Sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders. Sensory-based therapies involve activities that are believed to organize the sensory system by providing vestibular, proprioceptive, auditory, and tactile inputs. Brushes, swings, balls, and other specially designed therapeutic or recreational equipment are used to provide these inputs. However, it is unclear whether children who present with sensory-based problems have an actual “disorder” of the sensory pathways of the brain or whether these deficits are characteristics associated with other developmental and behavioral disorders. Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. Other developmental and behavioral disorders must always be considered, and a thorough evaluation should be completed. Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders.
Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Important roles for pediatricians and other clinicians may include discussing these limitations with parents, talking with families about a trial period of sensory integration therapy, and teaching families how to evaluate the effectiveness of a therapy.
Background: Development of the Sensory System
Sensory integration is a framework first described by occupational therapist A. Jean Ayres, PhD, in the 1970s. It refers to the body’s way of handling and processing sensory inputs from the environment.1 Ayres felt that the sensory system develops over time, much like other aspects of development (language, motor, etc), and that deficits can occur in the process of developing a well-organized sensory system. A well-organized sensory system can integrate input from multiple sources (visual, auditory, proprioceptive, or vestibular). Ayres postulated that sensory integration dysfunction occurs when sensory neurons are not signaling or functioning efficiently, leading to deficits in development, learning, and/or emotional regulation.
The ability of the brain to process sensory information from the environment has been an expanding area of basic neuroscience research. Hubel and Wiesel were among the first to document the important effects of early experience (eg, deprivation) on the way visual sensory input is processed in the brain.2,–5 Animal and human research is beginning to explore how other senses are processed and integrated6,–10 and how those processes are disrupted in specific syndromes (eg, autism,11,12 schizophrenia13,14) and by specific experiences (eg, institutionalization, international adoption15,16).
Statement of the Problem
Since Ayres1 described sensory integration dysfunction in the 1970s, sensory-based therapies have been used increasingly, mainly by occupational therapists (but sometimes other health professionals) to treat a range of symptoms seen in children presenting from across a variety of settings, including the home, community organizations, clinics, and schools. Sensory integration, sensory “diets,” and other sensory-based therapies typically are based on classic sensory integration theory but often do not use all of the originally described sensory integration protocols. Sensory-based therapies involve activities that are believed to organize the sensory system, by providing vestibular, proprioceptive, auditory, and tactile inputs, by using brushes, swings, balls, and other specially designed equipment to provide these inputs. Occupational therapists and other health professionals may also use a sensory processing approach when identifying and modifying barriers that limit the individual’s ability to participate in everyday activities or occupations.
Proponents of sensory integration theory believe that inappropriate or deficient sensory processing is a developmental disorder amenable to therapy and that treatment can improve developmental outcomes.17 A definition of sensory processing disorder has been proposed but has not been universally accepted.18 Standardized measures, such as the Sensory Profile,19 have been developed to classify a child’s sensory deficits. The Sensory Profile provides a standard method for professionals to measure a child’s sensory processing abilities and to provide a profile of the effect of sensory processing on functional performance in the daily life of a child.20 Such standardized measures are commonly used by occupational therapists to quantify how much these developmental and behavioral differences affect the child’s functional performance of the daily activities of childhood.
The possible diagnosis of sensory processing disorders remains a challenging clinical issue. In the sensory processing disorder classification system proposed by Miller et al,18 sensory processing disorders are subdivided into 3 specific patterns: sensory modulation disorder, sensory discrimination disorder, and sensory-based motor disability. These patterns are then categorized into subtypes. Sensory modulation disorder is subdivided into overresponsive, underresponsive, and sensory seeking/craving subtypes. Sensory discrimination disorder has no subtypes. Sensory-based motor disability is subdivided into postural disorder and dyspraxia.
Sensory processing disorder or a similar diagnosis has been included in Zero to Three’s Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Revised21 and the Diagnostic Manual for Infancy and Early Childhood of the Interdisciplinary Council on Developmental and Learning Disorders,22 where “regulatory-sensory processing disorder” in infants has also been classified as a developmental difference for this group. For older children and adolescents, no commonly accepted definition of sensory processing disorder exists. Some experts have proposed that the definition of autism spectrum disorders in the forthcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition be expanded to include definitions of associated sensory issues, such as under- and overresponsiveness; however, the committee that is preparing the textbook has requested that more studies be performed before sensory processing disorder can be officially recognized.23
It remains unclear whether children who present with findings described as sensory processing difficulties have an actual “disorder” of the sensory pathways of the brain or whether these deficits represent differences associated with other developmental and behavioral disorders. Specifically, the behavioral differences seen in children with autism spectrum disorders,24 attention-deficit/hyperactivity disorder,25 and developmental coordination disorders26 overlap symptoms described in children with sensory processing disorders. Studies to date have not demonstrated that sensory integration dysfunction exists as a separate disorder distinct from these other developmental disabilities. Furthermore, numerous challenges exist for evaluating the effectiveness of sensory integration therapy, including the wide spectrum of symptom severity and presentation, lack of consistent outcome measures, and family factors, which make response to therapy variable.27,–29
Despite the challenges of defining and studying the effectiveness of sensory integration therapy, it is possible that the treatment of sensory processing difficulties is helpful to children who have problems identified in sensory processing measures. Some published case series and observational studies have reported positive outcomes of sensory integration therapy for children with sensory processing disorders.27,29 Older meta-analyses30,31 and at least 2 more recent reviews32,33 have been published that suggested a positive trend in meeting occupational goals with the use of sensory integration therapy. However, the authors of the 1999 meta-analysis cautioned that most studies in the field were of insufficient scientific rigor to be included in a meta-analysis, studies varied in the use of outcome measures, and the ability to draw conclusions and detect a treatment effect was limited.31 Many of the more recent studies, unfortunately, share some of these traits.
