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Sensory Integration Therapy for Children with Autism

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Title: Sensory Integration Therapy for Children with Autism


1
Sensory Integration Therapy for Children with
Autism
2
What is Sensory Integration Therapy?
  • Sensory Integration Therapy (SIT) is a
    sensory-motor treatment
  • SIT looks like play, because play is a childs
    way of learning and developing
  • SIT is designed to restore effective neurological
    processing by enhancing the vestibular,
    proprioceptive, and tactile systems

3
Vestibular System
  • Involves inner ear responses to movement and
    gravity
  • Influences balance, emotions, muscle tone, and
    eye movement
  • Vestibular processing may be under-responsive or
    over-responsive

4
Proprioceptive System
  • Receives input from joints and muscles
  • This input helps us to locate our bodies in space
  • Movement is often slow and clumsy
  • Trouble learning new skills

5
Tactile System
  • Involve increased or decreased reaction to touch
  • Or difficulty receiving information by touch
  • May experience under-responsive tactile
    processing
  • May experience over-responsive tactile processing

6
History of Sensory Integration Therapy
  • Ayres developed a theoretical model, the theory
    of Sensory Integration
  • Based on principles from neuroscience, biology,
    psychology and education
  • Faulty integration of sensory information
  • Inability of higher centers to modulate and
    regulate lower brain sensory-motor centers

7
History of Sensory Integration Therapy (cont)
  • Sensorimotor development is an important
    substrate for learning
  • The interaction of the individual with the
    environment shapes brain development
  • The nervous system is capable of change
    (plasticity)
  • Meaningful sensory-motor activity is a powerful
    mediator of plasticity

8
Meet Dr. A Jean Ayres
  • Born in 1920 and grew up on a farm in Visalia,
    California
  • As a child, she struggled with learning problems
  • Masters Degree in Occupational Therapy
  • Doctorate in Education Psychology
  • Postdoctoral work at UCLAs Brain Research
    Institution

9
Meet Dr. A Jean Ayres (cont)
  • Developed diagnostic tools for identifying the
    disorder
  • Proposed a therapeutic approach that transformed
    pediatric occupational therapy
  • 1972, Sensory Integration International was
    established

10
The Ayres Clinic
  • Founded in 1976 by A. Jean Ayres
  • Was Dr. Ayres private practice
  • Today, it is part of Sensory Integration
    International

11
The Ayres Clinic
  • Assessment
  • Treatment
  • Education
  • Research

12
Sensory Integration The Theory
  • Ayres (1972) hypothesized that
  • learning is a function of the brain and
    learning disorders reflect some deviation in
    neural functions
  • Since some individuals with learning disorders
    have motor or sensory problems, they have
    difficulty processing and integrating sensory
    information
  • This inability to integrate sensory information
    causes behavior and learning problems
  • This is referred to as Sensory Integrative
    Dysfunction

13
Sensory Integration The Theory
  • Later, Ayres and Tickle (1980) applied the theory
    to children with autism and further hypothesized
    that
  • SI helped decrease tactile and other
    sensitivities to stimuli that interfere with
    these individuals ability to play, learn, and
    interact
  • Poor sensory processing among individuals with
    autism may contribute to maladaptive behaviors of
    these children and impact their ability to
    participate in social, school, and home
    activities
  • Autism is said to be a factor contributing to
    Sensory Integrative Dysfunction

14
Sensory Integration The Theory
  • According to Ayres,
  • A sensory integrative approach to treating
    learning disorders differs from many other
    approaches in that it does not teach specific
    skills. Rather, the objective is to enhance the
    brains . . . capacity to perceive, remember, and
    motor plan. Therapy is considered a supplement,
    not a substitute to formal classroom instruction.

15
Sensory Integration The Theory
  • The focus is on 3 sensory systems Tactile,
    Vestibular, and Proprioceptive
  • The interrelationship among these sensory systems
    is critical to ones basic survival (most people
    can integrate and interpret sensory information
    automatically)
  • These systems interact with each other, allowing
    us to experience, interpret, and respond to
    different stimuli in our environment

16
Sensory Integration The Therapy
  • SI therapy provides opportunities for engagement
    in sensory motor activities that are rich in
    tactile, vestibular, and proprioceptive
    sensations
  • The child is guided through challenging and fun
    activities designed to stimulate and integrate
    sensory systems, challenge his or her motor
    systems, and facilitate integration of sensory,
    motor, cognitive, and perceptual skills

