|
Sensory Diet Applications and Environmental Modifications:
A Winning Combination
Victoria L. Nackley, OTR/L
Occupational therapists use a sensory integrative frame of reference when addressing
a child’s development of functional skills from a sensory standpoint (Kimball,
1999a). Using the sensory integrative approach, the therapist analyzes the child’s
processing of vestibular, proprioceptive, and tactile sensations in relation to
his or her ability to learn and move, essential components of the child’s
daily life. Sensory integration theory postulates that difficulties with processing
sensory information can impede a child’s acquisition of concept and motor
learning. Using sensory integrative principles, the therapist incorporates meaningful
activities that provide specific sensory stimuli to elicit an adaptive response,
thereby assisting the child in his or her overall motor and conceptual learning
(Fisher & Murray, 1991).
Once a child with sensory processing difficulties has been identified, the occupational
therapist is responsible for devising an effective treatment plan (Koomar &
Bundy, 1991). Although direct therapeutic intervention is a key component in the
process, the implementation of an individualized sensory diet regularly addresses
the child’s sensory processing needs throughout the day (Wilbarger, 1995).
The sensory diet allows the child ample opportunities to receive beneficial sensory
input at frequent intervals, thereby enabling him or her to participate more fully
in the activities that comprise his or her daily schedule. Implementation of the
sensory diet should span all aspects of the child’s day, particularly those
involving the school and home environments. As Kimball (1999b) stated, “The
change in environment that a parent can influence can also result in beneficial
changes well beyond the reach of a therapy session” (p. 203). To have an
optimum effect, the sensory diet should be designed for the child’s unique
sensory processing needs (Wilbarger, 1995). In this manner, the child benefits
from specific sensory input that is synchronized with the recommended treatment
approaches.
In addition to the sensory diet, the occupational therapist often makes recommendations
that will afford the child greater opportunities for success throughout the day.
These suggestions, though not sensory based, are essential to the child’s
favorable participation in school, home, and play activities. Modifications are
thus made in the child’s environment that encourages the child’s competence
in various contexts (Primeau & Ferguson, 1999). The list of sensory diet and
environmental modification suggestions presented in Table 1 represents a cooperative
effort of 31 therapists, assistants, students, and teachers who participated in
the BOCES Occupational Therapy/Physical Therapy Professional Network of New Hartford,
New York. This list was designed to be a starting point and, therefore, is not
all-inclusive. Each therapist is responsible for adapting these ideas for a specific
child and for creating additional ideas pertinent to the child’s home, school,
and family situations. Common classifications of sensory integrative disorders
have been used as a framework for the sensory diet and environmental modification
suggestions.
Decreased Discrimination of Vestibular and Proprioceptive Information
Children with decreased discrimination of vestibular and proprioceptive information
often exhibit poor posture, frequent falling, clumsiness, poor balance, constant
moving and fidgeting, and poor attention. Treatment generally focuses on providing
intense vestibular and proprioceptive information and improving postural responses
(Koomar & Bundy, 1991).
Decreased Discrimination of Tactile Information
Children with decreased tactile discrimination often present with a poor body
scheme. In addition, they have difficulty with praxis and poor hand skill development.
They may also crave touch input. Treatment generally focuses on providing a variety
of deep- and light-touch experiences (Koomar & Bundy, 1991). Resistance activities,
such as those given in the sensory diet ideas for decreased discrimination of
vestibular and proprioceptive information, should be used in addition to the ideas
specific to tactile discrimination.
Somatodyspraxia
Children with somatodyspraxia often exhibit poor tactile and proprioceptive processing;
clumsiness; frequent tripping, falling, and bumping into objects; difficulty with
fine motor and manipulation skills; and poor organization (Cermak, 1991). Treatment
focuses on providing heavy work, deep pressure, and light-touch experiences. Verbal
cuing and feedback may also be used (Koomar & Bundy, 1991). The sensory diet
and environmental modification ideas for decreased discrimination of tactile and
proprioceptive information should be used in addition to the ideas specific to
praxis issues.
