1. Sensory Integration Therapy for Children with Autism

2. What is Sensory Integration Therapy?
Sensory Integration Therapy (SIT) is a sensory-motor treatment
SIT looks like play, because play is a child’s way of learning and developing
SIT is designed to restore effective neurological processing by enhancing the vestibular, proprioceptive, and tactile systems

3. Vestibular System Involves inner ear responses to movement and gravity
Influences balance, emotions, muscle tone, and eye movement
Vestibular processing may be under-responsive or over-responsive

4. Proprioceptive System
Receives input from joints and muscles
This input helps us to locate our bodies in space
Movement is often slow and clumsy
Trouble learning new skills

5. Tactile System Involve increased or decreased reaction to touch
Or difficulty receiving information by touch
May experience under-responsive tactile processing
May experience over-responsive tactile processing

6. History of Sensory Integration Therapy
Ayres developed a theoretical model, the theory of Sensory Integration
Based on principles from neuroscience, biology, psychology and education
Faulty integration of sensory information
Inability of higher centers to modulate and regulate lower brain sensory-motor centers

7. History of Sensory Integration Therapy (con’t)
Sensorimotor development is an important substrate for learning
The interaction of the individual with the environment shapes brain development
The nervous system is capable of change (plasticity)
Meaningful sensory-motor activity is a powerful mediator of plasticity

8. Meet Dr. A Jean Ayres
Born in 1920 and grew up on a farm in Visalia, California
As a child, she struggled with learning problems
Masters Degree in Occupational Therapy
Doctorate in Education Psychology
Postdoctoral work at UCLA’s Brain Research Institution

9. Meet Dr. A Jean Ayres (con’t)
Developed diagnostic tools for identifying the disorder
Proposed a therapeutic approach that transformed pediatric occupational therapy
1972, Sensory Integration International was established

10. The Ayres Clinic Founded in 1976 by A. Jean Ayres
Was Dr. Ayres private practice
Today, it is part of Sensory Integration International

11. The Ayres Clinic
Assessment
Treatment
Education
Research

12. Sensory Integration: The Theory
Ayres (1972) hypothesized that…
“learning is a function of the brain [and] learning disorders reflect some deviation in neural functions”
Since some individuals with learning disorders have motor or sensory problems, they have difficulty processing and integrating sensory information
This inability to integrate sensory information causes behavior and learning problems
This is referred to as Sensory Integrative Dysfunction

13. Sensory Integration: The Theory
Later, Ayres and Tickle (1980) applied the theory to children with autism and further hypothesized that…
SI helped decrease tactile and other sensitivities to stimuli that interfere with these individuals’ ability to play, learn, and interact
Poor sensory processing among individuals with autism may contribute to maladaptive behaviors of these children and impact their ability to participate in social, school, and home activities
Autism is said to be a factor contributing to Sensory Integrative Dysfunction

14. Sensory Integration: The Theory
According to Ayres,
“A sensory integrative approach to treating learning disorders differs from many other approaches in that it does not teach specific skills. Rather, the objective is to enhance the brain’s capacity to perceive, remember, and motor plan. Therapy is considered a supplement, not a substitute to formal classroom instruction.”

15. Sensory Integration: The Theory
The focus is on 3 sensory systems: Tactile, Vestibular, and Proprioceptive
The interrelationship among these sensory systems is critical to one’s basic survival (most people can integrate and interpret sensory information automatically)
These systems interact with each other, allowing us to experience, interpret, and respond to different stimuli in our environment

16. Sensory Integration: The Therapy
SI therapy provides opportunities for engagement in sensory motor activities that are rich in tactile, vestibular, and proprioceptive sensations
The child is guided through challenging and fun activities designed to stimulate and integrate sensory systems, challenge his or her motor systems, and facilitate integration of sensory, motor, cognitive, and perceptual skills

17. Sensory Integration: Key Principles of Therapy
Description
Just Right Challenge
Therapist creates playful activities with achievable challenges
The Adaptive Response
In response to challenge, the child adapts his or her behavior with new and useful strategies, furthering development
Active Engagement
The methods of play incorporate new and advanced abilities that increase the child’s repertoire of skills and processing
Child Directed
Therapist constantly observes the child’s behavior and reads behavioral cues, follows the child’s lead or suggestions, and uses these cues to create enticing, sensory rich activities

18. Sensory Integration: The Therapy
Tactile System
Processes information taken in by touch
Some deficits may include:
sensitivity to touch
difficulty in discriminating textures
avoiding getting wet or dirty
food selectivity based on texture or temperature