One recent small study cautions health care practitioners about the possible negative behavioral effects of sensory integration therapy in certain populations. Devlin et al34 reported on the comparative effects of sensory integration therapy and behavioral interventions on rates of challenging or self-injurious behavior in 4 children in whom autism spectrum disorder was diagnosed. A functional assessment was conducted to identify the variables maintaining the challenging behaviors. The sensory integration therapy was designed by an occupational therapist who was trained in sensory integration therapy. The sensory integration therapy and a behavioral intervention were compared within an alternating treatments design. Results from this study clearly demonstrated that the behavioral intervention was more effective in reducing challenging behavior and self-injurious behavior than was the sensory integration therapy. Finally, in the best treatment phase, only the behavioral intervention was implemented, and further reduction was observed in the frequency of challenging behavior and self-injurious behavior.
Recommendations
At this time, pediatricians should not use sensory processing disorder as a diagnosis. When these sensory symptoms are present, other developmental disorders—specifically, autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorder, and anxiety disorder—must be considered and thoroughly evaluated, usually by appropriate referral(s) to a developmental and behavioral pediatrician, child psychiatrist, or child psychologist. The American Academy of Pediatrics clinical report on the management of children with autism spectrum disorders is a useful resource to help with these referrals.35
Pediatricians should recognize and communicate with families about the limited data on the use of sensory-based therapies for childhood developmental and behavioral problems.
If the pediatrician is managing a child whose therapist is using sensory-based therapies, the pediatrician can play an important role in teaching families how to determine whether a therapy is effective.
Help families design simple ways to monitor effects of treatment (eg, behavior diaries, pre-post behavior rating scales). Help the family be specific and create explicit treatment goals, designed at the onset of therapy, focused on improving the individual’s ability to engage and participate in everyday activities (eg, ability to focus, tolerate foods, and be in a room with loud noises).
Set a time limit for seeing the family back to discuss whether the therapy is working to achieve the stated goals.
Pediatricians should inform families that occupational therapy is a limited resource, particularly the number of sessions available through schools and through insurance coverage. The family, pediatrician, and other clinicians should work together to prioritize treatment on the basis of the effects the sensory problems have on a child’s ability to perform daily functions of childhood.
With input from the following committees/councils: COCWD, ASC, SOAI, COPACFH, SOAH, SODBP, SON, SOEH, and COCHF.
Lead Authors
Michelle Zimmer, MD
Larry Desch, MD
Section on Complementary and Integrative Medicine Executive Committee, 2011–2012
Lawrence D. Rosen, MD, Chairperson
Michelle L. Bailey, MD
David Becker, MD
Timothy P. Culbert, MD
Hilary McClafferty, MD
Olle Jane Z. Sahler, MD
Sunita Vohra, MD
Liaison
Lt Col Della Livesay Howell, MD – Section on Young Physicians
Staff
Teri Salus, MPA, CPC
Council on Children With Disabilities Executive Committee, 2011–2012
†Gregory S. Liptak, MD, MPH, Chairperson
Nancy A. Murphy, MD, Interim Chairperson
Richard C. Adams, MD
Robert T. Burke, MD, MPH
Sandra L. Friedman, MD
Amy J. Houtrow, MD, MPH
Miriam A. Kalichman, MD
Dennis Z. Kuo, MD, MHS
Susan Ellen Levy, MD
Kenneth W. Norwood Jr, MD
Renee M. Turchi, MD, MPH
Susan E. Wiley, MD
Liaisons
Carolyn Bridgemohan, MD – Section on Developmental and Behavioral Pediatrics
Georgina Peacock, MD, MPH – Centers for Disease Control and Prevention
Bonnie Strickland, PhD – Maternal and Child Health Bureau
Nora Wells, MSEd – Family Voices
Max Wiznitzer, MD – Section on Neurology
Staff
Stephanie Mucha Skipper, MPH
† Deceased.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Comments
In Support of The American Academy of Pediatric's Policy Statement on Sensory Integration Therapies.
The American Academy of Pediatrics (2011)'s policy statement (1) on Sensory Integration Therapy (SIT) with children with developmental and behavioral disorders, after reviewing evidence from three meta-analyses and one more recent experiment on SIT recommended that "Pediatricians should recognize and communicate with families about the limited data on the use of sensory-based therapies for childhood developmental and behavioral problems": They were right to do so as their conclusions are based on the available good quality evidence. Clark's (2) defense of SIT claims that four studies that use an adequate dose of SIT are evidence of the effectiveness of SIT, but the studies cited (3, 4, 5, 6), like almost all other studies of SIT are in adequate to support that conclusion. Case-Smith and Bryan (3) reported data from five non-experimental AB case studies in which the participants experiences 10 weeks of SIT. AB designs are not experiments; they do exclude the possibility that behavior changed due to variables other than the treatment. Additionally, some of the graphs have unstable, trending baseline data, so that in some cases it is neither clear if the behavior changes due to treatment or due to continuing baseline trends. No data on treatment integrity were reported and at least one of the children also started intensive ABA during SIT treatment. Finally, the data were scored by the authors who also provided the treatment, thus, the data are unlikely to be blind. Fazlioglu and Baren (4) reported data from two groups of 15 children with autism randomly assigned to SIT or treatment as usual. They collected data using a 42-item checklist of sensory problems. They found no differences between the groups at baseline. Treatment consisted of 24, 45-min sessions scheduled twice per week. At baseline there was no difference between the groups and after treatment there was a statistically significant difference. It is unclear if the measures used had adequate inter-rater reliability since the authors only presented an item analysis from a pilot study, but did not report and inter-observer reliability for the data reported in their study. It is unclear who collected the data and whether they were blind to conditions. The authors did not only use SIT, but also sued used of standard behavior modification procedures, such as teaching activities step by step, reinforcement, prompting and fading. Thus, even if there was a change in children's behavior, it is unclear if it was due to observer expectancy effects or use of behavioral procedures. The third study cited by Clark was Linderman and Stewart (5). They reported two AB non-experimental case studies evaluating 11 weekly sessions of SIT. As with Case-Brown and Baram, the use of non-experimental designs cannot preclude factors other than treatment causing any behavior change. The use of a rating scale, probably by non-blind raters, again raises the possibility of rater expectancies being responsible for changes in the data, rather than changes in child behavior. Finally, the best conducted study comes from Pfeiffer et al. (6) who reported a pilot study for a full scale RCT in which 37 children were randomly assigned by an independent statistician to either SIT or fine motor interventions as an active placebo. Both groups received equal treatment duration. Small, but statistically significant effects (p<.05) were observed on some, but not all dependent variables, but the statistic presented did not correct for the use of multiple statistical tests. Although treatment integrity was measured in both groups the measured used were questionable because the items on the treatment integrity checklists were not clearly operationalized. For example, SIT was defined by items such as "(1) arranging the room to entice engagement, (2) ensuring physical safety, (3) presenting sensory opportunities .." etc. Thus, it is unclear what procedures these items refer to. Clark (2) asserted that differential outcomes of SIT studies are due to dosing and treatment integrity effects, but the data she presented do not support that conclusion. Rather, the studies cited are more examples of poor quality SIT outcome studies that fail to demonstrate that any dose of SIT results in behavioral change. Well conducted future studies might demonstrate this, but the data are not yet in. Clark stated that a sufficient dosage of SIT is "minimally several weeks and ideally at least 6 months." Even if future studies do show benefits of this dose of SIT, we should still prefer other more economic forms of available evidence-based practices for children with developmental and behavioral disorders.
