Effectiveness of Sensory Integration Therapy in Elementary-Aged Children

Matt Bogen, Katie Dunbar, Alex Hofstetter, Laren Lenth

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Introduction

Autism Spectrum Disorder (ASD) is a developmental disorder that impairs one’s ability

to communicate and interact with others. About 1 in every 68 children is diagnosed with ASD

(Baum, Stevenson, & Wallace, 2015). In the United States alone, there are about 700,000

children diagnosed with some form of ASD (Pfeiffer et. al, 2011). ASD is a life-long disorder

with varying degrees of impairment present (Mastrangelo, 2009). While there is increasing

awareness of ASD among the general public, its characteristics are not fully understood. General

understanding of ASD suggests difficulty with communication and motor control; further, there

are undesired behaviors (UB) prevalent in children with ASD (Pfeiffer et. al,

2011). Unfortunately, these behaviors are under-reported. Baum et. al (2015) stated that sensory

functions are more difficult to assess than social and verbal functions.

When it comes to alleviation of UB in those with ASD, there are many options available

(Baum et. al, 2015). There are both psychopharmacological and non-psychopharmacological

treatment options for anxiety within ASD (Vasa et. al, 2014). Play therapy is another commonly

used therapy whose aim is to decrease communication deficits and improve behaviors in

individuals with ASD (Mastrangelo, 2009). One relatively new modality that addresses UB in

children with ASD is Sensory Integration (SI). Researchers have noted positive changes in

behavior among individuals exposed to SI techniques (Pfeiffer, Koenig, Kinnealey, Sheppard, &

Henderson, 2011).

The UB prevalent in ASD are wide in scope; they include but are not limited to repetitive

actions, rocking, mood disturbances, and attention deficits (Pfeiffer et. al, 2011). SI therapy

targets sensory deficits and overloads common in individuals with ASD by providing specific

stimuli that mimics natural responses in individuals without ASD (Pfeiffer et. al, 2011; Zimmer
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et. al, 2012). SI therapy is an individualized modality that is targeted to address specific sensory

deficits through tactile, vestibular, and proprioceptive input (Case-Smith & Bryan, 1999; Watling

& Dietz, 2007). An especially notable aspect of high-end ASD is self-injurious behavior (SIB),

and SI specialists aim to normalize detrimental behaviors through targeted stimulation (Pfeiffer

et. al, 2011). Children with ASD are treated for self-inflicted injury almost 8 times more

frequently than children without ASD (McDermott et. al, 2008). As stated by Pfeiffer et. al

(2011), SI is used to assist individuals in the development of acquired motor responses specific

to the particular needs of individuals on the autism spectrum. A few common techniques used in

SI therapy are weighted vests, deep pressure therapy, and manual brushing (Bjornsdotter et. al,

2014; Doughty & Doughty, 2008). It is of interest to the scientific community to determine if

these various techniques are effective in the treatment of UB in children with ASD. Research on

SI is limited, and many occupational therapists (OT) report a SI-focused mindset without

research knowledge necessary to provide adequate treatment (Doughty & Doughty,

2008). Further research is necessary in order to validate the effectiveness of SI

therapy. However, existing studies show promising data with regard to certain SI techniques,

and it is thus important to consider SI therapy as a potential behavior intervention strategy for

children with ASD.

Further research on the effectiveness of SI therapy would assist practitioners in making

informed decisions about treatment prescriptions, as much of the current literature is

inconclusive on the effects of SI therapy. The purpose of this study is to examine the effects of

SI on the reduction of UB in children with ASD. We hypothesize that SI therapy will effectively

reduce the prevalence of UB in children with ASD.

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Methods

Twenty children (10 male, 10 female) aged 4-8 years old and diagnosed with ASD will

be recruited to participate in this study. Children will be identified after a pamphlet is sent to

local schools inviting parents to reach out for more information regarding a study with ASD.

