Evidence-Based & Supported Sensory Integration Interventions for Autism | Occupational Therapy Practice

Not all Sensory Integration interventions are effective or supported by the latest evidence.

Introduction

This is not to say that sensory integration as a whole is not effective. Even still, as occupational therapists should strive to be holistic – research suggests that a top-down approach/perspective instead should at least be considered in addition to SI for occupational therapy clients. (SI is bottom-up.)

Ethics

It is imperative that the clients and their families such as parents are informed of the effectiveness of the specific intervention that you will use. Just because you learned (as did I) an intervention in OT school does not mean that it will necessarily be effective and produce meaningful outcomes for clients.

For example, if you are using intervention A and it is not as efficacious based on the evidence as intervention B (not SI-related), but intervention A seems to be based on your own anecdotal experience – tell the parents this.

Population

The primary population for these SI interventions is children with an autism spectrum disorder.

The Primary Systematic Research Articles

A systematic review [1]Stefanie C. Bodison, L. Diane Parham; Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory Integration Difficulties: A Systematic Review. Am J Occup … Reference List examined the effectiveness of many commonly used sensory techniques and environmental modifications for children with SI difficulties over the years.

Other notable articles worth reading (all published in AJOT) include:

  • Miller-Kuhaneck, H., & Watling, R. (2018). Parental or teacher education and coaching to support function and participation of children and youth with sensory processing and sensory integration challenges: A systematic review. American Journal of Occupational Therapy, 72, 72011900030.
  • Pfeiffer, B., Frolek Clark, G., & Arbesman, M. (2018). Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: A systematic review. American Journal of Occupational Therapy, 72, 7201190020. https://doi.org/10.5014/ajot.2011.09205
  • Schaaf, R. C., Dumont, R. L., Arbesman, M., & May-Benson, T. A. (2018). Efficacy of occupational therapy using Ayres Sensory Integration®: A systematic review. American Journal of Occupational Therapy, 72, 7201190010.
  • Tanner, K., Hand, B. N., O’Toole, G., & Lane, A. E. (2015). Effectiveness of interventions to improve social participation, play, leisure, and restricted and repetitive behaviors in people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180010. https://doi.org/10.5014/ajot.2015.017806
  • Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180030. https://doi.org/10.5014/ajot.2015.018051
  • Weaver, L. L. (2015). Effectiveness of work, activities of daily living, education, and sleep interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180020. https://doi.org/10.5014/ajot.2015.017962

In addition to this research article, I did my due diligence a Google Scholar search of the most recent articles for each of the interventions mentioned, and added these as citations after the ones in the primary article.

In 2012 the American Academy of Pediatrics (AAP) issued a policy statement recommending that pediatricians not use sensory processing disorder as a diagnosis.

Outcome Measures

Here are some outcome measures that you may want to consider using. They were used in the studies reviewed.

  • Social Responsiveness Scale-2 (SRS-2)
  • Children Sensory Profile-2 (CSP2)
  • Canadian Occupational Performance Measure (COPM)
  • Goal Attainment Scaling (GAS)
  • Parent Stress Index-Short Form (PSI-SF)
  • Parent Sense of Competence Scale (PSOC) [2]Mische Lawson, L., Foster, L., Hamner, K., & Wright, L. (2022). Exploring Effects of Sensory Garments on Participation of Children on the Autism Spectrum: A Pretest-Posttest Repeated Measure … Reference List

TL;DR (Too Long; Didn’t Read)

Insufficient evidence has been found for the use of ball chairs, seat cushions, brushing, weighted vests, and swinging when used as stand-alone sensory interventions or when used in the classroom.[3]Gloria Frolek Clark, Renee Watling, L. Diane Parham, Roseann Schaaf; Occupational Therapy Interventions for Children and Youth With Challenges in Sensory Integration and Sensory Processing: A … Reference List

