Sensory Modulation in Pre-K & Kindergarten

Many children with behavioral, developmental and sensory challenges have difficulty maintaining a quiet alert state for learning.  These children tend to be low registration (miss important sensory input) and/or sensory sensitive (overly responsive to functionally irrelevant sensory input) the majority of the time.  The Sensory Profile is a reliable, valid assessment that can be used to determine if children have significantly different sensory modulation.  It is important to help children with significantly different sensory modulation to learn to monitor and regulate their arousal levels and maintain a quiet alert state for learning.  Colors can help children understand their sensory modulation level by using Blue to designate hypo-responsive, green an optimal quiet alert state for learning, yellow a hyper-responsive, and red an extreme hyper-responsive state.connotapres2017handout



A visual support integrating colors, energy levels, and sensory modulation can help children learn to identify and modulate their arousal levels.  Children are encouraged to work with the teacher or therapist to identify their common feelings and actions when experiencing various energy levels.


A simpler alternative is to make a High, Low and Medium Energy visual, and have children identify their arousal level and whether their current energy level feels O.K. or not O.K and why.  Some children learn better using the visual supports shown above, while others do better without it through only adult modeling. without it can be used to teach children to modulate their arousal levels. For example, the therapist might model by saying, I am high energy and feel not OK, because I’m too hyper to be a good teacher.  My heart is beating really fast, I’m breathing fast, my hands are shaking, my arms feel tight like raw spaghetti, and I’m talking fast and loud.  I’m going to do 10 pushups to lower my energy level”.

For some children high energy is their only problem, while others experience low energy as well.  For low energy children I model “I’m low energy and feel not OK  because I don’t have enough energy to be an exciting teacher.  My heart rate and breathing feel slow, my arms are soft like over-cooked spaghetti, and I’m talking slowly and soft.  I feel sad and dead inside.  I’m going to do do 10 fast jumping jacks to increase my energy level”.


As children develop, yellow can be added to designate a slightly hyper-alert state that precedes the red hyper-arousal state in which they misbehave.  This is helpful because early recognition of high energy is easier to control.  They can also be encouraged to use colors to relate their most frequent arousal level accompanying their feelings. The student who constructed the feeling wheel shown below depicted sad and lonely as low energy; embarrassed as high energy; and frustrated & mad as very high energy.  In addition, happy & nervous were depicted as related to both average energy and high energy states.


A general FAB Strategy for helping all students modulate their energy levels is to first decrease, then if needed gradually increase sensory input.  This is depicted below using a visual support that shows a student who frequently fluctuates between a low energy and high energy state, with only a small window of quiet alert functioning.  In a classroom the teachers response would involve first lowering the noise level and visual distractions for a dysfunctional high energy or low energy student.  This alone will often enable students to achieve a quiet alert state.  If they are still not in a quiet alert state, give graded input from the lowered sensory level in a predictable, socially acceptable way until a quiet alert state is reached.


Once the therapist is able to vary environmental input to enable a student to reliably achieve a quiet alert state, they can help the teachers, parents and student to do this independently.

Therapists and teachers can expand their understanding of arousal levels by synthesizing theories of the Autonomic Nervous System, sensory modulation, influences of early childhood PTSD, and Bipolar Disorder to expand their understanding of arousal level challenges.  The focus is on helping children notice when they first enter the blue or yellow zones, so they can find ways to increase or decrease their arousal levels as needed.

fab-energy-level-theoryStudents can use colors through visual supports, modeling, and/or using the smells of the scented color markers to learn if they are in the blue, green, yellow or red arousal zone.  This understanding provides a foundation for developing individualized coping strategies to manage their arousal levels.






Sensory-Based Intervention Groups

Sensory-based intervention (SBI) groups can be useful in schools and clinical settings to improve sensory skills, behavior and learning.  SBIs are the guided use of sensory strategies to improve behavior by addressing specific sensory modulation or sensory discrimination challenges.  SBIs are commonly implemented in early intervention, school, and mental health settings through individual, group and consultative interventions. SBIs include directing other professionals in embedding goal-directed sensory activities into a student’s daily routine to improve behavior for learning.

