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Perceptualand Motor Skills, 2008, 106,415-422. O Perceptual and Motor Skills 2008

A SENSORY INTEGRATION THERAPY PROGRAM O N SENSORY PROBLEMS FOR CHILDREN WITH AUTISM '

YESIM FAZLIOGLU AND GULEN BARAN

Trakya University, Edirne Ankara University, Ankara

Summary.-The study was planned to investigate the effect of a sensory integration therapy program on sensory problems of children with autism. This study was conducted at the Trakya University Training and Research Center for Mentally and Physically Handicapped Children in Turkey. The children were separated into two groups, each comprising 15 children between 7 and 11 years of age with autism, according to DSM-IV criteria. The children in each group were assessed initially on a checklist, Sensory Evaluation Form for Children with Autism, developed to evaluate sensory characteristics of children with autism, and at the end of the study, participants were assessed again on the checklist. Statistically significant differences between groups indicated that the sensory integration therapy program positively affected treated children.

A normally developing child is born with a complete sensory system, which continues to develop during life (17); however, some disorders like autism affect the integration of sensory experiences. Such sensory processing abnormalities are not specific to autism, although their prevalence in autism is relatively high (12).

Children with autism sometimes are unreactive to sounds, an expression of their closedness to environmental stimulation. In addition, abnormalities have been described in perception of vision, touch, taste, and smell, as well as in kinaesthetic and proprioceptive sensations. These include hyper- and hyposensitivity to stimulation (25).

Modulation of activity refers to the brain's regulation of mental, physical, and emotional behaviour (22). Disturbances in modulation are a main problem seen in autism. Although children with autism show various sensory reactivity, they usually use the senses of smell and touch. They sometimes discover objects by touching, smelling, or licking; some children with autism like to touch and be touched, while others do not (18, 21). Of the sensory modalities, those most affected by autism seem to be not smell and touch but auditory and visual modalities. Some authors have suggested that auditory abnormalities should be included among the diagnostic criteria of the disorder (15, 16). These sensory problems affect virtually all aspects of adap- tive, cognitive, social, and academic functioning, so it is important to ad-

'Address correspondence to Yegim Fazl~oglu, Trakya Universitesi Egitim Fakdtesi, Okuloncesi Egitim A.B.D., Edirne, Turkey or e-mail ([email protected]).

DO1 10.2466/PMS.106.2.415-422

dress sensory problems. Sensory and motor interventions have been used with children having autistic symptoms (12). The purpose of this study was to develop a program of sensory integration therapy for use in assessment and treatment of autistic children.

This study was conducted with 30 low functioning children with autism (diagnosed according to DSM-IV), who attended the Trakya University Training and Research Center for Mentally and Physically Handicapped Chil- dren. Consent was obtained from the children's parents. Participants were selected by searching the files to eliminate those who had previously been part of any sensory integration program or who had epileptic seizures. The selected group was between 7 and 11 years of age.

The majority of the children could not use language to communicate and were part of the special education program at the center. They were randomly assigned to a treated group and control group based on a stratifica- tion procedure to ensure equivalence of groups. Children were assigned to experimental and control groups randomly, matching on age and sex as possible. Fifteen children (12 boys, 3 girls) were in the experimental group, and 15 children (12 boys, 3 girls) with similar characteristics were in the control group. These two groups were matched for age, sex, and level of function. Measure

The Sensory Evaluation Form for Children with Autism was used for assessing sensory problems seen in these children. The items were developed by the authors based upon data reported previously (12, 23, 24, 25). In a pilot study, the evaluation form's validity and reliability were studied with 50 children with autism at the age of seven or above (age M=9.4 yr., SD=2.5). To assess whether the scale had discriminative validity, the form was also applied to 50 typical children of similar age and sex. Scores of children with autism and typical children differed statistically; children with autism had higher scores than nonautistic children. Reliability of the scale was assessed as internal consistency and in item analysis. Cronbach coefficient alpha was .74. The item analysis included a test-retest correlation of .96 (p < .05) over a 2-wk. period.

Following these pilot results, a form of 42 items (cf. Table 1) measured sensory problems of hearing-speaking, seeing, taste-smell, touch, balance, muscular tonus, attention, and behaviour characteristics of children with autism (13). Three response alternatives for each response were 1: Not true, 2: Sometimes true, and 3: Usually true. High scores indicated more sensory problems.

