Content uploaded by Heather Miller Kuhaneck
Author content
All content in this area was uploaded by Heather Miller Kuhaneck on Feb 19, 2019
Content may be subject to copyright.
Sacred Heart University
DigitalCommons@SHU
$$40"3*/.",9&1"07"$4,374#,*$"3*/.2 $$40"3*/.",9&1"07
Understanding Ayres' Sensory Integration
Susanne Smith Roley
University of Southern California
Zoe Mailloux
Heather Miller-Kuhaneck
Sacred Heart University+4)".&$+)2"$1&%)&"13&%4
Tara Glennon
Quinnipiac University
/,,/53)*2".%"%%*3*/.",5/1+2"3 ):0%*(*3",$/--/.22"$1&%)&"13&%4/3!'"$
"13/'3)& $$40"3*/.",9&1"07/--/.2
9*213*$,&*2#1/4()33/7/4'/1'1&&".%/0&."$$&22#73)&$$40"3*/.",9&1"07"3*(*3",/--/.23)"2#&&."$$&03&%'/1*.$,42*/.*.
$$40"3*/.",9&1"07"$4,374#,*$"3*/.2#7"."43)/1*8&%"%-*.*231"3/1/'*(*3",/--/.2/1-/1&*.'/1-"3*/.0,&"2&$/.3"$3
'&11*#702"$1&%)&"13&%4
&$/--&.%&%*3"3*/.
-*3)/,&742"..&"*,,/46 /&*,,&14)".&$+&"3)&1,&../."1".%&123".%*.(71&2&.2/17.3&(1"3*/.
1"$3*$&
CE-1SEPTEMBER 2007 n OT PRACTICE, 12(17) ARTICLE CODE CEA0907
AOTA Continuing Education Article
Earn .1 AOTA CEU (one NBCOT PDU/one contact hour, see page CE-7 for details)
SUSANNE SMITH ROLEY, MS, OTR/L, FAOTA
Project Director, USC/WPS Comprehensive Program in Sensory
Integration
USC Division of Occupational Science and Occupational Therapy
Los Angeles, CA
Coordinator of Education and Research
Pediatric Therapy Network
Torrance, CA
ZOE MAILLOUX, MA, OTR/L, FAOTA
Director of Administration
Pediatric Therapy Network
Torrance, CA
HEATHER MILLER-KUHANECK, MS, OTR/L
Instructor
Sacred Heart University
Fairfield, CT
TARA GLENNON, EDD, OTR/L, FAOTA
Professor of Occupational Therapy
Quinnipiac University
Hamden, CT
Owner
Center for Pediatric Therapy
Fairfield, CT
ABSTRACT
Occupational therapists and occupational therapy assistants
rely on knowledge and skills to guide their intervention plan-
ning as they help clients who are experiencing difficulties
with engaging in occupation. Sensory integration theory, with
its rich history grounded in the science of human growth
and development, offers occupational therapy practitioners
specific intervention strategies to remediate the underlying
sensory issues that affect functional performance.
This article articulates the core principles of sensory inte-
gration as originally developed by Dr. A. Jean Ayres, explains
the rationale for developing a trademark specifically linked
to these core principles, and identifies the impact that this
trademark can have on practice.
LEARNING OBJECTIVES
After reading this article, you should be able to:
1. Recognize why the term Ayres Sensory Integration® was
trademarked.
2. Identify the core concepts of Ayres Sensory Integration in
relation to typical development, patterns of sensory inte-
gration dysfunction, and principles of intervention.
3. Differentiate Ayres Sensory Integration from other
approaches that use similar terms and strategies but
do not include the same theoretical principles of this
approach.
INTRODUCTION
Biologist Edward Wilson (1998) stated that “scientific theo-
ries are the product of imagination—informed imagination.
They reach beyond their grasp to predict the existence of
previously unsuspected phenomena” (p. 57). Sensory inte-
gration theory, originated by A. Jean Ayres, fits this descrip-
tion because many aspects of her work represent concepts
that require a great deal of imagination about previously
unsuspected phenomena. Generated by an occupational
therapist and developed primarily within the profession of
occupational therapy, sensory integration theory and its
application provide an important set of knowledge and skills
for practitioners world-wide. Sensory integration is also one
of the first theories generated within occupational therapy
to undergo the rigor of providing evidence that validates its
constructs while providing direction for the strategies clini-
cians use to remediate the underlying sensory issues that
affect performance.
Since Ayres’s early writings, beginning in the 1950s,
many publications have contributed to the evolution of this
theory, which is one of the most cited and applied of all
theories within occupational therapy (Mulligan, 2002). As
greater interest has developed in the role of brain function in
behavior and learning, increased attention has been directed
toward Ayres’s work. The result has been increased apprecia-
tion of the eloquence and substance of her research, as well
as controversy related to documentation of the efficacy of
some aspects of this approach. Part of the controversy stems
from the many publications and intervention programs that
do not truly reflect the principles of Ayres’s work but that
have nonetheless been mistakenly associated with sensory
integration (Parham, Cohn, et al., 2007). In an effort to clar-
ify the concepts that do reflect Ayres’s sensory integration
framework and to preserve the integrity of this work within
occupational therapy, the Baker/Ayres Trust trademarked the
term Ayres Sensory Integration®. This article presents the
rationale for establishing a trademark for this term, identi-
fies the core concepts of Ayres Sensory Integration, and
discusses the implications of this trademark for occupational
therapy practitioners.
This article does not evaluate the validity or usefulness of
other sensory-based theories, diagnostic terms, or interven-
CE-1
Understanding
Ayres Sensory Integration®
AOTA Continuing Education Article
NOW AVAILABLE! CE Article, exam, and certificate are now available ONLINE.
