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DOI: 10.1177/0031512516662895
Interventions in pms.sagepub.com

Preterm Infants

Serkan Pekcetin
Department of Occupational Therapy, Trakya University, Edirne, Turkey

Esra Ak
Department of Occupational Therapy, Hacettepe University, Ankara, Turkey

Zeynep Ustunyurt
Zekai Tahir Burak Education and Research Hospital, Ankara, Turkey

Hulya Kayhan
Department of Occupational Therapy, Hacettepe University, Ankara, Turkey

Abstract
This study aimed to explore the effects of individualized sensory integration inter-
ventions on the sensory processing functions of preterm infants. Thirty-four preterm
infants (intervention group) at a corrected age of seven months and 34 term infants
(control group) were included. The preterm infants underwent an eight-week sen-
sory integration intervention. Before and after the intervention, the preterm infants
sensory processing functions were evaluated using the Test of Sensory Functions in
Infants and compared with those of term infants. Preterm infants had significantly
poorer sensory processing function preintervention when compared with term
infants. There was a significant improvement in preterm infants sensory processing
functions after the sensory integration intervention. In conclusion, preterm infants
should be evaluated for sensory processing disorders and individualized sensory
integration interventions should be implemented.

Keywords
sensory integration in infants, preterm infants, sensory processing

Corresponding Author:
Serkan Pekcetin, Department of Occupational Therapy, Trakya University, Edirne 02250, Turkey.
Email: serkanpekcetin@gmail.com
2 Perceptual and Motor Skills 0(0)

Introduction
Preterm is dened as infants born alive before 37 weeks of gestation. Preterm
infants constitute a signicant newborn group in Europe and Turkey.
According to the World Health Organization (WHO), 5.5%11.4% of preg-
nancies in Europe and 11.97% of all pregnancies worldwide result in prema-
ture birth (WHO, 2012). Preterm birth has therefore become a public health
priority, especially considering that since the 1990s, the survival of preterm
infants has improved signicantly due to advances in perinatal and neonatal
care. However, this improvement has led to increases in the prevalence of
complicated neonatal problems and the length of hospitalization (Kenner &
McGrath, 2004). For some survivors of preterm birth, the detrimental eects
may continue throughout life; increased risk of cerebral palsy, learning impair-
ment, and visual disorders can result in impaired neurodevelopmental func-
tioning, and a higher risk of noncommunicable disease aects long-term
physical health (WHO, 2012). Hence, attention has increasingly focused on
the neurodevelopmental outcomes of children born preterm. Kessenich
(2003) reported that preterm infants experience more problems in cognitive
functions, learning, language development, visual-motor and visual-spatial
skills, attention, executive functions, and sensory integration functions com-
pared with term peers.

Sensory processing disorders in preterm infants

Sensory processing disorders (SPD) in preterm infants seem to occur as a
result of both their immature neurological and biological systems and being
in the neonatal intensive care unit environment, which is unable to meet the
sensory needs of preterm infants (Blackburn, 1998; White-Traut, Nelson,
Burns, & Cunningham, 1994). SPD in infants can be identied with the
Test of Sensory Functions in Infants (TSFI), Sensory Rating Scale, and
Infant Toddler Sensory Prole (ITSP) test batteries. TSFI is a performance-
based assessment, while Sensory Rating Scale and ITSP are parent-reported
questionnaires (Eeles et al., 2013). Researchers demonstrated that preterm
infants experience more SPD and have poor sensory modulation compared
with term peers (Bart, Shayevits, Gabis, & Morag, 2011; Case-Smith, Butcher,
& Reed, 1998; Wiener, Long, DeGangi, & Battaile, 1996). Preterm infants are
at higher risk for SPD (39%) in terms of auditory, tactile, and vestibular
systems in a study using the infant/toddler and standard versions of the
Sensory Prole questionnaire (Wickremasinghe et al., 2013). In a recent
review that examined 45 studies of SPD in preterm infants aged 03 years,
43% of SPD diagnoses were related to sensory modulation disorders, 82% of
which were hyperresponsivity to sensory stimuli (Mitchell, Moore, Roberts,
Hachtel, & Brown, 2015).
Pekcetin et al. 3