19. Sensory Integration: The Therapy
Tactile System
Some tactile activities include:
Koosh ball games
Feely bags
Hiding objects in rice, beans, kitty litter, and sand
Shaving cream painting and drawing
Drawing shapes on the child’s back
Brushing, interspersed with joint compression
Deep pressure massages

20. Sensory Integration: The Therapy
Vestibular System
Processes information based on balance and gravity
Some deficits include:
lack of awareness of body in space
intolerance of movement
avoiding physical activities
constant movement, spinning

21. Sensory Integration: The Therapy
Vestibular System
Some vestibular activities include:
Teaching children to spin
Rolling in a barrel
Sitting or bouncing on an exercise ball
Swinging on a hammock
Scooter board relay races
Walking on a balance beam
Stair climbing

22. Sensory Integration: The Therapy
Proprioceptive System
Processes information based in muscles and joints
Some deficits include:
difficulty with motor skills
lack of coordination
difficulty holding a writing utensil
falls or walks into objects often

23. Sensory Integration: The Therapy
Proprioceptive System
Some proprioceptive activities include:
Tug-of-war
Backpack hiking
Jumping over obstacles
Crab walking relay races
Crawling under a parachute

24. Sensory Integration: Outcomes
According to Ayres, some outcomes from SI therapy include:
Ability to concentrate
Ability to organize
Increase in self-esteem
Increase in self-control
Increase in self-confidence
Improvement in academic learning ability
Capacity for abstract thought and reasoning
Specialization of each side of the body and the brain

25. What does the research tells us?
THE ARGUMENT:
Howard Goldstein, in 2000, wrote a commentary to research studies conducted by Edelson, Rimland and Grandin.
Commentary entitled, Interventions to Facilitate Auditory, Visual and Motor Integration: “Show Me the Data”

26. The Argument cont.
Goldstein dissected the research done in these fields. His conclusion was that there was no substantial evidence to conclude the effectiveness of such treatments.
Most of the data was unreliable due to lack of experimental control, subject selection, research design (or lack there of), and subjective measurement tools.
Since there was no data to support claims made by such therapies, it is not justifiable nor ethical to promote such therapies to parents using such claims.

27. The Argument cont. THE REBUTAL:
Edelson, Rimland and Grandin in 2003 discuss the false accusations made by Goldstein that their research was lacking such data.
The researchers claim that statistically significant data was found in conclusion to their research studies and that with such a large number of participants their claims were justified.
This article does not include how these claims are justified but instead uses numbers to explain effects. The numbers are arbitrary in that they do not explain how participants were selected, the research method, and the measurement tool.

28. The Argument cont. THE COUNTER ARGUMENT:
Goldstein comments again in 2003 to the claims made by his opponents. He justifies his claims of his want for data.
Goldstein takes apart studies done in:
AIT
SIT

29. The Argument cont.
Goldstein claims that research is lacking in AIT but mostly in SIT (especially Grandin’s hug machine)
Goldstein explains the lack of data using four criteria:
The lack of randomization of participants
The choice of variables
Statistically Significant data that is NOT
Replication is lacking

30. SIT on SIB Iwata and Mason, 1990 study:
Investigated three types of SIB:
Attention-getting SIB
Stereotypic SIB
SIB that functioned as escape behavior
Study used previous research of SIT and its affects on decreasing SIB in individuals.

31. Iwata and Mason cont. Participants:
Sally, 6 years old, severely mentally retarded with no language skills. She also had very few independent skills.
Kathy, 3 years old, profoundly mentally retarded with cerebral palsy and scoliosis and no language skills and no independent skills.
Mort, an 18-year-old male, profoundly retarded, with microcephaly and scoliosis. He had minimal skills and no language skills.
All participants displayed SIB producing tissue damage that was at a moderate risk level.

32. Iwata and Mason cont. 3 phases to study:
1- observation/baseline condition to determine function of SIB
2- exposure to SIT
A variety of techniques were utilized:
Auditory, kinesthetic, tactile, vestibular, and visual stimulation.
Used three types of settings to utilize these techniques. Each subject exposed to all three during each 15- minute session.
3- using behavioral interventions

33. Iwata and Mason cont. Results:
All participants SIB decreased significantly and at near zero levels only during the behavioral intervention phase.
During the SIT phase SIB was variable and SIB only decreased during therapy sessions.
Parents were trained in implementing the behavioral interventions to reduce SIB after the conclusion of the study.
During a 6-month follow-up Mort’s and Sally’s SIB remained at 0% and Kathy’s SIB was similar to that in phase 3 of the experiment at 8%.
The data show that behavioral interventions show a maintained effect on decreasing SIB.