Register at www.aota.org/cea or call toll-free 877-404-AOTA (2682).
CE-2 SEPTEMBER 2007 n OT PRACTICE, 12(17)
ARTICLE CODE CEA0907
tions within or outside of occupational therapy. The terminol-
ogy used in this article is consistent with that used by Ayres.
Many terms have multiple meanings, such as sensory inte-
gration as a theory and frame of reference, and as a process
related to multimodal processing that supports the forma-
tion and retrieval of multisensory perceptions in the central
nervous system. Sensory processing is a generic term used
to describe the way in which sensation is detected, trans-
duced, and transmitted through the nervous system. Sen-
sory processing deficits, therefore, can be used to describe
any of the ways in which the above is flawed. Sensory
integrative deficits, as used within occupational therapy,
have been defined through many years of factor and cluster
analyses, including confirmatory analyses, and may be identi-
fied through the use of standardized assessments, skilled
observations, and parent and teacher report. Sensory-based
strategies may or may not include those that are considered
part of Ayres Sensory Integration. The varying ways in which
these terms overlap and are used in practice may be confus-
ing. Therefore, when using these terms and evaluating a
client’s abilities or a practitioner’s focus during intervention,
it is important as therapists and consumers to understand
the research underlying the identification of a certain type of
sensory problem and the sensory-based methods used during
intervention.
RATIONALE FOR ESTABLISHING A TRADEMARK FOR THE
TERM AYRES SENSORY INTEGRATION®
A review of the use of the term sensory integration yields a
concerning number of references to sensory integration that
involve methods void of key occupational therapy principles,
such as promoting an adaptive response and engagement in
occupation (Glennon & Smith Roley, 2006, 2007; Smith Roley
& Glennon, 2006). In recent years, a proliferation of sensory
stimulation treatment centers have typically involved passive
visual, auditory, and movement sensations (e.g., www.sen-
sorylearning.com, www.sensorycenter.com, www.neurosen-
sorycenter.com, www.sirri.com), which often are provided by
individuals who are not occupational therapists and whose
professional credentials are sometimes difficult to discern.
Several therapists from outside the United States also have
reported concerns about other professions, such as physical
education and psychology, whose members claim sensory
integration as a psychoeducational tool while also demon-
strating some efforts to limit occupational therapy’s involve-
ment in the assessment and intervention of children with
sensory integration deficits. Lastly, it has become common
for sensory activities to be proposed as rewards for appropri-
ate behavior or performance during discrete trial training for
children with autism and sensory integration, which is often
misunderstood or misrepresented within these communities
(e.g., www.autism-society.org/site/PageServer?pagename=ab
out_treatment_learning#SensoryIntegration).
The Baker/Ayres Trust shared the professional concerns
regarding confusion around sensory integration theory
and established a trademark for the term Ayres Sensory
Integration®.
CORE CONCEPTS IN AYRES SENSORY INTEGRATION
Bundy, Lane, and Murray (2002) noted that sensory integra-
tion theory is used to explain behavior, plan intervention, and
predict how behavior will change through intervention. They
identified the three main components of sensory integration
theory as describing typical sensory integration development,
defining sensory integrative dysfunction, and guiding inter-
vention programs. A clear and comprehensive understanding
of these three aspects of Ayres Sensory Integration will assist
occupational therapy professionals in appropriate and effec-
tive application of this approach.
TYPICAL SENSORY INTEGRATION FUNCTIONING
Ayres built sensory integration theory on her understanding
of neurobiology. Before the publication of her classic book,
Sensory Integration and Learning Disorders (Ayres,
1972b), she published numerous essays on her theories,
setting forth the key components of the relationship between
sensory integration and performance through her analysis of
existing research. These principles informed her work in test
development and later research that defined various types of
sensory integration deficits and the related deficits in motor
learning, academic abilities, attention, and behavior.
In 1960, Ayres challenged the principles of “purposeful
activity” that focused on exercising a component of a motor
pattern, proposing that “1) learning takes place as a func-
tion of reward or reinforcement, 2) one learns what he does,
and 3) learning takes place because there is a purpose for its
taking place” (Ayres, 1960, p. 38). She believed that a person
must perceive the goal and process of the intervention in
order to benefit from it, highlighting the perceptual aware-
ness of occupational engagement.
Drawing on motor control theories, Ayres (1960) pro-
posed that motor learning follows inherent maturational
sequences and is influenced by, if not dependent on, incom-
ing sensation. In 1961, Ayres proposed that the development
of the body scheme in children created a postural model to
understand visual-motor development, and she proposed
that the ability to sit up and sit still required perceptual sup-
port from the vestibular and proprioceptive systems in addi-
tion to the neuromotor systems, thus highlighting postural
control as an essential foundation for more skilled academic
and motor performance. She further posited that the tactile,
vestibular, proprioceptive, and visual systems provided key
data in the development of reading and writing and may be
impaired in children with learning disabilities. Ayres’s early
references to what is now commonly called sensory modula-
tion began in 1964. Ayres (1964) informed readers of the
Earn .1 AOTA CEU (one NBCOT PDU/one contact hour, see page CE-7 for details.
CE-3SEPTEMBER 2007 n OT PRACTICE, 12(17) ARTICLE CODE CEA0907
importance of tactile functions, and she proposed that the
ability to focus and maintain attention and to keep a steady
level of activity were related to the way in which the nervous
system responds to tactile and other sensations.
In 1972, Ayres wrote about one of the most important fea-
tures of her theory: the aspect of sensory integration itself.
