A systematic review of sensory processing interventions for children with autism spectrum disorders

Article Reviews
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Read Full Text: A systematic review of sensory processing interventions for children with autism spectrum disorders (Free to access via ProQuest access to which comes with NBCOT certification)
Journal: Autism
Year Published: 2015
Ranked 12th on our 2015-2020 list of the 100 most influential OT-related articles

This week, we are tackling a topic that can be sensitive for those in the OT community. And, the article itself notes the topic has been a cause for confusion.

This topic is: sensory processing interventions for children with Autism Spectrum Disorder (ASD).

This 2015 systematic review attempts to provide clarity on the topic by categorizing sensory processing interventions into two categories:

1.) Sensory Integration Therapy (SIT)
2.) Sensory-Based Interventions (SBI)

As the researchers looked at evidence related to both approaches, the results were largely inconclusive (due to the small scale of studies involved). However, the authors seemed to point to the potentially promising results behind SIT.

There is a lot to unpack in this article. I hope that Club members will help me make sense of this article by sharing their own insight about autism research.

Why the historical confusion about sensory interventions?

Anyone who has worked with patients with ASD would likely agree that the topic of sensory interventions can be very confusing. Let’s explore why that might be.

The relatively new use of sensory processing problems as diagnostic criteria

The article estimates that 80% of children with ASD exhibit co-occurring sensory processing problems. And, while these sensory processing issues are certainly common in those with ASD, it is important to remember that using said issues as diagnostic criteria for autism is a relatively new concept.

It was not until DSM-5 was released (in 2013) that hyper- or hypo-reactivity to sensory input became a diagnostic criteria for ASD.

We still lack widely accepted frameworks for diagnosing sensory challenges

The article did not directly mention the lack of accepted diagnostic frameworks—but the question has arisen in previous research we have examined in the Club. (It has also come up in a 2017 systematic review.)

We know that sensory challenges can have many different presentations, but identifying specific subsets and finding criteria for diagnosing them is still a work in progress. As we mentioned previously, we hope that new technologies and biomarkers will help bring more precision to this process.

The complex relationship between sensory processing and function is not fully understood

Even if we could precisely diagnose and categorize sensory issues, there would still be a missing piece of the puzzle. As the article states, it is believed that sensory processing problems are an underlying factor in functional performance problems. BUT, the relationship between sensory-driven behavior, arousal, self-regulation, attention, activity levels, and stereotypic behavior are not well understood.

In other words, we don’t yet fully understand how sensory processing impacts function.

Finally, “sensory interventions” have been inconsistently defined—and they refer to widely varied practices

Since occupational therapist Jean Ayres first pioneered sensory integration (SI) therapy in the 1970s, a wide variety of sensory interventions have been delivered. Combined with the inconsistent use of terminology, the article points out that this has caused “considerable confusion for parents, practitioners, and researchers.”

How this article defined two types of sensory interventions

To bring some clarity to the confusion, the authors distinguished between two types of sensory interventions which they defined as follows:

  1. Sensory Integration Therapy (SIT): Clinic-based, child-centered interventions originally developed by Ayres. SIT provides play-based activities with enhanced sensation to elicit and reinforce children’s adaptive responses
  2. Sensory-Based Intervention (SBI): Structured, adult-directed sensory strategies that are integrated into the child’s daily routine to improve behavioral regulation.

Did the researchers find evidence related to sensory integration therapy (SIT)?

The authors found 5 studies that looked at SIT and met their criteria for inclusion into this review.

2 of these were randomized controlled trials (RCTs), but both had a low number of participants. The largest study had 37 participants. We actually discussed the most recent RCT here in the Club, and looking at our discussion will give you a sense of the limitations.

Some promising results were seen in 4 of the 5 studies, but it is worth looking at all 5 individually, as each had its own limitations.

In their discussion, the authors concluded: It is premature to draw conclusions as to whether SIT….is ultimately effective.

What evidence did the researchers find related to sensory-based interventions (SBI)?

The authors identified 14 studies that looked at SBI and met their criteria for inclusion.

These studies were widely variable, and research topics included:

  • Sitting on therapy balls (2)
  • Brushing (1)
  • Weighted vests (7)
  • Multiple sensory strategies (4)

13 of these studies used a single-subject design. In all but one study, the interventions took place in a school setting.