17
Sensory Integration Key Principles of Therapy
Principle Description
Just Right Challenge Therapist creates playful activities with achievable challenges
The Adaptive Response In response to challenge, the child adapts his or her behavior with new and useful strategies, furthering development
Active Engagement The methods of play incorporate new and advanced abilities that increase the childs repertoire of skills and processing
Child Directed Therapist constantly observes the childs behavior and reads behavioral cues, follows the childs lead or suggestions, and uses these cues to create enticing, sensory rich activities
18
Sensory Integration The Therapy
  • Tactile System
  • Processes information taken in by touch
  • Some deficits may include
  • sensitivity to touch
  • difficulty in discriminating textures
  • avoiding getting wet or dirty
  • food selectivity based on texture or temperature

19
Sensory Integration The Therapy
  • Tactile System
  • Some tactile activities include
  • Koosh ball games
  • Feely bags
  • Hiding objects in rice, beans, kitty litter, and
    sand
  • Shaving cream painting and drawing
  • Drawing shapes on the childs back
  • Brushing, interspersed with joint compression
  • Deep pressure massages

20
Sensory Integration The Therapy
  • Vestibular System
  • Processes information based on balance and
    gravity
  • Some deficits include
  • lack of awareness of body in space
  • intolerance of movement
  • avoiding physical activities
  • constant movement, spinning

21
Sensory Integration The Therapy
  • Vestibular System
  • Some vestibular activities include
  • Teaching children to spin
  • Rolling in a barrel
  • Sitting or bouncing on an exercise ball
  • Swinging on a hammock
  • Scooter board relay races
  • Walking on a balance beam
  • Stair climbing

22
Sensory Integration The Therapy
  • Proprioceptive System
  • Processes information based in muscles and joints
  • Some deficits include
  • difficulty with motor skills
  • lack of coordination
  • difficulty holding a writing utensil
  • falls or walks into objects often

23
Sensory Integration The Therapy
  • Proprioceptive System
  • Some proprioceptive activities include
  • Tug-of-war
  • Backpack hiking
  • Jumping over obstacles
  • Crab walking relay races
  • Crawling under a parachute

24
Sensory Integration Outcomes
  • According to Ayres, some outcomes from SI therapy
    include
  • Ability to concentrate
  • Ability to organize
  • Increase in self-esteem
  • Increase in self-control
  • Increase in self-confidence
  • Improvement in academic learning ability
  • Capacity for abstract thought and reasoning
  • Specialization of each side of the body and the
    brain

25
What does the research tells us?
  • THE ARGUMENT
  • Howard Goldstein, in 2000, wrote a commentary to
    research studies conducted by Edelson, Rimland
    and Grandin.
  • Commentary entitled, Interventions to Facilitate
    Auditory, Visual and Motor Integration Show Me
    the Data

26
The Argument cont.
  • Goldstein dissected the research done in these
    fields. His conclusion was that there was no
    substantial evidence to conclude the
    effectiveness of such treatments.
  • Most of the data was unreliable due to lack of
    experimental control, subject selection, research
    design (or lack there of), and subjective
    measurement tools.
  • Since there was no data to support claims made by
    such therapies, it is not justifiable nor ethical
    to promote such therapies to parents using such
    claims.

27
The Argument cont.
  • THE REBUTAL
  • Edelson, Rimland and Grandin in 2003 discuss the
    false accusations made by Goldstein that their
    research was lacking such data.
  • The researchers claim that statistically
    significant data was found in conclusion to their
    research studies and that with such a large
    number of participants their claims were
    justified.
  • This article does not include how these claims
    are justified but instead uses numbers to explain
    effects. The numbers are arbitrary in that they
    do not explain how participants were selected,
    the research method, and the measurement tool.

28
The Argument cont.
  • THE COUNTER ARGUMENT
  • Goldstein comments again in 2003 to the claims
    made by his opponents. He justifies his claims
    of his want for data.
  • Goldstein takes apart studies done in
  • AIT
  • SIT

29
The Argument cont.
  • Goldstein claims that research is lacking in AIT
    but mostly in SIT (especially Grandins hug
    machine)
  • Goldstein explains the lack of data using four
    criteria
  • The lack of randomization of participants
  • The choice of variables
  • Statistically Significant data that is NOT
  • Replication is lacking

30
SIT on SIB
  • Iwata and Mason, 1990 study
  • Investigated three types of SIB
  • Attention-getting SIB
  • Stereotypic SIB
  • SIB that functioned as escape behavior
  • Study used previous research of SIT and its
    affects on decreasing SIB in individuals.

