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252 Occupational Therapy International, 5(4), 252–272, 1998 © Whurr Publishers Ltd

Sensory integrative techniques

applied to children with learning
disabilities: An outcome study

LAURIE L. STONEFELT Mountain Board of Cooperative Education Ser-

vices, Leadville, Colorado, USA
FRANKLIN STEIN Department of Occupational Therapy, University of
South Dakota, Vermillion, USA

Abstract: Learning disabilities are the most frequently reported causes of functional
limitation among school-age children (McNeil, 1995). Many children with learning
disabilities have an underlying sensory integrative dysfunction (Hoehn and Baumeister,
1994); therefore, sensory integration therapy has been widely used in treating those
children. Research on the effectiveness of sensory integration therapy in treating chil-
dren with learning disabilities has shown conflicting results; many studies supported the
use of sensory integration therapy, whereas others did not. Most of the literature indi-
cates a need for further study in this area. The current study focused on the effective-
ness of sensory integration therapy in treating children with learning disabilities, as
perceived by their parents, teachers and occupational therapists. Thirty surveys were
sent to participants in the Midwest: 10 each to parents, teachers and occupational ther-
apists. Twenty-three surveys were returned, giving a response rate of 77%. Most of
the respondents identified that sensory integration therapy was extremely or somewhat
effective in helping the children improve function in 12 skill areas. All parents reported
doing activities in the home to help their child and all teachers reported making adapta-
tions in the classroom to better accommodate the child. The sensory integrative tech-
niques most frequently used by the therapists were linear activities, tactile stimulation,
games and jumping/bouncing. Seven of the therapists reported using another treatment
method in addition to sensory integration. These seven noted that a combination of
treatments, a multimodel approach, was more effective than sensory integration alone.
This study was consistent with previous research showing that sensory integration is an
effective treatment method for children with learning disabilities. However, further
research is needed using prospective designs involving single-subject or group studies
where extraneous variables are rigorously controlled.

Key words: sensory integration, sensory integrative techniques, learning dis-

abilities.
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Sensory integrative techniques: an outcome study 253

Introduction
Learning disabilities are the most frequently reported causes of functional lim-
itation among school-age children (McNeil, 1995). Children with learning
disabilities account for about 45% of all children who receive special services
in the public school system (National Center for Education Statistics, 1993).
Nearly 4 million school-age children have been diagnosed with learning dis-
abilities. Under the Individuals with Disabilities Education Act (1990), all
children with learning disabilities are entitled to public schooling and an Indi-
vidualized Education Program tailored to their needs (National Institute of
Mental Health (NIMH), 1993).
Many children with learning disabilities have problems in sensory integra-
tion, to which some or all of their learning difficulties can be attributed
(Hoehn and Baumeister, 1994). Although sensory integration therapy has
been used in treating many people with various disabilities, it has been applied
primarily to children with learning disabilities (Clark et al., 1989). Whether
or not sensory integration therapy is an effective treatment for this popula-
tion, however, is a controversial issue.
Cummins (1991), Polatajko and colleagues (1992) and Hoehn and
Baumeister (1994) stated that sensory integration therapy is not effective in
treating children with learning disabilities. In contrast, research by Wilson
and Kaplan (1994) and Fanchaing (1996) indicated that sensory integration
therapy is effective. Furthermore, many other studies have indicated that
there is a need for further research before conclusions can be made (for
example, Yack, 1989; Wilson et al., 1992; and Kaplan et al., 1993).
There are several specific areas in which children with learning disabilities
have difficulties. According to Schaffer and colleagues (1989), more research
is needed to determine the effectiveness of sensory integration therapy with
children with sensorimotor difficulties related to learning disabilities. It has
been shown, however, that sensory integration is a vital prerequisite for acade-
mic abilities. Therefore, an effective treatment for sensory integration dys-
function must be demonstrated in order to successfully treat children with
learning disabilities and help them achieve at their fullest potential in school.
Werry and colleagues (1989) concur with Schaffer et al. (1989). They state
that sensory integration is a popular treatment method for children with
learning disabilities and although much evidence has been found against it,
more research is clearly needed.

The literature review

Conceptual definitions

Sensory integration is the automatic organization of all sensory input (sound,

sight, taste, proprioception, vestibular information, and so on) to be used
together for perception, adaptation or a learning process (Ayres, 1979). It is a
developmental process in the nervous system; the ability to take in informa-
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254 Stonefelt and Stein

tion through the senses, organize it in the brain and use it to generate a
response to the environment (Toronto Sensory Integration Group, 1987).
Sensory integration therapy uses the patient’s natural reactions and adapta-
tions to the environment. Treatment involves various types of sensory input
to help the brain to learn to organize this input for use (Ayres, 1979). Accord-
ing to Ayres, ‘The central idea of this therapy is to provide and control sen-
sory input, especially the input from the vestibular system, muscles and joints,
and skin in such a way that the child spontaneously forms the adaptive
responses that integrate those sensations’ (p.140). An important part of sen-
sory integration therapy is allowing the patient to choose activities in which
he or she would like to participate. The therapist may give the patient specific
activities to choose from, but the patient makes the ultimate decision. The
therapist should direct the environment unobtrusively, allowing the patient to
direct his or her actions (Toronto Sensory Integration Group, 1987).
Learning disability is a disorder that affects a person’s ability to interpret
what is seen and heard or to integrate information from different parts of the
brain. These limitations can be seen in many areas (for example, spoken and
written language, coordination, self-control, attention and mathematics).
Learning disabilities can have an effect on many aspects of a person’s life, not
just school (NIMH, 1993). Common characteristics of children with learning
disabilities include: male, IQ within the normal range (but at the lower end),
developmental delay in speech, with the greatest academic deficits in lan-
guage and reading (Schaffer et al., 1989).