9 of the studies showed no-to-limited effects. 3 showed mixed-to-moderate effects. And 2 showed high/strong effects.

But, again, the extremely small samples led the authors to conclude: In sum, the evidence for SBI is insufficient to recommend its use.

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

The results of this systematic review seem consistent with other reviews/recommendations: available evidence on SI approaches is low-to-moderate, and the studies are too small to draw conclusions about efficacy.

The results of this current article were more recently echoed in this 2017 systematic review of the same topic, which I found easier to decipher—and thus recommend to anyone who is interested in this topic.

I also like to check in on how UpToDate (a well-respected clinical decision support resources) is summarizing the evidence and relaying it to physicians. Here’s what UpToDate says:

The role of sensory integration therapy in ASD is not clear. The American Academy of Pediatrics recommends that treatment programs focus on behavioral and educational interventions…However, sensory integration therapy may be included as part of a comprehensive program that focuses on behavioral and educational interventions to calm the child, reinforce desired behaviors, or help with transitions between activities. Continued use of sensory integration should be based upon the treatment response in the individual child.

I was disappointed in the lack of economic considerations in this article.

From looking at research each week, we know that many interventions are used clinically when they only have small, promising studies to back them—because large-scale, rigorous studies are so hard to carry out.

But, I think some of the controversy that accompanies SI is the fact that the interventions can be time-consuming, relatively costly, AND often lack strong support in evidence. If families are going to make a large investment in care, they want assurance that the intervention is going to help them meet their needs.

It seems to me that the biggest obstacles to the growth of this approach involve economic factors. The cost-benefit problem is why we are seeing more cost-effective options on the market, such as the PLAY Project and CO-OP Approach (both are also in need of growing their research base.) Other approaches that have come up in discussion in the Club have also included the Early Start Denver Model, and TEACCH.

It will be interesting to watch how the science around this topic progresses—as well as how our business models adapt to support our delivery of these services.

Ultimately, we hope to arrive at interventions that are effective and achievable for families to carry out.

Listen to my takeaways in podcast form:

Find other platforms for listening to the [OT Potential Podcast here.](https://otpotential.com/ot-potential-podcast) ## (Possibly) Earn CEUs/PDUs for reading this article

Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.

And, here’s the full APA citation you many need:

Case-Smith, J., Weaver, L. L., & Fristad, M. A. (2014). A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism, 19(2), 133–148. doi: 10.1177/1362361313517762

What questions/thoughts does this article raise for you?

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I found it interesting and important that you mentioned the lack of economic considerations. Having completed one of my fieldworks in a rural school based setting I really was able to see the impact firsthand on lack of awareness and resources for the area and that more knowledge based expansion on sensory intervention and community based resources could help and more access to affordable resources. Schools were able to access a local university an hour away for some behavioral resources and a parent had established a resource center gaining in support but still yet and true access to interventions beyond that were limited.

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I agree that there is a lot to unpack in this article, so I will likely add to this comment as the week goes on and I also look forward to other more experienced OT’s comments!

I’m glad that an article with a focus on sensory processing interventions qualified for review by the Club. Still within my first two years of practice I find that I am one of those practitioners that is experiencing “considerable confusion” in regards to organizing and delivering sensory interventions that physicians and families are expecting me to provide. I received very little hands-on instruction in either Sensory Integration Therapy (SIT) or Sensory-Based Interventions (SBI) in my pediatrics course in school. Then I received basic exposure and training in my Level II fieldwork placement, but most of that exposure was to SBI over SIT. Now I feel as if I’m a Sensory Magpie, picking up shiny pieces of knowledge and techniques and trying to form them into some cohesive nest of practice.

My clinic uses the Sensory Profile 2 Caregiver Questionnaire, the MFUN, the BOT-2 as well as parent and child interviews to try to reveal sensory processing deficits and their impact on function in our kids with ASD, though I agree with the article that this is not yet the most effective way to depict what these kids are experiencing. We then regularly provide parents instruction on proper delivery of the Wilbarger Therapressure Brushing Protocol followed by joint compressions, proprioceptive input and heavy work. We instruct on safe and effective use of weighted blankets, weighted vests, body socks, in-hand fidgets and SPIO compression garments as well as provision of steady linear swinging over rotary swinging. We also provide VitaLinks’ Therapeutic Listening and Astronaut Training Therapy. These have varying levels of evidence to support their efficacy, but tons of anecdotal support, so what’s the best thing to do?

