Sensory Integration Education

Dr Heather Miller-Kuhaneck, PhD, OTR/L, Associate professor of Occupational Therapy in the College of Health Professions at Sacred Heart University, Connecticut, USA. We are honoured and privileged to have Dr Kuhaneck join us for the Big Interview for this month’s edition of SensorNet. Dr Kuhaneck has practiced as an occupational therapist for over 30 years, specialising in autism and sensory integration and is one of the key figures in this field of practice. Dr Kuhaneck is the co-editor of one of the main paediatric Occupational Textbooks, Case-Smith's Occupational Therapy for Children and Adolescents. She is the editor/co-editor of three editions of Autism: A Comprehensive Occupational Therapy Approach. She has co-authored the textbook Activity Analysis, Creativity and Playfulness in Pediatric Occupational Therapy: Making Play Just Right. 

She has been involved in the development of key sensory integration assessment tools including the SPM-2 and the Classroom Sensory Environment Assessment (C-SEA). She is a fellow of the American Occupational Therapy Association and has worked in urban and rural schools as well as private clinics in CT, West Virginia and Ohio. Her years of experience and expertise in sensory integration research and practice continue to provide inspiration to all occupational therapists. I had the opportunity to sit down and meet Dr Kuhaneck for a discussion in which we covered a wide range of topics. The full interview is available to watch as a video or listen as a podcast too:

_{Dr Heather Miller-Kuhaneck}

SensorNet: Can you tell us about your current role and what your work is focusing on currently?

Dr Kuhaneck: My primary role is as a full-time faculty member so I am primarily teaching. I teach paediatrics, research and coordinate our student Capstone projects. I am based in a teaching institution and so I teach a full load. Within that, we do have research requirements and that is something I really enjoy. Currently, I am in a 'finishing up mode'. My research work right now is mainly finishing up a lot of things I had started, including writing up results from a single subject study of Ayres SI for children with ASD, and also getting the Classroom Sensory Environment Assessment done and published. I am also in the process of finishing writing the second edition of the book Activity Analysis, Creativity and Playfulness in Pediatric Occupational Therapy: Making Play Just Right. All of my work would fall within the realm of sensory integration, autism, and or play.

SN: You have completed extensive research and work in the area of sensory environments and adapting the sensory environment for individuals with sensory differences. Can you share more with us about the key principles of this work, factors to consider and how we, as clinicians, can translate these principles into our everyday work?

Dr Kuhaneck: The two projects I have been involved with that focus on the environment have been assessment tools. The Sensory Processing Measure and the Classroom Sensory Environment Assessment both consider the environmental impact in relation to sensory processing. The SPM includes forms for different environments and different raters, and the C-SEA specifically is rating the environment, not the child. I think for myself and my co-authors, our primary focus was on helping others understand the potential impact of environmental sensation on children’s attention, behaviour, and ability to learn. This is something that OTs learn in school but not all parents do, and not all teachers do, at least not in the way we do. 

For the C-SEA in particular, we have designed it to be used as a collaborative tool and hopefully also a teaching tool. We had that same intention with the SPM, that the team members would work together and collaborate on interventions that would work across environments and that they would attempt to understand differences in performance across environments as perhaps being because of something in that environment (either in a positive or detrimental fashion). I think clinicians can use these concepts in their assessment practices to ensure that whenever a child is dealing with a difficult behaviour or difficulties in performance, the environmental factors are considered. There can always be environmental stimuli that are bothersome to them that perhaps we would barely notice. This tool was designed to help make environments work for our clients. It is also important to question how to collaborate with others to bring people’s attention to the way environment impacts the function of the clients we are working with.

SN: As therapists we support many individuals with sensory processing difficulties in the classroom. How can we best support individual sensory needs and then whole class needs? 

Dr Kuhaneck: This can be difficult depending on the teacher, the classroom, and the space and materials you have at hand, but ideally you will be able to work together with the teacher to create varied learning spaces that in total, work for the whole class. Each individual space may not. But then the teacher hopefully can be encouraged to allow children to choose the portion of the room where they work best. For example, there can be a quiet corner, a darkened den, a noisy neighbourhood etc. The teacher can name the areas within the classroom, but the areas can include a variety of different types of sensory environments, quiet and loud, dim and bright, visually stimulating and plan, etc. That way a student can choose. Someone may want a quiet bright area to work while someone else may want to work in an area with dimmer lighting and less visual distraction. It can actually be part of the teacher’s first “getting to know” the students at the beginning of the year, to see what the students like and then have them help set up areas they would like to work in. Then the OT can help set up areas for students with sensory issues or inability to describe what they need on their own.

