The Efficiency of Sensory Integration Interventions in Preterm Infants

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1 Article The Efficiency of Sensory Integration Interventions in Preterm Infants Perceptual and Motor Skills 0(0) 1 13! The Author(s) 2016 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / pms.sagepub.com Serkan Pekçetin Department of Occupational Therapy, Trakya University, Edirne, Turkey Esra Akı Department of Occupational Therapy, Hacettepe University, Ankara, Turkey Zeynep Üstünyurt Zekai Tahir Burak Education and Research Hospital, Ankara, Turkey Hülya Kayıhan Department of Occupational Therapy, Hacettepe University, Ankara, Turkey Abstract This study aimed to explore the effects of individualized sensory integration interventions 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 sensory 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 Pekçetin, Department of Occupational Therapy, Trakya University, Edirne 02250, Turkey. serkanpekcetin@gmail.com

2 2 Perceptual and Motor Skills 0(0) Introduction Preterm is defined as infants born alive before 37 weeks of gestation. Preterm infants constitute a significant newborn group in Europe and Turkey. According to the World Health Organization (WHO), 5.5% 11.4% of pregnancies in Europe and 11.97% of all pregnancies worldwide result in premature 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 significantly 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 effects may continue throughout life; increased risk of cerebral palsy, learning impairment, and visual disorders can result in impaired neurodevelopmental functioning, and a higher risk of noncommunicable disease affects 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 compared 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 identified with the Test of Sensory Functions in Infants (TSFI), Sensory Rating Scale, and Infant Toddler Sensory Profile (ITSP) test batteries. TSFI is a performancebased 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 Profile questionnaire (Wickremasinghe et al., 2013). In a recent review that examined 45 studies of SPD in preterm infants aged 0 3 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).

3 Pekçetin et al. 3 Sensory integration intervention programs Sensory integration has been defined as a neurological organization process enabling the effective use of one s body through stimulus from his body and the environment (Ayres & Robbins, 2005). Ayres stated that the sensory system develops gradually, and that deficits can occur during this developmental process. 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 functioning efficiently, leading to deficits 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 child s sensory responsivity (Parham & Mailloux, 2010). Based on Ayres s theory, therapists began to use sensory-based intervention techniques. The efficiency of sensory integration interventions has been demonstrated for different diagnostic groups in childhood such as Down s 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 effectiveness 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 effect on sensory processing functions. The aim of the study was to detect SPD in preterm infants with sensory processing risks and determine the effectiveness of an individualized intervention program. Method This study was performed at Dr. Zekai Tahir Burak Women s 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 ( /Number: GO 14/235). Participants Sixty-eight infants were enrolled in this study. Infants who were born at a gestational age above 36 weeks, were seven months of age at assessment, lived with

4 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 physical development were evaluated by a developmental pediatrician. Infants with major congenital anomalies, systemic diseases, neurological problems, physical or mental developmental delays identified in the first 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 five 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 ¼ Adverse, 1 ¼ Mildly Defensive, 2 ¼ Integrated). 2. Adaptive Motor Functions: the ability to motor plan and initiate exploratory movements in handling textured toys (0 ¼ No response, 1 ¼ Disorganized, 2 ¼ Partial, 3 ¼ Organized). 3. Visual-Tactile Integration: toleration of contact with various visually interesting textured toys (0 ¼ Hyperreactive, 1 ¼ Hyporeactive, 2 ¼ Normal). 4. Ocular-Motor Control: lateralization of the eyes and visual tracking (0 ¼ No Response, 1 ¼ Integrated). 5. Reactivity to Vestibular Stimulation: in vertical, circular, and inverted prone and supine body positions (0 ¼ Adverse, 1 ¼ Mildly Defensive, 2 ¼ 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 classified 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 (Cronbach s reliability coefficient was.78) (Jirikowic, Engel, & Deitz, 1997).

