Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory Integration Differences

Article Reviews
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Read Full Text: Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory Integration Difficulties: A Systematic Review (This is a paid article, but we still thought it was important to cover.)
Journal: The American Journal of Occupational Therapy
Year Published: 2018
Ranked 99th on our 2017-2021 list of the 100 Most Influential OT Journal Articles
CEU Podcast: #43: OT Supports for Sensory Processing Differences: A Conversation on the Evidence with Bryden Giving (CE Course)

I’ve never wanted to skip an article on our top 100 list…until now. Honestly, it’s a bit tempting to bypass emotionally charged topics.

That said, our mission is to squarely look at influential research impacting our profession. This week, we’re diving head-first into a sensitive subject in the OT world: sensory techniques.

The authors of this systematic review present the evidence behind specific sensory techniques and environmental modifications for children with sensory integration (SI) differences.

OTs have collectively invested a tremendous amount of energy and training into different types of sensory techniques. Many of us view sensory expertise as our professional identity, believing it sets us apart from other rehab disciplines.

Some therapists will find this paper too hard on sensory techniques. Others will feel the authors were too generous in their appraisal. Wherever you land, I am glad you are here to look at this paper with us, as part of our community.

Let’s dive in.

An intro to SI differences

The term “sensory integrative dysfunction” was coined in 1969 by an occupational therapist named Jean Ayers. The phrase referred to children who had difficulty organizing and using sensory information to accomplish everyday tasks.

Our language has evolved over the years, and the authors of this paper refer to this population as “children with sensory integration difficulties (SI difficulties).”

Something to note before moving on: we’ve heard from members of the neurodivergent community that they prefer the more empowering term of “sensory processing differences.” We have chosen to use the term “SI differences” instead of “SI difficulties” throughout this breakdown (when it does not alter the meaning of the article).

A 2004 study suggested a roughly 5% incidence of SI differences among typically developing kindergartners.

SI differences are thought to be much more common among kids with developmental or behavioral conditions, such as autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD). This text estimated that the prevalence of SI differences in autistic people ranges from about 40% to more than 90%.

OT and SI differences

Historically, OT practitioners have been the leading professionals in evaluating and treating SI differences.

We have used both remedial and compensatory techniques.

Ayres Sensory Integration (ASI) is an example of an intensive remedial approach. Many OTs also provide specific sensory techniques or sensory environmental adjustments as compensatory modifications.

In fact, some practitioners use these techniques and modifications as their singular occupational therapy intervention, despite the fact that leaders in the field have advocated that a multifaceted approach is best.

What was the intent of this study?

Despite the widespread use of specific sensory techniques, little is known regarding whether children’s participation measurably improves after receiving these interventions.

So, the authors sought to answer the question:

What is the effectiveness of OT interventions that use specific sensory techniques or sensory environmental modifications to support function and participation of children and youth who have SI difficulties?

What methods were used in this research?

This systematic review was completed as part of AOTA’s Evidence-Based Practice Project, with the intent to inform The AOTA Guidelines for Children with SI Difficulties and for Children with ASD.

Evidence was considered for this review, if:

  • It was published from 2007-2015
  • It was a high level of evidence, involving the comparison of two groups (designated as level 1, 2, or 3)
  • The participants were aged 2-21
  • The participants had documented SI difficulties
  • The intervention was a specific sensory technique or environmental modification
  • There was a documented functional performance or participation level outcome

What were their results?

8 studies were included in this review. Here is a summary of the studies that were included:

Qigong massage

3 level-1 studies (randomized control trials)
1 level-2 study

The authors found “strong evidence” for the effectiveness of Qigong massage for young children with ASD. Specific improvements were found in self-regulatory behavior, tactile abnormalities, ASD symptoms, and parenting stress. (Please see my editorial note below.)

The randomized control trials suggest that 50 hours of therapist training is required for a therapist to administer this intervention. The intervention is recommended to be delivered daily for 4-5 months.

