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Occupational Therapy International, 6(3), 195–206, 1999 © Whurr Publishers Ltd 195

The relationship between sensory

defensiveness, anxiety, depression
and perception of pain in adults

MOYA KINNEALEY Occupational Therapy Department, College of Allied

Heath Professions, Philadelphia, PA 19140, USA
MARGO FUIEK Nova Care, Brookline Village, State College, PA 16801,
USA

ABSTRACT: The impact of sensory defensiveness on performance, behaviour and

adjustment of children has been addressed in the literature, but little has been written
concerning its impact on adults. The purpose of this study was to explore whether
sensory-defensive adults had more symptoms of anxiety, depression and pain than
adults without sensory defensiveness. Participants were 32 volunteers who were
normal functioning adults aged 21 to 48 years, without physical or psychological diag-
noses or history of abuse. They were screened to eliminate persons with undiagnosed
psychological problems using the Forty-eight Item Counseling Evaluation.
Participants were assigned to a sensory-defensive or non-sensory-defensive group
based on their score on the ADULT-SI, a sensory history interview, which assesses
sensory defensiveness in adults. The two groups were matched for age, gender and
race. Participants were then administered the IPAT Anxiety Scale, the IPAT
Depression Scale and the Pain Apperception Test. Differences were found between
sensory-defensive and non-defensive adults in anxiety (p=0.014) and depression
(p=0.019), but not in pain perception. Analysis of the screening scores of the Forty-
eight Item Counseling Evaluation indicated an unexpected difference between groups
in psychological adjustment (p=0.005). This study supports clinical impressions that
sensory-defensive adults differ from non-defensive adults in some psychological para-
meters. A sequela of sensory defensiveness in adults may be a tendency towards
increased symptoms of anxiety and depression. Further, investigation of sensory defen-
siveness and its sequelae in adults is recommended, using larger samples, more
sensitive tools and various diagnostic categories. Exploration of the impact of sensory
defensiveness on adult roles and performance and life satisfaction is also recommended.

Key words: sensory defensiveness, tactile defensiveness, sensory integration,

sensory processing.
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196 Kinnealey and Fuiek

Introduction

Sensory defensiveness is described by Royeen and Lane (1991) as a modula-

tion disorder in the processing of sensory input by the central nervous system,
which is characterized by hypersensitivity, over-orienting and aversion.
Modulation is one of three theorized components of sensory processing
described by Ayres (1972). It includes: (1) registration or paying too little
attention or overreacting to sensory stimuli; (2) modulating the incoming
stimuli; and (3) integration of sensations, which influences the body percept
and is a foundation of motor planning (Ayres, 1979).
Wilbarger and Wilbarger (1991) have estimated that as much as 15% of
the population may experience some level of sensory defensiveness. They
define sensory defensiveness as:

a tendency to react negatively or with alarm to sensory input that is generally consid-
ered harmless or non-irritating. Common symptoms include oversensitivity to touch,
sudden movement, or over reaction to unstable surfaces, high frequency noises, excesses
of noise or visual stimuli and certain smells. (p.3)

Sensory defensiveness and other sensory processing and modulation disor-

ders have been studied in children (Cermak and Daunhauer, 1997; DiGangi
and Brienbauer, 1997; Dunn, 1997) but have not been explored widely in
adults. The effect of sensory defensiveness in adults, as described by Oliver
(1990), may be that a person’s routine decisions may be ‘ruled’ by perceptions
of the sensory experience they will engender, including choice of clothing,
where they go and with whom they relate.
Kinnealey, Oliver and Wilbarger (1995) described the subjective experi-
ence of five sensory-defensive adults. The adults vividly described how sensory
defensiveness affected their roles and occupational performance, as well as
whether or not or how they engaged in daily routines. The adults also
described the emotional and cognitive energy which was required as well as
the time-consuming strategies they employed to cope with the discomfort of
being sensory defensive. Kinnealey et al. (1995) proposed a conceptual frame-
work for studying sensory defensiveness in adults which included
investigating: (1) its causes; (2) the physical, social and emotional sequelae of
defensiveness; and (3) the effectiveness of intervention strategies.
The emotional and behavioural aspects of sensory defensiveness were first
described by Ayres (1961, 1964, 1972, 1979) in their relationship to tactile
defensiveness, which Ayres saw as part of a set of nervous-system responses to
auditory, olfactory and visual stimuli (Ayres, 1972). She described behaviours
of hyperactivity and distractibility in some children and noted that anxiety
surrounded all tactile experiences that were not self-initiated. Ayres suggested
that there was an interaction between anxiety and somatic afferent imbalance
that was self-perpetuating. That is, anxiety may be both a causative and a
resultant factor of the somatic or afferent imbalance which leads to emotional
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The relationship between sensory defensiveness and other factors 197