5 Pekçetin 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 effectiveness of the interventions. It is important to point out that sensory integration and sensory stimulus are different terms. Schaaf and Anzalone (2001) define sensory integration as child s active participation with a sensory stimulus, while a sensory stimulus was defined as providing sensory stimuli without the child s active participation. However, eliciting active participation can be challenging with young infants. We provided opportunity for active participation by presenting different toys and activities in each session, and activities were chosen according to the infant s sensory responsivity. Each infant s sensory responsivity profile was the primary determiner of his/her interventions and individualized sensory integration interventions 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 m 2 therapy room in the maternity hospital. The therapy room was designed according to Parham s fidelity 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 program. Normality of data was analyzed with the Shapiro Wilk test. Differences between groups were analyzed with chi square test for nominal data and the Mann Whitney U test for ordinal data. Differences between preintervention and postintervention results of groups were analyzed with the Wilcoxon signed-rank test; effect size was calculated as the rank correlation, r. Level of significance 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 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 significant differences 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, g in the intervention group and 3, g in the control group (effect size, rank correlation r ¼.85, p <.001). Preterm infants had lower TSFI total scores before intervention when compared with term peers (r ¼.84, p <.001) (Table 2). Comparison of the results of the first and second assessments in the control group revealed significant differences in TSFI total scores (r ¼.41, p <.001), visual-tactile integration (r ¼ 0.27, p ¼.02), and adaptive motor functions scores (r ¼.36, p ¼.003). The scores for responses to tactile deep pressure (r ¼.20, p ¼.08) and reactivity to vestibular stimuli increased but the difference was not statistically significant (r ¼.17, p ¼.15). The scores for the oculo-motor control subtest did not differ between the first and second assessment (r ¼.00, p ¼ 1.0) (Table 3). The TSFI total score increased significantly between the pre- and postintervention assessments in the intervention group (r ¼.61, p <.001) (Table 4). The changes in the TSFI total score between the first and second evaluations in the intervention and control groups were compared. The intervention group showed a significantly larger improvement in the TSFI total score compared with the control group (r ¼.86, p <.001) (Table 5).

7 Pekçetin et al. 7 Table 1. Demographic characteristics of the groups. Demographic characteristics Control group Intervention group n % n % p Sex.81 Female Male Maternal education status.86 Primary school High school Bachelor s degree Family type 1.0 Nuclear family Extended family Gestational age 8.3e-13 Term Moderate preterm Very preterm Extremely preterm Table 2. Comparison of baseline TSFI scores between groups. Sensory processing functions subtest scores (TSFI) Control group Intervention group M SD M SD r p Reactivity to tactile deep pressure e-6 Adaptive motor functions e-8 Visual-tactile integration e-9 Ocular-motor control e-8 Reactivity to vestibular stimulation e-9 Total test e-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 deficiencies in sensory processing skills and that individualized sensory integration intervention is effective in improving SPD in preterm infants.

8 8 Perceptual and Motor Skills 0(0) Table 3. Comparison of control group TSFI results. Sensory processing functions subtest scores (TSFI) First assessment Second assessment M SD M SD r p Reactivity to tactile deep pressure Adaptive motor functions Visual-tactile integration Ocular-motor control Reactivity to vestibular stimulation Total test e-4 Note. TFSI: Test of Sensory Functions in Infants. Table 4. Comparison of pre-intervention and postintervention TSFI scores in the intervention group. Sensory processing functions subtest scores (TSFI) Preintervention Postintervention M SD M SD r p Reactivity to tactile deep pressure e-5 Adaptive motor functions e-7 Visual-tactile integration e-7 Ocular-motor control e-5 Reactivity to vestibular stimulation e-6 Total test e-7 Note. TFSI: Test of Sensory Functions in Infants. Table 5. Comparison of changes in TSFI scores from pre- to postintervention. Sensory processing functions subtest scores (TSFI) Control group Intervention group M SD M SD R p Reactivity to tactile deep pressure e-7 Adaptive motor functions e-9 Visual-tactile integration e-11 Ocular-motor control e-6 Reactivity to vestibular stimulation e-10 Total test e-12 Note. TFSI: Test of Sensory Functions in Infants.