It is important to distinguish occupational therapy utilizing SBIs from Sensory Integration Intervention. While SBIs and Sensory Integration both utilize the theory of sensory integration, they are distinct interventions with unique research efficacy. Sensory integration intervention, also referred to as Ayres Sensory Integration® is a developmental clinic-based, child-led intervention that follows specific core concepts.

SBIs can empower clients to actively substitute the sensory input provided through aggressive, inappropriate and self-injurious behavior with sensory coping strategies and adaptive equipment. SBIs are goal-directed and specifically matched to the client’s needs and preferences. The use of SBIs has been integrated into the evidence-based Greenspan Floortime Approach for Autism Spectrum Disorders, Collaborative Problem Solving Approach for children with oppositional defiant disorder, Dialectical Behavioral Therapy for adolescents with borderline personality disorder, and models for reducing restraint and seclusion in mental health facilities and schools a-reducing-restraint-and-seclusion OTPractSchoolOTRedAgg .

The new ESSA “Every Student Succeeds Acts” (2015) potentially expands the role of school therapists in helping at risk students and consulting with parents and teachers to improve school climate.  Under ESSA occupational, physical, speech/language, and school mental health therapists are designated as Specialized Instructional School Personnel (SISP) and given a role in helping at-risk regular education as well as special education students.  SBI’s can be included in interventions to educate students, staff and parents in enhancing student self-regulation school therapist consultations and group leadership.

Effectively using sensory-based interventions (SBIs) to improve functional behavior is different from the more common practice of randomly distributing adaptive equipment or using a single sensory strategy such as brushing for every student in a class. Using SBI adaptive equipment and sensory strategies to optimally promote functional behavior begins with an occupational therapy assessment, developing an individualized functional behavioral goal, gathering baseline data on the goal, and matching the client with the most appropriate individualized environmental adaptation.  Once a specific environmental adaptation has been implemented consistently for a month in conjunction with other professionals, it’s effectiveness is assessed to determine if the environmental adaptation should be continued, modified, or discontinued.

Sensory modulation is the ability to respond to functionally relevant sensory information while screening out irrelevant input.  Simply helping students understand their sensory modulation and/or sensory discrimination differences is an important first step in SBI.  Therapists can begin by discussing sensory modulation “energy levels” as low, medium and high, to help students identify when their energy levels are too high or low for behaving appropriately and learning.  Consistently using the color codes developed by the Zones of Regulation program can be part of the effort in helping students gain a better understanding of how their arousal levels affect their behavior and emotional regulation.

Once students have modulated their energy level, consider and intervene if sensory discrimination disorders are negatively impacting behavior.  When in the quiet alert state some students can still become dysregulated because of sensory discrimination disorders in which they have difficulty distinguishing, interpreting and organizing the information coming in from all their various senses.  For example, sensory discrimination disorder can involve problems organizing and combining information from the pressure, touch, and movement senses to appropriately print the “b”.

Sensory discrimination disorder can occur in any combination of ones sensory systems: tactile (touch), proprioceptive (muscle force/tension), interoceptive (internal organ states such as hung & pain), olfactory (smell), gustatory (taste), auditory, and visual.   it is most widely described in tactile discrimination disorder. A common assessment item regarding tactile discrimination from the Miller Assessment for Preschoolers involves the therapist having a client identify which finger is touched with eyes closed, with consistently accurate identification expected by age 3. Some high school students who are above grade level who had a trauma history and psychiatric disorder were inconsistently able to do this task. This difficulty alerts me to the need of increasing body awareness. Sensory Discrimination Disorders can involve the sense of: touch, proprioception (body awareness), vestibular (movement), vision, sound, taste, and/or smell. Interventions of sensory discrimination disorder are best done after basic sensory modulation has been addressed.