Identification and operational definition of variables

Determining the operational definition of sensory integration therapy is diffi-
cult. There is not one specific treatment protocol to follow for all patients in
sensory integration therapy; treatment depends on each individual and his or
her needs. It is the responsibility of the therapist to determine which activities
will be most beneficial to the patient. The following is an example of a sen-
sory integration treatment session with a child (referred to here as J) who had
a sensory-integrative dysfunction. According to Trott and colleagues (1993) of
Albuquerque Therapy Services, a typical therapy session would take place as
follows:

A typical treatment session with J begins in a large treatment room equipped with
simple, yet special equipment. Swings, bolsters, slides, therapeutic balls, mattresses filled
with water, and mattresses filled with foam comprise some of the equipment used. J is
treated by an occupational therapist (Sue) in conjunction with a speech pathologist
(Marci). Sue swings J in a linear direction and then adds moderate rotary components
to the direction of the swing. This vestibular activity helps J to be at an optimal arousal
level for the treatment session.
Next, both J and Sue straddle a big air-filled inner tube (Blackie) and bounce up
and down while going round and round. This proprioceptive input helps to modulate J’s
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Sensory integrative techniques: an outcome study 255

overactive vestibular system. It is important to encourage heavy work or proprioceptive

activities which support J’s ability to process both tactile and vestibular input. After J
and Sue bounce around the tube, Sue hands J a flash card which pictures the body of an
animal. J runs to Marci who has flash cards laid out on the floor picturing the heads of
animals. J matches her card to Marci’s. Marci says the name and asks J to repeat it. J
repeats the name with limited success. J then runs to Sue, mounts Blackie, and starts to
bounce up and down and around and around. Marci and Sue encourage J to say ‘alliga-
tor’ while she is bouncing. This bouncing helps to increase the respiratory support for
speech.
The treatment session continues as the flexion swing is the next activity that J
chooses. She hangs on to the bolster while Sue swings and bounces. This requires a
good flexor pattern. Antigravity flexion is an important component that helps motor
planning in early development.
The next activity involves both speech and occupational therapy. After climbing
onto a platform, J chooses two colored marking pens to throw to Marci who is sitting
on a water-filled mattress. She then swings from the platform on a trapeze ... J then
releases the trapeze bar and falls into a large soft mattress filled with pieces of foam. The
mattress feels like gelatin. The fall provides joint compression, which also activates the
joint receptors to increase proprioception for stability and mobility. J then walks across
the unstable surface of the mattress, which adds rotational and transitional components
of proprioception to the activity.
J then sits down with Marci who draws a picture of a cake with candles. She asks J
to help blow them out. This blowing helps to increase J’s respiratory support for speech.
Marci has J repeat words such as ‘birthday’ because multi-syllable words aid in oral-
motor planning. J can choose to have candy during the treatment session. Sucking hard
candy is believed to aid in flexion components. Chewy, sticky candy aids in the mobili-
ty of the oral mechanism involving chewing and tongue lateralization as well as sensory
registration. All of these components improve oral-motor skills, which facilitate speech
and language development ... J repeats the sequence ... This repetition allows for
sequencing of events as well as initiation components of praxis. (pp.33–4)

The above scenario is just one example of how a treatment session can be
conducted. For each patient, therapy will be highly individualized. However,
there is one constant in treating all patients: they should be allowed to choose
the activities (that the therapist has already set up) in which they want to
participate. It is very important to remember, also, that treatment sessions are
as unique as the individual for whom they are developed and implemented.
Each person has different disabilities and needs around which therapy should
be centred.
There have been many different definitions reported for learning disabili-
ties. Professionals often disagree on which definition is most appropriate and
most accurately defines learning disabilities. However, one definition that has
been widely accepted, according to Rourke and DelDotto (1994), is a modifi-
cation of the definition by the National Joint Committee on Learning Dis-
abilities:

Learning disabilities is a generic term that refers to a heterogeneous group of disorders

manifested by significant difficulties in the mastery of one or more of the following: lis-
tening, speaking, reading, writing, reasoning, mathematical, and other skills and abili-
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256 Stonefelt and Stein

ties that are traditionally referred to as ‘academic.’ The term learning disabilities is also
appropriately applied in instances where persons exhibit significant difficulties in mas-
tering social and other adaptive skills and abilities. In some cases, investigations of
learning disabilities have yielded evidence that would be consistent with hypotheses
relating central nervous system dysfunction to the disabilities in question. Even though
a learning disability may occur concomitantly with other handicapping conditions (e.g.,
sensory impairment, mental retardation, social and emotional disturbance) or environ-
mental influences (e.g., cultural differences, insufficient/inappropriate instruction, psy-
chogenic factors), it is not the direct result of those conditions or influences. However,
it is possible that emotional disturbances and other adaptive deficiencies may arise from
the same patterns of central processing assets and deficits that generate the manifesta-
tions of academic and social learning disabilities. (p.90)

Underlying theoretical assumptions

• The number of children with learning disabilities is increasing at a rapid
rate (Feagans, 1983).
• It is important to provide effective treatment for children with learning
disabilities (NIMH, 1993).
• Some children with learning disabilities have problems in sensory integra-
tion to which some or all of their learning difficulties can be attributed
(Hoehn and Baumeister, 1994).
• Sensory integration therapy is used to alleviate some sensorimotor disor-
ders that cause motor or academic difficulties and facilitate sensory pro-
cessing necessary in these skills (Hoehn and Baumeister, 1994).
• Sensory integration treatment is still in an experimental stage (Kaplan et
al., 1993).
• More research is needed in determining the effectiveness of sensory inte-
gration therapy on children with learning disabilities (Kaplan et al., 1993).