9 Pekçetin et al. 9 In the literature, there are differing 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 7 24 months demonstrated that SPD difficulties persisted and further sensory integration therapy was needed after the home program (Jorge, de Witt, & Franzsen, 2013). In another study investigating the effect 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 significant statistical difference between the posttest results of the intervention and control groups (p ¼.0013) (Lecuona, 2012). In our study, we decided on an intervention duration of eight weeks, taking two important factors 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 beneficial. The results show that individualized sensory integration therapy for eight weeks was sufficient to improve sensory processing functions with no detrimental effects. Age, gender, and maternal education status have been identified 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 developmental delays and preterm infants who have risk factors for SPD (DeGangi & Greenspan, 1989). The results of the current study support the TSFI an appropriate 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 difficulties with motor planning skills. The current study observed similar results in younger infants (seven months corrected 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 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 affect 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 oculomotor 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 affect 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 vestibular 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 quadrant) 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 significant 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 significant increase in term infants TSFI scores for deep pressure, vestibular, and vision systems compared with their age-appropriate scores in the first 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 throughout the normal early development period.

11 Pekçetin 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 differences of preterm infants sensory functions from those of term infants, and the control group did not receive any intervention 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 conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References Ayres, A. J., & Robbins, J. (2005). Sensory integration and the child: Understanding hidden sensory challenges (pp ). 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), Blackburn, S. (1998). Environmental impact of the NICU on developmental outcomes. Journal of Pediatric Nursing, 13(5), 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), 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, 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), 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), Elbasan, B., Kayıhan, H., & Duzgun, I. (2012). Sensory integration and activities of daily living in children with developmental coordination disorder. Italian Journal of Pediatrics, 38(1), 1 7.

12 12 Perceptual and Motor Skills 0(0) Jirikowic, T. L., Engel, J. M., & Deitz, J. C. (1997). The test of sensory functions in infants: Test retest reliability for infants with developmental delays. American Journal of Occupational Therapy, 51(9), 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), Kayihan, H., & Bumin, G. (2001). Effectiveness of two different sensory-integration programmes for children with spastic diplegic cerebral palsy. Disability and Rehabilitation, 23(9), Kenner, C., & McGrath, J. (Eds.). (2004). Developmental care of newborns & infants: A guide for health professionals (pp ). 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), Kolb, B., Brown, R., Witt-Lajeunesse, A., & Gibb, R. (2001). Neural compensations after lesion of the cerebral cortex. Neural Plasticity, 8(1 2), Lecuona, E. R. (2012). Sensory integration intervention and the development of the extremely low to very low birth weight premature infant (Master s thesis). University of The Free State, South Africa. Retrieved from 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), Mitchell, A. W., Moore, E. M., Roberts, E. J., Hachtel, K. W., & Brown, M. S. (2015). Sensory processing disorder in children ages birth 3 years born prematurely: A systematic review. American Journal of Occupational Therapy, 69(1), 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 dissertation). University of Stellenbosch, South Africa. Retrieved from net/ /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 Õ intervention. American Journal of Occupational Therapy, 65(2), Parham, L. D., & Mailloux, Z. (2010). Sensory integration. In J. Case-Smith & J. C. O Brien (Eds.), Occupational therapy for children (6th ed., pp ). 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 ). San Antonio, TX: Therapy Skill Builders. Swanepoel, E. (2013). The impact of sensory-overstimulation (pp. 1 8). 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), Uyanik, M., Bumin, G., & Kayihan, H. (2003). Comparison of different therapy approaches in children with Down syndrome. Pediatrics International, 45(1),

13 Pekçetin 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), 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), 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), World Health Organization. (2012). Born too soon: The global action report on preterm birth (pp. 8 32). Geneva, Switzerland: World Health Organization. Author Biographies Serkan Pekc etin, 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 He has ten years of experience in pediatric physical therapy. His research interest is early intervention in occupational therapy. Esra Akı, 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 Her research interest is occupational therapy in psychiatry, rehabilitation of people with low vision and blindness, vocational rehabilitation. Zeynep U stünyurt, 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 Her research interest is preterm infants and developmental pediatry. Hu lya Kayıhan, 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 Her research interest is occupational therapy, sensory integration, vocational rehabilitation.