Final Edited Paper 1w4m2l

Running Head: The Autism Sensory Attention Program; ASAP

The Autism Sensory Attention Program; ASAP: An occupation-based program in Marrakech, Morocco Kenzie Smith University of Utah

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The Autism Sensory Attention Program; ASAP

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The Autism Sensory Attention Program; ASAP An occupation-based program in Marrakech, Morocco The purpose of this assignment is to determine how to incorporate the skill set and knowledge base of an occupational therapist into a rehabilitation program of an underserved country. The needs analysis that was carried out at this setting involved one-on-one interviews with staff, patients, and parents of patients, discussions involving the group of clinicians at the MAIR (Moulay Ali Institute for Rehabilitation) clinic, and observation of current services provided at this clinic. The needs analysis also involved video conference with both the staff and owner of the clinic due to the overseas aspect of this project. This facilitated the information we were able to obtain and helped to provide information on some of the clinician’s current needs and concerns. After spending two weeks in the MAIR clinic and completing a thorough needs analysis, an occupational therapy program was developed revolving around how to address the sensory and attention-based needs for patients on the autism spectrum.

Description of setting The MAIR clinic is a small, non-profit clinic located in the heart of Marrakech, Morocco. Being an African country with little knowledge or implementation of rehabilitation services, MAIR clinic serves a unique and highly sought-after service to the Marrakech population and the populations of surrounding towns and cities. The mission of this clinic is as follows: To trigger a neuroplastic change is the foundation of our therapy. To accomplish maximal recovery is our most important goal. (MAIR, the Moulay Ali Institute for Rehabilitation, 2018, para. 4). While this mission statement stands true in the MAIR clinic, their work has expanded


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much farther due to patient load growth. The clinic itself is filled with therapy beds, plinths, exercise balls, and shelves lined with various toys and equipment. Through the years the clinic has accumulated these items through donations from the Rotary club, the Life Skills Clinic, and other generous organizations. As the clinic expands and progresses, their equipment and tools are expanding as well to match the unique needs of their patients.

History of the MAIR Clinic Founded in 2015, the MAIR clinic opened its doors in the heart of Marrakech to the surrounding population. The history and meaning behind the MAIR clinic hold a deep meaning to Mohammed (Mo) Sbai, the founder of the clinic. In 1999, Moulay Ali, the brother of Mo Sbai endured a severe traumatic brain injury (TBI) that caused him to go into a vegetative state. After months of little to no progress, Mo and his family realized that Moulay needed intensive neurological rehabilitation. Being that there was none offered in the Moroccan area, Moulay’s family brought him to where he would have health coverage. It was here that he experienced a regression in his health and was sent back to Morocco due to his lack of progress. It was then that Mo knew that if his brother had a chance of surviving, he needed to bring him to the states with him. After 5 years of rehabilitation services in the United States, Moulay had 100% of his speech regained, 65% of his range of motion and mobility on his affected side, as well as normalized short and longterm memory (M. Sbai, written communication, September 26, 2018). A series of unfortunate events involving Moulay’s visa lead him back to Morocco where he ed away in 2007. While this story holds a tragic end, it is the basis of the MAIR clinic. In Mo’s interview he states, “I have promised Moulay Ali to do everything I can to help patients like him get access to neurological rehabilitation in Morocco and achieve their maximum recovery potential” (M. Sbai, written communication, September 26, 2018). Through the growth of the


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clinic, there have been partnerships made in attempts to grow the clinic. Around a year into the clinic’s production, Sbai and his team partnered up with a local public sector hospital. The hospital therapists did not share the same values as Sbai, and eventually became upset with Sbai and his team as they were making real progress with the patients, as this was not a concern for the hospital therapists. This soon led to Sbai and his rehab team terminating their partnership with the hospital. This termination resulted in the public sector hospital keeping a majority of the MAIR clinic’s equipment, resulting in an unfortunate setback for the clinic. Since then the clinic has been able to build itself back up with generous donations and grants from various establishments and are building their business based on their respected morals and values (M. Sbai, personal communication, October 10, 2018).

Target Population With an average caseload of 18-25 patients a day and a total of approximately 40 patients on their current caseload, the MAIR clinic has treated around 250 individuals since they opened their clinic in 2015, the majority being people with neurological conditions (I. Bentahar, personal communication, October 9, 2018). While there are some adults that are seen at the MAIR clinic, this facility serves 60-65% pediatric clients. Neuro-based treatments are at the forefront of this clinic. Diagnoses commonly seen consist of neurologically-based diagnoses including cerebral palsy, traumatic brain injury, strokes, spinal cord injury, spinal/ chronic pain, and autism spectrum disorder. The typical length of stay for individuals at this clinic varies. Initially the clinic will offer one session per week for one month. This will then be adjusted based on client adherence to intervention, as well as needs assessments (M. Sbai, personal communication, September 18, 2018). After further observation and interviewing with the therapists, it has become clear that there are also many patients that have been attending the clinic for upwards of two years now. These specific patients show a great deal


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of motivation and potential for growth in their recovery, which is the leading factor for the therapists to continue working with them after a substantial period of time. External and Internal Influences External Policy. The Moroccan government spends approximately 5 billion dollars on the health care system each year, with 3.2% being allocated toward health care each year. The Moroccan healthcare system is comprised of AMO (Mandatory Health Insurance), which is then separated into private, which will reimburse up to 70 percent, and public, which reimburses up to 80 percent (Morocco’s Health Care, 2013). One of the main issues surrounding the health-care system include that of lack of medical resources within accessible limits. Health Care System. The health care system is also continuously facing is lack of medical supplies that is leading to medical professionals having to use intuition and knowledge rather than actual supplies to treat. According to the Health Ministry figures from varying countries, Morocco has one doctor per 1,600 inhabitants compared to one doctor per 800 people in Tunisia and one per 600 in Algeria (Examples of Morocco’s, 2018). This drastic variance in physician coverage is greatly reducing the amount of access that the Moroccan population has to necessary medical treatment and care. Among 22 countries and territories of the East-Mediterranean region, Morocco has shown to be among the five lowestranking for adult health and expenditure of health for the Human Development Index. Due to the Moroccan health-care and insurance structure being less structured and stringent, there is a freedom that is provided to the clinic that allows therapists to see patients more often and for longer durations of time. For patients with severe diagnoses or patients that live hours away from the clinic, this freedom enhances the efficiency and progress that is seen (C. Elghazi, personal communication, October 7, 2018).4


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Impact on Families. The out of pocket cost for health expenditure has reached 88.3%. This leads to drastic financial burdens for individuals that have no other option than out of pocket payment. This can also lead to families avoiding health care services altogether so that they do not have to face these hardships (Morocco-Healthcare, 2017). For those that do have the access and means to obtain health services, there is often a disconnect between the physicians and the rehab therapists due to patients continuously moving between physicians. This makes access to medical records incredibly challenging. The country of Morocco continues to be heavily influenced on the French health-care system. The view of this system is not focused on rehabilitation of the disease or disability like the focus of the U.S.. Rather, the focus has been heavily built on a bottom up approach where physicians focus on maintaining the disability and ensuring it does not worsen. In essence, the physicians and staff show little concern for the patients personal and environmental factors, nor their unique client factors that determine what is important and relevant to them. This has made the need for actual rehabilitation that much more necessary (Tinasti, 2015). While this inadequate health-care system remains, one of the strengths being seen is that of the new King, Mohammed VI. The King currently is very progressive and is pushing to make great changes within the health-care system in hopes to make health services more accessible to the general public. Internal Policy. While all of these external factors greatly influence the service, structure, and financial status of the MAIR clinic, the social context within the clinic is an internal influence that greatly impacts the services. The therapists have made efforts to work not as individuals, but as a team. The strong collaborative methodology of the clinic has enhanced both the service that is provided, and the camaraderie between the rehab team. Geographic. Located in the Northwest region of Africa, bordered by the Mediterranean Sea, the Straits of Gibraltar, and the Atlantic Ocean, Morocco spans ~706,550


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km2 and is home to 31,478,000 inhabitants. To the north of the Atlas Mountains lies Marrakech, the fourth largest Moroccan city (The World Factbook: Morocco, 2018). While this vast mountain range provides beautiful scenery for the city of Marrakech, it also acts as a barrier to those that are seeking out access to the clinic. Unlike the United States, the country of Morocco does not have readily available access to rehabilitation services. Because of this, many patients of the MAIR clinic travel from other cities and countries (M. Sbai, personal communication, September 10, 2018). The city of Marrakech, while holding true to many of its traditions and history, has also acquired more modern businesses, restaurants, architecture, and transportation services, in turn bringing a growing population to the Marrakech area. This increase in population acts a service to the clinic for greater caseload growth while simultaneously increasing the demand for rehabilitation services that cannot always be met (Hassan, 2010). The location and geographic structure of Marrakech also produces difficulty with transportation. The typical driving habits surrounding this area differ greatly in comparison to one may be used to in the U.S. Taxi drivers fill Marrakech streets, and driving guidelines are typically lax. For those coming into the city to receive services, driving and navigating can be a dangerous feat. Fortunately, there are various public transit services to accommodate those who do not have access or means to their own vehicle (Morocco Geography (n.d.)). Sociocultural. A major cultural commonality amongst Marrakech residents that can become a barrier is that of their religion. The ethnicity and religion of this region are valued by most of the population being that the dominant religion is that of Islam. This religion tends to influence the population and their availability to access health care facilities. Being that Muslims who follow Islam are accustomed to praying five times per day, they may face challenges with maintaining religious expectation while still obtaining the services they need. Friday is also known as their holy day and shops and markets typically close mid-day, again