References 1. American Academy of Pediatrics. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics. 2012; 129 (6): 1186-1189 2. Clark F. Response to the American Academy of Pediatrics' policy statement on sensory integration therapy. http://www.aota.org/DocumentVault/Response-Letter-to-AAP.aspx. 3. Case-Smith J, & Bryan T. The effects of occupational therapy with sensory integration emphasis on preschool-age children with Autism. Am J Occ Ther. 1999. 53 (5): 489-497 4. Fazioglu, Y, Baran G. A sensory integration program on sensory problems for children with Autism. Percep Motor Skills. 2008; 106 (2) 415-422 5. Linderman TM, Stewart KB. Sensory integrative-based occupational therapy and functional outcomes in young children with Pervasive Developmental Disorders: A single-Subject study. Am J Occ Ther, 1998, 53 (2) 207-213 6. Pfeiffer BA., Koenig, K., Kinnealey, Sheppard, M, Henderson L. Effectiveness of sensory integration interventions in children with Autism Spectrum Disorders: A pilot study. 2011. Am J Occ Ther 65 76-85
Conflict of Interest:
None declared
Sensory variations vs. sensory 'disorders'
Dr. Clark's response included some important points which were good to read, including recognition that single modality interventions tend to be ineffective; I am hopeful that her statements will help to move occupational therapy practice away from these interventions.
I was also glad to see mention of the neurobiological literature as theoretical backing for some interventions. This is important literature that we should all keep in mind when trying to understand apparent processing difficulties.
Finally I was glad to see mention that occupational therapists use a wide variety of interventions with sensory processing interventions among them but not representing them solely. I think we need to remind or medical colleagues of this fact lest we become associated with only a single intervention strategy.
I would like to encourage AOTA leaders and my occupational therapy colleagues to carefully consider the comments of Dr. William Carey, noted above.
I believe that Dr. Carey expresses an important point when he states "Where normal variations leave off and abnormal degrees supposedly begin has not been clearly defined. Clinical problems probably occur most often when the particular level of sensitivity or reactivity makes a poor fit with the demands and expectations of the environment. That dissonance may lead to stress and to some form of dysfunction in the child. In these cases it is helpful to assist the child and parents in finding ways to get along better and reduce the impact of the mismatch. But this does not mean that the child has a disorder."
I think that occupational therapists have done an incomplete job of making distinctions between truly pathological levels of dysfunction vs. identifying traits and tendencies regarding processing differences. In part this has been facilitated by over-reliance on parental report measures and the an apparent desire to get this labeled as a disorder first and to develop valid and reliable client factor assessments second.
Occupational therapists remain well positioned, and I would even argue best positioned, to still provide important interventions to children and families where sensory processing differences are causing stress, anxiety, and even performance difficulties. However, when we take the opportunity to consider that this is not always a primary disorder but sometimes a complex and dynamic relational point of dysfunction between the child and their contextual environment, then suddenly we have a whole different set of tools available to us in addition to the process and structural components that are currently being suggested as preconditions for any kind of effective intervention.
So why do we need to re-frame this so that we are not restricted to calling it a disorder and thinking that we need special equipment and 6 months of therapy (ideally)???? Because of pragmatics and the real world.
Dr. Clark talks about real world applications and so here we need to acknowledge the real world. Insurance companies do not pay for months and months of therapy - nor should we expect that in this current health care environment. What good do we do when we state that the only proper studies to consider are those that include a frequency and intensity of therapy that is not reimbursed? Do we restrict this intervention only to the wealthy who are able to go to private clinics and pay these fees out of pocket?
Ultimately, I believe that the model of sensory integration therapy that calls for specific structural and process elements that are not found in the majority of intervention settings will not serve the public and will be discarded. The model of sensory integration therapy that calls for high dosage requirements that are not reimbursed anywhere in the country will not serve the public and will also be discarded. This high intensity and high dose strategy is not a model that will position us to help children and families who experience these difficulties.
We need to consider the words of Dr. Carey carefully. His words do not delegitimize the role of occupational therapy; rather, his words are a clarion call to provide occupational therapy in a way that is more congruent with actual child/family needs and more congruent with a responsible and conservative intervention strategy.
Christopher J. Alterio, Dr.OT, OTR
Conflict of Interest:
None declared
Letter to the Editor Re:
On behalf of the American Occupational Therapy Association (AOTA), I would like to commend the American Academy of Pediatrics for issuing a policy statement on sensory integration therapy (SIT) that is both fair minded and highly informative. Key conclusions such as the viability of using SIT as an acceptable component within a more comprehensive treatment plan, the necessity to conduct further studies on the efficacy of SIT treatment, the need to better validate sensory integration dysfunction as a separate disorder, and the importance of involving families in the treatment process are all extremely important.
