Running Head: INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH

AUTISM

Increased Effectiveness of Sensory Integration in Occupational Therapy

Intervention for Children with Autism
Colton Savage
Nicole Nagata
University of Utah

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Increased Effectiveness of Sensory Integration in Occupational Therapy
Intervention for Children with Autism
Sensory integration therapy (SIT) was originated by Jean Ayres. SIT interventions were
individualized and focused on how one processes sensory information from their surroundings
and from this how they function in their environment. SIT focuses on how sensory information
affects behaviors, learning, motor function, and neurophysiological processes (Lane, Roley,
Champagne, 2014). Interventions are client centered and focus on sensory stimulation while the
client is participating in an activity. The goals of SIT are to reduce maladaptive behaviors and
increase clients ability to function successfully in their environment (Pfeiffer, Koenig, Kinnealey,
Sheppard, Henderson, 2011). From Jane Ayres original SIT there have been adaptations of new
sensory integration (SI) treatments used in interventions.
SI is well used in the field of occupational therapy. In 2007 there were about 50,000
occupational therapists practicing in the United States alone. Of those 50,000 one third consider
themselves a practitioner in the field of pediatrics. Within this third half say that sensory
integration therapy to be one of their main focuses in their practice. Also, the Sensory Integration
Special Interest Section, as of 2006 had 12,000 members. Within the American Occupational
Therapy Association (AOTA) this is the second highest number of members of their specialty
sections (Miller, Coll, & Schoen, 2007).
There is a significant cost associated with the use of sensory integration. It costs
somewhere between $500 and $1000 to do a sensory integration evaluation, and between $80 to
$180 for a single 60 minute session. These costs, when combined with the numbers of
occupational therapists who use SI as a regular therapeutic tool highlight the need for empirical
research to determine the effectiveness of SIT (Miller et al. 2007).

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Approximately 1 out of every 110 children have been diagnosed with autism spectrum
disorders (ASDs). SI has been used with individuals with ASDs because of symptoms such as
deficits in social participation, communication, and undesired behaviors are associated with
sensory input issues, and between 42-88% of children with ASD are also diagnosed with sensory
processing disorder (SPD) (Pfeiffer et al. 2011). According to Case-Smith and Miller (2009)
95%-99% of occupational therapists working with individuals with ASD frequently use SI in
therapy interventions.
The purpose of this literature review is to use the current research to determine if
sensory integration (SI) is an effective treatment for children with Autism.
Methods
Research of The Literature
The articles were found using PubMed and CINAHL databases. Keywords used for the
search included: occupational therapy, sensory dysfunction, intervention, sensory integration,
autism, autism spectrum disorder, and individuals with autism. A few of the keywords were
found within the major subjects of our chosen articles. After searching each key term articles
were narrowed down by using the filtering function to show articles from academic and peer
reviewed journals, had been published within the last 5 years, and ages ranged from birth-18
years old. Other methods of research included using references of chosen articles to find
additional relevant articles. Twenty articles were found and and eight were analyzed for this
systematic review.
Selection of Studies
Only those articles investigating the effectiveness of sensory integration therapy on
children with sensory disorders secondary to ASD were considered for this review. Studies

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

included randomized control trials, experimental pre-post test designs, retrospective studies, and
case studies. Studies with an emphasis of sensory integration in occupational therapy
interventions were prioritized to be used in this review over others used other fields besides
occupational therapy. Because there were minimal articles in our search, we chose all articles
that met our inclusion criteria for this review.
Results
Main Findings
After reviewing and synthesizing the studies we found that there are many different areas
that SI can be used in. Because sensory information has such a large effect on behaviors,
learning, motor function, and neurophysiological processes, it is very important for therapists to
understand if it is a viable treatment for children with sensory dysfunction. The eight articles that
were chosen focused on modification of undesired behaviors, social participation and social
responsiveness, and sensory process and functional motor skills.
Quality of Study and Study Size
The studies focused on the effectiveness of SI in treating sensory disorders in children
with ASD. They used many different assessments to determine effectiveness of therapy (Figure
1). The most common problems in sensory disorders, discovered through research of the
literature, were undesired behaviors as well as participation skills and functional motor skills.
Two of the 10 studies were randomized control trials (Miller et al., 2007; Pfeiffer et al., 2011).
Undesired Behaviors
Three of the studies had evidence that SI was an effective treatment to use on decreasing
undesired behaviors (Fazlioglu, & Baran, 2008; Pfeiffer et al., 2011; Watling, Dietz, 2007). The
studies evaluated children with ASD compared to other treatment groups or control groups. They