Weighted vests

1 level-1 study

One study demonstrated improved in-seat behavior and attention of 6-7 year olds with ADHD during classroom activities, when using a weighted vest. This indicated “limited evidence.”

Slow linear swinging

1 level-1 study

Slow linear swinging failed to show improved on-task behavior of children with ASD during a tabletop activity, following the intervention. This is “insufficient evidence.”

Sensory enrichment in preschool

1 level-1 study

A sensory enrichment program of 12 weeks—which embedded tactile, proprioceptive, and vestibular activities into a preschool’s daily routines—found no difference between this group and another that received the intervention plus Ayres Sensory Integration. The authors concluded the evidence was “insufficient.”

Sensory environmental modifications in a dental office

1 level-1 study

In this study, altering the visual and auditory environment of a dental office, plus providing weighted wrap, improved the outcomes in pain intensity, sensory discomfort, and participation. Improvements were seen for both children with ASD and those who were typically developing. The authors concluded the evidence was “moderate.”

Techniques that lacked a level of evidence to be included

The authors specifically mention these techniques as not having levels 1,2, or 3 to be considered for this review:

  • Wilbarger Protocol
  • Therapy ball chairs
  • Astronaut Training
  • Auditory stimulation listening programs

Discussion

Only studies with a certain threshold of evidence were included in this review, which led to a small number of papers being studied.

Qigong massage was the only intervention with strong evidence behind it—but the authors caution that all of the studies were done by the same research group. (See my note for more concerns below.)

Moderate evidence supports sensory modification to dental offices.

Other techniques showed limited/insufficient evidence.

The authors emphasize that OT practitioners should use caution when an intervention has limited or no evidence to back its efficacy—and such interventions should only be used after considering interventions with a strong level of evidence supporting their use.

(I would also add that I believe it is our ethical imperative to make families aware when an approach that lacks evidence is being considered.)

Editorial note on Qigong massage

I personally saw a major red flag in reading about the mechanism of Qigong massage. The Qigong Sensory Training Institute (QSTI) website says its treatment is grounded in the belief that autism is caused by lack of touch—which is simply not true.

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The organization also states, “Qigong Sensory Treatment (QST) is a proven, touch-based autism treatment for children that parents perform for 15 minutes each day for up to two years to normalize sensory issues and reduce or eliminate symptoms of autism.”

This type of statement can be seen as ableist and not in line with autistic or neurodivergent-affirming care.

Takeaways for OT practitioners

(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)

1. We need to keep referring back to our pediatric evidence traffic light.

Thankfully, these sensory techniques are not the only tools in our OT toolbox. We do have treatments that have a much stronger evidence base. If you haven’t yet, I encourage you to explore the Pediatric OT Interventions Traffic Light.

2. We need an evidence traffic light that is specific to OT supports for autism.

Our profession is lacking an evidence traffic light specifically designed for autism supports. I’ve said this multiple times, but I would like to see this created by an organization that would faithfully update it each year. Our patients deserve this. For inspiration, see this evidence traffic light for cerebral palsy.

3. We need to stay focused on what is best for our patients—NOT on what makes us distinct as a profession.

Rehab is certainly experiencing a sea change right now. During changing times, it is all too tempting to cling to what makes us feel distinct. That said, it’s more important than ever that we stay laser-focused on doing what is best for our patients. This is the only thing that will keep us anchored.

I say that not to discount all things sensory. We certainly are sensory beings, and I look forward to future developments in our knowledge base in this area. But, as more and more evidence emerges, I do want to encourage us to be open to reexamining and redefining the idea of best practice.

And, as always, I’m eager to hear your thoughts.

Here’s the full APA citation for this article:
Bodison, S. C., &; Parham, L. D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with Sensory Integration Difficulties: A systematic review. The American Journal of Occupational Therapy, 72(1).

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Bryden Giving. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

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Sensory Integration is an ongoing topic of discussion, especially regarding evidence-based practice. A few things I appreciated from the review were the distinguishing between specific sensory techniques (brushing, swinging, weighted vest) and sensory environmental modifications (changing lighting, sounds, etc.)

