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C a s e s tu d y

The effects of sensory


integration therapy on verbal
expression and engagement
in children with autism
Janet Preis, M eaghan M cKenna

Background/Aim: Sensory-based interventions, including sensory integration therapy (SIT), are one o f the
m ost highly requested and provided services fo r children w ith autism spectrum disorders (ASDs). A lthough
SIT is predom inantly provided b y occupational therapists, other service providers, including speechlanguage pathologists, are expected to understand and, on occasion, are requested to integrate SIT Into
their treatment. The purpose o f this study was to determine whether: (a) SIT im proved the communication
skills o f children w ith autism, specifically spontaneity, complexity o f utterance, and engagement; (b) effects
continued follow ing the provision o f SIT; and (c) effects were consistent across young children w ith autism
w ith different learning profiles.

Methods: A single-subject applied behaviour analysis design was im plem ented to assess the effectiveness
o f SIT on verbal spontaneity, gram m atical complexity (measured through mean length o f utterance) and
engagem ent in fo u r young children w ith ASD, measuring each area before, during and a fte r SIT. The effects
o f sensory integration intervention were measured by comparing each participant's expressive language and
engagem ent in a no-treatm ent phase (A phase) to those same skills in the treatm ent phase (B phase).

Findings: A ll o f the participants p erform ed best in the occupational therapy o r post-occupational


therapy conditions fo r spontaneity, com plexity o f utterance, and engagement, a n d the w orst in the preoccupational therapy condition. Specifically, the greatest percentage o f spontaneity was n o te d post-SIT,
w ith the longest measured length o f utterance during SIT, and the greatest engagem ent fo u n d both
during and post-SIT. The pre-SIT condition consistently ranked as the low est fo r all dependent measures.

Conclusions: Results fro m this sm all stu d y indicate th a t the SIT c o n d itio n (occupational therapy)
y ie ld e d b e tte r co m m u n ica tio n a n d engag e m e n t than the co n d itio n im m e d ia te ly p rio r (preo ccu p a tio n a l therapy); therefore, specific com ponents o f SIT n eed to be examined, p a rticu la rly issues
o f m o tiv a tio n a n d m o m e n tu m .
Key words: Autism Sensory integration therapy Sensory-based interventions Speech-language pathology

ensory functioning is an area of con


cern for individuals with autism
spectrum disorders (ASDs), and has
recently been added to its definition
of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) (American Psychiatric
Association, 2013). These sensory differences
may manifest themselves in unusual, rigid, and
routinised behaviours, and contribute to diffi
culties in social communication (Donnellan et
al, 2013). As noted by the National Research
Council (2001), the developmental trajectory
in sensory regulation significantly impacts the
ability of a person with ASD to be socially
engaged, attend to the most salient aspects of
an interaction, and to appropriately regulate
emotions and behaviour, all of which directly

Janet Preis is a
speech-language
pathologist at Loyola
University MD\
Meaghan McKenna
is a speech-language
pathologist at Loyola
University MD
Correspondence to:
Janet Preis
e-mail:
jpreisl@ loyola. edu

476

affect social communication. Sensory function


ing, therefore, has an effect on skills across
the board, becoming the purview of educators,
therapists, paraprofessionals and parents.
For interventions addressing sensory func
tioning, although the evidence is controversial,
services are in high demand, or at least in high
supply. Hodgetts and Hodgetts (2007) report
that a sensory-based occupational therapy (OT)
approach is most frequently recommended for
children with ASD, ranging from 21% for chil
dren younger than 8 years (Thomas et al, 2007),
to 38% for the 0 to 14-year range (Green et
al, 2006). Although the term sensory-based
approach is not synonymous with sensory inte
gration therapy (SIT), there is much overlap
between the two in terms of theory and service.

International Journal of Therapy and Rehabilitation, October 2014, Vol 21, No 10

2014 MA Healthcare Ltd

Submitted 17 February 2014, sent back for revisions 7 July 201 4;accepted for publication following double-blind peer
review 22 September 2014

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Sensory integration therapy:


