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Autism Spectrum Disorder and Occupational Therapy: Efficacy of Sensory Integration Therapy

By Kjirsten Magnuson, Loyola Marymount University

Even as the prevalence of Autism Spectrum Disorder (ASD) continues to increase, there is still little known about its cause and proper therapy for people with ASD.  The prevalence rate is currently estimated at one in eighty-eight children in the United States have ASD (Autism spectrum disorders, 2013).  Children with ASD have occupational and performance problems that effect social skills, school, and home life.  The characteristics of autism include limited social interaction, language difficulties, behavioral problems and sensory-processing issues (Case-Smith and Arbesman, 2008).  Because of these issues, occupational therapy is a common service received by children with ASD.  Most occupational therapists focus on the sensory-based issues that the majority of children with ASD face (Kadar, McDonald, & Lentin, 2012).  However, even though this is a treatment that over 56% of occupational therapists use and is the most commonly utilized intervention approach by occupational therapists when treating children with ASD (Kadar et al., 2012), little is known about its effectiveness.  Most studies do show that sensory-integration therapy has positive effects, (Schaaf, Benevides, Kelly, Mailloux-Maggio 2012, Fazlioglu & Baran, 2008) but it is difficult to determine their reliability because of the huge heterogeneity of the ASD population (Schaaf, et al., 2012) and long term effectiveness because there are not enough long term studies to know definitively. Additionally, many occupational therapists indicated in a survey study that they were only “somewhat confident,” or “neither confident nor under-confident or fluctuating confidence” while working with children with ASD (Kadar et al., 2012).  However, children with Autism Spectrum Disorder can seriously benefit from proper early interventions.  But many occupational therapists are unsure about their ability to help these children and are unsure about the reliability of what they do know.  This is compounded with the issue that most occupational therapists only know to treat the sensory difficulties when the goal should be to improve the occupation of the child as a whole.  The limited studies that have been done have very different results and are, therefore, misleading and confusing.  There needs to be more large, longitudinal studies about the effectiveness and validity of sensory integration therapy and more research on other therapies that will allow a child with ASD to live a life that is more incorporated in the community.

There are a number of studies that support the effectiveness of sensory integration therapy in children with ASD.  Sensory integration is “the neurological process that organizes sensations from one’s body and from the environment and makes it possible to use the body effectively in the environment” (Ayres, 1989, p.22).  Children develop connectedness with the world through their sensory experiences (Fazlioglu & Baran, 2008), and when children with ASD are reactive to sensory stimuli, life can be very difficult.  Sensory integration therapy purportedly engages the child through individualized sensory-motor activities that help their nervous system better modulate, organize, and integrate sensory information (Schaaf et al., 2012).  This, in turn, will hypothetically improve the lives of children with ASD.  One study by Schaaf et al. (2013) studied thirty-two children with ASD between the ages of four and seven that demonstrated difficulty processing and integrating sensory information.  Children in the treatment group received sensory integration therapy for thirty sessions over ten weeks and children in the control group went to their regular therapies.  The sessions also included individually tailored treatment activities depending on the child’s specific needs.  The children in the treatment group had a decreased need for help from their caregiver on activities such as self-care and social interactions compared to the control group.  However, this data may be affected because the parents were not blind as to which treatment their child was receiving.

Another study by Fazlioglu and Baran (2008) supports the positive outcomes of sensory integration therapy.  This study used thirty children with ASD between seven and eleven years of age that fell into the low functioning category.  Most of these children were not able to use language to communicate.  There were fifteen children in the control group that received their regular care and fifteen children who attended a forty-five minute sensory integration session twice a week for a total of twenty-four sessions.  They found that the sensory problems observed in the children were significantly lower after the study than before.