“What is the effectiveness of occupational therapy interventions that use specific sensory techniques or sensory environmental modifications to support function and participation of children and youth who have SI difficulties?” In our question, the population of interest is children and youth (ages 2–21 yr) with SI difficulties.

At first glance, the PICO appears to limit and focus the review, but I have questions. SI was determined by evaluation, which is good and follows best practice standards, but different children have different levels of disruptions in their sensory systems.

How do researchers begin to distinguish between levels of disruption and outcomes? What client factors impact outcomes: client’s level of sensory disruption, client’s cognition, etc., that were not considered within the study?

Check out a recent study done by Camarata, Miller, and Wallace (2020), which considers the neuroscience within the treatment and factors not implicitly noted within sensory integrative interventions. These factors might lend themselves to upcoming neuroscience studies. The authors present an argument for using Naturalistic Developmental Behavioral Intervention: Recast treatment using a transactional intervention framework to study SI/SP-T. The authors’ purpose that considering NDBI would include look at both the SI treatment and the unstated interactions between OT practitioner and the child. They feel that auditory and visual stimuli during the SI/SP-T treatment may be a positive force that has not been accounted for in traditional research in SI/SP-T. Check out their article and hypothesis using brushing.

Evaluating Sensory Integration/Sensory Processing Treatment

Neuroscience is exciting to read and to consider!

Camarata, S., Miller, L. J., & Wallace, M. T. (2020). Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis. Frontiers in integrative neuroscience , 14 , 556660. Frontiers | Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis

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I would love to see more Nature Based approaches being looked at. While I agree the tx,model,and theory being evaluated is very important, I’d love to see more about the environment it’s delivered in. The article also left me wanting to see more Neuro Affirming language and approaches. It made me want to learn more about delivery methods and learning how to use language in a more inclusive way. When I saw the topic of the article, I was immediately intrigued and ultimately was just left wanting more out of the whole article and the studies in general.

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Sensory integration or sensory processing difficulties is an interesting topic to keep up with. As Sarah has stated in her takeaways, we as OTs need to be open to constantly reexamining and redefining our standards of care and not continue doing the age-old practices. Recently, one of my student on FW with an OT told me that she saw most of the children in that practice just swinging on swings for a long time and sometimes that was the bulk of their intervention. She asked me how that was therapeutic and shouldn’t the parents question the efficacy of that intervention. The student was too intimidated to question her CI at the practice. We have an obligation to look for evidence in our practices and be able to explain to parents as well.
In this review, I was surprised to see that a sensory enrichment school-based program that included tactile, vestibular and proprioceptive activities had ‘insufficient evidence’ and some others such as Wilbarger protocol, therapy ball chairs were not even included in the review. I think that there is not much research done on these interventions and hence the result. Thank you, Sarah for keeping us on our toes with recent evidence-informed articles such as this one.

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As someone with sensory processing differences, this article excites me in so many ways. It really challenges us to reflect on our practices which are often entrenched in a deficit-based/medicalized perspective of sensory processing and the need to “correct” or “fix” sensory processing differences. This includes many sensory-based interventions and SI-OT (Ayers’ Sensory Integration). For example, the Star Institute (the primary research hub for sensory integration, though they have their own model that differentiates them from ASI’s model) states " to foster appropriate responses to sensation in an active, meaningful, and fun way so the child is able to behave in a more functional manner. Over time, the appropriate responses generalize to the environment beyond the clinic including home, school, and the larger community." OT-SI is described as "The goal of [SI/SP-T] is not to teach specific skills or behaviors but to remediate deficits in neurologic processing and integration of sensory information to allow the child to interact with the environment more adaptively.” Are these descriptions highly deficit-based and medicalized? For me, common perspectives of sensory processing differences are so focused on what non-disabled individuals view sensory processing differences with rarely inviting those with the disability into the conversation and ensuring the theories and models informing the intervention actually match our identities and priorities.