She proposed that sensory systems do not develop indepen-
dently of one another; rather, visual and auditory processing
depends on the foundational body-centered senses (Ayres,
1972a, 1972b, 1972c, 1972d). According to Ayres, sensory
information is not processed in isolation and, given this
essential feature of the central nervous system, therapeutic
intervention that incorporates sensation to affect multisen-
sory perception will influence learning and behavior. Ayres
(1961) proposed that through the development of these
sensorimotor functions and, specifically, by facilitating adap-
tive somatomotor responses, a person can develop improved
learning, reading, math, visual and auditory perception, and
skilled motor tasks. Bundy et al. (2002) stated this postulate
of sensory integration theory as follows: “Learning is depen-
dent on the ability to take and process sensation from move-
ment and the environment and use it to plan and organize
behavior” (p. 5).
The hypotheses that Ayres proposed continue to reflect
forward thinking about brain function and learning and
behavior, such as:
n Perceptual awareness supports and facilitates occupa-
tional engagement.
n Motor learning is influenced by, if not dependent on,
incoming sensation.
n Body awareness creates a postural model to understand
visual-motor development.
n Postural control is essential for skilled academic and
motor performance.
n Tactile, vestibular, proprioceptive, and visual systems pro-
vide key data in the development of reading and writing.
n The ability to focus and maintain attention and to keep a
steady level of activity, and the way in which the nervous
system responds to tactile sensation, are related.
n The sensory systems develop in an integrated and depen-
dent manner.
n Visual and auditory processing depend on foundational
body-centered senses.
SENSORY INTEGRATIVE DYSFUNCTION
With a systematic and comprehensive research program
unique within the field of occupational therapy at the time,
Ayres tested the hypotheses she developed based on her
study of neurobiological function and childhood occupation.
Kielhofner (2005) noted, Ayres was a “notable exception” as
an occupational therapist who “remained a practitioner while
creating theory and conducting research” (p. 232). This com-
bination of scientific inquiry alongside clinical observation
and experience guided her study of the challenges children
with learning and behavioral concerns face.
Through the use of a series of factor analyses with
standardized measures of sensory discrimination, sensory
responsivity, fine and gross motor skills, and praxis, Ayres
developed sensory integration theory and identified pat-
terns of function and dysfunction. She proposed that these
factor analyses would help to discover relationships among
the different kinds of sensory perception, motor activ-
ity, laterality, and selected areas of cognitive function. She
analyzed literature that included children with perceptual
deficits, motor deficits, cognitive deficits, and sensory loss
and hypothesized that although multisensory perceptual and
motor deficits may affect these persons, it was possible that
a child could show impairment in one area and not the other
(Ayres, 1965). Indeed, Ayres found that this was the case.
Beginning with factor analyses on the Southern California
Sensory Integration Tests (SCSIT; Ayres, 1972c) and later
with the Sensory Integration and Praxis Tests (SIPT; Ayres,
1989), Ayres confirmed the relationships between sensory
and motor functions in children who were typically devel-
oping and showed that perceptual deficits were found in
children with an array of symptoms or syndromes in different
ways from those seen in the general (normal random sample)
population.
Beginning in 1965, and until her last paper published in
1989 shortly after her death, Ayres documented the presence
of patterns of sensory integration dysfunction that included
(a) developmental dyspraxia, distinguished by a link between
motor planning and tactile perception; (b) visual perception,
form and space perception, and visual-motor functions; (c)
tactile defensiveness linked with hyperactive-distractible
behaviors; (d) vestibular and postural deficits, including
integration of two sides of the body, right–left discrimina-
tion, midline crossing, and bilateral motor coordination; (e)
deficits in visual figure ground discrimination; and (f) deficits
in auditory and language functions.
Over this 24-year period, repeated factor analyses showed
similar patterns of deficits with different samples of children.
These repeated analyses provided the construct-related
evidence that sensory integrative deficits exist as reproduc-
ible patterns. Ayres completed numerous unpublished factor
analyses in addition to those that were published (Ayres,
1989; see also Parham & Mailloux, 2005). Early analyses
included as many as 35 other perceptual and motor mea-
sures, cognitive tests, auditory processing measures, behav-
ioral measures, and clinical observations of neuromotor func-
tions. The SIPT, a revised and new set of tests that replaced
the earlier SCSIT, provided the opportunity for an expansion
of tests normed on a large national sample. (The SIPT allows
the therapist within a 2-hour testing period the opportunity
to objectively sample multiple areas of performance, such
as visual perception; visual-motor skills; visual construction;
AOTA Continuing Education Article
NOW AVAILABLE! CE Article, exam, and certificate are now available ONLINE.
Register at www.aota.org/cea or call toll-free 877-404-AOTA (2682).
CE-4 SEPTEMBER 2007 n OT PRACTICE, 12(17)
ARTICLE CODE CEA0907
tactile discrimination; tactile defensiveness; kinesthesia;
vestibular-ocular nystagmus; balance; bilateral motor control;
sequencing; several types of praxis, such as sequencing; imi-
tation of body gestures and oral-motor gestures; and follow-
ing verbal commands. The SIPT provides standard scores for
children between 4 years and 8 years 11 months of age.)
In 1998, Mulligan embarked on a monumental study that
used more than 10,000 sets of data, each representing an
individual child. She performed confirmatory and exploratory
factor analyses and found similar patterns of deficits with
her data as Ayres did. Mulligan also found a commonality
between the individual patterns she identified as bilateral
integration and sequencing, somatopraxis, visuopraxis,
somatosensory, and postural-ocular movements. Ayres origi-
nally called this commonality “generalized praxis dysfunc-
tion” and subsequently called it “general sensory integration
dysfunction” (Ayres, 1989, p. 176).
Ayres, and later Mulligan, also performed cluster analyses.
