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.

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  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, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He 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 CBT. He is also editor of a 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).

Can School Professionals Diagnose Autism?

Can School Professionals Diagnose Autism?

Since Congress added autism as a disability category to the Individuals with Disabilities Education Act (IDEA), the number of students receiving special education services in this category has increased over 900 percent nationally. The number of students receiving assistance under the special education category of autism over the past decade has increased from 1.5 percent to 9 percent of all identified disabilities. Autism now ranks fourth among all IDEA disability categories for students age 6-21. It’s critically important that school professionals understand the parameters of providing evidence-based assessment and identification practices for children and adolescents who may have an autism spectrum disorder (ASD).

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are the two major systems used to diagnose and classify children with ASD. The DSM-5 is considered the primary authority in the fields of psychiatric and psychological (clinical) diagnoses, while IDEA is the authority with regard to eligibility decisions for special education. The DSM was developed by clinicians as a diagnostic and classification system for both childhood and adult psychiatric disorders. The IDEA is not a diagnostic system per se, but rather federal legislation designed to ensure the appropriate education of children with special educational needs in our public schools. Unlike the DSM-5, IDEA specifies categories of ‘‘disabilities’’ to determine eligibility for special educational services. The definitions of these categories (there are 13), including autism, are the most widely used classification system in our schools. According to IDEA regulations, the definition of autism is as follows:

(c)(1)(i) Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a child’s educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in this section.

(ii) A child who manifests the characteristics of ‘‘autism’’ after age 3 could be diagnosed as having ‘‘autism’’ if the criteria in paragraph (c)(1)(i) of this section are satisfied.

This educational definition is considered sufficiently broad and operationally acceptable to accommodate both the clinical and educational descriptions of autism and related disorders. While the DSM-5 diagnostic criteria are professionally helpful, they are neither legally required nor sufficient for determining educational placement. A medical diagnosis from a doctor or mental health professional alone is not enough to qualify a child for special education services. It is state and federal education codes and regulations (not DSM-5) that drive classification and eligibility decisions. In fact, the National Research Council (2001) recommends that all children identified with ASD, regardless of severity, be made eligible for special educational services under the IDEA category of autism. Thus, school professionals must ensure that children meet the criteria for autism as outlined by IDEA or state education agency (SEA) and may use the DSM-5 to the extent that the diagnostic criteria include the same core behaviors. All professionals, whether clinical or school, should have the appropriate training and background related to the diagnosis and treatment of neurodevelopmental disorders. The identification of autism should be made by a professional team using multiple sources of information, including, but not limited to an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to help with intervention planning and determining eligibility for special educational services.

Guidelines

Legal and special education experts recommend the following guidelines to help school districts meet the requirements for providing legally and educationally appropriate programs and services to students who meet special education eligibility for autism.

1. School districts should ensure that the IEP process follows the procedural requirements of IDEA. This includes actively involving parents in the IEP process and adhering to the time frame requirements for assessment and developing and implementing the student’s IEP. Moreover, parents must be notified of their due process rights. It’s important to recognize that parent-professional communication and collaboration are key components for making educational and program decisions.

2. School districts should make certain that comprehensive, individualized evaluations are completed by school professionals who have knowledge, experience, and expertise in ASD. If qualified personnel are not available, school districts should provide the appropriate training or retain the services of a consultant.

3. School districts should develop IEPs based on the child’s unique pattern of strengths and weaknesses. Goals for a child with ASD commonly include the areas of communication, social behavior, adaptive skills, challenging behavior, and academic and functional skills. The IEP must address appropriate instructional and curricular modifications, together with related services such as counseling, occupational therapy, speech/language therapy, physical therapy and transportation needs. Evidence-based instructional strategies should also be adopted to ensure that the IEP is implemented appropriately.

4. School districts should assure that progress monitoring of students with ASD is completed at specified intervals by an interdisciplinary team of professionals who have a knowledge base and experience in autism. This includes collecting evidence-based data to document progress towards achieving IEP goals and to assess program effectiveness.

5. School districts should make every effort to place students in integrated settings to maximize interaction with non-disabled peers. Inclusion with typically developing students is important for a child with ASD as peers provide the best models for language and social skills. However, inclusive education alone is insufficient, evidence-based intervention and training is also necessary to address specific skill deficits. Although the least restrictive environment (LRE) provision of IDEA requires that efforts be made to educate students with special needs in less restrictive settings, IDEA also recognizes that some students may require a more comprehensive program to provide FAPE.

6. School districts should provide on-going training and education in ASD for both parents and professionals. Professionals who are trained in specific methodology and techniques will be most effective in providing the appropriate services and in modifying curriculum based upon the unique needs of the individual child.

Key References and Further Reading

Aiello, R., Ruble, L., & Esler, A. (2017). National Study of School Psychologists’ Use of Evidence-Based Assessment in Autism Spectrum Disorder. Journal of Applied School Psychology, 33(1), 67-88. DOI: 10.1080/15377903.2016.1236307

American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (2014). Standards for educational and psychological testing. Washington, DC: American Educational Research Association.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Campbell, J. M., Ruble, L. A., & Hammond, R. K. (2014). Comprehensive Developmental Approach Assessment Model. In L. A. Wilkinson (Ed.), Autism spectrum disorders in children and adolescents: Evidence-based assessment and intervention (pp. 51-73). Washington, DC: American Psychological Association.

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).

Kratochwill, T. R. (2007). Preparing psychologists for evidence based school practice: Lessons learned and challenges ahead. American Psychologist, 62, 826-843.

National Association of School Psychologists. (2016). School Psychologists’ Involvement in Assessment. Bethesda, MD: Author.

National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

Ozonoff, S., Goodlin-Jones, B. L., & Solomon, M. (2005). Evidence-based assessment of autism spectrum disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34, 523–540.

Twachtman-Cullen, D., & Twachtman-Bassett, J. (2011). The IEP from A to Z: How to create meaningful and measurable goals and objectives. San Francisco, CA: Jossey-Bass.

Wrightslaw: Special Education Law, 2nd Edition (2007).

Yell, M. L., Katsiyannis, A, Drasgow, E, & Herbst, M. (2003). Developing legally correct and educationally appropriate programs for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18, 182-191.

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (second edition). London and Philadelphia: Jessica Kingsley Publishers.

Zirkel, P. A. (2014). Legal issues under IDEA. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools (pp 243-257). Washington, DC: American Psychological Association.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He 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 CBT. He is also editor of a 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).