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reducing their access and availability to necessary health systems and facilities (Belief and Practices (n.d.)). Time spent in the MAIR clinic showed their true devotion to their patients as well as their cultural practices, as they have established a private prayer room for those using the clinic during times of worship. In the United States we are seeing a continuous growth in the inclusion, , and involvement of individuals with disabilities. The stigma in Morocco, however, remains prevalent. Children, for example, are not readily accepted into regular school systems due to the stigma and lack of resources in schools to meet the needs of children with disabilities. This lack of normalcy and increased sense of isolation can decrease the quality of life of these children and tends to bring on an increase of mental health related issues (Education Morocco, (n.d.)). The familial roles also create barriers in the way of splitting the role of child care. From the experience at the clinic, it was clear that the mothers are the primary caregivers for the children and are responsible for bringing them to and from the clinic. The mothers and clinicians stated that the fathers typically do not feel any investment in the role of their child’s rehabilitation (I. Bentahar, personal communication. October 11, 2018). External Economic. Like many countries, Morocco has had its share of economic hardships. However, a 2017 study by the CIA shows that ~15% of Moroccan’s fall below the poverty line and there is a 10% unemployment, demonstrating a slight economic improvement over the last decade (The World Factbook: Morocco, 2018). While these facts hold true, Morocco is also one of the countries with the lowest disposable income of between $400 and $700 a month. With Moroccan healthcare payment being largely out of pocket, this again creates a barrier to health services as families of lower socioeconomic status (SES) are often unable to cover the costs of rehabilitation and other medical services (The World Factbook: Morocco, 2018). Another economic disparity being seen within Morocco is that of male vs female income inequality. Men in Morocco typically have jobs surrounding labor and


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more corporate workforce. Women on the other hand are typically given jobs in factories that are less demanding. This is partially due to the fact that women are still commonly seen as the “homemaker” and men are the main provides of the family (Hassan, 2010). Despite Morocco’s poor economic history, the country is progressing towards building an open economy. The main economic foundation of Morocco is ed by agricultural farming (including wheat, fruits and vegetables, livestock and wine), tourism, aerospace, phosphate mining, and textile production and exportation (The World Factbook: Morocco, 2018). Internal Economic. While these outside economic factors greatly impact the services that are available to the citizens of Morocco, there are also internal economic influences in the MAIR clinic that contribute to the quality and amount of service provided. The system in which patients are billed for services is not regulated on consistent basis, as there are a substantial number of patients that are not covered by insurance. While the clinic goes to great efforts to allow therapy service to anyone, despite their coverage, they have experienced unfortunate circumstances where this was taken advantage of by patients. This issue is currently being addressed in the clinic to ensure that those that are able to cover their rehabilitation services are doing so (M. Sbai, personal communication, October 9, 2018). Political. Throughout the country of Morocco, a constitutional monarchy is in place. This means that the Monarch, Muhammad VI, exercises authority in unity with constitution (The World Factbook: Morocco, 2018). Currently in Morocco, the greatest impact that their political state is having on health care is that of corruption. The trend being seen throughout the country is that more times than not, medications and procedures are being given that are unnecessary as a means to increase pharmaceutical costs. The internal political policies of the clinic being seen include that of the fair wage distribution among the therapists. This reflects back to the notion that the MAIR clinic is making strides to remain distant from the


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corruptness of the Moroccan health care system. Unlike previous Monarchs of Morocco, Muhammad VI is very progressive and is making strides in the political corruptness. This includes improving the way in which healthcare is received by the population and expanding the access of insurance to the citizens of Morocco (The World Factbook: Morocco, 2018). Demographic. The leading ethnicity of the country of Morocco is that of ArabBerber, with the majority of these individuals being of the Islam religion. While the majority of the population is of the Islam religion, those who are of varying faith are typically welcomed by Muslims and encouraged to learn about their monotheistic views (The World Factbook: Morocco, 2018). The country of Morocco is also undergoing demographic change as its population is growing but at a lessening rate. This is due to the fact that, through better health care, hygiene, nutrition, and vaccinations, individuals are living longer, and women are having fewer children. The country is also seeing a downward trend of infant, child, and maternal mortality rates (The World Factbook: Morocco, 2018). While the decrease in infant childhood mortality is a national success, it also causes a potential barrier as it increases the medical and rehabilitation services that will be required for children that experience disabilities or impairments. Health care services in Morocco will need to make efforts to meet the needs of this population surplus. This rise in population has also led to 26% of the nation’s population being between the ages of 15-29. Similar to the health care services, the jobs in Morocco have not been able to keep up with this growing rate, making the working population unemployment rate rise. The literacy rate throughout the country of Morocco falls at approximately 78.6% for males, and 58.8% for females. This again creates a barrier to services as this leads to a decrease in education amongst the population. This may reduce the awareness that the general population has on available health services to them, especially for those in rural areas (The World Factbook: Morocco, 2018).


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Services provided Staff. The MAIR clinic currently has three full time therapists on site. These therapists have three years of training after their high school education that include basic anatomy, physiology, and other health sciences. Their degree is comparable, but less intensive, to that of a United States Physical Therapy Assistant (PTA). It is the goal of the clinic to eventually have these therapists certified as neuro-therapists, though this is their current given title. Aside from the main therapists that treat on a daily basis, the clinic also consists of an individual that manages the front office, as well as interns that rotate in and out of the clinic in 1-3-month rotations (M. Sbi, personal communication, October 12, 2018). The motivation from the therapists stems from personal experience with health-related familial issues, as well as a love for rehabilitation and the medical field. The main services that are provided by these therapists include that of ranging their patients to increase mobility, as well as assisting with locomotor training (I. Bentahar, C. Elghazi, S. Berrada, personal communication, October 12, 2018). Home health visits are also an emerging area of service provided by the clinic to better assist patients on carry over of exercise within their home and providing recommendations on modifications for safety and function (I. Bentahar, personal communication, October 10, 2018).

Related services. While a majority of rehabilitation clinics have a variety of therapists including physical therapists, occupational therapists, and speech language pathologists, the MAIR clinic therapists play a unique, multi-professional role. Due to the lack of health-related services and training in the Marrakech area, the rehab therapists act mainly as physical therapists, and with the assistance of program developments and rehab team collaboration, they are attempting to take on the role occupational therapists, speech


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therapists, and nutritionists. These therapists are talented and have the ability to learn and synthesize large amounts of information. The increased disadvantage to this, however, is that the therapists are forced to split their focus, rather than solely narrowing their training and services on one type of therapy. This division of services makes program development with sponsors that much more beneficial. The communication with local Moroccan doctors is becoming increasingly more prominent. This is the one health-related service that the clinic does have access to. The MAIR clinic therapists will frequently or attempt to the doctors for information on their patient, or to receive and secure plans of care (I. Bentahar, personal communication, October 11, 2018). The clinic is also currently working with a social worker that assists with helping determine patient cost of care. Parent’s income and overall economic standing is taken into consideration to determine payment. This has helped tremendously with preventing dishonesty from patients to avoid paying for treatment when it is within their means (M. Sbai, personal communication, October 9, 2018).

Funding Sources. Due to the low income of the majority of the client’s receiving services at the MAIR clinic, the funding for the clinic comes from various grants and private foundations. The MAIR clinic is currently being funded by the Zahra Charity, the non-profit started by Mo in 2009. The Zahra charity is able to use various grants and private foundations and donations to fund MAIR operations. The Salt Lake City Rotary has been generous enough to provide medical training to the staff of the clinic that they received from medical professionals in the US and in Morocco, as well as donate ~$140,000 over the last three years. The MAIR clinic has also established an ongoing relationship with the Life Skills Clinic (LSC). The LSC has been able to provide educational resources, toys, and adaptive equipment. the LSC has also reached out several times to varying companies like Therapro, Thera Shoppe, and Fun and Function (M. Sbai, personal communication, October 11, 2018).


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Future plans. With a rehabilitation clinic that is so new and is developing in a region with little to no rehabilitation services, the future plans for the clinic are abundant. Being that the current clinic is around 2,700 square feet and has limited space for their caseload, the longterm goal is for the clinic to be housed in a space that is around 50,000 square feet. This area would allow for greater space to treat patients, provide more individualized space for those that need it (e.g. children on the autism spectrum), and provide room for more advanced equipment. This larger facility would also allow the clinic to staff more therapists, in turn increasing their potential caseload. This facility would also house educational buildings and apartment suites for various patients and guests to reside in (M. Sbai, personal communication, October 10, 2018).

Programming strengths and areas of growth Director Perspective. The MAIR clinic of Marrakech holds a great deal of value and promise for its community as well as surrounding communities. The work being carried through is rare and necessary for the citizens of Morocco. While the program has many strengths, it is still new in its development and does have areas of growth. To determine the strengths and weaknesses through the eyes of the clinic director/ owner, an interview was conducted with him, myself, and the rest of the students participating in the development of MAIR clinic programs. The most prevalent strength of this clinic, Sbai explained, is its service in general. This means that the services the MAIR clinic is offering is a prominent strength to the of this community. Sbai explained that another prominent strength of this clinic is that of its staffing. While the staff needs to continue growing based on the surplus of incoming clients, Sbai feels that the quality and care being provided by the staff is outstanding (M. Sbai, personal communication, October 8, 2018). Being that this clinic is still


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in its developing stages and is in a third world country, it has great potential for growth. One of these areas is that of istrative structure within the clinic. Currently, the MAIR clinic does not have any source of istrative organization. This includes a lack of thorough scheduling, assessment, documentation, therapy protocols, and financial assessment. As the clinic grows and word of mouth becomes more prominent, the need for this organization becomes even more crucial. With the MAIR clinic being the only one of its kind in the region of Marrakech, its size and treatment availability serve as another downfall of the clinic. The current space that the clinic resides in is approximately 2,700 square feet and has three on staff therapists. With the strong influx of patients that the clinic is experiencing, the MAIR clinic is having difficulties meeting the needs of the total number of patients seen each day (M. Sbai, written communication, September 26, 2018).