Ayres’s (1989) study using the SIPT yielded four dysfunc-
tional groups, namely, low-average bilateral integration and
sequencing, visual and somatodyspraxis, dyspraxia on verbal
command, and generalized sensory integrative dysfunc-
tion. Mulligan’s groups were generalized sensory integration
dysfunction and dyspraxia—severe; dyspraxia; generalized
sensory integration dysfunction and dyspraxia—moderate;
and low-average bilateral integration and sequencing.
The extensive research Ayres conducted and Mulligan
reinforced formed the basis for identifying patterns of
sensory integrative dysfunction with new information and
related research now contributing to the refinement and
further understanding of these types of dysfunction. Some
of the ways in which the factor analyses moved the theory of
sensory integration along are as follows:
n Tactile perception is linked to praxis (Ayres, 1965, 1966a,
1966b, 1971; Ayres, Mailloux, & Wendler, 1987).
n Tactile defensiveness is linked to hyperactivity rather than to
tactile perception (Ayres, 1965, 1966a, 1966b, 1969, 1972d).
n Most children show more than one factor, demonstrating
relationships among factors, and less variation in patterns
is seen in children who are typically developing (Ayres,
1965, 1966a, 1966b, 1989; Ayres et al., 1987).
n Introduction of a measure of postrotary nystagmus test
clarifies the role of vestibular system with postural and
bilateral pattern (Ayres, 1975).
n Inclusion of auditory language measures suggest left hemi-
sphere versus sensory integrative dysfunction (Ayres,
1969, 1971, 1972d, 1977).
n Sensory integrative patterns are not along sensory sys-
tems (Ayres, 1965, 1966a, 1966b, 1971, 1972A, B, D; 1977,
1989; Ayres et al., 1987).
PRINCIPLES GUIDING INTERVENTION PROGRAMS
According to Spitzer and Smith Roley (2001), “Intervention
emphasizing a sensory integration approach addresses the
sensory needs of the child in order for the child to make
adaptive and organized responses to a variety of circum-
stances and environments” (p. 17). It is best distinguished by
the active engagement of the child who is allowed to move,
jump, swing, and crash. Additionally the child is encouraged
to move and change the environment to create higher and
more challenging demands for perceptual-motor integra-
tion. The hallmark of sensory integration is that it is done in
the context of play, the children love the activities, and the
activities are their own reward.
Ayres structured her intervention approach using sensory
integration theory around principles of motor learning, the
adaptive response, and purposeful activity.
The following principles are deemed essential to the
delivery of intervention using a sensory integration approach
(Parham, Cohn, et al., 2007):
n Intervention is delivered by a qualified professional—
occupational therapist or occupational therapy assistant
under the direct supervision of the occupational therapist,
physical therapist, or speech-language pathologist.
n The intervention plan is family centered and based on a
complete evaluation and interpretation of the patterns
of sensory integrative dysfunction in collaboration with
significant persons in the client’s life and with adherence
to ethical and professional standards of practice.
n Therapy takes place in a safe environment that includes
equipment that will provide vestibular, proprioceptive,
and tactile sensations and opportunities for praxis.
n Activities are rich in sensation (especially vestibular, tac-
tile, and proprioceptive sensation), and offer opportuni-
ties for integrating that information with other sensations,
such as visual and auditory.
n Activities promote regulation of affect and alertness
and provide the basis for attending to salient learning
opportunities.
n Activities promote optimal postural control in the body,
oral-motor, ocular-motor areas, and bilateral motor con-
trol, including maintaining control while moving through
space and adjusting posture in response to changes in the
center of gravity.
n Activities promote praxis, including organization of activi-
ties and self in time and space.
n Intervention strategies provide the “just-right challenge.”
n Opportunities exist for the client to make adaptive
responses to changing and increasingly complex environ-
mental demands. Highlighted in Ayres Sensory Integra-
tion intervention principles is the “somatomotor adaptive
response,” which means that the person is adaptive with
the whole body, moving and interacting with people and
things in the three-dimensional space.
n Intrinsic motivation and drive are used to interact through
pleasurable activities; in other words, play.
Earn .1 AOTA CEU (one NBCOT PDU/one contact hour, see page CE-7 for details.
CE-5SEPTEMBER 2007 n OT PRACTICE, 12(17) ARTICLE CODE CEA0907
n The therapist engenders an atmosphere of trust and
respect through contingent interactions with the client.
The activities are negotiated, not preplanned, and the
therapist is responsive to altering the task, interaction,
and environment based on the client’s responses.
n The activities are their own reward, and the therapist
ensures the client’s success in whatever activities are
attempted by altering the activities to meet the client’s
abilities.
Although more than 80 studies have been published on
evidence in the effectiveness of sensory integration meth-
ods, many have methodological flaws (Miller, 2003; Parham,
Cohn, et al., 2007). Most do not report fidelity, and those
that do have minimally adhered to the fidelity principles that
define Ayres Sensory Integration. Clearly, further research is
needed.
The intervention principles of Ayres Sensory Integration
highlighted through the fidelity work not only demonstrate
how this approach differs from the sensory stimulation pro-
tocols, but also reflect the many ways in which this approach
is occupation based. Cohn’s (2001a) work on parental
perspectives of sensory integration revealed that parents’
overarching concerns for their children with sensory integra-
tive disorders were related to social participation. Through
interviews, parents reported that they valued their children’s
improved ability to engage in activities as being important in
relation to the children’s sense of self-worth. In related work,
Cohn (2001b) also reported on the ways in which the family-
centered nature of the sensory integration approach affects
engagement and participation for parents as well as for the
child in treatment.