Both of these studies concluded that sensory integration therapy improved sensory processing in children with ASD.  However, these studies, and ones like them, should be analyzed more critically.  First, both these studies were short term, ten and twelve weeks respectively.  This can limit what can be deduced from the findings.  Neither study did a follow up analysis on the individuals involved to see if the children in the treatment groups were still reaping the benefits of the therapy.  It is possible that most of the children had regressed back to their starting point.  If so, one could argue that sensory integration therapy should be a continuing treatment for children with ASD.  However, this is unrealistic as the child ages into adulthood.  Additionally, studies like this are hard to carry out without biases becoming involved.  Many of these studies collect data on the parents’ experience with their child throughout the study.  However, it is almost impossible to keep the parents blind about what group their child is placed in.  So, when being interviewed about the behaviors of the child, parents who know their child was receiving sensory integration therapy are much more likely to say they saw an improvement, whether true or not, than if their child was in the control group.  This is true for many studies in the occupational therapy field in general.  Although it may seem like a small detail, biases can severely affect data.

As this is becoming an increasingly problematic issue, many review studies have been performed to analyze the efficacy of sensory integration therapy.  A study by Lang et al. (2012) sought to “identify, analyze, and summarize research involving the use of SIT in the education and treatment of individuals with ASD.”  The purpose was to determine of sensory integration therapy would qualify as a research-based treatment for children with ASD.  They reviewed twenty-five studies that fit their criteria of being peer-reviewed, written in English, and having keywords associated with sensory integration therapy.  Interestingly, they only found three studies of the twenty-five that found that sensory integration therapy was effective.  Additionally, they found that eight studies reported mixed results and fourteen found no positive benefits of this treatment.  Along with looking at the results of the studies, Lang et al. looked at how empirically sound the evidence was.  Of the three studies that reported positive results, all were classified as being at the “lowest level of certainty due to serious methodological limitations.”

The study by Fazlioglu and Baran (2008) mentioned previously that found positive results when using sensory integration therapy was also featured in the review by Lang et al. (2012).  However, Lang points out that their study seems to have used behavioral intervention as well as sensory integration therapy. So the positive results could have been mainly or partly related to this type of therapy. Another of the studies by Linderman and Stewart (1999) reported that the individuals started receiving speech therapy after the study began.  This additional therapy probably influenced the results of the study.  Furthermore, Linderman and Stewart did not provide details of exactly what the initial assessments were and how the results guided what interventions the subjects received.  This makes it difficult to repeat this study to test its validity.  Finally, the third study by Thompson (2011) seemed to provide the most certainty in its results.  However, it failed to provide graphs and tables regarding the results.  The author’s included written descriptions of what occurred but did not provide sufficient information to interpret the results fully, so one would have to rely on what was concluded by Thompson without being able to reference graphs and data to support these conclusions.

The studies that reported mixed results should be analyzed critically as well.  These studies were either unable to demonstrate that the participants achieved gains or had all of their participants make progress but not in the same areas of need.  It seems that when the certainty of evidence is in question, one should be in favor of the conservative conclusion that the study is not effective.  It should also be mentioned that of the fourteen studies that showed negative results, five were judged to be conclusive.  However, all of the studies used sensory integration therapy that involved the use of a weighted vest but their procedures were all different.  These differences in sensory integration therapy procedures and the lack of fidelity within the studies prevent a proper direct comparison to be made.  Nevertheless, this review concluded that sensory integration therapy does not qualify as an evidence-based practice for occupational therapists.

This conclusion is alarming when one looks at the data of how often occupational therapists use sensory integration therapy.  Individuals with Disabilities Education Act (IDEA) require that providers receiving federal funding, such as public schools, use evidence-based interventions.  However, 66% of occupational therapists employed by public schools say they use sensory integration therapy (Lang et al. 2012).  “This discrepancy between research findings, legal requirements, and actual practice is made more troublesome by the possibility that SIT may actually exacerbate behavior problems in some children” (Lang et al. 2012).  Many think that sensory integration therapy reinforces the abnormal behavior because it allows children to do fun activities, get attention from therapists, and time away from school.