Impaired Bilateral Motor Coordination
Children with impaired bilateral motor coordination often exhibit difficulty with
bilateral activities, such as clapping, hopping, skipping, jumping jacks, and
keyboarding. Difficulty with bilateral self-care skills, such as fastening and
shoe tying, is often present. These children may have some right–left confusion,
avoid midline crossing, and have difficulty developing a hand preference. Additionally,
they appear to have vestibular and proprioceptive difficulties. Treatment generally
focuses on providing vestibular and proprioceptive experiences and graded bilateral
activities. Treatment may start with simple crossing midline, rotation, and symmetrical
activities and work toward asymmetrical activities and more complex coordination
skills (Koomar & Bundy, 1991).
The sensory diet and environmental modification ideas from decreased discrimination
of vestibular and proprioceptive information that address vestibular input should
be used in addition to the ideas specific to bilateral motor coordination.
Tactile Defensiveness
Children with tactile defensiveness often exhibit an aversive response to a variety
of tactile experiences, such as craft materials, food, clothing, and bathing.
They will often avoid a variety of activities and may react aggressively at times.
They can be easily distracted and have difficulty with attention. Therapy generally
focuses on providing heavy work and deep pressure input. Slow linear vestibular
input may also be helpful. Therapy also provides opportunities for participation
in graded tactile experiences (Royeen & Lane, 1991). The proprioceptive sensory
diet ideas from decreased discrimination of proprioceptive and vestibular information
could be used in addition to the ideas specific to tactile defensiveness.
Gravitational Insecurity
Children with gravitational insecurity may exhibit limited participation in gross
motor play; avoidance or fear of escalators, elevators, cars, or planes; or resistance
to being off the ground. Treatment in the clinic environment generally focuses
on providing proprioceptive input and graded vestibular input. The child is always
in control of the amount of vestibular input received and is never pushed beyond
his or her limits (Koomar & Bundy, 1991). Environmental modifications would
focus on helping the child to feel safe in all environments and situations. Sensory
diet activities would focus on providing calming proprioceptive input throughout
the day. The proprioceptive sensory diet ideas from decreased discrimination of
proprioceptive and vestibular information could be used in addition to the ideas
specific to gravitational insecurity.
Projected Action Sequences
Children who have difficulties with projected action sequences are unable to plan
and initiate movement in response to changing environmental stimuli. These difficulties
are associated with inefficiencies in processing vestibular and proprioceptive
input. Intervention strategies are aimed at enhancing vestibular and proprioceptive
processing while enhancing the child’s ability to both plan and produce projected
action sequences (Koomar & Bundy, 1991). Sensory diet suggestions and environmental
modifications for decreased discrimination of vestibular and proprioceptive information
should be considered in addition to the ideas specific to projected action sequences.
General Recommendations
The therapist should recognize that each child processes sensory information uniquely.
Although the treatment techniques and the associated sensory diet suggestions
described in this article are recommended for the various areas of sensory integrative
dysfunction, the therapist must discern whether these measures are appropriate
for the individual child or for the specific performance context. The therapist,
in conjunction with caregivers and school personnel, should monitor the child’s
responsiveness to the strategies in order to determine effectiveness. Should adverse
reactions occur, the therapist should discontinue the activity and modify the
treatment approach accordingly (Koomar & Bundy, 1991).
Conclusion
The format addressed in this article affords the therapist the opportunity to
convey pertinent sensory diet suggestions and environmental modifications to classroom
personnel and caregivers from a sensory integrative frame of reference. The combination
of sensory diet strategies and environmental modifications, in association with
therapeutic intervention, provides the child with a multifaceted approach to addressing
sensory processing needs while promoting successful participation in daily activities.
Table 1
Sensory Diet and Environmental Modification Suggestions
|
Classification
and Activities
|
Suggestions
|
|
Decreased
discrimination of vestibular and proprioceptive information
|
|
Desk
work
|
|
|
Sensory diet
|
Active
resistance:chair push-ups, chair/body
squeezes, pocket push-ups, theraband stretches, hand gripper exercises, leaning
on upper extremities, weighted vest or lap tray. Finger-fidget activities:
pinches, spider push-ups, rubber band stretches, fidget balls, theraputty, pen
walking, and pencil aerobics. Seating options for linear motion: casters,
inflatable cushions, T stool, ball, peanut ball, bounce or rocking chair, one
or two slightly shortened legs of chair for rocking.
|
|
Environmental modifications
|
Solid
seat with armrests of correct height, tilt-top desk, frequent position changes,
dycem to stabilize objects on desk, paper placement outlined with masking tape.