a brief review of the literature
SIT is a specific approach that is based on
a theory that originated in 1972 and was
further elaborated in the late 1980s by Anna
Jean Ayres. In her work, Ayres primarily
addresses the individuals ability to organize
sensory information for use (Ayres, 1972; 2),
specifically the sensations from ones body and
from the environment [that] makes it possible
to use the body effectively in the environment
(Ayres, 1989; 22). According to Schaaf et al
(2012), the notion of an intervention is based
on Ayres theory that individually designed
sensory-motor activities will facilitate greater
modulation, organisation and integration of
sensory information; these in turn will allow
the sensory information to be used in more
appropriate and adaptive ways. The theory
posits that appropriate and specific doses of
sensory stimulation will directly affect the
nervous system, resulting in improved attention,
behaviour and learning (Baranek, 2002; Lang
et al, 2012; Schaaf et al, 2012; Schooling et al,
2012). In addition, the successful processing
of sensory information through these systems
provides a basis for higher-order learning
such as language (Ayres, 1979; Hoehn and
Baumeister, 1994).
SIT is consistent with other types of OT as
the goals of intervention are designed to sup
port functional and meaningful activities in a
childs natural environment. SIT is an individu
ally designed, child-centered, playful approach
that uses scaffolding to support the continued
development of adaptive behaviours (Schaaf
et al, 2012). SIT includes both structural and
process elements, both of which are critical
to the development of sensory integration
(Parham et al, 2007; 2011). The structural ele
ments include the more readily observable and
evaluated characteristics of the programme,
particularly that of therapist competence, such
as the occupational therapists training, experi
ence, certification, and supervision. The proc
ess elements are more difficult to evaluate but
are of equal importance and include: what the
authors refer to as the therapeutic alliance
or therapeutic relationship; the physical envi
ronment (i.e. room set-up and materials that
motivate engagement); and critical events in
a session related to collaboration, challenges,
context, safety and success for the client.
There is an ongoing need for evidence to
support interventions for children with autism,
particularly those focused on sensory processing. Although the 2010 review of SIT by May-

Benson and Koomar recognises that the SI


approach may result in positive outcomes in
the areas of sensorimotor skills and motor
planning; socialization, attention, and behav
ioural regulation; reading and reading related
skills; and individualized goals for the study
populations (May-Benson and Koomar, 2010;
412), other meta-analyses do not concur for
individuals with autism. According to a review
of current treatment methods by the National
Autism Center (2009), the sensory integrative
package (i.e. using all of the senses to assist
with environmental stimulation) was deemed
an unestablished intervention with little or
no evidence to establish treatment effective
ness for ASD. This rating was supported more
recently by Kadar et al (2012; 290):
'G iv e n th e p a u c ity o f research re g a rd in g
t h e e ffe c tiv e n e s s o f th e sen so ry processing
in te rv e n tio n in im p ro v in g o c c u p a tio n in
d a ily a c tiv itie s a m o n g c h ild re n w it h A S D ,
it m a y b e tim e t o r e v ie w th e e v id e n c e f o r
b o th sen so ry processing a n d o c c u p a tio n based a p p ro a c h e s a m o n g o c c u p a tio n a l
th e r a p y p ra c titio n e rs w it h th is p o p u la tio n .'

In addition, following a systematic review of


SIT, Lang et al (2012; 2) recommended that
practitioners and agencies serving children
with ASD that endeavour, or are mandated,
to use research-based, or scientifically-based,
interventions should not use SIT outside of
carefully controlled research as SIT is not
currently supported in the evidence base.
Occupational therapists and professionals
involved in the management of children with
ASD are often advised to integrate sensorybased activities, or SIT specifically, into their
treatment of children with ASD. For exam
ple, Schooling et al (2012) reported that
speech-language pathologists often receive
this request from families hoping to prepare
a child for communication by regulating his/
her sensory system. This request is probably
due to the original correlation of SIT with
improved language, as proposed by its founder,
Ayres (1972), who suggested that the effect
of SIT at the brain stem level has the capacity
to support higher levels of processing needed
for language. Although this theory has been
disputed (Bloom and Lahey, 1978; Fisher and
Murray, 1991), speech-language pathologists
continue to integrate activities consistent with
SIT into communication therapy, with intended
outcomes ranging from readiness to learn to
increased verbal communication.

International Journal of Therapy and Rehabilitation, October 2014, Vol 21, No 10

477

C a s e s tu d y

In 1999, Griffer acknowledged this crosso


ver of SIT, noting its increased popularity
with speech-language pathologists in relation
to language-learning deficits. The influence of
SIT on speech-language pathology was in part
due to Ayres research, as well as the research
of others (Kantner et al, 1982; Ottenbacher,
1982). Research by Reilly et al (1983) and
Ray et al (1988) examined the effect of SIT
on speech production and expressive lan
guage, and reported mixed results for children
with ASD, while other studies (Humphries et
al, 1990; 1992) indicated that SIT had no sig
nificant effect on language. Most recently, in
2012, the American Speech-Language Hearing
Association conducted a systematic review of
SIT specific to communication outcomes, and
identified four studies (Kantner et al, 1982;
Fallon et al, 1994; Monville and Nelson, 1994;
Tatum et al, 2004), which met the criteria to be
considered well controlled. Authors Schooling et
al (2012; 13) concluded that current data on the
clinical effectiveness of SIT are minimal and
provide little guidance to clinicians, adding:
'S p e e c h -la n g u a g e p ath o lo g ists and
a u d io lo g ists should be cautious a b o u t
p ro v id in g sensory-based in te rv e n tio n s ,
such as SIT, in lieu o f m o re d irect or
e m p iric a lly -s u p p o rte d tre a tm e n ts
ta rg e tin g c o m m u n icatio n deficits, such
as skill-based tre a tm e n ts .'

