A Review of Sensory Integration Therapy as a
Treatment For Autism
Elizabeth Kraljic
Evelyn Agrusti
Joanne Tasy
Caldwell College Graduate Program In Applied Behavioral Analysis
What Is Sensory Integration?
Founder of Sensory Integration Theory: A. Jean Ayres Ph.D, OTR, FAOTA
Credited with having first identified sensory integrative dysfunction.
Author of three major standardized tests. Occupational therapy’s foremost leader in theory
development
A. Jean Ayres
Other Accomplishments:Educator at University of Southern California 1955-
1984Wrote books, journal articles, and training videosFounder of Sensory Integration International Licensed Psychologist
Credentials BS and MA in Occupational Therapy Ph.D in Educational Psychology Post-Doctoral Traineeship at UCLA Brain Research
Institute
A. Jean Ayres and Theory of Sensory Integration Systematically investigated the brains
processing of sensory informationShe developed a theory to explain the
relationship between the behavior and brain functioning
Sensory Integration: A Neurobiological process that organizes
sensations from one’s own body and environment and makes it possible to use the body effectively within that environment.
What is Sensory Integration
The senses are the primary building blocks of the central nervous systemExternal senses-all five senses Internal senses
Tactile System- sense of touch through skinVesticular System- balance and weightProprioceptive System- sensory data from tendons,
muscles and joints The three systems are interconnected but are also
connected with other systems in the brainCritical for basic survivalAllow us to experience, interpret and respond to different
stimuli in the environment.
…Continued
Sensory impact nourishes the brain Raw material for brain development and learning
Sensory stimulation produces “ brain tone” which is responsible for basic brain waves of the conscious state
They provide the input that stimulates the Reticular Activation System of the brainstem to arousalRegulates alertness, coordination, focus, and the
regulation of input and output
Multi-various sensations Stimulated simultaneously, and must be organized
quickly and accurately
Sensory Integration (S.I.)Provides the foundation for complex learning and
behavior. All skills are complex processes based on a strong
foundation of sensory integration
S.I. is information processing. Praxis and perception are the resulting products.
Theory Of S.I.
Sensory Integration is an automatic process. Natural outcomes include:
Motor planning Adaptive ability to incoming sensations
When S.I. does not efficiently the process is disordered Learning problems Developmental lags Behavioral or emotional issues
…Continued
The young brain is malleable Structure and function become set with age
Formative- allows person- environment interaction to promote and enhance neuro-integrative efficiency
A deficiency in effective interaction at critical periods interferes with optimal brain development and overall brain ability
Early detection and therapeutic interaction can enhance individual opportunity for normal development
Signs of Sensory Integrative DysfunctionSensory Integration focus’s on three basic senses
or systems:
Tactile, Vesticular, and proprioceptive Tactile System- nerves under skin that send information to
brain (light touch, pain, temperature, and pressure) • Important for perceiving environment and for protective reactions
for survival
Dysfunctions:• Withdrawal from touch • Food texture avoidance • Sensitivity to types of clothing • Reaction to washing face or hair
Dysfunctions continued:Avoiding getting hands dirty (glue, sand, mud, paint)Using fingertips rather than full hand Misperception of touch or pain (hypo or hyper
sensitivity)Self imposed isolation, irritability, distractibility and
hyperactivity
Tactile Defensiveness: Is a condition where individuals are extremely sensitive
to light touch.Abnormal signals to the cortex in the brain interfere with
other brain processes.
Sensory Integration DysfunctionVestibular System
Refers to structure within the inner ear called the semi-circular canals. These structures detect movement and the position of the head.
Dysfunction-Hypersensitivity Hypersensitive to vestibular stimulation and have fearful
reactions to ordinary movement. They may have trouble learning to climb or descend stairs or hills. They may be apprehensive walking or crawling on uneven or unstable surfaces.
Dysfunction- Hypo-Reactive Vestibular System:Actively seeks very intense sensory experiences.
