SENSORY PROCESSING & INTEGRATION HANDBOOK

HENRICO COUNTY PUBLIC SCHOOLS OCCUPATIONAL THERAPY

This information was compiled by: past & current members of the OT team reviewed Spring 2013

TABLE OF CONTENTS Mission Statement

p. 2

What is Sensory Integration

p. 3

How Do We Know If A Child Has Sensory Integration Dysfuction?

p. 4

Auditory Integration

p. 5

Body Awareness

p. 6-7

Fine Motor Control

p. 8-9

Motor Planning

p. 10

Ocular Control

p. 11

Perception of Movement

p. 12

Tactile Integration

p. 13-14

Visual Spatial Perception

p. 15-16

Evaluations

p. 17

References

p. 18

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MISSION STATEMENT This booklet was compiled to provide teachers, parents, and Child-Study members a frame of reference to be used to identify, understand, and modify sensory and sensory-motor function as they relate to classroom learning and behavior. In keeping with the theory of the least restrictive environment, we hope you will try the following suggestions prior to initiating an Occupational Therapy referral.

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WHAT IS SENSORY INTEGRATION? Sensory integration refers to the ability of an individual to receive information about the world through his sensory systems: sight, sound, touch, taste, and smell. Our proprioceptive and vestibular systems also give us much needed information. Proprioception refers to the ability to process information from our muscles and joints, while the vestibular system provides information about how we move our bodies in space. Our bodies receive all of this information and our nervous system then interprets and organizes the information to produce a skill or a response. Children naturally develop this ability as they grow. A child whose system has not developed the ability to use sensory information correctly might be overly sensitive to touch, movement, sound, sights, or smell; or he might under react to the environment.

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HOW DO WE KNOW IF A CHILD HAS SENSORY INTEGRATIVE DIFFICULTIES? Students who have difficulties in sensory integration might have problems with learning or behavior as a result. It needs to be clarified however, that sensory integrative dysfunction is not the only reason that a child may have a learning, behavior, or motor skill problem. Children who have “difficulty processing sensory information” may show more than one of these signs: Easily distracted. Overly sensitive or under sensitive to touch, movement, sights, or sounds. An unusually low or unusually high activity level. Impulsive, lacking in self control. Inability to calm himself or be calmed. Poor self concept. Social or emotional problems. Physical clumsiness or apparent carelessness. If a student has difficulties in the area of sensory integration that directly impact his learning, then the school system should refer for a general occupational therapy evaluation. The Occupational Therapist, by reading the listed areas of difficulty, will decide which, if any, sensory integrative testing should be included in the evaluation process. The Occupational Therapist’s interpretation of the evaluation is then utilized to plan an effective individualized program for the student. Although specific therapy is needed in some cases, many students respond effectively to specific classroom procedures carried out by the teacher without therapy. If you have students in your classroom with suspected or documented sensory integrative difficulties, there are a variety of activities and accommodations that you can use to help make these students be more successful. The following definitions and activity lists were compiled to help you and your student be successful. Successful accommodations teach children how to compensate for weaknesses and keep them in the classroom, or in the least restrict environment.

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AUDITORY INTEGRATION Auditory integration involves listening and understanding sounds in the environment. This includes more than just the sense of hearing. It also includes being able to discriminate sounds, associate sounds with the source, decode sounds, and remember what is said. A baby learns to associate his mother’s voice as pleasurable or a loud noise as threatening. When the child grows, he begins to distinguish sounds more appropriately. He is able to block out background noises and focus on the important ones. Classroom performance can be affected by a child’s auditory integration ability. The child may appear confused or inattentive. He may begin an assignment but then have difficulty following the directions and completing the task. Background noises may be annoying and distract the child when he is trying to work independently. It may be difficult remembering and sequencing multi-step directions. The inability to integrate auditory information also affects language development. Activities to Develop Auditory Integration: Listening to stories and answering questions. Learning and singing songs. Learning and repeating rhymes. Modifications to consider for Auditory Processing Deficits: Ask the student to repeat directions before beginning work. Prepare the student for loud noises (i.e. intercom, fire alarm, bells, toilet flushing). Ear plugs or ear protectors may help a student sensitive to environmental noises. Use simple gestures or cues to reinforce verbal messages. Establish eye contact before speaking. Break directions down into steps and allow extra time for the student to process them. Teach the student to ask for help. Use preferential seating in the classroom. Use ear phones with quiet music. Use other strategies, i.e. visual – written directions.