CLARIFYING AYRES SENSORY INTEGRATION IN RELATION
TO SENSORY-RELATED TERMS AND APPROACHES
With increased attention on the role of sensation in develop-
ment, learning, and behavior, many usages and applications
of terms that share some similarity with those associated
with Ayres Sensory Integration now exist. The surge in
the diagnosis of autism (Centers for Disease Control and
Prevention, 2007), along with the prevalence of sensory-
related symptoms in this disorder, also have had the effect
of increasing attention toward and variation in application of
terminology. The overlap of terminology creates the poten-
tial for confusion and lack of clarity in an area that requires
thoughtful distinction for professionals internal and external
to occupational therapy as well as for consumers. Two areas
in which terminology confusion is evident relate to the “types
or patterns of dysfunction” and “intervention approaches.”
In relation to the terms used for the type or patterns of sen-
sory integration deficits, some of the variations have occurred
as research has contributed new and refining information. This
type of change in terminology is clearly documented through
Ayres’s and Mulligan’s factor analytic studies as well as through
other studies of sensory integration function and dysfunc-
tion. As the concepts that have emanated from Ayres Sensory
Integration continue to evolve, some work likely will expand
and add to Ayres’s original work, whereas other concepts may
eventually lead to different perspectives or frameworks. For
example, research in the area of sensory modulation in recent
years (Dunn, 1999; May-Benson & Koomar, 2007; Miller, Anza-
lone, Lane, Cermak, & Osten, 2007; Miller-Kuhaneck, Henry,
& Glennon, 2007; Parham, Cohn, et al., 2007; Parham, Ecker,
Miller-Kuhaneck, Henry, & Glennon, 2007; Schaaf, Miller, Sea-
wall, & O’Keefe, 2003) has clearly expanded the original factor
analysis findings from Ayres on tactile defensiveness and on
her clinical descriptions of gravitational insecurity. In another
example, however, the explanation for other variations in
terminology about the type of dysfunction is sometimes less
clear. In a series dedicated to sensory integration terminology
in the year 2000 Sensory Integration Special Interest Sec-
tion Quarterly newsletters (Hanft, Miller, & Lane, 2000; Lane,
Miller, & Hanft, 2000; May-Benson, Reeves, & Young, 2000;
Miller & Lane, 2000), terms such as dysfunction in sensory
integration and dysfunction in sensory modulation were
suggested as preferable over the term disorder (Lane et al.,
2000). However, more recently some of the same authors
began to use the term disorder instead of dysfunction
(Miller et al., 2007). Although this shift in terminology may be
related to efforts to submit some aspects of sensory integra-
tion problems to a categorization system (i.e., the Diagnostic
and Statistical Manual), the clinical reason for the suggested
change to disorder from dysfunction is unclear to practitio-
ners, particularly because previous occupational therapy publi-
cations suggested not using this term.
In addition, the same authors (Miller et al., 2007) have
now suggested using sensory processing instead of sensory
integration for the patterns of deficit. One of the reasons the
authors seem to suggest for changing from sensory integra-
tion to sensory processing is that they believe the term for
a disorder needs to be differentiated from the term for the
theory and intervention. However, Ayres and other research-
ers in sensory integration have already assigned more
specific terms to disorder patterns (e.g., bilateral integra-
tion and sequencing deficit [Ayres, 1989]) to accomplish
this differentiation. Another rationale given for using sensory
processing versus sensory integration is that
use of the term sensory integration…is often interpreted
differently within and outside the field of occupational
therapy. (For example, use of the term sensory integration
often applies to a neurophysiologic cellular process rather
than a behavioral response to sensory input as connoted
by Ayres.) (Miller et al., 2007, p. 136)
This rationale is equally confusing, however, because the
term sensory processing also is used extensively outside of
occupational therapy in neurophysiologic cellular applications.
AOTA Continuing Education Article
NOW AVAILABLE! CE Article, exam, and certificate are now available ONLINE.
Register at www.aota.org/cea or call toll-free 877-404-AOTA (2682).
CE-6 SEPTEMBER 2007 n OT PRACTICE, 12(17)
ARTICLE CODE CEA0907
A search of the two terms in PubMed (July 12, 2007) yielded
7,521 citations for sensory processing and 2,304 citations for
sensory integration, with almost all of the entries for both
terms citing research that does not apply to either term in
ways occupational therapists use. Thus, one must question
whether this reasoning supports a change in terminology from
sensory integration to sensory processing.
Intervention approaches represent another area that calls
for thoughtfulness in the use of terminology. Ayres devel-
oped her theory of sensory integration at a time when several
educators and psychologists were studying and developing
programs often referred to by such terms as perceptual-
motor, sensorimotor, or visual-motor approaches (Frostig
& Horne, 1964; Kephart, 1960). These perceptual-motor and
sensorimotor approaches tend to focus primarily on visual
and sometimes auditory perception but did not prioritize the
primary sensations of the tactile, proprioceptive, and vestibu-
lar sensory systems, as does Ayres Sensory Integration. Finally,
praxis or “motor planning” is highlighted in Ayres Sensory
Integration versus the emphasis on specific motor skills, such
as eye–hand coordination as seen in the perceptual programs.
Occupational therapists also have developed, and prac-
titioners commonly use, a variety of approaches that incor-
porate sensation or complement sensory-based strategies
(Bundy et al., 2002). For example, the Alert Program for
Self-Regulation is a complementary approach that encourag-
es cognitive awareness of alertness often with the use of sen-
sory strategies to support learning and behavior (Williams &
Shellenberger, 1994). Other approaches primarily use passive
sensory experiences or sensory stimulation based on specific
protocols, such as the Wilbarger Approach (Wilbarger &
Wilbarger, 2002) and the Vestibular-Oculomotor Protocol
(Kawar, 2002). Although these techniques include sensation
and may eventually demonstrate evidence of effectiveness
if they are researched in the future, they are not consistent
with the principles of Ayres Sensory Integration and, thus,
represent a different model.
