Running head: SENSORY INTEGRATION THERAPY

Evaluating the Effectiveness of Sensory Integration Therapy When Treating Limited Participation

in Children

Shayna Roberts and Kaysen Gilmore

University of Utah Occupational Therapy Department

Introduction

Children with sensorimotor impairments are often described as clumsy. They have

difficulties with balance and motor skills and they may appear unaware of their environment.

The sensorimotor system allows information from the environment to be processed and

organized into a motor response (Siaperas et al., 2011). Abnormalities in this system can lead to

motor dysfunction, impaired verbal expression, and the development of challenging behaviors

which hinder a childs participation in school activities, social activities, and activities of daily

living.

Sensorimotor impairments are common in children with Aspergers and Autism as well

as children with mild mental retardation. Children with Autism have been shown to have an

abnormality in at least one area of the sensorimotor system. Proprioception is especially difficult

for these children, which can cause problems with motor control and social impairments

(Siaperas et al., 2011). Children with mild mental retardation are limited in fine motor

movements resulting in motor delays as well as perceptual impairments (Wuang, Wang, Huang,

&Su, 2009). These children experience difficulties participating in school, social activities, and

independent activities of daily living.

Sensory integration therapy is a commonly used intervention to address these issues.

This intervention is interactive and facilitates taking in information, modulating and organizing

the information, and integrating the information for effective use in adaptive responses

(Siaperas et al., 2011). Through exposure in a very structured setting, children are able to

experience sensation without negative side effects. Repetitive exposure allows the their brain to

adapt to the sensation so they can use the sensory information effectively and participate in

activities that provide sensory information (Viel, Vaugoyeau, & Assiante, 2009).
Sensory Integration Therapy 3

While sensory integration therapy is a commonly used intervention with these

populations, there is some discrepancy in its effectiveness. Current research focuses on certain

populations when using sensory integration therapy. There are articles looking at its efficacy in

children with Autism, mental retardation, and sensory impairments. This review focuses on

sensory integration therapy and its role in treating deficits that influence participation in

activities in all children regardless of diagnosis. This will improve understanding of how sensory

integration therapy influences children and may allow for more widespread use of this

intervention for improving limited participation.

Methods

Search Strategy

Three health science databases were used in answering our research question: PubMed

(US National Library of Medicine National Institutes of Health; 2006 to 2016), CINAHL

(Cumulative Index to Nursing and Allied Health Literature; 1999 to 2016), and AJOT (The

American Journal of Occupational Therapy; 2006 to 2016). The specified publication date

involved in the search was from 2006 to 2016 for all of the database searches except the CINAHL

search. In the CINAHL search the two reviewers (occupational therapy students) found an article

that was published in 1999, which contained evidence that answered the research question in a

way they thought beneficial to include.

The keywords that were selected gave the reviewers a sufficient pool of potential

articles to choose from when answering the research question. The method of searching for

articles was separated between the two reviewers. Each reviewer found six articles that fit the

inclusion criteria (specified below). The 12 articles were then narrowed down to eight articles

because they had the highest level of quality found within the searches. The following is a list of

keywords used and search strategies that were implemented:

-Search 1: Sensory Integration, Occupational Therapy, Children (combined with and operator)

-Search 2: Sensory Integration, Occupational Therapy, Youth (combined with and operator)

-Search 3: Sensory Integration, Children, Participation, Effects (combined with and operator)

-Final Search: Sensory Integration, Children, Participation

Through these search strategies reviewers found 51 articles in the CINAHL database, 5 articles

from AJOT, and 98 from PubMed.

Study Selection Criteria

The studies found through the searches were reviewed, summarized, and organized into

a chart by two reviewers. In order to narrow down the number of articles used for this review,

the following inclusion criteria were used:

-The use of sensory integration therapy in the intervention.

-Reviewers had access to article.

-The article was peer reviewed.

-One of the interventions included the use of sensory integration therapy (supporting its use or

not supporting its use)

-The study focused on factors that affect participation level.

-There was some sort of involvement of an occupational therapist, but this wasnt an exclusion

criteria (if they didnt include an occupational therapist that didnt mean that it was excluded).

The exclusion criteria were:

-Participants were over the age of 18.

-Reviewers had no access to article.

-The study was not peer reviewed.

-The study was less than 3 pages or had no data.

Methodological Quality Assessment

The AHA (American Heart Association) Levels of Evidence Chart was used when

assessing the quality of the final eight articles to review. This was done to ensure that the

reviewers used educated judgments when choosing the highest quality studies available. The

reviewers looked for aspects within the studies that were comparative to a level A class I on the

AHA Levels of Evidence Chart. These characteristics included larger or multiple populations

being evaluated, recommendation that treatment was useful, benefits of the study were greater

than the risks, and there was little to no conflict within the evidence.

Results

Schaff, Hunt, and Benevides (2012) performed a case study on a boy with Autism and

Attention Deficit Disorder, which supports the use of a manualized sensory integration

intervention protocol. The participant improved in tactile discrimination, control, organized

responses to sensory input, motor skills, adaptation, and communication after receiving sensory

integration therapy. A relationship between changes in behavior and ability to process and

integrate sensory information was observed and the clinical reasoning used in this study

generated a hypothesis concerned about underlying sensory and motor deficits (Schaff, Hunt, &

Benevides, 2012). This case study shows positive results, but weak evidence because it only

involves a single participant and very few controlled variables.

