Erna Blanche PhD, OTR/L, FAOTA
Director of the Post-Professional Master’s Program and Associate Professor of Clinical Occupational Therapy
Room: CHP 222T
Phone: (323) 442-1857
Erna Imperatore Blanche received her basic training in occupational therapy at the University of Chile (Santiago, Chile) and later earned her Master of Arts degree in Special Education at Columbia University. She received her PhD degree in Occupational Science at the University of Southern California. She is an expert in pediatric occupational therapy and interventions based on occupational science. She has co-authored two books, "Understanding the Nature of Sensory Integration with Diverse Populations" and "Observations Based on Sensory Integration," and one video series, "Combining Neurodevelopmental Treatment and Sensory Integration Principles," on pediatric practice. She has also published numerous articles in English and Spanish on the topics of play, wellness and other issues in clinical practice. Her articles have appeared in the American Journal of Occupational Therapy, Occupational Therapy International, Journal of Occupational Science, and Play and Culture Studies, among others, as well as in pediatric textbooks. Blanche has lectured internationally in more than 20 countries and maintains ties with Therapy West, Inc., a clinic seeing over 400 children per week that was co-founded by her, as well as with the Department of Occupational Therapy at the University of Chile.
Dr. Blanche's research interests are in the areas of play, clinical evaluation of children with developmental disabilities including autism, and the relationship between sensory processing and lifestyle choices.
Doctor of Philosophy (PhD) in Occupational Science
University of Southern California
Master of Arts (MA) in Occupational Therapy
University of Southern California
Master of Arts (MA) in Special Education
Bachelor of Science (BS) in Human Services
Empire State College, State University of New York
Professional Degree in Occupational Therapy
Universidad de Chile (Santiago, Chile)
Blanche, E. J., & Decker, T. (2007). Sensory balance: A quick reference guide for parents and professionals. Lulu Press. Link to full text
The authors provide a simplified version of the theory of Sensory Integration with practical applications for both the lay person and practicing professionals. This book can serve as a quick reference guide for parents of children with sensory processing difficulties and for the general population for recognizing their own and others sensory processing styles throughout the lifespan.
Blanche, E. J. (2004). Sensorische integration: Grundlagen und therapie bei entwicklungsstörungen (German Edition). Berlin, Germany: Springer. Link to full text
Smith-Roley, S., Blanche, E. I., & Schaaf, R. C. (Eds.) (2001). Understanding the nature of sensory integration with diverse populations. San Antonio, TX: Therapy Skill Builders. Link to full text
Leading sensory integration researchers present state-of-the-art research and clinical insights on sensory integration theory and practice. Comprehensive information is presented on the treatment of Sensory Modulation Dysfunction, high-risk infants and young children, visual deficits, cerebral palsy, autism, institutionalized children, and Fragile X Syndrome. Current information on both clinical testing and standardized testing is presented. Learn how the latest neurological research supports and influences SI theory and practice.
Blanche, E. J. (1999). Play and process: The experience of play in the life of the adult. Ann Arbor, MI: University of Michigan.
Blanche, E. J., Botticelli, T. M., & Hallway, M. K. (1995). Combining neuro-developmental treatment and sensory integration principles: An approach to pediatric therapy. Tucson, AZ: Therapy Skill Builders. Link to full text
Blanche, E. J., Mailloux, Z., & Reinoso, G. (2012). Sensory functions — General. In A. Majnemer (Ed.), Measures for children with developmental disabilities: An ICF-CY approach. (b210-b270). London, UK: Mac Keith Press. Link to full text
Blanche, E. J. (2008). Play in children with cerebral palsy: Doing with — not doing to. In L. D. Parham & L. S. Fazio (Eds.), Play in occupational therapy for children (2nd ed.). (pp. 375-393). St. Louis, MO: Mosby Elsevier. Link to full text
Clark, F., Pyatak, E. A., Carlson, M., Blanche, E. I., Vigen, C., Hay, J., Mallinson, T., Blanchard, J., Unger, J. B., Garber, S. L., Diaz, J., Florindez, L. I., Atkins, M., Rubayi, S., & Azen, S. P. (2014). Implementing trials of complex interventions in community settings: The USC-Rancho Los Amigos Pressure Ulcer Prevention Study (PUPS). Clinical Trials, 11, 218-229. doi:10.1177/1740774514521904. Link to full text
BACKGROUND: Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects.