In its review, the Academy identified research supportive of SIT (e.g., Miller, Coll, & Schoen, 2007; Tochel, 2003), as well as at least one study (Devlin, Healy, Leader, & Hughes, 2011) that demonstrated no effect. Such discrepancies in the results of SIT outcome research have been commonplace, and suggest that it is critical to identify the characteristics that differentiate the intervention protocols that produced positive versus no effects. In surveying the broad set of randomized group comparisons and single-subject designs that have been conducted, it becomes apparent that positive results are most likely to emerge when the SIT intervention: (a) involves sufficient dosage (minimally several weeks and ideally at least 6 months); and (b) includes the application of multiple forms of sensory input tailored to the needs of the child as opposed to a single type of sensory stimulation (such as vestibular) or modality (such as a weighted vest). Sensory interventions that do not contain these two features tend to yield null effects (e.g., Devlin et al., 2011; Kane, Luiselli, Dearborn, & Young, 2004; Leew, Stein, & Gibbard, 2010; Reilly, Nelson, & Bundy, 1983). In contrast, interventions that meet these criteria usually produce positive outcomes (e.g., Case-Smith & Bryan, 1999; Fazlioglu & Baran, 2008; Linderman & Stewart, 1999; Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011). Because real world applications of SIT generally involve at least several weeks of exposure to a wide array of tailored sensory opportunities presented in an enriched environment, the results for interventions that are short in duration or that are limited to a single stimulus are questionable in terms of their ability to properly inform policy regarding SIT as it is currently practiced. Therefore, AOTA is concerned about the emphasis in the policy statement on the study conducted by Devlin et al. (2011). Insofar as participants in that study received sensory treatment for an average of 4.5 days only, which reflects insufficient dosage for any realistic expectation of positive effects, the negative outcome should be interpreted cautiously.
In order to promote best practice, AOTA encourages pediatricians to consider the evolving evidentiary base of SIT that is being established through studies on the beneficial effects of interventions that meet the above criteria (e.g., Case-Smith & Bryan, 1999; Fazlioglu & Baran, 2008; Linderman & Stewart, 1999; Miller et al., 2007; Pfeiffer et al., 2011). Among these, three are randomized controlled trials demonstrating positive outcomes in areas such as social responsiveness, stereotypes, attention, and goal attainment (Fazlioglu & Baran, 2008; Miller et al., 2007; Pfeiffer et al., 2011). Additionally, pediatricians may wish to review the AOTA Practice Guidelines for Children and Adolescents With Challenges in Sensory Processing and Sensory Integration (Watling, Koenig, Davies, & Schaaf, 2011) which is available through the Agency for Healthcare Research and Quality National Guideline Clearinghouse (http://www.guideline.gov/).
In another vein, AOTA was impressed with the Academy's citing of neuroscience research that underscores the link between exposure to sensory input and brain functioning. Such research is voluminous and provides general theoretical backing for the concept of SIT. For example, numerous studies using animal models demonstrate that environments that allow for exploration or play with objects such as wheels, swings, toys, and tactile media stimulate neural firing and sculpt synaptic connections, resulting in increased cortical thickness, neuronal size, synaptic density, or neocortical neurotransmission (Diamond, Lindner, & Raymond, 1967; Diamond, Rosenzweig, Bennet, Lindner, & Lyon, 1972; Gomez-Pinilla, Ying, Roy, Molteni, & Edgerton, 2002; Greenough & Volkmar, 1973; Greenough, Volkmar, & Juraska, 1973; Greenough, West, & DeVoogd, 1978; Merzenich, 2000; Zhang, Bao, & Merzenich, 2001). Consistent with these findings, recent models of neurodevelopment in humans posit that atypical sensory processing in disorders such as autism may disrupt the neurobiological circuitry that underlies the later development of motor skills, behavioral regulation, social interaction, language, and adaptive behaviors (Thompson & Levitt, 2010). It is interesting to consider that, at the neurobiological level, any correction for these types of adverse effects is expected to minimally require several weeks to several months to unfold (e.g. Baranek, 2002; Humphries, Wright, Snider, & McDougall, 1992; Miller et al., 2007; Ottenbacher, Short, & Watson, 1979; Wilson & Kaplan, 1994; Ziviani, Poulsen, & O'Brien, 2010), a time span that further underscores the assertion that extremely short-term sensory interventions should not be used to inform policy about SIT. Again, to best meet the challenge of studying the effectiveness of SIT, a key goal noted in the AAP Policy Statement, it will be critical to confirm that the studies considered meet the above criteria of sufficient dosage and availability of multiple forms of sensory input.
Overall, AOTA is pleased with the content of the AAP policy statement. Although occupational therapy treatment provision draws from a wide range of intervention approaches to be responsive to the needs of the child and his or her family, SIT is one approach frequently included in an overall plan of care. Such plans are aimed at promoting functional, participatory, and behavioral gains, which are continuously monitored. Also, in accord with the policy statement, AOTA recognizes the need to promote further research to determine whether the diagnosis of sensory processing disorder should be included in the Diagnostic and Statistical Manual of Mental Disorders in the future. Given this, it has recently urged the American Psychiatric Association to continue to monitor and promote research in this area. Finally, AOTA appreciates the guidance the policy statement provides to families with respect to collaborating with teams, obtaining a thorough assessment, prioritizing treatment options, and monitoring outcomes.
As a whole, the AAP policy statement presents an excellent summary of the pressing issues surrounding SIT, with sensible recommendations that reflect the body of currently available information. Accordingly, the policy statement promises to contribute to sound pediatric practice. AOTA would welcome opportunities to discuss these issues with AAP experts to further our mutual interest of helping children and families address developmental and behavioral disorders.
Sincerely,
Florence Clark, PhD, OTR/L, FAOTA President, American Occupational Therapy Association
References
Baranek, G. T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders, 32(5), 397-422.
