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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References (continued)

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