Therapy Staff Perspective. To gain an understanding of the perspectives of the three of the therapy staff, one-on-one interviews were conducted. Another strength of the clinic, as stated by the current therapists of the MAIR clinic, is that of their locomotor and manual therapy. These therapists are well trained in areas of ranging their patients, assisting with gait training, and dynamic and static standing. This physical therapy aspect has been greatly beneficial to the population that the MAIR clinic serves. The therapy staff also stated that they feel that the bond they have created not only amongst themselves, but with their patients has made their work that much more effective. This has also led to each of the therapists feeling comfortable with the full caseload, which is incredibly beneficial when one therapist is ill and needs their patients taken over. Interviews with the therapists also revealed that one of their greatest perceived strengths is their willingness to learn a wide variety of topics far beyond that of physical therapy (I. Bentahar, C. Elghazi, S. Berrada, personal communication, October 10, 2018). Some common areas of growth stated by the therapy staff


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at the MAIR clinic was that of the limited clinic space that is available. The therapists feel that if they had more space they would be able to better manage their large caseload. The other most significant area of growth of the clinic was that of addressing autism needs. The therapy staff feels that they do not have the resources and education to sufficiently provide autism interventions (I. Bentahar, C. Elghazi, S. Berrada, personal communication, October 10, 2018). It should be noted that due to nearly all the children being seen in the MAIR clinic being non-verbal, the established questions were not able to be answered by them. Parent Perspective. To evaluate the thoughts and perspectives of the eleven mothers of the patients, one-on-one interviews were conducted, as well as evaluation of their once-amonth group. Through these interviews and evaluations, it was clear that many of the mothers did not perceive the clinic as having any downfalls as they had nothing to compare it to. As one mother stated, “How am I supposed to think of things that could be improved when I have never seen anything like this in my life?” ( group, October 12, 2018). These women are incredibly thankful for the service being provided by the MAIR clinic and to them, it is the highest level of care they can imagine. One of the common strengths stated by mothers included that of the interaction provided to their children by the therapists. The mothers feel that the therapists of the MAIR clinic truly care about their children and giving them quality rehab that is progressing them through their diagnoses. The mothers also feel as though the work being done to address their children’s mobility has been one of their greatest appreciations of the clinic. The mothers feel that, despite their child’s diagnosis, if their child is able to walk, they will then be able to engage in other household activities and leisure’s. Student Perspective. From a student perspective, it seems that one of the greatest strengths for the MAIR clinic is that of the staff’s dedication and motivation. In comparison to the clinics one would witness in the United States, this clinic has very little and is operating in a manner that is drastically different. Despite this, the staff at the MAIR clinic


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continually pushes themselves, they are continuously seeking out ways to improve their knowledge base and care for their patients, and they use their creativity to utilize their resources in a way that will provide effective intervention for their clients. While being at the clinic for two full weeks seemed like a great deal of time for us, this was a miniscule amount of time for these therapists. There was not a single clinic day that ed that the therapists did not reach out to us to ask what they could be improving, advice on various patients/ diagnoses, and questioning things we would do with patients to gain knowledge and insight. After observation and hands on assistance, many of the areas of growth that I observed were similar to those that the therapist reported in their one-on-one interviews. One prominent area of growth for the clinic is that of the evaluation and discharge processes. The process in which they perform their evaluations is very brief. As of now there are a few simple questions that are asked, and often there is little medical data and background to base observations around. Establishing a more thorough evaluation process would assist in the effectiveness and variety of intervention provided. Another area of growth for this clinic is that of organization and cleanliness. The greatest challenge I see this clinic facing is that of the rehab therapists attempting to take on more than their scope allows. Due to this clinic being the only one of its kind, the therapists feel the pressure to take on roles of physical therapists, occupational therapists, nutritionists, and speech therapists. While this is irable and the therapists are capable of learning a vast amount of information, the therapists are having to divide their focus and expertise to accommodate for lack of training in the region. The strongest area of growth for this clinic, in my opinion, is that of their neuro-anatomy training. Through the work being done at the clinic, Mo has labeled the therapists “neurotherapists”. After observation and interviews, I was made aware that the therapists only have three total hours of neuro-anatomy training. While the therapists have learned a substantial amount over their years in the clinic through experience, I feel that to be labeled as a neuro-


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therapist, it would be beneficial and necessary for these therapists to receive more extensive training in this field. After assessing the needs of the clinic and gathering information from the therapy staff, therapy directory, and the parents of the clinic, a program surrounding the needs of children on the autism spectrum will be created. This program will help the therapy staff feel better suited to assist their autism spectrum patients in therapy and provide them with intervention strategies to increase attention and sensory modulation for these patients.

Evidence-Based Practice A literature review was completed in order to grasp the occupational needs of the Moulay Ali Institute for Rehabilitation (MAIR) clinic population, as well as to discover the evidence that is available for occupational therapy in an underserved country. Google Scholar, American Journal of Occupational Therapy, and the University of Utah Library online catalogs were searched for relevant articles. To collect valuable, relevant data, search used in the previously mentioned databases included combinations of the following: occupational therapy, Morocco, health care, rehabilitation, autism spectrum disorder, sensory integration, behavior, behavior acquisition, attention, visual schedules, and sensory motor. Being that there are a great deal of articles and resources available for students through the University of Utah Eccles Library database, a majority of the articles were accessed through this search engine. To determine whether an article would be kept for further evaluation or would be discarded, factors including relevance to the proposed program outline, and information comprehensiveness of the article were taken into consideration. For this literature review, a total of 13 articles were kept and are referenced through various sections below, as well as one textbook surrounding sensory integration.


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Moroccan health care and the need for occupational therapy in diverse rural areas To better understand the needs of the population at the MAIR clinic, literature was reviewed to gain a deeper knowledge of the relationship between the poverty seen in Morocco and disability, as well as the need for occupational therapy services in underserved, diverse rural areas like Marrakech, Morocco. While the economic well-being of the region in which the MAIR clinic resides is not the sole focus of the program being developed, one must evaluate the context as a whole to grasp the full needs and parameters of the patients benefiting from the program itself. An article evaluating the poverty rate in Morocco and its association to disability discusses the impact of disability on rural-based individuals with varying disabilities. Trani (2015) explains that those with disabilities are shown to be poorer than individuals without disability in the country of Morocco. Like many of the patients receiving rehabilitation services at the MAIR clinic, Trani (2015) states that individuals with disabilities, especially that of rural-based women and young girls are lacking basic s and means to access proper healthcare services. These individuals are also commonly lacking in general physical and developmental abilities that enhances social injustice seen through stigma. This statement relates to the observations of the MAIR clinic. A vast majority of the patients being seen at MAIR are lower-class, rural-dwelling individuals that, prior to the existence of the clinic, received little to no services for their disabilities. Similar findings from Martin et al. (2015), show that individuals with disabilities in rural areas, including Morocco, have commonly reported feeling as though there were no options in the way accessing basic healthcare needs, and many felt as though it would never be an option for them. This overall attitude and perception by low income rural-based Moroccan individuals with disabilities shows the overwhelming need at hand for increased rehabilitation services. To determine the perception of occupational participation in the Trani et al. study, individuals with disabilities and the parents of individuals with disabilities participated in


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semi-structured interviews. Common questions asked through the interviews included: “How would you explain occupation?”, “How would you explain health?”, “How would you explain well-being?”, and “What do you find to be the most important occupation to you/ your child?”. This was done to assist in gathering subjective data from the participants on their views of their disability or their child’s disability. Similar to results that one may expect to find in the United States through occupational therapy interviewing, the results of these questions varied greatly. However, there was emphasis on the way that occupation impacts the whole being. One woman being interviewed stated, “because...eh...my occupation is me, lives with me but at the same time it is also in relation to others and where I live” (Trani et al., 2015, pg. 4). Several individuals emphasized the need to engage in their desired occupations as a means to remain connected with their community, and many explained the need for occupational well-being to remain present and active in their religion (Trani et al., 2015). While the individuals in this study lead lives that in many ways are varying from what one may expect in the states, their answers surrounding occupational engagement, well-being, and the occupations that were meaningful to them are very similar to what occupational therapy in America would consist of. Additionally, the meaning of occupation to these individuals translated to something very similar to what would be understood in America. It represented engagement in activities that brought them joy, helped them remain true to tradition and religion, and to engage in familial expectations (Trani et al., 2015). These studies emphasize the importance of uncovering the need for occupational therapy services in low-income, rural areas like Morocco, as well as the commonalities seen in occupational therapy needs even in these diverse locations. Common characteristics and deficits seen in autism spectrum pediatric patients The range of deficits and characteristic seen in children with Autism Spectrum Disorder (ASD) is broad, hence the term “spectrum”. Although ASD is a diverse disorder


