Ayres Sensory

Integration® for
Infants and Toddlers
Susanne Smith Roley
OTD, OTR/L, FAOTA,
Mary Singer MS, OTR/L,
& Aja Roley MA, OTR/L

article DECEMBER 2016

 Article

Ayres Sensory
Integration®
for Infants & Toddlers
Susanne Smith Roley
OTD, OTR/L, FAOTA,
Mary Singer MS, OTR/L,
& Aja Roley MA, OTR/L

Early identification and intervention is Ayres Sensory Integration® (ASI): Ayres Sensory
advised for all infants and toddlers Integration® is a developmental theory that provides
with suspected difficulties. It is well insights into the way in which sensory information from the
established that early intervention body and about the world is integrated and informs actions
changes the trajectory of development and interactions. Sensory integration and processing is
throughout life. If we examine the the management and organization of incoming sensory
information from both the Central Nervous System (CNS)
research in neuroplasticity, we find that
and the Peripheral Nervous System (PNS) to produce
in young animals and humans’ exposure to
adaptive responses in people and the environment. These
sensory information and experiences from
adaptive responses influence performance during activities
their environment leads to specialization
of daily living including play, movement, socializing, and
and maturation that fosters growth and
learning.
development. In a recent series of articles
published in the journal of Pediatrics on
screening, evaluation, and treatment for In typical development, sensory experiences shape the
way in which the baby understands feelings from inside
0-3 and children with ASD, the results were
the body such as hunger, temperature, and the need to
conclusive (Zwaigenbaum et al, 2015a, b, c, d).
eliminate as well as information about body position and
Children who were identified and treated
movement from the vestibular and proprioceptive systems,
earlier had better outcomes. In fact,
and information about sensations emanating from the
three of these articles were considered
world outside the body through touch, vision, smell, taste,
within the top 20 most influential research and hearing. (See Table 1)
articles on autism of 2015 (Interagency
Autism Coordinating Committee, 2015).
Whether children are identified as having ‘In typical development,
autism or other developmental concerns, sensory experiences shape
it is incumbent upon practitioners to act
the way in which the baby
swiftly when concerns arise with infants
understands feelings from
and their families.
inside the body...’
2 DECEMBER 2016
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The perceptual knowledge of these sensations builds with definitive evaluation of sensory integration and praxis is
every experience, facilitating learning and adaptation to difficult with infants and young children, however, it is
environmental challenges. In most infants, this process imperative that informed occupational therapists identify
proceeds at an amazing pace, unconsciously, and with and treat these concerns in young children and not wait
few difficulties. All functions of the brain must be in for the time if and when they can perform on the SIPT.
balance with each other to produce the most effective
adaptive response in daily living activities (i.e. playing,
There are several classic patterns of sensory integration
eating, and school performance). Processing and
difficulties that present quite differently from one another
interpreting sensory information efficiently is imperative for
(Mailloux, Mulligan, Smith Roley et al, 2011). Based on
successful participation in home, community, and school
the babies that we have seen for evaluation and
environments. However, increasing numbers of infants are
intervention, we have consolidated these patterns of
struggling with sensory integration and for those families
difficulties into four main types, the Fussy Baby, the Sleepy
it is often confusing why their babies or toddlers are
Baby, the Clumsy Baby, and the Disorganized Baby. These
struggling, and why their lives are difficult.
sensory integration and praxis patterns we have identified
are related to how these babies present in parent reports
These hidden deficits in sensory integration are often and clinical observations in the intervention session.
mistaken for other types of issues such as motor control, (See Table 2)
behaviour, or emotional stability. They are not all the same
and are often missed.
The Fussy Baby: These babies have difficulty modulating
their responses to sensation, both from the exteroceptors
‘Limitation in creating and the interoceptors.
standardized measures was Sensory modulation is the nervous system’s process of
due to the difficulty testing self-organization and regulation of its own activity. It is the
children in younger age process of increasing (exciting) or reducing (inhibiting)
neural activity to keep that activity in harmony with all
ranges...’
other functions of the nervous system. Babies who are
experiencing poor regulation of sleep, feeding and mood
While Ayres identified sensory integration and praxis are struggling with homeostasis. Caregivers of these
difficulties across the lifespan including in young children babies are often worried, exhausted and confused about
(Ayres, 1979) and adults (Brown, 1974), Ayres Sensory how to support growth, development and behavioural
Integration® (ASI) theory and practice has been applied organization in their young charges.
primarily for preschool and school age children. This is
due in part to the availability of performance assessments,
Co-regulation between parents and babies may be
particularly the Sensory Integration and Praxis Tests
disrupted, leading to missed cues and poor bonding.
(SIPT) that has normative data from 4 years to 8 years 11
months (Ayres, 1989). Limitation in creating standardized
measures was due to the difficulty testing children in The Sleepy Baby: These babies have diminished
younger age ranges with these tests, and the maturation of perception from one or more sensations. They often under
abilities tested by the SIPT by age 9 so that normative data react to sensation and may not fully register important
in the older age ranges was not essential. Unfortunately, sensation such as hunger or temperature. They may get
the limitation in the age range of the tests has led some to sleepy during a feeding, taking prolonged time or not
believe that the identification and intervention for sensory waking when mother’s body is letting her know it’s time
difficulties is restricted to school age children. Certainly, for her baby to eat. They may not visually explore their

3 DECEMBER 2016
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environment and have decreased response to social Assessment:

interactions. They are at risk for missing perceptual Occupational therapists who provide evaluation of sensory
learning due to prolonged sleeping or lack of noticing that integration and praxis for babies and toddlers must have a
are critical foundations for social skills and development. solid understanding of typical and atypical development,
not only for motor, social or cognitive milestones but also
The Clumsy Baby: These babies have signs of poor for the sensory regulatory and perceptual abilities that are
vestibular-proprioceptive awareness essential for head the building blocks for development.
control, posture, and bilateral motor control. They are
often referred for delays in sitting, standing, crawling and
‘When they get a little older
walking. They may have delayed head control for midline
positions, have difficulty tolerating lying on their tummies, they may also have difficulty
and fall a lot once they start to independently sit, stand, or figuring out how to
walk. follow one or more verbal
instructions.’
The Disorganized Baby: These babies have
difficulty figuring out how to do even simple tasks unless While all of occupational therapy is meant to be family
someone shows them. Some babies have difficulty centered, the younger the child, the more critical it is
figuring out how to motor plan the use of their bodies to do to consider that baby within the social, environmental,
things or to move in and around obstacles. Some babies cultural, and socio-economic context within which they
have difficulty figuring out how to manage objects spatially are growing. Some say there is no such thing as a baby;
such as when fitting things inside of a container or stacking there is only the baby and his or her caregivers as one unit.
blocks. Some babies have difficulty imitating facial or hand Since babies are part of their family system, therapists
gestures during social play. must consider attachment to their family unit when we are
evaluating and creating intervention programs. Caregiver
feedback is critical to consider during assessment,
‘These babies have difficulty
intervention, and home follow-up.
figuring out how to do
even simple tasks unless
someone shows them.‘

When they get a little older they may also have difficulty
figuring out how to follow one or more verbal instructions.
This baby may be reaching developmental milestones
but has poverty in their repertoire of movement or play
ideas. There is a distinct lack of flexibility in motor skills.
The baby uses the same motion each time and becomes
frustrated when he or she is unable to use the preferred
pattern for the motor action. These babies often have
difficulty with transitions between sitting and crawling,
sitting and standing, getting down from standing, pulling
up to standing. They often cry for assistance in changing
position.

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The following assessment tools can be used to evaluate 3. Regulation of arousal states, state change, activity
sensory integration and praxis abilities in young children, level, emotion, and attention.
usually used in combination with each other and clinical Examples of dysregulation:
observations: • Difficulty establishing sleep/wake/eat/elimination
• Sensory Integration and Praxis Tests (SIPT) cycles
• (Ages 4 – 9 yrs.) (Ayres, 1989) • Poor maintenance of calm, alert state when awake
• Postrotary Nystagmus Test, 9 months to 4 years • Over or under reactive to typical sensations such
(Mailloux, et al, 2014) as hugs, clothing, bathing
• Preschool Imitation and Praxis Scale • Difficult to console, fussy, irritable
(Ages 1.5 – 4.9 yrs.) (Vanvuchelen et.al. 2011) • Difficult to wake and once awake, difficult to go
• Sensory Processing Measure-P back to sleep

(Ages 2 – 5 yrs.) (Parham & Ecker, 2010) • Dislikes movement or head position changes

• Test of Sensory Functions in Infants 4. Sensory Perceptual Skills:

(Ages 4 mo. – 18 mo.) (DeGangi & Greenspan, 1989) • Child’s unusual enjoyment or dislike of various
sensations
• Infant/Toddler Sensory Profile
• Child’s attention to usual things in the environment
(Ages 0-3 yr.) (Dunn, 2002)
or lack of awareness to sensations such as
• DeGangi-Berk Test of Sensory Integration someone calling his/her name
(Ages 3 – 5 yrs.) (DeGangi, 1983) 5. Vestibular-postural ocular and motor control:
• Miller Function and Participation Scales • Head position, head lag
(Ages 2.6 – 3:11 and 4 - 7.11) (Miller, 2006) • Righting responses
• Miller Assessment for Preschoolers • Dynamic equilibrium
(Ages 2.9 - 5.8) (Miller, 1988) • Postural adjustments
• Labyrinthine responses
The following clinical observations additionally inform our • Disassociated movements
understanding of the child:
• Bilateral coordination
1. Goodness-of-fit between the caregiver and child:
• Emergent laterality
Consideration of the caregiver’s sensory preferences
and how that fits with the child. 6. Praxis including the child’s ability to utilize the
affordances of the physical environment:
2. Signs of Autonomic Instability:
• Motor planning
• Flushing or other colour changes
• Sequencing
• Perspiring
• Imitation, oral facial gestures
• Gagging
• Tool use
• Turning and arching away from stimuli
• Exploring environmental space
• Digestive system changes such as spitting up,
bowel movements, and hiccups • Construction

• Changes in heart rate, respiratory rate, or oxygen • Symbolic play or representation of objects
saturation • Ideation

5 DECEMBER 2016
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Further training is required for the occupational therapist In this way self-regulation is learned and the attachment
to accurately differentiate sensory integration and praxis processes is improved.
difficulties from other neuromotor deficits or diagnoses
such as visual or hearing impairment or autism.
Tips for the SleepY Baby
Sensory integration and praxis deficits often co-exist with
Parents/caregivers become aware of their sleepy baby
these other diagnoses.
particularly when the baby is not staying awake to drink
or waking when it is time to eat. Sometimes babies
What to do (For specific sensory look sluggish or disinterested in people and objects, not
strategies see Table 3): looking when their name is called or not noticing relevant
Tips for the Fussy Baby things around them. It is particularly concerning when
it is affecting weight gain or when developmental skills
Sensitive babies tend to cry more, have more digestive
including motor milestones are delayed.
upsets, are easily awakened, and have difficulty settling
into sleep. Parents and caregivers often feel overwhelmed
by the fussy baby’s needs. These families need support Parents/caregivers may feel it takes a lot of effort
and guidance to find sensory strategies that help the fussy to engage their baby due to decreased social
baby find homeostasis. responsiveness, which interferes with attachment.