Whirling, jumping, spinning
Proprioceptive System:Components of muscles, joints, and tendons that
provide the subconscious awareness of body position. Praxis or motor planning
The ability to plan and execute different motor tasks
DysfunctionClumsiness,tendency to fall, lack of body position in
space, odd body posturing, difficulty manipulating small objects, eating in a sloppy manner, resistance to new motor movement activities
S.I.D. Implications Implications:
Dysfunction in the three previously mentioned systems can be manifested in many ways. Over or under responsiveness to sensory inputDeficiencies in gross and fine motor coordination,
speech/language delays and learning issues Behaviorally, the child is frequently impulsive,
easily distractible, and shows a general lack of planning.
Tendency towards difficulty in adjusting to new situations, easily frustrated, aggressive, or withdrawn
S.I.D. Resulting Problems
Attention and Regulatory:The ability to attend to a task depends on screening out
nonessential sensory information, background noises, or visual information.
Can produce distractibility, hyperactivity, or uninhibited output.
Sensory Defensiveness: Individual has highly aroused nervous system, which
prepares the body for survival. Individual does not recognize input as non threatening
…ContinuedActivity Level:
The child may appear disorganized or lacking purpose in their activity
Does not explore the environment or lacks variety in play activities
May appear clumsy or have poor balance
Behavior:The child exhibit negative behaviors They lack flexibility, may be explosive, or have difficulty
transitioning
Sensory Modulation:The child’s inability to regulate sensory input and maintain
a situation-appropriate state.
Patterns of S.I.D.
Research identified factors that highly correlate with each other, Patterns of sensory integration dysfunction
examples:Visual construction and praxis deficits, and Tactile
discrimination and praxisDevelopmental coordination disorder (fine and gross
motor, balance, and coordination deficits)Developmental regulatory disorder
• Under, over, or fluctuating response to sensations
Evaluating S.I.D.
Assessment-- First step of the treatment process Individualized- Identify the specific learning motor and
behavior difficulty of a child Tests, observations, interviews of neuromotor function
and sensory modulation abilities Standardized Tests: Ayres developed
seventeen standardized tests and many non standardized observations to identify and understand the multiple patterns of S.I.D. Her tests and others are currently used to test for sensory issues.
Evaluation continued
Examples:Sensory Integration and Praxis Tests (SIPT) for
children 4-8 years and 11 months Test for Sensory Integration (TSI) for children
3-5 years of ageBruininks Osteretsky Test for Motor Proficiency
for ages 5-15 years Peeramid ages 6-14
Evaluating S.I.D.
Evaluation and treatment of the basic sensory integrative processes is preformed by trained SI occupational therapists and or physical therapists or speech and language pathologistsGoals
Provide the child with sensory information which helps organize the central nervous system
Assist the child in inhibiting and or modulating sensory input
Assist the child in processing a more organized response to sensory stimuli
Validation of S.I. Treatment
In 2002 occupational therapy experts defined the core principles of sensory integration as used in professional practice such as occupational therapy.
This was done to validate methods reported as sensory integration in research.
These principles are deemed essential to providing sensory integration intervention
Intervention Principles Based on Sensory Integration TheoryQualified professional, occupational
therapist, physical therapist or speech and language pathologist.
Intervention plan is family-centered, based on a complete assessment and interpretation based on the patterns of sensory integrative dysfunction, collaboration with significant people in the individual’s life, adherence to ethical and professional standards of practice.
Safe environment that includes equipment that will provide vestibular, proprioceptive and tactile sensations and opportunities for praxis.
Activities rich in sensation especially those that provide vestibular, tactile and proprioceptive sensations and opportunities for integrating that information with other sensations such as visual and auditory.
Activities that promote regulation of affect and alertness and provide the basis for attending to salient learning opportunities.
Activities that promote optimal postural control in the body, oral-motor, ocular motor areas and bilateral motor control sustaining control while holding against gravity and maintaining control while moving through space.
Activities that promote praxis including organization of activities and self in time and space.
Intervention strategies that provide the “just-right challenge”
Opportunities for the client to make adaptive responses to changing and increasingly complex environmental demands. Highlighted in Ayres Sensory Integration intervention principles is the “Somato-motor adaptive response” which means that the individual is adaptive with the whole body, moving and interacting with people and things in the 3-dimensional space.
Intrinsic motivation and drive to interact through pleasurable activities, in other words, play.
Therapist engenders an atmosphere of trust and respect through contingent interactions with the client. That is the activities are negotiated, not pre-planned, and the therapist is responsive to altering the task, interaction and environment based on the client’s responses.