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with a multitude of psychiatric and medical-based deficits, there are specific symptoms and characteristics that define its diagnosis (Frye, 2018). Dunn (2009) and Frye (2018) both detail the main characteristics of ASD to be a lack of social communication as well as repetitive or restricted behaviors that often lead to decreased focus and attention, and sensory dysregulation. Perhaps the greatest contributor to deficits like poor attention and behavioral irregularities is that of decreased sensory integration. Ayres (2005), describes sensory integration as, “the organization of sensations for use (pg. 12)”. Senses work to provide us with valuable information about conditions of our body as well as the environment around us. While the process of sensory integration is an unconscious process performed by the human body, individuals with ASD commonly experience a disruption in this process. For a person without sensory integration issues, his or her body is able to process and organize incoming sensory information (Ayres, 2005). For children with ASD that experience a dysregulation with this integration, the brain does not function in an efficient manner. Schaaf et al. (2015) furthers the discussion of sensory dysfunction by explaining that children experiencing this dysregulation may also experience issues in school such as slower learning and behavioral issues as a result of their bodies not feeling organized, and them feeling as though their environment is not conducive of their success. Another common deficit seen in children with Autism Spectrum Disorder is that of decreased attention. Schaaf et al. (2015), explains the function of attention as being able to focus on one thing while putting other things out of our mind during the time being. An example of this would be when one is engaged in conversation with someone, he or she must ignore other conversations or stimuli around them to attend to the conversation at hand. Furthermore, the skill of attending is one that develops over time and while it is common for many children to experience challenges trying to focus at all times this challenge is


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heightened in children with ASD. Vivant et al. (2017) expands on this definition of attention by describing it as a multi-faceted process by which information is appraised and encoded. This inattention, Vivant explains, can make it incredibly challenging for children with ASD to focus on things that are not of interest to them. This may be school, play, or activity related. While these deficits may not appear to be as detrimental as other ASD characteristics, evidence shows that they often lead to decreased school performance, as well as decreased social engagement with peers (Vivant, 2017). Autism Spectrum Disorder is a diverse disorder that impacts individuals in a variety of ways, often including that of sensory dysregulation and attention-based deficits. Being that these main characteristics were also identified by the rehabilitation therapists at the MAIR clinic as areas they felt less competent in, the focus of the remaining evidence will be surrounding interventions for sensory integration and attention-based intervention. Effectiveness of sensory-based ASD treatment. Before detailing the research behind sensory-based intervention for children with ASD, it should be noted that while there is a great deal of evidence surrounding this topic, there is still a substantial amount of misunderstanding when it comes to the implementation, as well as crossover between sensory integration therapy and sensory processing. CaseSmith, Weaver, and Fristad (2015) explain that despite the growing recognition of sensory processing issues and their effects on engagement and participation for individuals with ASD, sensory-based interventions are inconsistently defined and refer to practices that are greatly varied. Because of this, the research behind sensory processing and sensory integration are commonly related. The following cases examine the various methods of sensory interventions for children with ASD. As the MAIR clinic does not currently employ occupational therapists (OTs), it was crucial to assess and review the evidence surrounding the role of OTs with sensory-based


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treatment for children with ASD. The research behind sensory based intervention for children with autism spectrum disorder is vast. To identify the research that would be most applicable to the program development for the MAIR clinic, studies focused on both sensory-based intervention (sensory processing) and sensory integration were selected for further analysis. Case-Smith, Weaver, and Fristad (2015) describe sensory integration as “clinic-based, child-centered intervention originally developed by Ayres, that provides play-based activities with enhanced sensation to elicit and reinforce the child adaptive responses” (pg. 14). In comparison to sensory processing interventions, which are defined as interventions that assist in organizing sensations from one’s own body and the environment, making it possible to use the body effectively within the environment (Case-Smith, Weaver, & Fristad, 2015, pg. 8), sensory integration is much more complex and focuses on strengthening the child’s tactile, proprioceptive, or vestibular response (Case-Smith, Weaver, & Fristad, 2015). Preis and McKenna (2014), discuss the implementation of sensory integration therapy (SIT). Their study assessed if SIT was an effective intervention for children with ASD in improving social engagement and communication. Additionally, their study assessed the continued effects of the intervention post-treatment. This study involved both a care as normal group, and a group involving the SIT for children on the spectrum ranging from 4-11 years of age. Children involved with this study worked with occupational therapists to receive their typical treatment, or their treatment in combination with SIT. Participants of the study engaged in sensory-based activities prior to the rest of their therapy activities (self-care, social engagement, etc.). For the SIT group, the children would engage in 15-20 minutes of SIT prior to engagement in their other rehab goals as a means to increase engagement, as well as continuously engage in sensory-related tasks through the entirety of the session. This would range from tactile sensory exposure, vestibular-based sensory activities, or proprioceptive activities. Results of this SIT study conducted by Preis and McKenna (2014) showed that


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children involved with sensory integration therapy were more likely to engage in other rehab activities immediately post SIT, as well as increase verbal communication. According to Case-Smith et al. (2015), sensory-based intervention can be described as “the use of discrete sensory experiences or environmental modifications to facilitate regulation of behaviors. In doing so, it assists children to engage appropriately in learning activities” (pg. 12). To compare the implementation of sensory-based interventions (SBI) to SIT for children with ASD, a systematic review conducted by Yunus, Liu, Bisset, and Penkala (2015) was reviewed. This review assessed studies including a variety of diseases and diagnoses, six of which assessed SBI in children with ASD. While the precise implementation of SBI in each study varied slightly, there were common themes among them including time, frequency, and type of stimuli. Yunus et al. (2015) revealed that among the studies, the time of SBI implementation was between 10-15 minutes prior to each therapy session. This was used as a means to establish modulation, or the ability to effectively regulate the degree to which one is influenced by sensory inputs, prior to engagement in other therapy-related activity (Yunus, Liu, Bisset, & Penkala, 2015, pg. 8). Though the length of each study differed, analysis form Yunus et al. (2015) shows that studies that implemented the SBI consistently prior to each therapy session yielded the strongest results in sensory modulation and overall engagement in the remaining therapy session. Intervention strategies for the studies assessed included tactile stimuli, proprioceptive-based activity (weighted vests, heavy work, etc.), and vestibular activity (swings, bouncing on balls, etc.). Similar to the results shown in Preis and McKenna (2014), children that engaged in the SBI interventions showed improved sensory modulation that lead to increased engagement in areas of self-care, social interaction, and interactive play. For the purpose of the program development for the MAIR clinic, evidence on both sensory processing and sensory integration needed to be evaluated to determine which


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strategy of intervention would be the most beneficial and conducive to the therapists, patients, and the clinic setting of MAIR. While there is a growing amount of research surrounding SBI and these varying intervention methods yielded similar results, sensory processing will be the method of choice for the ASAP program. The basis of SBI, its implementation, and its follow-through are much more realistic for MAIR than the level of complexity and training required for SIT. These methods will benefit the patients being seen in this clinic while still providing therapists with an approachable method to sensory-based therapy. Effectiveness of Attention Based ASD treatments. One concern reported by neurotherapists at the MAIR clinic that was their ability to increase attention and focus in their patients with ASD. Because of this, it was crucial to examine the literature surrounding attention-based interventions for children with autism spectrum disorder and how its implementation can assist with engagement in a therapy setting. To examine the use of attention-based therapy in a diverse setting similar to that of the MAIR clinic, an Indian study from Vivekananda University was examined to assess the effectiveness of visual communication to track activity schedule in children with autism as a means to increase attention and engagement. According to Ruhela (2018), visual communication can be defined as the “transmission of information and ideas using symbols and imagery” (pg. 4). Being that individuals with ASD often have greater challenges coping with unstructured time than typically developing individuals, visual communication is a common means of intervention used to increase attention and task engagement in children with ASD as it provides them with enhanced structure for play, self-care, and other activities (Ruhela, 2018). Ruhela (2018) furthered her discussion of visual communication by explaining benefits such as enhancing learning and interest in new activities, providing receptive communication to increase understanding, as well as developing independence and


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self-esteem. Meaden et al. (2011) explained that for children with ASD, “visual s are a fairly non-intrusive intervention strategy that can be individualized easily to provide assistance in the areas of social and behavioral learning” (pg. 3). The Ruhela (2018) study carried out at Vivekananda University included four children with ASD ranging from 7-10 years of age. For each of the children’s one-hour therapy sessions, visual tracking schedules were established portraying the activities that were to be completed during the session, as well as the order in which they would occur. Individualized schedules were created for each participant, and parents were encouraged to continue the use of this strategy in the home for daily tasks like self-care activities. While the results of the individual children varied slightly, results showed that after the 15 sessions used for each child with the visual tracking schedules, each child showed an improved ability to attend to tasks that were presented, as well as increase their engagement with therapy staff and peers (Ruhela, 2018). One factor examined in this study was that of carry-over of intervention from the clinic setting to parent implementation in the home. Ruhela (2018) explained that for the children that showed a less significant improvement in overall therapy engagement, there was a common factor of limited parent involvement and carry-over of visual tracking implementation in the home. To further assess parent implementation of visual schedules for children with ASD, Goldman (2018) examined two low-income families in Ghana with children with ASD. The mothers involved in this study were given similar training on use of the visual schedules to that in the Ruhela (2018) study. These mothers implemented the visual schedules during transitions for household related tasks and self-care activities, similar to how the implementation would occur in a therapy session (Goldman, 2018). Similar to the results found in the Ruhela (2018) study, children with parents that provided consistent use of the visual tracker in the home showed significantly higher improvement in their ability to transition between tasks and increase task engagement and


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attention (Goldman, 2018). While the use of visual schedules to increase attention and engagement in children with autism can be used in many ways depending on the child’s goals, studies done by Goldman (2018) and Ruhela (2018) the use of visual aides in both clinic settings and home environments. Summary The Moulay Ali Institute for Rehabilitation has made a name for itself in the country of Morocco as it is one of the only clinics of its kind. While this clinic is currently offering a multitude of services, the clinic is still in need of establishing programs to address their areas of need. One need, as explained by the therapists at the MAIR clinic, is working with children with ASD through attention and sensory based interventions. In order to better facilitate the success of the clinic when working with this population, a program designed around implementation of various ASD strategies to improve attention and sensory regulation would greatly benefit this clinic. It was determined through the literature the impact and effectiveness of these ASD interventions, as well as the role that they would play in a diverse, rural area. An occupational therapist would be best suited to implement this specific program as they are the individuals that receive the greatest amount of training in this area and will be able to educate the staff in a way that will be most conducive to them. A program of this sort would work to improve the overall therapy experience of patients with ASD by modulating their sensory processing and attention. A combination of the needs assessment performed through the MAIR clinic and the literature has increased awareness of the need of an autismbased program. The Autism Sensory and Attention (ASAP) Program would be filling a need that has been identified by both the istrative staffing at the MAIR clinic, as well as though clinical observation. The ASAP would also integrate client interests and goals, all while enhancing the overall services that are provided for the surrounding population of the MAIR clinic.