Teaching parents and caregivers calming and organizing We know we have sleepy babies when more intense
sensory tools that work for their baby builds confidence in stimulation wakes them up, increases smiles and laughter,
their caregiving abilities and supports attachment within and they are better able to engage in the world around
the families. them. Baby massage is an excellent strategy and is
associated with improved weight gain and growth in
infants (Feber, et al., 2002).
‘These families need support
and guidance to find
Tips for the Clumsy Baby
sensory strategies that
Parents/caregivers often become concerned about
help the fussy baby find their babies if they have difficulty holding up or turning
homeostasis.’ their head in the early months, fail to acquire typical
motor milestones or when moving, show asymmetry or
Parents/caregivers can identify what we call STOP SIGNS uncoordinated movements.
in their babies, such as colour changes, looking away, jerky Babies with difficulty acquiring motor skills and moving
movements or fussing, that alert them to signals that the in a coordinated way, often have difficulty with vestibular-
baby is becoming dysregulated, which is a sign of losing proprioceptive processing. They may have difficulty
homeostasis. sustaining their balance while sitting, standing, crawling
and walking. They often benefit from engaging in frequent
and more intense vestibular and proprioceptive sensory
Caregivers will see better regulation in babies if they see
input obtained through swinging, carrying, and dancing
one or more STOP SIGNS and cease to make social
together with their caregivers. Moving through space and
demands and apply one or more calming sensory activity
understanding where and how their bodies are moving are
until the baby is calm and organized again. Usually the
essential for babies to develop improved sensory motor
baby will calm to sleep or indicate their desire for cuddles
coordination.
or playful communication.

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Tips for the Disorganized Baby Imitation in play and in social interactions may be limited
Parents/caregivers are often confused when their children or missing. Activities that help babies to figure out how to
don’t seem to easily learn new skills. These babies seem do new things or old things in new ways are essential for
to need more assistance from their caregivers when doing supporting development of praxis.
simple tasks, even learning how to push into sitting, sit
down from standing, or navigate obstacles. When we When to refer for OT
observe these babies in play, they may prefer to do the
Parents/caregivers will benefit from occupational therapy
same game over and over and become upset with the
consultation when they have concerns about their baby’s
introduction of new or novel games, rather than showing
development. While typical development unfolds at
excitement with them or experimenting with different ways
different time frames caregivers with concerns should
to use their body or exploring different toys or spaces.

Table 1

Babies learn to enjoy, explore and navigate their

world through accurate and enjoyable information
form multiple sensations - essential for praxis and
social participation

VESTIBULAR
Where am I?
HEARING Where are you? VISION
Spatial orientation, Arousal regulation, Orientation, anticipation,
location, identification Head and body control, recognition and
of verbal and gestural rhythms decoding social ques
language

Regulation
TOUCH interoception
Praxis & participation
Language of love How do I feel?
Does touch make me What do I need?
feel good or bad, safe Who is taking care of
or not? me?
Does this feel good, PROPRIOCEPTION
nurturing and lovely? Intentional movement
Is this uncomfortable? toward or away from
others
Painful?
Movement as fun

© 2015 Smith Roley, Singer & Roley

7 DECEMBER 2016
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seek out assistance to confirm or calm their fears. When of praxis and social participation. Sensory strategies are
in doubt, call and see your occupational therapist to ask useful for supporting typical development. Occupational
whether the child will benefit from a full evaluation or if therapy using a sensory integration approach is advised
perhaps simply gaining some advice will suffice. when infants and young children have dysregulated
behaviours, motor delays or difficulty learning which is
not significantly improved through sensory enrichment
Conclusion
provided by the caregivers.
Babies learn to enjoy, explore, and navigate their world
through accurate and enjoyable information from multiple
sensations, essential for mastery and the development

Table 2
Sensory Integration including Praxis and Sensory Regulatory Difficulties
SIGNS AND SYMPTOMS IN INFANTS AND YOUNG CHILDREN
© Susanne Smith Roley and Kate Crowley 6/06; revised 2016

FUSSY BABY SLEEPY BABY CLUMSY BABY DISORGANIZED BABY

Sensory Over-responsive/ Sensory Under- Poor posture ocular motor Poor praxis including
Defensive responsiveness planning/sequencing

Pushes away when Withdrawn, self-absorbed Weak, poor muscle effort, Confused how to do
handled, held too closely, or seems lost floppy, sluggish, heavy to things; needs extra time to
cries during bath or with carry learn something
textures

Cries to noises, holds Slow to wake, lethargic Head lag, weak neck Tolerates transitions poorly
hands over ears; gets muscles, needs to hold
wild with loud music, high head up when sitting
energy, high affect

Excessive self-rocking, Repetitive behaviours,

Labile especially in Poor eye contact and poor transitional
situations with lots jumping, pounding or
head, neck and eye control movements
of people, noise and making-sounds
movement

Eating and feeding Clumsy, uncoordinated Poor imitation of gestures,

Stuffs mouth, poor
difficulties, including being chewing and swallowing finger or facial play
held or socializing while with food, craves extreme
feeding tastes

Easily stressed and difficult Seeks extreme sensations Awkward positioning of Immature play routines,
to console, withdraws from even those that may be body, doesn’t correct limited play repertoire, only
human comforting efforts perceived as painful familiar scenarios

Picky eater, gags at sight Crashes into people, Cannot sit still or stand still Rigid, inflexible, fearful of
and smell as well as taste objects, reckless behaviour without leaning new people or situations

8 DECEMBER 2016
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Demonstrates fight, fright, Self-stimulates on visual or Can run and climb, but May not use hands as
flight or freeze behaviours motor actions cannot learn ball skills tools; prefers others to do
things

Shields eyes to lights, poor Responds well to high Poor hand use for Difficulty following
eye contact affect, high energy manipulating objects directions

Intolerant to smells High pain tolerance Delayed motor skill Cannot track time
acquisition sequences

Dislikes head position Misses auditory & visual Poorly coordinated use of Difficulty with puzzles;
changes; cries when cues or other important two hands, no preference Poor construction
jostled features of the environment

Table 3
TIPS FOR SUPPORTING SENSORY INTEGRATION
INCLUDING SELF-REGULATION AND PRAXIS IN INFANTS AND YOUNG CHILDREN
© Susanne Smith Roley and Kate Crowley 6/06; revised 2016

FUSSY BABY SLEEPY BABY CLUMSY BABY DISORGANIZED BABY

Sensory Over-responsive/ Sensory Under- Poor posture ocular motor Poor praxis including
Defensive responsiveness planning/sequencing

Constant pressure touch Help child wake up with Spend more time carrying Provide activities that
rather than intermittent gentle and soothing but the baby through space increase body centered-
touch through swaddling alerting sensory activities and swinging to activate sensory information
or baby wearing in a sling head control and muscles
or carrier

Reduce ambient sounds Fast intermittent bouncing, Frequent swinging, Provide activities that
such as turning off rocking, or dancing dancing, and being increase movement
television providing vestibular held and carried awareness through
sensations in parent’s provides vestibular and vestibular and
arms, a baby swing or a proprioceptive sensations proprioceptive sensations
bucket swing at the park that support motor
(Look for STOP SIGNS to development
avoid overwhelming this
baby).

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Support environmental Provide more opportunities Pull baby to sit with Give the baby additional
adaptation using soothing for movement throughout support to their back while time to process
sounds such as a fan or the day encouraging head control information; wait for the
ocean sounds, pastel baby to initiate an action
colours and reducing before continuing
number of toys

Slow vestibular input in Stroking the baby’s Provide proprioception Encourage baby to play in
a rocking chair or baby cheeks and lips to prepare such as bouncing on a a way that invites imitation,
swing muscles before latch on small ball with baby in for example facial play,
and suck/swallow; use sitting, pulling into sitting, vocal play, songs with
cold or warm and lying on tummy in hand gestures, or using a
preparation for crawling toy such as shaking a toy
to make noise

Physically position babies Encourage baby to try

Increase proprioceptive Check for health related
so that their bodies are in different ways of moving in
sensations produced by conditions such as reflux
a well-aligned position of and out of positions; sitting
bouncing in a parent’s or gastrointestinal issues.
their head, trunk, and arms to prone, prone to sitting,
arms or seated on a small Provide additional sensory
sitting to crawling, sitting
ball opportunities throughout
to standing and back
the day
down

Nursing on demand; sitting Light tactile sensation Provide opportunities Take pictures of real
at eye level with the family such as lightly stroking for bouncing at various people, places and things
during mealtimes baby’s arms and legs, intervals that activates their to show and label for the
leaving baby’s skin open to muscles baby; can create baby
the air if the temperature books that help the child
is warm anticipate events

Daily baby massage Provide enticing toys that Introduce ball play starting Support baby’s ability to
support babies to move, with balloons or bubbles grasp different objects;
reach, lift their head, or that move slowly that they show what objects can do
track with their eyes can track and catch such as fork, or cause and
effect toys

Expose baby to pleasant Baby massage followed by Provide larger than usual Use songs and games for
non-chemical smells light touch to baby’s arms, objects to grasp such as following verbal directions
through herbs, flowers and legs and face baby spoons with built up for gestures, pointing, or
oils handles, large crayons, or body movement
other tools that support
grasp

Watch for STOP SIGNS Provide alerting sounds Physically help baby/child Create visual schedules
through music or vocal to move in various ways of activities; use kitchen
sounds and talk about through rolling games or timers and show clocks
what is going on around songs such as Row, row, with clock faces for time
the baby during social row your boat
interactions

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Talk quietly to the baby and Encourage baby to Show babies/child ways to
position caregivers face in use both hands first by build with blocks, knocking
front of baby at about 18 grasping two objects, then them down and rebuilding
inches distance without transferring hand to hand, and imitating structures
moving too much to gain and then with both hands
eye contact working together like
tearing paper or opening
containers

Prepare baby in advance

by talking quietly and
making eye contact before
moving; be aware of head
positions when moving
baby through space

References:
Ayres, A.J. (1979, 2005). Sensory integration and the child. Therapy, 68, 514–521. http://dx.doi.org/10.5014/
25th Anniversary edition. Los Angeles, CA: Western ajot.2014.011031
Psychological Services. Miller LJ (1988). Miller Assessments for Preschooler
Ayres, A.J. (1989). Sensory Integration and Praxis Tests (MAP). San Antonio, Texas: The Psychological Corporation.
manual. Los Angeles: Western Psychological Services. Miller LJ (2006). Miller Function & Participation Scales:
Brown, D. (1974) Help me be me (film). Center for the Examiner’s manual. San Antonio, Texas: PsychCorp
Study of Sensory Integration Dysfunction. Pasadena, CA. Harcourt Assessment.

DeGangi, G. (1983) DeGangi-Berk Test of Sensory Parham LD & Ecker, C (2007). Sensory Processing
Integration. Los Angeles: Western Psychological Measure - Home Form. Los Angeles, CA: Western
Association. Psychological Services.