The authors also called for further studies to


examine the effects of SIT on communication.

A IM

As noted by Patten et al (2013), children


with ASD are reported to receive as many
as seven different interventions at one time,
at great cost to families and the community.
In particular, it is essential that the effect of
SIT as provided by an occupational therapist
specifically certified in its administration be
examined for its effect on social communica
tion, including spontaneity, verbal language,
and engagement. Therefore, the purpose of
this study was to determine whether: (a) SIT
improves the communication skills of chil
dren with autism, specifically spontaneity,
complexity of utterance, and engagement;
(b) effects are continued following the pro
vision of SIT; and (c) effects are consistent
across young children with autism with dif
ferent learning profiles.
478

M ETH O D S
Participants

This study consisted of four Caucasian


males with autism , ranging in age from
3.50 to 6.10 years of age (mean=4.7 years).
The participants (pseudonyms Adam, Josh,
Colin, Victor) attended a private school for
ASD, and met the following criteria: (a) a
diagnosis of autism from a physician or psy
chologist in compliance with DSM-IV-TR
criteria; (b) current enrollment in sensory
integrative-based OT; (c) a mean length of
utterance (MLU) of at least 1.5 at the onset
of the study. The Institutional Review Board
(IRB) of the principal investigator approved
the study and parental consent was obtained
prior to the studys initiation. Full participant
information is presented in Table 1; additional
testing information is presented in Table 2.
Ethical approval

All procedures in this study were carried out


in accordance with the ethical standards of
the responsible committee on human experi
mentation (institutional and national) and the
Helsinki Declaration of 1975, as revised in
2000. As stated in the Methodology section of
this manuscript, ethical and research govern
ance approval was satisfied through approval
from the authors University Institutional
Review Board (IRB) awarded May 2009.
Anonymity and confidentiality were main
tained and all procedures were performed in
compliance with relevant laws and institutional
guidelines. Informed consent from the caregiv
ers of the participants was obtained prior to the
initiation of the study, each signed and dated
by the author, the caregivers and a witness,
with their names printed underneath.
Procedure

Design

A single-subject applied behaviour analysis


(ABA) design (Barlow and Hersen, 1984) was
implemented to assess the effectiveness of the
SIT intervention for each participant. The effects
of the intervention were measured by compar
ing each participants expressive language and
engagement in a no-treatment phase (A phase) to
those same skills in the treatment phase (B phase).
Setting

This study was conducted in the summer of f


2009 at a private school for children on the <
autism spectrum, aged 18 months to 7 years, g
The intervention sessions occurred in the OT S

International Journal of Therapy and Rehabilitation, October 2014, Vol 21, No 10

room at the school, which contained a carpeted


floor with a trampoline, nylon tunnel, tent, and
therapy ball. A platform with monkey bars and
various types of swings (e.g. round and square
platform, two-layered elastic, bolster) were in
the room, as well as a dry erase board, scooter,
sensory table, child-sized table and chairs, and
a shelf with various games and materials.
Measures

Expressive language, as measured through


language samples collected during each treat
ment day across three conditions (pre-, during
and post-intervention), was the primary source
for the three dependent variables examined
in this study. All language samples were
obtained using best practice of following the
childs lead for all conditions (see section on
Protocol) and analysed following standard
procedures (Retherford, 2000). All data
were transcribed by an observer and verified
via audiotape or live for inter-rater reliabil
ity (see section on Inter-rater agreement), and
were subsequently analysed using Systematic
Analysis of Language Transcripts (SALT)
(Miller and Iglesias, 2008) software.
Language samples were examined for:
(a) number of spontaneous verbal initiations (as
compared to imitative utterances); (b) MLU;
(c) number of on-topic or engaged responses
(as compared to no response or off-topic utter
ances). The number of spontaneous verbal
initiations was determined by analysing each
language sample (pre-, OT and post-condi
tions) and counting the number of spontane
ous verbal utterances, rather than imitations of
the examiners questions or comments. MLU
was determined by dividing the total number
of morphemes (i.e. smallest meaningful unit
of language) by the total number of spontane
ous utterances for each sample. Finally, utter
ances were analysed for engagement; that is,
if the participants utterance was off-topic or
there was a lack of response to the communica
tive partners bid (e.g. when asked a question
or given direction), the response was coded as
disengaged. These instances were counted for
each language sample and divided by the total
number of utterances, yielding a percentage
score; this score was subsequently converted
to percent engaged (e.g. 30% disengaged cong verted to 70% engaged) to provide consistency
I with the first measure spontaneity.
a
<u
EC