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Program Proposal: The Autism Sensory Attention Program (ASAP) Program Overview

A program that focuses on the development of sensory and attention-based interventions for children with autism spectrum disorder (ASD) will be beneficial for the Moulay Ali Institute for Rehabilitation (MAIR) clinic as they currently do not have the proper education or training to be able to efficiently treat their ASD population. A program of this sort will help to address the current gap in services found through the needs analysis and address the specific interventions for ASD that were found in the literature review that will be beneficial for these patients. This program will work to the MAIR clinic’s neurotherapists in enhancing their knowledge of ASD and ways to increase patient engagement through various sensory and attention-based interventions. The proposed program puts emphasis on developing the neuro-therapist’s abilities to provide care for their ASD population to enhance their overall engagement and success in therapy. Additionally, the proposed program would work to enhance the parent’s ability to carry-over intervention strategies into their home to help their child receive the most out of their therapy services as possible. Currently, the therapists at the MAIR clinic have very little education surrounding ASD and what strategies are most beneficial for their success. They are working with these individuals in a very biomechanically-based way that addresses their mobility and strength goals, but the implementation of sensory and attention-based techniques would help the children’s regulation, and thus enhance their treatment outcomes and further engagement in activities of daily living (ADL’s) and instrumental activities of daily living (IADL’s). As explained previously, one of the many strengths of the MAIR clinic is the engagement and interaction of the parents of the child patients. Currently the parents are observing during therapy, and the homework they are given is typically focusing on range


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of motion and balance. The ASAP program will also assist with parent education on simple, realistic, and cost-efficient sensory and attention strategies they can implement within their own home. Program Value The ASAP program aims to not only assist the MAIR clinic therapists to enhance their knowledge and ability to provide efficient, meaningful services to their pediatric patients with ASD, but it also aims to increase parent knowledge and ability to work with their child outside of therapy to enhance their child’s ability to increase their attention and sensory regulation to enhance their occupational engagement. With ASD being such a complex diagnosis, there is a great deal of education and training that goes into fully grasping the condition and ways to incorporate specific interventions into therapy sessions for successful engagement. The value of this program truly lies in the fact that it will be providing training to this clinic surrounding ASD treatment in the most simplistic, realistic way. This training will then assist the therapists in enhancing their ability to incorporate these strategies into their already existing interventions to help reach the child’s established goals. Occupational Justice The ASAP program decreases the amount of occupational imbalance and occupational apartheid that the child with ASD and their family may experience if an autismspecific program is not in place. The specific symptoms that children with ASD face, including sensory dysregulation, challenges attending to tasks, understanding proper socialization, and generalized interests commonly cause issues with typical occupational task involvement. This may range from activities of daily living like feeding, bathing, and dressing, to engagement in school and social activities. This can create an imbalance of personal occupations for the child as well as the parent (typically the mother) that is involved with their care. This is known as occupational imbalance (Scaffa & Reitz, 2014).


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Similarly, the children with ASD may be experiencing occupational apartheid; the idea that specific individuals or groups of individuals are deprived of meaningful and purposeful activities through segregation because of social, political, or economic factors (Aldrich, Boston, & Daaleman, 2016). While there is little segregation in the United States seen in children with disability due the continuous push toward success and inclusion for all, this same goal is not readily pushed for in Morocco. Because of this, many children with disabilities like ASD are commonly marginalized in their community as there is not sufficient education and awareness for the diagnosis. Prevention As this program is implemented in an outpatient setting, a primary prevention approach for this program would not be valid for the patients as they already have an existing ASD diagnosis. However, there are aspects of both secondary and tertiary prevention that will play a role in this program. One aspect of secondary prevention is that of preventing the worsening of the disease or diagnosis and preventing the emergence of symptoms (Centers for Disease Control, n.d.). While ASD is a spectrum-based diagnosis that is typically not progressive, there are certain symptoms of ASD that, with the implementation of various strategies and techniques, can prevent the heightening of said symptoms. An example of this would include the implementation of sensory-based strategies to assist with negative, learned behaviors when undesired sensory input is introduced to the child. While secondary prevention in the case of the ASAP is not working directly to prevent severe health risks, it would be assisting with the prevention of secondary symptoms and diagnoses like depression and anxiety that can stem from common ASD symptoms. This may include anxiety stemming from over-stimulating environments, or depression from a lack of social engagement that is caused by the child not having sensory regulation techniques when interacting with others. The strategies and


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interventions addressed in this program will assist in preventing the worsening of symptoms for children with ASD. The basis of tertiary prevention includes the reduction of the negative impact of an alreadyestablished disease by restoring function and reducing disease-related complications. It also aims to improve the quality of life for people with disease (Centers for Disease Control, n.d.). This level of prevention is the main prevention for the ASAP program. The implementation of various attention and sensory-based interventions not only increases the function of the child in the treatment session, but it works to prevent the negative impact of the sensory and attention-based symptoms that children with ASD face that impact their daily life and occupational function. Additionally, this level of prevention will be the most beneficial as there are minimal access to proper health care services and additional s for these patients, so the ASAP will work as a service to these children to help improve quality of life and help reduce the negative impact of their diagnosis. Rationale for Occupational Therapy’s Role For the implementation of a successful autism-based program revolving around sensory and attention, one must understand the symptoms experienced by pediatric patient with autism as well as the implications that these unique symptoms have on functional, occupational engagement in their environment. It is also important to understand the ability of the family to enhance the child’s therapy through at-home practice in their own natural environment. Occupational therapy (OT) is a profession that is specially trained in assessing individuals as who they are and their unique strengths, contextual and environmental barriers, and functional abilities. OT is also trained in the evaluation of one’s environment, as well as their desired and necessary occupations. Occupational therapists are also highly qualified to address the patient’s routines and the barriers to engagement in those activities. Most


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importantly, OTs are uniquely trained in implementing complex, individualistic evaluations and interventions for individuals on the autism spectrum to assist with increasing function and engagement in home, school, leisure, and peer-related activities. Because of this, occupational therapists are in an ideal position to be educating the neuro-therapists at the MAIR clinic through indirect services to ister a sensory and attention-based program to the pediatric ASD patients at the MAIR clinic. Ideally an occupational therapist would be providing direct services to these patients. However, due to the location and resources of this Moroccan clinic, the most efficient means for program implementation will be OT education to the MAIR clinic therapists. Theoretical Foundation In order to build a framework and guide reasoning for assessments and intervention in the realm of occupational therapy, theoretical frameworks are used. These various models establish postulate of changes that help determine how change will be made for specific populations and help identify expected outcomes when that model is used in occupational therapy interventions. The outcomes of this program are to enhance the occupational engagement and participation in the MAIR clinic’s patients with ASD through the use of sensory and attention-based intervention. The models explained below will help to create a framework for evidence and occupation-based intervention. The Person, Environment, and Occupation (PEO) is a broad, occupation-based practice model that is effective for individuals who are not satisfied with their occupational performance due to a decreased congruence between the three elements: person, environment, and occupation. One postulate of change for the PEO model is that increased congruence in the transaction between the three elements will enhance the patient’s occupational performance (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996). The PEO model will manifest in my program as it will help guide the intervention to focus on how the


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child is able to interact within the clinic environment, and what adaptations can be made to enhance this engagement. This may include modifying the location of treatment within the clinic to make the environment more conducive to the child (i.e. minimizing noise or distractions). This same PEO implementation will also be used to guide parent education on at-home modification and strategies that can be implemented to create a favorable home environment for engagement. Being that one primary focus for the ASAP program is that of attention-based intervention strategies, the model that will most successfully guide this practice is that of the Acquisitional Model. This ing frame of reference aims for the individual to establish the acquisition of specific skills required for optimal performance within their environment (Luebben & Royeen, 2010). One postulate of change for the Acquisitional Model is that if

the therapist guiding the intervention uses various schedules of reinforcement, the child will be more likely to acquire components of, or the entirety of the specified skill. Additionally, if a child acquires the specific skill and those skills are reinforced, the skill then has the potential of being self-reinforcing and generalized into other activities and settings. For the ASAP program, this model will manifest itself as the therapists introduce and enforce various visual schedules and timers in interventions for skill acquisition of activity transition and turn-taking during play. The second and final complimentary model that will guide intervention for the ASAP is that of the Sensory Processing Model. This goal of this model is to increase occupational performance through adapting responses to sensory input and adjusting the sensory environment to enhance the conduciveness of the child. The postulates of change for the Sensory Processing Model explain that one’s sensory processing patterns are to be assessed to determine (Luebben & Royeen, 2010). Additionally, this model shows that positive experiences and motivation are catalysts for sensory modulation. This model will help the