PURPOSE: We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury.
METHODS: Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes.
RESULTS: PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination.
LIMITATIONS: We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings.
CONCLUSIONS: Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.
Pyatak, E. A., Blanche, E. J., Garber, S. L., Diaz, J., Blanchard, J., Florindez, L., & Clark, F. A. (2013). Conducting intervention research among underserved populations: Lessons learned and recommendations for researchers. Archives of Physical Medicine and Rehabilitation, 94, 1190-1198. doi:10.1016/j.apmr.2012.12.009. Link to full text
Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.
Blanche, E. J., Reinoso, G., Chang, M. C., & Bodison, S. (2012). Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities [Brief report]. American Journal of Occupational Therapy, 66, 621-624. doi:10.5014/ajot.2012.004234. Link to full text
OBJECTIVE: Sensory processing difficulties among children with autism spectrum disorders (ASD) have been extensively documented. However, less is known about this population’s ability to process proprioceptive information.
METHOD: We used the Comprehensive Observations of Proprioception (COP; Blanche, Bodison, Chang, & Reinoso, in press) to describe the proprioceptive difficulties experienced by children with ASD. A sample of 32 children with ASD, 26 children with developmental disabilities excluding ASD, and 28 typically developing control children were studied using the COP.
RESULTS: Children with ASD present with proprioceptive processing difficulties that are different from those of children with developmental disabilities and their typically developing counterparts. Specific data, potential clinical applications, and directions for future research are described.
CONCLUSION: Results suggest that the COP has useful clinical research applications. Further assessment of psychometric properties, clinical utility, and meaningful differences among diverse clinical populations are needed.
Chang, M. C., Parham, L. D., Blanche, E. J., Schell, A., Chou, C. P., Dawson, M., & Clark, F. A. (2012). Autonomic and behavioral responses of children with autism to auditory stimuli. American Journal of Occupational Therapy, 66, 567-576. doi:10.5014/ajot.2012.004242. Link to full text
OBJECTIVES: We examined whether children with and without autism spectrum disorder (ASD) differ in autonomic activity at rest and in response to auditory stimuli and whether behavioral problems related to sounds in everyday life are associated with autonomic responses to auditory stimuli.
METHOD: We measured skin conductance (SC) at rest and in response to auditory stimuli as well as behavioral responses using the Sensory Processing Measure (SPM) Home Form. Participants were 25 children with ASD and 25 typically developing (TD) children, aged 5–12 yr.
RESULTS: The ASD group had significantly higher resting SC and stronger SC reactivity to tones than the TD group. Correlations between SC and SPM indicated that more severe auditory behavioral difficulties were associated with higher sympathetic activation at rest and stronger sympathetic reactivity to sound.
CONCLUSION: High sympathetic reactivity to sound may underlie the difficult behavioral responses to sound that children with ASD often demonstrate.
Blanche, E. J., Bodison, S., Chang, M. C., & Reinoso, G. (2012). Development of the Comprehensive Observations of Proprioception (COP): Validity, reliability, and factor analysis. American Journal of Occupational Therapy, 66, 691-698. doi:10.5014/ajot.2012.003608. Link to full text
OBJECTIVE: We developed an observational tool, the Comprehensive Observations of Proprioception (COP), for identifying proprioceptive processing issues in children with developmental disabilities.
METHOD: Development of the COP underwent three phases. First, we developed items representing proprioceptive functions on the basis of an extensive literature review and consultation with occupational therapists. We then established interrater reliability and content, construct, and criterion validity. Finally, we completed a factor analysis of COP ratings of 130 children with known developmental disabilities.
RESULTS: Adequate validity and reliability were established. Factor analysis revealed a four-factor model that explained the underlying structure of the measure as it was hypothesized.
CONCLUSION: The COP is a valid criterion-referenced short observational tool that structures the clinician’s observations by linking a child’s behaviors to areas identified in the literature as relevant to proprioceptive processing. It takes 15 min to administer and can be used in a variety of contexts, such as the home, clinic, and school.
