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Sensory interventions for children with autism “
A recent review of sensory integration therapy and sensory-based intervention for children with autism spectrum disorders found that sensory integration therapies have emerging positive evidence while sensory-based interventions have mixed and limited evidence of benefit.
”
Keywords: autistic disorder • intervention studies • occupational therapy • sensation • treatment effectiveness
Difficulty processing, integrating and responding to sensory stimuli (hereafter referred to as sensory difficulties) have been described as a feature of autism spectrum disorders (ASD) since the disorder was first identified [1] . Current estimates show that between 45 and 90% of children with ASD demonstrate these sensory difficulties and that they range from over and under reactivity to poor perception and discrimination of sensation [2–4] . Sensory difficulties are now included in the DSM 5 under the restricted, repetitive patterns of behavior, interest or activities criteria [5] . Families report that these sensory difficulties create social isolation, restrict participation in daily activities, and impact social engagement for them and their child [6–8] . Consequently, interventions to address sensory difficulties are among the most often requested and highly rated interventions by parents of children with ASD [9–11] . Survey findings report that over 60% of children with ASD receive some type of sensory intervention. Although sensory interventions are common for ASD, a wide range of protocols are implemented with conflicting evidence of efficacy. In this editorial, we explain the types of sensory interventions practiced and evidence of their efficacy. As found in the literature and in practice, sensory interventions utilize a variety of sensory modalities (e.g., vestibular, somatosensory, auditory and multisensory); target behaviors that may or may not be associated with sensory difficulties; involve a continuum of passive to active child participation; and are applied in different contexts. Many
10.2217/CER.14.18 © 2014 Future Medicine Ltd
authors have inaccurately used the term sensory integration therapy (SIT) to describe sensory-based interventions (SBIs) and these variations in intervention protocols, combined with inconsistent use of terminology and conflicting findings, has resulted in considerable confusion for parents, practitioners and researchers [12,13] . SIT is an occupational therapy intervention that uses individually tailored, sensoryrich activities in a child-directed, playful and interactive manner to facilitate adaptive responses and functional behaviors [14–18] . When using SIT, occupational therapists individually tailor intervention goals and activities to the child’s needs based on a thorough assessment of the sensory-motor factors that may be impacting participation in desired activities and skill development. The specific principles of SIT target improving the child’s adaptive responses as a foundation for higher level skills [19,20] . By contrast, SBIs are adult-directed sensory strategies designed to address sensory over or under reactivity and facilitate behavioral regulation. SBIs are prescriptive rather than interactive in nature [21,22] . Examples of SBI include wearing a weighted vest, brushing, sitting on a therapy ball or applying multisensory stimulation using a highly structured protocol [23–26] . SBIs have often been implemented without assessment of the child’s sensory needs, providing child choice or adapting the activity according to the child’s responses [24,23,27] . A recent review of SIT and SBI for children with ASD found that SITs have emerging positive evidence while SBIs have mixed
J. Compar. Effect. Res. (2014) 3(3), 225–227
Roseann C Schaaf Author for correspondence: Department of Occupational Therapy, Farber Institute for Neurosciences, Thomas Jefferson University, 901 Walnut Street, Room 605, Philadelphia, PA 19107, USA Tel.: +1 215 503 9609 Fax: +1 215 503 3499 roseann.schaaf@ jefferson.edu
Jane Case-Smith Occupational Therapy, School of Health & Rehabilitation Sciences, College of Medicine, The Ohio State University, OH, USA
part of
ISSN 2042-6305
225
Editorial Schaaf & Case-Smith and limited evidence of benefit [21] . These researchers reviewed five recent SIT/occupational therapy studies, including two randomized controlled trials that found large effects on individual goals and two studies that found positive effects on behavior (described in more detail below). Of the 14 SBI studies identified in this article, seven studies examined the effects of a weighted vest and six studies evaluated the effects of other vestibular (e.g., sitting on a ball, swinging) or tactile (e.g., brushing) stimulation. These studies (primarily single-subject design) have produced few positive effects. Six of seven studies on weighted vest demonstrated no or mixed effects on behavior and studies of the other sensory modalities produced mixed results. The researchers concluded that SITs show moderate effects on individualized child goals using parent- and teacher-reported measures and that SBIs show insufficient evidence to recommend their use. This article gives initial guidance to practitioners and families as to what types of sensory intervention can positively affect child behavior and performance. Recently, a small but rigorous randomized controlled trial examined the effects of SIT on functional skills and participation in daily activities for children with ASD aged 5–8 years [28] . Using gold-standard assessments to confirm diagnosis, groups were matched on mental age and autism severity. Treatment followed a manualized protocol and adherence to intervention was tested with a validated measure. Participants receiving SIT (n = 17) scored significantly higher (p = 0.003; d = 1.2) on Goal Attainment Scales (GAS; primary outcome), and also scored significantly better on measures of caregiver assistance in self-care (p = 0.008; d = 0.9) and socialization (p = 0.04; d = 0.7) than the usual care, or control group (n = 15). Independent evaluators (blind to intervention) rated GAS goals at postintervention via parent interview and compared these to therapists’ ratings in order to establish interReferences 1
Kanner L. Early Infantile autism. J. Pediatr. 25, 211–217 (1944).