DeGangi, G. A., & Greenspan, S. I. (1989). The Vanvuchelen, M., Roeyers, H., & De Weerdt, W. (2011).
development of sensory functions in infants. Physical & Objectivity and stability of the Preschool Imitation and
Occupational Therapy in Pediatrics, 8(4), 21-33. Praxis Scale. American Journal of Occupational Therapy,
65, 569–577. doi: 10.5014/ajot.2010.ajot00000414
Dunn, W. (2002). Infant/toddler sensory profile: User’s
manual. San Antonio, TX: Harcourt Assessment Company. Zwaigenbaum,L, Bauman, M. Choueiri, R., Fein,D. Kasari,
C., Pierce, K., Stone, W., Yirmiya, N., Estes, A., Hansen, R.,
Mailloux, Z., Mulligan, S., Smith Roley, S., Cermak, S.,
McPartland, J., Natowicz, M., Buie, T., Carter, A., Davis, P.,
Blanche, E., & Bodison, S., Coleman, G., & Lane, C.
Granpeesheh, D., Mailloux, Z., Newschaffer, C., Robins, D.,
(2011). Verification and clarification of patterns of sensory
Smith Roley, S., Wagner, S. & Wetherby, A. (2015a) Early
integrative dysfunction in a retrospective clinical sample.
identification and interventions for Autism Spectrum
American Journal of Occupational Therapy. 65.2. 143-151.
Disorder: Executive summary. Pediatrics (136), S1–S9.
Mailloux, Z., Lea˜o, M., Becerra, T. A., Mori, A. B., DOI: 10.1542/peds.2014-3667B.
Soechting, E., Roley, S., Cermak, S. A. (2014).
Zwaigenbaum,L., Bauman, M. Stone, W., Yirmiya, N., Estes,
Modification of the postrotary nystagmus test for evaluating
A., Hansen, R., McPartland, J., Natowicz, M., Choueiri,
young children. American Journal of Occupational
R., Fein, D. Kasari, C., Pierce, K., Buie, T., Carter, A.,

11 DECEMBER 2016
 Article

Davis, P., Granpeesheh, D., Mailloux, Z., Newschaffer, C.,

Robins, D., Smith Roley, S., Wagner, S. & Wetherby, A.
(2015b). Early identification of Autism Spectrum Disorder:
Recommendations for practice and research. Pediatrics
(136), S10–S40. DOI:10.1542/peds.2014-3667C Co-Sleeping:
 Zwaigenbaum, L., Bauman, M., Fein, D., Pierce, K., Buie, Dr William Sears:
T., Davis, P., Newschaffer, C., Robins, D., Wetherby, A., http://www.babycenter.com/2_the-benefits-of-swaddling-
Choueiri, R., Kasari, C., Stone, W., Yirmiya, N., Estes, your-baby_10347122.bc
A., Hansen, R., McPartland, J., Natowicz, M., Carter, A.,
Granpeesheh, D., Mailloux, Z., Smith Roley, S., & Wagner,
S. (2015c). Early screening of Autism Spectrum Disorder: Parenting the sensitive baby:
Recommendations for practice and research. Pediatrics. http://passporttofunction.com/2016/04/parenting-the-
(136), S41–S59. DOI: 10.1542/peds.2014-3667D sensitive-baby/
 Zwaigenbaum,L, Bauman, M. Choueiri, R., Kasari, C.,
Carter, A., Granpeesheh, D., Mailloux, Z., Smith Roley, Swaddling:
S., Wagner, S., Fein,D., Pierce, K., Buie, T., Davis, P.,
http://www.babycenter.com/2_the-benefits-of-swaddling-
Newschaffer, C., Robins, D., Wetherby, A., Stone,
your-baby_10347122.bc
W., Yirmiya, N., Estes, A., Hansen, R., McPartland,
J. & Natowicz, M. (2015d). Early intervention for
children with Autism Spectrum Disorder under 3 Baby Massage:
Years of age: Recommendations for practice and
http://www.researchgate.net/publication/10996314_
research. Pediatrics (136), S60–S81.DOI:10.1542/
Massage_Therapy_by_Mothers_Enhances_the_
peds.2014-3667E
Adjustment_of_Circadian_Rhythms_to_the_Nocturnal_
Period_in_Full-Term_Infants
Parent Resources:
Sensory strategies for Parents
or the Sensitive Baby:
Additional References
Sensory Strategies for the Sensitive Baby:
Ayres, A.J. & Cermak, S.A. (2011). Ayres Dyspraxia
www.youtube.com/watch?v=G3tengTlu40 Monograph: 25th Anniversary Edition. Torrance, CA.:
Pediatric Therapy Network.

Dr Harvey Karp: Carpenter, M., Uebel, J., & Tomasello, M. (2013). Being
mimicked increases pro-social behavior in 18-month-old
https://www.youtube.com/watch?v=eK4O9N3DjJM
infants. Child Development, doi:10.1111/cdev.12083
Cohn, E., & Cermak, S.A. (1998). Including the family
Fussy Baby Network, Erickson
perspective in sensory integration outcomes research.
Institute (2013). Partners in
American Journal of Occupational Therapy, 52(7), p. 540-
care: Supporting fussy babies in child
546.
care. Retrieved from
www.fussybabynetwork.org DeGangi, G. A., Berk, R. A., & Larsen, L. A. (1980). The
http://www.erikson.edu/fussybaby/ measurement of vestibular- based functions in pre-school
children. The American Journal of Occupational Therapy,
34(7), 452-459.

12 DECEMBER 2016
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Dowel, L.R., Mahone, E.M., & Mostofky, S.H. (2009). Ozonoff, S., Young, G. S., Goldring, S., Greiss-Hess, L.,
Associations of postural knowledge and basic motor skill Herrera, A. M., Steele, J., Rogers, S. J. (2008). Gross
with dyspraxia in autism: Implications for abnormalities motor development, movement abnormalities, and early
in distributed connectivity and motor learning. identification of autism. Journal of Autism & Developmental
Disorders, 38(4), 644-656.
Neuropsychology. 23(5), 563-570.
Reynolds, S., Lane, S.J., & Richards, L. (2010). Using
Dunn, W. (2007). Supporting children to participate
animal models of enriched environments to inform
successfully in everyday life by using sensory processing
research on sensory integration intervention for the
knowledge. Infants and Young Children, 20(2), p. 84-101.
rehabilitation of neurodevelopmental disorders. Journal
Dunn, W. (1997). The impact of sensory processing of Neurodevelopmental Disorders, 2(3), 120-132. Online
abilities on the daily lives of young children and families: first, DOI 10.1007/s11689-010-9053-4.
A conceptual model. Infants & Young Children, 9(4), p.
Serrano, MS., Doren, FM., Wilson L. Teaching Chilean
23-35.
mothers to massage their full-term infants: effects on
Dunn, W., Brown, C., McGuigan, A. (1994). The ecology maternal breast-feeding and infant weight gain at age 2
of human performance: A framework for considering and 4 months. Journal of Perinatal & Neonatal Nursing
the effect of context. American Journal of Occupational (2010). Vol. 24, issue 2:172-81.
Therapy, 48(7) p. 595-607. Schaaf, R. C., & Anzalone, M. A (2001). Sensory
Dzuik, M.A., Gidley Larson, J.D., Apostu, Mahome, E.M., integration with high risk infants and toddlers. In S. Smith
Denckla, M.B., Mostofsky, S.H. (2007). Dyspraxia in autism: Roley, E.I. Blanche, & R.C. Schaaf (Eds.), Understanding
association with motor, social and communicative deficits. the Nature of Sensory Integration with Diverse Populations
Developmental Medicine and Child Neurology, 49: 734- (pp. 275–312). San Antonio, TX: Harcourt Assessment,
739. Inc.
Ferber SG, Laudon M, Kuint J, Weller A, Zisapel N. Schaaf, R.C., & Smith Roley, S. (2006). Sensory
Massage therapy by mothers enhances the adjustment Integration: Applying Clinical Reasoning to Practice with
of circadian rhythms to the nocturnal period in full- Diverse Populations. San Antonio, TX: ProEd, Inc.
term infants. Developmental and Behavioral Pediatrics Sherrington, C.S. (1906). The integrative action of the
2002;23(6):410-5 nervous system. New Haven: Yale University Press.
Gibson, E.J. (1970). The development of perception as an Smith Roley, S., Blanche, E.I. & Schaaf R.C. (Eds.). (2001).
adaptive process. American Scientist, 58, 98-107. Understanding the nature of sensory integration with
Gibson, J.J. (1970). The theory of affordances. In R. Shaw diverse populations. San Antonio, Texas: Pro-Ed, Inc.
& J. Bransford (Eds.), Perceiving, acting, and knowing Tomchek, S.D., Dunn, W. (2007). Sensory processing in
(pp.67-82). Hillsdale, NJ: Erlbaum. children with and without autism: A comparative study
Hadders-Algra, M. (2008). Postural control: A key issue in using the Short Sensory Profile. The American Journal of
developmental disorders. London, England: John Wiley & Occupational Therapy 61(2). P. 190-200.
Sons, Inc. Visser, M. M., & Franzsen, D. (2010). The association of an
Hunziker, U. A., & Barr, R. G. (1986). Increased carrying omitted crawling milestone with pencil grasp and control
reduces infant crying: A randomized controlled trial. in five- and six-year-old children. South African Journal of
Pediatrics, 77(5), 641-648. Occupational Therapy, 40(2), 19-23.
May-Benson, T., & Koomar, J. A. (2007). Identifying Whitcomb, D.A., Carrasco, R.C., Neuman, A., & Kloos,
gravitational insecurity in children: A pilot study. American H. (2015). Correlational research to examine the
Journal of Occupational Therapy, 61(2), 142-147. relation between attachment and sensory modulation
Oakes, L., M., & Ellis, A., E. (2013). An eye-tracking in young children. American Journal of Occupational
investigation of developmental changes in infants’ Therapy, 69, 6904220020. http://dx.doi.org/10/5014/
exploration of upright and inverted human faces. Infancy, ajot.2015.015503
18(1),134-148. doi:http://dx.doi.org/10.1111/j.1532-
7078.2011.00107.x

13 DECEMBER 2016
SAISI WEBSITE: www.instsi.co.za
Views contained in articles appearing in this
newsletter do not necessarily reflect the opinion of
the South African Institute for Sensory Integration.
 Baby S.O.S

Sleep Solutions Based on Your Baby’s Sensory Personality

For the Sleepy, Organized or Sensitive Baby in your Life

Mary Singer MS, OTR/L

Suzanne Greenwood OTR/L
 Copyright © 2016 by Mary Singer MS, OTR/L and Suzanne Greenwood OTR/L

All rights reserved, including the right to reproduce this book or portions thereof in any form
whatsoever. For information about Passport to FUNction and related products and content,
please contact [email protected]
 To our families, friends and colleagues who have laughed with us,
learned with us, and continue to encourage us through our Passport to
FUNction journey - We love you!

-Mary and Suzanne

 TABLE OF CONTENTS

CHAPTER 1 Introduction: “Will I ever get sleep again?”

CHAPTER 2 What is Normal Sleep for a Baby?

CHAPTER 3 Sleep and Awake States: How do they influence sleep?

CHAPTER 4 Baby’s Sensory Personality

CHAPTER 5 Common Approaches to Sleep

CHAPTER 6 How Sensory Strategies Help Baby Sleep

CHAPTER 7 Parent Interviews About Sleep

CHAPTER 8 Parent Sensory Personality vs. Baby Sensory Personality

CHAPTER 9 Resources

ABOUT THE AUTHORS

 Chapter 1

INTRODUCTION
“Will I ever get sleep again?”

Sleep and babies is one of the hottest topics for parents of young babies. Getting babies to sleep,
helping them stay asleep, establishing bedtime routines and learning how to cope with disrupted
sleep are all HUGE issues for parents of young children.

There is one question that plagues new parents: “Will I ever get a full night of sleep again?”
Contrary to what you might think and feel in your sleep deprived (yet so in love) state, the
answer is yes! You’ve come to the right place.

Occupational therapists are often consulted for advice about how to help babies develop better
sleep habits. With over fifty years of combined experience as pediatric occupational therapists,
we have a lot to share about what techniques we use to help babies become great sleepers.

