Sensory Processing:
Differences Between Clinical and School Occupational Therapy
Occupational Therapy in the Clinic:
When parents are concerned about a child's development in the areas of sensory
processing and/or motor skills, physicians will often refer them to a private clinic for their
child to be evaluated by an occupational therapist. The occupational therapist may
conduct a variety of different tests, including parent questionnaires or surveys, to
determine if a child is having difficulty processing sensory information or having difficulty
with fine motor, gross motor, or self-help skills. These clinicians base their
recommendations on how the child performed in their clinic, as well as information from
parents on the child's functioning at home and their impressions of how the child is doing
in school.
Occupational Therapy in the Schools:
In the school setting, when a child is recommended for special education services, a
multidisciplinary team evaluation is performed. The occupational therapist may be one
member of this multidisciplinary team, which also includes several other professionals,
such as a psychologist, a nurse, a special educator, the classroom teacher, vision and/or
hearing specialists, a speech pathologist, a social worker, and a physical therapist.
The special education evaluation strives to provide a comprehensive, multidimensional
assessment. The student's performance may be observed over a period of time within
the school environment. The team of school professionals looks at the student's
functioning in several areas of development, including:
Cognitive development (thinking abilities)
Educational achievement (ability to learn)
Social functioning and mental health
Language development
Physical development
 Pertinent medical information from the child's physician
 Vision and hearing
 Gross and fine motor skills
 Sensory processing
Within the course of this assessment, the school OT observes the child performing
academically-related tasks in the school setting. In addition, the OT interviews the
classroom teacher(s) to determine if any difficulties that the student is experiencing are
related to problems with fine and gross motor skills, self-help skills, and/or sensory
issues.
Although a student may achieve low scores during a standardized assessment in an OT
clinic setting, this does not always directly relate to how a child is able to perform in the
school setting. Therefore, while a school occupational therapist will certainly take a
private clinical OT assessment into account, this information must be balanced with
observation of the student's performance in the school setting, engaging in
educationally-related tasks, as well as the findings of the other multidisciplinary team
members.
After consulting with the multidisciplinary team, the school OT may come to one of
several conclusions, such as:
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Conditions other than sensory processing problems are affecting the child's
functioning
Sensory processing may be a factor, but other interventions may be more
effective and should be tried first
Sensory processing may be one of many issues to address
Sensory processing is a primary issue requiring intervention
Differences in a Child's Behavior between Home and School Environments
Some children display different patterns of behavior in different situations. For example,
children who need a lot of ongoing stimulation may actually perform better at school
where there are lots of structured activities going on throughout the day, and where they
can see other students setting positive examples by sitting, listening and completing
their work. In this case, sensory strategies could be beneficial in the home environment,
but would not be needed in the school environment.
On the other hand, some children may have much more difficulty controlling their
behavior at school, particularly if busy environments easily distract them, or if they
demonstrate over-sensitivities to touch, noise, or visual stimulation. In this situation, they
might benefit from using some sensory strategies in the educational setting, although
this would not be necessary at home.
Other conditions that might be confused with (or may overlap) sensory
processing difficulties:
The reason that a special education assessment can be very beneficial is that there are
many conditions that might be confused with (or overlap) sensory processing difficulties.
A multidisciplinary team is often able to assist in the identification of some of these
conditions, which are described below.

ADD and/or ADHD: Medical research indicates that 70-80% of individuals with
this diagnosis benefit from a combination of medication and behavioral support.
Therefore, if it is suspected that a child has this diagnosis after a multidisciplinary
assessment is completed, the primary intervention should be for the parents to
work with their physician and/or mental health professional to determine how to
help the child. Sensory strategies could be beneficial, but should not be the
primary or only intervention. Although individuals with ADD or ADHD sometimes
have great difficulty with handwriting, this often improves when medication helps
the child to slow down and become more attentive and organized.

Mental health conditions (such as obsessive compulsive disorder, bipolar
disorder, anxiety disorder, oppositional defiant disorder, etc.): If long-standing
difficulties of an extreme and intense nature significantly interfere with a child's
functioning, a referral to a physician and/or mental health professional is
indicated to rule out the mental health conditions described above. These
conditions often respond very quickly to the appropriate medications and/or
emotional-behavioral supports.

