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Sensory Integration Therapy for Children with Autistic Spectrum Disorders

1. Introduction

Experts agree that there is an increase in the prevalence of pervasive developmental disorders (PDD),  especially in the early diagnosis of the disorder in the pre-school age group, compared with 30 years ago (Allik, H. 2006; Rutter, M. 2005; Fombonne, E. 2003; Powell, J.E. 2000;  Greenspan, S.I. 1998). Is this a real increase or a diagnostic shift?  Experts from the most recent Autism Conference in Sicily agree that 40% can be attributed to a real increase and 60% due to increased awareness amongst diagnosticians (Griesel, J. 2010). The number of young children referred for occupational therapy, with diagnoses which fall into the autistic spectrum in the last 10 years in South Africa has increased considerably (Jacklin, L. 2006, Venter, A. 2002).

Autism is a neurobiological disorder of development that causes discrepancies in the way the brain processes information.  This affects the child’s ability to understand language, communicate with people; understand and relate in typical ways to people, events and objects in the environment and to learn and think in the same way as typically developing children (Schaaf, R.C. 2007).  According to Baker, (2007), sensory processing difficulties have been reported in 95% of children with ASD, which affects their ability to understand and respond to sensory stimuli in typical ways (Tomchek, S.D. 2007; Baker, A.E. 2007).  Although there is significant individual variability in the autistic population, in the areas of tactile processing, attention, cognition, language, and sensory modulation consistent trends were seen  (Smith Roley, S. 2005).   These findings were confirmed in a recent study using the Short Sensory Profile (SSP) with children aged 3 – 6 yrs with the greatest differences reported on the under-responsive/seeks sensation, auditory filtering and tactile sensitivity scores processing functions (Wallace, 2010, Tomchek, S.D. 2007).  Children with ASD frequently demonstrate mixed patterns; and a picture where there is hyper-responsivity to auditory and tactile stimuli, and hypo-responsivity to proprioceptive and vestibular stimuli is reported (Wallace, 2010, Kientz, M.A. 1997).  Vision is typically the preferred sensory channel (Rogers, S.J. 2003)  and dyspraxia is a generalised deficit and a universal phenomenon in ASD (Dzuik, 2007, Mostovsky, S.H. 2006; Emde,R.N. 2005; Mailloux, Z. 2001; Ayres, A.J. 1972).

2. Diagnosis

The DSM IV :TR diagnosis of autism has three diagnostic criteria (DSM IV, 1994, 2001). 

  • The qualitative impairment in social interaction, is evident by marked impairment in non-verbal behaviours such as eye contact and gestures, resulting in a failure to develop peer relationships.  
  • The qualitative impairment in communication is seen in a delay or lack of development of spoken language; an impairment in ability to sustain conversation and repetitive or stereotyped use of language. 
  • Restricted repetitive, stereotyped patterns of behaviour, interests and activities, is seen in an abnormal pre-occupation with patterns, in an intensity or focus, the compulsive adherence to rituals or routines, or repetitive motor mannerisms and pre-occupations with parts of objects.  This manifests as a lack of pretend or social imitative play (related to developmental level) with onset prior to three years of age     (American Psychiatric Association, 2001; 1994).

The Multisystem Developmental Disorder diagnosis (MSDD ) includes the following additional diagnostic criteria in the evaluation of  infants and toddlers less than 2 yrs old: A significant dysfunction in the processing of visual, auditory, tactile proprioceptive and vestibular sensations, including hyper-reactivity and hypo-reactivity to sensory input and significant dysfunction in motor planning (sequencing movements) (Emde, R.N. 2005 ).
The DSM V that will be published in 2012 will classify all autistic disorders as one spectrum that will be defined in behavioural terms with only two criteria.  (Griesel, J. 2010)

  • A social, emotional communication aspect
  • A sensory processing component.

Because ASD is a developmental disorder, the understanding of the effect of these early sensory and motor manifestations is helpful in explaining some of the occupational performance challenges that are reported by parents of pre-school children with ASD. 