This article really advocates for us to focus on function and environmental adaptations to support a best-fit for the child, which also parallels disabilities research and the social model of disability. How affirming and validating is it to learn about a student’s sensory processing differences and instead of discussing treatment in a way that is aimed to change the child and “remediate” their differences, their differences are honored, valued, and treatment is focused on teaching the child how to advocate for their regulatory needs, co-regulation, and positive self-efficacy? To me, that screams incredible and disability-affirming occupational therapy and is best practice.

@sherry I will admit many NDBIs make me nervous for a variety of reasons. The majority of this research focuses on whether or not an intervention, service, or support can be considered “evidence-based.” In many cases, the standard for an “evidence-based” service is altered when it comes to people with disabilities. Because of the
medical model of disability, priority is given to interventions that reduce or eliminate disability, rather than try to accommodate the needs of individuals. Thus, the potential harms of an intervention may be downplayed because the perceived rewards - a cure or reduction of disability - are seen as much greater through the lens of non-disabled researchers and providers. More importantly, NDBIs typically incorporate tenets of Applied Behavioral Analysis (ABA) which many autistic individuals have advocated against for decades due to its harmful nature.

I am excited for occupational therapy and how disabled practitioners are getting more of our voices amplified. We are occupational therapy practitioners, not sensory therapists, and no one puts the focus on occupation better than we do :slight_smile:

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I agree that this article was a good marketing strategy but left me unfullfilled with the level of applicable interventions for autistic clients. I find the sensory lens to be lacking, and use a POE framework instead, much like Meg Proctor with her Strengths Based Autism course, which I 10/10 recommend. It is not nearly as expensive as the Qigong massage course, which appears to be 2,200. Yikes.

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Thanks so much for sharing this article- you are always so good at finding supplemental reading! I didn’t come across it when I was preparing for the podcast, so I’ll print it out and read it.

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Ohhh several great thoughts in here @preya! We did the episode on Nature-based approaches last year (and @lauraparkfig shared LOTs of supplemental reading.) I’ll be curious to circle back to the topic though in 2023 and see how the evidence base has evolved!

And, I totally agree this current article left us wanting. I felt like “Ok, what now??”

I ultimately landed in believing it was important to feel that reality. As it positions us to be open to changes that are to come in best practice. And, pushes us to consider approaches that already have a higher evidence level.

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Hey @HollyAnn I agree that this article did not feel super actionable, but for me still felt important to push us into considering other treatments.

I agree @meg2 does such a good job of sharing strengths based content, at all levels! This free podcast is a great place to start! (I’ve taken LPT course, but not the strength based goal writing one!)

I also feel like Meg’s teachings would pair really well the CO-OP approach, which is on our pediatric traffic light as an autism support. (I’m curious @meg2 if you have any experience with CO-OP?):

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Regarding the article, I appreciated how you highlighted our need as OTs to acknowledge when an intervention has fair or limited evidence, and when other stronger interventions may have yet to be identified. I find therapists I work with often disregard the possible benefit of low-evidence interventions in these cases, forgetting that there will always be some patients for whom it is a helpful intervention. (I’m all about evidence-based practice, but feel it’s important to remember how variable humans are in what they respond well to… and for some clients that might be an intervention that currently has limited evidence.)

On a related side note-- My familiarity with sensory protocols and approaches is limited as an OT who treats only adult neuro patients. But lately I’ve noticed a striking number of my patients who describe having undiagnosed sensory processing differences that limit their success with IADL (especially childcare, household management, and roles as a student). Someone earlier in the comments mentioned the STAR institute, which I plan to look into. Does anyone else have tips for resources to guide treatment of adults with sensory differences when they find those differences limiting their function?

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@HollyAnn Good to hear reinforcement for POE/PEO framework… lately I’m finding that to be what I fall back on when my (adult) clients do struggle with sensory issues that I can’t find applicable evidence for treatment approaches. Hard to go wrong by breaking something down to the essentials of a person, their environment, and what they’re trying to accomplish in occupation.