The activities are their own reward and the therapist ensures the child’s success in whatever activities are attempted by altering them to meet the child’s abilities.
Guidelines for Competency in Application of S.I. TheoryRestricted to professionals qualified
occupational therapists, physical therapists, speech and language pathologists
Competencies developed through post graduate continuing education, mentoring in clinical experience
Advanced training is through the same means Certification in S.I. should include administering
and interpreting the Sensory Integration and Praxis Tests (SIPT) when used in O.T.
Maintaining Competency
Applying clinical application of S.I. for a maximum of two years
Mentorship through supervision and professional guidance by a therapist certified in S.I.
Ongoing study and review of literatureOngoing feedback from professional peers
as a check and balance for best practice.
Maintaining Competency
Essential Knowledge for Occupational Therapist’s using Sensory IntegrationSensory Integration Theory Assessment of Sensory Integration and PraxisInterpretation of Assessment Data for
Intervention Planning Occupational Therapy Intervention using
Sensory Integration Strategies.
Part II:
TREATMENTS
&
SPECIFIC
BEHAVIORS
3 Keys to Treatment
1. Frequency
2. Duration
3. Intensity
Sensory Diet
Is a specifically designed plan of biochemical and neurological input to promote and facilitate function
Biochemical
Consists of two components
1. Sleep
2. Nutrition
Neurological
Consists of 3 things:1. Vestibular
2. Proprioceptive3. Tactile
AuditoryVisual
Vestibular System
The sensory system that responds to changes in head position and to body movement through space.
It coordinates movements of the head, body, and eyes
The receptors are in the inner ear
Vestibular Activities*
Hokey Pokey with “big” movementsHead, Shoulders, Knees and ToesDancing (with head and trunk movement)Sit ‘n’ SpinRollingRocking Chair
Proprioceptive System
Unconscious awareness of sensation coming through the muscles, joints, and tendons that tells you what position you are in
Proprioceptive Activities
Stair climbing and/or slidingPlaying tug of warPulling or PushingBig Ball activitiesBeing squished between pillowsScooter activitiesHitting a punching bag
Tactile System
The sensory system that receives sensations of pressure, vibration, movement, pain, and temperature through connections in the skin
This system helps to tell the difference between threatening and non-threatenting sensations
Tactile Activities
Finger paintingMaking things with foam soapClay/Play-Doh/PuttyWalking on the grass with no shoes“swim” and “dry off” with towelTexture adventure binsLotionsGlue projects
Sensory Seeking Behaviors
Running, Spinning, or other movementsProvides vestibular and proprioceptive stimulation
Treatments to try:Movement games like tag or relay racesBouncing on large therapy ballsRocking chairJumping
More Sensory Seeking Behaviors
Pinching, Squeezing, or Grabbing A students hand may be extremely sensitive compared to other body parts and
sensory input in the palm may help to override the painful response to a light touch
Treatments to try:Deep pressure massagesHand massages or pressing hands togetherWristbands that provide pressureVibration toys
More Sensory Seeking Behaviors
Flapping This movement of the body’s joints and muscles provides proprioceptive
sensation to the muscles and joints in the wrists, arms, and shoulders. (could signal sensory overload)
Treatments to try:Wheelbarrow walksPush-upsJumps with hands being heldFidget toy
More Sensory Seeking Behaviors
Pica (mouthing or eating non-food substances) Provides strong tactile and proprioceptive input for a child who is not
registering the sensation. It could also transmit vibration to the jaw which can stimulate the vestibular system
Treatments to try:Vibrating toys for the mouthCrunchy foods throughout the dayListerine to be swabbed inside the child’s mouth*
*with parental permission
Sensory Avoidant BehaviorsTakes off clothing
Clue to the fact that the clothing’s touch is uncomfortable to the child’s skin
Treatments to try:Calming techniquesSoft fabricsWashing new clothes several times before useAllow child to choose their clothes
More Sensory Avoidant Behaviors
Avoids eye contact Peripheral vision could be less stressful or processing visual and
auditory input could be difficult, looking away allows the child to process the auditory input better
Treatments to try:Look into a mirror and gradually increase to someone’s eyesTeach a child body positions that indicate listening
Using quiet hands
More Sensory Avoidant Behaviors
Avoids handling sensory material This is a common sign of tactile defensiveness because the hands
have a lot of touch receptors. Also, the temperature and wetness affect the child’s tolerance.