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BODY AWARENESS Our muscles and joints have receptors that send messages to our brain, alerting it to muscle contraction, stretching, joint movement or pull and compression. All of this information sent to the brain enables a person to understand which body part is reacting and moving without having to look. Crawling, climbing, lifting, carrying heavy objects, or pushing and pulling toys and wagons are all activities that a child normally performs as he grows which promote body awareness. The child utilizes this information to modify strength, posture, force, and dexterity when performing gross and fine motor activities. A child with poor body awareness may have to use visual feedback; and if unable to see his arms and legs, may not be able to move well. He may fall out of his seat, have difficulty with dressing or getting in and out of a car. He may accidentally break a toy because he does not realize how much force he is exerting. Holding a pencil may feel awkward, and it may be held too hard or too loose. Clumsiness, appearing sloppy or disorganized may be symptoms or poor body awareness. Some of these characteristics are an innate part of certain diagnoses including learning disability and neurological impairments. Activities to Develop Body Awareness: Hand games or finger play (i.e. Head, Shoulders, Knees and Toes, or Hokey Pokey). Simon Says. Tactile stimulation using a cloth and/or lotion and talking about the body part. Rolling on a mat or in a sheet. Playing games with wrist weights and ankle weights. With vision blocked, student identifies an object placed in his hand. Blind Man’s Bluff or blindfolding a student and asking him to move into certain positions. Student stands in the middle of the room, looks at an object, closes his eyes, then walks to the object. Pretending to walk like a statue, animal, or play charades. Student lies prone and props self on elbows or kneels when working. Write on the blackboard with eyes closed. Scooter board games – going down a ramp, riding through a row of chairs, in a tunnel, etc. Kneel walk across a vestibular board. Walk across a wide beam with eyes closed. Use your senses – Listen with your ears, what do you hear? Body Suits.

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Modifications to consider for Body Awareness Deficits: Use a t-stool or therapy ball as a classroom chair to alert the student to where his body is in space. Encourage a student to participate in weight resistive tasks, such as carrying books to the library, pushing a cart, wearing weighted book bag. Encourage student to use his vision and avoid walking into furniture or other students. Student may walk best at the beginning or end of the class line. Encourage student to sit in his own space with hands at side and legs crossed and not touching anyone. Have students sit on individual carpet squares.

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FINE MOTOR CONTROL Fine motor control is the ability to utilize hands and fingers in a skilled manner when interacting with finite hand activities. Fine motor control depends upon the solid integration of sensory and motor functions. It is important to have good muscle strength and joint stability not only in the fingers but also with the head, neck, trunk and upper extremities. Fine motor control also requires the eye muscles to work in a coordinated manner to track objects and to guide the hand to accurately interact with hand activities. Accurate fine motor control involves: 1) a subconscious awareness of where and how hands and fingers move in space; and 2) accurate discrimination of hand strength to control manipulation of objects of various sizes, weights, shapes and textures. Additionally, being able to motor plan or organize and carry out a sequence of familiar tasks and the coordination of the two sides of the body together are not only essential for fine motor control, but also for the development of hand dominance. The essentials for accurate hand use build upon the appropriate and sequential process of hand development. Early grasp uses the whole hand in a raking motion using a palmar grasp to press objects against the palm. The thumb then becomes involved in the grasping pattern. Initially, the hand functions as a whole, and finger isolations is not apparent. The initial gross grasp pattern is critical for mobility. A secure, strong grasp enables the baby to pull to stand and feel secure about maintaining that position. The ability to hold and grasp objects is followed by the ability to grossly release objects. Initially crude in motion, the baby refines the motion through playing with his toys. As the ability to refine gross grasp and release evolves, the baby accidentally starts to isolate his fingers to point and poke at toys. Thumb to index finger pinch improves with the addition of the middle finger to add more security to the pinch motion. With random practice of grasp and release with the addition of finger pinch, fine motor skills become more refined and give way to a timed motor response. Timed motor response is essential for finer motor precision, i.e. finger feeding and utensil use. Genetics, sensory processing and overall motor coordination affect the development of hand dominance. Overall motor coordination and accurate sensory processing is the end result of the earlier sequential steps of hand development. As the child practices his hand usage and precision, he tends to rely on one hand more than the other and this is the beginning of hand dominance. Hand dominance and good coordination of hand functions are the necessary precursors to tool use. Activities to Develop Fine Motor Control: Encourage weight-bearing/weight shifting activities (crawling/playing on all fours/weight-shifting to one side) with infants to develop the arches of the hands, for sensory awareness and to encourage position in space awareness/ refine movements of hand and fingers/and for eye-hand coordination.

