Kinnealey proposed that
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- - adult must be the architect or agent of change in his or own life and that the client knows best what will work ad what he or she is capable of doing. Intervention must focus on empowering the adult with being able to control and conquer sensory issues. Kinnealey and Pfeiffer's model advocates five major components of intervention: (1) education and insight, (2) self-advocacy, (3) sensory diet, (4) environmental adaptation, and (5) social supports. This model has been used primarily with adults with anxiety and emphasizes self-advocacy and integration of interventions within the context of daily routines and life activities. Champagne's model also emphasizes sensory diets and the use of sensory-based modalities for self-regulation. These intervention models do not, however, address sensory discrimination or praxis concerns, and they emphasize managing sensory concerns rather than remediating underlying problems. In addition to the assumptions proposed by Kinnealey and Pfeiffer, we would propose that making real change in the nervous system is necessary for long-lasting functional changes in life skills. Thus a comprehensive framework for sensory integration-based intervention that involves all aspects of SPDs is needed. However, adults are highly variable in their willingness and ability to engage in intervention activities because of financial concerns, time constraints, and/or social-emotional factors (May-Benson, 2009). Consequently, there is no single right program of intervention for adults with SPDs, and occupational therapy practitioners should be able to provide a range of therapeutic services, from direct intervention to indirect therapy and consultative services. The intervention framework proposed here involves two primary components: education and treatment activities. These two components are addressed simultaneously throughout the intervention process, but each component involves a therapeutic progression of activities.
functioning, and (4) becoming aware of how these interactive patterns affect their ability to participate effectively in social roles. Cohn (2001) found that parents of children with SPDs identified re-framing and understanding their child's needs to be the most helpful outcome of their child's OT-8I intervention. Thus, this process of understanding and reframing is conceivably important for adults in understanding their sensory integration problems and how those problems relate to their functioning, ability to engage in occupations, and participation in desired activities. Whereas resources for parents of children with SPDs abound, resources for adults with PDs are scarce. Some adults may find standard texts geared for parents helpful, but many do not see the relevance to themselves, and resources geared toward children's problems can make them feel childish. In addition, some resources have a mental health emphasis, and thus, clinicians must take care when selecting resources. The few resources that are available for adults are generally geared toward the sensory defensive adult or the adult with dyspraxia, but they do not address comprehensive sensory integration problems. Figure 1 on p. CE-5 presents some resources that adults may find helpful in understanding their sensory integration issues.
Education Interventions for sensory integration problems begin with educating adults with lifelong sensory integration issues about their challenges, starting with the first conversation at intake. This educational process involves three components: (1) insight development, (2) self-advocacy, and (3) identification of coping mechanisms and self-assessment of personenvironment compatibility (Kinnealey, 2012).
Self-Advocacy Throughout the education process, adults mus be empowered to be self-advocates. Becoming a self-advocate involves understanding the rationale for their difficulties and needs, and being able to articulate these to others. Being able to explain and educate others about their challenges and needs is an important first step in taking control of the impact of their condition and improving social-emotional relationships. Frequently, significant others, family members coworkers, and others do not understand why adults with 8PDs will not engage in activities, and they perceive them as being over-sensitive; standoffish, clumsy, or inept· or a failure at many activities others take for granted. Being the agent of re-framing others' perceptions of oneself is empowering and a vital part of improving one's self-worth and self-concept. The ability to self-advocate is important in building social supports and making environmental adaptations to support function resulting in better mental health and quality of life (Kinnealey et al., 2011).