AUTISM AND SENSORY INTEGRATION TIIERAPY

TABLE 1 SENSORY EVALIJATION FORM FOR CHILDREN WITH AUTISM: ~ T E M CONTENT

-

-. .-

--

1. Can answer when his name is uttered 2. Cannot express self by pointing out or signalling 3. Needs commands to be repeated 4. Cannot give answers to simple questions asked (such as, "What is your name?" and

"How old are you?") 5. Unable to understand concepts such as Upward/Downward, BefordAfter, Inside/

Outside 6. Cannot use pronouns in a sentence appropriately (uses "he" instead of "I") 7. Has difficulty in understanding concepts such as big/small, long/short, woman/man 8. Cannot use 'Yes' or 'No' for a specific purpose 9. Looks are either void or thoughtful

10. Unable to copy figures and lines (such as /, ----, 0, +, X) 11. Cannot write letters on a line 12. Has difficulty distinguishing colours 13. Has difficulty distinguishing numbers 14. Cannot match two identical objects 15. Has difficulty with single piece 16. Has difficulty with single and double piece puzzle 17. Often bites either the straw or the glass while drinking water or fruit juice 18. Overreacts to wet clothes or tissues 19. Nonreactive to pain 20. Has difficulty walking on the walking board 21. Has difficulty walking on the balance board 22. Has difficulty mimicking gross motor skills (such as clapping and swaying his head) 23. Has difficulty mimicking gross motor skills (such as hitting his index finger) 24. Unsuccessful in mimicking oral motor skills (such as opening and closing his mouth and

sticking out his tongue) 25. Unable to synchronize two targeted movements in coordination (swinging a rope while

jumping) 26. Has a different walking style (such as tip-toeing, walking on his heels, hopping, and

skipping) 27. Cannot use scissors for a specific purpose 28. No specific preference about right or left hand use durin activities (such as writing

sometimes with right hand or sometimes with left h a n 8 29. Has fears about climbing 30. Looks anxious on the playground (avoids getting on a swing or see-saw) 31. Cannot ride a bike 32. Weak in catching objects with both hands (such as catching a ball) 33. Does not pay much attention when he drops something from his hand 34. Has poor posture while standing or sitting 35. Has difficulty grasping objects (such as holding them too tight or too loose) 36. Unsuccessful pulling and pushing objects 37. Not interested in his environment 38. Cannot concentrate on a specific subject (even on the activities he likes) 39. Unsuccessful in playing games with rules 40. Has anger attacks 41. Nonreactive to others' feelings 42. Resorts to self-stimulative behaviors (such as swaying, watching his hands, and clapping) --- -- - --

Not~.-Rating scale has 3 points-1: Not true, 2: Sometimes true, 3: Usually true.

Procedure The sensory integration program is based on "The Sensory Diet," a

popular modern version of a sensory integration program in which the child is provided a home or classroom program of sensory-based activities aimed at fulfilling the child's sensory needs (10). A schedule of frequent and systematically applied somatosensory stimulation (i.e., brushing with a surgical brush and joint compression) is followed by a prescribed set of activities de- signed to meet the child's sensory needs and integrated into the child's daily routine (3). There were 13 target behaviours to somatosensory stimulation in addition to hearing, seeing, tasting, smelling, touching, balancing, moving (fine motor, gross motor, oral motor), and proprioception. This program has 68 activities to achieve 13 target behaviors. For example, when reduction of the child's intolerance to touching of different textures was the goal, the program procedure included exercises of touching different textures (play dough, finger paint, water, rice, vibrating toys, sandpaper, feathers), playing with these materials, and perceiving and feeling different textures.

The program was practiced in a specially arranged room in the center, called the sense room, in which were siecial materials such as different kinds of brushes, lotions, a massage table, massage instruments, pipes, musical instruments, a mirror, a trampoline, balls, and a touch board.

In the beginning, the families were informed about the aim and dura- tion of the study, and importance of continuity in the program was emphasized. A physiotherapist who helped develop the motor items evaluated muscular tonus, motor development, and posture.

A study plan showing the days and hours of application was prepared for every child, and the children were taken to the sensory integration sessions individually. Before a session, a special educator prepared the required materials and informed the child about the order of activities and the beginning and the finishing times of the session.

In the beginning, children were given permission to freely touch the materials so that they became familiar with the environment and materials. During the session, if children became overstimulated, activity was stopped for a while. Activity was separated into small skills and given step by step. Objective and symbolic reinforcements were used for motivation. Several types of prompts were used: verbal, modeling, physical, and gestural posi- tion cues. When new skills were taught to a child, the strategy began with a full physical prompt for the desired response, then was faded to a gesture or model, and finally to only a verbal instruction. After children gave responses, cues were eliminated over time (extinction). The performances of the children during each session were recorded and placed in their files. Perfor- mances were coded for each session as full physical prompt, verbal instruc-

AUTISM AND SENSORY INTEGRATION THERAPY 419

tion, and independent. When children learned one skill to independence, another skill was begun. Each child attended the 45-min. sensory integration sessions two days a week for 24 sessions.