Treatments to try:Deep pressure touchingWeighted lap bag or vestMassaging hands before the sensitive material is
handled
Calming Techniques
These are especially helpful for children with sensory defensiveness. They help to relax the nervous system They can reduce exaggerated responses to sensory input
• Techniques:• Help with heavy work• Ripping paper• Joint compression• Lap “snake”• Lavender, vanilla, or banana scents• Reduced noise or light levels• Sucking through a straw• Bear hugs
Organizing Techniques
Can help a child who is either over or under reactive become more focused and attentive
Techniques:Hard candyCatching/throwing heavy ballsPulling apart toys (Legos, etc)Adding rhythm to the activity
Altering Techniques
Help a child who is under reactive to sensory input
Need to be closely monitored
Techniques:Jump up & down (10x)The Airplane Activity (hand out)Fast swingingQuick unpredictable movementsRunning gamesLoud, fast music
Part 3
Evelyn Agrusti
Sensory Integration Therapy and InsuranceMany Insurance companies will not pay for Sensory
Integration Therapy (SIT)Aetna, Empire BC/BS, and Healthlink consider “sensory and
auditory integration therapies experimental and investigational for the management of persons with various communication, behavioral, emotional, and learning disorders and for all other indications. The effectiveness of these therapies is unproven.”
(Aetna, 2007; Empire BC/BS, 2006; Healthlink,2007 )
SIT is Experimental and UnprovenAetna references numerous studies that
support their view on sensory integrationNational Initiative for Autism (UK) (2003)Kaplan et al. (1993)Hoehn and Baumeister (1994)National Academy of Sciences (NAS) (2001)American Association of Pediatrics (2001)Tochel (2003)Vargas and Camilli (1999) Parham et al. (2007) Parr, (2006)
(Aetna, 2007)
Investigational and Not Medically Necessary
Cognitive rehabilitation Elimination diets (e.g., gluten
and milk elimination) Facilitated communication Immune globulin infusion Lovaas therapy (also known as
applied behavior analysis (ABA), intensive behavioral intervention (IBI), discrete trial training, early intensive behavioral intervention (EIBI), or intensive intervention programs)
Music therapy, pet therapy (e.g., Hippotherapy)
Nutritional supplements (e.g., megavitamins)
Secretin infusion Sensory integration
therapy Vision therapy
(Anthem BC/ BS, 2008)
A LOOP HOLE?
Current ICD diagnostic manual and DSM-IV: no recognized procedural codes for Sensory Processing Disorder
(Sensory Integration Dysfunction, Dysfunction of Sensory Integration.) SPD of the Bay Area tells people: “The child must be billed
with a diagnosis other than Sensory Processing Disorder or Autism.” 315.4 coordination disorder 728.9 disorder of muscle ligament/muscle hypotonicity 781.3 motor incoordination 781.92 abnormal posture
(http://www.spdbayarea.org/SPD_diagnosis.htm)
Make Your Own Manual
The Psychodynamic Diagnostic Manual (PDM) (2006)Psychoanalytic groups involved:
American Psychoanalytic Association International Psychoanalytical Association Division of Psychoanalysis (39) of the American Psychological
Association American Academy of Psychoanalysis and Dynamic Psychiatry National Membership Committee on Psychoanalysis in Clinical Social
Work Developmental Disorders include:
SCA321. Regulatory Disorders
IEC200 Series - Regulatory-Sensory Processing Disorders (RSPD)
(http://www.pdm1.org/toc.htm)
Sensory Processing DisorderRecognized in the new Diagnostic Manual for
Infancy and Early Childhood (DMIC) The formal diagnostic category is "Regulatory
Sensory Processing Disorder," (code #200). http://www.spdbayarea.org/SPD_diagnostic_codes.pdf
Published by Interdisciplinary Council on Developmental and Learning Disorders (ICDL) in 2005.
Dr. Stanley I. Greenspan is Chair of ICDL.
(http://www.spdbayarea.org/SPD_diagnosis.htm)
False Claims of Recovery
SPD Bay Area Resource Group: “Hope and Recovery!” “In our international SPD Parent Resource Network,
we believe and have experienced that recovering children from Sensory Processing Disorder is absolutely possible!”