Insight Development Improving clients' insight into their sensory integrationbased difficulties begins with identifying problem areas and requires collaboration between clients and therapists. Four areas are helpful to adults in developing insight into their sensory difficulties: (1) understanding their unique sensory and motor makeup, (2) recognizing their coping behavior(s) in response to offending sensory stimuli in the environment, (3) recognizing the impact of these responses to their daily
Coping and Person-Environment Compatibility This area of education refers to understanding coping strategies and patterns of behavior that clients use, whether consciously or unconsciously, to manage sensory and motor problems when there is not a good person-environment fit. Therapists must help adults with SPDs learn how to evaluate their person-environment compatibility in various situations. Together, they can then examine what strategies and patterns clients use to cope with and manage sensory and motor prob-
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Figure 1. Resources for Assessment and Education Interviews/Sensory Histories • Adult Sensory History (Koomar, Hurwitz, Kahler-Reis, & Szklut, 1996) • Adult Sensory Profile (Brown, Tollefson, Dunn, Cromwell, & Filion, 2001) • Adult-Sensory Interview (Kinnealey & Oliver, 1999) Assessments Body Functions andCogniJion Factors • See May-Benson (20Q9) • Quick NeurologicalScreening (Mutti, Martin,Sterling, & Spalding, 1999) • Motor-Free Visual Perceptual Test (Colarusso & Hammill, 2003) • Dynamic Loewenstern Occupational Therapy Cognitive Assessment (Katz, Livni, Bar-Haim, Erez, &Averbuch, 2011) • Allen Cognitive Scale (Allen, 1990) 7~
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Social/Emotional Factors • Goal Attainment.{Kiruseck, Smith, & Cardillo, 1994) . • Canadian Occupational Performance Measure (Law et aI., 2005) • Beck Depression Inventory II (Beck, Steer, & Brown, 1996) • Beck Anxiety Inventory (Beck & Steer, 1990) occupations • Kohlman Evaluation of Living Skills (Thompson, 1992) • Adaptive Behavior-Assessment Systems (Harrison & Oakland,2003) Participation • Short Form 36 Health:Survey (Ware & Sherbourne,1992) • Scaling Medical Outcomes Social Support Survey (Sherbou me & Stewart, 1991) • The World Health Organization Quality Of Life-Bref (We rid Health Organization,2004) Educational Materials • Occupational Therapy Using a Sensory Integration-Based Approach With Adult Populations (American Occupational Therapy Association; 2011) • Living Sensationally (Dunn, 2007) • Too Loud Too Tight (Heller, 2002) • Highly Sensitive Person (Aron, 1997) • Living with Dyspraxia: A Guide for Adults with Developmental Dyspraxia (Colley, 2006)
contact hour and 1.25 NBCOT PDU). See page CE-7 for details.
coping mechanisms were later confirmed by Koomar (2012) and May-Benson and Patane (2010) in adults who also demonstrated other aspects of SPDs. These coping mechanisms included: (1) avoidance of troubling stimuli or activities, (2) predictability, including the need to be organized and control situations and activities, (3) talking through or rationalizing a difficult situation and providing oneself with reassurances, (4) counteraction, or engaging in activities that reduced the effects of negative or disturbing stimuli, (5) mental preparation, through rehearsing what was to happen in a given situation or getting oneself mentally ready to encounter a challenging stimuli or activity, and (6) confrontation in facing and identifying an upcoming problem and developing a conscious plan to prepare or respond to it. Kinnealey et al. (1995), Koomar (2012), and May-Benson and Patane (2010), all found that the adults in their studies reported that these coping patterns are time consuming, exhausting, and not effective in enabling them to engage fully in life. In contrast, sensory integration principles and strategies let adults with SPDs substitute the coping approach for a more choice-based, activity-oriented, enjoyable approach to life. Treatment Activities Intervention with adults involves two major types of treatment activities: home-based and clinic-based. Optimally, interventions combine both types to some degree. Clinicians should consider not only daily life accommodations and adaptations that facilitate immediate functioning, but also remedial activities that are designed to make changes to the nervous system. The adult