lability (Ayres, 1961). Ayres (1964) also noted that control and perception of
control influence the response of the defensive person to various stimuli.
Consequently, there is an increased negative response when the stimuli are
unexpected.
The defensive responses described by Ayres in the tactile system (Ayres,
1964, 1972) and the vestibular system (1979) were postulated to occur in all
of the sensory systems (Knickerbocker, 1980; Royeen and Lane, 1991;
Wilbarger and Wilbarger, 1991). Like Ayres, the Wilbargers (1991) described
the behavioural and emotional effects of sensory defensiveness and how
defensive reactions involving primitive survival and arousal mechanisms,
related to the limbic system, have a potentially negative effect on every aspect
of a person’s life. The term ‘sensory affective disorder’ was used by Wilbarger
and Wilbarger (1991) to describe this situation.
Royeen and Lane (1991) further described the relationship between sen-
sory modulation disorders such as sensory defensiveness and the limbic system,
specifying its relationship to hyper-emotionality, exaggerated defence mecha-
nisms, increased levels of activity, sleep disturbance and failure to persist in
new tasks. Anxiety, stress, unfounded apprehension and fear are associated
with the limbic structures and components of the reticular system, hypothal-
amus and cortex, as well as the neurotransmitters that are associated with this
region (Ashton, 1987; Royeen and Lane, 1991).
Anxiety is considered normal when it is in response to a ‘realistic’ threat
and dissipates when the danger is no longer present (Beck and Emery, 1985).
A certain level of anxiety motivates individuals to participate in life and com-
plete tasks. However, anxiety can also be debilitating and paralysing (Beck
and Emery, 1985). Vulnerability is believed to be at the core of anxiety disor-
ders, that is, if a person perceives himself or herself as being subject to dangers
beyond his or her control (Clark et al., 1994).
According to DesLauriers (1995), anxiety disorders are the most common
psychiatric illness in the United States. There is a wide range of symptoms
and severity. In many cases anxiety is not diagnosed, but the individual seeks
treatment for somatic complaints. The cause of anxiety is currently believed
to be a combination of biological vulnerability and psychological stressors
(DesLauriers, 1995). More specifically, Rosenbaum and colleagues (1995) sug-
gest an approach to treating anxiety disorders which considers anxiety as a
consequence of constitutional vulnerability shaped by developmental experi-
ences and activated by environmental experiences.
Generalized anxiety is characterized as free-floating anxiety due to uniden-
tifiable stressors and somatic complaints. There is a 90% comorbidity rate in
people diagnosed with anxiety, with depression being the most common diag-
nosis (American Psychiatric Association, 1994; Kaplan et al., 1994; Hollifield
et al., 1997; Sussman, 1997). Many shared symptoms are found in generalized
anxiety and anxiety depressive disorder, including difficulty concentrating,
sleep disturbance, low energy and irritability. An additional symptom of
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198 Kinnealey and Fuiek

anxiety is being ‘on edge’, compared with hypervigilance in anxiety/depressive

disorder (American Psychiatric Association, 1994; Kaplan et al., 1994).
Depression and anxiety have been linked to somatic complaints and, in a
number of cases, pain has been suggested as a symptom in both (Beutler et al.,
1988; Castrogiovanni et al., 1989).
Sensory defensiveness, anxiety, depression and pain perception share a
number of behavioural and physiological traits. Hypervigilance and increased
levels of arousal, including increased sympathetic nervous system activity, are
signs observed both in individuals experiencing pain (Melzack and Wall,
1973) and in individuals with anxiety disorders (Last and Hersen, 1988).
Also, control or the perception of control is a factor mediating pain (Melzack
and Wall, 1973), anxiety (Kutash, 1980) and depression (Seligman, 1975).
All four conditions are influenced by perception of sensory/somatic stimuli,
result in increased attention to and increased reactivity to sensory/somatic
stimuli, have similar sympathetic nervous system responses to stimuli, and
employ control, control/avoidance and other affective responses. Given that
the literature supports the relationship of these conditions, it could be
deduced that adults who are sensory defensive would also report increased
anxiety, depression and somatic complaints or pain perception. Therefore, the
purpose of this study was to explore possible sequelae of sensory defensiveness
in adults by investigating the relationship between sensory defensiveness and
anxiety, depression and pain perception in adults. To explore the nature of the
phenomenon it was important to control for confounding variables such as
diagnosis or history which might have condition-related symptoms. Therefore,
normal functioning adults were recruited for this study.