All these offerings wind up being a thoughtful trial and error experience as these interventions are received by kids differently and I have limited hands on experience and a few (sometimes competing) text resources to base my treatment plans off of. Once I have practiced the recommended 3 years I am planning on pursuing training with the STAR Institute so that I can hopefully build a more cohesive, purposeful and research backed protocol for assessing and treating what is now the majority of the kids I work with.

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Thank you for this relevant topic. OTs in the school are so busy that most are not doing research and many are not taking data on SBIs. I wish there was more data. In the school setting, you can not really do true SI therapy. It is unfortunate that there is not more data on SIT and SBIs. I have the new book by John Pagona, PhD and OTR/L called Functionally Alert Behavioral (FAB) Strategies. I have also heard him speak a few times and find his work very helpful. FAB strategies involve applying the clinical reasoning process to improve a student’s behavior. He provides forms to guide the choice of strategies for environmental adaptation, sensory modulation, positive behavior supports, and self-regulation. Also, he uses the QABF (Questions About Behavior Functions) form to figure out the function of behaviors (Geared towards is it sensory or is behavior ?). I think that OTPs have to be very careful when we use SBIs to not be rewarding negative behavior and this information can help.

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I’m an autism specialist and do not rely heavily on sensory interventions in my work. While addressing sensory differences is an important component of supporting folks on the spectrum, I’ve been disappointed to see how many therapists use sensory lens to the exclusion of considering other components of autism learning styles. A couple of applications that seem reasonable and effective to me are 1) sensory accommodations such as noise-canceling headphones and sunglasses, and 2) sensory interventions used as systematic desensitization (an approach with decades of research evidence) to help kids whose sensory sensitivities make it very hard for them to explore their world.

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I think this article hits home about what can be really challenging day in and day out about whether the sensory interventions that are being provided are actually making a difference in the every day function of the kids that we work with. I believe more consistent assessments across the board will help our understanding about whether there are actual hyper or hypo sensitivities in the kids that are being evaluated for OT.
Our clinic has the Sensory Processing Measure and Sensory Profile Parent Questionnaires which appear to diagnose many kids that comes in for an evaluation as having sensory processing differences, even if they do not have autism. Using clinical observations and parents interview can help differentiate whether certain sensory differences are impacted across different contexts but it continues to be challenging to actually know for sure and feel confident in that.
I’m not certified in the Sensory Integration Praxis Test due to limitations in the expense of the training and employers not being able to pay for it. Not sure if anyone else is in the same boat on this? Will that test solve the problem of assessment?
I believe if we know for sure there is an underlying sensory component AND see a functional limitation in daily skills (through the MFUN, BOT-2 or PDMS) I think that will help guide our future treatment and limit the amount of insurance money being used to trial and error some of these interventions. Also, if in the future there are biomarkers in place to identify sensory differences, what will our role as OT’s look like in referring for those assessments? Which professionals would be carrying out those specific evaluations (neuropsychologists, developmental pediatricians)?

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@meg2 I think that’s a really good point that with the right environment and right learning supports we might see our kids succeed and complete daily activities they might not have been able to before.

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I’ve been specialized in autism for 34 years with extensive training in SI. Although we all want good research and more evidence, there is an inherent flaw in all such research that will never really be overcome. The fact that autistic people are vastly different and that there are hundreds of variables that are at play in a child’s day - therapists, teachers, parents, environments, demands, etc - combine to make it impossible to tease out the effects of one intervention. Even with the best trained therapist, sensory interventions are only one small part of the picture and so many other things need to be considered or in place for even the sensory interventions to have their intended effect. The premise that one specific intervention is going to make much of a quantifiable difference is a false assumption. I know from clinical experience that appropriate SIT or SBI can make a big difference but I also know there are many other considerations that, if not in place as well, will affect how well SI based interventions “work”. I think we need to get away from looking at single interventions (although I totally get why we do this and why it is “necessary”) and look more at multi-factoral interventions. What sort of results do we see when SI, learning strategies, environment, physiological considerations, etc are all implemented at once, individualized for the child? The presumption that ANY one intervention can be adequately evaluated in a situation with MANY factors, is not realistic.