Sensory integration intervention programs

Sensory integration has been dened as a neurological organization process
enabling the eective use of ones body through stimulus from his body and
the environment (Ayres & Robbins, 2005). Ayres stated that the sensory system
develops gradually, and that decits can occur during this developmental pro-
cess. An intact sensory system can integrate input from multiple sources (e.g.,
visual, auditory, proprioceptive, or vestibular). Ayres postulated that sensory
integration dysfunction occurs when sensory neurons are not signaling or func-
tioning eciently, leading to decits in development, learning, and/or emotional
regulation. Sensory integration interventions are intended to improve the way
the nervous system uses sensory information. Sensory integration interventions
applied on an individual basis involve a balance between structure and freedom,
with an emphasis on the inner drive of child. In the sensory integration process,
active participation is more important than passive participation. However,
there may be situations the child needs passive stimulation. Sensory integration
intervention settings must be arranged according to the childs sensory respon-
sivity (Parham & Mailloux, 2010).
Based on Ayress theory, therapists began to use sensory-based intervention
techniques. The eciency of sensory integration interventions has been demon-
strated for dierent diagnostic groups in childhood such as Downs syndrome
(Uyanik, Bumin, & Kayihan, 2003), cerebral palsy (Kayihan & Bumin, 2001),
developmental coordination disorders (Elbasan, Kayihan, & Duzgun, 2012),
and autism spectrum disorders (Case-Smith, Weaver, & Fristad, 2014).
However, there are few studies in the literature evaluating the eectiveness of
sensory integration interventions for SPD in infancy.
In this study, it was hypothesized that sensory integration interventions
applied to preterm infants would have a positive eect on sensory processing
functions. The aim of the study was to detect SPD in preterm infants with
sensory processing risks and determine the eectiveness of an individualized
intervention program.

Method
This study was performed at Dr. Zekai Tahir Burak Womens Health Education
and Research Hospital in Ankara, Turkey. Prior to the study, approval was
obtained from the Noninvasive Clinical Research Ethics Board of Hacettepe
University (06.26.2014/Number: GO 14/235).

Participants
Sixty-eight infants were enrolled in this study. Infants who were born at a ges-
tational age above 36 weeks, were seven months of age at assessment, lived with
4 Perceptual and Motor Skills 0(0)

families and had normal hearing and visual screening results, composed the
control group. Infants who were born with a gestational age below 37 weeks,
were at a corrected age of seven months at assessment, lived with their families
and had normal hearing and visual screening results, composed the intervention
group. For both groups, hearing screenings were evaluated by an audiometrist,
visual screenings were evaluated by an ophthalmologist, and mental and phys-
ical development were evaluated by a developmental pediatrician. Infants with
major congenital anomalies, systemic diseases, neurological problems, physical
or mental developmental delays identied in the rst examination and those with
no caregiver-signed informed consent were excluded from the study.
The infants clinical and developmental evaluations were performed by a
developmental pediatrician. All assessments and interventions were conducted
by the same therapist who adhered to ethical and unbiased principles. The term
infants comprising the control group did not receive any interventions. The
examiner was not blinded regarding which infants were term and preterm.

Evaluation of sensory processing

Test of sensory functions in infants (TSFI). Then presence of SPD was assessed using
TSFI. This test consists of 24 items. It was developed to assess SPD in infants 4
to 18 months of age. Sensory processing and ability to react to sensory stimulus
were measured by ve subtests, shown below with scoring framework:

1. Reactivity to Tactile Deep Pressure: responses to deep pressure applied on

arms and hands, stomach, soles of feet, mouth, and total body when held at
shoulder (0 Adverse, 1 Mildly Defensive, 2 Integrated).
2. Adaptive Motor Functions: the ability to motor plan and initiate exploratory
movements in handling textured toys (0 No response, 1 Disorganized,
2 Partial, 3 Organized).
3. Visual-Tactile Integration: toleration of contact with various visually inter-
esting textured toys (0 Hyperreactive, 1 Hyporeactive, 2 Normal).
4. Ocular-Motor Control: lateralization of the eyes and visual tracking (0 No
Response, 1 Integrated).
5. Reactivity to Vestibular Stimulation: in vertical, circular, and inverted
prone and supine body positions (0 Adverse, 1 Mildly Defensive,
2 Integrated).