Parents of the baby who does not sleep very well often feel that they are doing something wrong,
particularly when they hear about a friend’s baby who sleeps through the night and takes long
naps. Babies are all different and they require different strategies to help them settle into sleep
(and return to sleep once awakened).

Parents also have different tolerances for disrupted sleep. The parent who cannot function during
the day due to disrupted sleep at night is going to be less tolerant of a sensitive baby who has
difficulty settling into sleep and awakens frequently. We have seen many different combinations
of parents and babies, and just as many different approaches to sleep. There are so many
variables that impact sleep for a family! Success depends on matching your baby’s sensory
personality with the sleep approach that will work for him or her. Let’s take a look at the answers
to some important questions:

1. What are normal sleep patterns for a young baby?

2. What are sleep and awake states and how do they influence sleep?

3. What effect does a baby’s sensory personality have on sleep?

4. What are the most common approaches to sleep and what types of babies are they
appropriate for?

5. What sensory strategies have we found useful for helping babies learn to settle into
sleep?

6. A parent’s sensory personality vs. a baby’s sensory personality: Is a mismatch making

you feel like pulling out your hair? What can you do to smooth this out?
 CHAPTER 2

WHAT IS ‘NORMAL’ SLEEP FOR A BABY?

Sleep patterns in the young baby: How much does the typical baby sleep?

Keep in mind that there is a wide range of normal. Some babies take long naps and sleep many
consecutive hours at night, others take brief naps and wake frequently at night. The following
information is typical for most babies.

The 0-3 month old baby will sleep from 14 to 16 hours each 24-hour period. Babies have their
longest sleep periods at night, with cycles of light sleep for the first 20 minutes, followed by 40
minutes of deep sleep. This cycle repeats itself every hour. When babies are in the light sleep
part of the cycle, they are more easily awakened by internal and external sensations. Young
babies with little tummies need to be fed frequently and may wake every 3 to 4 hours for feeding
each night, until they are a few months older. As one of our favorite moms says, “It’s their show
for the first three months”. Trying to do any kind of sleep training at this stage is difficult and not
recommended for babies this age. This is a time when babies need to be feeding frequently and
gaining weight.

During the day, baby is awake for 30 to 60 minutes between naps. Naps are 15 minutes to 2
hours long and baby takes 3 to 8 of them. As you can see, there is a wide range of normal for the
typical baby.

Young babies from 0 to 3 months take some time to get their sleeping organized and this is takes
a bit longer for sensitive babies. Parents may need to use calming sensory strategies to help the
sensitive baby settle down and stay asleep. The sensory strategies we find useful are swaddling,
rocking, a pacifier, and white noise, like a fan or nature sounds.

Some babies need all of these strategies at first. Sensitive babies tend to spend more time in a
light sleep state and are easily awakened by movement or noise. As babies develop and become
better at screening out environmental changes like noise, touch and movement, they require less
help staying asleep.

The 3-9 month old baby will sleep 14 to 15 hours each 24 hour period. Babies are awake a little
longer, for 1 to 2 hours between naps. In general, a 3-month old baby will take 3 to 4 naps,
totaling 4 to 6 hours. Younger babies will still need to feed frequently at night and will wake
every 3 to 4 hours for a feeding.

You may notice that breast fed babies will “cluster feed”, waking every hour to feed when they
are in a growth spurt. This may last for one to three days before settling back down. Babies may
also be more wakeful when they are working on a challenging developmental skill or when they
are teething.

The best way to survive the sleep roller coaster in your baby’s first year is to stay flexible,
assume there will be good nights and bad ones and that eventually your baby will be an
independent sleeper. A sense of humor about the funny and endearing things your baby does in
the middle of the night goes a long way toward helping accept your own interesting and hilarious
brain changes from lack of sleep. It’s temporary! You will sleep again and your memory will
return to normal, trust us! You may even find yourself missing those middle-of-the-night sweet
moments with your little angel.

The 9-12 month old baby will sleep 13 to 14 hours each 24 hour period. The 9 month old will
usually take 2 naps, totaling 2 to 4 hours and the 12-month old baby will take 1 to 2 naps,
totaling 2 to 3 hours. The 6-12 month old baby may sleep 10-12 hours per night, but this varies
widely.

TIP for NEW PARENTS: The statement “sleeping through the night” means a five- hour period,
so don’t be alarmed if your baby is not managing 8 consecutive hours of sleep.

Baby’s awake time

Baby’s Age Nap duration # of naps per day
between naps

Birth 30 min. 15 min.

- - - 3-8
3 months I hour 2 hours
3 months 30 min.
- 1-2 hours - 3-4
6 months 2 hours
6 months 30 min.
- 2-3 hours - 3
9 months 3 hours
9 months 30 min.
about
- - 2
3 hours
12 months 2 hours
TIP for NEW PARENTS: Researchers have shown that at night, breast milk contains compounds
that help babies sleep longer! “Exclusive breastfeeding is associated with reduced
irritability/colic and a tendency toward longer nocturnal sleep. Breast milk (nocturnal) consists
of substantial melatonin levels, whereas artificial formulas do not.” (Engler, et al. 2012).
 CHAPTER 3

SLEEP AND AWAKE STATES

How do sleep and awake states influence sleep?

Researchers have identified six different sleep and arousal states in the newborn baby. Becoming
familiar with these states will not only support you in organizing your baby’s sleep patterns, but
will help you read your baby’s cues to establish a strong parent-infant bond that makes baby feel
supported and understood.

SLEEP STATES

Light sleep: This is when baby is dreaming. You may see eyelids moving while dreaming and
baby may make sucking movements on and off. He/she is likely to respond to sound, touch or
movement by waking up. Moving baby while in this state will often cause him or her to wake up.

Deep sleep: You will notice that breathing is regular; there are no eye movements and baby’s
body is limp and relaxed. Baby has a delayed response to sounds, movement or touch and is less
likely to wake up when moved or when the environment is noisy.

TIP for NEW PARENTS: The Sensitive Baby may have a difficult time staying in a deep sleep
state, with more time spent in a light sleep state that he or she is easily awakened from.

AWAKE STATES

Drowsy: Baby’s eyelids are fluttering, movements are smooth and less vigorous. From this state,
baby can either settle into sleep, or wake up if you talk to, move or touch baby.

Quiet Alert with a bright look: Baby is still, quiet and appears to be focused on your face or a
toy. This is a great time to engage baby in play.

Active Alert: Baby will have lots of large movements in the arms and legs and a few startles.
He/she will react to sound or touch with increased motion or a startle and may begin crying. If
you can intervene at this point with calming techniques, you can help baby avoid crying.

Crying: Baby will cry intensely, which is difficult to interrupt. Using calming techniques like
swaddling, slow movement and shushing will help baby regain a more organized state. In our
blog, we have a post titled Parenting the Sensitive Baby. Here we have highlighted some basics
strategies that we use to help babies become calmer. We have an active link for this blog in our
reference section.

TIP for NEW PARENTS: Remember, identifying your baby’s sleep states will help you support
baby’s transitions into sleep. If you want your baby to stay asleep, do not move him or her while
baby is in a light sleep state. Clues to look for are baby’s eyes moving under closed eyelids,
facial grimaces or uneven breathing.

Identifying awake states helps you know when baby is receptive to play or when he or she needs
help to calm down. Knowing how long your baby can stay in an active alert state before
beginning to cry gives you a chance to intervene with calming sensory strategies before baby
gets upset. Babies who get help calming down when they need it have better organization of their
behavior (less crying) and quickly learn to be better sleepers.
 CHAPTER 4

BABY’S SENSORY PERSONALITY

The Infant and Toddler Sensory Personality Checklist ™ was developed to help parents identify
their baby’s sensory personality. Understanding what type of personality your child has allows us
to do two important things for babies:

1. Tailor your approach to sleep to fit your child’s sensory needs. This equates to more
sleep for everyone!

2. Find the best ways to support your child’s acquisition of developmental milestones. We
adapt the way we play with babies depending on their sensory personality.

In our experience, baby personalities can group into 3 simple categories: Baby S.O.S!

The checklist below can be used to identify which sensory personality best fits your baby.

Infant and Toddler Sensory Personality Checklist ™

The Sleepy Baby

Sleepy, needs to be awakened for feedings

When environment is noisy, will shut down into a sleep state

 Difficult to engage socially, and does not try to engage adults with sounds or smiles

Tends to stare off into space

Seems to have lower muscle tone, may be slower to hold his head up or hold a toy

Prefers to sit on a caregiver’s lap, not interested in exploring the environment

Seems to not participate in being held, doesn’t cling to caregiver or hold his own weight

Content to spend most of his time playing by himself, doesn’t engage others

Needs an animated parent to help him engage in social interaction

May have slower digestion or constipation

The Sleepy Baby needs more frequent and more intense input from his senses to help him reach
a threshold where he can respond and interact with people and his environment. Parents and
caregivers need to be more animated to engage this baby in play.

THE ORGANIZED BABY

Spends most of the time he is awake in an alert and quiet state

Follows faces with his eyes

Socially engages others with eye contact and smiles

Sleeps well early on, easy to settle into sleep and stays asleep, despite noise

Cries for hunger or discomfort, easily soothed when needs are met
 Self-soothing, will gaze around after awakening before calling out or crying

Not usually upset by loud noises or sudden movements

Will mold into a care-givers arms

Feeding is coordinated, digestion is smooth

Movements appear smooth and coordinated

The Organized Baby is usually self-regulated with needs that can be easily predicted and met.

THE SENSITIVE BABY

Startles easily and cries frequently

Goes from alert to crying with little warning

Hard to soothe, needs holding, rocking, swaddling and a pacifier to calm down

Cries the minute he awakens, needs lots of reassurance and distraction through the day

Reacts negatively to certain sensory inputs: sound, vision, taste, touch or textures in clothing

Over-stimulated by social interaction, particularly with strangers

Needs to be held when awake, is much calmer if carried in a baby carrier

Dislikes being in a car seat or stroller

Stiffens when held, instead of molding his body to caregiver. Prefers one parent because of
how that parent holds him

May have difficulty with suck/swallow coordination, needs a quiet place when feeding

Digestive disturbances, excess gas, seems to cry more than other babies
The Sensitive Baby needs a lot of parent support to help him maintain a calm state. His
environment needs to be less stimulating. Successfully supporting this baby depends on
caregivers who can create a consistent daily schedule and intervene with calming sensory
strategies when baby is upset.

When talking about organized behavior, we refer to the ability to modulate, or adjust a response
to sensory information. Think of this as a volume control. When a baby’s response is set too
high, the baby is irritable or overreacts to sensation. If a baby’s response is set too low, he or she
misses important information that supports developmental skills.

Which category best fits your baby? How many observations were present in each category?

___ The Sleepy Baby

___ The Organized Baby

___ The Sensitive Baby

If your baby has 7 or more characteristics of one sensory personality, you have figured it out!

If your baby’s behavior is evenly distributed between two categories, go with the one that
requires more attention from a caregiver. For example, if your baby’s characteristics seem evenly
split between the sensitive baby and the organized baby, assume you have a sensitive baby.
Giving baby more help and support now will pay off later with a child who is able to
independently organize his or her response to the environment and life’s challenges.

Now that you know what type of sensory personality best fits your baby, let’s pick the sleep
approach that will be most successful.

Action Plan

The Sleepy Baby: Sleepy babies need more intense sensory inputs to help them focus and pay
attention to the people and world around them. We often use fast movement and light touch to
wake this baby up before engaging him or her in play.