SN: The classroom for autistic children poses many sensory challenges. How important is it to educate school staff on the sensory processing differences of these children?

Dr Kuhaneck: Educating people who work with the child can make all the difference to the child’s experience of acceptance and feeling understood as opposed to feeling constantly different from others and out of sorts and always in trouble. We call this 'reframing' behaviour. This is when we can reframe a child’s behaviour from something an adult 'understands' as wilful disobedience, or aggression or whatever negative perception there is about the behaviour instead to: this is a reaction to something the child experiences as unpleasant, just like how you would react if a spider were crawling on you, or if I made you eat a food you hated the worst in the world, or if I made you do something that scared you terribly. Having adults have that sort of understanding about the possible reason for a behaviour, changes the way the adult reacts to the child. It can change everything over time. It can change the way other children react to that child as well. If the adult accepts the behaviour and tries to help as opposed to shunning and punishing, the other children will as well. The consequences to self-esteem over time can be enormous. 

SN: Tell us more about how the C-SEA. What information can it provide?

Dr Kuhaneck: The C-SEA is a tool that a teacher fills out about their classroom, basically describing and rating their room in terms of the types of sensory experiences the room provides. The tool doesn’t give a score, so that teachers don’t receive any sort of rating of whether your classroom is a 'bad' or 'good' classroom. There are no normative classrooms to compare to. But what it does is tell the teacher, you have a certain number of stimulating items in your room and a specific number of calming experiences. For some children, specific sensory experiences might be difficult and here are some ideas about how you might make a change if you are so inclined. There will be a bit of explanation about why OTs think certain sensory input is stimulating based on evidence where we have it, and based on expert review where we don’t. Then the teacher can meet with the OT about a particular child in the classroom and have a discussion along the lines of “Johnny is auditory defensive and the C-SEA has identified these auditory stimulating features of my room. What can we try to make this better for Johnny?”

SN: How and when should we use this tool and how can it add to our clinical reasoning when assessing individuals with sensory processing differences?

Dr Kuhaneck: I think it will be something you might recommend a teacher complete if you are working with a student who you have assessed and who has sensory issues and who has difficulties learning in the classroom. If you suspect there is something hindering performance in the classroom, it might be good to have the teacher take a look at that. I am also really interested in the possible intersection of learning that could happen if the teacher also completed the adult form of the SPM, to learn about the teacher’s own sensory preferences at the same time. I think some interesting collaborations could occur between teachers and OTs, if given the time for meetings. 

SN: The SPM-2 newly revised edition has been released and there are many changes included. One such addition is the driving form. We would be interested to hear more about this tool and why it was included?

Dr Kuhaneck: When we were redoing the SPM and extending the age range and adding environments, the driving form was something I really pushed for because I have sensory issues myself and I remember having some difficulty learning certain aspects of driving initially. My issues are mild and I am functional and I can drive…but I always found the skill of driving fascinating. 

The items on this form came from all of us on our team thinking about all of the aspects of sensory processing required to drive well, beyond the visual system. Of course, the visual system needs to be working well, but you need good proprioception to judge the force of your leg on the accelerator or brake, and also for how much force to turn the wheel with. You need to be able to manage the auditory stimuli of the car, other cars, horns, sirens. So we created a form to help parents examine the specific aspects of driving that might be difficult for their teen. It is not meant to be a tool to tell someone if they are able to drive and we specifically state that it is for people who have their license, so they were able to pass the test and drive. However, they might be struggling with certain aspects of driving that an OT might be able to help them work through (or adapt). I am actually really excited to see where OTs might take this in terms of research with the form.

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SN: You have been working on a new book about the subject of play. Can you share some details about what this book will be about, its aim and what we can hope to learn from it?

Dr Kuhaneck: Yes, this book is a second edition of the book Activity Analysis, Creativity and Playfulness in Pediatric Occupational Therapy: Making Play Just Right that I had written with Susan Spitzer and Elissa Miller. The first edition focused more on the importance of activity analysis and how it could be used to help OTs play with children. But for this edition, we focused more specifically on play and expanded into many more topics about play and then activity analysis is part of it - as a way to assess and get play to be 'just right' for children. We have brought in additional authors on topics such as mental health and play, play and leisure for teens, OTs' unique focus and contribution to the play literature, and the differences in how play is considered in various countries outside of the US. The book has kept its focus on being a guide for clinicians to be more playful and to more consistently include play in therapy. It is something that is not done enough, at least in the US for a variety of reasons but mainly because of our reimbursement mechanisms. So we just keep hoping and pushing for more and more play in our OT sessions and try to give clinicians what they need to do so.