Scores on the TSFI range from a minimum of 0 to a maximum of 49, with

higher scores indicating better sensory processing capabilities. Infants are clas-
sied as normal, at risk, or inadequate in terms of sensory processing (DeGangi
& Greenspan, 1989). The validity of the TSFI was supported by a study showing
that the overall score on this test is valid and reliable for infants 7 to 18 months
old (Cronbachs reliability coecient was .78) (Jirikowic, Engel, & Deitz, 1997).
Pekcetin et al. 5

Intervention
Individualized sensory integration therapy was applied to preterm infants who
had risk factors or problems in one or more areas of sensory processing. The
intervention program included one session of 45 minutes each week for eight
weeks. At the end of eight weeks, at a corrected age of nine months, the preterm
infants were reassessed using the TSFI to determine the eectiveness of the
interventions.
It is important to point out that sensory integration and sensory stimulus
are dierent terms. Schaaf and Anzalone (2001) dene sensory integration as
childs active participation with a sensory stimulus, while a sensory stimulus was
dened as providing sensory stimuli without the childs active participation.
However, eliciting active participation can be challenging with young infants.
We provided opportunity for active participation by presenting dierent toys
and activities in each session, and activities were chosen according to the infants
sensory responsivity. Each infants sensory responsivity prole was the primary
determiner of his/her interventions and individualized sensory integration inter-
ventions were based on this information.
Understanding the responses of infants during sensory integration therapy
and using those responses to guide the intervention are important aspects of the
process. The therapist in the present study was a PhD student in occupational
therapy with 10 years of experience with infants. The same therapist applied all
interventions in this study, ensuring that the therapy was consistent for all
infants in the study group. The individualized sensory integration therapy was
provided in a 30 m2 therapy room in the maternity hospital. The therapy room
was designed according to Parhams delity criteria for the physical environment
of sensory integration intervention (Parham et al., 2011).

Statistical analyses
Data were analyzed with SPSS version 17.0 statistical software package pro-
gram. Normality of data was analyzed with the ShapiroWilk test. Dierences
between groups were analyzed with chi square test for nominal data and the
MannWhitney U test for ordinal data. Dierences between preintervention and
postintervention results of groups were analyzed with the Wilcoxon signed-rank
test; eect size was calculated as the rank correlation, r. Level of signicance was
accepted as p < .05.

Results
The families of 222 term infants were contacted regarding enrollment in the
control group for the study. Thirty-nine families consented to their infants
participating in the study; three infants were excluded because they did not
meet the inclusion criteria and two were excluded because they did not come
6 Perceptual and Motor Skills 0(0)

Figure 1. Flow diagram of the participants in the study.

to the second assessment. The developmental pediatrician invited the families of

95 preterm infants whose corrected age was seven months for the intervention
group. Eleven families declined to participate in the study, 19 infants did not
meet the inclusion criteria of the study, and 31 infants did not continue in the
study for various reasons. Therefore, the analyses included data from 34 infants
in the control group and 34 infants in the intervention group (Figure 1).
Table 1 shows the demographic characteristics of the study group. There were
no signicant dierences between the intervention and control group in terms of
gender, maternal education status, and family characteristics (p > .05) (Table 1).
Mean birth weight was 1,503.23  481.83 g in the intervention group and
3,291  366.97 g in the control group (eect size, rank correlation r .85,
p < .001).
Preterm infants had lower TSFI total scores before intervention when com-
pared with term peers (r .84, p < .001) (Table 2). Comparison of the results of
the rst and second assessments in the control group revealed signicant dier-
ences in TSFI total scores (r .41, p < .001), visual-tactile integration
(r 0.27, p .02), and adaptive motor functions scores (r .36, p .003).
The scores for responses to tactile deep pressure (r .20, p .08) and reactivity
to vestibular stimuli increased but the dierence was not statistically signicant
(r .17, p .15). The scores for the oculo-motor control subtest did not dier
between the rst and second assessment (r .00, p 1.0) (Table 3).
The TSFI total score increased signicantly between the pre- and postinter-
vention assessments in the intervention group (r .61, p < .001) (Table 4). The
changes in the TSFI total score between the rst and second evaluations in the
intervention and control groups were compared. The intervention group showed
a signicantly larger improvement in the TSFI total score compared with the
control group (r .86, p < .001) (Table 5).
Pekcetin et al. 7

Table 1. Demographic characteristics of the groups.