Recent research suggests that interoception can be a significant component of sensory discrimination disorders.  Interoception challenges involve confusion regarding internal body sensations such as hunger, thirst, and pain.  Exploring internal sensations through sensory mindfulness activities can help address interoception.  Research supports that mindfulness activities can be helpful interventions for individuals with somatic pain and post-traumatic stress disorder challenges.

mindfulnessSensory discrimination disorder contributes to difficulties with body awareness, embodiment, and organizational skills. Sensory discrimination disorder is more commonly seen in clients who experience early childhood post-traumatic stress disorder. It is hard to teach self-esteem and respecting others personal boundaries when clients don’t have adequate body awareness.


It is important to help students learn to identify what they are feeling before they yell, hitting others or engage in problematic behavior “because they suddenly feel horrible”.   For students with developmental challenges it can be helpful to combine feeling faces with the color codes from the Zones of Regulation so they can use pictures to identify their negative feelings and arousal level and get assistance with finding self-regulation activities.

SBI involves the use of individualized adaptive equipment to improve specific goal-directed behavior, such as reducing noise and visual distractions with a study carol and noise-canceling headphones to reduce peer conflicts and increase attention.  It can also include massage, mindfulness activities, or embedded classroom tasks involving delivering a box of books for the teacher as a deep pressure movement break.  The most important and often neglected step is to identify and educate students regarding their specific sensory challenges related to behavior, and to reinforce all efforts to self-regulate.

Adaptive Equipment

grpsbi2016 SLIDES

school-therapy SUPPLEMENTAL Therapy in the Schools Slides



Using Sensory Strategies to Improve Behavior

Sensory strategies have a significant impact on the behavior of children and adolescents with developmental, mental health, Post Traumatic Stress Disorder and sensory processing challenges. Deep pressure touch provided by pediatric occupational therapists through massage, brushing, weighted blankets, mat sandwiches and other sensory strategies are described as extremely positive experiences for children and adolescents with developmental, mental health, Post Traumatic Stress Disorder and sensory processing challenges. Finding preferred activities is helpful because motivation can be a significant problem when treating these youngsters.


A significant relationship was found between sensory and behavioral problems in children with developmental disorders. Research indicated that deep pressure sensory input functioned as positive reinforcement while matched sensory activities reduced repetitive non-purposeful behaviors in children with Autism Spectrum Disorder. Offering opportunities to use sensory strategies for self-regulation significantly reduced behavioral problems as well as the need for restraint and seclusion in adolescent and adult residential treatment centers for psychiatric and trauma challenges.


The usefulness of offering clients deep pressure sensory strategies as an alternative to aggression and restraint makes sense, as it can replace the use of restraint as reinforcement for aggression with sensory activities to reinforce avoiding physical aggression. School occupational and physical therapists have begun using sensory activities as reinforcement for avoiding aggression to reduce student restraint and seclusion. SchoolOTRedAgg  The functioning of sensory strategies as positive reinforcement makes it important for therapists to avoid using sensory strategies immediately following aggressive or inappropriate behavior. Despite bitter conflicts between behaviorists, pediatricians and therapists clients would greatly benefit from their collaboration.


Canfield, J. M. (2008). Sensory dysfunction and problem behavior in children with autism spectrum and  other developmental disorders.

McGinnis, A. A., Blakely, E. Q., Harvey, A. C., & Rickards, J. B. (2013). The behavioral effects of a procedure used by pediatric occupational therapists. Behavioral Interventions, 28(1), 48-57.

O’Hagen, M., Divis, M., & Long, J. (2008). Best practice in the reduction and and elimination of seclusion and restraint; Seclusion: time for change. Aukland: Te Pou Te Whakaaro Nui: The National Center of Mental Health Research, Information and Workforce Development.

Rapp, J. T. (2006). Toward an empirical method for identifying matched stimulation for automatically reinforced behavior: A preliminary investigation. Journal of Applied Behavioral Analysis, 39(1), 137-140.