The attempt to bring uniformity to the use of terms has
opened dialogue but has not necessarily led to clarity or con-
sensus. As the professional dialogue continues, it is important
for the occupational therapy community to be aware that the
terms Ayres applied as part of Ayres Sensory Integration were
chosen carefully based on theory and research. Acquiring a
clear understanding of the core principles of Ayres Sensory
Integration as well as other theories and frames of reference
allows occupational therapists and occupational therapy
assistants to identify the supporting literature to enhance their
evidence-based practice and clearly articulate to consumers
which principles they are implementing.
CONCLUSION
Ayres Sensory Integration encompasses a core theoreti-
cal framework developed by one of the first occupational
therapists to develop and implement a program in research.
Based on a long and rich history of theory formulation,
test development, hypothesis testing, and clinical practice,
sensory integration represents one of the most impressive
accomplishments to emanate out of occupational therapy.
The trademark of this term is intended to protect and pre-
serve this important work so that it can continue to evolve
and grow in ways that Ayres intended. In 1963, Ayres wrote,
“Twenty-five years from now a neurophysiological approach
to the treatment of patients with motor problems is going
to be quite well developed, fairly well accepted and we
are going to look back with respect and gratitude to those
people who helped start it” (Ayres, 1974, p. 63). Now more
than 25 years later, we indeed write this article with respect
and gratitude for the work of Ayres and all those who have
contributed to our understanding of the contributions of
sensation to learning, development, and participation in daily
activities. n
REFERENCES
Ayres, A. J. (1960). Occupational therapy for motor disorders resulting from
impairment of the central nervous system. Reprinted from Rehabilitation Lit-
erature, 21, 302-310 in (1974) The development of sensory integrative theory
and practice: A collection of the works of A. Jean Ayres (p. 38). Compiled
by A. Henderson, L. Llorens, E. Gilfoyle, C. Meyers, & S. Prevel. Dubuque, IA:
Kendall/Hunt.
Ayres, A. J. (1961). Development of the body scheme in children. Reprinted
from American Journal of Occupational Therapy, XV, 3. Reprinted from
Rehabilitation Literature, 21, 302–310 in (1974) The development of sensory
integrative theory and practice: A collection of the works of A. Jean Ayres
(pp. 125–132). Compiled by A. Henderson, L. Llorens, E. Gilfoyle, C. Meyers, &
S. Prevel. Dubuque, IA: Kendall/Hunt.
Ayres, A. J. (1963). The Eleanor Clarke Slagle Lecture: The development of
perceptual-motor abilities: A theoretical basis for treatment of dysfunction.
American Journal of Occupational Therapy, 17, 221–225.
Ayres, A. J. (1964). Tactile functions: Their relation to hyperactive and perceptual
motor behavior. American Journal of Occupational Therapy, 18, 6–11.
Ayres, A. J. (1965). Patterns of perceptual-motor dysfunction in children: A factor
analytic study. Perceptual and Motor Skills, 20, 335–368.
Ayres, A. J. (1966a). Interrelationships among perceptual-motor functions in
children. American Journal of Occupational Therapy, 20, 68–71.
Ayres, A. J. (1966b). Interrelations among perceptual-motor abilities in a group
of normal children. American Journal of Occupational Therapy, 20, 288–292.
Ayres, A. J. (1966c). Interrelation of perception, function and treatment. Journal
of the American Physical Therapy Association, 46, 741–744.
Ayres, A. J. (1969). Deficits in sensory integration in educationally handicapped
children. Journal of Learning Disabilities, 2(3), 44–52.
Ayres, A. J. (1971). Characteristics of types of sensory integrative dysfunction.
American Journal of Occupational Therapy, 25, 329–334.
Ayres, A. J. (1972a). Improving academic scores through sensory integration.
Journal of Learning Disabilities, 5, 338–343.
Ayres, A. J. (1972b). Sensory integration and learning disorders. Los Angeles:
Western Psychological Services.
Ayres, A. J. (1972c). Southern California Sensory Integration Tests. Los Ange-
les: Western Psychological Services.
Ayres, A. J. (1972d). Types of sensory integrative dysfunction among disabled
learners. American Journal of Occupational Therapy, 26, 13–18.
Ayres, A. J. (1974). Occupational therapy for motor disorders resulting from
impairment of the central nervous system. In A. J. Ayres (Ed.), The develop-
ment of sensory integrative theory and practice: A collection of the works
of A. Jean Ayres (pp. 34–53). Dubuque, IA: Kendall/Hunt. (Original work
published 1963).
CE-7SEPTEMBER 2007 n OT PRACTICE, 12(17) ARTICLE CODE CEA0907
Ayres, A. J. (1975). Southern California Postrotary Nystagmus Test. Los Ange-
les: Western Psychological Services.
Ayres, A. J. (1977). Cluster analyses of measures of sensory integration. Ameri-
can Journal of Occupational Therapy, 31, 362–366.
Ayres, A. J. (1989). Sensory Integration and Praxis Tests manual. Los Angeles:
Western Psychological Services.
Ayres, A. J., Mailloux, Z., & Wendler, C. L. W. (1987). Developmental apraxia: Is it
a unitary function? Occupational Therapy Journal of Research, 7(2), 93–110.
Bundy, A. C., Lane, S., & Murray, E. A. (Eds.). (2002). Sensory integration:
Theory and practice (2nd ed.). Philadelphia: F. A. Davis.