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

focused on treating children's behaviors and the results were found through parent
questionnaires, the Vineland Adaptive Behavior Scales (2nd Edition) (VABS2), behavioral
section of the Sensory Evaluation Form, and rating videos of participants engaging in activities.
Two of the articles found that SI was an effective treatment on undesired behaviors due to
sensory dysfunction. The third articles findings were not as substantial for short term use, but
may be beneficial as a long term treatment in home.
Social Participation and Responsiveness
Six of our eight studies had evidence that use of SI was successful in increasing social
participation and responsiveness in children with ASD (Fazlioglu et al., 2008; Miller et al. 2007;
Pfeiffer et al., 2011; Preis & McKenna, 2014; Roley et al., 2015; Schaaf, Hunt, Benevides,
2012). Interestingly enough, an exact definition for social participation does not exist. What we
did find is that social participation is important and is understood as an important condition for
the typical development of children. They must gain knowledge of and develop social skills
while interacting with other people. The best definition we found defines social participation as,
social activities that take place with friends or groups, involvement in voluntary activities or
events, or involvement in activities with a social element. An important area of social
participation, and one that some of our articles focused on, is social responsiveness, or the ability
for an individual to respond appropriately and successfully to others (Pikur et al., 2014).
In one specific randomized control trial the authors investigated the effectiveness of
sensory integration therapy on social responsiveness compared to a fine motor therapy (FM).
They used the Social Responsiveness Scale (SRS), which is a rating scale for children that
measures a child's social impairments, social awareness, information processing, and capacity for
social communication, social anxiety, and avoidance. They found significant improvements in

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

social responsiveness from both SI and FM, there was more improvement when doing SI
(Pfeiffer et al., 2011).
Sensory Processing and Functional Motor Skills
Problems with sensory processing have been associated with ASD since the seminal
reports by Asperger. Sensory stimuli can cause distress to individuals with ASD. Issues with
sensory stimuli include hypo- and hyperresponsiveness as well as aggressive and self harm
behavior due to their inability to communicate their distress (Marco, E. J., Hinkley, L. B., Hill, S.
S., & Nagarajan, S. S., 2011). Another common problem associated with ASD is motor
impairment. Some may even consider it a cardinal feature for ASD (Papadopoulos., Rinehart,
Bradshaw, McGinley, Enticott, 2014).
We found six articles that compared the use of SI and other therapeutic techniques on
improving sensory processing and functional motor skills (Fazlioglu et al., 2008; Iwanaga et al.,
2014; Miller et al., 2007; Pfeiffer et al., 2011; Roley et al., 2015; Schaaf et al., 2012 ). Across the
studies they looked at hearing-speaking, behavior, attention, muscular tonus, balance, touch,
taste-smell, seeing, coordination, sensory input, and sensory integration overall. It was found that
SI, compared to other treatments was more successful.
In one article, (Fazlioglu et al., 2008), they did a pre- post-test study on 30 children who
were randomly assigned into experimental and control groups. The experimental group received
SI and the control group attended their regular education classes. They used the Sensory
Evaluation Form for Children with Autism. The form asks questions about 42 items measuring
sensory problems of hearing-speaking, seeing, taste-smell, touch, balance etc. They used SPSS to
run their statics, and they ran a two-group analysis of variance for repeated measures. They
found that there was a main effect of test time, between the pre- and post-test, as well as a