Method

Participants

The participants consisted of volunteer adults, recruited through word of mouth

from a variety of work and social contacts of the investigators. No person
approached declined to take part in the study. To rule out variables which might
confound the exploration of sensory defensiveness, participants who reported a
history of physical or sexual abuse, or a diagnosis of psychopathology, were
excluded. One person was excluded because of a mental health diagnosis, one
because of a history of physical abuse, and two as a result of a history of sexual
abuse. Participants were screened, using the Forty-eight Item Counseling
Evaluation (McMahon, 1976), in order to exclude participants with unidenti-
fied psychopathology. No potential participant was excluded from the study
based on the results of this screening, as all met the criterion of no unidentified
psychopathology, that is, scoring 20 or above. All participants reported little or
no familiarity with the concept of sensory defensiveness.
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The relationship between sensory defensiveness and other factors 199

Group assignment was based on two criteria. The first criterion was the
score on the ADULT-SI (Kinnealey et al., 1994). Scores of more than 25 sug-
gest sensory defensiveness and scores of less than 25 suggest mild or no
defensiveness. All participants identified as having sensory defensiveness
scored above 28 and all non-defensive adults scored below 24.
The ADULT-SI, an assessment based on an interview to identify and
describe sensory defensiveness in adults, was in the process of being devel-
oped. Therefore, the second criterion was that scoring to determine sensory
defensive, non-sensory defensive and group assignment was corroborated by a
second rater, who independently listened to and scored the audiotaped inter-
views and recommended group assignment. There was 100% agreement
between raters on which participants had sensory defensiveness and which did
not, as well as on group assignment.
Each group consisted of 16 subjects: 12 female and 4 male; 2 African
American, and 14 Caucasian. Their ages, as shown in Table 1, ranged from
21 to 48 with a mean age of 32.9. The mean age of the sensory-defensive
group was 32.6, +6.7. The mean age of the non-sensory-defensive group was
33, +7.9.

Procedure

TABLE 1: Age of participants

n Mean SD

Total sample 31 32.90 7.23

NSD 16 33.10 7.92
SD 15 32.60 6.67

One participant in the SD group would not report her age.

Fifteen participants who were sensory defensive were recruited through word
of mouth among occupational therapists. The study was approved by the
Institutional Review Board for the use of human subjects of the university. For
the participants’ comfort, the researcher met with them in the setting of their
choice, most often in their homes. Consent to participate in the study and to
audiotape the ADULT-SI for reliability purposes was obtained. Participants
were administered the ADULT-SI to determine if they had sensory defensive-
ness. They were screened using the Forty-eight Item Counseling Evaluation
and asked whether they had a history of physical or sexual abuse or a mental
health diagnosis. If they had a history of abuse, a mental health diagnosis, or
scored more than 20 on the screening, they were excluded from the study.
Fifteen persons were sought. Because one participant refused to give her age, a
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200 Kinnealey and Fuiek

16th person was recruited. The IPAT Anxiety Scale, the IPAT Depression
Scale and the Pain Apperception Test were then completed by the partici-
pants.
Next, a non-sensory-defensive control group was recruited and participated
in the same procedure as the sensory-defensive group. Participants in the con-
trol group continued to be recruited until there was a group which matched
the sample in age, gender and race. A 16th person was recruited who seemed
the same age as the participant who refused to provide her age (otherwise
matched for gender and race) and was included in the control group.