34. More Research
Fertel-Daly, Bedell and Hinojosa in 2001 conducted a research study on the effects of a weighted vest on attention to task and self-stimulatory behavior.
Five participants for this study:
Ranged in age from 2-4 years old.
All were diagnosed with PDD.
Not currently treated with a weighted vest
Reported to have difficulties in attending to tasks.
Enrolled in a 5 day a week preschool program (3 hrs daily)
Program used principles of ABA

35. More Research cont. Followed an ABA reversal design.
Allowed for comparison between wearing and not wearing the vest and effects on attending.
Measurement procedure recorded the duration of focused attention to task, number of distractions, and duration and type of self-stimulatory behaviors during 5-min intervals.
Vests were worn for 2 hours and then off for 2 hours to follow previous research.

36. More Research cont. Results:
Duration of attention and duration of self stimulatory behavior were depicted on graphs in seconds for each participant. The number of distractions was also depicted per participant.
Each participant therefore had three categories graphed.

37. More Research cont. Results cont:
Results showed that there was a positive effect on at least two measures for the 5 participants. (less distractable and less self stimulatory behaviors occurred)
All increased in focused attention but the extent to which the increase occurred, varied.
All participants also showed an increase in this category when the vest was not worn during the withdrawl phase. What does this say about the functional relationship between the weighted vest and attending?
After removing the weighted vest 4 participants had an abrupt decrease in duration of focused attention. Therefore, demonstrating that effects are short lived.
No return to baseline between interventions could this effect results?

38. Conclusions and Recommendations:
Current research based on scientific criteria does not support Sensory Integration Therapy as an effective treatment for improving behavior and learning of individuals with autism.
However, some studies have been published indicating specific sensory intervention strategies have improved some specific aspects of behavior.
Many studies, either “proving” or “disproving” the effects of SIT have not clearly defined terms and have not followed rigorous research procedures.

39. The effect of Sensory Integration Therapy is neither proven nor
After a review of the literature, the appropriate scientific conclusion is that:
The effect of Sensory Integration
Therapy is neither proven nor
unproven at this point.
More research is needed!

40. Specifically: Terms must be clearly defined.
More objective criteria must be used to characterize and diagnose individuals with sensory processing deficits
Clinical trials must be administered in a replicable fashion using specific sensory integration techniques to address specific observable behaviors.
Autism practitioners must keep informed on current research in the field.

41. Research must depend on clear definition of terms:
Classical “Sensory Integration Therapy” based on A. Jean Ayres model specifically:
Is based on inference that tactile, vestibular and kinesthetic experiences treat disruptions in subcortical functions of CNS.
Utilizes activities chosen/controlled by child
Always involves use of specialized equipment such as swing, usually in clinical setting

42. Current “best practice” in field of occupational therapy uses “Sensory-Based O. T.” model:
Assessment and intervention imbedded in activities that are part of individual’s daily routine/instructional program
Goal is not to “cure” individual but to use purposeful and meaningful activities to maximize potential.
Intervention at impairment level (e.g., to address specific sensory problems in processing tactile, proprioceptive, or other sensory stimuli), but imbedded in occupational functioning.

43. Sensory-Based O.T., cont.
Emphasis not on repairing CNS functioning, but on increasing productive behavior by improving processing of sensory stimuli. Specific goals would include reduction in rates of aberrant behaviors that interfere with learning, enhanced ability to focus on relevant materials/activities, and increased ability to self-regulate.

44. “Sensory Stimulation” programs:
Involve providing specific type of sensory stimulation through circumscribed modality (e.g., touch pressure, vestibular stimulation, tactile stimulation)
Child is passive recipient of techniques
Used to modulate arousal, increase attention, increase self-regulation of behavior
Includes techniques such as sensory brushing, weighted vests, sensory diets, or deep pressure
Used either in isolation, or in conjunction with sensory-based O.T. or other programs (e.g., ABA)

45. More objective and direct methods must be used to diagnose/characterize individuals with sensory integration deficits:
Physiological measures currently being studied include:
Electrodermal Reactivity (EDR)
Vagal Tone (VT)
Posturography
Galvanic Skin Response (GSR)
EEG
Brain studies

46. Standardized behavioral measures currently being used to diagnose sensory integrative dysfunction include:
Sensory Integration and Praxis Test (SIPT)
Reported to measure visual, tactile, and kinesthetic perception and motor coordination using direct administration of 17 tests
Standardized on national sample of more than 2000 children. Provides norms for each test.
Must be administered by O.T. who has completed post-graduate courses and certification specifically in Sensory Integration and test administration
Developed by Ayres
Research indicates that about 1/3 of tests are unstable.
Children with ASD not included in normative sample.