|
| |
|
|
School
break time
|
|
|
Sensory diet
|
Play
activities:donkey kicks, heavy marching,
pushing against the wall, doorway pushes, “popcorn” activity in chair (popping
up at different speeds or intervals), seat walking while sitting on the floor
with legs extended, jumping, hopping, squeezes, stretches, self-imposed body hugs,
push-ups, sit-ups, jumping jacks, wheelbarrow walks, crab walking. Errands:
carrying heavy books, moving chairs.
|
|
Environmental modifications
|
Routine
that provides these activities before class and throughout the day, frequent breaks
during the day.
|
| |
|
|
Play
|
|
|
Sensory diet
|
Proprioceptive
input:Roughhousing, play wrestling,
leap frog, tug-of-war, wheelbarrow walking, jumping on a small trampoline, crawling
under couch cushions, chin-ups, play with weighted balls, jumping and crashing
on the bed, pushing another child on the swing, playing in a body sock, foot-to-foot
bicycling with friend, firm family hugging. Vestibular input: sitting on
a rocking chair; sitting on a ball to watch TV; jumping on a trampoline; playing
on slides, swings, seesaws, trapezes, rings, ladders, monkey bars, gliders, suspended
bridges.
|
|
Environmental modifications
|
Large,
open area with unbreakable items for roughhouse play; mattresses, pillows, and
beanbag chairs; outdoor swing set.
|
| |
|
|
Chores
|
|
|
Sensory diet
|
Proprioceptive
input:stirring, rolling/kneading dough,
digging, carrying, shoveling, raking, pushing/lifting heavy objects, moving furniture,
vacuuming, sweeping, mopping, carrying laundry basket.
|
|
Environmental modification
|
Avoid
chores with breakable items, such as putting away dishes.
|
| |
|
|
Snacks
and meals
|
|
|
Sensory diet
|
Healthy,
chewy foods (e.g., celery, carrots, apples, nuts, fruit leather, beef jerky),
thick liquids requiring straw (e.g., milkshakes, smoothies, gelatin, pudding).
|
|
Environmental modifications
|
Sturdy
chair with arms for meals, stabilized meal items to prevent breakage.
|
| |
|
Decreased
discrimination of tactile information
|
|
Desk
work
|
|
|
Sensory diet
|
Writing
tool alternatives:grippers, pencils
of different hardnesses, felt-tip pens, ballpoint pens, vibratory pens. Writing
surface alternatives: blotters, layers of paper, raised-line paper, textured
papers.
|
|
Environmental modifications
|
More
time for note taking and fine motor activities, oral tests, writing alternatives
(e.g., word processor, tape recorder), no grading on fine motor performance if
area of weakness, peer for note taking.
|
| |
|
|
School
break time
|
|
|
Sensory diet
|
Discriminatory
play activities:feely boxes, hidden
objects in sandbox.
|
|
Environmental modification
|
Breaks
for sensory diet activities, especially before fine motor activities.
|
| |
|
|
Snack
and meals
|
|
|
Sensory diet
|
Weighted
spoons.
|
|
Environmental modifications
|
Self-checking
during and after meals to ensure cleanliness; mirror for self-checking; weighted,
unbreakable dishes stabilized with a dycem.
|
| |
|
|
Dressing
|
|
|
Environmental modifications
|
Self-checking
while dressing and toileting, hook-and-loop fasteners.
|
| |
|
|
Somatodyspraxia
|
|
|
Desk
work
|
|
|
Sensory diet
|
Loops
and Other Groups writing program (Benbow, 1990).
|
|
Environmental modification
|
Grids
and graph paper.
|
| |
|
|
Gym
|
|
|
Sensory diet
|
Consult
physical education teacher about child’s needs and continual activity modification
to enhance motor planning.
|
|
Environmental modifications
|
Simplified
physical education activities; visual, auditory, and physical cues.
|
| |
|
|
Organizational
tasks
|
|
|
Environmental modifications
|
Simplified
instructions, colored folders to organize subject matter, daily schedule, child
verbalizes steps to complete task.
|
| |
|
|
Play
|
|
|
Sensory diet
|
Tactile
and proprioceptive play activities.