< Protocol

Language samples were collected during each

a treatment day under three conditions: pre-OT,

ABA: applied behaviour analysis; OT: occupational therapy; SS: summer school;
ST: Speech-language therapy
^Pseudonyms

during OT and post-OT. All language sam


ples were conducted using similar procedures
following the childs lead, consistent with
best practice (Leadholm and Miller, 1994).
Locations where the language samples were
collected remained consistent across the study,
with most conducted in the OT room. Pre-OT
language samples were collected according to
the participants schedule, immediately preced
ing the OT session in order to reduce physi
cal transition, and were conducted in either a
classroom or small therapy room.
Pre- and post-OT language samples were
obtained at a child-sized table, using items
established to be desirable by each participant
according to teacher and parent reports and direct
observations (e.g. art activities; books; bubbles;
cars or trucks; dolls or action figures; games;
puzzles). Each participant chose the item and
the examiner interacted, ensuring consistentcy
with the material and following the childs lead
with comments and open-ended questions; play
continued until the participant was no longer
interested and chose a different item. Sessions
averaged 30 minutes in length, and language
samples were collected for the entire session.
The intervention stage, or OT, consisted
of SIT implemented by a certified occu
pational therapist. The therapist followed
sensory integration intervention protocol
consistent with best practice (Parham et al,

International Journal o f Therapy and Rehabilitation, October 2014, Vol 21, No 10

479

Case study

Table 2. Test results


Adam (assessments adm inistered 2008)
M ullen Scales o f Early Learning

T-score (M eanSD=50+10)

Percentile

Visual reception

25

Fine m o to r

23

Receptive language

39

14

Expressive language

27

Gross m o to r

N.A.

N.A.

Preschool Language Scale 4

Standard score (M eanSD=10015)

Percentile

A u d ito ry com prehension

66

Expressive language

65

Total language

62

Vineland A daptive Behaviour Scale

Standard Score (M eanSD=10015)

Percentile

C o m m u n ic a tio n dom ain

100

50

Daily living skill dom ain

103

58

Socialization do m ain

83

13

M o to r skills dom ain

111

77

A d a p tiv e behaviour com posite

99

47

Percentile

Colin (assessments adm inistered 2008)


Preschool Language Scale-4

Standard Score (M eanS D =10015)

A u d ito ry com prehension

69

Expressive language

74

Total language

69

Josh (assessments adm inistered 2009)


Stanford-Binet Intelligence Scale-5

IQ score (M eanS D =10015)

Percentile

Full scale IQ

114

82

hhhhhi

N on-verbal IQ

115

Test o f Language Developm ent-Prim ary

Standard score (M ean+SD=103)

Percentile

Picture vocabulary

25

10

50

Relational vocabulary and sentence im ita tio n

mm

Oral vocabulary

11

63

G ram m atical understand in g

37

Vineland A daptive Behaviour Scale

Standard Score (M eanS D =10015)

Percentile

C o m m u n ic a tio n do m ain

104

61

Daily living skill do m ain

93

32

Socialisation dom ain

75

M o to r skills dom ain

84

14

A d a p tiv e be havior com posite

86

18

Standard score (M ean+SD=10015)

Percentile

65

Victor (assessments adm inistered 2009)


Expressive Vocabulary Test

Goldman Fristoe Test o f Articulation

Standard score (M eanS D =10015)

89

Peabody Picture Vocabulary Test

Standard score (M eanS D =10015)

Percentile

67

Preschool Language Scale-4

Standard score (M eanS D =10015)

Percentile

A u d ito ry com prehension

50

Expressive language
Total Language

480

50

f ; 50

b h b
1

International Journal of Therapy and Rehabilitation, October 2014, Vol 21, No 10

Table 3. Occupational therapy goals and activities


Participant

Occupational therapy goals

Activities (number of sessions implemented/


sessions observed)

Adam

A tte n tio n : s ittin g on th e flo o r fo r 1 0 -1 5 m inutes w h ile a tte n d in g to a

C lim b in g m onkey bars (3/7)

listening task w ith m inim al verbal cues fo llo w in g 20 m inutes o f vestibular

Eating (2/7)

and proprio ceptive in p u t

Fine m o to r (i.e. use o f crayons, scissors,

Feeding: to le ra tin g and try in g tw o n e w fo o d s per m o n th

Jum ping (0/7)

Integra tion: im proved vestibular in te g ra tio n ; im proved bilateral

Sensory in p u t: headphones (7/7)

in te g ra tio n skills

Colin

crayons zippers) (5/7)

Fine m o to r: fastening th e zipper on his jacket; using utensils ap prop riate ly

S w in ging (4/7)

P roprioceptive: increasing tolerance to vestibular in p u t; increasing tolerance


to his fe e t leaving th e gro u n d

C lim b in g m o nkey bars (5/7)


Eating (2/5)

S tim ulatio n: decreasing sensory-seeking behaviour

Fine m o to r (i.e. use o f crayons, scissors,


crayons zippers) (5/7)
Jum ping (2/5)
Sensory in p u t (0/5)
S w inging (4/5)

Josh

A tte n tio n : increased consistency o f eye co n ta ct to objects o r w ith people;

C lim bing m o nkey bars (2/3)

sustaining en ga g e m e n t in fu n c tio n a l tasks w ith the rap ist fo r 1 0 -1 5 m inu te