Instrumentation
Since the study was a pilot exploratory study using volunteers, instruments
were sought which were noninvasive, brief, reflected the participants’ perspec-
tive and did not require professional interpretation of scores. Instruments were
required which were standardized, and available through a test
publishing company with manuals reporting reliability, validity and standard-
ization data. There are no published tests for identifying sensory defensiveness
in adults, which is usually accomplished through clinical judgement of an
occupational therapist. Therefore, the pilot edition of the ADULT-SI was
used, supplemented by independent clinical judgement of two occupational
therapists.
In order to exclude participants with psychopathology, the Forty-eight
Item Counseling Evaluation Test (McMahon, 1976) was administered. This
self-administered, true/false questionnaire was designed to increase accuracy
in identifying personal and emotional problems of adolescents and adults. The
Forty-eight Item Counseling Evaluation manual (McMahon, 1976) reports
the following reliability and validity: reliability in three consecutive studies is
reported as 0.80, 0.82 and 0.88. A number of validity studies are reported in
the manual, with agreement of 0.92 between counsellor evaluation and the
results of the Forty-eight Item Counseling Evaluation (McMahon, 1976).
Scores can range from 0 to 48, with higher scores indicating a higher degree
of maladjustment or psychopathology. Scores of more than 20 indicate that
clinical attention is warranted. No participant in this study scored 20 or
above.
The ADULT-SI (Kinnealey et al., 1994) is a tool for identification and
assessment of sensory defensiveness in adults. The determination of sensory
defensiveness has traditionally been accomplished through clinical judge-
ment by the occupational therapist. Although several tools have been, or
are in the process of being, developed for children (Royeen and Fortune,
1990; Dunn and Brown, 1997; Dunn and Westman, 1997), none of these is
designed for adults. A pilot edition of the ADULT-SI was used for this study
and additional reliability and validity studies have been completed since
that time.
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The relationship between sensory defensiveness and other factors 201

The ADULT-SI is an 84-question tool with a semi-structured, open-

ended interview format. The questions are designed to elicit descriptive
responses which are judged by the therapist as defensive (scored as 1) or
non-defensive (scored as 0). Scores can range from 0 to 84. Scores of less
than 25 indicate no or mild defensiveness, whereas scores of more than 25
indicate defensiveness.
Since the ADULT-SI relies on the clinical judgement of the occupational
therapist for scoring, which in turn was the basis for group assignment, a
second independent rater scored the audiotaped interviews of the participants.
There was 100% concurrence between the two raters in identification of sen-
sory defensiveness and on group assignment. Present reliability of the
ADULT-SI reported in the ADULT-SI manual (Kinnealey and Oliver, 1999)
is as follows: co-coding transcripts, 0.90; identification of sensory-
defensive/non-sensory-defensive adults based on interview, 1.00; and clinical
decision summary based on ADULT-SI scores, 0.88.
The presence of anxiety was measured using the IPAT (Institute for
Personality and Ability Testing) Anxiety Scale (Cattell and Scheier, 1976).
This 40-item paper-and-pencil questionnaire has reliability coefficients
ranging from 0.80 to 0.93. Its validity is reported to approach 0.90 (Cattell
and Scheier, 1976). Raw scores range from 0 to 80 and can be transformed
into standard scores. However, the raw scores were used for this study.
The presence of depression was measured using the IPAT Depression Scale
(Krug and Laughlin, 1976), a 40-item paper-and-pencil questionnaire based
on factor-analytic studies of depression. The authors report validity of 0.88
and internal consistency of 0.93. Raw scores can be transformed into standard
scores. For this study, raw scores were used.
The presence of somatic complaints was measured using the Pain
Apperception Test (Petrovich, 1973), a projective instrument which focuses
on the emotional aspects of pain. Participants judged the intensity and dura-
tion of pain felt by individuals depicted in a picture. The authors report a high
degree of face validity. Split-half reliability coefficients for pain duration range
from 0.56 to 0.84 and, for pain intensity, from 0.66 to 0.89, depending on the
population tested.

Results
The Forty-eight Item Counseling Evaluation was originally designed to aid
counsellors from various fields in identifying personal and emotional problems
in adolescents and adults. For the purpose of this study, the Forty-eight Item
Counseling Evaluation was administered to screen out participants who had
clinical disorders. The test is constructed so that a higher numerical score
indicates a higher degree of maladjustment or psychopathology. Scores above
20 indicate that clinical attention is warranted. No participants recruited for
the study scored above 20. Although no research question was advanced
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202 Kinnealey and Fuiek

related to the results of this test, a t-test comparing the mean scores of the two
groups was calculated (see Table 2).