SN: The evolution of the theory of ASI is well documented. Where is the field of ASI currently - what research is needed do you think to further our knowledge and understanding about ASI specifically related to play?

Dr Kuhaneck: We are really just in the beginning stages of understanding the impact of ASI on play outcomes. The intervention clearly values and uses play and the theory clearly would suggest there would be impacts on play for a child with dyspraxia and modulation issues. We have some evidence of these relationships. But we have very little evidence of the efficacy of ASI to improve play - as of yet. I think that is where we need to go next. We need to be able to document that ASI improves praxis, and improved praxis improves play – if in fact that is what we find. Of course with research, you never know what you will find when you start and we have to be open to wherever the work takes us. But I think those of us who love and believe in ASI, believe that play improves and have anecdotal evidence of it.
 

SN: We cover a number of units across our SI modular pathway on the topic of playfulness. What role does playfulness have within an ASI approach?

Dr Kuhaneck: The appropriate level of playfulness of the therapist in ASI is critical. The therapist has to make the child feel safe first and foremost, but also understood, accepted and included as a playmate. The child needs to trust that therapist and trust that the OT sessions will be successful AND fun. A therapist who isn’t playful and is more authoritarian may get compliance, but likely won’t get a child who truly plays in the way we mean the word - as an occupation with meaning. I think one of the main differences between ASI and other approaches, aside from the use of multi-sensory environments and activities, is the playfulness of the therapist and the therapeutic approach as a playmate rather than a boss.

SN: You have done very valuable and detailed research in the area of Playfulness in Autism. One such research paper was A Systematic Review of Interventions to Improve the Occupation of Play in Children With Autism. What were your key findings from this research and how can these inform and translate into our practice as therapists?

Dr Kuhaneck: We looked at a lot of papers specifically focusing on those that had play as the outcome of the intervention as opposed to using play as the intervention to improve some other outcome. We used an occupational therapy lens for this review, considered what we feel we mean by play in terms of what we would include in the review, and then we also used an OT lens for the interventions we included. We were specifically looking for interventions that OTs might typically use in therapy sessions. So that did mean that we left some things out. But the interventions we ended up including were parent education, modified play materials or environments, imitation of the child, and modelling by an adult, a peer, or video. 

What we found in the 20 studies that met our inclusion criteria was that there was moderate to strong support for imitating the child as a strategy to improve play and also evidence for the strategy of modelling for the child. These are both behaviours easily used by an OT in a session. I would guess that we would typically use modelling for children more often than imitating children and I would recommend people look into the literature on adults imitating children with ASD. Specifically, there is a treatment approach called Reciprocal Imitation Training and there is a growing body of evidence for this approach. For me personally, anecdotally, I have found this strategy very helpful when I have the type of child in the clinic that is making minimal contact with me or is tending to run away or flee from any attempts at interaction or engagement. I will immediately change my approach to imitating the child to see what kind of interaction I get. You are hoping the child eventually notices you imitating them, maybe does something purposefully to see if you will imitate it and then you have created an interaction. The child can start playing a game with you of “hmmm- what can I make this adult do?” Of course, you have to maintain safety and you don’t allow anything harmful to happen and certainly don’t imitate or encourage any type of behaviour such as biting or hitting etc. But I have used this approach with quite a few children and it occasionally has been miraculous.

SN: Many of our readers are therapists working in clinical practice and completing their advanced training in sensory integration: have you any advice/inspiration to provide to them as they continue to advance their skills and knowledge?

Dr Kuhaneck: Yes - there are a few things. First, Jean Ayres has been one of my personal heroes for a variety of reasons, ever since my senior year of OT school when I learned all about ASI. One of her characteristics as a person, therapist, and educator was to continually question and to continually learn more. I think for all of us practising using her work, we need to continue to do so. We need to be like Jean but it is so much easier for us now. We have so many more tools at our disposal now than she did, that make it easier to learn, read, question, search, and grow. We have the internet, we have databases and online articles, we have online chat rooms and support groups, we have conferences online, we have videos we can share with each other to talk through clinical problems and help each other. Honestly, we have NO reason not to continue to learn and grow as a therapist. That learning and growth will keep you interested in what you are doing, will hopefully prevent burnout and boredom, and most importantly, it is critical for us to be able to help the children we are working with. Those children and their families are counting on us, many are desperate for our help, and we absolutely have to give them our best or we shouldn’t be doing this job.

We thank Dr Kuhaneck for her time for this interview. We look forward to linking back in with her soon and keep an eye out for all her newly published work over the coming months!