Related studies and their findings

Humphries and colleagues (1990) researched the effect of sensory integration
therapy compared with perceptual-motor training and no treatment on 30
children with learning disabilities. They chose to measure effects in four skill
areas: sensorimotor, cognitive, language and academics. On pre-test scores,
the three groups showed no differences in any of the areas. The group receiv-
ing sensory integration therapy showed significant improvement in motor
skills over the other groups on the post-test. However, significant differences
were not seen in any of the other areas. This study does not support Ayres’
theory that sensorimotor improvement will be followed by improvement in
higher-level processes such as language performance. The authors stated that
the debate about the efficacy of sensory integration therapy for children with
learning disabilities continues and more research is needed.
A study by Polatajko and colleagues (1991) examined the effect of sensory
integration therapy on academic achievement, motor performance and self-
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Sensory integrative techniques: an outcome study 257

esteem in children with learning disabilities. Some suggestions from previous

research to help control limitations – such as using a larger sample, including
a control group (which received perceptual motor therapy), using blind evalu-
ation of outcome, and providing follow-up data – were incorporated into their
study. Both groups showed significant improvement in academic achievement
and maintained or exceeded expected growth of motor performance. On the
self-esteem measure, the group receiving sensory integration therapy showed
no significant changes. The authors stated that the results could suggest that
both therapies are effective and it should be the therapist’s decision which to
use. Another possibility is that the two approaches could be used together for
maximum benefit; however, this needs to be researched further. Yet another
possibility is that the distinction often made between sensory integration
therapy and perceptual motor training is artificial. Again, this warrants fur-
ther investigation and discussion. The authors discussed possible errors/limita-
tions in their study. The sample may not have been homogeneous in some
unknown way, the sample may not have been large enough, and individual
differences in response to therapy may have been masked by the group results.
Since the authors found no significant differences between the two groups on
motor performance and academic achievement, they suggest a need for fur-
ther research in this area.
Law et al. (1991) also suggested that there is a great need for more
research. They saw a need to determine which children with which types of
difficulties best respond to sensory integration therapy. The results of the
study showed that children who were younger, who had more severe fine and
gross motor difficulties, who exhibited significant delays in written language
and who had higher mathematics scores, responded best to therapy. The study
by Law et al. generated a greater need for research. The authors suggest
descriptive work, single-case studies and naturalistic studies to aid in hypothe-
sis generation and population description. Law et al. stated that ‘once the
important characteristics of children who do respond to therapy are known,
then clinical trials with these children can more efficiently and effectively
measure the efficacy of sensory integration therapy’ (p.187).
Wilson et al. (1992) studied the effects of sensory integration therapy com-
pared with tutoring on children with learning disabilities, sensory integration
dysfunction and motor incoordination. After six months of treatment, no dif-
ferences were found in academics, fine and gross motor skills, or visual motor
skills between the groups. The group receiving sensory integration treatments
improved slightly on the behavioural measure whereas the group receiving
tutoring did not. The subjects were tested again 12 months on. Although chil-
dren in both groups showed improvement, there were no significant differences
between them except on the behavioural measure. The authors stated that it is
difficult to determine if improvement was a result of treatment or maturation.
However, they suggest that both treatments were somewhat effective, but it
must be determined which children respond best to which treatment.
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258 Stonefelt and Stein

Wilson and Kaplan (1994) did a follow-up study two years after comple-
tion of treatment in their first study. Neither group showed greater mainte-
nance of gains made in therapy, except in the gross motor area. More children
receiving sensory integration therapy continued to show gains in gross motor
skill two years after the completion of treatment than did children who
received tutoring. The authors stated that there is a need for more research
and ‘the challenge facing occupational therapists, therefore, is to clearly iden-
tify, possibly through qualitative, ethnographic investigations, the nature of
the change we hope to foster, and how other factors will modulate the
changes and our ability to measure them’ (p.263).
Humphries and colleagues (1993) also tested the effectiveness of sensory
integration therapy on children with learning disabilities. They compared a
group receiving sensory integration therapy with a group receiving perceptual
motor training and a group receiving no treatment at all. One factor that may
have influenced the outcome of the study was the type of sensory integrative
dysfunction that the children had. Although the groups were randomly
assigned, the types of dysfunction were not evenly distributed among them.
Results showed that children in the sensory integration group and children in
the perceptual motor group improved significantly over children who received
no treatment. However, there was no significant difference in the amount of
improvement between the two groups receiving occupational therapy inter-
vention. This finding may suggest that using more than one occupational
therapy intervention allows for more significant improvements.
Fanchaing (1996) reported on a narrative analysis of the life history of a
man (now 25 years old) with a learning disability who had received sensory
integration therapy as a child. Through reports made by the man, the author
discovered that with sensory integration therapy as well as other adaptations he
made, he was able to lead a successful life and achieve his goals. One source of
frustration for him was having energy bursts and a need for an adrenaline surge,
which would cause him to do delinquent acts to fulfil those needs. The sensory
integrative activities (for example, riding a bike and running) seemed to help
him burn up the extra energy while giving him the adrenaline surge he craved.
The man continues to choose sensory integrative activities to fulfil his needs
for sensory input. He has also learned to adapt to be successful in other areas of
his life, despite his learning disability. After working as a salesperson, he has
become a massage therapist which gives him the necessary tactile stimulation.
This man’s success is one example of how sensory integration can help some-
one overcome his/her learning disability and lead a fulfilling life.