Sutton, D., Wilson, M., Van Kessel, K., & Vanderpyl, J. (2013). Optimizing arousal to manage aggression: A pilot study of sensory modulation. International Journal of Mental Health Nursing, 22, 500-511.

Warner, E., Spinazzola, J., Westcott, A., Gunn, C. & Hodon, H. (2014). The body can change the score. Journal of Child & Adolescent Trauma, 7(4), 237-246.


School Occupational Therapy for Developmental Trauma

School occupational therapists emphasis on therapeutic relationships, mental health, sensory processing, attachment, development, purposeful activity and self-regulation offer a unique contribution for improving the behavior of students with developmental trauma disorder. School behavioral problems related to developmental trauma are seen in students who have experienced early chronic abuse. Many students with developmental trauma difficulties have significant sensory modulation, emotion regulation, attachment, self-regulation, sensorimotor, somatic, and developmental challenges.  Working in conjunction with school psychologists, social workers, and guidance counselors, occupational therapists can help improve the mental health and behavior of students who have developmental trauma challenges http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fact-Sheets/OT%20%20School%20Mental%20Health%20Fact%20Sheet%20for%20web%20posting%20102109.pdf http://www.aota.org/-/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Reducing-Restraint-and-Seclusion.pdf

Occupational therapy for improving the behavior of students with developmental trauma can include energy level modulate, sensory processing, deep pressure touch, and mindfulness strategies. The energy level modulate strategy involves increasing students’ awareness of their arousal level and teaching them to modulate dysfunctional high or low energy levels to better participate in school learning tasks. It can be introduced by explaining that “some students who have had difficult experiences early in their life can get into trouble by overreacting when they have really big feelings”. The energy level modulate strategy teaches students to identify whether their current energy level feels “High” (hyper, off the wall, with stiff muscles like raw spaghetti), “Medium” (just right and ready to learn) or “Low” (tired, numb, with loose muscles like over cooked spaghetti).

Visual chart for rating arousal level and if it feels comfortable

Visual chart for rating arousal level and if it feels comfortable

The energy level modulate strategy is extremely useful in school settings for students with sensory modulation difficulties who become aggressive following activities that raise their energy levels extremely high. While many students can use the energy level modulate strategy with teacher encouragement, some students with sensory modulation difficulties and developmental trauma need assistance. For example, a student receiving occupational therapy attended a wild physical education class where the students ran, screamed and threw balls at each other. His classmates behaved appropriately upon returning to class. However, this student who had significant sensory sensitivity and developmental trauma challenges was unable to sit down upon returning to class and threw a chair.

Following this experience the occupational therapist taught the school physical education teachers and mental health therapists the energy level modulate strategy so students could rate their energy levels before returning to class. The teacher or therapist would bring students who rated their energy level as uncomfortably high to a designated staff member (e.g., occupational therapist, speech therapist, principle, resource room teacher) who would help the student do pushups or other individualized sensory coping strategies to lower their energy level before returning to class.

The most effective strategies for normalizing energy levels involve deep pressure through the joints with slow linear movements. Activities such as regular or wall pushups, moving furniture, moving mats, delivering messages or boxes of books throughout the school, or wheelbarrow walking on your hands over a therapy ball can help achieve this.


Special consideration can be given in the energy level modulate strategy for students with both sensory modulation and developmental trauma challenges who have become use to maintaining a high energy level that interferes with appropriate attention and behavior for school functioning. This difficulty can be indicated by students who describe their energy level as “Hyper and comfortable” and students who actively resist efforts by their teachers and therapists to calm down to a functional energy level where they can pay attention to classroom activities. For students who resist regulating their energy to a functional level it is helpful for the therapist to begin by matching the student’s initial energy level, then support the student during individual sessions to gradually modulate their energy level.  http://www.traumacenter.org/products/pdf_files/Body_Change_Score_W0001.pdf 

Individual OT sessions using sensory processing, deep pressure touch, and sensory mindfulness strategies help students with self-regulation and developmental trauma challenges improve their attention, seated attention, and behavior for participation in school learning tasks.