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I will admit, it makes me nervous for our profession reading how many practitioners have a strong reliance on anecdotal data and less on evidence-based evidence. Working within pediatrics and a researcher, there is much I want to say about this article, common discussions/perspectives that are shared amongst OTs, and more.

First, evidence-based practice has three facets (clinical experience, unique client contexts, and best research evidence) and not just research. There are many SBIs being used in practice that have no high quality research to support them (e.g., Astronaut Program, Wilbarger Protocol, weighted vests, listening programs) and many professional organizations advocate for many of these interventions to not be used with autistic children, including the Wisconsin Treatment Intervention Advisory Committee and American Academy of Pediatrics. AOTA even advocates for many of these to only be considered as a last resort, but if selected, it’s essential to our code of ethics to let parents know about the limited research and always include them within the decision-making process. Interestingly enough, the American Speech and Hearing Association stated that their SLPs may be in violation of their ethics code if they use a listening therapy with their client due to the potential of these interventions to harm hearing. Already, insurance companies are catching on to our profession’s high use of these interventions and are already beginning to reduce reimbursement rates in some states. Where is the science included within our profession if we ignore the evidence or lack-thereof when patients come to us for vital decision-making to improve health-related outcomes? Many of these interventions’ research articles have not been published in peer-reviewed journals, are case studies, have serious methodological flaws, or have only been conducted by the creators of the intervention (extreme conflict of interest).

It’s within the autism-spectrum diagnosis for an autistic individual to have unique sensory strengths and challenges. But, why should we only choose sensory processing interventions to address these challenges? We can teach a child how to communicate for a break or their needs, recognize their arousal/energy levels, regulate themselves, modify the environment/task to cater to their sensory strengths, all which have research supporting these concepts and you are utilizing a strengths-based and occupation-based treatment approach.

I highly encourage anyone interested to examine the Autism Focused-Intervention Resource Modules, an education-base that provides free, online evidence-based trainings (literally over 20 to choose from). I also encourage you to examine more top-down intervention strategies that are evidence-based including TEACCH, CO-OP, SCERTS, Early Start Denver Model, social narratives, aspects of CBT, sensory desensitization, and resources from Autism Level Up!. Recently, AOTA joined with the Choosing Wisely Campaign and announced that its best practice to not provide sensory interventions unless that individual has document assessment results of difficulties with processing sensory information. For my practice if I suspect sensory processing challenges, I utilize the Sensory Profile-2 due to it being strength-based and relating an individual’s unique sensory experiences to their environment and occupations. AOTA does have an EBP section on Autism on their website that may be helpful for clinical decision-making as well.

Please let me know if you would like me to elaborate more on anything I shared or have questions. This is topic I am heavily passionate about (as you can probably tell). I will include other resources that I hope you may find helpful! Knowledge is power!

  • Open Journal of Occupational Therapy (OJOT) - https://scholarworks.wmich.edu/ojot/
  • Wisconsin Treatment Intervention Advisory Committee has a list of popularly used interventions to treat children with ASD and their evidence level - https://tiac.wisconsin.gov/summary-determinations-regarding-level-evidence.htm
  • AOTA Membership! -> Access to American Journal of Occupational Therapy (AJOT), British Journal of Occupational Therapy (BJOT), Australian Journal of Occupational Therapy, and Canadian Journal of Occupational Therapy (CJOT)
  • The Cochrane Collaboration - http://www.cochrane.org/index.htm - The Cochrane Collaboration provides accurate, up-to-date information regarding the effects of healthcare. It creates and disseminates systematic reviews of healthcare treatments, including those regarding children with ASD. The Cochrane Collaboration promotes the examination of evidence in the form of studies and clinical trials.
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Bryden, thank you so much for including these resources! Reading your response makes me wish I could take a step back from my practice and better prepare myself. I feel as if there’s no support around me to pursue any of the protocols and methodology that you mentioned. I’m apart of a network of clinics so I will reach our to other OTs and see if they’re familiar with any of the items you listed, because I know the two at my clinic have never mentioned any of these. I want to serve my kids and families as best I can, but I need support as a new practitioner!