Centers for Disease Control and Prevention. (2007). CDC releases new data
on autism spectrum disorders (ASDs) from multiple communities in the
United States. Retrieved July 13, 2007, from http://www.cdc.gov/od/oc/media/
pressrel/2007/r070208.htm
Cohn, E. S. (2001a). Parent perspectives of occupational therapy using a sensory inte-
gration approach. American Journal of Occupational Therapy, 55, 285–294.
Cohn, E. S. (2001b). From waiting to relating: Parents’ experiences in the waiting
room of an occupational therapy clinic. American Journal of Occupational
Therapy, 55, 167–174.
Dunn, W. (1999). Sensory Profile. San Antonio, TX: Psychological Corporation.
Frostig, M., & Horne, D. (1964). The Frostig program for the development of
visual perception. Chicago: Follet Educational.
Glennon, T. J., & Smith Roley, S. (2006, April 28). Sensory integration: Inside
and outside of occupational therapy practice. Paper presented at the 2006
American Occupational Therapy Association Annual Conference & Expo,
Charlotte, NC.
Glennon, T. J., & Smith Roley, S. (2007, April 21). Sensory integration: Interna-
tional network to support occupational therapy practice. Paper presented at
the 2007 American Occupational Therapy Association Annual Conference &
Expo, St. Louis, MO.
Hanft, B. E., Miller, L. J., & Lane, S. J. (2000, September). Toward a consensus in
terminology in sensory integration theory and practice: Part 3: Observable
behaviors: Sensory integration dysfunction. Sensory Integration Special
Interest Section Quarterly, 23, 1–4.
Holm, M. B. (2000). 2000 Eleanor Clarke Slagle lecture—Our mandate for the
new millennium: Evidence-based practice. American Journal of Occupa-
tional Therapy, 54, 575–585.
Kawar, M. (2002). Oculomotor control: An integral part of sensory integration. In
A. C. Bundy, S. J. Lane, & E. A. Murray (Eds.), Sensory integration: Theory
and practice (2nd ed., pp. 353–357). Philadelphia: F. A. Davis.
Kephart, N. C. (1960). The slow learner in the classroom. Columbus, OH: Merrill.
Kielhofner, G. (2005). Research concepts in clinical scholarship—Scholar-
ship and practice: Bridging the divide. American Journal of Occupational
Therapy, 59, 231–239.
Lane, S. J., Miller, L. J., & Hanft, B. E. (2000, June). Toward a consensus in termi-
nology in sensory integration theory and practice: Part 2: Sensory integration
patterns of function and dysfunction. Sensory Integration Special Interest
Section Quarterly, 23, 1–3.
May-Benson, T. A., & Cermak, S. A. (2007). Development of an assessment for
ideational praxis. American Journal of Occupational Therapy, 61, 148–153.
May-Benson, T. A., & Koomar, J. A. (2007). Identifying gravitational insecurity
in children: A pilot study. American Journal of Occupational Therapy, 61,
142–147.
May-Benson, T. A., Reeves, G. D., & Young, S. B. (2000, December). Creating a
consensus on terminology in sensory integration: Comments and reflections.
Sensory Integration Special Interest Quarterly, 23, 1–3.
Miller, L. J. (2003). Empirical evidence related to therapies for sensory process-
ing impairments. Retrieved July 7, 2007, from http://www.spdnetwork.
org/research/miller.empirical.html
Miller, L. J., Anzalone, M. E., Lane, S. J., Cermak, S. A., & Osten, E. T. (2007).
From the Guest Editor—Concept evolution in sensory integration: A pro-
posed nosology for diagnosis. American Journal of Occupational Therapy,
61, 135–140.
Miller, L. J., & Lane, S. J. (2000, March). Toward a consensus in terminology in sen-
sory integration theory and practice: Part 1: Taxonomy of neurophysiological
processes. Sensory Integration Special Interest Section Quarterly, 23, 1–4.
Miller-Kuhaneck, H., Henry, D. A. & Glennon, T. J. (2007). Sensory processing
measure—main classroom and school environment forms. Los Angeles, CA:
Western Psychological Services.
Mulligan, S. (1998). Patterns of sensory integration dysfunction: A confirmatory
factor analyses. American Journal of Occupational Therapy, 52, 819–828.
Mulligan, S. (2002). Advances in sensory integration research. In A. C Bundy, S.
Lane, & E. A. Murray, (Eds.). (2002). Sensory integration: Theory and prac-
tice (2nd ed., pp. 397–411). Philadelphia: F. A. Davis.
Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J. A., Miller, L. J., Burke, J. P., et
al. (2007). Fidelity in sensory integration intervention research. American
Journal of Occupational Therapy, 61, 216–227.
Parham, L. D., Ecker, C., Miller-Kuhaneck, H., Henry, D., & Glennon, T. (2007).
Sensory Processing Measure. Los Angeles: Western Psychological Services.
Parham, L. D., & Mailloux, Z. (2005). Sensory integration. In J. Case-Smith, A. S.
Allen, & P. N. Pratt (Eds.), Occupational therapy for children (5th ed., pp.
356–411). St. Louis, MO: Mosby.
Schaaf, R., Miller, L., Seawell, D., & O’Keefe, S. (2003). Children with disturbanc-
es in sensory processing: A pilot study examining the role of the parasym-
pathetic nervous system. American Journal of Occupational Therapy, 57,
442–449.
Smith Roley, S., & Glennon, T. J. (2006, July 28). International perspectives:
Ayres sensory integration theory in occupational therapy practice. Paper
presented at the 2006 Congress of the World Federation of Occupational
Therapists, Sydney, Australia.
Spitzer, S., & Smith Roley, S. (2001). Sensory integration revisited: A philosophy
of practice. In S. Smith Roley, E. I. Blanche, & R. C. Schaaf (Eds.), Under-
standing the nature of sensory integration with diverse populations (pp.