TABLE 2: T-test comparison of scores on the Forty-eight Item Counseling Evaluation

Group n Mean SD t

NSD 16 0.9375 0.929 –3.24

SD 16 4.4375 4.226

p=0.005

As shown in Table 2, a two-tailed t-test indicated that there was a differ-

ence significant at the 0.005 level between the sensory-defensive and
non-sensory-defensive groups, with the sensory-defensive group demon-
strating increased levels of maladjustment.
Question 1. Is there a difference between sensory-defensive (SD) and non-
sensory-defensive (NSD) adults in levels of anxiety as tested by the IPAT
Anxiety Scale? A t-test was calculated on the group mean.
As shown in Table 3, there was a difference in group means on the
IPAT Anxiety Scale at the 0.05 level of significance, indicating that the sen-
sory-defensive group experienced higher levels of anxiety than did the
non-sensory-defensive group.

TABLE 3: T-test comparison of scores on the IPAT Anxiety Scale

Group n Mean SD t

NSD 16 19.1250 9.069 –2.62

SD 16 28.6750 11.809

p=0.014

Question 2. Is there a difference between SD and NSD adults in depression

as tested by the IPAT Depression Scale? A t-test was calculated between
group means. The IPAT Depression Scale was constructed to yield two scores
– one of which was corrected for anxiety. This was the score that was used to
calculate the mean for the purposes of this study.
As shown in Table 4, there was a difference at the 0.05 level of signifi-
cance between the two groups in terms of reported levels of depression, with
the sensory-defensive group exhibiting higher levels of depression.
Question 3. Is there a difference between the SD and NSD groups in per-
ception of pain as tested by the Pain Apperception Test? A t-test was
calculated between the mean group scores. As shown in Table 5, no difference
was found between groups in the perception of pain as tested by the Pain
Apperception Test.
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The relationship between sensory defensiveness and other factors 203

TABLE 4: T-test comparison of scores on the IPAT Depression Scale on sensory-defensive

and non-sensory-defensive adults

Group n Mean SD t

NSD 16 11.6875 4.332 –2.55

SD 16 18.8750 10.417

p=0.019

TABLE 5: T-test comparison of scores on the Pain Apperception Test on sensory-defensive

and non-sensory-defensive adults

Group n Mean SD t

NSD 16 121.75 14.443 –0.36

SD 16 123.75 16.976

p=0.722

Discussion
The findings of increased scores on the tests in symptoms of maladjustment,
anxiety and depression in the sensory-defensive participants support clinical
impressions of this relationship. The mean difference between groups in anx-
iety and depression, while significant at 0.05, could be considered weak and
should be interpreted with caution. Severe sensory defensiveness, according
to Wilbarger and Wilbarger (1991), is usually found in conjunction with
other diagnoses. This study excluded participants with a diagnosis, thereby
possibly excluding participants with severe sensory defensiveness. In spite of
this, a difference was found between the groups in increased symptoms of anx-
iety and depression. If anxiety and depression are associated with sensory
defensiveness, then further study into the nature of the interaction is recom-
mended. Anxiety has long been clinically associated with sensory
defensiveness in children and is supported in this study with adults.
Conversely, sensory defensiveness may be an unrecognized contributing or
confounding factor in some people with anxiety.
The findings of increased symptoms of depression in the sensory-defensive
group also requires exploration into possible deleterious interactions.
Defensive reactions to sensory stimuli frequently result in social and physical
withdrawal, isolation and decreased sensation seeking (Oliver, 1990;
Kinnealey et al., 1995), all of which could conceivably contribute to depres-
sion. Social or physical isolation and reduced sensory stimulation, whether
exacerbated by depression or by sensory defensiveness, may have deleterious
effects on many aspects of functioning. In persons identified with sensory
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204 Kinnealey and Fuiek