Parents will contact the research team and will be briefed on study details, as well as answer

screening questions. Parents will be informed of their right to withdraw at any point throughout

the study, and no contact with the child will be made until informed consent is signed. At an

initial visit between the researcher and the parent(s), informed consent will be signed, and a

questionnaire regarding the child’s behavior at home will be completed. At this time a

questionnaire will also be sent to the child’s school instructor regarding behavior in a school

setting. At the conclusion of the meeting, a baseline visit for the child as well as SI sessions will

be scheduled. Children will be excluded if they have received any previous therapy for ASD.

Measures

A ten question survey will be given to both parents and the primary teacher for

participants regarding their behaviors in their particular environments. Questions will be

designed to provide feedback on frequency and severity of UB. The SI therapy sessions will be

used in the reduction of UB. The therapy sessions will focus on social interaction, learning, and

engagement. Literature was reviewed to operationally define these variables and was created to

be specific towards our study.

Social interaction. Social interaction is defined as the communication between two or

more people. For example, this may include behavior when sharing with others; did the

participant approach others to share/communicate or did someone approach them? Specific

attention would be applied towards social cues and behaviors exerted during this interaction.
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Learning. Learning would be defined as quantifiable performance improvements made

between therapy sessions from start to finish. Not only would improvements need to be made

among the study sessions, but also in their respective environments (i.e. home, school).

Engagement. Engagement is defined as focused, intentional, and persistent interaction

with the environment, both people and objects (Watling & Dietz, 2007). Not only do we want

these individuals to be interacting with their environment, but we want them to be engaged. For

example, if a participant was instructed to complete a drawing activity and during the period of

the activity exhibited a behavior in which they would chew on the marker and gaze across the

room, it would be noted as “not engaged.” Engaged would include drawing with focused

attention on the drawing activity.

Undesired behaviors (UB). UB are those that would interfere with specific task

engagement and participation in daily activities (Watling & Dietz, 2007). UB are different for

each individual with ASD and can range from minor to severe. Example behaviors may include

but are not limited to: repetitive movements, obsessive organization, eye squinting, tapping of

hands or feet, scratching at self, and putting objects in mouth.

Procedures

All meetings and sessions will be conducted at a specialized ASD therapy location. The

baseline and final measurements will be conducted by an OT specialized in evaluating ASD. All

SI sessions will be conducted by a different OT with a background in SI therapy. At the baseline

visit the child will be observed during casual play, and evaluated for levels of engagement and

willingness to share/co-play. Behaviors and interactions will be rated on a scale of 1-5 to

determine how often and how intensely they occur. Notes and evaluations will be kept in the

child’s file until the final visit, where they will be repeated. At the SI session, children will be
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verbally encouraged by the OT to participate in various activities involving touch sensation.

Examples of this will include sand box play and water table activities. A calm, relaxing

environment will be provided by dimmed lights and soothing auditory input. If the child strays

from activity they will be allowed to sit in comfortable chairs, and engage in a calming activity.

They will then be encouraged to return to the previous activity. These 30 minute sessions will be

conducted three times a week for six weeks.

The surveys will be completed by teachers and parents before the intervention begins, as

well as one week after its conclusion. These surveys will provide data on frequency and intensity

of UB in home and school settings. The OT will repeat the same methods used at the baseline

visit to evaluate engagement and sharing during play.

Analysis

Age, sex, and level of difficulty in performing tasks before and after 6 weeks of

intervention will be reported. Age is a determining factor in expected ability to perform tasks,

and sex will be equally split in order to reflect normal population distribution. Task performance

will assess effectiveness of SI therapy.

 Due to the survey-based nature of this study, statistical tests will be limited to T-tests

with pre and post scores (on a weighted scale).

 Since T-tests will be utilized, the alpha value is <0.05 for statistical significance.

 A paired samples T-test will be used because of pre and post test groups.

 Independent Variable: SI intervention therapy

 Dependent Variable: Pre and post SI therapy intervention behavior scores

 SPSS will be utilized

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 If statistical significance (p-value <0.05) is confirmed, SI therapy will be considered

effective for this study.

 Post hoc tests are not needed because t-tests show clear direction.