clients' resources, time, organizational skills, and emotional willingness to engage in intervention will be factors the clinician needs to consider when building an intervention program. If time or resources are a primary factor, clinicians will want to consider a model of intervention that is based on intermittent consultation and home-based interventions. Pfeiffer and Kinnealey (2003) provided some evidence that this model may be effective with individuals with sensory modulation problems. Individuals with sensory discrimination and praxis problems, however, may not benefit from an exclusively home-based program because it may be difficult to provide adequate sensory input or to promote a just-right adaptive response in a home environment. A clinicbased program with a home carry-over component may be recommended for these adults. Home-Based Interventions Sensory Diet
lems when there is a mismatch between their sensory systems and inputs provided during given activities. In addition, they must evaluate the cost or benefit of a particular coping strategy to clients in a particular situation (David, 1990). Kinnealey et al. (1995) identified six primary coping mechanisms used by adults with sensory defensiveness. These SEPTEMBER 2012 • OT PRACTICE, 17(17)
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Developing home-based activities that allow improved functioning on a daily basis is a good first place to begin intervention. It is important for adult clients to choose activities that provide the sensory input required for self-regulation, readily fit into their daily routines and the environment, and motivate them to pursue goals. Self-treatment through embedCODE CEA0912
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ding corrective sensory and motor activities within daily and weekly routines may be challenging to implement at times, but sensory diets may be all some clients are able to afford or incorporate into their lives. In addition, engaging in selftreatment empowers adults to take control of their difficulties. Sensory diets involve the following four components, all of which must be incorporated to be fully effective. • Routine sensory activities are a daily routine of activities to prepare the nervous system for function and promote self-regulation. Activities that promote coordination, postural control, and discrimination of inputs can also be incorporated if needed. These activities are sensory meals that feed the body. They should be done in preparation for difficult activities, such as at the beginning of the day or prior to engaging in a challenging activity to make participation easier. They may also be done to re-group or re-organize after a challenging activity. Developing a schedule of activities to be engaged in throughout the day is most helpful. • Sensory snacks are strategies that are available to clients for use as needed and may be used during particularly difficult or unexpectedly challenging times. Discussing with clients strategies and activities that are organizing for the nervous system and developing a menu of activity choices is helpful. In addition, it is helpful to develop a "survival kit." This is a collection of materials needed for sensory snacks that are kept near or with clients to use as needed. This may be as simple as a sealed plastic baggie that is kept in a pocket or purse with heavy-duty hair elastics (to provide some proprioception by stretching them), sour gum (oral input for organization), and ear plugs (to decrease noise); or it may be a more complex set of materials for use at home or work. • Supportive leisure activities are regular pleasurable activities that support self-regulation, motor coordination, posture, etc. This may range from activities such as yoga or martial arts several times a week to walking, jogging, swimming, weight training, or other fitness programs. Sports such as tennis, basketball, hiking, and biking are also excellent. Three times per week for an hour is the minimum advised. Some people require a great deal of strenuous, aerobic activity to feel the effects. • Recuperative/calming activities are important when environmental demands sap the person's ability to function. It is important for clients to identify sensory motor environments and times where they can recharge and regroup. This may include eating lunch in the park, or taking a bubble bath while listening to soft music after work.