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, 489-497.
Devlin, S., Healy, O., Leader, G., & Hughes, B. M. (2011). Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. Journal of Autism and Developmental Disorders, 41, 1303-1320.
Diamond, M. C., Lindner, B., & Raymond, A. (1967). Extensive cortical depth measurements and neuron size increases in the cortex of environmentally enriched rats. Journal of Comparative Neurology, 131, 357- 364.
Diamond, M. C., Rosenzweig, M. R., Bennett, E. L., Lindner, B., & Lyon, L. (1972). Effects of environmental enrichment and impoverishment on rat cerebral cortex. Journal of Neurobiology, 3(1), 47-64. doi:10.1002/neu.480030105
Fazlioglu, Y., & Baran, G. (2008). A sensory integration therapy program on sensory problems for children with autism. Perceptual and Motor Skills, 106, 415-422.
Gomez-Pinilla, F., Ying, Z., Roy, R. R., Molteni, R., & Edgerton, V. R. (2002). Voluntary exercise induces a BDNF-mediated mechanism that promotes neuroplasticity. Journal of Neurophysiology, 88, 2187-2195. doi:10.1152/jn.00152.2002
Greenough, W. T., & Volkmar, F. R. (1973). Pattern of dendritic branching in occipital cortex of rats reared in complex environments. Experimental Neurology, 40, 491-504.
Greenough, W. T., Volkmar, F. R., & Juraska, J. M. (1973). Effects of rearing complexity on dendritic branching in frontolateral and temporal cortex of the rat. Experimental Neurology, 41, 371-378.
Greenough, W. T., West, R. W., & DeVoogd, T. J. (1978). Subsynaptic plate perforations: Changes with age and experience in the rat. Science, 202, 1096-1098.
Humphries T., Wright M., Snider L., & McDougall B. (1992). A comparison of the effectiveness of sensory integrative therapy and perceptual-motor training in treating children with learning disabilities. Journal of Developmental and Behavioral Pediatrics, 13(1), 31-40. doi:10.1097/00004703-199202000-00007
Kane, A., Luiselli, J. K., Dearborn, S., & Young, N. (2004-2005). Wearing a weighted vest as intervention for children with autism/pervasive developmental disorder: Behavioral assessment of stereotypy and attention to task. Scientific Review of Mental Health Practice, 3(2), 19-24.
Leew, S. V., Stein, N. G., & Gibbard, B. W. (2010). Weighted vests' effect on social attention for toddlers with Autism Spectrum Disorder. Canadian Journal of Occupational Therapy, 77, 113-124.
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.
Merzenich, M. (2000). Cognitive neuroscience: Seeing in the sound zone. Nature, 404, 820-821. doi:10.1038/35009174
Miller, L. J., Coll, J. R., & Schoen, S. A. (2007). A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. American Journal of Occupational Therapy, 61, 228-238.
Ottenbacher, K., Short, M. A., & Wilson, P. J. (1979). Nystagmus duration changes of learning disabled children during sensory integrative therapy. Perceptual and Motor Skills, 48(3c), 1159-1164.
Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65, 76-85.
Reilly, C., Nelson, D. I., & Bundy, A. C. (1983). Sensorimotor versus fine motor activities in eliciting vocalizations in autistic children. Occupational Therapy Journal of Research, 3(4), 199-212.
Thompson, B. L., & Levitt, P. (2010). The clinical-basic interface in defining pathogenesis in disorders of neurodevelopmental origin. Neuron, 67, 702-712. doi:10.1016/j.neuron.2010.08.037
Tochel, C. (2003). Sensory or auditory integration therapy for children with autistic spectrum disorders. STEER, 3(17), London, UK: Wessex Institute for Health Research and Development, University of Southampton.
Watling, R., Koenig, K. P., Davies, P., & Schaaf, R.C. (2011). Occupational therapy practice guidelines for children and adolescents with sensory processing and sensory integration challenges. Bethesda, MD: AOTA Press.
Wilson B., & Kaplan B. J. (1994). Follow-up assessment of children receiving sensory integration treatment. OTJR: Occupation, Participation and Health, 14(4), 244-266.
Zhang, L. I., Bao, S., & Merzenich, M. M. (2001). Persistent and specific influences of early acoustic environments on primary auditory cortex. Nature Neuroscience, 4, 1123-1130. doi:10.1038/nn745
Ziviani, J., Poulsen, A., & O'Brien, A. (2010). Effect of a sensory integrative/neurodevelopmental programme on motor and academic performance of children with learning disabilities. Australian Occupational Therapy Journal, 29, 27-33.
Conflict of Interest:
None declared
Sensory variations not always pathological
The AAP Policy Statement on Sensory Integration Therapies for Children with Developmental and Behavioral Disorders (Pediatrics 129:1186- 1189;2012) makes important points about how the theory and treatments in this field are not adequately supported by appropriate research. The words of caution to pediatricians are important and timely. However, the Statement makes a significant error in the differential diagnosis: "When these sensory symptoms are present, other developmental disorders- specifically autism spectrum disorders, attention deficit/hyperactivity disorder, developmental coordination disorder, and anxiety disorder- must be considered thoroughly and evaluated usually with appropriate referrals..." Data supporting this recommended choice of alternatives are sparse. The Statement fails to recognize that all children have variations in the normal temperament characteristics of sensitivity and intensity of reactivity and that most of them are healthy and doing well. Where normal variations leave off and abnormal degrees supposedly begin has not been clearly defined. Clinical problems probably occur most often when the particular level of sensitivity or reactivity makes a poor fit with the demands and expectations of the environment. That dissonance may lead to stress and to some form of dysfunction in the child. In these cases it is helpful to assist the child and parents in finding ways to get along better and reduce the impact of the mismatch. But this does not mean that the child has a disorder. The AAP Statement should be revised to give this broader perspective. In our times too many aversive variations of normal are being labeled as disorders or defects in the child when the problem really lies in the child-environment interaction.