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Hi @bryden! I hear where you are at, but I actually don’t feel nervous for our profession. Each week I see in the Club OT professionals’ hearts for providing the best care possible for their patients. Every health profession is having to deal with a rapidly evolving evidence base, and compelled to adjust best practices. I see this as a call to action for therapists to join into conversations like this one—so we can collectively make sense of new evidence.

I think it is important to remember how much best practices have evolved over the past decades. I’m thankful to therapists like @barbara, who have helped pioneer considerations for sensory preferences. For many years, this seemed to be one of the primary tools in the therapists toolbox for serving clients with autism.

But, the common thread I see everyone saying is that we’ve reached a point where we know sensory interventions are only one tool in the box.

We are seeing a common thread across all of the evidence we are looking at that we should:

1.) Take a multifaceted approach to complex conditions (luckily this is OUR JAM! We are trained to consider environment, learning style, daily routines, habits, personal preferences, etc.)

2.) We should always consider ourselves part of a team (not the standalone “answer”) and coordinate with other professionals as closely as possible.

3.) Finally, we need to involve our clients as much as possible in any care decisions. I love the focus we are seeing in autism care given to strengths-based practice, and really understanding and leveraging strengths!

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@maggie, I’m really sensitive to the quandary you are in as to know which cont. ed. to pursue regarding autism.

So many therapists have invested lots of time and money in trainings over the year, but this big investment makes it hard to stay agile to changing research. These trainings on proprietary approaches that are still garnering an evidence base make sense for autism specialists (and those particularly invested in the topic), but for the majority of us who are generalists, it simply doesn’t make economic sense.

I’m really curious about the free AFIRM Modules that Bryden sent over. @Bryden, were you able to earn CEUs for these?

For OT specific trainings, I’ve heard good things about Meg Proctor’s Learn, Play, Thrive courses (I know Meg and so am totally biased!).

For many of us, a more modest investment in this continuing education makes economic sense, knowing that research will continue to evolve rapidly!

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@SarahLyon, absolutely! It’s vital we remember that this is a tremendous learning opportunity for our profession, though we need to remember that this has been a challenge for our profession historically longer than other rehab professions. I do want to be clear that I love occupational therapy and there is so much we can provide for the pediatric population. The reason why I am nervous is therapists (in my state, at least) are not listening to the research, will continue to provide interventions knowing insurance will not reimburse services, therefore performing fraudulent billing to still continue to use a treatment method knowing it would not be covered otherwise. This is one of the many reasons why OTPotential is an invaluable resource, Sarah :slight_smile: And yes, you can earn CEUs for the AFIRM Modules, but you will have to pay for each intervention ($20 - $40 each). I also second Meg Proctor’s Learn, Play, Thrive courses; they are tremendous for combining aspects of the Early Start Denver Model, TEACCH, and a strengths-based approach with a creative spin (they are so good).

@Maggie, let’s be newbie OT friends! Please email me at bgivingot@gmail.com on how I can be of assistance, how we can collaborate, and make positive change for our profession.

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Yay! @maggie and @bryden, we need newbies like you with clear eyes and fresh energy!

(I’m laughing to myself because I am only 33 :slight_smile: But, I would definitely put myself in the “feels old” camp. I’m totally shocked at how much best practices have evolved over my short time as an OT!)

Which points us to a larger problem that extends beyond autism care to almost every diagnoses we look at: What tools will we need to provide condition-specific care that adheres to currently best practices? There is simply too much information for us all to hold in our heads!

I’m trying to be part of the solution with building the Club, but I’d be curious to hear other’s thoughts on this. You can always email me at sarah@otpotential.com with any thoughts/suggestions! (I don’t want to divert this thread from the important topic of best practices for autism care.)