2
Leekam SR, Nieto C, Libby SJ, Wing L, Gould J. Describing the sensory abnormalities of children and adults with autism. J. Autism Develop. Dis. 37(5), 894–910 (2007).
3
Ben-Sasson A, Cermak S, Orsmond G, Tager-Flusberg H, Kadlec M, Carter A. Sensory clusters of toddlers with autism spectrum disorders: differences in affective symptoms. J. Child Psychol. Psychiatr. 49(8), 817–825 (2008).
4
226
Zachor DA, Ben-Itzchak E. The relationship between clinical presentation and unusual sensory interests in autism spectrum disorders. A preliminary investigation. J. Autism Develop. Dis. doi:10.1007/s10803-013-1867-y (2013) (Epub ahead of print).
J. Compar. Effect. Res. (2014) 3(3)
rater reliability. GAS assures that targeted outcomes are meaningful and important to families and scores were corroborated using a standardized, valid measure of functional skills. These findings are consistent with those of a previous study comparing SIT with finemotor intervention in which children with ASD who received SIT showed greater improvement on GAS (p
Sensory interventions for children with autism “
A recent review of sensory integration therapy and sensory-based intervention for children with autism spectrum disorders found that sensory integration therapies have emerging positive evidence while sensory-based interventions have mixed and limited evidence of benefit.
”
Keywords: autistic disorder • intervention studies • occupational therapy • sensation • treatment effectiveness
Difficulty processing, integrating and responding to sensory stimuli (hereafter referred to as sensory difficulties) have been described as a feature of autism spectrum disorders (ASD) since the disorder was first identified [1] . Current estimates show that between 45 and 90% of children with ASD demonstrate these sensory difficulties and that they range from over and under reactivity to poor perception and discrimination of sensation [2–4] . Sensory difficulties are now included in the DSM 5 under the restricted, repetitive patterns of behavior, interest or activities criteria [5] . Families report that these sensory difficulties create social isolation, restrict participation in daily activities, and impact social engagement for them and their child [6–8] . Consequently, interventions to address sensory difficulties are among the most often requested and highly rated interventions by parents of children with ASD [9–11] . Survey findings report that over 60% of children with ASD receive some type of sensory intervention. Although sensory interventions are common for ASD, a wide range of protocols are implemented with conflicting evidence of efficacy. In this editorial, we explain the types of sensory interventions practiced and evidence of their efficacy. As found in the literature and in practice, sensory interventions utilize a variety of sensory modalities (e.g., vestibular, somatosensory, auditory and multisensory); target behaviors that may or may not be associated with sensory difficulties; involve a continuum of passive to active child participation; and are applied in different contexts. Many
10.2217/CER.14.18 © 2014 Future Medicine Ltd
authors have inaccurately used the term sensory integration therapy (SIT) to describe sensory-based interventions (SBIs) and these variations in intervention protocols, combined with inconsistent use of terminology and conflicting findings, has resulted in considerable confusion for parents, practitioners and researchers [12,13] . SIT is an occupational therapy intervention that uses individually tailored, sensoryrich activities in a child-directed, playful and interactive manner to facilitate adaptive responses and functional behaviors [14–18] . When using SIT, occupational therapists individually tailor intervention goals and activities to the child’s needs based on a thorough assessment of the sensory-motor factors that may be impacting participation in desired activities and skill development. The specific principles of SIT target improving the child’s adaptive responses as a foundation for higher level skills [19,20] . By contrast, SBIs are adult-directed sensory strategies designed to address sensory over or under reactivity and facilitate behavioral regulation. SBIs are prescriptive rather than interactive in nature [21,22] . Examples of SBI include wearing a weighted vest, brushing, sitting on a therapy ball or applying multisensory stimulation using a highly structured protocol [23–26] . SBIs have often been implemented without assessment of the child’s sensory needs, providing child choice or adapting the activity according to the child’s responses [24,23,27] . A recent review of SIT and SBI for children with ASD found that SITs have emerging positive evidence while SBIs have mixed