Eating (3/3)

increm ents a fte r stru cture d vestibular-proprioceptive in p u t w as provided,

Fine m o to r (i.e. use o f crayons, scissors,

and electing one o f tw o sensory m odalities to adjust his level o f arousal fo r


increased focu s and organisa tion w ith m o dera te structure o r p ro m p tin g

crayons zippers) (3/3)


Jum ping (0/3)

Balance: balancing on one fo o t fo r a t least five seconds

Sensory in p u t (0/3)

Fine m o to r c o n tro l: eye-hand c o o rdina tion and visual-perceptual skills to

S w inging (2/3)

c om plete age-expected tasks (e.g. ap prop riate ly using a fork)


Fine m o to r co o rd in a tio n : m o to r p lan ning in order to p e rfo rm age-expected
fin e m o to r and gross m o to r activities (e.g. grasping scissors and paper
w ith m inim al rem inders, and snipp ing on 2-inch w id e lines; inde pen den tly
rem oving his shirt and p u ttin g it on w ith m inim al assistance, etc.)
Tolerance: engagin g in a rt activities w ith a variety o f ta ctile m edia

Victor

A tte n tio n : sustaining visual en ga g e m e n t in a co lou ring task to co lo u r 8 0 % o f

C lim bing m o nkey bars (3/6)

a 2x2 inch picture, w ith m inim al verbal cues, a fte r 10 m inutes o f structured

Eating (1/6)

vestibular and p roprio ceptive in p u t

Fine m o to r (i.e. use o f crayons, scissors,

Feeding: to le ra tin g and try in g on e ne w fo o d per m o nth

crayons zippers) (6/6)

Fine m o to r: b u tto n in g

Jum ping (2/6)

Stability: im proving proxim al s tab ility fo r increased fin e m o to r skills w h e n

Sensory in p u t (0/6)

com p le tin g d ra w in g and c o lou ring tasks; inde pen den tly stabilising paper by

S w inging (5/6)

grasping near th e scissors and placing his th u m b on to p o f th e paper


Visual m o to r: fu n c tio n a l pa rticip a tio n w ith w ritin g and dra w in g tasks

2014 MA Healthcare Ltd

2007), following the lead of the child for


object, activity or material choice according
to the established goals (Table 3), while placing
demands for engagement. Although the inter
vention was individually applied and specific to
the participant, all followed a similar approach,
and each consisted of at least half of the session
engaged in similar activities, including: climb
ing; fine motor manipulation (e.g. colouring,
cutting out shapes with a scissors, Play-Doh
modeling, drawing on the white board); eating;
sensory input (e.g. hands in beans; massage);
and swinging. Sessions ranged from 25-50 min
utes, and language samples were collected
for the entire session or until approximately
100 utterances were obtained.
Inter-rater agreement

Inter-rater reliability was conducted for 15 of


the 59 sessions (25% of the study) through
the principal investigator independently col
lecting language samples in vivo, as well as

reviewing previously taped language samples.


These results were compared with the exam
iners language samples, yielding a 97% agree
ment (range 87-100%). Any utterances with
disagreements were removed from samples and
subsequent analysis.

RESULTS

The data were analysed using the Friedman


test, the non-parametric alternative to analysis
of variance (ANOVA), to reduce the likelihood
of a Type I error due to the low number of
sessions. This test was implemented for each
of the dependent variables: (a) spontaneous
verbal utterances; (b) MLU; (c) frequency of
engagement. Each dependent variable was
examined for each of the participants, compar
ing results between conditions or periods of
time: (a) before OT (pre-OT); (b) during OT
(OT); (c) after OT (post-OT).

International Journal of Therapy and Rehabilitation, October 2014, Vol 21, No 10

481

C a s e s tu d y

effect size of 0.2 is indicative of a small


effect, 0.5 a medium, and 0.8 a large effect
size. See Table 4 for mean score, standard
deviation and mean rank for each participant
across all conditions for each measure, and
Table 5 for post-hoc analyses with Wilcoxon
signed-rank tests and effect sizes.
Adam

A total of 21 language samples were collected


for Adam across seven dates. Adams mean
percentage of spontaneous utterances, MLU
and engagement as measured through his ontask verbal responses were highest during OT,
all of which were statistically significant. His
pre-OT language samples revealed he had
the lowest level of spontaneity, the shortest
MLU, and was least engaged in this condi
tion. Friedman tests determined there were
statistically significant differences depending
on condition for: (a) frequency of spontane
ous utterances (xz(2)=7.58, p=0.023); (b) MLU
(xz (2)=7.14, /?=0.028) (c) mean percentage of
time engaged (xz(2)=12.08, p=0.002).
Colin

A total of 14 language samples were collected


for Colin (he was unavailable for one pre-OT
sample). Colins MLU and engagement
were highest during OT, while amount of
spontaneous utterances were greatest post-OT.
Only the MLU results were statistically
significant as a Friedman test determined
there was a difference depending on condition
(*z(2)=6.00, p=0.05).
Josh