3. Therapy

Ninety-five to ninety-seven percent of occupational therapists working with children with ASD, reported using a sensory integration (OT-SI) approach to guide intervention, due to their significant difficulty processing sensory information, which restricts participation in daily life activities (Miller-Kuhaneck, H. 2004;  Kraemar, G.W. 2001;  Case-Smith, J. 1999, Case-Smith, J. 1999a).  Sensory Integration is a way of viewing the neural organisation of sensory information for functional behaviour (Parham D. 1996).  The goal of intervention is to improve the child’s ability to process and integrate sensory information from their bodies and their environment and to provide a basis for improved independence and participation in daily, person management activities, play and school-related tasks (Schaaf, R.C. 2005).  In a survey of 1009 caregivers of children with ASD, SI intervention was the most frequent non-biological service requested by parents (Mandell, D.S. 2006). Sensation is an organiser of behaviour and arousal, and because sensory processing is invisible, therapists need to observe behaviour and use clinical reasoning to put together a working hypothesis (Schaaf, R.C. 2007). 

The experiences and meaning of touch among parents of children with autism attending an 8 week Touch Therapy Programme was measured, as parents frequently felt “hurt” in response to the aloof nature of autism and natural parenting instincts (e.g. spontaneous cuddles) were restricted.  As the children’s tolerance of touch improved and parents found that routine tasks like dressing were accomplished more easily, the children were found to be more relaxed.  Parents reported feeling “closer to their children” and that the touch therapy had opened a communication channel between themselves and their children (Cullen, L. 2002 ).  Preterm infants who received massage or tactile-kinaesthetic stimulation gained 47% more weight, slept better and had a better clinical course (Field, T. 1986 ).

Sensitivity to noise also causes conflict, as different family members have different requirements in terms of the volume of the TV or stereo, and there is frequently difficulty processing sound of different frequencies, so tolerance of certain voices can be stressful, and manifest in outbursts. Sensitivity to smell may create barriers to relationships and also impact on harmony at mealtimes.  People who use certain deodorants, perfumes or after-shaves can be very offensive to a child who is sensitive to smell.  Often the child does not know what is bothering him, and is only aware of the agitation or feeling of being out of control, and of not understanding what is happening in his environment.  Sensitivity to food tastes, smells and textures results in a very limited diet, and frequently makes it very difficult for the family to eat out of their own home environment (Cermak, S. 1998).   Difficulty maintaining eye contact while listening to somebody speak, is an example of the problem of attending to more than one stimulus at a time.  When she forced herself to maintain eye contact, a highly intelligent verbal adult autistic described that her mind would shut down, and she could not think, so even struggled to respond to seemingly simple questions. This in turn created a state of heightened anxiety, which she attempted to deal with by using a number of behavioural strategies.  Although jumping, flapping her hands, rocking, head banging would be regarded as strange maladaptive behaviour by others; they provided her with a sense of security and a release of tension.  The more extreme the movement, the greater the anxiety she was trying to combat ( Williams, D. 1994). It is postulated that children use motor stereotypies in order to help reduce abnormally high arousal levels, as well as increasing the arousal levels of children who are chronically under aroused (Rogers, S.J. 2005).  The highest percentages of atypical responses were found in the sections related to emotional responses and inattention distractibility.  A close relationship between these two sections and atypical sensory responses suggests that there is an association between the processing and modulation of emotion, attention and sensory information (Liss, M. 2006).  The attentional abnormalities in ASD may be due to a cerebellar dysfunction, and anatomic abnormalities in the cerebellum have been reported consistently ( Allen, G. 2006). As with the cerebellum, the amygdala, a structure that plays a crucial role in emotional modulation, has been postulated to be involved in ASD (Baron-Cohen, S. 2000). 

In choosing a suitable technique to address occupational based outcomes both the underlying components the associated with the ASD diagnosis and the typical occupations of the pres-school child need to be linked.  When considering a perceptual-motor approach, the focus would be on motor skill acquisition and postural control, and treatment that is planned and directed by the adult (Case-Smith, J. 2001). An approach which provides imposed sensory stimulation would not result in an adaptive response (Dru, D. 1987).  Although the Floortime technique considers the child’s individual sensory profile; the outcomes are social/emotional development, (Greenspan, S.I. 1998) so would not cover all the occupation based outcomes.  A behavioural approach, which uses operant conditioning to create and establish performance and skills, maintain performance, and modify context or activity demands to reinforce desirable behaviour is limited to the specific skill that is being trained  (Watling, R. 2004).   Ludos, free play of the child is indeed child directed. However if the child with ASD is not able to self regulate, and gets stuck in repetitive familiar play sequences, scaffolding by a trained therapist would be necessary to facilitate adaptive responses.