Conflict of Interest:
None declared
Re:Letter to the Editor Re: Sensory Integration Therapies for Children with Developmental and Behavioral Disorders
Reply to Letter from Lucy Miller, PhD:
The lead authors of the Policy Statement would first of all like to thank Dr. Miller for her thoughtful and comprehensive response. We also appreciate her bringing to our attention the additional published research studies, a few of which we were unaware of. However, most of the papers which were cited by Dr. Miller had been at least superficially reviewed by one or both of the authors of the Policy Statement. Space constraints prevented us from including every reference that had been reviewed in preparation for the development of the statement. In addition, most of the references provided by Dr. Miller deal with descriptions of sensory based issues and their diagnosis in different groups of children. The Policy Statement, however, focused on the published evidence for the treatment effectiveness of sensory integration techniques (whether or not following the original methods of Dr. Ayres). The additional references provided by Dr. Miller or her presentation of her own experiences did not provide any significant new information that would refute our conclusion in the Policy Statement that there currently is insufficient evidence to state that sensory-based therapies are effective enough methods to be used without at least some concerns. Also there is not yet enough evidence to determine which specific treatments are the most effective for particular symptoms/problems. Although more research is being published, especially recently, regarding the establishment of sensory processing disorder as a potentially separate disorder (i.e., the problems seen not being a part of another disorder, such as autism), there still seems to be considerable controversy. The fact that the committees who are developing the DSM-5 decided, after reviewing the literature, that they would not consider including sensory processing/integration as a disorder also gives some credence to the concerns we stated in the Policy Statement. Both of the lead authors of the Policy Statement are "believers" in the existence of sensory-based neurobehavioral problems but feel that more research is definitely needed before a clearer understanding is reached that may lead to a consensus on what characteristics make up the "disorder". Hopefully, a relatively specific and clear list of criteria will be developed.
Conflict of Interest:
None declared
Re:Letter to the Editor Re: Sensory Integration Therapies for Children with Developmental and Behavioral Disorders
I have been a treating occupational therapist for 5 years and believe that SPD is a valid diagnosis that should be recognized by DSM. I have many patients that fall into that specific category and do not have any other diagnosis. Due to SPD not presenting in the same way in all patients it makes for a broad dx. It is critical that this be recognized for on going education for professionals and families, as well as for accurate treatment.
Conflict of Interest:
None declared
Letter to the Editor Re: Sensory Integration Therapies for Children with Developmental and Behavioral Disorders
I am responding to your article of May 28, 2012 on behalf of the SPD Foundation and our constituents, primarily parents of children with Sensory Processing Disorder and physicians, therapists, educators and other professionals who are trying to help children with sensory challenges and their families. Our website, www.SPDFoundation.net, receives an average of 85,000 hits each day from individuals seeking information about this disorder, which shows how much information about the disorder is sought and needed.
First, let me applaud the Journal for conveying issues related to this controversial area with such even-handed scientific rigor. Many aspects of this article are accurate and we agree with much of what is conveyed wholeheartedly. For example, the conclusion that occupational therapy may be acceptable as a component of a comprehensive treatment plan is accurate. Another excellent statement provided in the article is that pediatricians should inform potential users of research related to any type of intervention they intend to use.
However, since 1995, the Wallace Research Foundation (WRF) has had an initiative to study Sensory Processing Disorder. To ensure rigor in the design of funded projects, many Principal Investigators with extensive NIH -funded research backgrounds are funded by the WRF projects. The researchers have formed a consortium, the SPD Scientific Work Group, with 49 members so far, representing renowned institutions such as Harvard, Yale, Duke, MIT, U of WI-Madison, UC San Francisco and many others. Notably, none of the dozens of peer-reviewed articles published by the Scientific Work Group are sited in the AAP Section article in Pediatrics. For example, the AAP committee neglected to mention the rigorous preliminary randomized controlled trial (RCT) (Miller et al., 2007), or publications related to: the prevalence of the disorder (Ben-Sasson, 2009, et al.), the validity of the diagnosis (Davies, et al., 2007), and/or the underlying neurological foundations suggested by the empirical data (McIntosh, et al., 1999; Schoen, Miller et al., 2009; Brett-Green, Miller et al., 2008, 2010). The 2007 RCT demonstrated the effectiveness of OT with children who have SPD, in achieving individualized parent priorities as well as other key outcomes compared to both a passive and an active placebo.
The following comments address the AAP Committee's three primary recommendations:
First, is SPD a diagnosis? According to the rule-based definition that a diagnosis is considered valid because it is in the DSM or the ICD, then it is true that SPD is not yet a "real" diagnosis. However, the research evidence includes multiple studies suggesting that SPD, while frequently comorbid with other disorders such as Autism Spectrum Disorder and ADHD, does exist as a separate stand-alone condition. Carter, Briggs- Gowan, and Ben-Sasson (Yale University, U MA-Boston, U Conn) studied all babies born from July 1995 to September 1997 in the New Haven greater metropolitan area. These children were followed from birth to age 8 years and tested several times during the longitudinal, epidemiologic, NIH- funded study. At age 8, with children diagnosed with ASD, genetic disorders, or developmental delays excluded from the research, 75% of the children with SPD symptomology were found to have no co-morbid diagnosis (Carter et al., 2011). In another rigorous NIH-funded epidemiologic study, Goldsmith and colleagues (Van Hulle, et al., 2012) at the University of WI -Madison followed 970 children. They administered the Diagnostic Interview Schedule for Children and excluded children with autism and pervasive developmental disorders from a study which reported that ~ 58% of the children with significant SPD symptoms had no other diagnoses. Thus evidence is building, regardless of the acceptance of SPD in diagnostic manuals, that SPD is a valid diagnosis, and exists in children who do not have other mental health or physical conditions. Regardless, we agree with the AAP committee's conclusion that caution is warranted in labeling the disorder; treating the symptoms (whatever the condition is labeled) is much more important than the diagnostic category into which the label falls.