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Hear! Hear! @Bryden!

Thank you all for the material and the contributions to rich discussion.

A concern I have is the projected affinity between specific sensory techniques and Ayres Sensory Integration. I was concerned enough as a pediatric practitioner that I needed to learn more about Ayres Sensory Integration (ASI) and chose coursework from sensoryintegrationeducation.com. I was grateful for the remedial work in neuroanatomy and the benefit of analysis and tools of the 8 different sensory systems when clients and families may report functional concerns related to sensory processing. The use of Data Driven Decision Making Process and the ASI Fidelity Measure are tools that can be used to determine if an intervention is considered to assist with outcome measurement, clinical reasoning or if an intervention can be considered to be ASI intervention. I have included some articles below if you might be interested in learning more. I have recently learned about the COOP approach and can share the avenue I went down to learn about this. Do contact me if you are interested. One take away from that learning is how powerful guided discovery with a child who a has a desire to learn a meaningful skill and how it contributes to generalization and transfer. What I continue to learn from my experience as a OT working with kiddos with neurodevelopmental differences is that a tailored, individualized approach based on the functional needs, building rapport and make plans collaboratively help the kiddos grow and learn requires a multi-faceted approach as stated above. Always worth checking the evidence and I remind myself daily from a reminder from OT Potential @Sarah Lyon that “Evidence-based practice is the integration of best (available) research evidence with clinical expertise and patient values.” https://club.otpotential.com/t/specific-sensory-techniques-and-sensory-environmental-modifications-for-children-and-youth-with-sensory-integration-differences/957

Onwards with the lifelong learning journey!

Faller P, Hunt J, van Hooydonk E, Mailloux Z, Schaaf R. Application of Data-Driven Decision Making Using Ayres Sensory Integration(ÂŽ) With a Child With Autism. Am J Occup Ther. 2016 Jan-Feb;70(1):7001220020p1-9. doi: 10.5014/ajot.2016.016881. PMID: 26709422.

Parham LD, Roley SS, May-Benson TA, Koomar J, Brett-Green B, Burke JP, Cohn ES, Mailloux Z, Miller LJ, Schaaf RC. Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration intervention. Am J Occup Ther. 2011 Mar-Apr;65(2):133-42. doi: 10.5014/ajot.2011.000745. PMID: 21476360.

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@randall You are correct! In the literature, sensory-based interventions (SBI) are often described as sensory techniques that are not a part of ASI. However, outcomes are similar between SBI and ASI where they aim to have a remedial approach of sensory processing differences vs. an affirming approach of recognizing them as valid form of human diversity that, do not need to be “fixed”, but affirmed and accommodated. I kindly suggest caution when applying remedial approaches regarding sensory processing differences due to many within the neurodiversity community advocating against such approaches (including ASI). The ASI Fidelity Measure tool is helpful for ensuring you are using ASI intervention with fidelity, but not necessarily for measuring occupation-based goals and am not a fan of it’s deficit-based language when talking about sensory processing differences (I utilize the COPM or GAS for occupation-based and client-centered goal-setting, and the Sensory Profile-2 to learn more about the client’s sensory processing differences). I do love the literature surrounding CO-OP and am excited the evidence of the intervention is extending beyond to other populations besides DCD.

Though the evidence is lacking for many SBIs, sensory processing differences are real and need to be recognized if we want to provide holistic and high-quality care. It’s how we support the sensory processing differences we are seeing a paradigm shift. Evidence is pushing us for more neurodiversity-affirming approaches such as environmental adaptations, a task analysis best-fit (think PEOP :slight_smile: ), reduction of stigma of such differences through education, and supporting the client in teaching them the self-advocacy skills so they can advocate for their needs. Traditionally as OTs, we think of improving sensory processing due to differences being a “dysfunction” whereas instead, there is a push for fostering self-determination and positive self-identity by supporting our clients with honoring their identity.

