As many of our members are keenly aware, one of the key challenges facing occupational therapy is the increase in the diagnosis of autism, along with related attempts to restrict access to and payment for occupational therapy practice utilizing sensory integration therapy (SIT). AOTA has been working diligently on these issues. As a scientific investigator with an abiding interest in pediatric occupational therapy, I would like to present my perspective on the current status of SIT in relation to the continuing challenges. On the whole, it is my contention that the criticisms against SIT are unjustified, and that there is cause for optimism regarding our ability to ensure that SIT will continue to be supported as an important intervention treatment option for children with special needs.
Major synopses of intervention studies for children with autism spectrum disorders (ASDs), such as the National Standards Report (National Autism Center, 2009), have concluded that insufficient scientific evidence exists to establish the effectiveness of SIT. Further, efforts have been made in various states (e.g., Wisconsin, North Dakota, California) to curtail access to SIT services for children with ASDs or other conditions due to the alleged lack of research support.
Four Common Misconceptions in the Anti-SIT Literature
In sorting through the literature that is critical of SIT (e.g., Devlin et al., 2011; Gardner, 2012; Lang et al., 2012), I have identified four very common areas of misunderstanding. A clear awareness of these misconceptions is helpful in providing occupational therapy that is grounded in science and evidence and in countering what may be premature conclusions concerning any presumed lack of effectiveness for SIT. Although the material that I present below pertains most specifically to the application of SIT to children with ASDs, the underlying issues extend to the use of SIT in treating behavioral and developmental disorders more generally.
The first common error in reviews critical of SIT research consists of ignoring issues of fidelity and dosage. This type of error leads to the inappropriate lumping together of a variety of dissimilar interventions and protocols, many of which have neither the active ingredients nor the intervention duration of standard SIT. Then, on the basis of negative results for interventions that do not truly correspond to SIT, reviewers conclude that SIT is ineffective. A classic example of this error is reflected in a recent review of SIT performed by Lang et al. (2012). Of the 25 SIT outcome studies that these authors surveyed, 14 demonstrated no benefits, 8 were associated with mixed results, and 3 reported positive findings. In connection with this poor overall outcome, Lang et al. concluded that SIT is unsupported and should not be used to treat children with ASDs. However, it cannot be stressed too strongly that all 14 of the sensory-related interventions that produced negative results failed to reflect SIT as it is typically performed, which includes prolonged exposure (minimally several weeks and ideally at least 6 months) to a wide variety of sensory options, as well as careful attention to the needs of the child in order to encourage appropriate adaptive responses as the intervention progresses. In this regard, studies included by Lang et al. (2012) such as those involving the use of weighted vests (or brushing) as the sole sensory stimulus (9 studies) or that involved less than 90 total minutes of sensory stimulation (2 studies) do not fairly address the question of whether SIT, as it is characteristically administered, should be provided. However, it is very telling that within Lang et al.’s sample of studies there was a strong tendency for interventions that more closely approximated standard SIT (i.e., those that involved multiple types of sensory stimulation over a period of several weeks or more) to produce findings that were characterized as either “positive” or “mixed.”
The second pitfall is that reviewers frequently ignore or minimize the available positive evidence for SIT. For example, in the area of ASD, all three group-based controlled experiments that have been thus far published have demonstrated some benefit for types of multisensory interventions (including SIT) (Fazlioglu & Baran, 2008; Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011; Smith, Press, Koenig, & Kinnealey, 2005). Although these studies contain flaws, they nonetheless paint a consistent picture of positive results that cannot be explained away by issues such as small sample sizes, ignoring non-significant outcomes, or a lack of control (Clark & Carlson, 2011; Clark, Carlson, Case-Smith, & Schaaf, 2011). In fact, based on the application of meta-analytic techniques for cumulating probability values, the odds that chance alone could produce the positive results that are reported in these three studies are miniscule (Clark & Carlson, 2011). From this result, it is not hard for me to conclude that sensory treatments have positive effects when administered to children with ASDs.
The third misconception corresponds to the contention that SIT does not have a positive effect, insofar as the evidence base for SIT is weak due to poorly designed studies. Even if it were the case that the evidentiary base for SIT was not sufficiently strong (and I have already countered that argument), this lack would not prove that the intervention is ineffective. Any intervention could in principle produce outstanding salutary effects, but for a variety of reasons lack sufficiently rigorous research that documents its effectiveness. Such a situation may be especially likely in a field such as ASD intervention research, in which there is a significant amount of heterogeneity and individualization of therapeutic needs in the treatment population, factors that create difficulties in attempting to perform tightly controlled studies. In the case of SIT, the existing studies that have demonstrated positive effects, the affirmative feedback from clients and parents, as well as the everyday clinical observation of developmental and functional gains, leave open the strong possibility that consistent beneficial effects for certain outcomes will emerge when a sufficient number of well controlled studies are performed. The challenge is to make these studies happen.