The second conclusion is that the "limited data on the use of sensory -based therapies should be communicated." Certainly the limitations on effectiveness data related to the many interventions used in pediatrics should be communicated. An informed clinician should have up-to-date references on many if not all therapies used to increase functioning in pediatric clients. In the case of occupational therapy for children with SPD, references should include: Miller et al, (2007), the RCT noted above, that demonstrated the effectiveness of OT in treating 1) parent priorities for treatment outcomes measured with Goal Attainment Scaling (Kiresuk et al., 1994) and cognitive/social issues measured with the Leiter International Performance Scale - Revised (Roid & Miller, 1997) and 2) the RCT administered by Pfeiffer, Kinnealey et al. (2011) that demonstrated the superiority of sensory-based OT to compared to fine motor -based OT and found that the former achieved individualized outcomes e.g., social emotional growth ,and self-regulation whereas the latter resulted in changes related only to fine motor skills. Other articles about the effectiveness of OT with pediatric disorders include: Case-Smith & Arbesman (2008) and May-Benson & Koomar (2010) and more.
We agree also with the third recommendation: families should be taught to determine whether interventions are effective. This key concept applies to all interventions and all service providers. In addition to evaluating interventions such as OT, parents should be taught to evaluate the effect of medications, nutritional supplements, dietary changes, and other interventions. At the STAR Center in Denver, CO, we assist parents in using either visual analog scales or Goal Attainment scaling to evaluate the services they receive. (See Kiresuk et al., 1994 and/or Dexter et al., 1999; van Laerhoven, H. et al., 2004; Paul-Dauphin, et al., 1999 for more information on these techniques.)
Finally, a few comments related to the body of the Pediatrics article follow. The article alludes to, but is non-specific about, the explosion of animal and human research that explores how sensory information is processed and integrated. Sensory integration in this context refers not to the behavioral pattern that OTs and others refer to as "SI" dysfunction. Instead it applies to sensory information that comes into the nervous system as unisensory (e.g., tactile only or auditory only) and synapses on a multisensory neuron or set of neurons, producing a different response than the domain specific (e.g. unisensory) input. An excellent current reference on MSI in animals and humans is the New Handbook of Multisensory Processing (Stein, B. Ed., released in June 2012, with 43 chapters related to MSI including MSI in SPD [Miller et al, 2012]).
In addition to MSI research, studies exist demonstrating differences between SPD and normal controls on other psychophysiologic functions including: arousal using electrodermal activity (McIntosh et al, 1999), vagal tone (Schaaf, 2003), and sensory gating (Davies, 2007). In addition, evidence related to the neurophysiologic mechanisms of sensory processing includes PET scans and environmental trauma studies with non-human primates that demonstrate sensory processing impairments (Schneider et al., 2007 and 2008), rat studies of PPI in animals with poor vs. good sensory gating (Levin et al., 2005 and 2007), and cat studies of MSI (e.g., Stanford, Quessy, Stein; 2005; Perrault, Rowland, Stein, 2012).
A final note regarding the treatment, occupational therapy with a sensory integration framework, is worth mentioning. The AAP committee is quite right in noting that most OTs who use sensory-based therapies do not base their intervention strictly on Ayres' protocols principles (cf. Ayres, 1972). Since the focus of current-day treatment increasingly is social participation, self-regulation, self-esteem/confidence and participation in everyday activities or occupations (Cohn, Miller et al., 2000), the therapeutic model that most advanced clinicians use and teach is enriched from Ayres original teachings. Though in some locations, treatment for SPD is limited to specific protocols, such as so-called "brushing," "spinning," wearing weighted vests, etc., and not tailored to the individual nor based on clinical reasoning, in many locations therapy is provided by advanced clinicians, who have been trained and participated in a mentored training on intervention for SPD.
Thus, best practice OT intervention includes principles from the model originally developed by Ayres (1972) but with striking expansions such as:
1) offering 'intensives' (therapy 3 to 5 days a week) over a short- term, 2) developing specific family-generated functional goals; 3) concentrating on parent education and coaching; and 4) focusing on enriched relationships and engagement, arousal regulation and social participation with the essence being 'joie du vivre,' improving the quality life for children and families.
Certainly, we agree with the AAP authors that "numerous challenges exist for evaluating the effectiveness of SI therapy, including the wide spectrum of symptom severity and presentation, lack of consistent outcome measures, and family factors." (Pediatrics p. 1187). In fact, we have offered additional issues for researchers to consider (Miller et al., 2007b) prior to initiating outcome studies such as:
1) The need for a manualized treatment protocol tied specifically to a fidelity to treatment measure; 2) The need and means to identify a homogeneous sample; 3) The need for consistent outcome measures that are sensitive and measure meaningful changes; 4) And, of course, methodological rigor which is sometimes hard to attain in real world, non-laboratory settings.
The cautions stated in the AAP article about the validity of outcome data relates to all pediatric interventions. We agree with the AAP committee that interventions must be examined in relation to the effectiveness of the treatment for the particular type of disorder a specific individual is exhibiting.
And finally, let us all keep in mind the teachings of Ayres, who consolidated sensory-based therapies into a field she called Sensory Integration; this quote aptly displays Ayres' scientific mind and evaluative spirit.
"Truth, like infinity, is to be forever approached, but never reached" (Ayres, 1972, p iv).
Those using Ayres' assessment and treatment approach should be mindful of her wisdom and humility.
Lucy Jane Miller, May 31, 2012 Executive Director, STAR (Sensory Therapies And Treatment) Center and Sensory Processing Disorder Foundation
References
Ayres, J.A. (1972). Sensory Integration and Learning Disorders. Western Psychological Services: Los Angeles, CA.
Ben-Sasson, A., Carter, A.S., & Briggs-Gowan, M.J. (2009). Sensory Over-Responsivity in Elementary School: Prevalence and Social- Emotional Correlates. Journal of Abnormal Child Psychology, doi 10.1007/s10802-008-9295-8.
Brett-Green, B. A., Miller, L. J., Gavin, W. J., Davies, P. l. (2008). Multisensory Integration in Children: A Preliminary ERP study, Brain Research, 1242, 283-290.