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

significant main effect for the total score on the evaluation form. There was also a significant
interaction effect of group and time. In the end their findings showed that receiving SI caused a
large change in response to sensory stimuli.
Discussion
Limitations
There is a limited amount of research looking at factors such as a specific SI intervention
with OT, children with Autism, and consistency of symptoms. This was prevalent with our
research because 6 of our 8 articles had small samples sizes (Fazlioglu et al., 2008; Iwanaga et
al., 2014; Miller et al. 2007; Pfeiffer et al., 2011; Preis & McKenna, 2014; Roley et al., 2015;
Schaaf et al., 2012; Watling et al.,2007). Though we had 2 randomized control trials, these
samples sizes were also small ( (Miller et al. 2007; Pfeiffer et al., 2011). Because individuals
with ASD vary in cognitive abilities, physical abilities, and severity of symptoms, there were 1
studie that created individualized interventions (Iwanaga et al., 2014).
Another limitation was using different types of SI, there was not specific type
determined to be most effective. There was only 1 study that used Jean Aryes original SI
intervention (Watling et al., 2007). The other 7 studies used Jean Aryres intervention as a base to
create other SI interventions talored to each study (Fazlioglu et al., 2008; Iwanaga et al., 2014;
Miller et al. 2007; Pfeiffer et al., 2011; Preis & McKenna, 2014; Roley et al., 2015; Schaaf,
Hunt, Benevides, 2012)
Fazlioglu et al., 2008; Iwanaga et al., 2014; Miller et al. 2007; Pfeiffer et al., 2011; Preis &
McKenna, 2014; Roley et al., 2015; Schaaf, Hunt, Benevides, 2012; Watling, Dietz (2007).

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Strengths
All of our articles showed improvement using SI for children with ASD (Fazlioglu et al.,
2008; Iwanaga et al., 2014; Miller et al. 2007; Pfeiffer et al., 2011; Preis & McKenna, 2014;
Roley et al., 2015; Schaaf, Hunt, Benevides, 2012; Watling et al.,2007). Because of there is not a
lot of research using standardized assessments, two studies created research designs with positive
results that support using their designs, interventions, and assessments as preliminary evidence
for use in future research (Pfeiffer et al., 2011; Schaaf, Hunt, Benevides, 2012; Watling et al.,
2007). Two of our studies were randomized control trials which are the the gold standard type of
studies for evidence based research (Miller et al. 2007; Pfeiffer et al., 2011).
Implications for Occupational Therapy Use
Since a significant amount of occupational therapists use SI as an intervention strategy
with treatment, which is expensive during evaluations and individual sessions, there is a need for
evidence based research to back up the therapy being used if it is financially economical. Based
on the American Heart Associations Evidence-Based scoring system. The Level of evidence was
both A and B the classification of recommendation was Class IIa. Therefore, this systematic
review found SI as reasonable intervention to use, but additional research on this topic is needed
to to gather evidence of specific interventions and symptoms.

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

References
Fazlioglu, Y., & Baran, G. (2008). A sensory integration therapy program on sensory problems
for children with autism. Perceptual and Motor Skills, 106(2), 415422.
Iwanaga R., Honda S., Nakane H., Tanaka K., Toeda H., & Tanaka G. (2014). Pilot study:
efficacy of sensory integration therapy for Japanese children with high-functioning
autism spectrum disorder. Occupational Therapy International, 21(1), 4-11.
Lane S.J., Roley S. S., & Champagne T. (2014). Sensory integration and processing. In B. A. B.
Schell, G. Gillen & M. E. Scheff (Eds). Willard and Spackmans occupational therapy
(12th ed., pp. 816-868). Philadelphia: Lippincott Williams & Wilkins.
Marco, E. J., Hinkley, L. B., Hill, S. S., & Nagarajan, S. S. (2011). Sensory processing in autism:
a review of neurophysiologic findings. Pediatric Resseach, 69(5 Pt 2), 48R-54R. doi:
10.1203/PDR.0b013e3182130c54.
Miller, L. J., Coll, J. R., & Schoen, S. A., (2007). A randomized controlled pilot study of the
effectiveness of occupational therapy for children with sensory modulation disorder.
American Journal of Occupational Therapy, 61, 228-238. doi:10.5014/ajot.61.2.228.
Papadopoulos, N., Rinehart, N., Bradshaw, J., McGinley, J., & Enticott, P. (2014). Motor
Functioning in Autism Spectrum disorders. Comprehensive Guide to Autism, 809-824.
Retrieved from http://link.springer.com/referenceworkentry/10.1007%2F978-1-46144788-7_41#\.
Pfeiffer B. A., Koenig K., Kinnealey M., Sheppard M., & Henderson L. (2011). Effectiveness of
sensory integration interventions in children with autism spectrum disorders: a pilot
study. American Journal of Occupational Therapy, 65(1), 76-85.