Not only have studies increasingly shown that sensory integration therapy does not provide children with ASD the therapy they need, but there are also many experts in the field that argue that sensory based therapy is not in line with the job of an occupational therapist.  As the name suggests, an occupational therapist’s job help improve the occupations of individuals with deficiencies in this area.  Rodger, Ashburner, Cartmill, and Bourke-Taylor (2010) wrote an article questioning occupational therapists’ role in autism.  “We propose that occupational therapy for children with ASD must not be seen as synonymous with sensory integration therapy” and “if as a profession we persist with offering child-specific interventions that focus only on a narrow-sensory perspective, we will have failed to deliver the breadth of interventions that occupational therapists have the expertise to provide” (Rodger et al., 2010).  They point out that the occupational therapy profession faces serious criticism for providing interventions for children with ASD that does not have proper evidence to support it.  Extensive reviews have found that there is little evidence supporting the use of sensory integration therapy.  However, occupational therapists should not ignore the sensory processing issues in children with ASD.  Instead of sensory integration therapy, occupational therapists should help modify the child’s environment in order to provide a “better ‘fit’ among the child, his/her occupations and the environment” (Rodger et al., 2010).  Additionally, occupational therapists can advocate for the reduction of sensory challenges in the common environments the child is exposed to.

A recent study found that 94% of adults with ASD still have atypical sensory processing (Crane, Goddard, & Pring, 2009).  This suggests that sensory processing issues persist regardless of what interventions are used. Occupational therapists should direct their attention away from trying to “fix” these issues and try instead to help the individual cope with their issues through self-management and advocate that society become more understanding to their sensitivities.

There are many complex factors that contribute to the behavior of children with Autism Spectrum Disorder.  This means that occupational therapists must not view ASD as synonymous with sensory integration therapy.  Occupational therapists need to remember the occupation based goals when treating children with ASD and not focus solely on their sensory processing issues.  Additionally, experts in the field must encourage researchers to do more studies in the field of ASD.  Specifically, more studies need to be performed with the goal of reviewing previously completed studies about therapy and ASD and also more research needs to be done on what therapies do actually benefit people with ASD. Finally occupational therapists must become more educated about the therapy options for children with ASD and also make it a priority to stay updated on the most current data about therapy options.  If these issues are addressed, children with ASD will be able to have a more positive future and will better be able to adapt to the demands of society.

References

Autism spectrum disorders. (2008). Center for Disease Control and Prevention. Retrieved December 8, 2013 from http://www.cdc.gov/ncbddd/autism/data.html

Ayres, A.J. (1989). The sensory integration and praxis tests. Los Angeles: Western Psychological Services.

Case-Smith,  J. & Arbesman, M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapy. American Journal of Occupational Therapy, 62, 416-429.

Crane, L., Goddard, L. & Pring, L. (2009). Sensory processing in adults with autism spectrum disorders. Autism, 13, (3), 215-228.

Fazlioglu, Y. & Baran, G. (2008). A sensory integration therapy program on sensory problems for children with autism. Perceptual and Motor Skills, 106, 415-422.

Kadar, M., McDonald, R. & Lentin, P. (2012). Evidence-based practice in occupational therapy services for children with autism spectrum disorders in Victoria, Australia. Australian Occupational Therapy Journal, 59, 284-293.

Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., Davis, T., Kang,S., Sigafoos, J., Lancioni, G., Didden, R., & Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6(3), 1004-1018.

Linderman, T. M., & Stewart, K. B. (1999). Sensory integrative-based occupational therapy and functional outcomes in young children with pervasive developmental disorders: A single-subject study. American Journal of Occupational Therapy, 53, 207–213.

Rodger, S., Ashburner, J., Cartmill, L. & Bourke-Taylor. (2010). Helping children with autism spectrum disorders and their families: Are we losing our occupation-centered focus? Australian Occupational Therapy Journal, 57, 276-280.

Schaaf, R., Benevides, T.W., Kelly, D. & Mailloux-Maggio, Z. (2012). Occupational therapy and sensory integration for children with autism: A feasibility, safety, acceptability, and fidelity study. Autism, 16(3), 321-327.

Schaaf, R.C., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., Freeman, R., Leiby, B., Sendecki, J. & Kelly, D. (2013). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disorders, 1-14.

Thompson, C. J. (2011). Multisensory intervention observational research. International Journal of Special Education, 26, 202–214.

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