Ayres (1972) developed her theory of sensory integration based on principles from neuroscience, developmental psychology and education.  It is an evolving theory based on non-linear relationships among dynamically interrelated neurobiological and functional systems.  Fundamental principles are :

  1. sensorimotor development affects motor performance and is an important substrate for learning; (Parham, L. D. 2001)
  2. the interaction of the individual with the environment shapes brain development;
    ( Parham, L. D. 2001)
  3. the nervous system is capable of change (plasticity) in response to environmental interactions or “press (Bennett, E.L. 1964)
  4. meaningful sensory perceptions and motor activity, guides actions with people and things, enhancing all aspects of development; which is a powerful mediator of neuro plasticity (Renner, M.J. & Rosenweig, M.R. 1972). In comparison passive stimulation, does not produce the same positive results (Dru, D. 1987)
  5. it has therefore been hypothesised that adaptive responses activate the brain’s neuroplastic capabilities, and increase the efficiency of sensory integration at a neuronal level (Parham, L. D. 2001).
  6. sensation improves attentiveness and responsivity so is a powerful motivator of participation and social relatedness, (Field, T. 1997) interactive play (Ingersoll, B. 2003), adaptive behaviour (Case-Smith, J. 1999) and communication (Case-Smith, J. 2001).
    These principles remain as applicable today as when they were first hypothesised in the 1970’s.  Advances in neuroscience that inform practice show increased complexity far beyond the research available to Ayres in the 1970’s.  More recent research demonstrates that structural, molecular and cellular changes in neural functions are possible, and that lifestyle redesign including meaningful sensory-motor activities can be mediators of plasticity and improve functional outcomes.  This entails modifying existing circuitry and creating novel circuitry by facilitating synaptogenisis and dentritic arborization (Schaaf, R.C. 2005; Buonomano, D.V. 1998; Greenough, W.T. 1987; Renner, M.J. & Rosenweig, M.R. 1972).

Individuals whose difficulties with participation are related to poor sensory processing due to difficulties interpreting sensory information from their bodies have the opportunity to engage in sensory integration therapy, which has the potential to address the underlying mechanisms of their behaviour.  Research into the biochemical underpinnings of autism indicates that 25 – 38% of individuals with ASD have increased serotonin levels.  We know that serotonin has a generalised inhibitory effect on defensive behaviour, filtering of sensory signals, social attachment and perception.  Hyperserotonemia may lead to a reduction in the drive for social attachment (Chamberlain, R.S. 1990). There is also evidence of increased cortisol and dysregulation of the hypothalamic-pituitary axis in ASD,  (Chamberlain, R.S. 1990) and by measuring heart rate variability, Toichi and Kamio (2003), found that individuals with ASD were more stressed experiencing autonomic hyperarousal in a resting state,  compared to when they were performing repetitive mental tasks (Toichi, M. 2003).  Interest in this disorder is at an all-time high, but until knowledge gained through research allows for prevention, appropriate intervention will remain of utmost importance (Miller-Kuhaneck, H. 2004).

4. Sensory Integration Therapy

Key principles of the SI approach include :

  • “the Just Right Challenge” where the therapist creates playful activities with achievable challenges;
  • “The Adaptive Response” whereby the child adapts their behaviour with new and useful strategies;
  • “Active Engagement” whereby the therapist’s artful creation of challenging, yet playful sensory rich environments, entice the child to participate actively in play;
  • “Child Directed” by reading the child’s behavioural cues, and following the child’s lead or suggestions, the therapist creates interesting sensory rich activities, within a therapeutic environment designed to tap into the child’s inner drive to play.  (Parham, D. 2007; Parham, L.D. 2006; Ayres, A.J. 1972)

OT-SI intervention planning needs to take into consideration the following: sensory modulation in order to achieve improvements in the child’s ability to self-regulate arousal levels, circadian rhythms, attention and affect.  Sensory discrimination is essential for improved perception of detail in the environment.  Postural and motor skills for lay the foundations for improvements in activities of daily living and participation in motor play. Praxis is vital for the ability to generalise and plan unfamiliar motor tasks.  Organisation of behaviour sets the stage for management of systems and relationships with people (Smith-Roley, S. 2008).