31
Iwata and Mason cont.
  • Participants
  • Sally, 6 years old, severely mentally retarded
    with no language skills. She also had very few
    independent skills.
  • Kathy, 3 years old, profoundly mentally retarded
    with cerebral palsy and scoliosis and no language
    skills and no independent skills.
  • Mort, an 18-year-old male, profoundly retarded,
    with microcephaly and scoliosis. He had minimal
    skills and no language skills.
  • All participants displayed SIB producing tissue
    damage that was at a moderate risk level.

32
Iwata and Mason cont.
  • 3 phases to study
  • 1- observation/baseline condition to determine
    function of SIB
  • 2- exposure to SIT
  • A variety of techniques were utilized
  • Auditory, kinesthetic, tactile, vestibular, and
    visual stimulation.
  • Used three types of settings to utilize these
    techniques. Each subject exposed to all three
    during each 15- minute session.
  • 3- using behavioral interventions

33
Iwata and Mason cont.
  • Results
  • All participants SIB decreased significantly and
    at near zero levels only during the behavioral
    intervention phase.
  • During the SIT phase SIB was variable and SIB
    only decreased during therapy sessions.
  • Parents were trained in implementing the
    behavioral interventions to reduce SIB after the
    conclusion of the study.
  • During a 6-month follow-up Morts and Sallys SIB
    remained at 0 and Kathys SIB was similar to
    that in phase 3 of the experiment at 8.
  • The data show that behavioral interventions show
    a maintained effect on decreasing SIB.

34
More Research
  • Fertel-Daly, Bedell and Hinojosa in 2001
    conducted a research study on the effects of a
    weighted vest on attention to task and
    self-stimulatory behavior.
  • Five participants for this study
  • Ranged in age from 2-4 years old.
  • All were diagnosed with PDD.
  • Not currently treated with a weighted vest
  • Reported to have difficulties in attending to
    tasks.
  • Enrolled in a 5 day a week preschool program (3
    hrs daily)
  • Program used principles of ABA

35
More Research cont.
  • Followed an ABA reversal design.
  • Allowed for comparison between wearing and not
    wearing the vest and effects on attending.
  • Measurement procedure recorded the duration of
    focused attention to task, number of
    distractions, and duration and type of
    self-stimulatory behaviors during 5-min
    intervals.
  • Vests were worn for 2 hours and then off for 2
    hours to follow previous research.

36
More Research cont.
  • Results
  • Duration of attention and duration of self
    stimulatory behavior were depicted on graphs in
    seconds for each participant. The number of
    distractions was also depicted per participant.
  • Each participant therefore had three categories
    graphed.

37
More Research cont.
  • Results cont
  • Results showed that there was a positive effect
    on at least two measures for the 5 participants.
    (less distractable and less self stimulatory
    behaviors occurred)
  • All increased in focused attention but the extent
    to which the increase occurred, varied.
  • All participants also showed an increase in this
    category when the vest was not worn during the
    withdrawl phase. What does this say about the
    functional relationship between the weighted vest
    and attending?
  • After removing the weighted vest 4 participants
    had an abrupt decrease in duration of focused
    attention. Therefore, demonstrating that effects
    are short lived.
  • No return to baseline between interventions could
    this effect results?

38
Conclusions and Recommendations
  • Current research based on scientific criteria
    does not support Sensory Integration Therapy as
    an effective treatment for improving behavior and
    learning of individuals with autism.
  • However, some studies have been published
    indicating specific sensory intervention
    strategies have improved some specific aspects of
    behavior.
  • Many studies, either proving or disproving
    the effects of SIT have not clearly defined terms
    and have not followed rigorous research
    procedures.

39
After a review of the literature, the appropriate
scientific conclusion is that
  • The effect of Sensory Integration
  • Therapy is neither proven nor
  • unproven at this point.
  • More research is needed!

40
Specifically
  • Terms must be clearly defined.
  • More objective criteria must be used to
    characterize and diagnose individuals with
    sensory processing deficits
  • Clinical trials must be administered in a
    replicable fashion using specific sensory
    integration techniques to address specific
    observable behaviors.
  • Autism practitioners must keep informed on
    current research in the field.