These interventions emphasize child-focused activities that optimally challenge students to discover activities that will enable them to modulate dysfunctional arousal levels for improved school functioning. Sensory processing interventions promote attachment relationships combining child-directed activities at their optimal level of challenge with an attitude of PACE (playfulness, acceptance, curiosity and empathy). Offered respectfully with choices to decline, firm pressure touch strategies can enhance attachment, relationships, and self-control in students with behavioral and developmental trauma challenges. Attached is a link showing integrated use of behavioral, sensory processing, PACE, and FAB Pressure Touch strategies. While this treatment was done with a preschooler who had Asperger’s syndrome, a similar approach is often also helpful for students with behavioral and developmental trauma challenges https://www.youtube.com/watch?v=W8fMdJ6l0AM


Beider, S., Mahrer, N. E., Gold, J. I. (2007). Pediatric massage therapy: An overview for clinicians. Pediatric Clinics of North America, 54(6), 1025-1041.

Engel-Yeger, B., Palgy-Levin, D., & Lev-Wiesel, R. (2013). The Sensory Profile of People With Post-Traumatic Stress Symptoms. Occupational Therapy in Mental Health, 29(3), 266-278.

Hanson, J. L., Chung, M. K., Avants, B. B., Shirtcliff, E. A., Gee, J. C., Davidson, R. J., & Pollak, S. D. (2010). Early stress is associated with alterations in the orbitofrontal cortex: a tensor-based morphometry investigation of brain structure and behavioral risk. The Journal of neuroscience30(22), 7466-7472.


Hughes, D. A. (2011). Attachment-focused family therapy workbook. New York, NY: W. W. Norton & Co.

Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738.


My Perspective on Sensory Integration

I frequently use Sensory Integration/Sensory Processing Intervention in my work as an occupational therapist with clients who have severe behavioral, sensory processing and developmental challenges. I get criticism both by professionals who question the validity of sensory processing intervention and those who dislike my integrating it with other treatment approaches. It is time to transcend the polarizing debate about the sensory processing model and put it in perspective.

CoopPlayTheraband chairarm rotation

Like most occupational therapists my treatment grew from my clinical practice and the influence of many gifted teachers. I was introduced to sensory integration intervention in my entry-level occupational therapy training and studied it extensively at the post-graduate level. I spent thousands of dollars on my sensory processing training and although I’m frugal (my son says “a cheap skate”) it was worth every penny.

My sensory processing teachers have had so many students that they wouldn’t even know my name, but they transformed my professional and personal life through their mentoring. Among my most effective sensory processing teachers were the late Ginny Scardinia, Mildred Ross, Winnie Dunn, and Lucy Jane Miller. Each holds a distinct view of sensory processing intervention, is an occupational therapist, master teacher, and base their practice on the teaching of A. Jean Ayres the founder of Sensory Integration.

I first met Mildred Ross as a guest lecturer in my undergraduate occupational therapy class. Using sensory (e.g., touch, movement, smells) strategies she developed individual and group interventions that improve the functioning of individuals with severe psychiatric and developmental challenges. Disagreeing with the “experts” who viewed these clients as “hopelessly regressed psychiatric patients”, Mildred motivated her clients by respecting them as people, caring about them, and beginning at their current developmental level then gradually improving their functional skills. Mildred used a similar approach with occupational therapists, teaching us what an honor it was to help others and motivating us to improve our skills. I remember that the professors and conference leaders who invited Mildred to speak often set an egg timer for one hour before she began, and kept it ringing until she stopped speaking. Although they told me the timer was essential and I usually hate listening to people talk, I always hoped the timer would break so I could listen to her all day.https://www.youtube.com/watch?v=vHuhYaYRIb8

After five years as a school occupational therapist a unique experience introduced me to my next mentor Ginny Scardinia. I was watching my OT student treat a 6-year old girl who had developmental, behavioral, and PTSD challenges using a net swing when the girl suddenly spoke for the first time. I’d been treating that girl for half a year and gotten little response, but after that single half-hour session from my OT student the child was able to consistently speak in school. My OT intern told me that she’d learned sensory integration treatment during her previous affiliation with Ginny Scardinia at the Ayres Clinic. I soon located Ginny, took classes with her, and bugged her to teach me whenever she could from that day on.