Neurological conditions (i.e. cerebral palsy, muscular dystrophy, tuberous
sclerosis, tremors, seizure disorders, etc.): In these conditions, the "northbound"
messages to the brain may be processed adequately, but the "southbound"
messages going to the muscles get scrambled and the motor pathways misfire;
ultimately medication, motor strategies, and/or compensatory skills are more
effective than sensory processing strategies in helping students.
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Learning Disabilities: In the IDEA legislation, a learning disability is defined as
"a disorder in one or more of the basic psychological processes involved in
understanding or in using language, spoken or written, which may manifest itself
in an imperfect ability to listen, speak, read, write, spell or do mathematical
calculations". A school's multidisciplinary team uses many different criterion and
testing instruments to determine if a learning disability exists. If this is found to be
the primary area of concern, educational intervention is deemed to be the most
appropriate avenue of support. It is possible that sensory processing issues may
coexist, and that sensory strategies could be helpful, but educational approaches
should receive the primary effort.

Developmental Disabilities (such as Down syndrome, limited cognitive
functioning, etc.): Sensory processing difficulties may coexist with these
conditions, but are not the primary cause of the functional difficulties. Sensory
strategies may be useful, if incorporated into the daily routine.

Autism, PDD and other related disorders: Sensory processing difficulties often
coexist with these conditions. Intervention to improve sensory processing and
sensory strategies are often very important and can certainly be useful, but not in
isolation. Research indicates that the most effective programs utilize a number of
different strategies, including programming to improve communication and social
skills, behavioral programming, skills training, visual strategies, etc.
Occupational Therapy Assessment for Sensory Processing Difficulties
When a student has known or suspected sensory processing difficulties, an OT in the
clinic may utilize standard evaluations designed to evaluate sensory processing.
Although the OTs at TBA often use standardized testing to evaluate physical or fine
motor concerns, we may use a combination of standardized assessment in the form of a
questionnaire and informal methods to assess sensory processing, gathering information
in any of the following ways:
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Reviewing previous student study reports, special education records,
occupational therapy evaluations and/or interventions
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Observing the student perform a variety of activities in the classroom
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Interviewing teachers and parents, which may include their completion of the
Sensorimotor History Questionnaire for Elementary/School-Aged Children or the
Sensory Processing Measure or the Sensory Profile Questionnaire (the latter is
normed and standardized for use with children)
Differences in Intervention Strategies between the Clinical and the School OT
When sensory processing difficulties are identified by a clinic-based OT, further clinical
intervention may be recommended (often referred to as "sensory integration therapy"),
or strategies for the home and/or school environment may be provided.
If sensory processing difficulties are determined to be a primary issue by a school OT,
he/she will provide education and consultation to the child's teacher and educational
team. This may include providing an inservice on "How Does Your Engine Run" or on
sensory processing disorder to the educational team, parents and other students in the
classroom, recommending strategies that can be implemented on a daily basis to help a
child maintain a calm, alert state for learning. Below are some examples of the kinds of
activities that may be recommended:
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Scheduling short movement breaks throughout the day
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Using "move and sit" cushions to provide more subtle and acceptable forms of
movement
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Allowing students to drink from an exercise water bottle for oral input, which can
help with focusing
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Offering a "fidget item" that the child can manipulate to reduce restlessness
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Developing a quiet, calming space in the classroom that the student can use as a
retreat when overstimulated
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Using a weighted vest or lap weight
In some cases, sensory processing difficulties may impact motor control and motor
performance at school. For instance, poor body awareness may lead to difficulty
handling materials or performing academic tasks. In these situations, direct services
from an OT to provide skills training for functional activities (dressing, eating, or
handwriting, etc.) may be warranted.
The role of the OT is to help students meet their sensory needs within their typical
classroom routine, so that they can benefit from the educational setting. Parents may
choose to pursue using their medical insurance to see if they can obtain additional OT
services from private clinics or home health agencies for the following reasons:
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To help their child to function more appropriately in the home environment
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To provide supplemental services to further increase sensory processing and
physical functioning
OTs in will offer the names of clinical and home health occupational therapists to parents
who are interested in pursuing these additional services, and will also attempt to
coordinate treatment with the clinical or home health therapist, as appropriate.
Sometimes clinical OTs may recommend a strategy known as "brushing", or the
"Wilbarger Protocol", that must be applied to the child every 90 minutes for a period of 46 weeks or longer. This can sometimes be carried over successfully in the preschool
setting, and sometimes in a special needs classroom, but it can be greatly disruptive
when children spend most of their day in the general education setting. In these cases, it
is recommended that the parent avoid starting an ongoing brushing program, or
"Wilbarger Protocol," during the school year. The parents could implement such a
program over a summer vacation, with support and consultation from a clinical or home
health OT.