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sensory aspect of the ASAP program by guiding therapist-driven interventions surrounding the inclusion of various sensory-based activities to help with sensory modulation prior to engagement in typical therapy activities. Delivery considerations When establishing service delivery options for the ASAP program, it was crucial to take into consideration the social and economic factors that would impact the way the program was carried out and its overall success. When considering the methods in which the mothers would be educated on carrying out the sensory and attention-based strategies and activities within their own home, the socioeconomic status of the families attending the clinic needed to be assessed. Home implementation of these various strategies could ideally include a vast assortment of toys, tools, and supplies to enhance the child’s ability to engage in daily occupations after increasing his or her sensory modulation and attention. Being that the majority of patients seen at the MAIR clinic are part of rural, low-income families, the strategies given to these mothers included minimal tools and ingredients and aimed to incorporate things that would be readily available within their home. This would include items like dry rice, dry beans, flour, couscous, and other inexpensive pantry items. Social factors were also considered when providing the mothers with activity ideas for their child. The Moroccan family culture is heavily founded upon tradition. This includes cooking, the way the homes are kept, and social gatherings that are common amongst most families. To connect these traditions to the ASAP, activities like bread making, cleaning dishes with a cloth, couscous preparation, and scrubbing floors or walls were included. These tasks, though varied, all address sensory-based activities ranging from tactile to proprioceptive input.


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The basis behind the inclusion of these specific ingredients or activities was to ensure engagement and follow-through of recommended tasks. If the mothers are encouraged to have their child engage in activities or incorporate supplies into play that would likely not be used or are out of the families budget, the likelihood of follow-through is minimal. However, if the mothers are educated on ways the child can engage in sensory input or play through activities that would already be performed within the home with tools and supplies that are already on hand, the mothers and their child will be set up for success and their engagement will be much higher.

Goals and Objectives Goal 1: To increase neuro-therapist competence in independently implementing sensory and attention-based interventions to patients with ASD. Objective 1. Neuro-therapists will independently implement sensory-based activities prior to remaining therapeutic engagement with ASD clients to increase sensory modulation within two months of receiving training. Objective 2. Neuro-therapists will implement attention-based strategies into ASD intervention to increase therapeutic engagement within two months of receiving training.

Goal 2.

To increase neuro-therapist competence in providing parents/ caregivers with

education for implementation of sensory and attention-based strategies for their children within their home. Objective 1.

Neuro-therapists will independently demonstrate ability to educate

parents on implementation of sensory-based strategies to increase child’s engagement in ADL’s and IADL’s within two months of receiving training.


Objective 2.

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Neuro-therapists will independently demonstrate ability to educate

parents/caregivers on implementation of attention-based strategies to diminish undesired behaviors and increase engagement in ADL’s and IADL’s within two months of receiving training. Detailed Program Outline The ASAP program is a sensory and attention-based intervention program that aims to increase sensory modulation of pediatric patients with ASD as well as increase sustained attention through various therapeutic strategies. Due to the lack of therapist education available through schooling or post-professional education, there is a lack of available training for autism-based interventions as a whole. The society and culture that the MAIR clinic resides in enhances social stigmas for those with disabilities or not widely recognized diagnoses due to this lack of education. As described previously in the need’s analysis portion of this proposal, the unique social, attention, and sensory-based deficits experienced by those with ASD are addressed from an early age in the United States, thus enhancing the patient’s ability to successfully function in day-to-day settings. The goal of the ASAP is to address the Moroccan health care and social systems that bring upon these stigmas and work to increase the acceptance and understanding of ASD by providing therapist training on increasing engagement in children with ASD. Program Organization. The organization of this program will be setup through modules that are provided to the neuro-therapists from the OTR/L implementing this program. These modules will be held over the course of 8 business days that will consist of A days and B days. A days will consist primarily of education provided by the OTR/L to the MAIR clinic therapists on specific topics ranging from sensory modulation to parent education. The other primary component to A days will be having the therapists work with themselves and the OTR/L on implementation of what they were educated on. B days will


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consist of hands-on task implementation with patients on what was provided in training the day prior. These days will give the therapists a chance to implement what was taught and receive from the OTR/L to ensure they feel competent. The education and activity implementation will occur solely within the clinic due to the goal being to use these strategies to increase engagement for the duration of the treatment session. Time requirements. The time requirements for the ASAP program implementation are based on consideration of the structure and hours of the MAIR clinic’s normal hours of business. Due to the MAIR clinic running approximately eight hours a day, the program will run for four hours each day, leaving the therapists time after the program to treat their typical client-base. On-site client involvement will occur on each B day for the typical planned out four hours. Prior to the program beginning, therapists will communicate with their ASD patients to schedule time slots for these specified hours to ensure that there are patients available to implement treatment strategies on. Space requirements. Being that the goal of the ASAP is to implement sensory and attention-based interventions in order to increase engagement through the remainder of the ASD patient’s session, the space requirements for each module will include the use of the MAIR clinic. Space for quiet, distraction-free intervention will also be a space requirement that will be utilized within the clinic space that is already available. Limited space will also be required for the additional toys, therapy equipment, and paper resources that will be provided as tools to enhance therapist knowledge and ability to carry out interventions. This will include one filing cabinet for paper handouts and educational manuals that guide interventions as well as one storage closet that will house the provided tools and therapy equipment. Module Schedule. The first module will be focused on the foundations of sensory modulation, how to identify sensory-based deficits in the ASD patients, and intervention


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strategies to assist with regulation prior to and intermittently through the patients session. Specifically, the sensory interventions in this module will be focused on strategies to increase alertness in children who are having difficulty engaging. It will be at this session that the therapists receive a binder containing both the educational material for the full program duration, as well as a pre-program survey that assesses their confidence and knowledge of implementing the information covered in the program. Education will also be provided in this session on tools and toys that were brought specifically for the program and how they can be implemented into sensory-based intervention. The B day for this module will include the implementation of these strategies on MAIR clinic clients. The therapists will be responsible for working collaboratively to brainstorm treatment ideas for each patient and carry out the intervention. The next module for the ASAP program, while similar to module one, will focus primarily on sensory-based interventions for decreasing hyperactivity in patients to increase overall engagement in therapy. The therapists will once again work with the therapist on interventions strategies that could be implemented with the tools available as well as a short information session on the tools that were brought for the program that could be used for these interventions. Implementation of intervention strategies will again be the B day for this module. The importance of the first two modules will be ensuring the therapists are able to grasp the foundations of sensory modulation to better implement appropriate sensory-based activities prior to and intermittently through the child’s therapy session as needed. The final module for this program will be focused on educating the therapists on the foundation of attention-based interventions for children with ASD and the ways in which these strategies assist with increasing alertness, social interaction, and turn-taking. This module will also cover various strategies for attention and task engagement including the use of visual schedules and timers to guide tasks. This module will have the same format as


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modules one and two where the A day will focus on education and B day will then be comprised of implementing the tools and techniques that were provided the previous day. The three modules will be the primary focus of the program. A key component to each of the modules will be educating the neuro-therapists on ways they can inform and educate the parents of their clients on ways to carry-over these strategies into their home. This will include educating them on inexpensive, readily accessible tools and ingredients that can be used in the home as well as ways to incorporate sensory and attention-based tasks into activities that would already be performed in the household (e.g. bread making or cleaning). To ensure that the therapists are competent in the implementation of these various interventions, the OTR/L will remain in the clinic for two additional days to act as a guide for the therapists, answer questions that arise, and assist with the hands-on patient interaction involving these sensory and attention-based methods. The same assessment that was provided in the first module will be provided on the last day of the program that assesses the change in therapist’s confidence and knowledge of implementing the information from the program. Program Marketing. Since this program will be automatically provided to all MAIR clinic patients with ASD, marketing outside the clinic would not be necessary for the program’s overall success. This is also due to the ASD patients being seen at the clinic primarily for mobility-related deficits. The ASAP is acting as a supplementary program to enhance their engagement in these biomechanically-based interventions. However, to spread awareness to the city of Marrakech and surrounding areas, marketing would be beneficial in public hospitals, health clinics, and the local orphanages to spread awareness of the services the clinic is now able to provide for patients with ASD. Budget. Since the ASAP program will be a program that supplements the already existing therapy of the MAIR clinic for patients with ASD, there will only be a small increase in operational spending. The clinic already has access to computers, printers and various


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treatment equipment, so minimal equipment will be needed for the success of the implementation of this program. This program will not increase the cost that is put toward the therapist salary as it will be implemented into already planned treatment. It should be noted that the training for this program may lead to decreases in clinic revenue due to the time being taken for training. However, this potential loss should be minimal due to many of the MAIR clinic patients receiving service at no cost to them. A line-item budget can be found in Appendix E. The cost of the OTR/L salary for training will be broken up into preparation, training, and supervision of the program. The training portion of the ASAP program will include 32 hours of the salary, the supervision of the program will encom eight hours of the salary, and the remaining hours will be put toward preparation of the program itself. The remaining items that make up the direct costs will be comprised of toys and other equipment that will enhance the ability of the therapists to implement attention and sensory-based activities. Funding Options. The MAIR clinic is a non-profit rehabilitation clinic that has been established through generous donations from various organizations. Past donations have been provided by organizations such as the Sorrenson Legacy Foundation and the Rotary Club of Salt Lake City. The Funding Opportunities for Occupational Therapy website through the Spencer S. Eccles Library was used to search for proper funding for the ASAP program. The Advanced Search option on this site was used to ensure that I was finding funding opportunities that would best fit my established program. Search that were used included: health, Morocco, children and youth, Sorrenson Foundation. This search is what brought me to the grant for the Sorrrenson Foundation. This foundation has a history or donating to a wide variety of business endeavors and typical grants run at ~$20,000 which is more than enough for the grants needed to fund the ASAP program (Application Guidelines for Grant Seekers, 2009).