A fourth problem is that critics often forget that a lack of solid evidence characterizes nearly all interventions for children with ASDs. For example, a recent report from the nationally prominent Agency for Healthcare Research and Quality (AHRQ) (2011) indicates that all existing interventions for ASD (with the exception of one drug-based treatment that produces side effects) lack a sufficiently solid foundation of empirical support to guide policy decisions. As an example, in the case of early and intensive behavioral and developmental interventions, although certain improvements were noted, the strength of evidence (confidence in the estimate) was deemed “low pending replication of the available studies” (AHRQ, 2011, p. 8). Thus, when critics single out SIT as being questionable in terms of its degree of adequate research support, they frequently invoke a double standard by failing to apply the same criterion to alternate interventions.
Grounds for Optimism
Several developments suggest that the battle to continue funding for occupational therapy–based SIT is winnable. A favorable outcome was achieved in North Dakota, where an insurance company agreed to pull back a policy that would have restricted services. In California, recent legislation named occupational therapy as a profession deemed qualified to provide behavioral health services to children with autism. These outcomes are in harmony with the recent American Academy of Pediatrics (AAP) policy statement on SIT for children with developmental and behavioral disorders. The AAP panel, despite acknowledging limitations in the amount of available research, indicated that “occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan” (American Academy of Pediatrics, 2012, p. 1186). On another front, increasing research support for SIT seems to be on its way. In this regard, Dr. Roseann Schaaf and her colleagues at Thomas Jefferson University have recently conducted a small scale randomized trial that produces further experimental evidence supporting the benefits of SIT for children with ASDs.
As a final basis for optimism, ongoing developments in neurobiology are strongly supportive of one of the basic assumptions of SIT, namely, that exposure to a sensory enriched environment leads to beneficial physical changes in the developing brain, such as increased synaptic connections. In one current neurodevelopmental model, co-authored by Drs. Barbara Thompson and Pat Levitt (2010), early exposure to a proper degree of sensory stimulation is theorized to build a neurobiological foundation for later-emerging functions such as motor skills, language, behavioral regulation, and executive functioning. This type of theorizing about human development, which is backed by voluminous literature on brain development in animals, is strikingly consistent with Ayres’ original thinking on the importance of integrating sensory systems.
In considering the future of SIT, it is important to stand firm. As I have noted, recent developments have in many ways been quite promising. I urge you to administer appropriate, authentic SIT as one of the prominent treatment options in your pediatric practice, based on such positive considerations as longstanding observations of clinical success, support from neurodevelopmental theory, and experimental evidence that shows beneficial results.
Agency for Healthcare Research and Quality. (2011). Therapies for children with Autism Spectrum Disorders. Comparative effectiveness review no. 26. AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Author.
American Academy of Pediatrics. (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 129, 1186–1189.
Clark, F., & Carlson, M. (2011). Quantitative synthesis of the experimental evidence for the efficacy of sensory integration therapy in treating autism spectrum disorders. Bethesda, MD: American Occupational Therapy Association. [Unpublished document]
Clark, F., Carlson, M., Case-Smith, J., & Schaaf, R.C. (2011). AOTA expert analysis of the 2011 Metastar Report. Bethesda, MD: American Occupational Therapy Association. [Unpublished document]
Devlin, S., Healy, O., Leader, G., & Hughes, B. M. (2011). Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. Journal of Autism and Developmental Disorders, 41, 1303–1320.
Fazlioglu, Y., & Baran, G. (2008). A sensory integration therapy program on sensory problems for children with autism. Perceptual and Motor Skills, 106, 415–422.
Gardner, A. W. (2012). An empirical investigation of sensory integration interventions for children with ASD. BRIDGE Brief: A Research to Practice Resource, 1(2), 1–2.
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.
National Autism Center. (2009). National standards report: The national standards project—Addressing the need for evidence-based practice guidelines for Autism Spectrum Disorders. Randolph, MA: Author.
Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65, 76–85.
Smith, S. A., Press, B., Koenig, K. P., &Kinnealey, M. (2005).Effects of sensory integration intervention on self-stimulating and self-injurious behaviors. American Journal of Occupational Therapy, 59, 418–425.