J. Compar. Effect. Res. (2014) 3(3), 225–227
Roseann C Schaaf Author for correspondence: Department of Occupational Therapy, Farber Institute for Neurosciences, Thomas Jefferson University, 901 Walnut Street, Room 605, Philadelphia, PA 19107, USA Tel.: +1 215 503 9609 Fax: +1 215 503 3499 roseann.schaaf@ jefferson.edu
Jane Case-Smith Occupational Therapy, School of Health & Rehabilitation Sciences, College of Medicine, The Ohio State University, OH, USA
part of
ISSN 2042-6305
225
Editorial Schaaf & Case-Smith and limited evidence of benefit [21] . These researchers reviewed five recent SIT/occupational therapy studies, including two randomized controlled trials that found large effects on individual goals and two studies that found positive effects on behavior (described in more detail below). Of the 14 SBI studies identified in this article, seven studies examined the effects of a weighted vest and six studies evaluated the effects of other vestibular (e.g., sitting on a ball, swinging) or tactile (e.g., brushing) stimulation. These studies (primarily single-subject design) have produced few positive effects. Six of seven studies on weighted vest demonstrated no or mixed effects on behavior and studies of the other sensory modalities produced mixed results. The researchers concluded that SITs show moderate effects on individualized child goals using parent- and teacher-reported measures and that SBIs show insufficient evidence to recommend their use. This article gives initial guidance to practitioners and families as to what types of sensory intervention can positively affect child behavior and performance. Recently, a small but rigorous randomized controlled trial examined the effects of SIT on functional skills and participation in daily activities for children with ASD aged 5–8 years [28] . Using gold-standard assessments to confirm diagnosis, groups were matched on mental age and autism severity. Treatment followed a manualized protocol and adherence to intervention was tested with a validated measure. Participants receiving SIT (n = 17) scored significantly higher (p = 0.003; d = 1.2) on Goal Attainment Scales (GAS; primary outcome), and also scored significantly better on measures of caregiver assistance in self-care (p = 0.008; d = 0.9) and socialization (p = 0.04; d = 0.7) than the usual care, or control group (n = 15). Independent evaluators (blind to intervention) rated GAS goals at postintervention via parent interview and compared these to therapists’ ratings in order to establish interReferences 1
Kanner L. Early Infantile autism. J. Pediatr. 25, 211–217 (1944).
2
Leekam SR, Nieto C, Libby SJ, Wing L, Gould J. Describing the sensory abnormalities of children and adults with autism. J. Autism Develop. Dis. 37(5), 894–910 (2007).
3
Ben-Sasson A, Cermak S, Orsmond G, Tager-Flusberg H, Kadlec M, Carter A. Sensory clusters of toddlers with autism spectrum disorders: differences in affective symptoms. J. Child Psychol. Psychiatr. 49(8), 817–825 (2008).
4
226
Zachor DA, Ben-Itzchak E. The relationship between clinical presentation and unusual sensory interests in autism spectrum disorders. A preliminary investigation. J. Autism Develop. Dis. doi:10.1007/s10803-013-1867-y (2013) (Epub ahead of print).
J. Compar. Effect. Res. (2014) 3(3)
rater reliability. GAS assures that targeted outcomes are meaningful and important to families and scores were corroborated using a standardized, valid measure of functional skills. These findings are consistent with those of a previous study comparing SIT with finemotor intervention in which children with ASD who received SIT showed greater improvement on GAS (p