Control group Intervention group

Demographic
characteristics n % n % p

Sex .81
Female 15 44.1 17 50
Male 19 55.9 17 50
Maternal education status .86
Primary school 18 52.9 16 47.1
High school 10 29.4 12 35.3
Bachelors degree 6 17.6 6 17.6
Family type 1.0
Nuclear family 6 17.6 7 20.6
Extended family 28 82.4 27 79.4
Gestational age 8.3e-13
Term 34 100 0 0
Moderate preterm 0 0 12 35.2
Very preterm 0 0 17 50
Extremely preterm 0 0 5 14.8

Table 2. Comparison of baseline TSFI scores between groups.

Control group Intervention group

Sensory processing functions
subtest scores (TSFI) M SD M SD r p

Reactivity to tactile deep pressure 9.73 0.44 8.41 1.28 .55 4.5e-6
Adaptive motor functions 13.79 1.38 10.73 2.24 .68 1.5e-8
Visual-tactile integration 9.32 0.47 7.94 1.15 .70 4.7e-9
Ocular-motor control 2.00 0.00 1.29 0.57 .68 1.9e-8
Reactivity to vestibular stimulation 11.70 0.62 8.94 1.93 .70 5.5e-9
Total test 46.61 1.98 37.32 4.84 .84 2.5e-12
Note. TFSI: Test of Sensory Functions in Infants.

Discussion
In the current study, it was demonstrated that preterm birth is associated with
higher rates of deciencies in sensory processing skills and that individualized
sensory integration intervention is eective in improving SPD in preterm infants.
8 Perceptual and Motor Skills 0(0)

Table 3. Comparison of control group TSFI results.

First assessment Second assessment

Sensory processing functions
subtest scores (TSFI) M SD M SD r p

Reactivity to tactile deep pressure 9.73 0.44 9.82 0.38 .20 .08
Adaptive motor functions 13.79 1.38 14.38 0.98 .36 .003
Visual-tactile integration 9.32 0.47 9.47 0.50 .27 .02
Ocular-motor control 2.00 0.00 2.00 0.00 .00 1.0
Reactivity to vestibular stimulation 11.70 0.62 11.76 0.60 .17 .15
Total test 46.61 1.98 47.50 1.26 .41 5.5e-4
Note. TFSI: Test of Sensory Functions in Infants.

Table 4. Comparison of pre-intervention and postintervention TSFI scores in the interven-

tion group.

Preintervention Postintervention
Sensory processing functions
subtest scores (TSFI) M SD M SD r p

Reactivity to tactile deep pressure 8.41 1.28 9.70 0.57 .52 1.7e-5
Adaptive motor functions 10.73 2.24 14.26 0.99 .59 9.2e-7
Visual-tactile integration 7.94 1.15 11.23 1.15 .60 4.9e-7
Ocular-motor control 1.29 0.57 1.82 0.38 .48 5.7e-5
Reactivity to vestibular stimulation 8.94 1.93 11.23 1.15 .56 2.9e-6
Total test 37.32 4.84 46.91 2.13 .61 3.5e-7
Note. TFSI: Test of Sensory Functions in Infants.

Table 5. Comparison of changes in TSFI scores from pre- to postintervention.

Control group Intervention group

Sensory processing functions
subtest scores (TSFI) M SD M SD R p

Reactivity to tactile deep pressure 0.08 0.28 1.29 1.05 .62 2.5e-7
Adaptive motor functions 0.58 0.98 3.52 1.92 .72 2.4e-9
Visual-tactile integration 0.14 0.95 1.88 1.06 .81 1.9e-11
Ocular-motor control 0.00 0.00 0.52 0.56 .57 2.4e-6
Reactivity to vestibular stimulation 0.05 0.23 2.29 1.36 .76 2.2e-10
Total test 0.88 1.24 9.58 3.55 .86 1.0e-12
Note. TFSI: Test of Sensory Functions in Infants.
Pekcetin et al. 9