Some articles I have hyperlinked have really revolutionized how I view sensory processing differences and have been helpful for challenging my own internalized ableism as a disabled OT: (1) [Supporting Autistic Adults in Occupational Performance],(https://www.scota.net/resources/Documents/Supporting%20Autistic%20Adults%20HANDOUT.pdf), (2) For Whose Benefit? Ethics, Evidence, and Effectiveness of Autism Interventions, (3) Helping children with autism spectrum disorders and their families: Are we losing our occupation-centred focus?, and (4) Navigating Sensory Processing Differences.

I appreciate us having the opportunity to have a discourse regarding this very important topic!

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@HollyAnn We have plentiful treatment strategies that are supported by high-levels of research that can be used to support autistic clients, especially supporting sensory processing differences. Some of my go-to favorites are the SCERTS model, mental health promotion, activity-based cognitive-behavioral strategies, the ALERT Program, environmental adaptations, and tools from Autism Level Up!. If you have any questions regarding these strategies please don’t hesitate to reach out! They are all financially accessible as well.

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@Bryden Thank you for sharing! I will indeed look out for deficit-based language and agree with the tools you have recommended for occupation-based and client-centered goal setting. I also like to use the Sensory Processing Measure for its connection to functionality. Thanks again.

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The Nature based OT has been one of my absolute favorites from OT Potential! Well worth your time!

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Absolutely! That is the beauty about about occupational therapy, we are always learning (including myself). Thank you for the wonderful conversation, @randall!

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I completely agree with your comments, thank you.

I believe the lack of inclusion and research is related to poor study designs, small study sizes and/or a very specific intervention or a very vague one. We do see so many articles about SI interventions but it is very difficult to prove that one specific intervention makes a difference, for the very reason that people are individuals with individual goals and interacting with many other environmental and sensory factors outside of an intervention. Systematic research, or other gold standard research like RCTs rely on study size, a control group and the same intervention and outcome measures for everyone. That often makes it difficult for OTs to contribute to the body of research, because if we are churning out the same supports to everyone, we really aren’t doing our job of supporting an individual towards their goals. The individuality of OT is what makes our role so interesting and so tricky, at times, but it can be frustrating not to see quality research entering the field on this tricky subjects. However, our job never gets old and we shouldn’t dismiss subjective and objective observations in individual practice. If one person consistently moves towards their goals because you have considered their sensory presentation, their motivation and their interests, and have supported those effectively, then you are on the right track.

Final thought about another comment further up, while we shouldn’t underestimate the importance of neuroscience research in finding evidence for SI strategies, but again, one person responding to a body brush that suggests a calming effect in their brain does not mean that the next person will feel the same. We always need to use our rationale and clinical reasoning to trial and provide appropriate interventions/education. Our professional point of difference is that we map all of the areas that makes a person the individual they are and we enhance that, so they hopefully feel more comfortable in their own skin and proud of reaching their goals. If we ignore the specifics of the individual and introduce a strategy/intervention just because a body of research says “this” or “it worked for the other three clients I tried it with”, then we really aren’t doing our jobs.

Happy OT week from Australia, everyone!!

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Like others have said, I agree that we need more about sensory interventions and ASD. You referenced the Traffic Light System for Cerebral Palsy, and there is also one for pediatric OT in general. https://onlinelibrary.wiley.com/doi/pdf/10.1111/1440-1630.12573. Sensory interventions for ASD fall within the “don’t do it” ineffective range. However, there are limited “effective” “do it” interventions for ASD in that article as well.

I feel as though as a society and profession, we are finally making large strides with the neurodivergent population. I am curious to see how listening to autistic voices and voices of people with sensory differences will affect future research. As we have seen both in research and in practice, individuals have highly variant sensory needs and therefore respond differently to sensory input. As we know that some sensory strategies work for some while not for others, I am curious about if we are defining “working” as a person feeling like their authentic selves or if they are more compliance-based. I would be interested to see how future research can define the effectiveness of strategies in a neurodiversity affirming manner.

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