F ig u re 1. O v e r a ll re s u lts acro ss c o n d itio n s

Results indicated that the greatest percent


age of spontaneity was noted in the post-OT
condition for three of the four participants,
with the OT condition yielding the longest
MLU for all four participants. OT and postOT conditions were both found to support
engagement, and the pre-OT condition con
sistently ranked as the lowest condition for
all dependent measures across all four par
ticipants (Figure 1). Effect size (Cohens d)
was calculated for all dependent measures
for all participants using the standard mean
difference method (Busk and Serlin, 1992).
According to Cohens (1988) standards, an
482

Nine language samples were obtained from


Josh during three different sessions (Josh was
absent for three weeks of the study). Overall
results indicated that the OT condition yielded
the longest MLU, and post-OT showed the
most engagement. However, the Friedman
tests indicated that none of the differences
were statistically significant. Very little differ
ences were noted for spontaneity as it was high
across all conditions.
Victor

A total of 21 language samples were obtained


from Victor across seven different sessions.
Although none of his results were statistically
significant, Victor had the greatest percentage
of spontaneous initiations and engagements in
the post-OT condition, and the longest MLU in
the OT condition. His lowest scores were noted
in the pre-OT condition. The Friedman tests

International Journal o f Therapy and Rehabilitation, October 2014, Vol 21, No 10

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Table 4. Mean score, standard deviation and mean rank across conditions
Pre-OT

OT

Post-OT

Mean (SD)

Mean rank

Mean (SD)

Mean rank

M (SD)

Mean rank

Spontaneity**

92.42 (8.28)

1.21

99.71 (0.48)

2.43

99.28(1.49)

2.36

MLUf

2.60 (0.40)

1.29

3.23 (0.42)

2.71

3.02 (0.38)

2.00

Engagement1

95.85 (2.03)

1.00

99.28(1.25)

2.64

99.00(1.00)

2.36

Spontaneity

75.2 (19.05)

1.50

83.25 (8.6)

2.00

85.5 (10.34)

2.50

MLU*

1.81 (0.29)

1.50

2.40 (0.09)

3.00

1.90 (0.18)

1.50

Engagement

96.75(2.36)

1.50

99.75 (0.5)

2.50

95.5(7.0)

2.00

Spontaneity

99.3 (9.86)

1.67

99.0(1.73)

1.83

100 (0.00)

2.50

MLU

3.04 (0.70)

1.33

3.53 (0.31)

3.00

3.18(0.30)

1.67

Engagement

93.3 (9.86)

1.83

94.66 (3.78)

2.00

96.0 (3.60)

2.17

Adam

Colin

Josh

Victor
Spontaneity

65.3 (26.38)

1.67

78.83 (8.42)

2.08

79.83 (7.93)

2.25

MLU

1.69 (0.23)

2.00

1.86 (0.39)

2.33

1.64 (0.32)

1.67

Engagement

87.16(1.60)

1.00

98.33 (2.42)

2.33

99.00 (2.44)

2.67

OT

Post-OT

Pre-OT to OT

OT to post-OT

Pre-OT to post-OT

MLU: mean length of utterance; OT: occupational therapy


*p<0.05; fp< 0-005
Table 5. Wilcoxon post-hoc results
Interquartile range
Pre-OT

Z-score (d)

Adam
Spontaneity

95 (75-100)

100 (99-100)

100 (96-100)

-2.20* (1.24)

-0.38 (0.39)

-2.19* (1.15)

MLU

2.44 (2.25-3.38)

3.33 (2.54-3.72)

3.02 (2.32-3.49)

-1.69* (1.54)

-1.86* (1.07)

-1.35 (1.07)

Engagement

96 (93-99)

99 (97-100)

99 (98-100)

-2.38* (2.03)

-0.37 (0.25)

-2.37* (1.97)

Spontaneity

N.A.

N.A.

N.A.

N.A. (0.54)

N.A. (0/24)

N.A. (0.67)

MLU

1.83 (1.44-2.14)

2.40 (2.29-2.51)

1.88(1.71-2.15)

-1.86* (2.75)

-2.02* (3.51)

-0.36 (0.34)

Engagement

N.A.

N.A.

N.A.

N.A. (1.76)

N.A. (0.86)

N.A. (0.24)

Colin

Josh
Spontaneity

N.A.

N.A.

N.A.

N.A. (0.04)

N.A. (0.82)

N.A. (0.10)

MLU

N.A.

N.A.

N.A.

N.A. (0.90)

N.A. (1.15)

N.A. (0.26)

Engagement

N.A.

N.A.

N.A.

N.A. (0.18)

N.A. (0.36)

N.A. (0.36)

Spontaneity

N.A.

N.A.

N.A.

N.A. (0.69)

N.A. (0.12)

N.A. (0.74)

MLU

N.A.

N.A.

N.A.