In this part of the study, the children with autism in the control group did not participate in the sensory integration program but attended their reg- ularly scheduled special education classes at the center. After the administra- tion of the sensory integration program, children in both groups were reas- sessed on the evaluation form and pre- and posttest scores were compared.

RESULTS Pre- and Posttest scores were analysed using SPSS (Version IO.O), using

a two group analysis of variance for repeated measures. Pretest and posttest means and standard deviations for the two groups are shown in Table 2. Children's scores in the experimental group and control group showed changes over time; however, the scores were significantly lower for the treated group attending sensory integration therapy.

TABLE 2 PRE- AND POSTTEST MEANS AND STANDARD DEVIATIONS FOR TWO GROUPS (ns = 15)

- -

Group Pretest Posttest --

M SD M SD Treated 98.2 19.3 66.5 11.4 Control 95.8 17.0 97.3 17.8

There was a statistically significant main effect for group in total scores (F1,*,=5.84, p < .05) as well as a main effect of test time (pre- and posttest) (F,,*, = 98.38, p < .01). Sensory problems observed in children with autism were reduced after the sensory integration program. The interaction of group and time was also significant (F,,*,= 119.38, p

In the literature, sensory problems have been associated with sensory processing in the vestibular and tactile systems (5, 6, 7 , 9, 19, 28). Case- Smith and Brayn (8) emphasized that sensory perceptual abnormalities in people with autism could be improved by sensory integration therapy. Ayres and Tickle (2) noted that children with autism were reactive to touch, and changes in movement and gravity. Connor (11) emphasized the importance of programs which develop motor skills, noting that such programs were ef- fective in reducing perceptual overselectivity. These programs develop skills related to discrimination of sensory input and play an important role in attention and concentration (4, 12).

Dawson and Watling (12) reviewed evidence regarding the prevalence of sensory and motor abnormalities from sensory integration therapy, tradi- tional occupational therapy, and auditory integration training. Researchers noted that sensory integration therapy positively affected development of motor skills. For this reason, play skills should be supported by a sensory integration approach. With a well-planned program, opportunity to interact with peers could be provided (1, 9, 29).

Case-Smith and Miller (9) studied five boys over a 3-wk. baseline phase and a 10-wk. intervention which consisted of a combination of classical sensory integration treatment and consultation with teachers. Independent cod- ing of videotaped observations of free play indicated that three of the five boys significantly improved in their mastery play. For only one boy were significant improvements evident in interaction with adults, and none changed in amount of peer interaction. Outcome measures more directly related to intrinsic features of the intervention (e.g., individual mastery play) appeared more improved than measures not directly addressed in treatment (e.g., peer interaction). Although it is possible that the positive results could be attrib- uted to factors other than the intervention (i.e., maturation, care-giving effects), the authors noted that the behaviours did not change systematically across all outcome measures.

Results of many studies seem to parallel present findings of a significant difference between treated and control groups, plus reduction in sensory problems after the sensory integration treatment. This implies that such a program could be used as an intervention for sensory and motor problems of children with autism.

Stagnitti, Raison, and Ryan (26) described a 5-yr.-old boy with severe sensory defensiveness who underwent a treatment program consisting of brushing followed by joining sessions of three to five times daily for two weeks. The program included integration of appropriate sensory activities in- terspersed throughout the child's daily activities and routines and was carried out by the parents at home under the supervision of a therapist trained in these methods. Following the initial improvements, the treatment program

AUTISM AND SENSORY INTEGRATION TIIERAPY 42 1

was repeated several months later as the child's behaviours seemed again to deteriorate. Posttreatment parental reports suggested improvements in toler- ance of tactile stimulation, fewer temper tantrums, an increase in activity, and better coordination.

It is through their sensory experience that children develop connected- ness with the world. When children show sensory dysfunction, it is harder for them to interact and learn about the world. Sensory integration therapy should be fun and inviting for children, stimulating the brain, so sensory and motor skills can develop more fully and functionally.

Most children with autism are treated with special classes at public or private schools in Turkey, but autism is accepted as a psychiatric and developmental problem in Turkey so both psychiatric and educational treatment are carried out in special education centers. In this process behaviour therapy is more common than sensory treatment. It seems reasonable that the present study be extended psychometrically and temporally.

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Accepted February 28, 2008

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