Method

Subjects
Subjects for this study included the parents, teachers and occupational thera-
pists of children with learning disabilities who are receiving or have received
sensory integration therapy from an occupational therapist in two Midwestern
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Sensory integrative techniques: an outcome study 259

states. The occupational therapists in the study had been practising sensory
integrative techniques for 1 to more than 10 years. Five reported practising
sensory integrative techniques for 3–4 years, two for 1–2 years, and one for
more than 10 years.

Survey
The survey (see appendix) consisted of 21 questions that were asked to all
participants, followed by two to seven additional questions specific to the par-
ent, teacher or occupational therapist. Questions 1–21 involved the perceived
efficacy of sensory integration therapy in helping the child improve function
in 12 skill areas as well as demographic data regarding the child. The addi-
tional questions on the surveys for the parents and teachers related to the
effects in the home or classroom and activities or adaptations made for the
child. Questions specific to the occupational therapists involved specific sen-
sory integrative techniques and their effectiveness.

Data collection procedure

Thirty surveys were sent to the participants after they were located. The
investigator initially telephoned occupational therapists to gain informed
consent to participate and the address where the surveys were to be sent. Sur-
veys were sent in packets of three to the principal or occupational therapist of
each school in which a child had received sensory integration therapy for
learning disabilities. The principal or occupational therapist at the school
then distributed the surveys to the participants. Included in the packet was a
cover letter to the principal of the school to explain the purpose of the study
and ask consent that it be conducted in his/her school. The principal of each
school was asked to sign the form and return it to the researcher in a pre-
stamped envelope to indicate his/her consent that the study be conducted in
his/her school. Attached to each participant survey was a cover letter to
explain the purpose of the survey and discuss informed consent. The partici-
pants were asked to complete the survey and return it to the researcher in the
provided self-addressed, stamped envelope.

Results

Subjects

Of the 30 surveys that were sent out, 23 were returned, giving a response rate
of 77%. Eight were received from parents, seven from teachers and eight from
occupational therapists of children with learning disabilities. Surveys were
returned by the parent, teacher and occupational therapist for seven of the
children and, for the eighth child, surveys were returned by the parent and
occupational therapist.
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260 Stonefelt and Stein

Demographics

Perceptions about eight children were included in the study. Parents, teachers
and occupational therapists were asked about the demographics of the chil-
dren. Six of the children were under the age of five when they were diagnosed
with a learning disability, one was between the ages of five and six and one
was between the ages of seven and eight. The children had been receiving
occupational therapy services for less than one year and upwards. Most of the
children received therapy twice a week; however, a few received therapy three
or more times a week both in school and privately. One child’s therapy ses-
sions were 30–45 minutes long and the other children’s sessions were either
15–30 minutes or 45–60 minutes long.
There were many discrepancies between the parents’, teachers’ and occu-
pational therapists’ answers to the question regarding the specific types of
learning disability with which the child had been diagnosed. Table 1 summa-
rizes the responses given by the parent, teacher and occupational therapist for
each child.

TABLE 1: Specific learning disability diagnoses for each child

Child Responses
Parent Teacher Occupational therapist

A speech/language, ADHD,* speech/language, motor speech/language, ADD,†

motor skills skills, coordination motor skills, coordination
B speech/language, poor speech/language speech/language,
attention coordination, attention
C speech/language, reading, speech/language speech/language, writing,
writing, arithmetic, motor ADHD, motor skills
skills, coordination
D speech/language, reading, reading, writing, arithmetic, speech/language, reading,
writing, arithmetic, motor motor skills, coordination writing, motor skills,
skills, coordination coordination
E speech/language autism coordination
‡
F PDD speech/language speech/language, reading,
writing, motor skills,
coordination
G speech/language, reading, speech/language, reading, ADD
writing, ADD writing, arithmetic
H speech/language writing

* ADHD = Attention deficit hyperactivity disorder

† ADD = Attention deficit disorder
‡ PDD = Pervasive developmental disorder
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Sensory integrative techniques: an outcome study 261

In addition to occupational therapy, all of the children in the study

received speech therapy. A few received other services such as physical thera-
py, counselling, resource room (an open area for reading, listening to tapes or
watching videos), music therapy, early childhood services and special educa-
tion. The children were highly motivated to attend occupational therapy and
to participate in the activities offered.

Parents’ responses
Most parents reported that sensory integration therapy was extremely
or somewhat effective in helping the child improve function in each of the
12 skill areas. The number of responses in each category is displayed in
Table 2.
Five of the eight parents who responded said that the effects of sensory
integration therapy were very noticeable at home and three said that the
effects were somewhat noticeable. All eight parents reported that they were
doing one or more activities in the home to help the child. Table 3 shows the
activities and the number of parents who report doing those activities.