Remedial Activities Sensory diet activities are necessary to allow immediate, day-to-day functioning and to promote noticeable change in function quickly. However, it is also necessary to engage in a CE-6
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routine that is designed to remediate and improve underlying problems. Depending on their needs, adults with SPDs may need to engage in activities to improve sensory processing, postural control, visual or oculo-motor control and integration with movement, or praxis skills. These activities are often initially introduced during clinical intervention and then carried out at home. They may be challenging for some adults because they target areas of weakness and are often difficult to complete. Structured programs, such as the Learning Breakthrough Program (Belgau & Belgau, 1982), are often helpful because they make completing activities easier. Some remedial activities may be perceived as childish, and adults with low self-esteem based on a lifetime of failure may not want to risk engaging in these kinds of activities. However, remedial home-based activities can also empower adults to be active agents in their own intervention. Direct Clinical Intervention Home-based activities can help improve function; however, adults with problems with praxis and motor coordination may need assistance with grading activities to the justright challenge level to promote improvements. Thus, some clinic-based services are often recommended for adults, and therapists' therapeutic use of self as cheerleaders, emotional supporters, and facilitators of the just-right challenge is vital for successful intervention with adult clients. May-Benson (2009) indicated that direct intervention may be most effective if initiated with an intensive period of treatment, and she described a process of clinical intervention in detail that involves four components: (1) preparatory activities, which promote overall functioning and establish a functional arousal level; (2) sensory activities, which target particular areas of difficulty· (3) integrating activities, which promote engagement in postural, motor, praxis, and visual vestibular activities for skill and (4) organizing sensory wrap-up activities, which organize, re-group, and regulate individuals to prepare for leaving the session. Numerous activities for each of these components are described and readers are referred to that article for more detailed information on treatment activities.
CONCLUSION Occupational therapy treatment of adults with sensory processing problems addresses the sensory regulatory, motor! praxis, and social emotional needs of adults that impact the areas of occupation and performance that compromise their quality of life. Therapists using a sensory integration approach must adjust their intervention to the life context of the adult, including responsibilities, priorities, finances, needs, and availability. A collaborative relationship is essential to support intrinsic motivation, teach principles of intervention, provide for the development of self-advocacy, and enable self-regulation and improved function. Reliable CODE CEA0912
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Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See below for details: and valid assessments; use of treatments that target areas of need for adults; and the use of just-right, relevant, and effective challenges need to be employed in an emotionally and physically safe environment.
How Tcr.Apply for Continuing Education Credit
REFERENCES
the article Clinical Reasoning in the Assessment 01 and Intervention lor Adults With Sensory Processing Disorders, regis-
A After reading
Allen, c. K (1990).AlJen Cognitive Level (ACL) Test. Colchester, CI: S&SIWoridwide.
ter to take the exam online by. either going to www.aotaorg/cea or calling toll-free 877404-2682.
American Occupational Therapy Association. (2011). Occupational therapy using a sensoru integration-based approach with adult populations. Retrieved from http://www.aot8..orglConsumersIProfessionalslWhatIsOTIHW/ FactslSensory-Approach-Adults.aspx?FT=.pdf
B. Once registered, you will receive your personal access information within 2 business days and can log on to www.aota-Iearning.org to take the exam online. You will also-receive a PDF version of the. article that may be printed for personal use.
Aron, E. N. (1997). The highly sensitiue person: How to thrive when the world overwhelms you. New York: Broadway Books. Beck, A. T., & Steer, R. A. (1990). Manuolfor Antonio, TX: Psychological Corporation.
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the Beck An:riety Inventory. San Answer
Belgau, F., & Belgau, B. V.(1982). Learning breakthrough program. Port Angeles, WA:Balametrics. Brown, C., Tollefson, N., Dunn, W.,Cromwell, R., & Filion, D. (2001). The adult sensory profile: Measuring patterns of sensory processing. American Journal of Occupational. Therapy, 55, 75-82. doi:10.50141ajot.55.l.75
Champagne, T., Koomar, J., & Olson, L. (2010). Sensory processing evaluation and intervention in mental health. OT Practice, 15(5), CE-1-CE-8.