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Hi all! I love all of your comments and thoughts!! & references!!
I’ve been an occupational therapist and a pediatric practice (various settings) for 25 years, presently private practice peds home health. Yes we definitely need to keep on our profession for finding the right research but all in all, #1 even if we implement a sensory strategy/intervention, we’re only in the home (or clinic, or school) a very small percentage of the time. The sensory strategies / interventions/ techniques are only going to work if the family can fit it into their routine… So Part of our responsibility is to help the family fit the strategy into their routine. Many sensory strategies and interventions (Or combinations of strategies including things like visual sched, social stories, etc) do not work because the families are not sure HOW to fit it into their schedule or daily routine, therefore they often don’t follow through (& we cant see how it if anythg helps). Like I read above… there at sooooo many facets to or processing. :blush:

#2 also, I’m beginning to see more and more that some of our degree programs are not including enough focus on pediatrics and sensory interventions & how relates to daily function. I’ve had multiple students that have very little knowledge of any BASIC concepts of sensory intervention (where to EVEN START with observations & txmt). Does anybody have any thoughts on how we can help our occupational therapy degree programs? … ways We can Use the evidence-based practice, educate the new therapist on how to talk to families about the difference in intervention versus strategies, and teach better observation skills so we can be a better compliment to other therapies/families, as well as how to coach families to follow through with the home program. (& all that was mentioned above :wink:). Want to help new grads so they can be better prepared to talk about all of it once in the field!

Thanks all!!
Ashley Harrell, OTR/L

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I find the lack of SI a research very disappointing! As an SI therapist I am constantly explaining what Sensory Processing Disorder is, what the types are, the overview of all of the sensory systems, some hypothesized reasons for it, what sensory techniques are and more. SI is a great approach with children who experience ASD, simply because children with ASD experience info overload. They process info so intensely and at such a high rate… most of the time… and seem to have too many neural pathways. Other children with SPD (although not actually in the DSM) experience a lack thereof of neurotransmitters and neurotransmitter movement in neural pathways.

A lot of people do consider SI interventions expensive BUT with the proper education of the client it is easy to think of more motivating and cost effective options. For example, toe touching (such as when singing head, shoulder, knees, and toes) is a great quick and easy supply of vestibular input. Or even skipping in the hallway! Whereas jumping in place or chair pushups is a great short supply of proprioceptive input.

I am also constantly, though following protocols from recently provided SI courses, learning new information on the connection between inflammatory foods, omega 3’s, dyes, breath support, and the effects of trialing old researched methods in novel ways.

Just some food for thought!

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I feel like most of what I’ve learned about SI has been from on the job training, trial and error, and what I have pursued myself… trying to teach as many level 1s and 2s as possible and share the info so they can do the same.

Sometimes it is SO difficult to find the right way to educate different families and different children on the topic. I’ve had some success with ALERT programs and things of that nature, educating parents on the topic, writing very small homework programs each week, and educating teachers to improve compliance.

I also really love love love the courses from Therapeeds by Julia Harper. She gives protocols, discusses the neurological processes behind SI, and various clinical ob. methods for testing for deficits in various brain regions.

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I agree!! And it is SO difficult to really draw any conclusive info from small case studies of such vast differences in client needs and presentations. Many times I find myself trying to identify the type of processing pattern a child has and then addressing it from there. This is where we can take EBP and combine it with our clinical judgement. We also have to realize that we do come from a decent neurological background as well and build from there. But also realizing that I need to work with the child and their facility to build functional skills training into sessions and into their daily routines.

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Hi @jillian! I’m so thankful you are willing to share with us as practicing SI therapist! It is helpful to see your processing, because I’m seeing so many common themes in this discussion:

1.) wishing the research was further along—which honestly is true of almost every condition/intervention we look at :slight_smile:
2.) seeing that individual therapist clinical reasoning plays a huge role in care
3.) that ultimately the need for anchoring our treatments in what is possible in the daily routines of patients and not lose sight that our ultimate goals is to improve function in areas that are important to our clients!

I’m glad you brought up the ALERT program, because we have discussed that before in the Club:
A critical review of research on the ALERT Program®

I’m also looking at the Therapeeds website, because it is totally new to me! @meg2, I’m seeing that these courses are about the same duration and costs as yours. I’m curious if you could let us know the differences and similarities with your Live Play Thrive courses?

Again, thank you, Jillian! I am SO GLAD you are here!!

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