Strengths and Limitations of Study

Given the lack of research in this area of study, it is our hope to continue the conversation

to help promote additional research of SI for individuals with ASD. Ideally, we will be able to

contribute to the development of a comprehensive and effective treatment program for children

with ASD. The lack of research in this area makes our study particularly significant. However,

the lack of research is also a limitation for our study. Since there isn’t a lot of research available

related to our topic it can be difficult to find information and previous research relevant to our

study. This can make it difficult to not only design our study but also find supporting research

specific to our focus area.

Another possible limitation is a lack of participants. Though our goal is 20 participants,

we could run into the problem of not gaining enough participants. Since we are reaching out to

parents of children with ASD, the parents may be reluctant to have their child participate in our

study. Ultimately, we want to have as many participants as possible given the many differences

in ASD symptoms. We also must consider adherence to our study. Given that each child

experiences ASD in different ways, we must also assume participants will respond to this

therapy in many different ways. We also must consider that parents may pull their children out of

the study before it is completed.

One last limitation is the brevity of the study. Although we are confident in being able to

examine whether or not SI is effective in reducing the prevalence of negative symptoms

associated with ASD, we will be unable to see whether or not these improvements are sustained
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long term. We would hope to be able to reach out to participating families and check in on the

child each year after the study. Whether or not they continued with SI therapy, it would help to

understand if there have been any long-term outcomes. Once SI becomes a more normal

treatment for ASD, it will become much easier to examine comprehensive long-term results of a

sustained participation in SI.

Background

SI is a therapy utilized by OTs looking to treat sensory disorders involving learning

impairments and physical disabilities. Many of the methods within the scope of SI have not been

extensively studied by researchers but have shown promising results in clinical applications

(Sandler, 2007). This lack of adequate research is problematic in terms of treatment funding, as

insurance companies are hesitant in supporting unverified treatments. Thus, many families are

denied treatment options that could improve activities of daily living in children who receive

early intervention. In order to grant more families access to treatment, more research must be

done to demonstrate the benefits of SI therapy in children with ASD.

SI was originally developed by A. Jean Ayres, who wanted to focus on neurological

information processing (Pfeiffer et. al, 2011). Ayres completed her study by observing the

processes of receiving, modulating, and integrating sensory input and the resulting output which

is now referred to as adaptive behavior. The goal of SI is to improve the process of receiving

and integrating sensory information while providing the means for independence and

autonomy. This independence will allow individuals to improve social skills, better interact with

others, and improve attention and quality of play. Through these characteristics defined by

Ayres, it is clear that her methods were developed to target the needs of individuals with learning

disabilities. However, SI is now applied to a variety of disorders such as: ASD, Fragile X
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Syndrome, ADHD, and Sensory Integration Disorder, with ASD being the most common

(Schaaf & Miller, 2005). The objective of SI is to enhance the brain’s capacity to perceive,

remember, and plan motor activities. Thus, observation during play activities is a key

component of developing a challenging yet integrative program that targets the UB of children

with ASD.

Watling and Dietz (2007) compared the effects of SI versus play therapy on the UB noted

within ASD. The goal of SI is to enhance the processing of senses to provide the means for

appropriate execution of behaviors through enhanced sensory experiences. Vestibular,

proprioceptive, and tactile sensations were targeted in 4 boys with ASD between the ages of 0

months to 3 years old. 10 developmentally-appropriate activities were provided for each child,

and the frequency of UB and engagement were observed. Engagement referred to interaction

with the activity and environment that was persistent, active, and focused. Interactions were

video-taped at 10 minute intervals, and results showed similar UB in the SI and play therapy

groups immediately after intervention. Though short-term improvements were not observed,

parents noted long-term changes in their children’s behavior. Thus, SI may have an effect on

long-term behavior.