Cousins, M., & Smyth, M. M. (2003). Developmental coordination impairments in adulthood. Human Movement Science, 22, 433-459. David, S. (1990). Environment: Implications for occupational therapy in mental health. In S. C. Merrill (Ed.), Environment: Implicationsfor occupational. therapy practice. A sensoru integrative perspective (pp. 65-82). Rockville, MD:American Occupational Therapy Association. Dunn, W. (2007). Living seru;ationally: Understanding your senses. Philadelphia: Jessica Kingsley Publishers. Harrison, P., & Oakland, T. (2003). Adaptive Behavior Assessment System (2nd ed.). San Diego, CA: Elsevier. Heller, S. (2002). Too loud, too bright, toofast, too tight: What to do if you are sensoru defensiue in an over stimulating world. New York: Harper Collins. Heufner, K, Cohn, E., & Koomar, J. (in press). Parenting when mothers and children both have sensory processing challenges. British Journal of Occupational Therapy. Katz, N., Livni, L., Bar-Haim Erez, A., & Averbuch, S. (2011). Dynamic Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery (2nd ed.). Pequannock, NJ: Maddak. Kinnealey, M. (2012, April). Adults with SMD: A comprehensive protocol for intervention. Paper presented at the American Occupational Therapy Association Annual Conference & Expo, Indianapolis, Indiana. Kinnealey, M., Koenig, K P, & Smith, S. (2011). Relationships between sensory modulation and social supports and health-related quality of life. American Journal of Occupational. Therapy, 65,320-327. dOi:10.50141ajot.201l.001370
of the exam (a score of 75% or receive your printa~le certificate.
Koomar, J. (2012, April). Examination of qualitative and quantitative aspects of sensory processing in adults. Paper presented at the American Occupational Therapy Association Annual Conference & Expo, Indianapolis, Indiana.
Champagne, T., & Koomar, J. (2012). Evaluating sensory processing in mental health occupational therapy practice. OT Practice, 17(5), CE-1-CE-8.
Colley, M. (2006). Living with dyspraxia: A guide for adults with developmental dyspra:xia (4th ed.). Philadelphia: Jessica Kingsley Publishers.
D. Upon successful completion more), you will immediately
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Colarusso, R. P., & Hammill, D. D. (2003). Motor Free Visual Perception Test (3rd. ed.). Novato, CA: Academic Therapy Publications.
to the fmal exam found on p. CE-8 by
Kinnealey M., Oliver, B., & WiJbarger, P. (1995). A phenomenological study of sensory defensiveness in adults. American Journal of Occupational. Therapy, 49,444-451. doi:1O.50141ajot.49.5.444
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Cohn, E. (2001). From waiting to relating: Parents' experiences in the waiting room of an occupational therapy clinic. American Journal of Occupational Therapy, 55, 168-175. doi:10.5014Jajot.55.2.167
the questions
September 30, 2014.
Beck, A. T., Steer, R. A., & Brown, G. K (1996). Mamual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
Koomar, J., Hurwitz, M., Kahler-Reis, R., & Szkiut, S. (1996). The adult sensoru history. Watertown, MA:Occupational Therapy Associates. Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (2005). Canadian Occupational. Performance Measure (4th ed). Ottawa, Ontario: CAOT Publications. May-Benson, T. A. (2009). Occupational therapy for adults with sensory processing disorder. OT Practice, 14(10), 15-19. May-Benson, T. A. (2011). Understanding the occupational therapy needs of adults with sensory processing disorder. OT Practice,16(10), 13-17. May-Benson, T. A., & Patane, S. (2010). Commonalities in sensoru processing of adults seeking sensory integration-based occupational. therapy services: A qualitative anal.ysis. Watertown, MA:The Spiral Foundation. Mutti, M. A., Martin, N. A., Sterling, H. M., & Spalding, N. V.(1999). Quick Neurological Screening Test-Srd Edition (QNST-3). Novato, CA: Academic Therapy Publications. Pfeiffer, B. (2012, June). Sensory hypersensitivity and anxiety: The chicken or the egg? Sensors Integration Special Interest Section Quarterly, 35(2), 1-4. Pfeiffer, B., & Kinnealey, M. (2003). Treatment of sensory defensiveness in adults. Occupational. Therapy International., 10, 175-184. Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science & Medicine, 32, 705-714. Thomson, L. K. (1992). Kohlman evaluation of living skiUs: KELS. Rockville, MD: American Occupational Therapy Association. Van Hulle, C. A., Lemery-Chalfant, K, & Goldsmith, H. H. (2007). Genetic and environmental influences on socio-emotional behavior in toddlers: An initial twin study of the infant/toddler social and emotional assessment. Journal of Child Psycfwlogy and Psychiatry, 48, 1014-1024. Ware, J. E., & Sherbourne, C. D. (1992). The MOS 35-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30, 473-483. World Health Organization. (2004). World Health Organization BREF. Geneva, Switzerland: Author.