“Parents in our Groups use a variety of occupational, medical, auditory, homeopathic and other alternative therapies that help a child recover from Sensory Processing Disorder.”
(http://www.spdbayarea.org/)
Research on Sensory Integration Theory (SIT)As of 2007, only 3 published studies existed
that used methods consistent with Ayres‘s sensory integration therapy that included people with ASDAyres and Tickle (1980)Linderman and Stewart (1999)Case-Smith and Bryan (1999)
(Watling & Dietz, 2007)
Ayres and Tickle (1980)Purpose: explore variables that predict positive or
negative outcomes after 1-yr of SITParticipants: 10 children (mean age of 7.4 yrs)Participants with ASD who had average or hyper-
responsive reactions to tactile and vestibular sensations showed better outcomes than those with hypo-responsive patternsAfter 11 months of Ayres's sensory integration reported
improvements in interaction, initiation, environmental awareness, and activity selection
(Baranek, 2002; Watling & Dietz, 2007)
Ayres and Tickle (1980)
Researchers suggest that differences in outcomes may be due to specific subject attributes including patterns of sensory processing.
Limitations:Small sample size (10 children)variability of the outcome measures usedlack of control over maturational effectsNo control group (within group design)
(Baranek, 2002)
Linderman and Stewart (1999)
Purpose: Track functional behavioral changes in the home associated with SIT
Participants: 2 children (3 yrs) with PDD (mild autism)
Method: therapy in clinic for 1 hr/wk for 7 to 11 wksResults:
Subject 1 (tactile hypersensitivity) demonstrated gains in all intended outcomes:social interaction, response to movement, approach to new
activities, and response to holding and hugging Subject 2 (hypo-responsive to vestibular and hyper-
responsive to tactile) made gains in activity level and social interaction, but not in functional communication
(Baranek, 2002; Watling & Dietz, 2007)
Linderman and Stewart (1999)
Limitations:No control group (single- subject design)Small sample size (only 2 participants)Confounding variables:
Other possible interventions (e.g. education)Maturation of participantsParent participation in evaluation procedures
(Baranek, 2002)
Case-Smith and Bryan (1999)
Purpose: to examine affect SIT has on play and interaction with others
Participants: 5 preschool boys with ASD Method: 3-week baseline and 10-week Ayres's sensory
integration Results:
3 boys had significant improvements in mastery play 4 boys had less “nonengaged” play 1 boy had improvements with adult interactions None changed in level of peer interactions
(Baranek, 2002; Watling & Dietz, 2007)
)
Case-Smith and Bryan (1999)Limitations:
Results could have been a product of other confounding variables (e.g., maturation, caregiving effects, other interventions)
Sensory processing variables could not be assessed directly, so it is not known if positive results are due to improvements in sensory processing mechanisms
Improvements could also have resulted from other components of intervention(e.g., play coaching, motivational strategies)
Watling & Dietz (2007)Purpose
to examine the effectiveness of Ayres's sensory integration compared to a play scenario for (a) reducing undesirable behaviors and (b) increasing engagement in purposeful activities for young children with ASD.
Method single-subject study ABAB design to compare the immediate effect of SIT and a play
scenario on the undesired behavior and task engagement of 4 children with ASD.
Familiarity phase also included to reduce effect of novelty of dependent variables and therapists
This study had three phases: familiarization, baseline, and treatment. Each phase of the study included three 40-min intervention sessions per week followed by a 10-min tabletop activity segment that served as the data collection period.
Watling & Dietz (2007)
The research questionsDoes participation in Ayres's sensory integration
immediately before tabletop tasks affect the occurrence of undesired behaviors during the tabletop activities
Does participation in Ayres's sensory integration immediately before tabletop tasks affect engagement in tabletop activities?
Tabletop paradigmfrequently encountered by children in education settingProvided standardized environment for data collection
Watling & Dietz (2007)Materials for the treatment phases included items that
commonly are used in Ayres's sensory integration suspended equipment such as swings, trapeze bar, and rope ladder; a small trampoline scooterboard and ramp plastic rings Tunnel balance beam toys with various textures toys that challenge bilateral coordination and manipulation skills
Watling & Dietz (2007)Tabletop activities had to meet 2 criteria
(a) the activity demands matched the cognitive and fine motor skills of the child
(b) the activity had the tendency to elicit focused attention and purposeful engagement.