1–27). San Antonio, TX: Therapy Skill Builders.
Wilbarger, J. L., & Wilbarger, P. L. (2002). Wilbarger approach to treating sensory
defensiveness and clinical application of the sensory diet. Sections in alterna-
tive and complementary programs for intervention, chapter 14. In A. C. Bundy,
E. A. Murray, & S. J. Lane (Eds.), Sensory integration: Theory and practice
(2nd ed., pp. 335–338). Philadelphia: F. A. Davis.
Williams, M., & Shellenberger, S. (1994). “How does your engine run?”: A
leader’s guide to the Alert Program for Self-Regulation. Albuquerque, NM:
TherapyWorks.
Wilson, E. O. (1998). Consilience: The unity of knowledge. New York: Vintage.
CE-7
Earn .1 AOTA CEU (one NBCOT PDU/one contact hour, see below for details.
New Electronic Exam:
Immediate Results and Certificate
How To Apply for
Continuing Education Credit:
1. After reading the article Understanding Ayres Sensory Integration®,
answer the questions to the final exam found on p. CE-8 by
registering to take the exam online and receive your certificate
immediately upon successful completion of the exam. Alter-
natively, you can complete the exam by using the Registration
and Answer Card bound into this issue of OT Practice. In either
case, each question has only one answer.
2. To register, go to www.aota.org/cea or call toll free 877-404-
2682. Once you are registered you will receive your personal ac-
cess information. Then log on to www.aota-learning.org to take
the exam online. If you are using the Registration and Answer
Card, complete Sections A through F and return the card with
the appropriate payment to the address indicated.
3. There is a nonrefundable processing fee to score the exam, and
continuing education credit will be issued only for a passing
score of at least 75%. Use the electronic exam and you can print
off your official certificate immediately if you achieve a passing
score. If you are submitting a Registration and Answer Card,
you will receive a certificate within 4 to 6 weeks of receipt of
the processed card.
4. The electronic exam must be completed by September 30, 2009.
The Registration and Answer Card must be received by Septem-
ber 30, 2009, in order to receive credit for Understanding Ayres
Sensory Integration®.
CE-8 SEPTEMBER 2007 n OT PRACTICE, 12(17)
ARTICLE CODE CEA0907
Final Exam
Article Code CEA0907
Understanding Ayres Sensory Integration®
September 24, 2007
Learning Level: Intermediate
Target audience: Occupational therapists and occupational
therapy assistants
Content Focus: Category 1, Domain of OT, Evaluation and
Intervention; Category 2, Client Factors
1. Which of the following incentives resulted in the trade-
mark Ayres Sensory Integration®?
A. Reduce confusion regarding the core principles of
Ayres’s approach
B. Distinguish features unique to Ayres Sensory
Integration
C. Clarify Ayres Sensory Integration as active, child
directed, and playful
D. All of the above
2. Which of the following would be considered an Ayres
Sensory Integration intervention?
A. Lying on a table that moves and rotates while listening
to music through headphones
B. Sitting at a desk imitating the therapist in creating
Theraputty designs
C. Performing collaboratively created activities adjusted
to promote the child’s success
D. Receiving a sensory diet, created by a therapist, pro-
vided at specific times each day
3. Ayres Sensory Integration intervention may be provided
by which of the following professionals?
A. Physical therapists
B. Speech-language pathologists
C. Occupational therapists
D. All of the above if properly qualified
4. Which of the following is not a core feature of Ayres
Sensory Integration?
A. Child-directed activities
B. Passively applied sensory stimulation
C. Play
D. Collaboration between client and therapist
5. Ayres’s work included which of the following?
A. Theory
B. Standardized assessments and nonstandardized
observations
C. Patterns of dysfunction that helped guide intervention
D. All of the above
6. Which of the following is false regarding Ayres Sensory
Integration?
A. Research in basic science supports Ayres’s original
hypotheses
B. Research using factor analysis supports the patterns
of sensory dysfunction
C. Research does not exist regarding the effectiveness of
sensory integration
D. Research from basic and applied science supports the
use of sensory integration in practice
7. Which of the following separates Ayres Sensory Integra-
tion methods from other interventions?
A. Contingent responses of the child guiding the
moment-by-moment choice of activities
B. The use of visual and auditory strategies
C. The therapist’s choice of activities
D. Reliance on appropriate evaluation data
8. The trademark of Ayres Sensory Integration is used in
which of the following ways?
A. To restrict its use by the therapy community
B. To protect sensory integration theory and practice as
used within occupational therapy
C. To promote sensory integration equipment
D. To include widely used intervention methods that are
called sensory integration
9. The fidelity to treatment measure was originally
designed for
A. Research
B. Education
C. Consumers
D. Legal purposes
10. Ayres Sensory Integration trademark is owned by
A. Occupational therapists
B. The Baker/Ayres Trust
C. The American Occupational Therapy Association
D. Consumer groups
11. Sensory integration dysfunction includes:
A. Praxis deficits
B. Tactile, visual, vestibular, and proprioceptive-based
disorders
C. Postural and bilateral coordination problems
D. All of the above
12. Ayres Sensory Integration
A. Can be combined with other frames of reference in
occupational therapy
B. Has limited evidence on the various patterns of sen-
sory integration dysfunction
C. Highlights the use of olfactory and auditory stimuli to
support development
D. Does not address postural and coordination problems
CE-8
AOTA Continuing Education Article
NOW AVAILABLE! CE Article, exam, and certificate
are now available ONLINE. Register at www.aota.
org/cea or call toll-free 877-404-AOTA (2682).