defensiveness, possible coexisting depressive symptoms may need to be identi-

fied and addressed.
Although the literature linked sensory defensiveness and pain perception,
results of this study did not support this relationship. Responses were based on
the participants’ projection of perception of pain when viewing pictures.
Some participants verbalized confusion in interpreting the pictures. Although
the participants might recognize their own low pain tolerance, they may
answer questions in a way they believed most people would respond. This
question requires further investigation.
Results of this research support the clinical impressions described by Oliver
(1990), Wilbarger and Wilbarger (1991) and Kinnealey et al. (1995), that
social and emotional problems are found in conjunction with sensory defen-
siveness in adults. Wilbarger and Wilbarger (1991) further theorize that
sensory defensiveness can result in social and emotional issues that can impact
many aspects of a person’s life, resulting in a ‘sensory affective disorder’.
Further research, however, is required to support a causal relationship.
Application of the results of one pilot study to treatment is premature.
However, the identification of the presence of sensory defensiveness in adults
referred for occupational therapy intervention and knowledge of its sequelae
could lead to the choice of more efficient and effective intervention strategies
by occupational therapists. One approach might be the incorporation of a sen-
sory diet into the treatment programmes or lifestyles of the patients
(Wilbarger, 1995).
Limitations of this study include the small size and non-random selection
of voluntary participants. The results, therefore, cannot be generalized. A
second limitation is the instrument used to identify participants with sensory
defensiveness. Traditionally, sensory defensiveness has been determined
through clinical judgement of an occupational therapist, based on behaviour
described or observed. For this study a pilot edition of the ADULT-SI was
used. It is a tool designed to identify and assess sensory defensiveness in adults.
Two raters independently scored the interviews from audiotapes and judged
whether a person was sensory defensive. There was 100% agreement between
raters on whether a person was or was not sensory defensive. Reliability and
validity studies of the tool have since been completed.

Conclusion
In conclusion, sensory-defensive adults with no history of physical or sexual
abuse, or psychological diagnosis, were compared with a matched group of
non-sensory-defensive adults in an exploratory pilot study. The sensory-defen-
sive adults demonstrated increased scores on anxiety, depression and
maladaptation compared with the non-defensive group. They did not differ in
pain perception as tested in this study. The study supports literature which
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The relationship between sensory defensiveness and other factors 205

suggests that there are increased social and emotional issues in persons with
sensory defensiveness. It also supports literature suggesting a relationship
between sensory defensiveness and anxiety. Further research is required to
explore this relationship as well as the nature and implications of the sensory
emotional link in adults. Research is also recommended into the impact of
sensory defensiveness and its sequelae on the performance of life roles, occu-
pational performance and life satisfaction.

References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disor-
ders (4th edn). Washington, DC: American Psychiatric Association.
Ashton J (1987). Brain Disorders and Psychotropic Drugs. New York: Oxford University Press.
Ayres AJ (1961). Development of body scheme in children. American Journal of Occupational
Therapy 15(3): 102–28.
Ayres AJ (1964). Tactile functions: Their relation to hyperactive and perceptual motor behav-
ior. American Journal of Occupational Therapy 18(1): 6–11.
Ayres AJ (1972). Sensory Integration and Learning Disorders. Los Angeles: Western Psycho-
logical Services, pp. 207–17.
Ayres AJ (1979) Sensory Integration and the Child. Los Angeles: Western Psychological Ser-
vices.
Beck AT, Emery G (1985). Anxiety Disorders and Phobia. New York: Basic Books.
Beutler LE, Daldrup R, Engle D, Guest P, Corbishley A, Merideth KE (1988). Family dynamics
and emotional expression among patients with chronic pain and depression. Pain 32:
65–72.
Castrogiovanni P, Maremmani I, Deltito JA (1989). Discordance of self ratings versus observer
ratings in the improvement of depression: Role of locus of control and aggressive behavior.
Comprehensive Psychiatry 30(3): 231–5.
Cattell RB, Scheier IH (1976). IPAT Anxiety Scale. Los Angeles: Western Psychological Ser-
vices.
Cermak SA, Daunhauer LA (1997). Sensory processing in the post institutionalized child.
American Journal of Occupational Therapy 51(7): 500–7.
Clark DA, Beck AT, Beck JS (1994). Symptom differences in major depression, dysthymia,
panic disorder, and generalized anxiety disorder. American Journal of Psychiatry 151:
205–9.
DesLauriers MP (1995). Introduction. Bulletin of the Menninger Clinic 59(2): 1–3.
DiGangi GA, Brienbauer C (1997). The symptomatology of infants and toddlers with regulato-
ry disorders. Journal of Developmental and Learning Disorders 1(1): 183–215.
Dunn W (1997). The impact of sensory processing abilities on the daily lives of young children
and their families: A conceptual model. Infants and Young Children 9(4): 23–35.
Dunn W, Brown C (1997). Factor analysis on the sensory profile from a national sample of
children without disabilities. American Journal of Occupational Therapy 51: 25–34.
Dunn W, Westman K (1997). The sensory profile: The performance of a national sample of
children with and without disabilities. American Journal of Occupational Therapy 52:
283–90.
Hollifield M, Katon W, Skipper B, Chapman T, Ballenger JC, Mannuzza S, Fyer AJ (1997).
Panic disorder and quality of life: Variables predictive of functional impairment. Journal of
Psychiatry 154(6): 766–72.
OTI 6(3) 2nd/JH 15/12/05 2:31 pm Page 206