Schaaf, R. C., & Blanche, E. J. (2012). Emerging as leaders in autism research and practice: Using the data-driven intervention process [From the desk of the guest editors]. American Journal of Occupational Therapy, 66, 503-505. doi:10.5014/ajot.2012.006114. Link to full text
Blanche, E. J., Fogelberg, D., Diaz, J., Carlson, M. E., & Clark, F. A. (2011). Manualization of occupational therapy interventions: Illustrations from the Pressure Ulcer Prevention Research Program. American Journal of Occupational Therapy, 65, 711-719. doi:10.5014/ajot.2011.001172. Link to full text
The manualization of a complex occupational therapy intervention is a crucial step in ensuring treatment fidelity for both clinical application and research purposes. Toward the latter end, intervention manuals are essential for ensuring trustworthiness and replicability of randomized controlled trials that aim to provide evidence of the effectiveness of occupational therapy. In this article, we review the literature on the process of intervention manualization. We then illustrate the prescribed steps through our experience in implementing the University of Southern California/Rancho Los Amigos National Rehabilitation Center's collaborative Pressure Ulcer Prevention Project. In this research program, qualitative research provided the initial foundation for manualization of a multifaceted occupational therapy intervention designed to reduce the incidence of medically serious pressure ulcers in adults with spinal cord injury.
Schaaf, R., & Blanche, E. J. (2011). Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior [Letter to the editor]. Journal of Autism and Developmental Disorders, 41, 1436-1438. doi:10.1007/s10803-011-1303-0. Link to full text
Mailloux, Z., Mulligan, S., Smith Roley, S., Blanche, E. J., Cermak, S. A., Coleman, G. G., Bodison, S., & Lane, C. J. (2011). Verification and clarification of patterns of sensory integrative dysfunction. American Journal of Occupational Therapy, 65, 143-151. doi:10.5014/ajot.2011.000752. Link to full text
Building on established relationships between the constructs of sensory integration in typical and special needs populations, in this retrospective study we examined patterns of sensory integrative dysfunction in 273 children ages 4–9 who had received occupational therapy evaluations in two private practice settings. Test results on the Sensory Integration and Praxis Tests, portions of the Sensory Processing Measure representing tactile overresponsiveness, and parent report of attention and activity level were included in the analyses. Exploratory factor analysis identified patterns similar to those found in early studies by Ayres (1965, 1966a, 1966b, 1969, 1972b, 1977, & 1989), namely Visuodyspraxia and Somatodyspraxia, Vestibular and Proprioceptive Bilateral Integration and Sequencing, Tactile and Visual Discrimination, and Tactile Defensiveness and Attention. Findings reinforce associations between constructs of sensory integration and assist with understanding sensory integration disorders that may affect childhood occupation. Limitations include the potential for subjective interpretation in factor analysis and inability to adjust measures available in charts in a retrospective research.
Vaishampayan, A., Clark, F. A., Carlson, M. E., & Blanche, E. J. (2011). Preventing pressure ulcers in people with spinal cord injury: Targeting risky life circumstances through a community-based interventions. Advances in Skin and Wound Care, 24, 275-284. doi:10.1097/01.ASW.0000398663.66530.46. Link to full text
OBJECTIVE: The objectives of the study were to sensitize practitioners working with individuals with spinal cord injury (SCI) to the complex life circumstances that are implicated in the development of pressure ulcers (PrUs) and to document the ways that interventions can be adapted to target individual needs.
METHODS: This study was a content analysis of weekly fidelity/quality control meetings that were undertaken as part of a lifestyle intervention for PrU prevention in community-dwelling adults with SCI.
RESULTS: Four types of lifestyle-relevant challenges to ulcer prevention were identified: risk-elevating life circumstances, communication difficulties, equipment problems, and individual personality issues. Intervention flexibility was achieved by changing the order of treatment modules, altering the intervention content or delivery approach, or going beyond the stipulated content.
CONCLUSION: Attention to recurrent types of individual needs, along with explicit strategies for tailoring interventions published in a manual, has the potential to enhance PrU prevention efforts for adults with SCI.
Jackson, J. M., Carlson, M. E., Rubayi, S., Scott, M. D., Atkins, M. S., Blanche, E. J., Saunders-Newton, C. D., Mielke, S. E., Wolfe, M. K., & Clark, F. A. (2010). Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disability and Rehabilitation, 32, 567-578. doi:10.3109/09638280903183829. Link to full text
PURPOSE: The aim of this article is to identify overarching principles that explain how daily lifestyle considerations affect pressure ulcer development as perceived by adults with spinal cord injury (SCI).