|
|
Environmental modifications
|
Containers
to organize items; child verbalizes steps in a task; visual, auditory, and physical
cues while teaching new play activities.
|
| |
|
|
Dressing
|
|
|
Sensory diet
|
Tactile
and proprioceptive play activities.
|
|
Environmental modifications
|
Lay
out clothing in order, with labels for cuing and tabs to hold; simple clothing
with big fasteners; simplified activities of daily living.
|
|
Impaired
bilateral motor coordination
|
|
Desk
work
|
|
|
Sensory diet
|
Chair
push-ups performed bilaterally, then alternating R-L-R-L and varying the rhythm
(first use arms then legs); theraband to encourage pulling tasks while stabilizing
with one arm and moving with the other; two-hand grippers with child using different
alternating patterns and rhythms to grip bilaterally; finger fidget activities
performed in alternating fashions.
|
|
Environmental modifications
|
Dycem
to stabilize papers, reinforced use of dominant hand, strategies for remembering
right from left hands, stamp or sticker to indicate dominant side, index card
with red LR
to reinforce left-to-right progression.
|
| |
|
|
nbsp; School break
time
|
|
|
Sensory diet
|
Donkey
kicks with alternating patterns (e.g., jump-jump-kick, jump-kick-jump, R-L-R-kick;
L-R-L-kick); march in place, alternating the speed and rhythm; games with clapping
patterns using speed and rhythm; jumping, hopping, skipping, galloping, and so
forth; these activities to transition to another activity.
|
|
Environmental modifications
|
Simplified
recess and play activities, variety of simple recess games.
|
| |
|
|
Gym
|
|
|
Sensory diet
|
Simple
bilateral activities.
|
|
Environmental modifications
|
Simplified
games and gym activities, as needed.
|
| |
|
|
Play
|
|
|
Sensory diet
|
Clapping
games while reciting jingles, foot-to-foot bicycling, Chinese jump rope games,
jump rope activities, dancing, swimming and pool activities, ball activities (e.g.,
bouncing and catching with L-R-L hands, basketball dribbling, soccer dribbling,
kicking R-L-R, running and kicking).
|
|
Environmental modification
|
Simplify
sports activities to ensure successful performance.
|
| |
|
|
Tactile
defensiveness
|
|
|
Desk
work
|
|
|
Sensory diet
|
Deep
pressure input (e.g., weighted vest, backpack, lap tray), active resistance activities,
finger fidgets and resistive hand activities (e.g., cutting, erasing, hand grippers).
|
|
Environmental modifications
|
Separate
space areas to prevent incidental touch by others; designate spaces for circle
time (e.g., carpet square); approach the child from the front and warn the child
before touch; avoid touch to sensitive areas (e.g., hair, face, neck, abdomen);
use firm touch and avoid light touch; minimize other possible overwhelming environmental
stimuli (use natural lighting; shut the classroom door; use blotters on desks;
use rubber bottoms on the chair and desk legs; provide curtains, blinders, and
room dividers; eliminate aromas in the classroom).
|
| |
|
|
School
break time
|
|
|
Sensory diet
|
Play
and break activities that provide resistance and heavy work input, “How Does Your
Engine Run?” program (Williams & Shellenberger, 1994).
|
|
Environmental modification
|
Frequent
breaks during the day.
|
| |
|
|
Gym
|
|
|
Sensory diet
|
Regular
calisthenics (e.g., push-ups, sit-ups, jumping jacks, wheelbarrow walks, crab
walking), self-imposed deep touch and active resistance activities before gym
class.
|
|
Environmental modification
|
Minimize
touch contact with other children when engaged in physical education activities.
|
| |
|
|
Arts
and crafts
|
|
|
Sensory diet
|
Variety
of tactile art media; never force children to do more than they are ready to do.
|
|
Environmental modifications
|
Glue
stick instead of glue or paste, paintbrush instead of finger paints.
|
|
Riding
the bus
|
|
|
Sensory diet
|
Backpack,
weighted vest, or heavy jacket.
|
|
Environmental modifications
|
Child
has own seat, is first or last in line to board bus, and wears headphones to filter
out extraneous sensory stimuli.
|
| |
|
|
Play
|
|
|
Sensory diet
|
Deep
pressure and resistance:rolling up with
a blanket to make a hot dog or burrito, rolling a large ball over the child to
make a pizza, playing tug-of-war, crawling under couch cushions, using a chin-up
bar, crawling into a stretchy pillow case.