206 Kinnealey and Fuiek

Kaplan HI, Sadock BJ, Grebb JA (1994). Synopses of Psychiatry (7th edn). Baltimore:
Williams and Wilkins, pp. 516–632.
Kinnealey M, Oliver B, Wilbarger P (1994). ADULT-SI (Adult Defensiveness, Understanding,
Learning, Teaching: Sensory Interview). Pilot edition. Philadelphia: Temple University.
Kinnealey M, Oliver B, Wilbarger P (1995). A phenomenological study of sensory defensive-
ness in adults. American Journal of Occupational Therapy 49(5): 444–51.
Kinnealey M, Oliver B (1999). ADULT-SI (Adult Defensiveness, Understanding, Learning,
Teaching: Sensory Interview) Manual. Unpublished. Philadelphia: Temple University.
Knickerbocker BM (1980). A Holistic Approach to the Treatment of Learning Disabilities.
Thorofare, NJ: Slack, pp. 35–49.
Krug SE, Laughlin JE (1976). IPAT Depression Scale (Personal Assessment Inventory). Los
Angeles: Western Psychological Services.
Kutash IL (1980). Handbook on Stress and Anxiety. San Francisco: Louis B. Schleshinger and
Associates, Jossey-Bass Publishers.
Last CG, Hersen M (1988). Handbook of Anxiety Disorders. New York: Pergamon Press.
McMahon FB (1976). The Forty-eight Item Counseling Evaluation Test: Revised. Los Angeles:
Western Psychological Services.
Melzack R, Wall PD (1973). The Challenge of Pain. New York: Basic Books.
Oliver BF (1990). The social and emotional issues of adults with sensory defensiveness. Ameri-
can Occupational Therapy Association Sensory Integration Special Interest Section
Newsletter 13(3): 1–3.
Petrovich DV (1973). Pain Apperception Test. Los Angeles: Western Psychological Services.
Rosenbaum JF, Pollock RA, Otto MW, Pollack MH (1995). Integrated treatment of panic dis-
order. Bulletin of the Menninger Clinic 59(2): 4–26.
Royeen CB, Fortune JC (1990). TIE: Touch inventory for school aged children. American
Journal of Occupational Therapy 44: 165–70.
Royeen CB, Lane SJ (1991). Tactile processing and sensory defensiveness. In Fisher AG,
Murray EA, Bundy AC (eds) Sensory Integration Theory and Practice. Philadelphia: FA
Davis, pp.108–33.
Seligman MEP (1975). Helplessness: On Depression, Development and Death. San Francisco,
CA: Freeman.
Sussman N (1997). Toward an understanding of the symptomatology and treatment of general-
ized anxiety disorder. Primary Psychiatry 4(6): 68–9.
Wilbarger P (1995). The sensory diet: Activity programs based on sensory processing theory.
American Occupational Therapy Association Sensory Integration Special Interest Section
Newsletter 18(2): 1–4.
Wilbarger P, Wilbarger J (1991). Sensory Defensiveness in Children age 2–12. Santa Barbara,
CA: Avanti Publications.

Address correspondence to Moya Kinnealey, PhD, OTR/L, FAOTA, Assistant Professor, Occu-
pational Therapy Department, College of Allied Health Professions, 3307 N. Broad Street,
Philadelphia, PA 19140, USA. Email: mkinneal@astro.temple.edu