Results Summary

  • Qigong Massage – strong evidence of effectiveness[4]Silva, L., & Schalock, M. (2013). Treatment of tactile impairment in young children with autism: Results with Qigong massage. International Journal of Therapeutic Massage and Bodywork, 6, 12–20.[5]Silva, L. M. T., Schalock, M., Ayres, R., Bunse, C., & Budden, S. (2009). Qigong massage treatment for sensory and self-regulation problems in young children with autism: A randomized controlled … Reference List It is worth noting that the sources are based on one author and their colleagues – Silva et al. I would like to see different researchers looking at this intervention in addition to these over the years. My additional research shows mixed results (see below).
  • Weighted Vests – limited evidence of effectiveness for children with ADHD.[6]Buckle, F., Franzsen, D., & Bester, J. (2011). The effect of the wearing of weighted vests on the sensory behaviour of learners diagnosed with attention deficit hyperactivity disorder within a … Reference List[7]Lin, H.-Y., Lee, P., Chang, W.-D., & Hong, F.-Y. (2014). Effects of weighted vests on attention, impulse control, and on-task behavior in children with attention deficit hyperactivity disorder. … Reference List
  • Slow Linear Swinging – insufficient evidence to improve on-task behavior for children with ASD.[8]Murdock, L. C., Dantzler, J. A., Walker, A. N., & Wood, L. B. (2014). The effect of a platform swing on the independent work behaviors of children with autism spectrum disorders. Focus on Autism … Reference List
  • Sensory Enrichment in Preschool – insufficient evidence to support tactile, proprioceptive, and vestibular activities in preschool daily routines.[9]Dunbar, S. B., Carr-Hertel, J., Lieberman, H. A., Perez, B., & Ricks, K. (2012). A pilot study comparison of sensory integration treatment and integrated preschool activities for children with … Reference List
  • Other Techniques [Wilbarger brushing protocol, therapy ball chairs, sensory diets, auditory stimulation programs, e.g., therapeutic listening and integrated listening systems] – research designs were of low evidence (Level IV or V) and indicated threats to internal validity and conclusions could not be drawn from them.

Qigong Massage

“Qigong seems to be able to decrease severity of individual sensory, behavioural, and language components of autism, and improve self-control, sociability, sensory and cognitive awareness as well as healthy-physical behaviour. Besides positive effect on children and adolescents, benefits seem to extend to parents and caregivers as well. However, quality of methodology seems to be insufficient to state that Qigong is an alternative to common behavioural therapies. We suggest that, until more investigation is performed, Qigong may only be used as a complement, or when behavioural therapies are not accessible.”[10]Rodrigues, J. M., Mestre, M., & Fredes, L. I. (2019). Qigong in the treatment of children with autism spectrum disorder: A systematic review. Journal of Integrative Medicine, 17(4), 250-260.

An article from 2010 reported limited evidence of massage for the effectiveness of symptomatic treatment of autism. One article stated that there was a high risk of bias and a lack of rigorous RCTs.[11]Lee, M. S., Kim, J. I., & Ernst, E. (2010). Massage therapy for children with autism spectrum disorders: a systematic review. The Journal of clinical psychiatry, 71(3), 11297.

A 2022 article reported that the efficacy of massage therapy for the treatment of ASD still “remains unclear”.[12]Ruan, H., Eungpinichpong, W., Wu, H., Shen, M., & Zhang, A. (2022). Medicine Insufficient Evidence for the Efficacy of Massage as Intervention for Autism Spectrum Disorder: A Systematic Review. … Reference List These researchers did a literature search and found that while there was significant improvement of symptoms, the overall quality of the studies was poor. These researchers also reported a high risk of bias with poor study design, inconsistent massage protocols, and subjective outcome measures. They concluded that there was insufficient evidence to conclude that massage is an effective treatment for ASD.

Weighted Vests & Blankets

The primary article reported limited evidence, so I set out to see if there was evidence that showed that weighted vests were effective for children with ASD using the keywords ‘weighted vests + autism’ with recency from 2018.

A 2018 systematic review reported the strongest support for the improvement of attention, but only a moderate recommendation (there are likely better interventions) could be made. There was again, high variability of the results in the studies and an overall small positive effect. Weighted vests showed the lowest support for sleep efficacy.