|
|
Environmental modification
|
Teach
family members about the child’s sensory needs and the need to avoid unwanted
touch.
|
| |
|
|
Snack
and meals
|
|
|
Sensory diet
|
Deep
pressure techniques before meals:biting
down hard on teeth and releasing, pursing lips and releasing, sucking in cheeks,
flapping tongue, blowing balloons, clicking tongue; thick liquids to drink with
straw; chewy and crunchy foods.
|
|
Environmental modifications
|
Experiment
with different utensils (e.g., plastic, weighted, rubber coated); explore different
textures acceptable to the child and reinforce those textured foods for nutrient
intake.
|
| |
|
|
Dressing
|
|
|
Sensory diet
|
Deep
touch pressure to limbs and torso before dressing, body hugs, hand squeezes.
|
|
Environmental modifications
|
Determine
whether baggy, loose-fitting clothing is preferable; ensure that clothing is prewashed,
with labels and tags removed (clothing with minimal seams may be preferred); cut
tight elastics for comfort; wear socks inside out to avoid seams at the toes;
determine whether overalls may be preferred to pants with a waistband; avoid becoming
overheated.
|
| |
|
|
Bathing
|
|
|
Sensory diet
|
Heavy
rubdown before and after bath; towel wrapped tightly after bath with heavy hugs;
lotion applied firmly, if tolerated.
|
|
Environmental modifications
|
Experiment
with different sponges, wash mitts, cloths; have child wash self.
|
| |
|
|
Hair
care
|
|
|
Sensory diet
|
Deep
pressure to torso, limbs, and scalp before hair care; heavy blanket worn during
haircuts.
|
|
Environmental modifications
|
Conditioner
and detangler, different combs.
|
| |
|
|
Nail
care
|
|
|
Sensory diet
|
Deep
pressure and finger exercises before nail care.
|
|
Environmental modification
|
Soak
nails before cutting.
|
| |
|
|
Tooth
care
|
|
|
Sensory diet
|
Deep
pressure activities before brushing teeth (e.g., eating, water pick, gum massage);
deep pressure techniques while in the dentist’s chair; weighted x-ray blanket
worn while at the dentist.
|
|
Environmental modifications
|
Experiment
with different toothbrushes, use electric toothbrush, use of a washcloth initially.
|
| |
|
|
Sleep
and bedtime routine
|
|
|
Sensory diet
|
Deep
pressure hugs and slow rocking before bedtime; no roughhousing and TV before bedtime;
heavy blanket; sleep under couch cushions or pillows.
|
|
Environmental modifications
|
Prewashed
soft sheets, sleeping bag.
|
|
Gravitational
insecurity
|
|
|
Desk
work
|
|
|
Sensory diet
|
Continual
implementation of “grounding” input throughout the day via the use of active resistance
and joint compression and teaching the child to implement the strategies.
|
|
Environmental modifications
|
Firm,
supportive seat with arms that does not tip; proper desk and chair fit.
|
| |
|
|
Gym
|
|
|
Sensory diet
|
Active
resistance and joint compression activities before class; do not push child beyond
his or her limits.
|
|
Environmental modifications
|
Limit
number of children and space to increase sense of security; limit activity on
movable or suspended equipment; allow child to always have two feet flat on the
floor or allow the child to have someone or something to hold.
|
| |
|
|
Recess
|
|
|
Sensory diet
|
Child
pushes another child on the swing or catches another child at bottom of slide;
child holds jump rope for other children.
|
|
Environmental modifications
|
Allow
the child to be sedentary during recess; organize one-on-one play with a buddy.
|
| |
|
|
Riding
the bus
|
|
|
Sensory diet
|
Routine
of calming activities before the bus ride (e.g., slow rocking, heavy joint compression,
active resistance activities, deep breathing exercises); teach child to implement
these strategies; child wears a backpack on the bus.
|
|
Environmental modification
|
Child
sits alone with headphones to minimize stimuli.
|
| |
|
|
Snack
and meals
|
|
|
Sensory diet
|
Thick
liquids to drink with straw, chewy and crunchy foods.