Devlin, Healy, Leader and Hughes (2009) conducted an alternating treatment design in

order to determine the effectiveness of sensory integration therapy (SIT) and behavioral therapy

interventions on challenging behaviors in four boys with ASD. Results of each intervention were

compared between each individual as well as baseline and final treatment results. The study

found that behavioral therapy was more effective than SIT in preventing challenging behaviors.

There was very little difference between baseline measures and sensory integration therapy

measures for participation in challenging behaviors. The lack of consistent interventions across
Sensory Integration Therapy 6

treatment sessions could have affected the efficacy of the interventions (Devlin et a., 2009).

Further research should be done on SIT for behaviors involving sensory function rather than

environmental events.

The main purpose of Preis and McKennas study (2014) was to see if sensory integration

therapy helped improve communication skills in four boys with Autism Spectrum Disorder (ASD).

Language samples were assessed before, during, and after receiving SIT to examine the

participants expressive language. Results of the study showed that after SIT occupational

therapy sessions the greatest number of instances of expressive language was present in three

of the four participants. The SIT occupational therapy interventions also lead to the longest

mean length of utterance in all children and supported engagement during interactions. This

study used a very small and specific population.

Case-Smith and Bryan (1999), examined if SIT would increase engagement, mastery

play, and interaction in five year-old boys with Autism (1999). This study measured spontaneous

and responsive behaviors such as mastery play, engagement, and interaction. The results of the

study showed significant improvement in mastery play for three out of five children, which

researchers correlated to improved motor planning and decreased sensory defensiveness (Case-

Smith & Bryan, 1999). All but one of the children showed fewer non-engagement behaviors.

Only one child consistently interacted with adults and peers on a level that was significantly

relevant. Focusing on each child as a single subject allowed researchers to get more valid results

and gave the participants a chance to exhibit their individual behaviors. Because this study only

had four participants, it provides weak evidence even though sensory integration therapy

resulted in positive outcomes.

Watling and Dietz examined the immediate effects of sensory integration on four

children with ASD (2007). This single subject study used 50-minute sessions to determine the
Sensory Integration Therapy 7

effect SIT had on behavior and task engagement. Treatment phases were compared to no

treatment phases for each individual. The study found that there were no significant immediate

effects of SIT as there was overlap in both variables for each child. The authors could not

determine any immediate effects, however both the therapists and the parents reported

positive effects from SIT (Watling & Dietz, 2007). New engagement behaviors such as

vocalizations, eye contact, tolerance for transitions, choice making, and compliance were

observed in the therapeutic session and in the home environment (Watling & Dietz, 2007).

While SIT did not have immediate effects on behavior, it did have a positive influence on the

behavior of children given a more long-term perspective. The small sample size and potential for

bias in observations may have influenced the results of this study.

Wuang, Wang, Huang, and Su (2009) studied sensorimotor functioning in children with

mental retardation by randomly assigning 120 children to treatment groups of sensory

integration, neurodevelopmental, or perceptual-motor therapy. The scores were compared to

baseline measures and compared between treatment groups. This study found significant

differences between treatment groups. SIT provided the largest increase in BOTMP fine motor

scores and TSIF scores. This treatment improved integrated processing as well as organization of

sensory input, allowing for an increase in planning and sequencing (Wuang et al., 2009). PM

resulted in the largest increase in BOTMP gross motor scores and motor coordination. The main

conclusion of the study was that all three interventions were beneficial in improving different

sensorimotor functions in children with mild mental retardation. The differences in environment

and resources could have played a role in this study.

Discussion

The strength of these studies ranged from level 5 to level 2, including one case study,

four single subject design pre and post-test studies, and one multi-group non-randomized study.
Sensory Integration Therapy 8

The results from the articles in this systematic review showed several common themes: sensory

integration therapy was less effective in gross motor outcomes as compared to fine motor

measures, sensory integration therapy was not effective in preventing challenging behavior, and

the use of sensory integration therapy showed improvements with engagement.

Results from the study done by Wuang, Wang, Huang, and Su showed that SIT was less

effective in gross motor outcomes than fine motor outcomes. The perceptual motor (PM)

intervention resulted in the largest increase in BOTMP gross motor scores and motor

coordination. This was the strongest study in the systematic review.

The contrast between SIT and behavioral intervention in preventing challenging

behavior was made in the study done by Devlin, Healy, and Leader; it showed that the use of BI

was more effective than SIT (2009). Watling and Dietz also did a study looking at a similar

relationship. The results from their study werent definitive on the effectiveness of sensory

integration therapy on preventing undesired behavior (2007). Both of these studies only

included four participants, and found that SIT was not effective in preventing challenging

behaviors.