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Encourage activities for gross/large grasp and release-position activities at mid-line and either side of the child to work on crossing mid-line and to refine movements distally-also works on hand dominance. Encourage finer finger pinch with finger-feeding/encourage activities (i.e. pegged puzzles) as finer pinches develop. Encourage activities that require the small muscles in the hand to develop for in-hand manipulation skills (for example: rolling playdough into small balls within the hand, moving small toys from the base of the palm to the fingertips, closing fasteners, mazes, sorting, sewing cards, Tinker toys, paper/pencil tasks, cutting, stringing beads/macaroni, tracing and coloring, painting at an easel, etc.)

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MOTOR PLANNING Motor planning is the ability of the brain to think of, organize and carry out an unfamiliar sequence of actions. It is the first step in learning a new skill and relies on information from each of the five senses as well as movement (vestibular) information and proprioception (where you are in space). Children who have difficulty with motor planning will appear excessively clumsy, accident prone or messy. Motor planning problems make it difficult to learn new tasks or changes in task. The child may rely on routines and may avoid difficult tasks. If the child is successful at an unfamiliar activity, it may appear to take extraordinary effort and energy because the child is using his cognitive skills to compensate for motor planning problems. Activities to Develop Motor Planning: Mazes on paper or a variation of this activity such as walking through a maze or forming a road maze and driving a toy car through it. Obstacle courses. Simon Says game. Hand Games or finger play (i.e. Miss Mary Mac, Where is Thumbkin, Head, Shoulders, Knees and Toes). Jump rope games (may include initially going over and under a stationary rope and progressing to jumping a turning rope). Catching, hitting and throwing ball games. The games will require the child to move his body in response to what they see to catch or hit a ball. Batting a balloon in the air is another good way to work on this. Charades. Pretending to move like animals or grow like plants. Many children’s tapes or records are available to do this. Craft activities (i.e. paper plate animals, etc.). The child must take pieces to form a whole object. Copying patterns from blocks, beads, etc. Follow the leader. Cooking activities. Playing on unfamiliar play ground equipment. Modifications to consider for Motor Planning Deficits: Position child’s desk so that he has a straight clear path to the door, sink, etc. Use structure and repetition for frequent tasks. Provide step-by-step instructions, written directions or picture directions. Review concepts frequently so they are not forgotten. Allow extra time to learn new concepts. May need handwriting alternatives. See Alternative to Handwriting Handbook by Carolyn Stone. 10

OCULAR CONTROL Ocular control is the smooth coordinated movement of both eyes to attend and follow objects/people in the environment. Controlled eye movements are necessary for finding and tracking moving objects, scanning the environment, sustaining eye contact on a fixed object or person, and being able to rapidly shift focus from one thing to another for accurate eyehand coordination. Ocular control is challenged and refined when children are involved in gross motor activities such as rolling, crawling, walking, playing ball, manipulating toys, and tool usage (i.e. utensils, crayons, etc.). Poor ocular control may interfere with eye contract with a person or object, making it difficult for a child to look at something long enough to process its meaning. The child may have a hard time copying from the board, reading across a line, or using his eyes to guide his hands for writing and using tools. The child may have a tendency to work too close to his work, and he may have problems with depth perception. Activities to Develop Ocular Control: Use a mobile with an infant as the first external introductions to tracking other than tracking the bottle or breast or spoon to mouth for feeding OR the act of tracking when they first look around their environment/tract their parent AND observing their hands and feet. Tracking toys and retrieving them. School-aged: ball handling. Gross and fine motor mazes. Eye-hand activities. Modifications to consider for Ocular Control Deficits: Copies of notes at desk. Proximal seating. Writing on an incline (example – large 3 ring notebook turned) Remain in one position while giving oral directions (teacher facing child) Visual guide – such as, highlighting margins/writing space on worksheet/and where to begin.