|
|
Environmental modification
|
Solid,
supportive chair that allows child’s feet to touch floor.
|
| |
|
|
Mobility
|
|
|
Sensory diet
|
Weighted
backpack, vest, or fanny pack.
|
|
Environmental modifications
|
Stairs
with railings or child holds onto someone when ascending or descending, no escalators
and elevators, a “safe” environment with no items on the floor and no extraneous
material (e.g., scatter rugs).
|
| |
|
|
Sleep
and bedtime routine
|
|
|
Sensory diet
|
Heavy,
weighted blankets or cushions to sleep under, a calming routine before bedtime
(e.g., joint compression, slow rocking).
|
|
Environmental modification
|
Bed
mattress on the floor.
|
| |
|
|
Projected
action sequences
|
|
|
Play
or gym
|
|
|
Sensory diet
|
Activities
that yield active resistance before engaging in gross motor activities (see “decreased
discrimination of vestibular and proprioceptive information”).
|
|
Environmental modifications
nbsp;Mobility
Environmental modifications
|
Activities
in which the child can experience success (e.g., hook-and-loop ball and mitt,
T-ball stand, kick the can, kick ball with the ball stationary, tether ball, golf,
croquet); make sure that any ride (swing, merry-go-round) has stopped moving before
child gets onto it.
Avoid
escalators.
|
Acknowledgments
Input for sensory diet strategies and environmental modifications were received
from D. Albin, C. Bandych, B. Carlson, N. Dalby, D. Dillabough, A. Dunfield, E.
Dvorak, B. Fontaine, M. Gerace, R. Gilligan, N. Hinge, C. Holmes, A. Kinsella,
C. Kinsinger, R. Marcus, M. Mielnick, M. Mills, M. Moylan, S. Pardee, M. Pfeiffer,
L. Roberts, J. Rogers, P. Rooney, J. Rosinski, C. Szyper, J. Tinker, J. Vindigni,
C. Vollmer, K. Young, and P. Zumba.
References
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Cermak, S. A. (1991). Somatodyspraxia. In A. Fisher, E. Murray, & A. Bundy
(Eds.), Sensory integration theory and practice (pp. 137–165). Philadelphia:
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Fisher, A., & Murray, E. (1991). Introduction to sensory integration theory.
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practice (pp.3-26). Philadelphia: F. A. Davis.
Kimball, J. (1999a). Sensory integration frame of reference: Postulates regarding
change and application to practice. In P. Kramer & J. Hinojosa (Eds.), Frames
of reference for pediatric occupational therapy (2nd ed., pp. 169–204). Baltimore:
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Kimball, J. (1999b). Sensory integration frame of reference: Theoretical base,
function/dysfunction continua, and guide to evaluation. In P. Kramer & J.
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Koomar, J., & Bundy, A. (1991). The art and science of creating direct intervention
from theory. In A. Fisher, E. Murray, & A. Bundy (Eds.), Sensory integration
theory and practice (pp. 251–314). Philadelphia: F. A. Davis.
Primeau, L., & Ferguson, J., (1999). Occupational frame of reference. In P.
Kramer & J. Hinojosa (Eds.), Frames of reference for pediatric occupational
therapy (2nd ed., pp. 469–516). Baltimore: Lippincott Williams & Wilkins.
Royeen, C. B., & Lane, S. J. (1991). Tactile processing and sensory defensiveness.
In A. Fisher, E. Murray, & A. Bundy (Eds.), Sensory integration theory and
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Wilbarger, P. (1995, June). The sensory diet: Activity programs based on sensory
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Williams, M. S., & Shellenberger, S. (1994). “How does your engine run?”
A leader’s guide to the Alert Program for Self-Regulation. Albuquerque, NM:
TherapyWorks.
Victoria L. Nackley, OTR/L, is a Half-Time Lecturer, Occupational Therapy Department,
Utica College of Syracuse University, 1600 Burrstone Road, Utica, New York 13502-4892.
She is working on completion of her master’s degree in early childhood special
education at Syracuse University.
Reprinted with permission from The American Occupational Therapy Association,
Inc. (AOTA). Copyrighted 2001 by AOTA, 4720 Montgomery Lane, Bethesda, MD. 20814-3425.
All rights reserved. For more information on products published by AOTA, please
call 301-652-2682 or visit www.aota.org.
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