The strongest connection of sensory integration therapy in improving an outcome was

with engagement. Communication is a large part of engagement and was increased using SIT

during a case study done by Schaff, Hunt, and Benevides in 2012. The case study showed that

SIT improved a childs communication score from moderately low to adequate. Another

element of communication that plays into the level of engagement was seen in Preis and

Mckennas study on spontaneous statements, complexity of utterances, and session

engagement in four participants (2014). All four participants showed statistically significant

improvements in these areas after receiving sensory integration therapy. Watling and Dietz

found that participants participated in new engagement behaviors after receiving sensory
Sensory Integration Therapy 9

integration therapy (2007). The new engagement behaviors included vocalizations, eye contact,

tolerance for transitions, choice making, and compliance. Case-Smith and Bryan observed

participants in their study improve from participating in non-engaged behaviors such as

wandering around, staring into space, spinning, and distracted behaviors during sensory

integration therapy (1999). They all showed more active engagement behaviors after receiving

sensory integration therapy. One of these studies was a case study, making it a lower level of

evidence. The others only had four participants, also making them low levels of evidence.

However, the common findings of improved engagement are moderately strong evidence of SIT

since they came from multiple studies.

Strengths

There was a common theme of having strong evidence of the use of sensory integration

in engagement in several of our studies. Along with this common theme there were various

strengths we found in each article that prompted their inclusion in this analysis. These included

the methods used to gather data, measures taken to limit the possibility for different outcomes

based on therapist-participant interaction, inclusion of a non-treatment group to better

illustrate the effects of the intervention, and containing results that are similar to other studies

done on the relationship between the use of sensory integration therapy and changing

behavior. These strengths added quality to our analysis and were necessary in answering our

research question.

Limitations

The studies in this analysis contained limitations including small sample sizes,

environmental and resource differences between treatment groups, and potential bias in

observations. These factors need to be considered when looking at the results of the studies.

The studies used very restricted populations. There isnt a wide age range and the studies
Sensory Integration Therapy 10

focused on specific populations, making it difficult to generalize to a wider population. The

articles were also mostly lower levels of evidence. Results from these studies are not as strong;

however, the common themes between studies are strong evidence. The research showed that

sensory integration therapy is effective for very specific outcomes, but that it is not the most

effective intervention for behavior change, gross motor functioning, and coordination. Further

research needs to be done on sensory integration therapy, especially for generalized

populations.

Recommendations

After analyzing the previously described articles, it can be concluded that sensory

integration therapy is useful in increasing the level of engagement in children, especially with

the diagnosis of Autism. This conclusion cannot be generalized to a larger population though

due to the studies designs. Therefore, the recommendation for using this evidence is classified

according to the AHA evidence chart as a Level B Class IIa. The population in each of these

studies is limited by small sample sizes, which makes it unethical to generalize these findings to

larger populations, as well as each study was done on a short term basis on similar diagnoses.

Further research needs to be done on the effects of sensory integration therapy on behaviors,

communication, gross and fine motor skills, and social interaction to make a stronger

connection between sensory integration therapy and engagement. Conducting studies on larger

populations, for longer periods of time, using a larger variety of diagnoses, and measuring other

dependent variables would increase the strength of using sensory integration therapy to

address engagement.
Sensory Integration Therapy 11

References

Case-Smith, J., & Bryan, T. (1999). The effects of occupational therapy with sensory

integration emphasis on preschool-age children with autism. American Journal of

Occupational Therapy, 53(5):489-497. doi: 10.5014/ajot.53.5.489.

Devlin, S., Healy, O., & Leader, G. (2009). Comparison of behavioral intervention and

sensory integration in the treatment of challenging behavior. Research in Autism

Spectrum Disorders, 3(1), 223-231. doi: 10.1007/s10803-010-1149-x.

Preis, J., & Mckenna, M. (2014). The effects of sensory integration therapy on verbal

expression and engagement in children with autism. International Journal of Therapy

and Rehabilitation, 21(10), 476-486.

Schaaf, R. C., Hunt, J., & Benevides, T. (2012). Occupational therapy using sensory

integration to improve participation of a child with autism: a case report. American

Journal of Occupational Therapy, 66(5), 547-555.

Siaperas, P., Ring, A., McAllister, C., Henderson, S., Barnett, A., Watson, P.,

& Holland, A. (2011). Atypical movement performance and sensory integration in

Aspergers syndrome. Journal of Autism and Developmental Disorders, 42(5), 718-725.

doi: 10.1007/s10803-011-1301-2.

Viel, S., Vaugoyeau, M., & Assaiante, C. (2009). Adolescence: A transient period of

proprioceptive neglect in sensory integration of postural control. Motor Control, 13(1),

25-42.

Watling, R. & Dietz, J. (2007). Immediate effect of Ayres Sensory Integration-

based occupational therapy intervention on children with autism spectrum disorders.

American Journal of Occupational Therapy, 61(5), 574-583.

Wuang, Y., Wang, C., Huang, M., & Su, C. (2009). Prospective study of the effect of

sensory integration, neurodevelopmental treatment, and perceptual-motor therapy on

the sensoriomotor performance in children with mild mental retardation. American

Journal of Occupational Therapy, 63(4), 441-452.