TABLE 2: The effectiveness of sensory integrative techniques on specific skill areas as per-
ceived by parents

1 – extremely 2 – somewhat 3 – not very 4 – not effective 5 – not

effective effective effective at all relevant
# % # % # % # % # %

Mathematics 3 38 1 13 0 0 0 0 2 25

Language 3 38 3 38 0 0 0 0 0 0

Reading 2 25 2 25 0 0 0 0 2 25

Gross motor 4 50 3 38 0 0 0 0 1 13

Fine motor 5 63 2 25 1 13 0 0 0 0

Balance 4 50 3 38 0 0 0 0 1 13

Coordination 6 75 2 25 0 0 0 0 0 0

Self-esteem 4 50 2 25 1 13 0 0 0 0

Behaviour 5 63 3 38 0 0 0 0 0 0

Social skills 3 38 3 38 1 13 0 0 0 0

Attention 4 50 3 38 1 13 0 0 0 0

Overall 5 63 3 38 0 0 0 0 0 0
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262 Stonefelt and Stein

TABLE 3: Activities parents are doing in the home with their children

Activities # of responses

Activities suggested by the child’s occupational therapist 8

Activities suggested by the child’s teacher 7

Hiring a tutor for the child 1

Other
Brushing 1
Joint compression 1
Reading and writing 1
Role playing 1

Teachers’ responses

Most of the seven teachers reported that sensory integrative techniques were
somewhat effective or extremely effective in the various skill areas. Table 4
shows their responses.

TABLE 4: The effectiveness of sensory integrative techniques on specific skill areas as per-
ceived by teachers

1 – extremely 2 – somewhat 3 – not very 4 – not effective 5 – not

effective effective effective at all relevant
# % # % # % # % # %

Mathematics 1 14 2 29 0 0 1 14 2 29

Language 1 14 3 43 0 0 1 14 1 14

Reading 1 14 2 29 0 0 1 14 2 29

Gross motor 2 29 2 29 1 14 0 0 1 14

Fine motor 2 29 3 43 1 14 0 0 0 0

Balance 2 29 3 43 0 0 0 0 1 14

Coordination 2 29 4 57 0 0 0 0 0 0

Self-esteem 2 29 2 29 0 0 0 0 2 29

Behaviour 2 29 3 43 0 0 0 0 1 14

Social skills 1 14 3 43 0 0 0 0 1 14

Attention 1 14 3 43 0 0 0 0 0 0

Overall 1 14 2 29 1 14 0 0 0 0
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Sensory integrative techniques: an outcome study 263

When asked whether the effects of therapy using sensory integrative tech-
niques were noticeable in the classroom, six teachers reported that effects
were noticeable and one did not answer the question. All seven teachers
reported that they had made adaptations in the classroom for the child. The
specific adaptations that were made are listed in Table 5.

TABLE 5: Classroom adaptations made by the teachers

Adaptations # of responses

Alternative methods of instruction 7

Allowing the child extra time to complete assignments 6

Changing the seating arrangement 4

Other
Allowing the child to use an Alpha-Smart computer 1
Allowing the child to take breaks as needed 1
Having a teacher’s aide in the classroom to help the child 1

Occupational therapists’ responses

Most of the eight occupational therapists reported that sensory integration
therapy was extremely or somewhat effective in helping the child improve
function in each of the 12 skill areas. The number of responses in each cate-
gory is shown in Table 6.
The most common sensory integrative techniques used by the therapists
were linear activities, tactile stimulation, games and jumping/bouncing. A
complete list of techniques used as reported by the therapists is displayed in
Table 7.
The therapists were asked to rank-order (from most effective to least effec-
tive beginning with 1) the techniques they used with the child. Three of the
therapists misunderstood the question; therefore, their responses cannot be
used. The rankings (from most effective to least effective) of the techniques
used by the other five therapists are summarized in Table 8.
The therapists were asked if they combined other treatment techniques
with sensory integrative techniques. Seven of the eight therapists reported
that they did use other techniques and one did not. All seven therapists who
used other techniques said that a combination of the techniques was more
effective than sensory integration alone. Table 9 lists the other techniques
and the number of therapists reporting their use.
The final question on the therapist survey asked about the rationale
behind using sensory integrative techniques with children who have learning
disabilities. A basic theme was found among the answers. The therapists stat-
ed that sensory processing must be intact and functioning well in order for the
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264 Stonefelt and Stein

TABLE 6: The effectiveness of sensory integrative techniques on specific skill areas as per-
ceived by occupational therapists

1 – extremely 2 – somewhat 3 – not very 4 – not effective 5 – not

effective effective effective at all relevant
# % # % # % # % # %

Mathematics 1 13 0 0 0 0 0 0 5 50

Language 4 50 3 38 0 0 0 0 0 0

Reading 1 13 3 38 0 0 0 0 2 25

Gross motor 4 50 4 50 0 0 0 0 0 0

Fine motor 5 63 3 38 0 0 0 0 0 0

Balance 4 50 3 38 1 13 0 0 0 0

Coordination 5 63 2 25 1 13 0 0 0 0

Self-esteem 4 50 2 25 0 0 0 0 0 0

Behaviour 6 75 2 25 0 0 0 0 0 0

Social skills 6 75 2 25 0 0 0 0 0 0

Attention 6 75 2 25 0 0 0 0 0 0

Overall 6 75 2 25 0 0 0 0 0 0

TABLE 7: Specific sensory integrative techniques used by therapists

Techniques # of responses

Linear activities 8
Tactile stimulation 8
Games 8
Jumping/bouncing 8
Rotary activities 7
Deep pressure 7
Therapy balls 4
Activities involving food 3
Massage 1
Equilibrium discs 1
Other
Oral motor/resistive motor 3
Obstacle courses 2
Fine motor activities 2
Occular motor techniques 2
Reflex integration 2
Brushing 1
Joint compression 1
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Sensory integrative techniques: an outcome study 265