41
Research must depend on clear definition of terms
  • Classical Sensory Integration Therapy based on
    A. Jean Ayres model specifically
  • Is based on inference that tactile, vestibular
    and kinesthetic experiences treat disruptions in
    subcortical functions of CNS.
  • Utilizes activities chosen/controlled by child
  • Always involves use of specialized equipment such
    as swing, usually in clinical setting

42
Current best practice in field of occupational
therapy uses Sensory-Based O. T. model
  • Assessment and intervention imbedded in
    activities that are part of individuals daily
    routine/instructional program
  • Goal is not to cure individual but to use
    purposeful and meaningful activities to maximize
    potential.
  • Intervention at impairment level (e.g., to
    address specific sensory problems in processing
    tactile, proprioceptive, or other sensory
    stimuli), but imbedded in occupational
    functioning.

43
Sensory-Based O.T., cont.
  • Emphasis not on repairing CNS functioning, but on
    increasing productive behavior by improving
    processing of sensory stimuli. Specific goals
    would include reduction in rates of aberrant
    behaviors that interfere with learning, enhanced
    ability to focus on relevant materials/activities,
    and increased ability to self-regulate.

44
Sensory Stimulation programs
  • Involve providing specific type of sensory
    stimulation through circumscribed modality (e.g.,
    touch pressure, vestibular stimulation, tactile
    stimulation)
  • Child is passive recipient of techniques
  • Used to modulate arousal, increase attention,
    increase self-regulation of behavior
  • Includes techniques such as sensory brushing,
    weighted vests, sensory diets, or deep pressure
  • Used either in isolation, or in conjunction with
    sensory-based O.T. or other programs (e.g., ABA)

45
More objective and direct methods must be used to
diagnose/characterize individuals with sensory
integration deficits
  • Physiological measures currently being studied
    include
  • Electrodermal Reactivity (EDR)
  • Vagal Tone (VT)
  • Posturography
  • Galvanic Skin Response (GSR)
  • EEG
  • Brain studies

46
Standardized behavioral measures currently being
used to diagnose sensory integrative dysfunction
include
  • Sensory Integration and Praxis Test (SIPT)
  • Reported to measure visual, tactile, and
    kinesthetic perception and motor coordination
    using direct administration of 17 tests
  • Standardized on national sample of more than 2000
    children. Provides norms for each test.
  • Must be administered by O.T. who has completed
    post-graduate courses and certification
    specifically in Sensory Integration and test
    administration
  • Developed by Ayres
  • Research indicates that about 1/3 of tests are
    unstable.
  • Children with ASD not included in normative
    sample.

47
Sensory Profile
  • Behavioral questionnaire completed by parent
  • Contains 125 items grouped into categories of
    Sensory Processing, Modulation, and Behavioral
    and Emotional Responses
  • Standardized on more than 1200 children.
  • High internal reliability, validity measures vary
    between sections
  • Has been used to correctly distinguish between
    children with ASD, ADHD, and typically developing
    children
  • Results are correlated with physiologic measures
    (EDR) of sensory reactivity (p lt .01)

48
Additional clinical research must be administered
in a replicable fashion
  • Research must
  • utilize subjects identified by licensed
    professionals as demonstrating sensory
    integration deficits using standardized
    behavioral and/or physiological assessments
  • target specific observable behaviors and/or
    physiological measures and incorporate
    specifically defined SI techniques
  • use randomized assignment of subjects to
    treatment groups, non-treatment groups, and/or
    alternative treatment groups

49
Research must
  • use blind assessments of specific behaviors pre-
    and post-treatment
  • Utilize research design which will increase
    validity of study (e.g., alternating treatment
    design vs. pre-post-treatment design).
  • Be published in peer-reviewed journal
  • Stand up to replication and analysis by other
    professionals in the field

50
As professionals/parents in the autism field, we
should
  • Keep current on research in the field of Sensory
    Integration, analyzing all information presented
    in terms of scientific criteria
  • If sensory integration therapy is recommended for
    a particular child, share research findings with
    parents/other professionals
  • Make sure all parties have clearly defined
    specific type of therapy being proposed and
    specific observable outcomes expected.