METHOD: Qualitative in-depth interviews over an 18-month period with 20 adults with spinal injury and a history of pressure ulcers were conducted using narrative and thematic analyses.
RESULTS: Eight complexly interrelated daily lifestyle principles that explain pressure ulcer development were identified: perpetual danger; change/disruption of routine; decay of prevention behaviors; lifestyle risk ratio; individualization; simultaneous presence of prevention awareness and motivation; lifestyle trade-off; and access to needed care, services and supports.
CONCLUSIONS: Principles pertaining to the relationship between in-context lifestyle and pressure ulcer risk underscore previous quantitative findings, but also lead to new understandings of how risk unfolds in everyday life situations. Pressure ulcer prevention for community-dwelling adults with SCI can potentially be enhanced by incorporating principles, such as the decay of prevention behaviors or lifestyle trade-off, that highlight special patterns indicative of elevated risk. The identified principles can be used to theoretically drive future research or to guide innovative lifestyle-focused intervention approaches. Public policies that promote short-term preventive interventions at critical junctures throughout a person's life should be considered.
Schaaf, R. C., Benevides, T., Blanche, E. J., Brett-Green, B. A., Burke, J. P., Cohn, E. S., Koomar, J., Lane, S. J., Miller, L. J., May-Benson, T. A., Parham, D., Reynolds, S., & Schoen, S. A. (2010). Parasympathetic functions in children with sensory processing disorder. Frontiers in Integrative Neuroscience, 4(4), doi:10.3389/fnint.2010.00004. Link to full text
The overall goal of this study was to determine if parasympathetic nervous system (PsNS) activity is a significant biomarker of sensory processing difficulties in children. Several studies have demonstrated that PsNS activity is an important regulator of reactivity in children, and thus, it is of interest to study whether PsNS activity is related to sensory reactivity in children who have a type of condition associated with sensory processing disorders termed sensory modulation dysfunction (SMD). If so, this will have important implications for understanding the mechanisms underlying sensory processing problems of children and for developing intervention strategies to address them. The primary aims of this project were: (1) to evaluate PsNS activity in children with SMD compared to typically developing (TYP) children, and (2) to determine if PsNS activity is a significant predictor of sensory behaviors and adaptive functions among children with SMD. We examine PsNS activity during the Sensory Challenge Protocol; which includes baseline, the administration of eight sequential stimuli in five sensory domains, recovery, and also evaluate response to a prolonged auditory stimulus. As a secondary aim we examined whether subgroups of children with specific physiological and behavioral sensory reactivity profiles can be identified. Results indicate that as a total group the children with severe SMD demonstrated a trend for low baseline PsNS activity, compared to TYP children, suggesting this may be a biomarker for SMD. In addition, children with SMD as a total group demonstrated significantly poorer adaptive behavior in the communication and daily living subdomains and in the overall Adaptive Behavior Composite of the Vineland than TYP children. Using latent class analysis, the subjects were grouped by severity and the severe SMD group had significantly lower PsNS activity at baseline, tones and prolonged auditory. These results provide preliminary evidence that children who demonstrate severe SMD may have physiological activity that is different from children without SMD, and that these physiological and behavioral manifestations of SMD may affect a child's ability to engage in everyday social, communication, and daily living skills.
Fogelberg, D., Atkins, M., Blanche, E. J., Carlson, M. E., & Clark, F. A. (2009). Decisions and dilemmas in everyday life: Daily use of wheelchairs by individuals with spinal cord injury and the impact on pressure ulcer risk. Topics in Spinal Cord Injury Rehabilitation, 15(2), 16-32. doi:10.1310/sci1502-16. Link to full text
Individuals with spinal cord injury (SCI) use wheelchairs for mobility and for full participation in their daily activities. The use of wheelchairs, however, can increase the risk of pressure ulcers. This study focused on wheelchair users’ perceptions of the interplay between their wheeled mobility and the development of pressure ulcers by performing a secondary analysis of data gathered during a 2-year ethnographic study of 20 community-dwelling adults with SCI. Data from a subset of these individuals are described; each of these stories contains a pressure ulcer risk episode related to wheeled mobility or cushion use. Identified risk episodes were associated with wheelchair selection, wheelchair adjustment, habituation to new equipment, lifestyle choices, and challenging life contexts. Examples highlighted the crucial relationship between individuals’ minute-to-minute decision-making and pressure ulcer risk.