TABLE 8: Rank orders of the effectiveness of specific sensory integrative techniques

Rank Therapist F Therapist D Therapist A Therapist B Therapist G

1 Tactile stim. Tactile stim. Food activities Brushing Jumping

2 Deep pressure Deep pressure Rotary activities Jumping Deep pressure

3 Rotary Oral Therapy Tactile Rotary

activities stimulation balls stim. activities

4 Jumping Jumping Tactile stim. Deep pressure Linear

activities

5 Linear activities Games Cognitive games Equilibrium Cognitive

disc games

6 Games Rotary activities Games Rotary Games

activities

7 Fine motor Fine motor Linear activities Linear Tactile stim.

activities

8 Occular motor Occular motor Jumping Massage Therapy balls

9 Reflex Reflex Equilibrium Equilibrium

integration integration disc disc

10 Games

11 Cognitive games

TABLE 9: Other techniques combined with sensory integrative techniques

Other techniques # of responses

Behaviour modification 3

Neurodevelopmental theory 2

Sensorimotor 2

Visual motor 1

Visual perceptual 1

Motor skills 1

Motor planning 1
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266 Stonefelt and Stein

child to develop necessary skills for learning. A basis for learning disabilities is
often found in poor sensory processing. Therefore, for a child with learning
disabilities, therapy must promote sensory processing skills, thereby facilitat-
ing his/her ability to learn. Therapists also reported that, through sensory inte-
gration therapy, the child’s attention and sensory awareness increase and
motor control and quality of movement improve.

Discussion

Significance of study related to prior research

The parents, teachers and occupational therapists included in this study per-
ceived sensory integration therapy to be an effective method in treating chil-
dren with learning disabilities. Their perceptions concur with findings from
studies conducted by Wilson and Kaplan (1994) and Fanchaing (1996). How-
ever, the study by Wilson and Kaplan showed that significant gains were only
sustained in the area of gross motor skills. In this study, coordination and
behaviour were the functional areas in which sensory integrative techniques
were perceived to be the most effective. Other areas in which sensory integra-
tive techniques had a significant effect were fine motor, gross motor, balance
and coordination.
This study showed that sensory integration therapy was somewhat effective
in facilitating improvement in academic areas. It supports the finding from
Ayres (1972) that children who received sensory integration therapy
improved in reading. Other studies reported improvements in arithmetic for
children who had received sensory integration therapy. This study supports
their finding as well. However, improvements in academics may be secondary
to an increase in attention span and better behaviour.
This study also supported the finding by Humphries et al. (1993) that a
combination of therapies may be more effective than using sensory integrative
techniques alone. In their study, Humphries et al. (1993) suggested the combi-
nation of sensory integrative techniques and perceptual motor training as
being highly effective. The therapists in this study reported behaviour modifi-
cation, neurodevelopmental theory and sensory motor techniques as the
methods most frequently used in addition to sensory integrative techniques.
In this study, the therapists’ rationale for using sensory integrative tech-
niques with children with learning disabilities coincided with what was found
in the sensory integration literature. Most children with learning disabilities
have underlying sensory integrative dysfunctions and if these dysfunctions are
treated, then the necessary skills for learning will be developed (Hoehn and
Baumeister, 1994).
The common conclusion found in sensory integration literature (for exam-
ple, Humphries et al., 1990; Polatajko et al., 1991; Kaplan et al., 1993; and
Wilson and Kaplan, 1994) is that there is a great need for further research in
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Sensory integrative techniques: an outcome study 267

this area. This study provides a small addition to the existing research, but it
has many limitations, and therefore supports the need for future studies.

Future research
The great need for further research on sensory integration therapy used in
treating children with learning disabilities has been clearly demonstrated in
this study as well as in many other studies in this area. Sensory integration
therapy was originally intended for use with this population (Clark et al.,
1989, 1991); however, its effectiveness is still inconclusive. First, it must be
determined which sensory integrative technique (or combination of tech-
niques) is most effective for children with specific types of learning disabili-
ties. This type of study could be implemented using larger samples that
classify specific learning disabilities and control groups. It is also important
to conduct studies that allow for individual differences in responsiveness to
therapy. Law et al. (1991) suggested using single-case studies, descriptive
studies and naturalistic studies. Follow-up studies would be helpful to deter-
mine the maintenance of gains made in therapy. Finally, a holistic approach
is necessary in future research. The effects of other factors such as activities
in the home and adaptations made in the classroom should be taken into
consideration.

Summary
As learning disabilities are the most commonly reported reason for children
needing special services in the state school system, effective treatment tech-
niques must be found. Many children with learning disabilities have problems
in sensory integration, which may be the cause of their learning difficulties.
Sensory integration therapy is commonly used in the treatment of these chil-
dren, but many questions still remain regarding specific techniques applied.
This study, along with other studies, has shown sensory integrative techniques
to be effective in treating children with learning disabilities; however, there is
still a pressing need for further research in this area.