51
We should
  • If SIT is already part of childs program, use
    principles of ABA to attempt to establish
    functional relationship between treatment and
    observable outcomes in terms of specific and
    observable behaviors.
  • Collect data baseline, during treatment,
    post-treatment, generalization.
  • Investigate possible antecedent or consequent
    effects of intervention (e.g., adult attention,
    engagement in preferred activity, etc.)

52
We should
  • If possible, incorporate aspects of
    single-subject research design to further
    establish whether or not treatment affected
    behavior ABAB design, alternating treatment
    design, or multiple baseline design.
  • Share results with parents/other professionals in
    order to make better informed program decisions

53
It is simplistic to say that Sensory
Integration Therapy does not work.
  • While Ayres underlying theory does not appear
    to be based on scientific data and has not been
    supported by current research, there is
    increasing research in the area of physiological
    evidence for differences in sensory processing
  • Current research may be used to create
    hypotheses for further, more scientifically
    valid research in the field of sensory
    integration.

54
References
  • Baranek, G.T. (2002). Efficacy of sensory and
    motor interventions for children with autism.
    Journal of Autism and Developmental Disorders,
    32,397-422.
  • Baron-Cohen, S. (2004). The cognitive
    neuroscience of autism. Journal of Neurology,
    Neurosurgery and Psychiatry, 75, 945-948.
  • Bundy, A.C. Murray, E.A. (2002). Sensory
    Integration A. Jean Ayres Theory Revisited. In
    A.C. Bundy, E.A. Murray S. Lane (Eds.), Sensory
    Integration Theory and Practice. Philadelphia
    F.A. Davis.
  • Dunn, E.J. (1998). The sensory profile a
    discriminant analysis of children with and
    without disabilities. American Journal of
    Occupational Therapy, 52, 283-290.
  • Edelson, S.M., Rimland, B., Grandin, T. (2003).
    Response to Goldsteins Commentary
    Interventions, to Facilitate Auditory, Visual,
    and Motor Integration Show Me the Data.
    Journal of Autism and Developmental Disorders,
    33, 551-552.
  • Fertel-Daly, D., Bedell, G. Hinojosa, J.
    (2001). Effects of a Weighted Vest on Attention
    to Task and Self-Stimulatory Behaviors in
    Preschoolers with Pervasive Developmental
    Disorders. The American Journal of Occupational
    Therapy, 55,629-639.
  • Goldstein, H. (2003). Response to Edelson,
    Rimland, and Grandins Commentary. Journal of
    Autism and Developmental Disorders, 33, 553-555.
  • Goldsetin, H. (2000). Commentary Interventions
    to Facilitate Auditory, Visual, and Motor
    Integration Show Me the Data. Journal of
    Autism and Developmental Disorders, 30, 423-425.
  • Iwata, B. Mason, S. A. (1990). Artificial
    Effects of Sensory-Integrative Therapy on
    Self-Injurious Behavior. Journal of Applied
    Behavior Analysis, 23, 361-370.
  • Miller, L.J. (2003). Empirical evidence related
    to therapies for sensory processing impairments.
    NASP Communiqué, 31.
  • Schaaf, Roseann C., Miller, Lucy Jane. (2005).
    Occupational Therapy Using A Sensory Integrative
    Approach for Children with Developmental
    Disabilities. Mental Retardation and
    Developmental Disabilities Research Reviews, 11,
    143-148
  • Smith, T., Mruzek, D.W., Mozingo, D. (2005).
    Sensory Integrative Therapy. In J.W. Jacobson,
    R.M. Foxx, J.A. Mulick, (Eds.), Controversial
    Therapies for Developmental Disabilities.
    Mahwah, N.J. Lawrence Erlbaum Associates.

55
Resources
  • Sensory Integration Disorder. www.geocites.com/Hea
    rtland/2085/SENSORY.htm?200613
  • Sensory Integration International-The Ayres
    Clinic. www.sensoryint.com/ayres.html
  • Sensory Integration Therapy. www.moddrc.com/infor
    mation-disabilities/fastfacts/sensoryintegration.c
    om
  • Sensory Integration and Praxis Tests (SIPT).
    https//www-secure.earthlink.net/www.wpspublish.co
    m/Inetpub4/catalog/W-260.htm
  • Sensory Integration Courses. http//www.wpspublis
    h.com/Inetpub4/w0903.htm
  • Sensory Profile. http//harcourtassessment.com/ha
    iweb/Cultures/en- US/dotCom/SensoryProfile/About/S
    ensoryProfile
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