Sensory Integration Therapy for Children with Autism

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 childs
  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 (cont)

• 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 UCLAs Brain Research
  Institution

9
Meet Dr. A Jean Ayres (cont)

• 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
  brains . . . 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 ones 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
Principle 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 childs repertoire of skills and processing
Child Directed Therapist constantly observes the childs behavior and reads behavioral cues, follows the childs 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 childs 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 Grandins 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 Morts and Sallys SIB
  remained at 0 and Kathys 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
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 individuals 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 lt .01)

48
Additional clinical research must be administered
in a replicable fashion

• Research must
• 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 childs 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,
  32,397-422.
• 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 Ayres 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 Goldsteins 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 Behaviors in
  Preschoolers with Pervasive Developmental
  Disorders. The American Journal of Occupational
  Therapy, 55,629-639.
• Goldstein, H. (2003). Response to Edelson,
  Rimland, and Grandins Commentary. Journal of
  Autism and Developmental Disorders, 33, 553-555.
• Goldsetin, H. (2000). Commentary Interventions
  to Facilitate Auditory, Visual, and Motor
  Integration Show Me the Data. Journal of
  Autism and Developmental Disorders, 30, 423-425.
• Iwata, B. Mason, S. A. (1990). Artificial
  Effects of Sensory-Integrative Therapy on
  Self-Injurious Behavior. Journal of Applied
  Behavior Analysis, 23, 361-370.
• 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,
  143-148
• 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. www.geocites.com/Hea
  rtland/2085/SENSORY.htm?200613
• Sensory Integration International-The Ayres
  Clinic. www.sensoryint.com/ayres.html
• Sensory Integration Therapy. www.moddrc.com/infor
  mation-disabilities/fastfacts/sensoryintegration.c
  om
• Sensory Integration and Praxis Tests (SIPT).
  https//www-secure.earthlink.net/www.wpspublish.co
  m/Inetpub4/catalog/W-260.htm
• Sensory Integration Courses. http//www.wpspublis
  h.com/Inetpub4/w0903.htm
• Sensory Profile. http//harcourtassessment.com/ha
  iweb/Cultures/en- US/dotCom/SensoryProfile/About/S
  ensoryProfile