There were some positive reports of the vest helping children to calm down, but they were therapist-reported (mailed survey to 514 pediatrics OTs).[13]Olson, L. J., & Moulton, H. J. (2004). Use of weighted vests in pediatric occupational therapy practice. Physical & Occupational Therapy in Pediatrics, 24(3), 45-60.

A 2017 study reported that there was an “ineffectiveness of deep pressure therapies” compared to exercise for decreasing stereotypical behaviors (excluding attention level).[14]Losinski, M., Cook, K., Hirsch, S., & Sanders, S. (2017). The effects of deep pressure therapies and antecedent exercise on stereotypical behaviors of students with autism spectrum disorders. … Reference List

A 2011 article published in the AJOT concluded that weighted vests were not effective in increasing attention for students.[15]Collins, A., & Dworkin, R. J. (2011). Pilot study of the effectiveness of weighted vests. American Journal of Occupational Therapy,65(6), 688-694. doi:10.5014/ajot.2011.000596

Swings / Swinging

According to Murdock, “No significant differences in on-task behavior were evident between children who experienced swinging and children in the control group, who watched a video.”[16]Murdock, L. C., Dantzler, J. A., Walker, A. N., & Wood, L. B. (2014). The effect of a platform swing on the independent work behaviors of children with autism spectrum disorders. Focus on Autism … Reference List

I conducted a search for “slow linear swinging” and similar search on Google Scholar. There were not any published articles really regarding this intervention for ASD. Pfeiffer et al. (2018) drew similar conclusions as the primary article in their own systematic review of the ineffectiveness of slow linear swinging for ASD that was published in AJOT.[17]Pfeiffer B, Clark GF, Arbesman M. Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: a systematic review. Am J Occup … Reference List

SI Technique that Does Work in the Study

Sarah of OT Potential produced an excellent podcast episode that highlighted this research along with her guest Bryden Giving.

They note that while attempts to ‘change’ the client do not empower the client and embrace their differences.

My thoughts on this: why change the client when their differences are unqiue. Instead, modify or look at the environment and occupation.

One study (Level I) in a dental office aimed at sensory environmental modifications for the visual and auditory perceptions showed moderate improvement in children with ASD for pain intensity, sensory discomfort, and participation. This was combined with a weighted wrap.

Summary

Not all sensory integration interventions or techiques are supported by evidence for children with ASD. Things that OTs continue to do or use this day such as weighted vests, therapy balls, and swings have low levels of evidence. As children and their families may spend signifidcant amounts of time, energy, and money (as well as their hopes) on occupational therapy, I believe it is vital that all occupational therapy practitioners be transparent with their clients and mention this research and what is best practice before using these techinqus with their clients. The theme of what does not appear to work are bottom-up attempts to regulate or change the client. So what does work? Environmental approaches combined with holistic techniques are a better alternative supported by evidence for children with ASD.

A notable systematic review published in 2019 by Novak & Honan looked at OT interventions for children (in general, not necessarily ASD). I highly recommend that you take a look at this article, if not the very least, scroll down to the figure of the summary evidence for commonly used interventions.

Examples of effective interventions for ASD with higher levels of evidence include CO-OP, behavioral interventions, coaching, problem-solving, mindfulness, joint attention, and social skills training.[18]Novak, I., & Honan, I. (2019). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Australian occupational therapy journal, 66(3), 258-273.

For Parents; In the Media

“While it probably won’t do much, if you want to do sensory integration therapy as one part of a comprehensive treatment plan, there’s probably no harm in proceeding. But please don’t divert time, money, and attention away from therapies that are scientifically validated as effective.”