This baby will tolerate the co-sleeping, the swaddle and swing and the shush and pat approaches
to sleep (see chapter 5). However, the sleepy baby tends to be less aware of people and the
environment, so co-sleeping would be our recommendation to foster better parent-baby bonding.

The Organized Baby: The integrated baby responds positively to new experiences and interacts
with toys and people happily. We support this baby by providing plenty of sensory experiences
to create the building blocks for development. Our website, Passport to FUNction, has tons of
fun park activities sure to bring smiles to the whole family. This baby does well with all the sleep
approaches. Choose one that works for your parenting style!

The Sensitive Baby: Sensitive babies need help modulating, or adjusting, their responses to
sensation and often need an environment that provides soothing sensory inputs as they explore
the world. Think of modulation as a volume control. When a baby’s response is set too high, the
baby is irritable or overreacts to sensation. If a baby’s response is set too low, he or she misses
important information that supports developmental skills.

We find that bouncing and slow movement during play help to support a calm and alert state,
reducing the possibility of overstimulation that makes the sensitive baby upset.

Since this baby is struggling with behavior modulation and staying asleep, co-sleeping works
best because it helps regulate sleep and behavior. If this is not an option for you, the swaddle and
swing approach can help during the early part of baby’s life. This approach will give you time to
apply daily sensory strategies that will help calm and organize the sensitive baby. We have seen
this approach move a sensitive baby towards better sleep patterns.

TIP for NEW PARENTS: It is important to factor in what will also fit your sensory personality
and the demands of your daily life when deciding on a sleep approach for your baby. Every
baby/parent relationship is different and the goal is to find an approach that is a good fit for
your whole family.

Swaddle &
Co-sleeping Shush & Pat Swing

Sleepy Baby

Organized
Baby

Sensitive
Baby

As you can see from the table above, we are big fans of the co-sleeping method of nighttime
parenting. Co-sleeping encourages breathing co-regulation in the newborn, is thought to decrease
the incidence of SIDS, eliminates nighttime fears, makes breastfeeding easier and supports a
feeling of well-being in the young child. It seems ideal but may not work for every family.

The shush & pat and the swaddle & swing sleep approaches will work for both the organized and
the sleepy baby. We think they are kind and respectful of the baby’s needs, if co-sleeping is not
an option. For more information about co-sleeping, Dr. Sears’ has a wonderful article on his
website titled “Co-sleeping: Yes, No, Sometimes?”. You can find the link to it in our resources at
the end of this book.
 CHAPTER 5

COMMON APPROACHES TO SLEEP

What effect does a baby’s sensory personality have on sleep?

Most parents of a new baby find out pretty quickly that there are many “sleep experts” who
promote their foolproof approach to sleep and are quite certain that their ideas will work for you.
We think parents should make up their own minds about which sleep approach works for their
family. We have filtered all these ideas for you and organized them into three basic approaches
to helping babies sleep. You can use what you learned about your baby’s sensory personality to
tailor a successful sleep approach for your baby and family.

The 3 basic approaches for helping babies sleep

1. Attachment parenting & co-sleeping: Attachment parenting encourages bonding between

parents and babies because babies are often carried for much of the day. Parents learn to read
their baby’s subtle physical and emotional cues and can intervene before baby gets upset. This
approach helps baby learn to modulate his or her behavior, builds attention and helps develop
social skills.

TIP for NEW PARENTS: Research has found that there is a direct correlation between the
amount of time a baby is carried during the day and how much time that baby spends crying.
Babies who are carried more, cry less.

When putting baby to sleep, baby is fed and held until he drifts into a deep sleep and gently
placed where he or she will sleep. You will know that your baby has reached deep sleep when he
or she is limp and relaxed, with regular breathing and no eye movements. The attachment
approach often includes co-sleeping. Baby is tucked next to mom in bed and mom simply nurses
baby back to sleep each time he or she wakes.

A research study with families who used co-sleeping with their babies found that parents
reported “...less infant crying, more maternal and infant sleep and increased milk supply due to
the increased frequency of night time breast feeding that close contact facilitates.” (McKenna,
McDade, 2005).

The co-sleeping approach works well for the sensitive baby who may awaken more easily when
moved into a crib and is difficult to soothe. It is also a great fit for the sleepy baby who benefits
from more sensory input and interactions with people and the environment.

Parents who use co-sleeping say that one benefit is that mom does not have to wake up
completely to nurse her baby back to sleep. Dads often don’t know how many times baby has
awakened at night because there is very little crying. More sleep for everyone!

Some parents use an attachment parenting approach during the day but are light sleepers and
simply can’t do the family bed. If this is the case for your family, you may find that the swaddle
and swing method works for you. Do whatever works and feels right for your family.

TIP for NEW PARENTS: The research team Forbes, et. al.(1992) conducted a large longitudinal
study of adults who had been co-sleepers as babies and found that they all shared a similar
“feeling of satisfaction with life”.

2. Swaddle & Swing: In this approach, baby is fed, wrapped in a swaddling blanket, burped
and held until sleepy and then placed in a motorized baby swing. This works well for the
sensitive baby whose parents have difficulty co- sleeping with a baby in the bed. Researchers
have found that swaddling is a very effective calming technique and helps improve baby’s ability
to self-calm. When baby outgrows the swing, your approach to sleep will need to change but
parents often find that this approach helps get their family through the first few months of sleep
challenges.

Swaddling is a great sensory tool for parents because it is calming and organizing for a baby. “In
general, swaddled infants arouse less and sleep longer. Preterm infants have shown improved
neuromuscular development, less physiologic distress, better motor organization, and more self-
regulatory ability when they are swaddled” (Van Sleuwen, et al, 2007).

3. Shush & Pat: To use the shush and pat approach, baby is fed, swaddled and held until
drowsy. He or she is placed in the crib while sleepy, but still awake and is patted and shushed for
a few minutes. Parents then leave the room, often when baby is not quite asleep. The parent in
charge of bedtime returns and repeats the pat and shush as many times as needed until baby
settles into sleep. This approach works for the baby who is organized and calm. The sleepy baby
and the organized baby usually do well with this approach.

This will not work for the sensitive baby, who may escalate into crying that is very hard to
interrupt. This leads to more time spent calming baby down and can result in everyone’s sleep
being choppy and disrupted during the night.
 Daytime activities and sleep

We have found that what happens during a baby’s day often predicts the type of sleep he or she
has at night. This is particularly true of the sensitive baby, who may need an adjustment of the
day-time schedule to prevent over stimulation that leads to poor sleep.

Here is the story of Reina, a sensitive baby whose parents used an attachment parenting
approach, combined with sensory strategies to help their baby learn to cry less and become a
better sleeper.

Three-month-old Reina is the second child in her family. She was a bright, alert baby who was
identified as a sensitive baby. She was much more difficult to feed than her older sister, requiring
careful positioning during breast-feeding to help her to coordinate her nursing. In the afternoon,
after a long and stimulating day, she often cried for about an hour, just because she was over-
tired. She napped for a short period of time, usually while her mom was driving to do errands.
Reina had difficulty settling down into sleep at night and required a lengthy bedtime routine to
help her recover from her overly stimulating day. She woke every hour at night and required a
lot of help to return to sleep, resulting in exhausted parents. Her parents consulted with an
occupational therapist for advice, and they developed the following sensory strategies:

• Reina spent most of her waking hours carried by mom, dad or a caregiver in a baby
sling, which provided her with deep pressure to back and arms. This sensory strategy
helped her to calm and regulate her behavior.
• Reina’s parents were more careful about noisy and brightly colored toys during the
day. They gave her only one toy at a time and eliminated toys with loud music or
sounds. They watched her for STOP SIGNS that meant she might be overwhelmed. An
overwhelmed baby will often proceed to crying, so her parents used calming techniques
before she became upset.
• To help Reina establish a good nap schedule, her mom made sure to be at home at
naptime, eliminating the quick nap in the car. Reina was given a baby massage for ten
minutes in the early afternoon, about an hour before her fussy time usually started. This
helped Reina start the afternoon in a calm, alert state, interrupting her pattern of
extended fussing.
• Starting an hour before putting her down for the night, Reina’s parents lowered the
lights in her room, put her in a warm bath, swaddled her in a warm towel and rocked
her slowly while feeding her one last time before sleep. Her parents waited until she
was in a deep sleep state before putting her in her crib. They turned on a fan to provide
white noise. This helped Reina screen out noises that normally caused her to awaken.

The results: After two weeks of her new sensory strategies, Reina was a calmer, happier baby
while awake and began to sleep more soundly for longer periods at night. Her entire family was
better rested. Sensitive babies like Reina become easier to parent when they have help learning
how to regulate their behavior with the external support of sensory strategies.
 STOP SIGNS

How baby tells you he is done playing.

Too much sensory input equals a cranky baby.

Behavior to watch for:

• Averting her eyes or her head

• Sneezing
• Yawning
• Color change; reddening or blanching
• Excessive, jerky movement of arms and legs
• Hiccups
• Crying

Remember, when babies start to show us STOP SIGNS, we stop what we are doing and apply
calming sensory strategies like swaddling, slow rocking, a pacifier, patting or walking with baby
in the baby carrier. Sometimes babies need all of the strategies we have to calm down. Find the
ones that work for your baby!
 CHAPTER 6

HOW SENSORY STRATEGIES HELP BABY SLEEP

Our approach whenever a baby is struggling with settling down to sleep is to implement daily
calming sensations in what is often referred to as a “calming sensory diet”. We have found that
after a few weeks of implementing a daily sensory diet, babies are calmer with more organized
behavior, better sleep and less crying!

One of the things we recommend is carrying babies in a baby carrier on the caregiver’s body (not
in a car seat). This provides baby with slow movement, firm touch from the carrier and the
proprioceptive input of adjusting his or her body to the caregiver. These sensations are calming.
The researchers Hunziker and Barr, (1985), found that the more a baby is carried, the less he or
she cries overall.

These are the four sensory strategies that most babies find calming. Providing these sensations
daily results in your baby being calmer, crying less and sleeping better.

1. Slow movement (rocking, walking with baby in your arms, slow swinging).

2. Firm touch/pressure such as: being carried in a baby sling, being swaddled or
receiving baby massage.

3. Proprioceptive sensation, which happens when we use muscles and joints against
gravity. Ideas would be: bouncing in a parent’s arms, crawling, climbing, jumping,
baby actively moving around the environment.

4. A calmer home environment, with less stimulating toys and sounds. When putting
baby to bed for the night, parents often use the “white noise” of a fan or a “nature
sounds” track that remains on throughout the night. This creates background sound
that helps baby stay asleep, despite noise in the environment.

The predictability of a consistent bedtime routine for baby (like the one Reina’s parents used)
signals that it’s time to settle down and prepare for sleep. A recent study found that regular
bedtime routines helped children develop sleep regulation and decreased nighttime waking
(Staples, et al., 2015). Routine helps all types of babies settle into sleep, stay asleep and return to
sleep once awakened. Parents report that the most useful strategies to help baby get ready to
sleep is using the same calming bedtime ritual every night. An example of a bedtime sequence
could be:

1. Warm bath and jammies

2.“Topping off” with one or two last feeds before bed

3. Slow repetitive movement in a rocking chair

4. Reading a book or singing a repetitive song

5. Dimming the lights and adding white noise

 CHAPTER 7

PARENT INTERVIEWS ABOUT SLEEP

For the past few years, we have been asking parents how they approach sleep with their
newborns and infants. We interviewed four mothers with four different approaches to their
baby’s sleep. Here’s what they told us.