Quality of Life-
Kinnealey, M., & Oliver, B. (1999). Adult Defensiveness. Understanding, Learning, Teaching: Sensory Interview (ADULT-SI). Unpublished document. SEPTEMBER 2012 • OT PRACTICE,
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CODE CEA0912
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Research, Education, & Practice
AOTAContinuing EducationArticle CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/ cea or call toll-free 877-404-AOTA (2682).
Final Exam
CEA0912
An Approach to Assessment of and Intervention for Adults With Sensory Processing Disorders· September 24, 2012 To receive CE credit, exam must be completed by September 30, 2014.
learning level: Intermediate Target Audience: Occupational therapists and occupational therapy assistants
Content Focus:
Category 1: Domain of Occupational Therapy: Areas of Occupation, Performance Skills; Category 2: Occupational Therapy Process: Evaluation, Intervention
1. Which of the following is an underlying assumption regarding intervention with adults with sensory processing disorders (SPDs)? A. The sensory and motor problems experienced by adults with SPDs are the only reality they know. B. Adults with SPDs will eventually grow out of or compensate for their sensory and motor difficulties. C. Adults with SPDs are usually able to manage or compensate for their sensory and motor difficulties such that their quality of life is not impacted. D. Intervention with adults with SPDs should focus on the occupational therapist directing and leading the intervention and identifying goals for the client. 2. Which of the following is not a major reason for adult self-referral for occupational therapy services? A. Interpersonal difficulties with significant others B. A desire to be calm and relaxed, and to reduce anxiety C. Health problems and allergies D. Difficulty completing functional activities, interfering with participation 3. Evaluation of adults with SPDs should always include a comprehensive interview to identify areas of sensory motor difficulty and problems with occupational performance and participation. A. True B. False 4. Occupational therapists should assess sensory processing areas related only to sensory modulation and defensiveness because this is the most common type of problem seen with adults with SPDs. A. True B. False
5. A mismatch between the sensory styles and needs of adults with SPDs and other individuals in their lives may contribute significantly to emotional difficulties in their relationships. A: True B. False 6. Which of the following assessments may be helpful in identifying the level of social support available to adults with SPDs? A. Kohlman Evaluation of Living Skills B. MOS C. Quick Neurological Screening-3 D. Adult/Adolescent Sensory Profile 7. A necessary component of a comprehensive evaluation of adults with SPDs includes which of the following? A. B. C. D.
Areas of occupation Performance skills Client values All of the above
8. What are two major components of intervention with adults with SPDs? A. Fostering self-esteem and social participation B. Developing social supports and psychological well-being C. Educating clients about their sensory and motor difficulties and developing treatment activities D. Learning functional activities and coping skills 9. Which of the following is not a component of education of an adult with an SPD? A. B. C. D.
Sensory diets Insight Coping mechanisms Self-advocacy
10. A sensory diet includes all of the following except: A. B. C. D.
Routine sensory activities Sensory snacks Home-based visual-vestibular activities Supportive leisure activities
11. Which of the following is not a coping strategy used by adults with SPDs? A. B. C. D.
Avoidance Ignoring stimuli Mental preparation Confrontation
12. Which of the following is not considered to be a regular component of direct intervention? A. B. C. D.
Preparatory activities Sensory diet activities Integrating activities Organizing wrap-up activities
ARTICLE CODE CEA0912
CE-8
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