Thompson, B. L., & Levitt, P. (2010). The clinical-basic interface in defining pathogenesis in disorders of neurodevelopmental origin. Neuron, 67, 702–712. doi:10.1016/j.neuron.2010.08.037
Nicely said! I think it's important for OT's to administer "appropriate and authentic SIT", we also need to collaborate on researching the true effects of it. As an OT peer said to me yesterday, we need researchers and clinicians to work together to make OT practice work. Also, as you said in some past presidential addresses, the OT profession also needs to develop some scientists to provide evidence of our practice. What should happen in my opinion- OT's from different pediatric clinics should join forces and collaborate with a university to make a big RCT (in this case will be stratified random sampling) to prove the true effects of SIT. Basically, we need some researchers to not only provide some positive background information on SIT, but also a uniformed system that the pediatric OT's can agree upon for research purposes. That way, the researchers won't have to compare apples and oranges, if you know what I mean.
I believe the question remains 'What is meant exactly by appropriate and authentic SIT?'
The primary fidelity problem is reflected directly in this essay. Does ASI(TM) equate to 'authentic' SIT? Or do we refer to something else when we say that SIT has to be 'authentic?'
If there have been too many studies of 'inauthentic' sensory approaches (many of which have been completed by occupational therapists), do we really have anyone to 'blame' other than ourselves when people are critical of the research?
Many other people, including some who have looked at the same studies referenced herein, don't come to the conclusion that criticisms about SIT are unjustified. The root problem remains in this 'authentic' issue, and by reading this essay I really have no idea what 'authentic' means although it seems to imply adherence to Ayres by my understanding of what is written here. The essay expresses the notion of "SIT, as it is classically administered" and that very notion is foreign to me. I do not see evidence that there is any "standard SIT."
In fact, that has been the problem all along.
So to me, the use of this 'authentic' term adds to the confusion - and especially so with how meaning-laden that term is in our profession.
I appreciate the optimism but I still think that we can't ignore our critics. It is good that we continue to evolve our research. Appropriately, in consideration of what is and what is not authentic, it seems most appropriate to simply re-state, "This substantial progress does not mean that we have made it."
I suspect I will be corrected if I am abusing the quote but I could not resist while bandying about this 'authentic' concept. :D
Christopher J. Alterio, Dr.OT, OTR
Thank you for your very thoughtful response to my essay. In fact, I want to confirm that you did understand the meaning I intended by using the term ‘authentic’ as, to quote your words, an 'adherence to Ayres.' By authentic SIT, I simply mean intervention delivery that is reasonably faithful to the principles that were established by A. Jean Ayres (and the Fidelity Measure of Ayres Sensory Integration©), as Ayres originally coined the term ‘sensory integration therapy’ to designate specific therapeutic procedures guided by explicit principles. Please take my use of ‘authentic’ at face value. By no means do I intend to imply that ‘authentic’ SIT is superior to other sensory-based treatment approaches for individuals with ASD, although I do understand that the use of this term can be interpreted to imply degrees of worth and value. For this very reason, I actually hesitated to use the term ‘authentic,’ and removed it from previous drafts. Only comparative effectiveness studies, which I hope will be undertaken in the future, are capable of demonstrating which of the many sensory-based approaches may be more effective than others for specific populations. As you detected, in the end I decided to use the term in a very circumscribed way to signify reasonable fidelity to Ayres’ treatment principles. I concur that there are many perspectives within our field regarding what constitutes ‘standard SIT.’ This issue needs to be sorted out within our profession through discussions about ‘authenticity’ using a value-free conceptualization. I hope my response clarifies my intent, and once again I very much appreciated your comments. Your response has given me a chance to be more precise, and that is always a good thing.
With much gratitude,
Thank you for your time with this difficult and important issue. As a practioner having mentored and worked with Lorna Jean King, developed and worked in an OT SIT clinic for over 25 years, developed OT programs in various school districts in Arizona, for the last 12 years having traveled across the US working with school districts to address sensory integration and sensory processing challenges and having had the opportunity to develp with my co-authors the Sensory Processing Measures (SPM and SPM-P) I do appreciate the thoroughness in your posting. I recently presented to a group of pediatricians in my area (after asking for 'help' from many of our SIT guru practioners, AOTA and your colleague Mike Carlson). I was able to discuss the May AAP SI article on a positive note. The pediatricians appreciated hearing the distinction between SIT (Ayres SI) and sensory-based strategies and I directed them to AOTA's publication (April 2011) OT Practice Guidelines for Children and Adolescents With Challenges in Sensory Processing and Sensory Integration. They expressed that their biggest challenge continues to be how to label what they see, so that the children are able to obtain the services and insurance coverage their families need. Thank you for your optimism! As an OT for over 35 years, I know we have evolved in this journey and I too am optimistic about the future!