N.A. (0.53)

N.A. (0.62)

N.A. (0.18)

Engagement

86.50(86.0-90.0)

99.5(94.0-100.0)

100.0(94.0-100.0)

-2.21* (5.44)

-1.34(0.27)

-2.21* (5.73)

Victor

MLU: mean length of utterance; OT: occupational therapy


*p<0.05

es
|
|
<
s
2

determined there was no statistically signifi


cant difference in the percentage of spontaneity (x2(2)=1.13, p=0.57) or MLU (x2(2)=1.33,
p=0.51); however, there were statistically
significant differences in the mean percentage of time engaged depending on condition
(jc2(2)= 11.20, p=0.004).

DISCUSSION

Analysis of results yielded statistical sig


nificance on each measure, with a pattern of
increased spontaneity, complexity of utter
ance, and engagement for three of the four
participants during the OT sessions. These

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483

C a s e s tu d y

findings suggest that SIT improves these


qualities of expressive language during the
intervention and that there may be carryover
for some children post-OT.
Overall, all of the participants performed
best in the OT or post-OT conditions for
spontaneity, complexity of utterance and
engagement, and the worst in the pre-OT
condition (apart from Colin for engagement).
Two of the participants, Adam and Josh,
demonstrated a high level of spontaneity
across the conditions, ranging from 92-100%,
with Adam showing a significant increase
from pre-OT to OT and post-OT conditions.
Colin and Victor, who engaged in much more
echolalia than the other two participants,
improved substantially as reflected in their
medium effect sizes, but without statistical
significance from pre-OT to OT and post-OT.
Grammatical complexity and sentence length
were the highest for all four participants in the
OT condition, and significantly improved with
large effect sizes for Adam and Colin. Large
effect size was noted for Josh as well, although
results were not significant. Adam continued
the gains for grammatical complexity and
sentence length into the post-OT condition.
Finally, each participant was highly engaged
under each condition, ranging from 87-99%
engagement, rendering a potential ceiling effect.
However, Victors pre-OT to OT and post-OT
scores yielded statistical significance. For all of
the participants, the measure of engagement in
the OT condition was greater than the pre-OT
condition, with Adam, Colin, and Victor yield
ing large effect sizes. Two of the participants
continued to improve into the post-OT condition
with a small effect.
The results from this small study indicated
that the SIT condition (OT) yielded better com
munication and engagement than the condition
immediately prior (pre-OT); therefore, specific
components of SIT need to be examined. As
noted previously, Parham et al (2007; 2011)
posit that SIT is not defined solely by its struc
tural elements, such as the specific activities
presented during therapy; rather, it includes
these as well as process elements, such as the
therapeutic relationship, motivating materials
and collaboration with the client. This latter ele
ment of SIT may be an important component
contributing to behaviour change for those who
receive it, particularly as it relates to issues of
motivation and momentum.
Research shows that motivation is a criti
cal element in intervention for children with
autism as greater motivation positively affects:
484

how long it takes to begin academic tasks;


overall performance; level of interest; and dis
ruptive behaviour (Koegel et al, 1987; 1992;
Koegel and Koegel 2010). Although the preOT condition was one that followed the childs
lead and included what was deemed to be
motivating materials, it is possible that the set
ting itself (i.e. table and chairs) as well as the
therapists ability to scaffold affected the over
all motivation to engage and communicate. OT
using sensory integration requires the thera
pist to scaffold activities to match the childs
needs, as well as to choose experiences that are
challenging but achievable and motivating for
the child, both of which are as central to the
success of SIT as are the actual therapeutic
events, such as swinging and jumping.
M otivation may have been another cen
tral element of the intervention that affected
g ram m atical com plexity (as m easured
through MLU), and the use of fam iliar
phrasing (e.g. First swinging, then balls)
com bined with im m ediate and tangible
responses by the occupational therapist may
have been a strong influence in expressive
language. In the pre- and post-OT language
samples, although m aterials were chosen
specific to each participant and were based
on reported and observed interests, none of
the materials allowed for movement beyond
the workspace of the table and chairs. As
noted in the results, each participant was
highly engaged in the post-OT language
samples (and most in the pre-OT ones as
well), but the participants utterances did not
render as much bang for the buck in terms
of excitement and interaction, and little, if
any, physical movement was provided out
side of the OT condition.
In a typical language sample, the examiner
comments on what he/she and the partici
pant are doing, occasionally asking questions
to promote engagement. For children with
autism, social engagement and talking about
or commenting on what the child is doing is
typically an area of need. Even requesting a
puzzle piece or a crayon in the pre- and postOT language samples, although more action
and result-oriented than social commenting,
appear to be less motivating than a phrase
such as I want the blue swing, resulting in
not just salient but physical results. In SIT, a
core element of the intervention is addressing more than one sensory modality at a time
while providing the ju st-rig h t challenge
(Parham et al, 2007) to keep the participant
engaged, interested and active.