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To locate my next relevant grant that would assist in funding the ASAP, search included: health, Morocco, and children and youth. This search lead me to the Johnson and Johnson Family of Countries Contribution Fund. This organization has served businesses all across the United States as well as Thailand and various regions of Africa. Their funding interests include disease and disabilities, pediatrics, health, public health, and youth development, all of which pertain to the foundations of the ASAP program. Typical grants provided by this foundation run between $10,000-$25,000 which will assist in covering any remaining costs for the program (The Grantsmanship Center, 2018). Expected Outcomes. The expected outcome of this program is that the neurotherapists at the MAIR clinic will be able to implement sensory and attention-based interventions to their patients with ASD to better enhance their therapeutic engagement. The longer-term goal of this program is that the therapists will feel competent not only in implementing these intervention strategies, but also being able to educate the parents/ caregivers of the patients on ways to implement strategies in the home to ensure that there is carry-over of strategies occurring. With parents having a basic understanding of these strategies and how to implement them in a realistic, cost-efficient manner within their home, the hope is that the child will then be more successful in his or her participation in ADL’s and IADL’s, social engagement, and activity tolerance. Program Evaluation. The efficacy of the ASAP program will be evaluated in two different ways. The first way this program will be evaluated is through a therapist-directed pre and post survey that will be aimed towards assessing the therapists comfort level surrounding the education that was provided to them on sensory and attention-based interventions. This survey will include open-ended questions that are related to the therapist’s satisfaction with the program implementation process and its benefit. The five questions on


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this survey will include the following: 1) How would you rate your understanding of sensory modulation? 2) How would you rate your understanding of sensory-based intervention strategies? 3) How would you rate your understanding of attention-based intervention strategies? 4) How would you rate your comfort level with working with children with ASD? 5) To what level do you feel the ASAP will assist you patients with ASD? Survey responses will then be coded, and data will be collected in order to identify trends that address the effectiveness of the program as well as possible changes that can be made to improve the program. To better assess the therapist’s thoughts over the program and its value, a postprogram survey will be given. The questions for this survey include the following: 1) What did you find most beneficial about the training that was provided for the ASAP? 2) In what ways do you feel the ASAP training could be improved? 3) What did you find to be the most challenging aspect of the ASAP training? 4) In what ways do you feel the ASAP will assist the ASD patients that are provided with its service? 5) In what ways do you feel the parent education portion of the ASAP could be improved? Like the pre and post survey that will be given, this pose-program survey will be coded, and data will be collected to better identify ways in which the program could be improved moving forward. Each of these surveys will be available in Appendix F for further evaluation. Being that one other key component to the ASAP program is that of parent education on the strategies that are being implemented in therapy, a post-program quiz will be provided to determine the therapist’s competence in the material that they were educated on. Questions given in this quiz will include the following: 1) Define sensory modulation 2) Explain one way to increase attention through sensory-based strategies 3) Explain one way to increase alertness through sensory-based strategies 4) Write a brief explanation of how to create and use a visual schedule with a patient 5) What are three different activities for sensory-play that


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could be implemented in the child’s home? These various questions cover a wide range of information that was provided through the ASAP. Once completed, these answers will be scored by the OTR/L to determine if there were common areas that were misunderstood by the therapists that need further detail or explanation. If this is the case, the two extra days at the end of the modules will be used to better educate the neuro-therapists on areas of confusion prior to the OTR/L having to leave.


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References Africa/. (2017, April 07). Retrieved from https://www.worldatlas.com/webimage/countrys/africa/morocco/maland.htm Alami, A. (2013, March 27). Fewer Than 30 Percent of Moroccans Have Health Insurance. Retrieved from https://www.nytimes.com/2013/03/world/middleeast/fewer-thanPercent-of-moroccans-have-health-insurance.htm Application Guidelines for Grant Seekers. (2009). Retrieved from https://www.sorensonlegacyfoundation.org/grant_seekers/application_guidelines

Ayres, A. J., Robbins, J., & McAfee, S. (2005). Sensory integration and the child: Understanding hidden sensory challenges. Los Angeles, CA: Western Psychological Services. Beliefs and Practices. (n.d.). Retrieved from https://rlp.hds.harvard.edu/religions/islam/beliefs-and-practices Case-Smith, J., Weaver, L. L., & Fristad, M. A. (2014). A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism, 19(2), 133-148. Dunn, W. (2009). Living sensationally: Understanding your senses. London: Jessica Kingsley. Education | Morocco. (n.d.). Retrieved from https://www.usaid.gov/morocco/education Examples of Morocco's continually failing health care system. (2018, March 06). Retrieved from https://www.moroccoworldnews.com/2018/03/241860/morocco-continually-failinghealth-care-system Frye, R. E. (2018). Social skills deficits in autism spectrum disorder: Potential biological


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origins and progress in developing therapeutic agents. CNS Drugs, 32(8), 713-734. doi:10.1007/s40263-018-0556-y

Goldman, S. E., Glover, C. A., Lloyd, B. P., Barton, E. E., & Mello, M. P. (2017). Effects of parent implemented visual schedule routines for African American children with ASD in low-income home settings. Exceptionality, 26(3), 162-175. doi:10.1080/09362835.2017.1294984 Hassan, S. (2010). The Moroccan country case study: Positive practice environments. Retrieved from http://www.who.int/workforcealliance/knowledge/PPE_Morocco_CaseStudy.pdf

Luebben, A. J., & Royeen, C. B. (2010). An acquisitional frame of reference. In P. Kramer & J. Hinojosa (Eds.), Frames of reference for pediatric occupational therapy (3rd ed., pp. 461-488). Philadelphia: Lippincott Williams & Wilkins.

Martín, I. Z., Martos, J. A., Millares, P. M., & Björklund, A. (2015). Occupational therapy culture seen through the multifocal lens of fieldwork in diverse rural areas. Scandinavian Journal of Occupational Therapy. 22(2), 82-94. doi:10.3109/11038128.2014.965197 Meadan, H., Ostrosky, M. M., Triplett, B., Michna, A., & Fettig, A. (2011). Using visual s with young children with autism spectrum disorder. TEACHING Exceptional Children, 43(6), 28-35. doi:10.1177/004005991104300603 Morocco. (2018, September 22). Retrieved from http://www.who.int/countries/mar/en/ Morocco - HealthcareMorocco - Healthcare. (n.d.). Retrieved from https://www.export.gov/article?id=Morocco-Healthcare


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Preis, J., & Mckenna, M. (2014). The effects of sensory integration therapy on verbal expression and engagement in children with autism. International Journal of Therapy and Rehabilitation, 21(10), 476-486. doi:10.12968/ijtr.2014.21.10.476 Ruhela, V. (2018). Effect of visual communication in tracking activity schedule among Children with autism spectrum disorder. Indian Journal of Health and Well-Being. 9(5), 748-751.

Schaaf, R. C., & Miller, L. J. (2005). Occupational therapy using a sensory integrative approach for children with developmental disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 11(2), 143-148. doi:10.1002/mrdd.20067 The Grantsmanship Center. (2018, September 04). Johnson & Johnson Family of Companies Contribution Fund. Retrieved from https://www.tgci.com/fundingsources/funders/johnson-johnson-family-companies-contribution-fund The World Factbook. (2018). Retrieved from https://www.cia.gov/library/publications/theworld-factbook/geos/print_mo.html. Tinasti, K. (2015). Morocco’s policy choices to achieve Universal health coverage. Pan African Medical Journal, 21. doi:10.11604/pamj.2015.21.53.6727 Trani, J., Tiapek, S., Lopez, D., Gall, F. Disability and poverty in Morocco and Tunisia: A multidimensional approach. (2015). Journal of Human Development and Capabilities, 16(4). Vivanti, G., Fanning, P. A., Hocking, D. R., Sievers, S., & Dissanayake, C. (2017). Social attention, t attention and sustained attention in autism spectrum disorder and Williams syndrome: Convergences and divergences. Journal of Autism and


Developmental Disorders, 47(6), 1866-1877. doi:10.1007/s10803-017-3106-4 Yunus, F., Liu, K., Bisset, M., Penkala, S. (2015). Sensory-based intervention for children with behavioral problems: A systematic review. Journal of Autism Developmental Disorder, 5(12):3565–3579.