In addition to direct intervention with the child, the occupational therapist collaborates with parents, teachers and other professionals involved with the child, to help them to understand the child’s behaviour from a sensory perspective. The therapist assists them in adapting the child’s natural environments and creating sensory and motor experiences. These experiences are planned throughout the child’s day, to meet sensory needs, and ensure that there is carryover from gains made in therapy enabling the child to be more functional in activities of daily living.  Therefore SI therapy must always be imbedded in the context of a full OT programme as was originally described by Ayres (Schaaf, R.C. 2005 ).

However, parent mediated early intervention for pre-school children with autistic spectrum disorders  has long been accepted as helpful.  As part of this intervention, each child’s specific sensory needs, the behaviours the child uses to self regulate and their capacity for sensory modulation, needs to be understood (Cermak, S. 1998).  Bundy(2002), stated that occupational therapy using sensory integration; which provides enhanced sensory experiences within the context of meaningful activities, and results in more adaptive behaviours e.g. regulation of sleep-wake cycles, feeding, emotional regulation, play and socialisation has been identified as an approach to be used with younger children with ASD, whose nervous systems are still actively developing (Bundy, A. 1981, 2002).   OT-SI therapy targets the parts of the brain which register novelty, and encourages other structures within the nervous system to develop (Mailloux, Z. 2001). 

In a study conducted by Diggle, parent training was found to be beneficial, in terms of the child’s language development and improved maternal knowledge of autism.  Increased skill and reduced stress are potential benefits.     In the second study which involved parents, but where the treatment was primarily delivered by professionals; better child outcomes were reported.  No differences were found in relation to parent and teacher’s perception of skills and behaviours.  Larger samples, randomised controlled trials including both short and long-term outcome measures and full economic evaluations were recommended (Diggle, T. 2003).  Earlier intervention, and the preventative benefits of sensory and motor interventions embedded in naturalistic environments needs to be encouraged (Baranek, G.T. 2002).

5.       Conclusions

Early intervention is accepted as being more cost effective in the long term. The child’s level of participation in occupationally relevant activities within the home and the community, will predict their independence in the occupational realms of adulthood. This translates into a  reduction in  the cost to the society, in terms of governments providing lifelong financial support for people with ASD.  OT-SI has the potential to change the developmental trajectory of children with ASD   (Esdaile, S.A. 2003). OT-SI has been criticised as being a component based child centred treatment model, with no occupational relevance.  In its true purest form it embeds SI firmly in the realm of occupational therapy the goals being active engagement in the occupation roles of childhood.

There is a growing trend for families of severely disabled children to care for them in the home (Weiss, S.J. 1991).   Addressing the issue of parental well-being is thus important for both the parents their children, and the society as a whole (Esdaile, S.A. 2003). The importance of family-centred services for children with disabilities was emphasised by Cohn  (Cohn, E. 2000).  Suggested interventions for parents were aimed at enhancing parenting skills, as well as stress management programmes for both parents as part of the occupational therapy programme     The need to incorporate a parent stress measure as well as an engagement and family occupational performance an outcome measure, and correlating this with change in the child’s occupational performance has not been researched to date. 

Practice in early-intervention has more recently emphasised a family-centred approach, in which the family’s concerns are the starting point for defining needs and priorities  (Meisels, S.J. 1996).  Home based intervention needs to be more grounded in typical family occupations, and writings in this area have emphasised the importance of embedding therapeutic activities in the child’s regular daily routines. Intervention has limited impact, and carry-over into family life by incorporating sensorimotor activities in daily routines would be beneficial (Case-Smith, J. 2001). Practice in the school environments has also confronted therapists with the need to consider the context of the child, both in trying to understand his behaviour, and in designing meaningful interventions in the classroom and on the playground. 

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