Mom #1 Using the swaddle and swing approach: This mom has adorable fraternal twin girls.
Her family’s approach to sleep might best be described as attachment parenting when the babies
were under a year followed by shush and pat as they approached 18 months.

The babies were a few weeks early and as young infants, they needed to be awakened every 2-3
hours to nurse to make sure they were getting enough calories. Grandma and great grandma
participated in daily childcare when the girls were infants. The cultural norm for their extended
family is to hold babies until they are asleep and avoid letting them cry. This approach helped the
babies gain weight quickly and removed the stress of crying.

From newborn until 9 months, they were swaddled and placed in side-by-side baby swings for
naps during the day. They loved it and slept really well! We know that the sensory strategies of
swaddling and slow movement in a baby swing helps babies stay asleep. This approach was
continued until the girls were about a year.

Mom and dad tried co-sleeping but found that it didn’t work for their family, so they decided to
try the shush and pat. The girls had a bedtime routine, and were then placed in their cribs and
encouraged to go to sleep. A sound track with lullabies helped the girls fall asleep. The girls
were given a few minutes to work out how to get themselves to sleep. Mom or dad returned to
comfort them if they were having trouble settling down or if they woke at night and couldn’t get
back to sleep. After about two weeks, the girls could settle themselves into sleep. Now they sleep
through the night unless they have a nightmare and need comforting. At three years of age, the
girls have different personalities and need different nighttime routines to settle down for sleep.
One of the twins needs more interaction, with stories and tucking in but the other is content to
play quietly until she falls asleep.

Mom #2 Using the shush & pat approach: This mom is a first-time mother with triplets. She
has the advantage of being a naturally organized person and a pediatric occupational therapist.
She has a nanny to help during the day but she and her husband handle night-time parenting
themselves, without assistance. Since there are three babies, it was vital that nighttime sleep not
be a management problem for mom and dad. Playtime, feeding and sleep are scheduled and their
caregivers stay with a strict feeding, play and sleep routine to keep the babies’ behavior
organized. It seems to work beautifully, and the babies are happy, social and reaching
developmental milestones nicely. Mom talks about letting the babies cry for a few minutes, and
intervening with a pacifier or patting if necessary. She also brings up the importance of
recognizing the different types of crying. Crying due to “I can’t get comfortable” as opposed to
“I’m in pain and need help” require different responses from parents.

Mom #3 Using the shush & pat approach: This is a great mom who has three little boys under
5 years. For the first three to four months, she nurses the baby on demand and doesn’t expect him
to self-soothe at night. As the baby gets older, their family moves to an approach where “We try
to make them confident sleepers without stressing them out”. She recommends the sleep
approach outlined in the book “The Sleep Ladies Good Night, Sleep Tight: Gentle Proven
Solutions to Help Your Child Sleep Well and Wake Up Happy” by Kim West.

Their family’s approach (after the first three months) is to go through a nighttime routine of bath,
jammies, breastfeeding on both sides for a full tummy, swaddling, and placing baby in the crib
while sleepy but awake. If the baby fusses, mom returns and shushes him and sometimes pats
him or gently rocks the bassinet to let him know that she is there but doesn't pick him up. Her
babies are quick to fall into the routine and seem to be happy sleepers. It’s important to note that
all of her boys were organized babies from the start and they are all quick to settle down when
comforted.

Mom #4 Using the attachment parenting & co-sleeping approach:

This first-time mom and her husband have always used co-sleeping with their one-year-old
daughter. Mom and dad both work full time and mom feels that her daughter nurses more at
night to make up for mom being gone during the day. They don’t have a strict bedtime routine,
but both parents watch baby for signals that she is tired and needs to go to sleep. Mom also has
verbal cues she uses with baby when it is time for bed, like “It’s time to quiet our bodies” and
“It’s time to sleep”. Mom has noticed that if her baby stays awake too long, she has more
difficulty getting to sleep and wakes frequently during the night. When this happens, the baby
will nurse more frequently to settle back into sleep.

This baby girl has an extended family, who all take turns being her caregivers during the day.
They each have slightly different approaches to sleep for naps. She takes better naps when she is
with the caregiver who lies down with her during her nap because she is used to the proximity of
another person. She is a well-adjusted, social baby who engages with new people easily.
 CHAPTER 8

PARENT SENSORY PERSONALITY VS. BABY SENSORY PERSONALITY

Is there a mismatch?

A wise person said, “There is no such thing as an individual baby, there is only a family with a
baby”. A baby is part of a family system, so occupational therapists also help parents learn how
to negotiate the balance between meeting baby’s needs, while not completely neglecting their
own. When there is a mismatch between a parent and child’s sensory personalities, it can cause
misunderstandings that interfere with bonding. The parent/infant bond is baby’s first relationship
and we want it to be a successful foundation for developing strong social skills. In that light, here
are some solutions we have developed.

Sensitive Baby and the Sensitive Parent

As occupational therapists, we tend to see a large percentage of sensitive babies because they are
over-responding to their internal and external environments and as a result, tend to have
difficulties with sleep, feeding and crying. Caregivers usually find these babies challenging to
comfort and parent.

When we explain to a parent that this baby is finding it hard to modulate his or her response to
sensations like touch, sound and movement, we usually hear that one parent has experienced
similar issues with sensory modulation. Adults have usually learned how to cope with their own
sensitive sensory systems, but having a baby who cries a lot and is difficult to feed and soothe is
a real challenge!

The parents of the sensitive baby benefit from scheduling regular breaks in caregiving by
enlisting baby sitters, family or friends to care for baby over short periods of time. Recruiting
help gives parents a little break and time to themselves. Taking a walk, having an uninterrupted
dinner or conversation will help you increase your patience and coping abilities.

Mindfulness-based stress reduction techniques are helpful for parents who are feeling
overwhelmed, (Williams-Orlando, 2012). Apps such as “Stop, Breathe & Think”, “Headspace”
and “Insight Timer” are great resources that walk you through some of these techniques.
Sensitive Baby and the Relaxed Parent:

By relaxed, we mean the parent who tends to be under-reactive to environmental stressors such
as loud sounds, bright lights, or busy places. Typically, this parent has difficulty understanding
why their sensitive baby is so bothered by everything. This parent needs to plan ahead to
anticipate what sensations and environments might overwhelm their sensitive baby.

For this parent/baby dyad, we suggest using calming sensory strategies liberally, particularly
baby carriers that allow you to wear your baby. The relaxed parent doesn’t mind carrying the
baby all day and we know that being carried is a sure bet for helping a baby cry less and become
more resilient to change.

Sleepy Baby and the Sensitive Parent

Sometimes we see babies who are delayed in development because they are under-responding to
people and sensations in their environment. The sensitive parent may have difficulty
understanding their sleepy baby’s under-reaction to sound, movement or touch because he or she
has such a big response to those same environmental stimuli. Parents of these babies can begin to
feel that their baby “doesn't like them” because the baby’s response to social interaction is
muted.

This baby needs help “waking up”. Social interactions need to be more intense and more
frequent to get baby’s attention. We also like to use alerting sensations to help these babies
become more focused. Our favorites are:

• Fast movement (in a baby swing or a parent’s arms)

• Light touch (gently stroking baby’s arms or face)
• Talking to baby about everything in the environment
• Singing to baby
• Toys with sounds, different textures and bright colors

As a sensitive parent, the idea of light touch, excessive talking and toys with loud sounds and
bright lights may just make you cringe! It may be too much overstimulation for your own
sensory personality. In these circumstances, adopting some of the strategies listed for the
sensitive baby/sensitive parent may be beneficial for you too.

We know that activities that involve proprioception (using muscles against resistance) and firm
touch/pressure are calming and organizing, in babies and adults. Taking a brisk walk with baby
in a stroller or wearing baby in a front carrier can produce those mood elevating and calming
sensations. This may help you tolerate the activities that your baby needs to increase alertness.
Sleepy Baby and the Relaxed Parent:

The relaxed parent may not notice that baby is underreacting to the people and environment until
development starts to become delayed. Babies should register social contact with parents and
family members and have a lot of interest in exploring the world, first visually, then by
physically moving. Babies who seem content to just sit on a parent’s lap may need more help
getting started. The sensations we find helpful are the ones we mentioned above: movement,
light touch, sound, bright colors and lots of social interactions.

Identifying your baby’s sensory personality allows parents to better understand what sensations
their little one needs for a blissful night sleep and encouraging optimal development. With
sensory tools, parents can:

• Tailor the perfect sleep approach for maximal success.

• Help sensitive babies learn to be calm and organized.
• Help sleepy babies interact with the world and their families.

We hope that as you read and reread Baby S.O.S: Sleep Solutions Based on Baby’s Sensory
Personality, you begin to truly tune in to your baby’s personality, gifting everyone in your
household a well-deserved night sleep.

Sweet Dreams!
 RESOURCES

Doan, T., Gay, C., Kennedy, H., Newman, J., Lee, K. (2014). Nighttime breastfeeding behavior
is associated with more nocturnal sleep among first time mothers at one month postpartum. J
Clin Sleep Med., 10(3), 313-319. doi: 10.5664/jcsm.3538

Engler, A. C., Hadash, A., Shehadeh, N., Pillar, G. (2012). Breastfeeding may improve nocturnal
sleep and reduce infant colic: Potential role of breast milk melatonin. European Journal of
Pediatrics, 171 (4), pp. 729-732. http://www.ncbi.nlm.nih.gov/pubmed/22205210

Forbes F, Weiss DS, Folen RA. The co-sleeping habits of military children. Military Medicine
1992; 157: 196–200.

Hunziker, U. A., & Barr, R. G. (1986). Increased carrying reduces infant crying: A randomized
controlled trial. Pediatrics, 77(5), 641- 648.

Pantley E. (2002). The No-cry sleep solution: Gentle ways to help your baby sleep through the
night. New York, NY: McGraw-Hill.

Sanchez, C., Cubero, J., Sanchez, J., Chanclon, B., Rivero, M., Rodriguez, A., Barriga, A.
(2009). The possible role of human milk nucleotides as sleep inducers. Nutritional Neuroscience,
12(1), pp. 2- 8. http://www.ncbi.nlm.nih.gov/pubmed/19178785

Sears, W., Sears, R., Sears, J., Sears, M. (2005). The baby sleep book: The complete guide to a
good night’s rest for the whole family. New York, NY, Little Brown & Co.

Shepard, Jane. (2008). The Benefits of Co-Sleeping. Retrieved from

https://www.healthychild.com/the-benefits-of-co-sleeping/

Sears, W., Sears, R., Sears, J., Sears, M. (2017). Co-sleeping:Yes, No, Sometimes? Retrieved
from https://www.askdrsears.com/topics/health-concerns/sleep-problems/co-sleeping-yes-no-
sometimes

Staples, A., Bates, J., Petersen, I. (2015). Bedtime routines in early childhood: Prevalence,
consistency, and associations with nighttime sleep. Monographs of the Society for Research in
Child Development, vol. 80, issue 1, pp.141-159. March 2015

Van Sleuwen, BE, Engelberts, AC, Boere-Boonekamp NM, Kuis W, Schulpen TW, L’Hoir MP.
(2007). Swaddling: A systematic review. Pediatrics, 120(4).
http://www.ncbi.nlm.nih.gov/pubmed/17908730

West, K., Kenen, J. (2010). The Sleep Ladies Good Night, Sleep Tight: Gentle Proven Solutions
to Help Your Child Sleep Well and Wake Up Happy. Philadelphia, PA, Perseus Book Group.