47. Sensory Profile Behavioral questionnaire completed by parent
Contains 125 items grouped into categories of Sensory Processing, Modulation, and Behavioral and Emotional Responses
Standardized on more than 1200 children.
High internal reliability, validity measures vary between sections
Has been used to correctly distinguish between children with ASD, ADHD, and typically developing children
Results are correlated with physiologic measures (EDR) of sensory reactivity (p < .01)

48. Additional clinical research must be administered in a replicable fashion:
utilize subjects identified by licensed professionals as demonstrating sensory integration deficits using standardized behavioral and/or physiological assessments
target specific observable behaviors and/or physiological measures and incorporate specifically defined SI techniques
use randomized assignment of subjects to treatment groups, non-treatment groups, and/or alternative treatment groups

49. Research must:
use blind assessments of specific behaviors pre- and post-treatment
Utilize research design which will increase validity of study (e.g., alternating treatment design vs. pre-post-treatment design).
Be published in peer-reviewed journal
Stand up to replication and analysis by other professionals in the field

50. As professionals/parents in the autism field, we should:
Keep current on research in the field of Sensory Integration, analyzing all information presented in terms of scientific criteria
If sensory integration therapy is recommended for a particular child, share research findings with parents/other professionals
Make sure all parties have clearly defined specific type of therapy being proposed and specific observable outcomes expected.

51. We should:
If SIT is already part of child’s program, use principles of ABA to attempt to establish functional relationship between treatment and observable outcomes in terms of specific and observable behaviors.
Collect data: baseline, during treatment, post-treatment, generalization.
Investigate possible antecedent or consequent effects of intervention (e.g., adult attention, engagement in preferred activity, etc.)

52. We should:
If possible, incorporate aspects of single-subject research design to further establish whether or not treatment affected behavior: ABAB design, alternating treatment design, or multiple baseline design.
Share results with parents/other professionals in order to make better informed program decisions

53. It is simplistic to say that “Sensory Integration Therapy does not work.”
While Ayres’ underlying “theory” does not appear to be based on scientific data and has not been supported by current research, there is increasing research in the area of physiological evidence for differences in sensory processing
Current research may be used to create hypotheses for further, more scientifically valid research in the field of sensory integration.

54. References
Baranek, G.T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders, 32,
Baron-Cohen, S. (2004). The cognitive neuroscience of autism. Journal of Neurology, Neurosurgery and Psychiatry, 75,
Bundy, A.C. & Murray, E.A. (2002). Sensory Integration: A. Jean Ayre’s Theory Revisited. In A.C. Bundy, E.A. Murray & S. Lane (Eds.), Sensory Integration: Theory and Practice. Philadelphia: F.A. Davis.
Dunn, E.J. (1998). The sensory profile: a discriminant analysis of children with and without disabilities. American Journal of Occupational Therapy, 52,
Edelson, S.M., Rimland, B., & Grandin, T. (2003). Response to Goldstein’s Commentary: Interventions, to Facilitate Auditory, Visual, and Motor Integration: “Show Me the Data”. Journal of Autism and Developmental Disorders, 33,
Fertel-Daly, D., Bedell, G. & Hinojosa, J. (2001). Effects of a Weighted Vest on Attention to Task and Self-Stimulatory Behaviors in Preschoolers with Pervasive Developmental Disorders. The American Journal of Occupational Therapy, 55,
Goldstein, H. (2003). Response to Edelson, Rimland, and Grandin’s Commentary. Journal of Autism and Developmental Disorders, 33,
Goldsetin, H. (2000). Commentary: Interventions to Facilitate Auditory, Visual, and Motor Integration: “Show Me the Data”. Journal of Autism and Developmental Disorders, 30,
Iwata, B. & Mason, S. A. (1990). Artificial Effects of Sensory-Integrative Therapy on Self-Injurious Behavior. Journal of Applied Behavior Analysis, 23,
Miller, L.J. (2003). Empirical evidence related to therapies for sensory processing impairments. NASP Communiqué, 31.
Schaaf, Roseann C., & Miller, Lucy Jane. (2005). Occupational Therapy Using A Sensory Integrative Approach for Children with Developmental Disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 11,
Smith, T., Mruzek, D.W., & Mozingo, D. (2005). Sensory Integrative Therapy. In J.W. Jacobson, R.M. Foxx, & J.A. Mulick, (Eds.), Controversial Therapies for Developmental Disabilities. Mahwah, N.J.: Lawrence Erlbaum Associates.

55. Resources
Sensory Integration Disorder.
Sensory Integration International-The Ayres Clinic.
Sensory Integration Therapy.
Sensory Integration and Praxis Tests (SIPT).
Sensory Integration Courses.
Sensory Profile. US/dotCom/SensoryProfile/About/Sensory+Profile