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Pikur, B., Danils, R., Jongmans, M. J., Ketelaar, M., Smeets, R. J., Norton, M., & Beurskens,
A. J. (2014). Participation and social participation: are they distinct concepts? Clinical
Rehabilitaion, 28(3), 211-220. doi: 10.1177/0269215513499029.
Preis J., & McKenna M. (2014). The effects of sensory integration therapy on verbal expression
and engagement in children with autism. International Journal of Therapy and
Rehabilitation, 21(10), 476-486.
Roley S. S., Mailloux Z., Parham L. D., Schaaf R. C., Lane C. J., & Cermak S. (2015). Sensory
integration and praxis patterns in children with autism. American Journal of
Occupational Therapy, 69(1), 1-8.
Schaaf R. C., Hunt J., & Benevides T. (2012). Occupational therapy using sensory integration to
improve participation of a child with autism: a case report. American Journal of
Occupational Therapy, 66(5), 547-555.
Watling R.L., Dietz J. (2007). Immediate effect of Ayres sensory integration-based occupational
therapy intervention on children with autism spectrum disorders. American Journal of
Occupational Therapy, 61(5), 574-583.

Results

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Author/Dat
e

Undesired
Behaviors

Watling et
al. (2007)

Objective
during
interventio
n - no
changes

Task
Engagemen
t

Adaptive
Behaviors

Participatio
n
(social)/So
cial
responsive
ness

Sensory
Processing

Schaaf et
al. (2012)

Increase
participatio
n at home,
school, and
family
activities

Increase

Roley et al.
(2012)
*Strengths
and
difficulties
of children
w/ASD

Increase

Increase

Increase in
social
responsive
ness

Increase

Functional
Motor
Skills

Social/Emo
tional
Factors

Subjective
- long term
during
treatment
and at
home may
be
beneficial

Pfeiffer et
al. (2011)

Decrease in
autistic
mannerism
s

Iwanagana
et al.
(2013)

Increase

Preis et al.
(2014)

Increase

Bagatell et
al. (2010)

Increase in
lassroom
participatio
n

Miller et al.
(2007)

Fazlioglu
et al.
(2008)

Increase in
positive
behaviors,
decrease in
negative
behaviors.

Increase

Increase in
attention
intelligence
(leiter-r)

Increase

Increase in
hearingspeaking,
attention,

Increase in
seeing,
taste-smell,
touch

Increase in
social
intelligence
(leiter -r)
Increase in
balance,
muscular
tonus

Communic
ation

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Tests/Assessments
Watling et
al. (2007)

Schaaf et
al.
(20012)

Roley et
al. (2014)

Sensory
Integratia
nd Praxis
Test
(SIPT)

Yes

Yes

Goal
Attainme
nt Scale

Yes

Yes

The
Parent
Rating
Form of
the
Vineland
Adaptive
Behavior

Yes

Yes

Scales,
Second
Edition
(VABS
II)

Yes

Pervasive
Develop
mental
Disorder
Behaviora
l
Inventory
(PDDBI)

Yes

Video

Yes

Rating

Yes

Procedura
l
Reliablity
Checklsit

Yes

Sensory
Processin
g
Measure
(SPM)

Yes

Total
Sensory
Scale

Yes

Ideas and
planning
score

Yes

Bagatell
et al.
(2010)

Yes

Miller et
al. (2007)

Fazlioglu
et al.
(2008)

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

Leiter
Internatio
nal
Performa
nce Scale
- Revised:
Parent
Rating
Scale
(Leiter
-R)

Yes

Short
Sensory
Profile
(SSP)

Yes

Child
Behavior
Checklist
(CBCL)

Yes

Electrode
rmal
reactivity
(EDR)

Yes

Sensory
evaluatio
n form for
children
with
autism

Yes

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM

INCREASED EFFECTIVENESS OF SENSORY INTEGRATION WITH AUTISM