Williams-Orlando, C. (2012). Holistic medicine for infants: Holistic-and mindfulness-based

stress reduction for parents. Integrative Medicine: A Clinician's Journal, 11(5), 32-37. Retrieved
from:http://search.proquest.com/openview/3b24c7282261769c28a13 2d0069b8fa1/1?pq-
origsite=gscholar
OCCUPATIONAL THERAPY EVALUATION

Name: Parents:
Date of Birth:
Test Date:
Age: 3 years

Referral: Cutie-pie was referred for an occupational therapy evaluation by her parents to assess
her development and to determine the need for occupational therapy services. Her parents
report that Cutie-pie is an active, affectionate girl who is caring and tries hard to accomplish
tasks. She has the diagnosis of cerebral palsy and speech and language delays. She is active,
but has difficulty controlling her body and acquiring adaptive skills. Her parents wish to determine
the nature and extent of services that will support her development.

Medical History: Cutie-pie was delivered at 28 weeks gestation via Caesarian section and
required a 3 month NICU-stay. She had gastroesophageal reflux. She has the diagnoses of
Cerebral Palsy NOS, Homonomous Hemianopsia, Optic Atrophy, Strabismus, Developmental
Delays, Plagiocephaly, and Apraxia. She had Patent Ductus Arteriosus. Additionally she has
ocular motor syndrome and benign neoplasm of the pineal gland.

Educational History: Cutie-pie qualified for special education services under the primary
eligibility of Intellectual Disability and Secondary eligibility of Low Incidence Disability. She
receives adapted physical education 30 minutes weekly and orientation and mobility.

Intervention History: Cutie-pie received early intervention services through Regional Center
that included additional time for occupational therapy (once weekly), physical therapy (twice
weekly) and speech and language therapy services (twice weekly). She also received vision
therapy services. She was recently dismissed from school-based physical therapy. She
continues to receive occupational therapy 30-minutes twice monthly (30 sessions per year), and
speech and language therapy services 30-minutes weekly in group.

Developmental History (Parent Report):

State Regulation – Cutie-pie’s parents indicated that she was an active baby who liked being
held. She was fussy, irritable, cried a lot, and was somewhat floppy when held. She had irregular
sleep patterns. She will take an afternoon nap for approximately 45 minutes, but cries and fusses
during the night. She is soothed by her night light and music. She will communicate her
frustration and anger through screaming and shaking her head. She will lie on the floor and kick
people around her. If she wants a toy from her brother she will grab his arm and pull him to the
floor, grabbing the toy.
Gross Motor – Cutie-pie had delayed gross motor milestones. She sat at 18 months, pulled to
stand at 27 months, and crawled at 30 months. She can walk independently with adult monitoring
for safety approximately 10 feet. She has high tone throughout her trunk and extremities. She is
clumsy and often falls. She will push a tricycle with her feet but does not use peddles.
Fine Motor - Her fine motor skills emerged slowly. She is still working on learning to draw simple
shapes when given a visual model. She has difficulty with finger opposition required to open and
close the scissors. She does not yet cut with a knife.
Communication – Cutie-pie said her first word at 30 months. She has speech and language
deficits and communicates nonverbally for the most part. She is using signs such as “more”,
“again”, and following along with some words to songs such as “Twinkle, Twinkle, Little Star”.
She follows single step familiar verbal instructions.
Self-Care – She requires adult support with hygiene, feeding, and dressing. She will take off her
shirt, socks, and shoes. She can finger feed and will drink from a cup by herself. She tends to
suckle with a straw. She will over-eat and needs adult guidance to regulate the quantity of her
food intake. If she goes into the pool following a large meal, she will throw up. She can now get
into the pantry by herself. If not watched closely, she will eat nonfood items such as sand and put
small things in her mouth such as buttons or bottle caps. She is not yet toilet trained. Her parents
have her sit on the toilet at regular intervals so that she will begin to make the association.
Affect, Attention, & Activity - On a behavioral checklist her parents indicated that she is not
usually happy. She is overly active, impulsive, restless, stubborn and inattentive. She has
difficulty separating from her primary caregivers.
Self-Direction – Daily routines such as getting ready for bed, meal preparation and clean-up, and
getting ready for bed sometimes go smoothly. Bathing and grooming always goes smoothly.
Leaving the house in the morning and meal preparation are often difficult. Birthday parties, family
outings, and recreational activities sometimes go smoothly. During community outings, she needs
to stay in a stroller. She will run away from her caregivers.
Play and Leisure – Cutie-pie plays with toys by shaking or banging. She engages in some
pretend play with her doll. She is curious about people and often interacts with other significant
adults. She is often too aggressive with other children when taking toys or initiating contact. She
enjoys music and movement. She enjoys playing in water but does not try to kick her legs to keep
afloat.

Performance Test Situation: Cutie-pie was assessed during one two-hour performance
evaluation with intermittent breaks as necessary to sustain her attention. Her parents were
present throughout the evaluation. Her mother carried her into the clinic area and set her down on
the mats. She was animated, friendly, and alert throughout the testing. She easily engaged with
me, sitting in my lap as we got acquainted. She clapped for herself when she did an activity. I
presented standardized tests including puzzles from the space visualization test and visual figure
ground. She randomly provided responses without consideration to the nature of the test
therefore I switched to an observational and play-based assessment. Overall, Cutie-pie
performed the best of her abilities and the results may be considered a reliable indicator of her
abilities at this time.

She tended to lean on people or equipment when sitting on the mats. She was able to crawl
around but was unstable. She was a bit reluctant to crawl between the mats and tiled area. Her
mother reported that she crawls more often at home and will ascend the stairs. She was able to
crawl through a tunnel. She had some protective neck flexion when falling onto her back. She
seemed to be stronger with her flexor muscles than her extensor muscles. She appeared to be
frightened when presented the platform swing. She was willing to go on the playground style
swing, but could not sustain her balance and tended to fall backwards unless given physical
support. She enjoyed the Lycra swing.

She did not hold her head in midline but tended to hold it off to one side or the other, as if
attempting to see better at an angle. She did not seem to favor one side over the other.
Intermittently she shook her head as if in preparation to look at something. Her mother said it
was due to her ocular motor dyspraxia. When playing, following the prompt “Ready”, she said
“Set” and “Go”. Following more active play, she sat for 10 minutes and did visual motor tasks that
included opening and closing containers, putting objects in and out of them, transferring objects
from hand-to-hand, and sorting shapes. She did not seem to know her colors.

Tests Used: The assessment report is based on information from the following:
1. Parent report: Developmental and Family Impact Questionnaires
2. Adaptive Behavior Assessment System II (ABAS-II) – Parent Form (Ages 0-5)
3. Sensory Processing Measure (SPM-P) – Home Form (Ages 3-5)
4. Developmental Profile 3 (DP-3) Parent Caregiver Checklist
5. Clinical observations of postural control, muscle tone, ocular and oral motor control and
sensory responsiveness

2
6. Parent interview
7. Record Review

Results: The test results are reported in the categories below.

DP-3: The DP-3 provides an indicator of skill development across multiple domains. Cutie-pie’s
parents report that she demonstrates skills approximately in the one to two year range across all
domains.

Developmental Profile 3 (DP- Raw Score Standard Score % Age Equivalent

3)
Physical 8 <50 <0.1 1.0
Adaptive Behavior 10 <50 <0.1 1.4
Social-Emotional 13 <50 <0.1 1.8
Cognitive 12 <50 <0.1 1.8
Communication 9 <50 <0.1 1.4

On the ABAS-II, according to parent report, Cutie-pie has difficulties across all areas of adaptive
functions.

ABAS-II Parent Report Raw Score Scaled Scores Standard Scores %

Communication 38 1 55 <1%
Community Use 12 2 60 <1%
Functional Pre-Academics 5 1 55 <1%
Home Living 38 4 70 2%
Health and Safety 21 1 55 <1%
Leisure 36 1 55 <1%
Self-Care 49 5 75 5%
Self-Direction 37 1 55 <1%
Social 34 1 55 <1%
ABAS-II Summary
Composite Sum of Scaled Composite Percentile Rank 95% Confidence
Scores Scores Interval
GAC 17 45 <0.1% 41-49
Conceptual 3 45 <0.1% 38-52
Social 2 48 <0.1% 40-56
Practice 12 55 <0.1% 49-61

SPM-P: On the SPM-P, her parents reported some problems with social participation and definite
dysfunction with overall sensory processing and planning and ideas.

SPM-P Home Form Raw Score T-Score Interpretive Range

Social Participation 21 69 Some Problems
Vision 36 77 Definite Dysfunction
Hearing 17 66 Some Problems
Touch 29 69 Some Problems
Body Awareness 23 76 Definite Dysfunction
Balance and Motion 21 71 Definite Dysfunction
Planning and Ideas 30 80 Definite Dysfunction
Total Sensory Score 137 73 Definite Dysfunction

Visual Perception

3
Reactivity: On the SPM Cutie-pie’s parents reported definite dysfunction with visual
responsiveness. She seems bothered by light, is distracted by busy visual environments, has
trouble paying attention if there are a lot of things to look at and enjoys watching things spin more
than other children.
Discrimination: Cutie-pie often walks into things as if they weren’t there. She has difficulty
recognizing how objects are similar or different. She often looks at things out of the corner of her
eye.
Visual motor skills: Cutie-pie is able to do functional tasks with her hands such as opening
containers and sorting shapes. Her visual motor skills including tool-use and ball skills are
significantly delayed.

BEERY VMI Raw score Standard Score Scaled Score Percentile

2 53 -1 0.1%

Auditory-Language Processing
Receptive: Cutie-pie responded to one-step familiar instructions. She did not follow any multi-
step or unfamiliar verbal instructions.
Reactivity: According to her parents’ responses on the SPM Cutie-pie has some problems with
auditory reactivity. She responds negatively to loud noises. She likes to make the same sounds
happen over and over.

Tactile Perception
Reactivity: On the SPM her parents reported some problems with tactile responsiveness. She is
sensitive to grooming activities including hair combing, tooth brushing, and nail cutting.
Discrimination: Cutie-pie has difficulties discriminating tactile sensations. She did not seem to be
able to accurately locate single or multiple areas of light touch to her arms and legs or identify
shapes via touch.

Vestibular Processing
Gravitational Security: Cutie-pie is fearful of movement against gravity, showing signs of
gravitational and postural insecurity.
Vestibular-ocular responses: Cutie-pie had approximately 5 seconds of nystagmus following
rotation required for the postrotary nystagmus test.
Postural Control: Cutie-pie has low tone and poor proximal joint stability. She was able to sit on
the swing but tended to fall backwards rather than independently supporting her trunk. During the
clinical observation, she has low tone and significantly poor righting and equilibrium responses.
She has poor antigravity postures during prone extension and supine flexion. She had difficulty
stabilizing her postures, disassociating her movements, and coordinated bilateral tasks. On the
SPM her parents reported definite dysfunction with balance and motion. She often falls out of her
chair, leans on people and things when sitting, and shows poor coordination and often rocks her
body when standing or sitting.
Ocular Motor Control: Cutie-pie had difficulty with ocular pursuits, gaze shifting, and stabilizing
her gaze during head movements. She has significant difficulty organizing her head, neck, and
eye movements.

Proprioceptive Awareness: According to SPM results, Cutie-pie’s parents reported definite

dysfunction with body awareness. She seems unsure of how to raise or lower her body when
moving, tends to pet animals with too much force, bumps or pushes other children and chews on
nonfood objects.