Sensory Integration and Autism: Part 6 of Myth Busters: Alternative Therapies for 2e Learners

References

References
1 Stefanie C. Bodison, L. Diane Parham; Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory Integration Difficulties: A Systematic Review. Am J Occup Ther January/February 2018, Vol. 72(1), 7201190040p1–7201190040p11. doi: https://doi.org/10.5014/ajot.2018.029413
2 Mische Lawson, L., Foster, L., Hamner, K., & Wright, L. (2022). Exploring Effects of Sensory Garments on Participation of Children on the Autism Spectrum: A Pretest-Posttest Repeated Measure Design. Occupational Therapy International, 2022.
3 Gloria Frolek Clark, Renee Watling, L. Diane Parham, Roseann Schaaf; Occupational Therapy Interventions for Children and Youth With Challenges in Sensory Integration and Sensory Processing: A School-Based Practice Case Example. Am J Occup Ther May/June 2019, Vol. 73(3), 7303390010p1–7303390010p8. doi: https://doi.org/10.5014/ajot.2019.733001
4 Silva, L., & Schalock, M. (2013). Treatment of tactile impairment in young children with autism: Results with Qigong massage. International Journal of Therapeutic Massage and Bodywork, 6, 12–20.
5 Silva, L. M. T., Schalock, M., Ayres, R., Bunse, C., & Budden, S. (2009). Qigong massage treatment for sensory and self-regulation problems in young children with autism: A randomized controlled trial. American Journal of Occupational Therapy, 63, 423–432.
6 Buckle, F., Franzsen, D., & Bester, J. (2011). The effect of the wearing of weighted vests on the sensory behaviour of learners diagnosed with attention deficit hyperactivity disorder within a school context. South African Journal of Occupational Therapy, 41, 36–42.
7 Lin, H.-Y., Lee, P., Chang, W.-D., & Hong, F.-Y. (2014). Effects of weighted vests on attention, impulse control, and on-task behavior in children with attention deficit hyperactivity disorder. American Journal of Occupational Therapy, 68, 149–158.
8, 16 Murdock, L. C., Dantzler, J. A., Walker, A. N., & Wood, L. B. (2014). The effect of a platform swing on the independent work behaviors of children with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 29, 50–61. https://doi.org/10.1177/1088357613509838
9 Dunbar, S. B., Carr-Hertel, J., Lieberman, H. A., Perez, B., & Ricks, K. (2012). A pilot study comparison of sensory integration treatment and integrated preschool activities for children with autism. Internet Journal of Allied Science and Practices, 10(3), Article 6. Retrieved from http://nsuworks.nova.edu/ijahsp/vol10/iss3/6/
10 Rodrigues, J. M., Mestre, M., & Fredes, L. I. (2019). Qigong in the treatment of children with autism spectrum disorder: A systematic review. Journal of Integrative Medicine, 17(4), 250-260.
11 Lee, M. S., Kim, J. I., & Ernst, E. (2010). Massage therapy for children with autism spectrum disorders: a systematic review. The Journal of clinical psychiatry, 71(3), 11297.
12 Ruan, H., Eungpinichpong, W., Wu, H., Shen, M., & Zhang, A. (2022). Medicine Insufficient Evidence for the Efficacy of Massage as Intervention for Autism Spectrum Disorder: A Systematic Review. Evidence-Based Complementary and Alternative Medicine, 2022.
13 Olson, L. J., & Moulton, H. J. (2004). Use of weighted vests in pediatric occupational therapy practice. Physical & Occupational Therapy in Pediatrics, 24(3), 45-60.
14 Losinski, M., Cook, K., Hirsch, S., & Sanders, S. (2017). The effects of deep pressure therapies and antecedent exercise on stereotypical behaviors of students with autism spectrum disorders. Behavioral Disorders,42(4), 196-208. doi:10.1177/0198742917715873
15 Collins, A., & Dworkin, R. J. (2011). Pilot study of the effectiveness of weighted vests. American Journal of Occupational Therapy,65(6), 688-694. doi:10.5014/ajot.2011.000596
17 Pfeiffer B, Clark GF, Arbesman M. Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: a systematic review. Am J Occup Ther. 2018 Jan/Feb;72(1):7201190020p1-7201190020
p9.
18 Novak, I., & Honan, I. (2019). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Australian occupational therapy journal, 66(3), 258-273.