IDENTIFICACIÓN DE LAS MC EN EL MECANISMO DE EBB&SA

A. Jean Ayres was born in 1920 and died in 1988 in California. At the University of Southern California she received bachelor’s and master’s degrees in occupational therapy and a Ph.D. in educational psychology.

She did postdoctoral training in child development and neuroscience.

As a therapist, Ayres worked with children. Her observations of learning-disabled children sparked an interest in exploring perceptual and motor contributions to learning. She devoted her career to developing a theory explaining relationships among neural functioning, sensorimotor behavior, and early academic learning. She identified specific subtypes or patterns of sensorimotor dysfunction and developed specific intervention strategies for them. She was the first to identify and describe sensory integration dysfunction, previously thought to be a broad spectrum of unre-lated and unexplained cognitive and perceptual-motor problems. She developed standardized tests to better understand children’s problems. Ayres developed a rigor-ous research program to validate her tests and to test her theoretical arguments and clinical approaches.

In 1976, she founded the Ayres Clinic, which served as her private practice and as a training context for educating therapists in sensory integration principles and ther-apy. Her theory building and research always aimed to improve direct service. Ayres wrote numerous books and articles addressing her theory and techniques for clinical application. Her most definitive works on sensory integration theory include two books, titledSensory Integration and Learning Disorders (1972) and Sensory Integration and the Child (1979).

In sum, Ayres devoted her career to the development of a specific applied theory. With her focus on the mechanisms underlying function and dysfunction, Ayres influenced development of the field’s second paradigm. Her work exempli-fies how knowledge should be generated for practice. She combined theory, research, and practice, developing tools to apply her theory in practice and conducting research to test the theory and its application. Her development of sensory integration was the first well-developed example of what is termed in this text a conceptual practice model.

The psychodynamic perspective stressed the relationship of unconscious processes to per-formance and the development of this relation-ship in the course of psychosexual maturation

(Azima & Azima, 1959; Fidler & Fidler, 1958;

Fidler & Fidler, 1963). From this point of view adequate performance required a normal process of psychosexual maturation.

A client engages in a tabletop activity designed to provide appropriate exercise for his fingers.

Practicing fine motor skills, a client manipulates zippers, buttons, and ties on a fastener board.

Understanding Impairment Related to the Neuromotor, Musculoskeletal, or Intrapsychic Functions

Therapists became increasingly concerned with understanding the nature of musculoskeletal, neu-rological, and intrapsychic impairments and how they were involved in a given performance prob-lem. For example, therapists sought to understand how deficits in movement capacity were related to disease or trauma that affected muscles and joints.

Therapists analyzed activities to determine the particular movements they required so that they could identify and bridge any gaps between a per-son’s movement capacity and those demands.

From the psychodynamic perspective, dys-functional behavior was seen as a result of inter-nal tension (i.e., anxiety) or of early blocked needs that prevented maturation of the ego (Azima & Azima, 1959; Fidler & Fidler, 1958;

West, 1959). Therapists sought to determine the underlying conflicts or unfulfilled needs that

interfered with functioning because these were the mechanisms to be altered in therapy. Often, the therapists used activities to diagnose the person’s hidden feelings and unconscious motives by interpreting the unconscious meaning of col-ors, themes, and other characteristics of a person’s creations (Llorens & Young, 1960; West, 1959).

Addressing Neuromotor, Musculoskeletal, or Intrapsychic Impairments

In this new paradigm, therapy sought to identify the specific cause or problem underlying the inability to perform and to change and/or com-pensate for it. In cases of neurological disorders, new treatment methods stressed identification of abnormal movement patterns and techniques to inhibit them and facilitate normal movement (Bobath & Bobath, 1964; Rood, 1958; Stock-meyer, 1972). Other approaches used activities and specialized equipment to stimulate the

A client practices use of adaptive equipment designed to enable her to eat independently.

malfunctioning nervous system in order to elicit normal responses (Ayres, 1972, 1974). Thera-pists tried to provide a therapeutic rationale for every activity used in therapy, and the rationale had to be in terms of the impact on underlying mechanisms (i.e., reducing impairments). For example:

Sensory stimulus is developed through adapted cutaneous contact with tools, the beater of the loom, or the handle of a sander.... Gross motor reaching and throw-ing activities stimulate proprioception and kinesthetic awareness.... Use of a skateboard attached to the forearm for directed range of motion activities stimulates upper arm active movements. (Spencer, 1978, p. 355)

Under the new paradigm, therapists also developed new treatment methods for muscu-loskeletal dysfunction, including such things as splinting and positioning limbs for optimal performance and providing exercises to restore

muscle strength. Therapists analyzed activities to determine the movements needed for crafts and other activities. They made or prescribed adap-tive devices to bridge the gap between persons’

limited motion and the tasks they had to perform.

Therapists also taught people compensatory techniques that allowed them to perform in spite of ongoing impairments.

Occupational therapy in psychiatry was predicated on the belief that if a person could learn to satisfy blocked childhood needs, the intrapsychic conflict could be removed, and the person would return to healthy functioning (Fidler, 1969; Llorens & Young, 1960; West, 1959). Thus, it was common to determine the psychosexual stage of development where needs had not been met and to provide activities as occasions for corresponding need fulfillment:

Occupational therapy can offer opportu-nities for the expression and satisfaction of

A client engages in an activity designed to develop perceptual motor skills.

unconscious oral and anal needs in an actual or symbolic way through activities which in-volve sucking, drinking, eating, chewing, blow-ing and those which use excretory substitutes such as smearing or building with clay, paints, or soil. (Fidler, 1958, p. 10)

Overall, psychiatric occupational thera-pists conceptualized treatment as a means to act out or sublimate feelings (Fidler & Fidler, 1963). In another approach, therapists used activities to establish a therapeutic relation-ship that would permit the person to develop healthy means of resolving intrapsychic con-flict and fulfilling needs. As indicated in the following quote, activities themselves were less important than the therapist’s therapeutic use of self:

The effective therapeutic approach in occupational therapy today and in the future is one in which the therapist utilized the tools of his trade as an avenue of introduction.

From then on his personality takes over.

(Conte, 1960, p. 3)

Across the three mechanistic approaches to treatment (intrapsychic, neurological, and kine-siological), therapists attempted to isolate partic-ular effects that the activity was meant to have on the neuromotor, musculoskeletal, or psychody-namic functions. By so doing, they sought to achieve more specificity in the intended effects of therapy.

Values

The values of the new paradigm reflected its focus on scientific precision. Therapists came to emphasize objectivity and exactness in problem identification and measurement. Therapists also changed their value orientation toward the activ-ities in which clients engaged during therapy.

Therapists previously valued occupation as a natural human need that was also therapeutic.

Now, therapists began to focus on the value of

A client practices using an adaptive hand splint and an adapted utensil to eat independently.

activity as a means for strengthening muscles, influencing the nervous system, and expressing unconscious desires.

Summary

By the 1960s occupational therapy’s paradigm had radically changed. This meant that the field had adopted the new focal viewpoint, core constructs, and values that are summarized in Table 4.1. This mechanistic paradigm resulted

in important advances in the field. The new paradigm resulted in a substantially increased technology for remediating impairments. The par-adigm also resulted in a deeper understanding of how bodily structures and processes facilitated or limited performance. The technology for adapting devices and environments to the needs of persons with motor impairment improved. The psycho-dynamic perspective increased understanding of how emotional problems might interfere with competent performance.