References
Ayres AJ (1972). Improving academic scores through sensory integration. Journal of Learning
Disabilities 5: 24–8.
Ayres AJ (1979). Sensory integration and the child. Los Angeles, CA: Western Psychological
Services.
Clark F, Mailloux Z, Parham D, Bissell JC (1989). Sensory integration and children with learn-
ing disabilities. In Pratt PN, Allen AS (Eds) Occupational Therapy for Children (2nd
edn). St Louis, MO: CV Mosby, pp. 457–509.
Clark F, Mailloux Z, Parham LD, Primeau LA (1991). Statement: Occupational therapy provi-
sion for children with learning disabilities and/or mild to moderate perceptual and motor
deficits. The American Journal of Occupational Therapy 45(12): 1069–74.
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Cummins RA (1991). Sensory integration and learning disabilities: Ayres’ factor analyses reap-
praised. Journal of Learning Disabilities 24(3): 160–8.
Fanchaing SPC (1996). The other side of the coin: Growing up with a learning disability. The
American Journal of Occupational Therapy 50(4): 277–85.
Feagans L (1983). A current view of learning disabilities. Journal of Pediatrics 102(4): 487–93.
Hoehn TP, Baumeister AA (1994). A critique of the application of sensory integration therapy
to children with learning disabilities. Journal of Learning Disabilities 27(6): 338–50.
Humphries TW, Snider L, McDougall B (1993). Clinical evaluation of the effectiveness of sen-
sory integrative and perceptual motor therapy in improving function in children with learn-
ing disabilities. The Occupational Therapy Journal of Research 13(3): 163–82.
Humphries T, Wright M, McDougall B, Vertes J (1990). The efficacy of sensory integration
therapy for children with learning disability. Physical and Occupational Therapy in Pedi-
atrics 10(3): 1–17.
Kaplan BJ, Polatajko HJ, Wilson BN, Faris PD (1993). Reexamination of sensory integration
treatment: A combination of two efficacy studies. Journal of Learning Disabilities 26(5):
342–7.
Law M, Polatajko HJ, Schaffer R, Miller J, Macnab J (1991). The impact of heterogeneity in a
clinical trial: Motor outcomes after sensory integration therapy. The Occupational Therapy
Journal of Research 11(3): 177–89.
McNeil JM (1995). Disabilities among children aged <17 years – United States, 1991–1992.
Journal of the American Medical Association 274(14): 1112–14.
National Center for Education Statistics (1993). Digest of Education Statistics (ISBN 0-16-
042052-0). Washington, DC: United States Government Printing Office.
National Institute of Mental Health (1993). Learning Disabilities (No. 93-3611). Washington,
DC: United States Government Printing Office.
Polatajko HJ, Kaplan BJ, Wilson BN (1992). Sensory integration treatment for children with
learning disabilities: Its status 20 years later. The Occupational Therapy Journal of Research
12(6): 323–41.
Polatajko HJ, Law M, Miller J, Schaffer R, Macnab J (1991). The effect of a sensory integration
program on academic achievement, motor performance, and self-esteem in children identi-
fied as learning disabled: Results of a clinical trial. The Occupational Therapy Journal of
Research 11(3): 155–75.
Rourke BP, DelDotto JE (1994). Learning disabilities: A neuropsychological perspective. Thou-
sand Oaks, CA: Sage Publications.
Schaffer R, Law M, Polatajko H, Miller J (1989). A study of children with learning disabilities
and sensorimotor problems or let’s not throw the baby out with the bathwater. Physical and
Occupational Therapy in Pediatrics 9(3): 101–17.
Toronto Sensory Integration Group (1987). Sensory integration therapy [video].
Available from Therapy Skill Builders, 3830 E. Bellevue, PO Box 42050-Y, Tucson, AZ
85733.
Trott MC, Laurel MK, Windeck SL (1993). SenseAbilities: Understanding sensory integration.
Tucson, AZ: Therapy Skill Builders.
Werry JS, Scaletti R, Mills S (1989). Sensory integration and teacher judged learning problems:
A controlled intervention trial. Journal of Paediatrics and Child Health 26(1): 31–5.
Wilson BN, Kaplan BJ (1994). Follow-up assessment of children receiving sensory integration
treatment. The Occupational Therapy Journal of Research 14(4): 244–66.
Wilson BN, Kaplan BJ, Fellowes S, Gruchy C, Faris P (1992). The efficacy of sensory integra-
tion treatment compared to tutoring. Physical and Occupational Therapy in Pediatrics
12(1): 1–36.
Yack E (1989). Sensory integration: A survey of its use in the clinical setting. Canadian Journal
of Occupational Therapy 56(5): 229–35.
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Sensory integrative techniques: an outcome study 269

Address correspondence to Professor Franklin Stein, Department of Occupational Therapy,

University of South Dakota, 414 East Clark Street, Vermillion, SD 57069-2390, USA. Email
fstein@usd.edu.

Appendix
Survey/data collection form
(Questions 1–21 were included on surveys completed by all participants.)

Think of an actual child with a learning disability that you have provided sensory integration
therapy to (if you are an occupational therapist), a child in your classroom who has received
sensory integration therapy for a learning disability (if you are a teacher), or your own child
diagnosed with a learning disability (if you are a parent). Please answer the following questions
based on your observations of that child.

