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 child’s 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 (con’t) • Sensorimotor development is an important substrate for learning • The interaction of the individual with the environment shapes brain development • The nervous system is capable of change (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 UCLA’s Brain Research Institution

9. Meet Dr. A Jean Ayres (con’t) • Developed diagnostic tools for identifying the disorder • Proposed a therapeutic approach that transformed pediatric occupational therapy • 1972, Sensory Integration International was established

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 brain’s . . . 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 one’s basic survival (most people can integrate and interpret sensory information automatically) • These systems interact with each other, allowing us to experience, interpret, and respond to different stimuli in our environment

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

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 child’s 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 Grandin’s hug machine) • Goldstein explains the lack of data using four criteria: • The lack of randomization of participants • The choice of variables • Statistically Significant data that is NOT • Replication is lacking

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 Mort’s and Sally’s SIB remained at 0% and Kathy’s SIB was similar to that in phase 3 of the experiment at 8%. • The data show that behavioral interventions show a maintained effect on decreasing SIB.

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 individual’s 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 < .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.