ASD affects communication with peers and adults, and SI may improve communication

deficits in some individuals (Case-Smith & Bryan, 1999). Case-Smith and Bryan (1999)

outlined 3 key elements to the SI approach: 1. helping parents understand their child’s behavior

and fostering nurturing relationships, 2. helping parents and teachers modify the environment to

meet the child’s specific sensory needs, and 3. helping children organize responses to sensory

input. 5 boys aged 4 or 5 years were evaluated with SI OT sessions performed 3 times per week

for 10 weeks. A general increase in mastery play (utilizing slides, beanbag chairs, rocking
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equipment, and a sand and water table) and interaction with peers and instructors was noted,

along with a general decrease in non-engaged behaviors.

The SIB of 138,111 research participants were evaluated by researchers in pursuit of

understanding the variance in SIB among individuals with as opposed to without ASD

(McDermott, Zhou, & Mann, 2008). 92,000 participants did not have ASD, and the remaining

46,111 participants had ASD or another related disorder. Children with ASD showed higher

prevalence of TBIs, head, face, and neck injuries, upper body injuries, fractures, open wounds,

contusions, and burns. Self-inflicted injuries send many children with ASD to hospitals and

emergency rooms every year, so practitioners are concerned with prevention of SIB. While the

sample size for this study was large, a significant limitation is that SIB not warranting

hospitalization were disregarded in analysis. The above study serves only as a starting point in

prevention of avoidable injuries in children with severe ASD, and SI therapy is a possible

management strategy for such prevention.

As SI is under-researched, there is an abundance of single participant and case study

designs on the subject matter. While these in-depth case studies are helpful to practicing

therapists looking to apply SI treatment, they do not hold statistical significance. Thus, larger

studies are needed in order to determine the power of the interventions and the implementation

of the best method of practice. The biggest limitation in previous studies involving SI is the

failure to link changes link changes in behavior to the changes in dysfunction within the

individual (Pfeiffer et. al, 2011). Displays of dysfunction vary in individuals with similar

disorders; this is one of the reasons conducting larger studies is difficult. The variability in

symptoms of similar disorders translates to unpredictable responses to the most effective method

of intervention. In general, the symptoms of sensory processing disorders have much overlap
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with other disorders, which correlates with difficulty in pinpointing a single treatment that will

be beneficial to a large group of people (Ahn et. al, 2004).

A larger study by Pfeiffer et. al (2011) included 37 participants ranging in age from 6-12

years with 32 male and 5 female participants. All participants were clinically diagnosed with

ASD or Pervasive Developmental Disorder (PDD), which is often referred to as a milder form of

Autism. Participants were randomly selected to receive either SI or fine motor

interventions. These participants received 18 45-minute sessions of various treatments for 6

weeks. SI treatment focused on presenting sensory opportunities while guiding self-regulation of

behavior while fine motor intervention focused on constructional tasks, drawing and writing

improvements, and crafts. The goal of this study was to focus on areas of sensory processing

and regulation, functional fine motor skills, and social-emotional skills. No statistically

significant results were found in pursuit of advancing the field; however, the study provided

evidence toward the effectiveness of SI in individual study participants. The SI group

demonstrated more improvement than the fine motor intervention group did over the 6 week

period. Another important finding within this study was that goal-attainment setting (GAS) was

found to be most effective in the recording process. This information may be helpful to

therapists who observe progress in patients throughout treatment. This may also serve as a tool

for future research.

One of the most common uses of SI is to reduce or eliminate SIB in individuals with

sensory processing disorders. It is believed that SIB is a result of over or under-stimulation, and

those who exhibit this behavior use self-harm to compensate for dysfunction in sensory

processing. One study evaluated the use of a weighted vest in reducing the frequency of

SIB. This particular study involved a 14-year-old male with a diagnosis of ASD and a history of
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SIB (Doughty & Doughty, 2008). SIB is concerning because it causes many injuries that result

in tissue damage such as brain swelling or bleeding. The aim of weighted vest application is to

stimulate relaxation and a reduced frequency of SIB. In this particular case study, the participant

did not experience improvements in SIB frequency as a direct result of SI

intervention. However, the weighted vest was considered a highly-preferred item, so its benefits

are difficult to assess. As aforementioned, individuals diagnosed with ASD vary greatly in their

response to SI treatment, so a single case study may not reflect the general population of children

with ASD. Because minimal research has been conducted regarding the use of weighted vests,

there are no established guidelines related to optimal weight. The study by Doughty and

Doughty (2008) applied a vest that was 5% of the participant’s body weight; behaviors were

observed before, during, and after wearing the vest. Though SIB was not reduced with weighted

vest application, results were more promising when the individual was observed without direct

contact with researchers.