1. What is your relationship to the child?

a. parent
b. teacher
c. occupational therapist

2. What specific types of learning disabilities does the child have?

a. developmental speech and/or language disorder
b. developmental reading disorder
c. developmental writing disorder
d. developmental arithmetic disorder
e. attention deficit disorder
f. attention deficit hyperactivity disorder
g. motor skills disorder
h. coordination disorder
i. other, please list________________

3. How old was the child when the learning disability was diagnosed?
a. <5 years
b. 5–6 years
c. 7–8 years
d. 9–10 years
e. 11–12 years
f. other________

4. How long has the child been receiving occupational therapy services?
a. less than 1 year
b. 1–2 years
c. 2–3 years
d. 3–4 years
e. other_______

5. How often does the child receive therapy?

a. once a week
b. twice a week
c. three times a week
d. other, please specify_________
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270 Stonefelt and Stein

6. How long do the therapy sessions last?

a. less than 15 minutes
b. 15–30 minutes
c. 30–45 minutes
d. 45–60 minutes
e. more than 1 hour

7. Does the child have any other disabilities?

a. yes. Which ones?_____________________________
b. no

8. Which, if any, other special services does the child receive?

a. physical therapy
b. speech therapy
c. counselling
d. other, please specify______________
e. none

9. Which of the following best describes the child?

a. is excited about therapy and participates willingly
b. goes to therapy willingly
c. is reluctant to go to therapy, but participates
d. dislikes going to therapy and refuses to participate

Please answer questions 10–21, according to the following scale:

1 – extremely effective
2 – somewhat effective
3 – not very effective
4 – not effective at all
5 – irrelevant

How effective do you think sensory integration therapy was in helping the child improve func-
tion in each of the following skill areas?
10. Mathematics 1 2 3 4 5
11. Language 1 2 3 4 5
12. Reading 1 2 3 4 5
13. Gross motor skills 1 2 3 4 5
(e.g., kicking a ball, riding a bike)
14. Fine motor skills 1 2 3 4 5
(e.g., buttoning a shirt, writing)
15. Balance 1 2 3 4 5
16. Coordination 1 2 3 4 5
17. Self-esteem 1 2 3 4 5
18. Behaviour 1 2 3 4 5
19. Social skills 1 2 3 4 5
20. Attention 1 2 3 4 5
21. Overall 1 2 3 4 5

(The following two questions were included only on the surveys completed by the parents of children
with learning disabilities who were receiving sensory integration therapy.)
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Sensory integrative techniques: an outcome study 271

22. How noticeable are the effects of sensory integration therapy at home?
a. very noticeable
b. somewhat noticeable
c. not noticeable

23. What activities are you doing in the home to help your child?
a. hiring a tutor for your child
b. doing activities suggested by your child’s teacher
c. doing activities suggested by your child’s occupational therapist
d. other, please specify__________________________________________
e. other, please specify__________________________________________
f. other, please specify __________________________________________

(The following four questions were included only on the surveys completed by the teachers who have
the child with a learning disability in their classroom.)

22. Are the effects of sensory integration therapy readily noticeable in the classroom?
a. yes
b. no

23. What is the attitude among the other children toward the child with a learning disability?
a. friendly
b. supportive
c. indifferent
d. unfriendly
e. other______________________

24. Have you made any adaptations in the classroom to facilitate learning for the child with a
learning disability?
a. yes
b. no

25. If you answered yes to the previous question, what types of adaptations have you made?
a. changing the seating arrangement
b. allowing the child more time to complete assignments
c. providing alternative methods of instruction for the child
d. other___________________________________________
e. other___________________________________________
f. other___________________________________________

(The following seven questions were included only on the surveys completed by the occupational thera-
pists providing sensory integration treatment to the child.)

22. How long have you been practising in the school system?
a. <1 year
b. 1–2 years
c. 3–4 years
d. 5–6 years
e. 7–8 years
f. 9–10 years
g. 10+ years
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272 Stonefelt and Stein

23. How long have you been practising sensory integration therapy?
a. <1 year
b. 1–2 years
c. 3–4 years
d. 5–6 years
e. 7–8 years
f. 9–10 years
g. 10+ years

24. What specific types of sensory integration therapy have been used with the child? (Choose
all that apply.)
a. rotary activities
b. linear activities
c. tactile stimulation
d. games
e. jumping/bouncing
f. therapy balls
g. equilibrium discs
h. activities involving food
i. massage
j. deep pressure
k. other, please list ___________________________________

25. Based on your opinion, rank-order beginning with 1 (from most effective to least effective)
the specific treatments that have been used in treating the child. (Put a 0 next to the treat-
ments that have not been used.)
___rotary activities
___linear activities
___tactile stimulation
___cognitive games
___other games
___jumping/bouncing
___therapy balls
___equilibrium discs
___activities involving food
___massage
___deep pressure
___other, please specify_________________
___other, please specify_________________
___other, please specify_________________

26. Is another treatment (e.g., NDT, perceptual-motor) combined with sensory integration?
a. yes
b. no

27. If you answered yes to question 26, which other treatments are used?
_____________________________________________________________________
Does the combination seem to be more effective than sensory integration therapy alone?
a. yes
b. no

28. What is your rationale for using sensory integration therapy with children with learning
disabilities?