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PERCEPTION OF MOVEMENT Perception of movement is the coordination of receptors in the joints, muscles and inner ear coordinating with higher centers of the brain. In turn, the brain coordinates posture, balance and attention during movement. Children who do not receive enough information on movement may have difficulty maintaining balance and posture. This child may lean or lay on the desk or need to lean against objects or lay down during floor activities. Children who overreact to movement information may display fear of movement. They may resist playing on playground equipment, not be able to keep up with their peers and/or become easily nauseated by movement. Their reactions to movement activities may be misinterpreted as behavior problems. Activities to enhance under processing movement: Circular movements are stimulating, such as swinging from a swing attached to one point, such as a tire swing. Jumping or hopping activities such as jumping rope, hop scotch, etc. Using playground equipment to design an obstacle course incorporating jumping down, walking a line, climbing up, sliding, etc. During normal movement times in class (such as traveling to specials or lunch), allow the class to hop on one foot five times, walk a distance, jump five times, etc. This could be especially useful for the entire class after lunch as it will stimulate the alerting systems in the brain. Carrying heavy objects, such as the box of books to the library, or the trash can around the room during clean up time. Activities to remediate over processing movement: Linear movements are calming, such as gliding rockers, two point swings, slides, etc. Slow gentle movement with deep pressure, such as rolling in a sheet or blanket. Allow the child to hold a stuffed animal or weighted stuffed animal during an activity that tends to be stimulating. Weighted vest. While the child is seated at his/her desk, gently apply pressure at the shoulders, holding for a few seconds and releasing (repeat five or six times).

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TACTILE (TOUCH) The tactile system refers to ones perception of touch. There are two divisions of the tactile system: the discriminative system and protective system. The discriminative system sends information to the brain about the size, shape, and texture of an object. The protective system sends information to the brain about sensation of pain, temperature, and touch (i.e. tickle or itch). This system plays a role in a tactile defensive response to a light touch that is received by the brain as being painful. A child may have a hypersensitive or a hyposensitive tactile system. Signs of high sensitivity to touch: aversive to touch, avoids certain textures (i.e. glue, paint, tape, Play-Doh), temperatures, tastes, clothes, and overreacts to being bumped in line or tapped on shoulders, rubs spot that was touched, covers skin in clothes. Signs of low sensitivity to touch: does not respond to being touched, does not respond appropriately to tactile input (i.e. food on face, painful stimuli). These responses to touch can inhibit play, tool use, and development of peer relationships. Observation of the student provides valuable information about their individual tactile preferences. Activities to Develop Tactile Integration: Use heavy work to help calm a child that appears anxious or agitated (i.e. carrying books, erasing blackboards, carry backpacks with books, wearing fanny packs). Engage child in non-contact sports and games (i.e. gymnastics, Simon Says, track, Mother May I, tennis, chess, checkers, tic-tac-toe, card games). “Steam Roller” – To increase attention for learning by normalizing levels of alertness: 1) dim lights, 2) have children lie on their backs on the floor, 3) roll a large ball over their body between the neck and the feet providing deep pressure, 4) encourage the children to imagine they are the road (which is very quiet), 5) tell the children the stream roller is here to flatten the road. Rub on lotion or powder. Have the child be the peanut butter in a PBJ sandwich between two mats or pillows while he is lying on his stomach or have the child pretend to be the meat between two pieces of bread and have him tell you what to add next (i.e. lettuce, tomato, mayonnaise, mustard, etc.) Draw shapes or letters in shaving cream on a mirror/tray (i.e. grade tactile activities from neat to messy to increase tolerance). Paint pictures using finger-paints or paint on wax paper using pudding (licking fingers is OK!). Roll or walk barefoot in the grass. Crawl through a tight tunnel and pretend to explore the caves of Virginia. Encourage tactile awareness activities such as playing in water, sand, beans, and rice. Child is a messy eater: increase awareness of sensations around mouth by providing touch input around the mouth (i.e. rubbing the mouth, using whistles or party horn, making raspberries, blowing bubbles, or paint by blowing paint through a straw). Obstacle course – crawling under mats and through tunnels. Play in a rice table or bean pool with hidden treasure. 13