Examples of activities were puzzles, stickers, figurines, beads and string, and blocks. None of the toys used in the tabletop segments were the same as those used in baseline or treatment sessions for any child.
Watling & Dietz (2007)Undesired behavior was defined as those behaviors that interfere with task engagement and participation in daily activities Identified through caregiver report and observation
by the primary investigator during the familiarity period of the study
For 42% of data collection forms, interobserver agreement for undesired behavior was calculated using the point-by-point method (Kazdin, 1982)
Agreement for undesired behavior ranged from 85% to 100% (mean of 91%)
Watling & Dietz (2007)
Engaged behavior was defined as intentional, persistent, active, and focused interaction with the environment, including people and objects.did not require typical use of the tabletop materials to
capture all interactions that held meaning for each child. Engaged behavior: object was used in a manner that was
clearly playful or imaginative and that appeared to have meaning to the child. For example: when a child used a marker to color on his hand and
directed his gaze toward his coloring, his behavior was coded as engaged.
When a child bit or chewed on a marker while looking across the room, his behavior was coded as not engaged.
Interobserver Agreements for engagement ranged from 81% to 100% (mean of 95%).
Watling & Dietz (2007)
ResultsNo clear patterns of change in undesired behavior or task
management emerged through objective measurement. Subjective data suggested that each child exhibited positive
changes during and after intervention.Conclusion
immediately after intervention, short-term Ayres's sensory integration does not have a substantially different effect than a play scenario on undesired behavior or engagement of young children with ASD.
subjective data suggest that Ayres's sensory integration may produce an effect that is evident during treatment sessions and in home environments.
Research
More studies examining SIT for children with ASD are needed.
Conclusions regarding the effectiveness of the intervention cannot be drawn.
Well-controlled studies with relevant and reliable outcome measures are needed to expand knowledge of the effectiveness of Ayres's sensory integration. (Dawson & Watling, 2000; Goldstein, 2000)
Ayres's sensory integration remains under development and efficacy studies should include "well-controlled single-subject design experiments with a few subjects" (Goldstein, 2000)
Possible Benefit
“Although therapies do not appear to work as intended, there is some evidence that they serve as reinforcement (Mason & Iwata, 1990), and they may have other benefits, such as promoting healthy and physical exercise.”
•(Jacobson, Foxx, and Mulick,2005)
Temple University Study (2007)
Pfieffer & Kinnealey from OT Dept in Temple Uniersity’s College of Health Professions
American Occupational Therapy Association’s 2008 conference Children with ASD who underwent SIT exhibited fewer autistic
mannerisms compared to children who received standard treatments.
71 percent of parents who pursued alternatives to traditional treatment used sensory integration methods
91 percent found these methods helpful.
(http://www.temple.edu/newsroom/2007_2008/04/stories/aota.htm)
Temple University Study (2007)Participants and setting
summer camp near Allentown, Pa., for children with autism. Participants were between the ages of 6 and 12 years old and
diagnosed with autism or PDD-NOS. Method
One group (17) received traditional fine motor therapy and the other group (20) received sensory integration therapy.
Each child received 18 treatment sessions over a period of six weeks. A statistician randomly assigned the participants to groups; this
information was provided to the project coordinator at the site. Primary researchers were blinded to group assignment and served as
evaluators before and after the study. Parents were blinded to the interventions assigned and were not on site.
Temple University Study (2007) Results
Researchers used a series of scales that measure behavior. While both groups showed significant improvements, the children in
the sensory integration group showed more progress in specific areas at the end of the study.
Conclusion Sensory integration intervention group:
reached more goals specified by their parents and therapistsProgressed toward goals in areas of:
• sensory processing/regulation• social-emotional and functional motor tasks.
Temple University Study (2007)
Need for research such as randomized control trials to validate sensory integration
Provided a foundation for designing randomized control trials for sensory integration interventions with larger sample sizes in the future
It identified issues with measurement such as the sensitivity of evaluation tools to measure changes in this population
Develop accurate ways of measuring sensorimotor abilities before and after treatment to evaluate the therapy’s outcome with scientific quantitative data.
Questions?
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