A side effect of ASD is sensory processing disorder (SPD), which is prevalent in 50% of

children with ASD (Pfeiffer et. al, 2011). Children with SPD fail to interpret and react to

incoming sensory inputs. Pfeiffer et. al (2011) evaluated 37 children (32 males and 5 females)

ages 6-12 with ASD over the course of 6 weeks. Participants received either SI or fine motor

treatments, which include writing, drawing, and construction exercises. Children in the SI group

were found to have significantly less ASD-related mannerisms and greater motor skills than

those in the fine motor intervention group. Significant limitations included convenience

sampling and intense intervention over a short period of time as opposed to moderate

intervention over time. Long-terms effects of treatment were not able to be adequately

monitored.
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Another commonly-used method of SI involves tactile and vestibular stimulation. Tactile

stimulation can be defined as a range of varying stimulations through the sense of

touch. Vestibular stimulation can be defined as the sensation the body perceives when

experiencing movement (Kranowitz, 1998). This particular study focused on the use of vibration

and tactile massage via rotation of the participant in a hammock. The participant was a 9-year-

old boy with a history of SIB. Researchers wanted to see if this method of sensory stimulation

would be most effective compared to other methods of SI. The participant laid in a hammock in

a dark room, was given a 5 minute massage, and proceeded to use a vibrating mattress for 5

minutes. Lastly, researches gently swung the hammock for 1 minute. During the stimulation

sessions, a 50% drop in SIB levels was observed. After the stimulation session concluded, lower

SIB levels were maintained (Sandler & McLain, 2007). This study may prove useful to

therapists wishing to apply sensory stimulation treatments to patients with ASD. However, the

small sample size again has no relevance in terms of application to the general population.

In alignment with sensory stimulation procedures, Bjornsdotter et. al (2014) utilized

fMRI brain scans to assess brain function during SI manual brush stroking. 41 research

participants with ASD ranging in age from 5.6-35 years were expected to experience whole brain

activation. Age and gender affected touch perception and brain activity, but individuals with

ASD had little to no difference in brain activity as compared to individuals without

ASD. Sensory-discriminative and affective-motivational processing was more developed in

adults than children, so early intervention is a key component of SI treatment. Failure to develop

brain regions normally increases the prevalence of ASD, so targeted, manual intervention is key

to elimination of undesired mannerisms. The somatosensory cortex is activated through touch

perception, and individuals with ASD typically experience impaired maturation of neural touch
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pathways, which leads to abnormal perception and/or sensitivity to touch. SI therapy aims to

artificially stimulate soothing touch in a way that aids in the development of acquired,

normalized response to stimulation. Tactile processing research is of fundamental importance to

understanding the effect of SI therapy on reduction of UB in individuals with ASD.

Though there are concerns with the validity of the SI approach to therapy, benefits have

also been observed in some scenarios. Many case studies have reported benefits associated with

therapeutic methods in individual patients. Current treatment options for individuals with ASD

are often limited to psychopharmacological prescriptions, and long-term improvements in

anxiety levels have not been noted with this method of intervention (Vasa et. al, 2014). Thus, SI

is a hopeful alternative to psychopharmacological treatments. Due to the fact that SI treatments

don’t target a specific symptom, more research is needed in order to discover a root cause that

can be targeted with a specific treatment. The current lack of distinction between sensory

processing issues and related disorders is a key problem that needs to be addressed (Zimmer &

Desch, 2012). SI intervention targets visual processing, auditory processing, and other such

receptive sensory processing (Baum, Stevenson, & Wallace, 2015). The ultimate goal of SI is to

permanently-reduced UB in individuals with ASD, and further research would enhance the

validity of SI methods and would assist children with ASD in reducing the prevalence of SIB.
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