Modifications to consider for Tactile Defensiveness: Use firm pressure vs. light touch (e.g. bear hug, physical prompts). Do not tickle or surprise the child with a touch. Remember to never force a sensation that is overwhelming. Seating: seat away or encourage child to choose a seat away from main traffic areas (i.e. end of row, corner desk, outside row and end seat during circle time). Child should be first or last in line; allow child to leave class early to miss traffic in halls or give responsibility of closing door and turning off lights and being the last one out of the room. Give verbal instructions to allow the child to initiate touch required. If child is resistive to playing with Playdoh, modify the activity by using tools like cookie cutters or hammers to decrease a negative response. Use a chalk holder for writing on board. Mirror for visual feedback when eating in self-contained or preschool classes.

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VISUAL SPATIAL PERCEPTION Visual spatial perception is how an individual perceives the relationship of his body to the environment, or space. It is also how he perceives objects in space relative to other objects. Visual spatial perception provides us with information about our environment. The way a child perceives space, and his orientation within that space, can affect his gross motor skills and classroom performance. Without adequate visual spatial perception a child may bump into things. The formation of letters may be laborious, there may be difficulty complying with margins, and the space between letters and words may be poor. Words may not be oriented to the lines. Alignment of figures may be poor, and copying from the blackboard onto paper may be difficult. A student with visual spatial perception difficulties may not be able to organize his/her belongings. The following activities can be used in the classroom or at home to enhance a student’s visual spatial perception. They can also be used as successful accommodations. Please try these before you make a referral to Occupational Therapy. Activities to Develop Visual Spatial Perception: Obstacle course - they help develop directional concepts: have students climb over a chair, jump over a rope, crawl under a table, walk up and down an aisle of chairs or desks that are close without bumping. Block designs – have students copy a design of your making. Parquetry Blocks are also good for this. Hokey Pokey Twister Dot-to-dot designs Mazes – remind students that their lines cannot bump the guidelines of the maze. Puzzles Blind Man’s Bluff Bat the balloon – keep it up in the air Design copy using large squared graph paper – make designs using one or two colors and have the child reproduce it. Coloring, cutting, or tracing Lacing cards Sequencing picture stories Origami Estimating distances – use a map or just objects in your classroom Othello the board game Simon Connect Four Crossword puzzles Dodge ball When print or cursive is introduced, the child should have five minutes of handwriting homework every night. 15

Modifications to consider for Visual Spatial Deficits: For students having difficulty using margins or working left to right: color code the paper by making a green line down the left side of the paper – green for go or start – and a red line down the right side of the paper for stop. Paper may also be marked with a green dot on the top line for start and a red dot in lower right corner to stop. Right Line paper or Note taker paper is available to help orient the child’s letters to the line. Right Line paper has a bright green, raised line which gives good tactile feedback as to where to sit the letters. Note taker paper comes in a notebook, is college ruled, and has every other line shaded in blue for a good visual cue. Teach children to place their index finger or a Pop sickle stick between each word for spacing – this is “Mr. Spaceman”. Manuscript writing should be taught from top to bottom. If lining up columns or math problems are difficult, use notebook paper and turn it horizontally and use the lines as columns. You can also use graph paper and even mark off enough boxes for each problem before giving it to the student. If children are copying from the blackboard, be sure the blackboard is as clear of clutter as possible and use yellow chalk. It appears to have the best visibility. A student can also copy from a large easel that you have written on in bold black marker. Instead of copying from the board, copy from one paper to another on his desk. Reduce the amount to be copied or supply notes for the student.