In the literature, there are diering opinions about the optimal duration of
sensory integration intervention programs. It has been suggested in a review that
interventions may vary from 5 to 72 hours in childhood, and the most important
factor in determining the duration of treatment is to assess the response time of
the results (May-Benson & Koomar, 2010). A study evaluating the outcomes of
a two-week sensory integration home program for infants aged 724 months
demonstrated that SPD diculties persisted and further sensory integration
therapy was needed after the home program (Jorge, de Witt, & Franzsen,
2013). In another study investigating the eect of a 10-week sensory integration
intervention program, it was found that preterm infants sensory processing
functions improved and fell into an age-appropriate range after the intervention.
There was a signicant statistical dierence between the posttest results of the
intervention and control groups (p .0013) (Lecuona, 2012). In our study, we
decided on an intervention duration of eight weeks, taking two important fac-
tors into consideration. First, researchers have pointed out that plasticity of the
nervous system is high in infancy (De Graaf-Peters & Hadders-Algra, 2006;
Kolb, Brown, Witt-Lajeunesse, & Gibb, 2001). Second, sensory overstimulation
in infancy may cause SPD (Swanepoel, 2013). If sensory integration intervention
continues for too long, it could become more harmful than benecial. The
results show that individualized sensory integration therapy for eight weeks
was sucient to improve sensory processing functions with no detrimental
eects.
Age, gender, and maternal education status have been identied as factors
impacting SPD in infants (Tirosh, Bendrian, Golan, Tamir, & Dar, 2003). In our
study, these factors were homogenous and being preterm was the sole variable.
There are many studies in the literature documenting higher rates of SPD in
preterm infants compared with term infants (Bart et al., 2011; Case-Smith et al.,
1998; Wiener et al., 1996; Wickremasinghe et al., 2013). The TSFI is deemed
appropriate for evaluating SPD in infants with regulation disorders or develop-
mental delays and preterm infants who have risk factors for SPD (DeGangi &
Greenspan, 1989). The results of the current study support the TSFI an appro-
priate tool for determining infant SPD.
Bart et al. (2011) evaluated late preterm infants at 12 months of age by TSFI
and ITSP tests and compared their results with those of term infants. They
indicated that late preterm infants were hyperresponsive to tactile, vestibular,
and proprioceptive stimuli and had diculties with motor planning skills. The
current study observed similar results in younger infants (seven months cor-
rected age). This result emphasizes two important outcomes. First, premature
infants can show earlier detectable symptoms of SPD. Second, these problems
may continue at older ages unless intervention programs appropriate for SPD
are applied as soon as possible.
A study examining the sensory processing functions of preterm infants using
TSFI demonstrated that preterm infants seven to nine months of age showed
10 Perceptual and Motor Skills 0(0)

hyperresponsivity to proprioceptive and vestibular stimuli but had no problems

in motor planning and visual systems. The authors attributed the results to
socioeconomic status, ethnicity, and maternal education, which are known to
aect sensory processing but were ignored while planning the study (Wiener
et al., 1996). In contrast, the current results showed that preterm infants have
problems with motor planning skills, response to tactile stimulus, and the oculo-
motor system compared with term peers. This result may be explained by the
fact that the study and control groups were comparable in terms of factors which
could aect sensory processing.
Sensory processing issues in infants may be characterized as hyper- or
hyporesponsivity. SPD in preterm infants was evaluated with the ITSP by
Wickremasinghe et al. (2013). They suggested that hearing, touch, and ves-
tibular disorders were more common than oral defensiveness and visual
system disorders. They determined that behaviors such as low registration,
sensory seeking, sensory sensitivity, and sensory avoiding could all be
observed in preterm infants (39% had an atypical response at least one quad-
rant) and the rate of hyporesponsivity to sensory stimuli was 24%. Before this
study, which was published in 2013, SPD in preterm infants was thought to
comprise only hyperresponsivity to sensory stimuli and disorders of sensory
modulation. This research demonstrated that preterm infants can also
show hyporesponsivity to sensory stimuli (Wickremasinghe et al., 2013)
and emphasize the importance of individualization of sensory integration
intervention in infancy.
The literature clearly indicates that intervention for infants with SPD is
helpful. Nieder-Heitmann (2010) implemented the Sensory Developmental
Care Programme to preterm infants in the neonatal intensive care unit,
and the infants sensory processing functions were assessed at corrected
ages of 6, 12, and 18 months. It was found that the infants participating
in the Sensory Developmental Care Programme had less SPD compared with
the control group. Lecuona applied 10 sessions (once a week for 10 weeks)
of sensory integration intervention to 12 preterm infants and obtained a
signicant reduction in SPD compared with preterm controls (Lecuona,
2012). Similar to the above mentioned studies, in the current study,
there was an improvement in preterm infants SPD related to tactile, deep
pressure, vestibular and visual systems, and adaptive motor functions
after sensory integration intervention. On the other hand, at the end of
the eight-week period, there was no signicant increase in term infants
TSFI scores for deep pressure, vestibular, and vision systems compared
with their age-appropriate scores in the rst assessments. We believe the
improvement we observed in the tactile and adaptive motor functions of
term infants without intervention was due to changes that continue through-
out the normal early development period.
Pekcetin et al. 11

Limitations and conclusion

The most important limitation of this study was that the examiner was not
blinded to the groups. However, we created a control group consisting of
term infants to show the dierences of preterm infants sensory functions
from those of term infants, and the control group did not receive any interven-
tion in this study. A better structured evaluation processes to obtain more
objective results should be planned in the further studies.
Therapists who work in early intervention services should assess preterm
infants for SPD and then plan and implement sensory integration intervention
programs individually for each infant diagnosed with SPD.