Ginny Scardinia was unique in her ability to motivate me to do whatever it took to learn to help children like she could.  I recently learned that Ginny inspired many occupational therapists, and a research study was conducted summarizing her skills as a master mentor  http://www.ncbi.nlm.nih.gov/pubmed/23927618 Over 25 years have past but I still remember that after she first saw me treat she said, “You’re off to a good start, but you need to learn a lot more about neurology and sensory integration and honey, I can teach you”.   I knew that she was right and although I never reached her level as a clinician I am still trying.

Ginny inspired me to take all the sensory integration courses I could and to take motor learning classes at Columbia University T C. The motor learning research taught me that clients have the ability to recover from neurologically based challenges through engaging in developmentally appropriate sensory experiences in their natural environments. My experiences with Ginny and Mildred Ross inspired me to lead a group for children with Autism Spectrum Disorders with the help of occupational therapy students and the children’s parents.


I met Winnie Dunn and Lucy Jane Miller at an AOTA symposium where they were mentoring new researchers by letting us help with their projects. I remember asking them both why they were developing assessments when new treatments were needed, and they told me that until we learned to measure sensory integration interventions we couldn’t improve and validate our treatments. Winnie Dunn developed the Sensory Profile, a reliable and valid measure of sensory processing abilities www.sensoryprofile.com Dr. Dunn also went on to develop an intervention model that used the sensory profile to coach clients on adapting their sensory modulation styles so they could function more effectively. http://events.jeena.org/media/blog_media/2011/05/13/Sensory_Integration.pdf  While I still do direct and group interventions I always include consultation to the client, family, and teachers regarding how their sensory styles impact their interactions and functioning.

Adaptive EquipmentWallPushBulBrd

By taking the Sensory Profile I found I had significant Low Registration and Sensory Sensitivity, at a level where only 2 out of 100 adults my age score. Being low registration influences me to often miss sensory input that others notice. Because I am also sensory sensitive I also frequently get overwhelmed by sensory input I do notice and take a long time to accommodate to touch (e.g., I’m bothered by neck ties, rings and watches).

I’ve learned to stomp my feet and look people in the eye when they are telling me something important, and to take an hour walk when I’m feeling overwhelmed so I don’t yell at anyone. I still can’t wear a tie when I speak but can tolerate wearing shoes rather than sneakers. Knowing my sensory profile helps me accommodate my behavior to the needs of my clients. I tend to talk loudly and quickly, but consciously speak softer and slower when working with clients who have sensory sensitivity and attention deficit hyperactive disorder.

As a new researcher who was a member of Lucy Jane Miller’s team I learned to be a better observer. Although she is arguably one of the most influential leaders in sensory processing intervention (helping to create the term) what inspired me most about her was her honesty. I was putting off getting my Ph.D. because I felt I wasn’t smart enough, but was inspired when Dr. Miller asked me for help changing her flat tire. I figured if someone that smart couldn’t change a tire I could try to get my Ph.D. even though I didn’t feel smart enough.

Dr. Miller has evolved from developing assessment tools to supporting sensory processing intervention research through the Sensory Processing Disorder Network www.spdnetwork.org Her organization presents workshops on sensory processing basic and clinical research. I refer parents and clinicians to her organization because it is both factual and parent friendly.

My clinical experiences have shown me that sensory processing intervention helps clients with severe sensory processing, behavioral and developmental challenges to improve their functional skills. I have discovered the value of sensory processing intervention through individual, group, client/family education, and environmental consultation treatment. My perspective on sensory processing and professional vision wouldn’t have been possible with out my teachers and mentors. To paraphrase Isaac Newton, “If my professional vision has expanded it is because I stand tall on the shoulders of giants”.