Sensory Integration Therapy review by pharmphresh23

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									Sensory Integration Therapy
  for Children with Autism
   What is Sensory Integration
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
       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
     Proprioceptive System
Receives input from joints and muscles
This input helps us to locate our bodies in
Movement is often slow and clumsy
Trouble learning new skills
          Tactile System
Involve increased or decreased reaction to
Or difficulty receiving information by touch
May experience under-responsive tactile
May experience over-responsive tactile
 History of Sensory Integration
 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
 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
Meaningful sensory-motor activity is a
powerful mediator of plasticity
    Meet Dr. A Jean Ayres
Born in 1920 and grew up on a farm in
Visalia, California
As a child, she struggled with learning
Masters Degree in Occupational Therapy
Doctorate in Education Psychology
Postdoctoral work at UCLA’s Brain
Research Institution
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
         The Ayres Clinic
Founded in 1976 by A. Jean Ayres

Was Dr. Ayres private practice

Today, it is part of Sensory Integration
        The Ayres Clinic



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
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
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.”
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
Sensory Integration: The Therapy
SI therapy provides opportunities for
engagement in sensory motor activities that are
rich in tactile, vestibular, and proprioceptive
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
Sensory Integration: Key Principles
            of Therapy
   Principle                           Description

Just Right       Therapist creates playful activities with achievable
Challenge        challenges

The Adaptive     In response to challenge, the child adapts his or her
Response         behavior with new and useful strategies, furthering

Active           The methods of play incorporate new and advanced
Engagement       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
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
Sensory Integration: The Therapy
              Tactile System

Some tactile activities include:
– Koosh ball games
– Feely bags
– Hiding objects in rice, beans, kitty litter, and
– Shaving cream painting and drawing
– Drawing shapes on the child’s back
– Brushing, interspersed with joint compression
– Deep pressure massages
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
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
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
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
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
What does the research tells us?
– 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”
        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
        The Argument cont.
– 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.
      The Argument cont.
– 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:
       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
              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.
     Iwata and Mason cont.
– Sally, 6 years old, severely mentally retarded with no
  language skills. She also had very few independent
– 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.
    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
     – Used three types of settings to utilize these techniques.
       Each subject exposed to all three during each 15- minute
– 3- using behavioral interventions
       Iwata and Mason cont.
 – 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
 – 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.
            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
– Program used principles of ABA
      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.
     More Research cont.
– 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
– Each participant therefore had three
  categories graphed.
        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
      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
                   Conclusions and
  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.
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!

 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.
Research must depend on clear
definition of terms:
 Classical “Sensory Integration Therapy”
 based on A. Jean Ayres model
  – 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
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

   – 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.
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
“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)
More objective and direct methods
must be used to diagnose/characterize
individuals with sensory integration
 Physiological measures currently being
 studied include:
  – Electrodermal Reactivity (EDR)
  – Vagal Tone (VT)
  – Posturography
  – Galvanic Skin Response (GSR)
  – EEG
  – Brain studies
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
  – Children with ASD not included in normative sample.
•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
  – Results are correlated with physiologic measures
    (EDR) of sensory reactivity (p < .01)
Additional clinical research must be
administered in a replicable
Research must:
  – utilize subjects identified by licensed professionals as
    demonstrating sensory integration deficits using
    standardized behavioral and/or physiological
  – 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
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
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.
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.)
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

 Share results with parents/other professionals in
 order to make better informed program
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.
Baranek, G.T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and
      Developmental Disorders, 32,397-422.
Baron-Cohen, S. (2004). The cognitive neuroscience of autism. Journal of Neurology, Neurosurgery and Psychiatry,
      75, 945-948.
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, 283-290.
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, 551-552.
Fertel-Daly, D., Bedell, G. & Hinojosa, J. (2001). Effects of a Weighted Vest on Attention to Task and Self-Stimulatory
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Sensory Integration Disorder.
Sensory Integration International-The Ayres Clinic.
Sensory Integration Therapy.
Sensory Integration and Praxis Tests (SIPT). https://www-
Sensory Integration Courses.
Sensory Profile.

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