Declaration of Conflicting Interests

The author(s) declared no potential conicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no nancial support for the research, authorship, and/or publica-
tion of this article.

References
Ayres, A. J., & Robbins, J. (2005). Sensory integration and the child: Understanding hidden
sensory challenges (pp. 2743). Los Angeles, CA: Western Psychological Services.
Bart, O., Shayevits, S., Gabis, L. V., & Morag, I. (2011). Prediction of participation and
sensory modulation of late preterm infants at 12 months: A prospective study.
Research in Developmental Disabilities, 32(6), 27322738.
Blackburn, S. (1998). Environmental impact of the NICU on developmental outcomes.
Journal of Pediatric Nursing, 13(5), 279289.
Case-Smith, J., Butcher, L., & Reed, D. (1998). Parents report of sensory responsiveness
and temperament in preterm infants. American Journal of Occupational Therapy, 52(7),
547555.
Case-Smith, J., Weaver, L. L., & Fristad, M. A. (2015). A systematic review of sensory
processing interventions for children with autism spectrum disorders. Autism, 19,
133148.
De Graaf-Peters, V. B., & Hadders-Algra, M. (2006). Ontogeny of the human central
nervous system: What is happening when? Early Human Development, 82(4), 257266.
DeGangi, G., & Greenspan, S. (1989). Test of sensory functions in infants (TSFI). Los
Angeles, CA: Western Psychological Services.
Eeles, A. L., Spittle, A. J., Anderson, P. J., Brown, N., Lee, K. J., Boyd, R. N., & Doyle,
L. W. (2013). Assessments of sensory processing in infants: A systematic review.
Developmental Medicine & Child Neurology, 55(4), 314326.
Elbasan, B., Kayhan, H., & Duzgun, I. (2012). Sensory integration and activities of daily
living in children with developmental coordination disorder. Italian Journal of
Pediatrics, 38(1), 17.
12 Perceptual and Motor Skills 0(0)

Jirikowic, T. L., Engel, J. M., & Deitz, J. C. (1997). The test of sensory functions in
infants: Testretest reliability for infants with developmental delays. American Journal
of Occupational Therapy, 51(9), 733738.
Jorge, J., de Witt, P. A., & Franzsen, D. (2013). The effect of a two-week sensory diet on
fussy infants with regulatory sensory processing disorder. South African Journal of
Occupational Therapy, 43(3), 2834.
Kayihan, H., & Bumin, G. (2001). Effectiveness of two different sensory-integration pro-
grammes for children with spastic diplegic cerebral palsy. Disability and Rehabilitation,
23(9), 394399.
Kenner, C., & McGrath, J. (Eds.). (2004). Developmental care of newborns & infants:
A guide for health professionals (pp. 157181). St. Louis, MO: Mosby Incorporated.
Kessenich, M. (2003). Developmental outcomes of premature, low birth weight, and
medically fragile infants. Newborn and Infant Nursing Reviews, 3(3), 8087.
Kolb, B., Brown, R., Witt-Lajeunesse, A., & Gibb, R. (2001). Neural compensations after
lesion of the cerebral cortex. Neural Plasticity, 8(12), 116.
Lecuona, E. R. (2012). Sensory integration intervention and the development of the extre-
mely low to very low birth weight premature infant (Masters thesis). University of The
Free State, South Africa. Retrieved from http://hdl.handle.net/11660/1281
May-Benson, T. A., & Koomar, J. A. (2010). Systematic review of the research evidence
examining the effectiveness of interventions using a sensory integrative approach for
children. American Journal of Occupational Therapy, 64(3), 403414.
Mitchell, A. W., Moore, E. M., Roberts, E. J., Hachtel, K. W., & Brown, M. S. (2015).
Sensory processing disorder in children ages birth3 years born prematurely: A sys-
tematic review. American Journal of Occupational Therapy, 69(1), 111.
Nieder-Heitmann, E. (2010). The impact of a sensory developmental care programme for
very low birth weight preterm infants in the neonatal intensive care unit (Doctoral dis-
sertation). University of Stellenbosch, South Africa. Retrieved from http://hdl.handle.
net/10019.1/3180
Parham, L. D., Roley, S. S., May-Benson, T. A., Koomar, J., Brett-Green, B., Burke, J.
P., . . . Schaaf, R. C. (2011). Development of a fidelity measure for research on the
effectiveness of the Ayres Sensory Integration intervention. American Journal of
Occupational Therapy, 65(2), 133142.
Parham, L. D., & Mailloux, Z. (2010). Sensory integration. In J. Case-Smith & J.
C. OBrien (Eds.), Occupational therapy for children (6th ed., pp. 325373).
St. Louis, MO: Elsevier.
Schaaf, R. C., & Anzalone, M. E. (2001). Sensory integration with high risk infants and
young children. In S. S. Roley, E. I. Blanche & R. C. Schaaf (Eds.), Understanding the
nature of sensory integration with diverse populations (pp. 275300). San Antonio, TX:
Therapy Skill Builders.
Swanepoel, E. (2013). The impact of sensory-overstimulation (pp. 18). Johannesburg,
South Africa: Mind Moves Institute.
Tirosh, E., Bendrian, S. B., Golan, G., Tamir, A., & Dar, M. C. (2003). Regulatory
disorders in Israeli infants: Epidemiologic perspective. Journal of Child Neurology,
18(11), 748754.
Uyanik, M., Bumin, G., & Kayihan, H. (2003). Comparison of different therapy
approaches in children with Down syndrome. Pediatrics International, 45(1), 6873.
Pekcetin et al. 13