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Appendix A: Therapist Interview Questions ● Where do the majority of your patients come from? ○ Are most of them local or are they coming from a different city/ country? ● What is the payment setup like for patients? ○ Are there varying options for those patients who are unable to pay out of pocket of do not have proper insurance coverage? ● How long is a typical session? ● How many times is each patient typically seen? ● Are translators always available? ○ I know that the French language is common in the part of Africa, are you all fluent in Arabic, French, and English? ● Is your facility able to order any kind of AE or DME? ○ If so, from where? ○ If not, who has been your biggest contributor to accessing this equipment? ● Who is funding your clinic? ○ Is the clinic currently seeking out funding from local, African companies rather than solely US based corporations? ● Do you ever do any charity/ pro bono therapy work? ● Have you ever considered branching out to a home health type service? ○ If you are currently doing this, how often? ○ What are common recommendations being made in these home health visits? ● What is your long term clinic goal/ goals? ● Would you ever open another clinic in another area of the country? ● How does scheduling happen? ○ Computer based? ○ Phone calls? ○ In person scheduling? ● Are patients typically on time? What happens if they aren’t? ○ Is there any kind of consequence if there are a certain amount of no-shows to ensure efficiency within your clinic? ● Do you accept walk ins? ● I know your caseload is typically large. Are you open to decreasing caseload to be able to make tx more occupation based? ○ Do you ever feel like your caseload is too large to provide the best service you could be? ● What do you feel are the biggest strengths of the clinic currently? ● What do you feel are the biggest areas of growth for the clinic? ○ How do you think these changes could realistically occur? ● What lead you to a career in rehabilitation? ● How did you hear about the job position at the MAIR clinic? ● What are some of the greatest changes/ improvements you have witnessed in the clinic since beginning your job here? ● How active are the parents typically?


● ● ● ● ●

● ●

● ●

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○ Is it mainly the mothers present or are there ever fathers that assist/ engage in the patients therapy? Do you feel as though your workload is evenly spread? ○ Do you feel like you are overloaded in any certain areas? Do you feel as though the parents are responsive and active when you provide them with home exercise programs/ tools? What programs have been beneficial from past therapists that have visited the clinic? Do you have a system in place to ensure the cleanliness of the clinic? Do you feel that you have an adequate amount of time to complete documentation each day? ○ If you are not finishing it at the clinic, how much time are you taking after work to complete daily documentation? If you had a larger space, what would be your goal for that clinic? ○ What items would you like to see implemented into a larger clinic space? From our two weeks spent working with you in the clinic, what are some of the most beneficial pieces of information you will take away? ○ Do you see yourself regularly using any of the information we provided? If so, what? Do you feel more competent in the area of integrating functional tasks into treatment after our time here? What do you feel we as a group could have done differently to better inform you all on various topics?


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Appendix B: Parent Interview Questions ● What is your favorite thing about the clinic/ what it offers to you child? ● What is the biggest progression you have seen in your child since they have been attending the clinic? ● How did you hear about the MAIR clinic? ● What does your child like to do for fun? ● What are your current goals for your child? ● What are your long term goals for your child through therapy? ● Has the clinic provided any home exercise programs for you to continue at home between sessions? ○ Have you felt that you are able to successfully carry them out in your home? ● What do you feel is the greatest burden you are facing for managing your child’s disability? ○ Do you find you have time to yourself/ take a break during the day? (burnout)


Appendix C: Child Interview Questions: ● ● ● ● ● ● ● ●

What is your favorite part about coming to the MAIR clinic? What are some of your favorite things to do for fun? What are some of your favorite things to do at home and school? What are some things you would like to be able to do that you currently cannot? (Various occupations) What do you want to be able to do but cannot do right now? What is your favorite part of therapy/coming to the MAIR clinic? What is your least favorite part about therapy? What do you think you are good at?

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Appendix D: Therapy Director Questions: 

What is the length of stay for the MAIR clinic? Typical length of each session?



How many patients are seen a day, and what percentage are adults vs. children?



What current programs are you implementing at MAIR clinic (ex. Feeding, gait training, ROM, etc.) and what programs would you like to implement in the future?



What does funding look like for the clinic? How does Rotary club play a role in funding?



How many therapists are on staff? How many interpreters? Any other staff and what role do they play?



Education of the therapists?



How do you prioritize patient care/your waiting list?



How far are they traveling to get to the clinic? What type of transportation is needed? Is public transportation accessible for individuals with special needs?



How do people pay for services? How do you charge for different services (if you have different charges)? Do you use a pay scale?



How do you envision occupational therapy being incorporated into the clinic? What do you hope to achieve by incorporating OT services?



What are your plans for the future?



Ultimately, what do you need or would you like us to contribute?



How are people referred to, or find out about, the clinic?



What type of scheduling system do you use?



What is process for evaluating patients and planning their care? How do the therapists determine exactly what they are going to do with a patient?



How do the therapist currently document? Will we have access to charts to assess what they are doing/plan of care?



If they don’t do plans of care is this something we can build? (ie. protocol for assessment/treatment)




I read online that the clinic is incorporating telehealth using TruClinic (as of 2014) - is this something that is still happening? Is it working for your patients?



What is your plan to make the clinic sustainable?



What is currently working for the clinic, what needs improvement?



Are the Zahra charity and Neuroworks no longer assisting in funding the MAIR clinic (like the Salt Lake Rotary Club is)?



Target population - Would you say that this is children or cerebral palsy? In my notes I have that Mo stated 65% of the population is kids, and 65% have .



What would you say some strengths of the clinic are?



What are some weaknesses of the clinic?

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Appendix E: Therapist pre and post program survey

-

How would you rate your understanding of sensory modulation? 1) 2) 3) 4) 5)

-

How would you rate your understanding of sensory-based intervention strategies? 1) 2) 3) 4) 5)

-

How would you rate your understanding of attention-based intervention strategies? 1) 2) 3) 4) 5)

-

How would you rate your comfort level with working with children with ASD? 1)

-

2)

3)

4)

To what level do you feel the ASAP will assist you patients with ASD? 1) 2) 3) 4) 5)

Please rate each question using the following 4-point scale: 1234-

5)

Very low Low Moderate High


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Appendix F: Therapist post program survey

1) What did you find most beneficial about the training that was provided for the ASAP?

2) In what ways do you feel the ASAP training could be improved?

3) What did you find to be the most challenging aspect of the ASAP training?

4) In what ways do you feel the ASAP will assist the ASD patients that are provided with its service?

5) In what ways do you feel the parent education portion of the ASAP could be improved?


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Appendix G: Line-Item Budget Detail

Start-up Costs OT salary for training

Source of Specific costs or sources of income Training OTR Salary (based on average salary in the Utah) for training: $80,000/52 weeks in a year= $1,538.46 x 2

Cost

$3,076

weeks of program implementation (8 days for actual program implementation, 6 days for preparation for program implementation)

Total= $3,076 Direct Costs Travel expenses: Flight: Round trip from SLC to Marrakech (x1 therapist) - Delta KLM flight Hotel: 14-night stay ($57.14 per night x 10 x 1 therapist) - Blue Sea Le PrimTemps Other: Food, city travel ($20 per day x 10 days x 1 therapist) Supplies: - Audible countdown timer x2 (Amazon including shipping) - Laminator (Costco) - Laminating sheets x2 (Costco) - Plastic bins (13x8x5) x3(Wal Mart) - 10 lb bag of black beans (Wal Mart) - 10 lb bag of white rice (Wal Mart) - Small plastic figurines 12 count x3 (Wal Mart) - Exercise balls- 55 cm x2 (Amazon including shipping) - Exercise balls- 75 cm x2 (Amazon including shipping) - Therapy swing -Platform swing (Amazon including shipping) - Hug swing (Amazon including shipping) - Gym mats x2 (Fun and Function Store including shipping) - Crash pad (Autism Community Store including shipping)

$1,100

$571.40

$200

$59.90 $21.99 $20.00 $24.96 $22.44 $11.04 $14.97 $57.90 $77.90 $432 $85 $66 $229.99

$32.50


-

-

-

-

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Wiggle cushion x2 (Autism Community Store including shipping) Weighted stuffed animals lap pad x2 (Autism Community Store including shipping) Tactile hand fidgets x2 (Autism Community Store including shipping) Filing cabinet (Amazon including shipping) Storage Closet (Amazon including shipping)

$95.98 $19.98 $60.09 $119.99

Total= $3,324.03 Indirect Costs In Kind

In Kind In Kind In Kind

Income

Total costs

Total income or in-kind contributions Net cost of program

Rent $13.00 x 2,700 Square Ft. = 35,100 / 52 weeks= $675 x 2 total weeks Utilities Maintenance Rent ($1,350/ 10) Full Time MAIR Neuro-Therapist $800 per month / 4 weeks in a month x 2 weeks for program implementation $0 Total= Budget Summary $8,385

$1,985

$6,400.03

$1,350

$100 $135.00 $400

$0 $1,985


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Appendix H: Day One ASAP Module Module 1. The first module will be focused on the foundations of sensory modulation, how to identify sensory-based deficits in the ASD patients, and intervention strategies to assist with regulation prior to and intermittently through the patient’s session. This session will detail pediatric cases involving varying sensory deficits, and strategies that would modulate these various dysregulations. Additionally, the therapist will be given ideas for tools that are commonly used to assist with sensory regulation activities. Following this lesson, the therapists will then walk through the clinic with the therapist and assist them with creating ideas of sensory modulation activities that utilize the toys and equipment that are already in the clinic. The day following this educational module will be comprised of implementation of the strategies that were taught the day prior. Patients with ASD will be assessed by the therapists for specific sensory deficits and will then engage in interventions addressing the modulation of these deficits. The OT’s role in this session will be to provide to the therapists on modifications to their intervention strategies, as well as answering questions that the therapists have surrounding these interventions. The importance of this first module will be ensuring the therapists are able to grasp the foundations of sensory modulation to better implement sensory-based activities prior to and intermittently through the child’s therapy session.


Personal Statement: I, McKenzie Smith, attest to the fact that Lexi Sybrowsky has read and made edits to my paper that I have then implemented. Kenzie Smith

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