Brett-Green, B., Miller, L.J., Schoen, S. A., Nielsen, D.M., (2010). An Exploratory Event Related Potential Study of Multisensory Integration in Sensory Over-Responsive Children. Brain Research, doi:10.1016/j.brainres.2010.01.043.
Carter, A.S., Ben-Sasson, A., Briggs-Gowan, M.J. (2011). Sensory Over -Responsivity, Psychopathology, and Family Impairment in School-Aged Children. Journal of the American Academy of Child & Adolescent Psychiatry, 50(12):1210-1219.
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(4): 416-429.
Cohn, E., Miller, L. J., & Tickle-Degnen, L. (2000). Parental hopes for therapy outcomes: Children with sensory modulation disorders. American Journal of Occupational Therapy, 54, 3 6-4 3.
Davies, P. L., & Gavin, W. J. (2007). Validating the diagnosis of sensory processing disorders using EEG technology. American Journal of Occupational Therapy, 61, 176-189.
Dexter, F., Chestnut, D.H. (1999). Analysis of Statistical Tests to Compare Visual Analog Scale Measurements among Groups. Anesthesiology, 82 (4): 896-902
Kiresuk, T.J., Smith, A., Cardillo, J.E. (1994). Goal Attainment Scaling: Applications, Theory and Measurement. Erlbaum: Hillsdale, NJ.
Levin, E.D., Petro, A., Caldwell, D.P. (2005). Nicotine and clozapine actions on pre-pulse inhibition deficits caused by N-methyl-D-aspartate (NMDA) glutamatergic receptor blockade. Progress in Neuro- Psychopharmacology & Biological Psychiatry, 29:581-586.
Levin, E.D., Caldwell, D.P., Perraut, C. (2007). Clozapine treatment reverses dizocilpine-induced deficits of pre-pulse inhibition of tactile startle response. Pharmacology Biochemistry and Behavior, 86(3):597-605.
May-Benson, T.A. & Koomar, J.A. (2010). Systematic Review of the Research Evidence Examining the Effectiveness of Interventions Using a Sensory Integrative Approach for Children. American Journal of Occupational Therapy, 64:403-414.
McIntosh, D.N., Miller, L.J., Shyu, V., & Hagerman, R. (1999). Sensory-modulation disruption, electrodermal responses, and functional behaviors. Developmental Medicine and Child Neurology, 41, 608-615.
Miller, L.J., Coll, J.R., Schoen, S.A. (2007a). A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. American Journal of Occupational Therapy, 61:228-238.
Miller, L. J., Schoen, S. A., James, K., & Schaaf, R. C. (2007b). Lessons learned: A pilot study on occupational therapy effectiveness for children with sensory modulation disorder. The American Journal of Occupational Therapy, 61 (2), 161-169.
Miller, L.J., Schoen, S.A., Nielsen, D.M. (2012). Sensory Processing Disorder: Implications for Multisensory Function. In B. E. Stein (Ed) The New Handbook of Multisensory Processing (pp. 707-724). MIT Press: Cambridge, MA.
Paul-Dauphin, A., Guillemin, F., Virion, J-M., and Brian?on, S. (1999). Bias and Precision in Visual Analogue Scales: A Randomized Controlled Trial. American Journal of Epidemiology, 150 (10): 1117-1127. Perrault, T.J., Rowland, B.A., Stein, B.E. (2012). The Organization and Plasticity of Multisensory Integration in the Midbrain. In Murray MM, Wallace MT (Eds). The Neural Bases of Multisensory Processes (Chapter 15). Boca Raton, FL: CRC Press.
Roid, G.H. & Miller, L.J. (1997). Leiter International Performance Scale--Revised. Wood Dale, IL: Stoelting. [Test battery, Manual, and computer scoring software].
Schaaf, R. C., Miller, L. J., Seawell, D., & O'Keefe, S. (2003). Children with disturbances in sensory processing: A pilot study examining the role of the parasympathetic nervous system. American Journal of Occupational Therapy, 57, 442-449.
Schneider ML, Moore CF, Gajewski LL, Laughlin NK, Larson JA, Gay CL, Roberts AD, Converse AK, DeJesus OT (2007). Sensory Processing Disorders in a Nonhuman Primate Model: Evidence for Occupational Therapy Practice. American Journal of Occupational Therapy, 61:247-253.
Schneider, M.L., Moore, C.F., Gajewski, L.L., Larson, J.A., Roberts, A.D., Converse, A.K., DeJesus, O.T. (2008). Sensory Processing Disorder in a Primate Model: Evidence From a Longitudinal Study of Prenatal Alcohol and Prenatal Stress Effects. Child Development, 79(1):100-113.
Schoen, S. A., Miller, L.J., Brett-Green, B., Nielsen, D.M. (2009) Physiological and behavioral differences in sensory processing: a comparison of children with Autism Spectrum Disorder and Sensory Modulation Disorder. Frontiers in Integrative Neuroscience 3, 29: 1-11.
Stanford, T.R., Quessy, S., Stein, B.E. (2005). Evaluating the operations underlying multisensory integration in cat superior colliculus. Journal of Neuroscience, 25(28):6499-6508.
Stein, B.E. (Ed) The New Handbook of Multisensory Processing. (2012) MIT Press: Cambridge, MA.
Van Hulle, C.A., Schmidt, N.L., Goldsmith, H.H. (2012). Is sensory over-responsivity distinguishable from childhood behavior problems? A phenotypic and genetic analysis. Journal of Child Psychology and Psychiatry, 53(1):64-72.
van Laerhoven, H., van der Zaag-Loonen, H.J., Derkx, B.F.X., (2004). A comparison of Likert scale and visual analogue scales as response options in children's questionnaires. Acta Paediatrica, 93 (6): 830-835.
Conflict of Interest:
I am the Executive Director of the Sensory Processing Disorder Foundation and STAR (Sensory Therapies And Research) Center.