With much admiration and respect,
I am very new to the OT world... I am actually an architecture student. I am focusing my thesis around SIT and how I can design a therapy clinic around the sensitivities of the user and the therapist. Please take a look at my blog. I have a million questions to ask about SIT therapy and the work environment. If anyone can help I would be extremely grateful. The ultimate goal is to get it built but for now it is just conceptual.
Hi Fallon (or Fallynn?)
A must would be to visit and interface with some of the best SIT clinics across the US and around the world. Off the top of my head are OTA Watertown near Boston (Jane Koomar), The Starr Foundation near Denver (Lucy Jane Miller), Pediatric Therapy Network near LA (TERRI NISHIMURA), Rehab Dynamics in Toledo, Ohio (Maureen Kane Wineland) and Wee Care Therapy in Sunman, Indianna (Sue Swindeman). Those are just a few in the USA. When you are ready to look at designing sensory safe spaces in schools, please contact me at www.ateachabout.com
I would just like to also comment and thank Dr. Clark for her thorough reflection on where we are at this time with SIT and the challenges that we face as a profession in this area. I think that one of our biggest obstacles at times is ourselves. It may be time for us to go back to the grass roots and really advocate the necessary post-professional training needed to be able to communicate and deliver SIT and the use of evidence based practice. While there are many sensory based interventions that therapists use daily in their practice, we cannot document and bill these as sensory integration, and I think that we all need to be on the same page with an understanding of what is sensory integration and what is not. The AOTA practice guidelines on children and adolescents with challenges in sensory processing and sensory integration does a wonderful job of delineating what is sensory integration and what is a sensory based intervention. The main difference between the two is that the sensory based intervention is passively applied to the child and changes in neurological processing require active engagement.
I believe that if you promote yourself as an occupational therapist who practices sensory integration or is "trained" in sensory integration, that a requirement is to become certified as a basis of performance in this area. I prefer not to use some of the newer sensory techniques that therapists frequently administer and prescribe, but I am not against them if there is adequate justification and defined outcomes that are monitored during its use. I think that certification provides one with a basis of knowledge that then allows you to have better clinical reasoning behind the intervention methods that you choose. This is especially crucial for therapists practicing sensory integration in community based settings where consumers and third party payers are learning what we do through our actions and documentation. We don't want them getting the wrong ideas.
This is such a great conversation. What maddens me is the SIT "research" that is undertaken by Behavioral Consultants because it gives the wrong idea about what SIT is even more so than what another OT might do as they begin SIT training and treatment practice. One of the ABA studies consisted of putting a child in a room with a suspended swing and telling them to play because SIT is a child directed treatment. They also said that SIT is not a clearly defined protocol. The children they observed in the room with the swing did not play or interact with the swing and the adult did not interact with the child or offer any support. I think they obviously don't understand SIT or scaffolding within child directed and child centered treatment protocols.
Another recent study looked at Snuggy Vests and referred simply wearing the vest as SIT treatment even though no professional on the team was an OT or SIT trained. They put a child in a room without play media and told them to play for 20 minutes. The adult in the room was not allowed to interact with the child. The children all engaged in stereotypy and the study reported that the SIT treatment failed to decrease these behaviors. I don't understand how this could be approved by any DRB and it certainly does not constitute SIT research. This is the extreme of what we are speaking about but I believe the new focus on creating fidelity in treatment within our profession and operating under a copy written model is important to prevent this kind of hostile research from affecting our professional ability to practice.
I have also read ABA articles where they cite an OT in an article and they report that the OT reports that the treatment is proven not to work when the original OT article actually report an improvement in many participants who participated in the study but a lack of statistical power of the overall data which is common in a small sample size. Either they haven't taken basic statistics or they have no interest in reporting results that do not fit within the narrative they are set on creating. I find that when other professionals or shareholders are having difficulty with the term SIT, I change the conversation to sensory processing because the existence of sensory processing can't be argued. I then frame the conversation within the diagnosis of Developmental Coordination Disorder and how sensory processing effects this condition. I know how my SIT training has helped children. I am changing some of the terms but the theory and effects are the same.