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EVALUATION TOOLS A variety of tools are available to assess sensory processing and integration problems including directed observation, norm-referenced rating scales, and standardized tests. Through directed interview and observation, an occupational therapist can assess the effect of possible sensory processing problems on motor skills and participation, attention, and other behaviors. Occupational therapy staff are knowledgeable in sensory issues and can be a valuable resource as part of the school team in determining the impact of sensory processing and integration on school function, relative to other underlying strengths and weaknesses. Designed for use in the school setting, the Sensory Profile School Companion and Sensory Processing Measure are two instruments therapists may also use to gather and assess sensory processing information. Winnie Dunn’s profile measures are judgment-based questionnaires; the School Companion is completed by the teacher and when appropriate additional rating scales can be completed by the caregiver (Sensory Profile or Infant/Toddler Sensory Profile) or student (Adolescent/Adult Sensory Profile) - the Short Sensory Profile is a screening tool that can be administered by a range of personnel trained in tools of assessment. The Sensory Processing Measure/Sensory Processing Measure-Preschool gathers information about sensory processing in both Home and School settings. This measure assesses not only five sensory systems (vision, hearing, touch, body awareness, balance/motion) but also the integrative functions of social participation and planning & ideas. The school age/environment measure includes optional rating scales on separate school environments (Art, Music, Physical Education, Recess/Playground, Cafeteria, and School Bus). School-based occupational therapy staff can also provide guidance regarding evaluations and interventions completed or available in other settings apart from school. For example, The Sensory Integration and Praxis Test is a diagnostic test using a neurobiological model to test children from 4 yr. - 8 yr. 11 mos. The children who are appropriate for this test should not have a severe neuromotor problem, significant vision problem or require administration in a language other than English. The SIPT should be administered by a therapist certified in its administration; however, this certification is not for providing therapy in clinical or other settings. It takes approximately 8-10 hours to administer and can only be broken in two sessions as the test looks at a cumulative response to sensory stimulation and the subtests must be given in order. The test provides information about the child’s areas of sensory dysfunction on the test only, it does not provide information about functional performance at home or school. In the school setting the focus of both assessment and interventions is a student’s ability to perform at school. Through Jean Ayres’ sensory integrative theory and/or other theories of function, occupational therapy staff can not only provide support school teams in assessment but also offer suggestions to enhance occupational performance in the school environment.

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REFERENCES 1993 Therapy Skill Builders, Appendix B: Suggestions for Teachers. AOTA Newsletter: Adapted by Janet McLaughline, OTS and Karyn Russell, OTS from A. Jean Ayres (1979) and Ginger Grass, OTS, Cincinnati Public Schools Revised February 1992 by Linda Palmstrom, MS.OTR/L SI and School Performance: Organizing and Planning Perceptual/Motor Tasks 3/94 Barbara Hanft MA, OTR, FAOTA 1991 Therapy Works, Inc. Williams/Shellenberger Presentation given by Angela Macri, OTR and based primarily on a course by Bonnie Hanschu, OTR entitled Evaluation and Treatment of Sensory Processing Disorders. Common Parent/Teacher Observations of Children with Developmental Problems by Judith G. Kimball, Ph.D., OTR, Revised by Julie L. Adler, OTS, Donna R. Intravauam OTS, and Jane Koomer, MS, OTR King, L.J., Tips for Parents of Attention Deficit/Hyperactive Children. (1990) Hinojosa, J., and Kramer, P., Frames of Reference for Pediatric Occupational Therapy. (1993) Bissell, J., Fisher, J., Owens, C., and Polcyn, P., Sensory Motor Handbook: A Guide for Implementing and Modifying Activities in the Classroom. Torrnace: CA, Sensory Integration International, (1988). Haldy, M., and Haack, L. Make It Easy: Sensory Motor Activities for Home and School. Tuscon: AZ, Therapy Skill Builders, (1995). Herring, K., and Wilkinson, S. Action Alphabet: Sensory Motor Activities for Groups. San antonio: TX, Therapy Skill Builders, (1995).

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