Gross motor skills: Cutie-pie has significantly delayed gross motor skills.

Praxis: Cutie-pie shows difficulties with all areas of praxis including ideation, imitation,
construction, and complex tool use. On the SPM her parents reported definite dysfunction with
planning and ideas. She often fails to complete tasks with multiple steps, has trouble figure out

4
how to hand multiple objects at the same time, and tends to play the same preferred activities
repeatedly.

Social Skills: On the SPM, Cutie-pie’s parent reported some problems with social participation.
She enjoys interacting with others, but she has difficulty joining into play with others and playing
cooperatively with others.

Discussion: Cutie-pie is an adorable, lively, and friendly child with global developmental delays
including speech and language, fine and gross motor skills, and adaptive functions. She had a
complex early medical history. She was born prematurely requiring medical care in the NICU for
3 months. She was subsequently diagnosed with Cerebral Palsy NOS, Homonomous
Hemianopsia, Optic Atrophy, Strabismus, Developmental Delays including speech and language
deficits, Plagiocephaly, Apraxia, ocular motor syndrome and benign neoplasm of the pineal gland.

The results of this evaluation reveal that Cutie-pie is a determined little girl who pursues her
interests with vigor. She is loving, cooperative, and socially interested in her environment. She
learns by repetition and trial and error. She has limited ideation for ways to do new and novel
activities, indicative of apraxia. She has neuromotor deficits that limit the ease and skill of her
motor performance including poor grading, force, and directionality of her movements,
coordination of muscle synergies, strength, endurance, and symmetry and coordination of
bilateral movement patterns. Additionally, Cutie-pie has difficulty rapidly and accurately
processing sensory information. She has poor sensory perceptual awareness of her body in
space and slow and inaccurate processing of environmental data from her visual and auditory
systems. She has atypical sensor reactivity to single and multiple sensations in her environment.
In multisensory and high stimulus environments, she has difficulty regulating her attention,
alertness, and activity level due to heightened sensory reactivity and diminished body awareness.
These sensory, motor, and praxis deficits interfere with her functional performance and ease of
interactions with people and things in the environment.

Speed will also play a role in her ability to perform skillfully or not. If activities or people in the
environment are moving quickly, she will have more difficulty figuring out what she is going to do
to accommodate the challenge. She needs time to figure out what is going on and additional time
to figure out her response. When the steps are broken down she can do the components, but
she has difficulty chaining action sequences together. Replicating action sequences is needed
throughout the day to accomplish daily routines and to learn new skills. Therefore, she benefits
from assistance and direction from adults to help her decode information and figure out what is
expected of her. During learning activities, as the working load increases, her persistence may
decrease, and she may feel fatigued. Tasks that simultaneously ask for sustained or dynamic
postural control along with visual motor control, language interpretation, social interaction, and
cognitive reasoning will be particularly challenging.

Cutie-pie has ocular-motor apraxia. She shakes her head in preparation for visually regarding
objects. This may be an attempt to activate the vestibular-ocular system. She had decreased
nystagmus and poor balance responses along with decreased core stability and difficulties with
static and dynamic postural-ocular control and balance responses, requiring vestibular-
proprioceptive processing. The vestibular system contributes to a sense of body position in
space by providing sensory data about head position and gravity. The proprioceptive system
detects the muscles acting on the joints and provides a sense of the body’s position and
movement. The vestibular and proprioceptive systems work together to enhance muscle tone
and motor skills and provide her information about where and how she is moving or supporting
her position against the pull of gravity. These sensations work in concert with the visual system
and allow a person to orient in space and rapidly perceive 3-dimensional space. The vestibular
system is also intimately linked with spontaneous coordination of head, neck and eye
movements. Many times children will have difficulty controlling their eye movements especially
when shifting from different spatial planes, from varying distances, and when there is movement

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involved. It is likely that Cutie-pie requires additional vestibular-proprioceptive information for her
to organize her head, neck and eye movements in concert with her body movements.

Cutie-pie is remarkably vigorous during her physical and social play activities. However,
decreased postural stability will impact her attention to tasks as well since she becomes rapidly
fatigued just by the need to hold her body up against gravity. During stationery activities Cutie-
pie may experience postural fatigue which is problematic if she has to sit too long while working.
She may become uncomfortable, fidget, lose her attention to the task or show decreased
motivation to do long writing tasks. She will benefit from frequent movement breaks to increase
her physical endurance and stamina and to increase her motivation to engage in physical
activities. Frequent movement breaks and adjusting where and how she is positioned during
sedentary tasks will be helpful. Working in various positions such as standing or lying down may
help. She also needs opportunities throughout her day for physical activities so that she develops
a better sense of her body and refines the way in which she interacts with other people and things
in her environment. Tactile, vestibular and proprioceptive activities such as jumping up and down
to wake up or rocking for calming are known for their regulating abilities. She will benefit from
frequent sensory and movement breaks that alternate being active with taking rests.

Cutie-pie has difficulty with multiple foundational abilities that will interfere with her written
communication. Writing is a complex task requiring postural stability, fine motor control,
somatosensory guidance of her hand when writing, and the ability to shift her gaze from point A to
point B or from near-to-far to copy things down on her paper. While visual motor tasks needed
for writing, tool use, and activities of daily living are significantly delayed, she shows interest and
ability to manipulate interesting objects and open containers. She continues to have difficulty
tracing, copying designs, visual construction, and with spatial organization of her materials.

Cutie-pie is likely to perform better when she can predict the routine with a balance between
structured and unstructured activities. She will benefit from being allowed to explore a variety of
sensory regulatory strategies that assist her to regulate her level of alertness, and therefore her
learning and participation throughout her day, so that she can stay organized and learn new
skills. The more ways in which Cutie-pie has to predict what she has to do during routines as well
as when learning new things, the less stressful it will be for her and the better she will be able to
learn and problem solve what to do.

Conclusion: Cutie-pie is an active and engaging child who enjoys interacting with others. Cutie-
pie’s condition is chronic and severe requiring intensive and long-term therapy services. She has
a significant early medical history and a complex array of diagnoses that include Cerebral Palsy
NOS, Homonomous Hemianopsia, Optic Atrophy, Strabismus, Developmental Delays including
speech and language deficits, Plagiocephaly, Apraxia, ocular motor syndrome and benign
neoplasm of the pineal gland. She has neuromotor and sensory integration difficulties including
heightened sensory reactivity, poor somatosensory and vestibular-proprioceptive processing
affecting postural control and balance, and delayed visual motor skills. She has difficulty
interpreting and guiding her movements in fast paced and multi-sensory environments. She has
delayed adaptive, gross and fine motor skill development that interferes with her independence in
needed and desired skills. These difficulties impact her participation at home, at school, and in
the community.

Recommendations:
Occupational therapy is recommended as follows:
a. Occupational therapy, 1:1 for two 60-minute sessions per week, in a specialized therapy
room to address issues related to sensory integration, praxis, play, and fine and gross
motor skills.
b. Consultation for 30 minutes per month with the IEP team including family is necessary.
c. Reassessment at 6-month intervals is necessary to determine future recommendations.

Sample Goals in preparation for setting goals and objectives include but are not limited to:

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1. Self-Regulation: Cutie-pie will choose from a set of sensory regulatory strategies
that either help alert or calm her, depending on her needs that result in a more
organized state as demonstrated by increased attention, on-task behavior, and work
production with minimal adult prompts 2/3 opportunities.
2. Postural and Bilateral Control: Given active breaks prior to sedentary tasks,
Cutie-pie will assume and maintain a seated position with her hips, knees and ankles
in 90/90/90 degrees of flexion and her head and trunk in midline, for approximately 5
minutes at a time with no loss of balance, on 2/3 opportunities without adult prompts
or guidance.
3. Ocular Motor Control: Cutie-pie will demonstrate improved head/neck/eye control
by showing more efficient ability to look at desired objects in her near visual field with
50% reduction in extraneous head movements in advance of her visual search and
visual fixation in a 30-minute period, on 2/3 opportunities.
4. Visual Motor Control: Cutie-pie will demonstrate improved visual motor control
(grasp/visual tracking) by visually searching, locating desired visual targets such as
directions on the blackboard and efficiently copy shapes during a lesson with good
spatial accuracy and alignment with minimum adult supports, on 2/3 opportunities.
5. Sequencing and Imitation: Cutie-pie will demonstrate an improved ability to learn a
3-step sequence of actions necessary for play activities, games or dance routines by
completing them with 80% accuracy with no more than one verbal prompt/adult
guidance 4/5 opportunities.

Referrals/Recommended Evaluation/Services:
1. Special education
2. 1:1 aide support at school
3. Physical Therapy
4. Speech and Language Therapy
5. Vision Therapy
6. Orientation and Mobility Training

Accommodations for the School Environment: Sensory strategies are important to help her
alertness and attention and ability to self-regulate throughout her day. These accommodations
may include:
a. Engagement in short bursts of physical activity intermittently throughout the day that
builds her strength and endurance
b. It is important that Cutie-pie is given activity breaks before during and after school. Break
times are a critical part of her day and must not be taken away due to missed work or
other consequence. During her breaks, encourage Cutie-pie to participate in physically
active games in cooperation with other children so that she can build a broader repertoire
of social skills.
c. Regular activity breaks to help her pay attention during sedentary tasks
d. Flexibility in the classroom so that she can move around while completing an activity.
e. Opportunities to do her work in various positions such as standing, in bean bag chair, on
large pillows.
f. Mobile seating devices such as a peanut ball, ball-chair, or therapy ball are options that
may work for her as long as someone is close-by at all times.
g. Heavy work activities such as scooter board, climbing, and playing “tug-of-war”.
h. Spot lighted work areas help with visual attention
i. Enjoyable sensory opportunities such as a fuzzy toy or jumping time with special
attention for work well-done
j. Visual reminders of unfamiliar sequences of activities that she has to do during the day
k. Pressure garments such as dance-tards and sports-style Lycra undergarments
l. Allow her short periods to retreat if she becomes overwhelmed, avoidant or
overstimulated. Let her know that she will come back to the activity in a certain period of

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 time such as 1 minute. She might like to use a timer that helps her to understand how
much time she has to get herself organized.
m. Create spaces in which she can retreat such as a fort or tent.

Suggestions for the Home and Community:

1. Provide Cutie-pie with opportunities for physical activities in which she can build strength and
stamina. Swinging and moving frequently are advised. If she has difficulty sitting still, or prior
to this demand, it may help to have her go out and swing for 5 minutes, do an errand, or run
around the building.
2. Encourage tactile activities with a variety of textures, temperatures and pressure. For
example, heavy beanbag chairs that she can crawl between and jump into, pressure
garments such as dance-wear, or weighted toys such as beanie babies. She may enjoy
wrapping herself with a 4 yard length of 60 inch wide Lycra spandex fabric. She could wrap
up in it or use it as a hammock to swing in.
3. Jumping, climbing, hanging, pushing and pulling activities will be organizing for her. Provide
opportunities to play on bouncing equipment such as a trampoline.
4. The Alert Program for Self-Regulation by Mary Sue Williams and Sherry Shellenberger.
5. Extra-curricular community-based activities such as swimming and therapeutic horseback
riding are encouraged.
6. In order for Cutie-pie to develop optimally and feel healthy and happy, it is important that she
maintains an active life-style.

Susanne Smith Roley OTD, OTR/L, FAOTA

Licensed Occupational Therapist