White-Traut, R. C., Nelson, M. N., Burns, K., & Cunningham, N. (1994). Environmental
influences on the developing premature infant: Theoretical issues and applications to
practice. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 23(5), 393401.
Wickremasinghe, A. C., Rogers, E. E., Johnson, B. C., Shen, A., Barkovich, A. J., &
Marco, E. J. (2013). Children born prematurely have atypical Sensory Profiles. Journal
of Perinatology, 33(8), 631635.
Wiener, A. S., Long, T., DeGangi, G. A., & Battaile, B. (1996). Sensory processing of
infants born prematurely or with regulatory disorders. Physical & Occupational
Therapy in Pediatrics, 16(4), 118.
World Health Organization. (2012). Born too soon: The global action report on preterm
birth (pp. 832). Geneva, Switzerland: World Health Organization.

Author Biographies
Serkan Pekcetin, is an assistant professor in Trakya University Occupational
Therapy Department. He recieved his bachelor of science degree in physiotherapy
at Hacettepe University (2002), his master of science at Pamukkale University (2005)
and his doctor of philosophy at Hacettepe University Occupational Therapy
Department (2015). He worked at Dr. Zekai Tahir Burak Women Health and
Education Hospital between 2005-2016. He has ten years of experience in pediatric
physical therapy. His research interest is early intervention in occupational therapy.

Esra Ak, is a professor in Hacettepe University, Occupational Therapy

Department. She recieved her bachelor of science degree in physiotherapy at
Hacettepe University (1993), her master of science at Hacettepe University
(1995) and her doctor of philosophy at Hacettepe University (2002). She had
associated professor degree in 2004, and professor degree in 2011. Her research
interest is occupational therapy in psychiatry, rehabilitation of people with low
vision and blindness, vocational rehabilitation.

Zeynep Ustunyurt, is an associated professor in Dr. Zekai Tahir Burak Women

Health and Education Hospital. She graduated from medical faculty of Ankara
University (1997), completed her residency at pediatric department of Ankara
University (2002). She completed the developmental pediatrics subspecialty at
pediatric department of Ankara University 2010. Her research interest is pre-
term infants and developmental pediatry.

Hulya Kayhan, is a professor in Hacettepe University Occupational Therapy

Department. She recieved her bachelor of science degree in physiotherapy at
Hacettepe University (1979), her master of science at Hacettepe University
(1982) and her doctor of philosoph at Hacettepe University (1986). She had
associated professor degree in 1991, and professor degree in 1995. Her research
interest is occupational therapy, sensory integration, vocational rehabilitation.