Friday, October 26, 2018

Sensory Integration Therapy (SIT) and Autism: Research and Practice


Sensory Integration Therapy (SIT) and Autism Spectrum Disorder

Unusual sensory responses (i.e., sensory over-responsivity, sensory under-responsivity, and sensory seeking) are relatively common in children with autism spectrum disorder (ASD) and when present, may interfere with performance in many developmental and functional domains across home and school contexts. Sensory issues are now included in the DSM-5 ASD symptom criteria for restricted, repetitive patterns of behavior, interests, or activities (RRB), and include hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment; such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects. It should also be noted that sensory processing disorder (SPD) is not recognized as a distinct diagnostic entity by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), Individuals with Disabilities Education Act (IDEA), or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Research

The use of sensory integration therapy (SIT) for treatment of ASD has been both popular and controversial. Although SIT is often used individually or as a component of OT services for children with ASD, this intervention is best described as unsupported.  For example, a systematic review of intervention studies involving the use of SIT concluded that the current evidence-base does not support its use in the education and treatment of children with ASD. The National Autism Center’s National Standards Project also identifies SIT as an “Unestablished Treatment.”  Likewise, the National Professional Development Center on Autism Spectrum Disorders (NPDC) found “insufficient evidence” for sensory diets and sensory integration and fine motor intervention. Further, the American Academy of Pediatrics Section on Complementary and Integrative Medicine and Council on Children with Disabilities has issued a policy statement indicating that although OT with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan, parents and professionals should be informed that the research regarding the effectiveness of SIT is limited and inconclusive. They recommend that when utilized, interventions to address sensory related problems should be integrated at various levels into the student’s individualized educational program (IEP). The American Occupational Therapy Association also suggests that practitioners utilizing a SIT approach use clinical reasoning, existing evidence, and outcomes to create a comprehensive, individualized approach for each client, rather than employing isolated, specific sensory strategies. It is important to recognize that other OT treatments which focus on improving functional skills (e.g., activities of daily living) are essential for a range of neurodevelopmental disorders, thus children with ASD should have access to those interventions when indicated.
In summary, the current evidence-base does not support the use of SIT in the education and treatment of children with ASD. Although SIT has been researched and practiced for nearly 40 years, its underlying theory, accompanying diagnoses, and treatments lack scientific support. At this time there no convincing research to conclude that SIT and similar interventions promote improvement in behavioral or social functioning of individuals with autism. Consequently, professionals should present SIT as untested and encourage families who are considering this intervention to evaluate it carefully. There is a need for more research using scientifically robust, experimental methodologies with larger numbers of more diverse participants to determine whether SIT should be termed an evidence-based intervention. Future research should also investigate if SIT is more or less effective than other interventions designed to reduce or overcome sensory difficulties and whether specific individuals are more likely to benefit from SIT than other individuals.
 Practice
Despite the paucity of research demonstrating the effectiveness of SIT, best practice guidelines indicate that when needed, comprehensive educational programs for children with ASD should integrate an appropriately structured physical and sensory milieu in order to accommodate any unique sensory processing patterns. Students with ASD frequently require accommodations and modifications to prevent the negative effects that school and community environments can have on their sensory systems. While many schools may find it difficult to make major environmental changes, relatively simple adaptations and accommodations can be implemented to lessen the impact of sensory issues on the student with ASD. These include (a) reducing the amount of material posted on classroom wall for a student who has problems with excessive visual stimulation; (b) teaching the student to recognize the problem and ask in their mode of communication to leave the area; (c) providing a low distraction, visually clear area for work; (d) providing alternative seating and a quiet/calming space when students become overwhelmed; and (e) using headphones or similar device to minimize high noise levels. The accommodations and modifications needed to address sensory issues should be specified in the student’s individualized educational program (IEP). The collaboration of knowledgeable professionals (e.g., occupational therapists, speech/language therapists, physical therapists, adaptive physical educators) is necessary to provide guidance about supports and strategies for children whose sensory processing and/or motoric difficulties interfere with educational performance and access to the curriculum.
Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
  Key References and Further Reading
American Academy of Pediatrics, Section on Complementary and Integrative Medicine and Council on Children with Disabilities, Policy Statement (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 1186-1189. doi: 10.1542/peds.2012-0876. Available from http://pediatrics.aappublications.org/content/early/2012/05/23/peds.2012-0876.full.pdf+html
American Occupational Therapy Association. (2010). The scope of occupational therapy services for individuals with an autism spectrum disorder across the life course. American Journal of Occupational Therapy, 64 (Suppl.), S125–S136.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.
Autism. 2015 19(2):133-48. doi: 10.1177/1362361313517762. Epub 2014 Jan 29. A systematic review of sensory processing interventions for children with autism spectrum disorders. Case- Smith J, Weaver LL, Fristad MA.
Brondino, N., Fusar-Poli, L., Rocchetti, M., Provenzani, U., Barale, F., & Politi, P. (2015). Complementary and Alternative Therapies for Autism Spectrum Disorder. Evidence-Based Complementary and Alternative Medicine. Article ID 258589, 31 pages http://dx.doi.org/10.1155/2015/258589
Chhatwani, S., & Fried, K. (2016). Research review: An intervention for sensory difficulties in children with. autism: a randomized trial. Science in Autism Treatment, 13(1), 26-27.
Cote, J., & Fried, K. (2016). Research review: Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. Science in Autism Treatment, 13(2), 11-13.
Dawson, G., & Watling, R. (2000). Interventions to facilitate auditory, visual, and motor integration in autism: A review of the evidence. Journal of Autism and Developmental Disorders, 30, 415-421.
Devlin, S., Healy, O., Leader, G., & Hughes, B. (2011). Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. Journal of Autism and Developmental Disorders, 41(10), 1303-1320.
Hodgetts, S., Magill-Evans, J., Misiaszek, J.E. (2011). Weighted Vests, Stereotyped Behaviors and Arousal in Children with Autism. Journal of Autism and Developmental Disorders, 41, 805–814 doi: 10.1007/s10803-010-1104-x
Lang, R., O’Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., … Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6, 1004–1018. doi: 10.1016/j.rasd.2012.01.006
Leong H. M, Carter M, & Stephenson J (2015). Systematic review of sensory integration therapy for individuals with disabilities: Single case design studies. Research in Developmental Disabilities, 47, 334-351.
National Academy of Sciences (NAS), National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Educational Interventions for Children with Autism. Educating Children with Autism. C Lord, JP McGee, eds. Washington, DC: National Academies Press; 2001.
National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Available from: http://www.nationalautismcenter.org/national-standards-project/phase-2/ http://www.autismdiagnostics.com/assets/Resources/NSP2.pdf
National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. Available from: http://autismpdc.fpg.unc.edu/evidence-based-practices
Pfeiffer, B., Koenig, K., Kinnealey, M., Shepperd, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, January/February 2011, 65(1), 76-85
Schaaf, R., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., & Kelly, D. (2014). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disorders, 44(7), 1493-1506. doi: 10.1007/s10803-013-1983-8. http://doi.org/10.1007/s10803-013-1983-8
Smith, T., Mruzek, D., & Mozingo, D. Sensory Integrative Therapy. In J. W. Jacobson & R. M. Foxx (Eds.) (2005)., Fads, dubious and improbable treatments for developmental disabilities. (pp. 331-350). Mahwah, NJ: Laurence Erlbaum Associates
Smith, T., Mruzek, D., & Mozingo, D. Sensory Integrative Therapy. In R. M. Foxx & J. A. Mulick (Eds.) (2016). Controversial Therapies for Autism and Intellectual Disabilities: Fads, Fashion and Science in Professional Practice. (pp. 247-269). New York, NY: Routledge.
Taylor, M., & Fried, K. (2016). Research synopses: Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. Science in Autism Treatment, 13(4), 40-41.

Weitlauf, A.S., Sathe, N., McPheeters, M.L., Warren, Z.E.. Interventions targeting sensory challenges in autism spectrum disorder: A systematic review. Pediatrics. 2017;139(6):20170347
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. Jessica Kingsley Publishers. London and Philadelphia.
Williames, L. D., & Erdie-Lalana, C. R. (2009). Complementary, holistic, and integrative medicine: Sensory Integration. Pediatrics in Review, 30, e91-e93.
Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk…Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45, 1951-66. doi: 10.1007/s10803-014-2351-z
Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group. Available from: http://fpg.unc.edu/sites/fpg.unc.edu/files/resources/reports-and-policy-briefs/2014-EBP-Report.pdf
Zane, T. (2011). Putting a dead horse in a weighted vest: Another review of sensory integration training. Science in Autism Treatment, 8(1), 18-19.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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