International Journal o f Therapy and Rehabilitation, October 2014, Vol 21, No 10

f
<
g
S

This is not to imply that the element of


physicality is not central to the motivation and
subsequent attention and engagement of the
children in the SIT condition. Recent studies
have found that physical movement improved
the attention of children with autism (Azrin et al,
2006) and attention deficit hyperactivity disorder
(Schilling et al, 2003; Azrin et al, 2007; Kercood
and Banda, 2012), as measured through task
comprehension. It is possible that the physical
movement provided in this study during the OT
condition contributed to the attention directly.
Finally, momentum may have also come into
play, particularly for spontaneity and engagement
as the subsequent condition (post-OT), although
not as physically active, engaging or motivating,
was in the same physical space, allowing for
engagement and attention carryover.
Overall, the core elements of SIT hold
valuable lessons for the speech-language
pathologist as although language samples are
based on following a childs lead, they are not as
multifaceted as the approach implemented by a
certified occupational therapist. Speech-language
pathologists allow child choice for materials
during a language sample, and base the selection
on a childs general likes and dislikes. However,
language samples do not typically involve the
components of optimal arousal or the balanced
challenges found in SIT (Parham et al, 2011) as
the focus may be more on containing a child for
the purpose of language sampling, rather than for
optimal engagement and interest.

2014 MA Healthcare Ltd

Limitations

A number of limitations were present in this


study, including history, treatment effects,
individualised intervention and research design.
One of the main strengths of SIT and OT is the
ability of a trained clinician to modify goals, as
well as procedures to achieve those goals, while
a therapy is being implemented, specific to the
needs of an individual child. This, however,
creates a dilemma for a research study, where
the independent variable should be held constant
across participants to determine its effect.
By definition, SIT is broad and inclusive of
a number of goals and activities, as reflected
in this studys protocol. All participants did
not receive identical sensory input for the
same amounts of time, but all received SIT for
the majority of their OT session. Beyond the
variations in their goals, the participants also
differed in the focus and amount of intervention
they received each week, rendering an internal
validity threat. Finally, the focus of the study was
on measures of communication, rather than OT

goals. It is possible that the lack of direct focus


on spontaneity, MLU and engagement affected
the outcome, particularly if there was any
difference in how each were supported across
the participants; however, the continuity of OT
across the study should have minimized this.
Additionally, although an ABA design was
attempted, there was no reversal to true baseline
as the target of the intervention was the acquisi
tion of a skill, thus reducing experimental control.
Future research

As noted in the literature, continued research


is needed to examine the direct effects of SIT
on the goals of sensory regulation, as well as
the secondary effects of such interventions
on communication and engagement (Kadar
et al, 2012; Lang et al, 2012). Future stud
ies, with more rigorous experimental designs,
could specifically examine whether certain
types of stimulation (e.g. vestibular, tactile)
affect functional measures of engagement,
attention, and communication by isolating
each and providing, over a period of time, for a
much larger sample of participants.
Analysis could be conducted to determine the
effects of SIT according to varying diagnosis
and descriptions, particularly that of sensory
and language functioning. Finally, in order to
differentiate between the effects of motivation
and sensory stimulation, a hierarchy of prefer
ence materials and activities (high to low) could
be presented across participants, and analysis
conducted to determine whether effects are sim
ilar, regardless of level of desirability and/or
motivation to access.

CONCLUSIONS

SIT is a frequently recommended service for


children with ASDs, designed to improve sen
sory functioning. Recent research has rendered
inconclusive evidence to the effectiveness of SIT
specific to communication outcomes, resulting in
a call for continued evaluation before implemen
tation into practice. The present study attempts
to contribute to the research in its findings that
the presentation of SIT yielded better commu
nication and engagement than the condition
immediately prior, possibly supporting its role
in communication intervention. This study also
brings to light the critical nature and potential
influence of motivation and momentum inherent
in the practice of SIT, encouraging practitioners
and researchers to consider its importance and
value in any therapeutic setting.
Ullil

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C a s e s tu d y

KEY POINTS
The core elements of sensory integration therapy (SIT) hold valuable
lessons for the speech-language pathologist in its multifaceted approach to
engagement and m otivation
In the present small study, all o f the participants performed best in the
occupational therapy (OT) or post-OT conditions fo r spontaneity, complexity
o f utterance, and engagement; and the w orst in the pre-OT condition, a
possible rationale fo r its inclusion in communication therapy
Continued research is needed on which elements o f SIT are most responsible
fo r improvements in communication: motivation, physicality or scaffolding

Acknowledgments: The authors wish to extend their gratitude to


the faculty, staff, and families o f The Shafer Center. In particular,
the authors wish to thank the Centers director, Dr Christine
Accardo, and the occupational therapist, Dr Shayna Stoogenke,
fo r their support and expertise.
Conflict o f interest: This research was supported in part by a
2009 Summer Research Grant awarded by Loyola University
MD through The Office o f Research and Sponsored Programs.
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