Koomar, J., Miller, L. J., Schoen, S. A., Brett-Green, B., Schaaf, R. C., Benevides, T., Lane, S. J., Reynolds, S., Parham, D., May-Benson, T. A., Teasdale, A., Mailloux, Z., Smith-Roley, S., Blanche, E. J., & Bodison, S. (2008). Collaborative research programs in sensory integration and processing. Sensory Integration Special Interest Section Quarterly, 31(4), 1-4. Link to full text
Clark, F. A., Sanders, K., Carlson, M. E., Blanche, E. J., & Jackson, J. M. (2007). Synthesis of habit theory. Occupational Therapy Journal of Research, 27(4), S7-S23. Link to full text
During the past century, numerous researchers and theorists have argued that human lives are largely shaped by the nonreflective realm of habit. Beyond this observation, however, scholarly conceptualizations of habit are widely divergent, ranging from neural-level to culturally saturated macro-level constructs. To clarify the multiple ways that habit has been construed and is related to rehabilitation, the authors present a typology of nine categories of habits: habit as tic; habit as neural networks; habit as conditioned responses; habit as addiction; habit as single, everyday activities; habit as routine; habit as custom, ritual, rite, or ceremony; habit as character; and habit as habitus. Although these categories overlap and share common properties, their conceptual features differ along several dimensions. Each category offers a distinct perspective from which to understand the role of habit in the lives of clients undergoing rehabilitation, which the authors illustrate using examples from the Pressure Ulcer Prevention Study (PUPS), a qualitative study on the contextual factors that lead to serious recurrent pressure ulcers in people with spinal cord injuries. The authors argue that habit is a ubiquitous, protean force that presents itself in many interlinking forms, steering the course of human lives in both health-promoting and destructive directions. To have the greatest effect on health and participation, rehabilitation professionals must examine the nuanced ways that habit may operate both in the lives of clients and in professional practice.
Blanche, E. J. (2007). The expression of creativity through occupation. Journal of Occupational Science, 14, 21–29. doi:10.1080/14427591.2007.9686580. Link to full text
Creativity is widely recognized as a powerful and enriching element of people’s lives. However, the actual experience of creativity is seldom described in occupational science or occupational therapy literature. This research paper focuses on the presence of creativity as a process-oriented, intrinsically motivated activity in the lives of 22 individuals. The study included three methods of data collection: Daily Occupational Experience Survey (DOES), intensive interviews, and participant observations. The participants in this study described the experience of creativity as occurring often during their daily occupations, not only during the performance of primary and secondary or enfolded occupations but also while engaging in extraordinary occupations, when the experience of creating was identified a spiritual or transcendental experience. The three themes that emerged from the data are creativity as a process-oriented experience occurring during the performance of daily occupations, the experience of creativity occurring during primary and secondary occupations, and the manifestation of creativity as a transcendental process. This last type of creative expression often served the purpose of selfactualization.
Blanche, E. J., & Henny-Kohler, E. (2000). Philosophy, science and ideology: A proposed relationship for occupational science and occupational therapy. Occupational Therapy International, 7, 99–110. doi:10.1002/oti.110. Link to full text
This paper explores the interaction between the philosophy of occupational therapy, the science of occupation and the regional ideology of a specific geographical area, and proposes two models to depict the relationship. One model focuses on the interaction between daily occupational therapy practice in a specific geographical region and the international influences on that practice. The international influences include the effect of occupational science. The second model focuses on the relationship between the philosophy of occupational therapy, occupational science and regional ideology. It concludes by showing the importance of developing a global identity through the importation of knowledge from evolving sciences in industrialized countries at the same time as basic and applied knowledge is developed in the scientific community of a geographic region.
Blanche, E. J. (1996). Alma: Coping with culture, poverty, and disability. American Journal of Occupational Therapy, 50, 265–276. doi:10.5014/ajot.50.4.265. Link to full text
This article raises questions about the ways culture affects the nature of health care services. By examining the life story of Alma, a Central American woman who has a daughter with disabilities; her interactions with health care providers; and my own assumptions about cultural differences, I note the impact of cultural differences on coping and adaptation in Alma and in the health care system when working with poor, non-English-speaking clients.