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Autism1 16 The Author(s) 2014Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1362361313517762aut.sagepub.com
Current estimates indicate that more than 80% of children with autism spectrum disorders (ASD) exhibit co-occur-ring sensory processing problems (Ben-Sasson et al., 2009), and hyper- or hyporeactivity to sensory input is now a diagnostic criterion for ASD in the Diagnostic and Statistical Manual of Mental DisordersFifth Edition (DSM-5; American Psychiatric Association, 2013). Children who exhibit sensory hyperreactivity may respond negatively to common sensory stimuli, including sounds, touch, or movement. Their responses include distress, avoidance, and hypervigilance (Mazurek et al., 2012; Reynolds and Lane, 2008). Children who are hyporeac-tive appear unaware or nonresponsive to sensory stimuli that are salient to others (Miller et al., 2007a). A subgroup of children who are hyporeactive exhibit sensory-seeking behaviors (i.e. they appear to seek intense stimulation to
increase their arousal) that may manifest as restricted, repetitive patterns of behavior (Ornitz, 1974; Schaaf et al., 2011).
Historically, Kanner (1943) documented that children with ASD had sensory fascinations with light and spinning objects and oversensitivity to sounds and moving objects (p. 245). More recently, researchers have documented that children with ASD seek or avoid ordinary auditory, tactile, or vestibular input (Baranek et al., 2006; Ben-Sasson et al.,
A systematic review of sensory processing interventions for children with autism spectrum disorders
Jane Case-Smith, Lindy L Weaver and Mary A Fristad
AbstractChildren with autism spectrum disorders often exhibit co-occurring sensory processing problems and receive interventions that target self-regulation. In current practice, sensory interventions apply different theoretic constructs, focus on different goals, use a variety of sensory modalities, and involve markedly disparate procedures. Previous reviews examined the effects of sensory interventions without acknowledging these inconsistencies. This systematic review examined the research evidence (20002012) of two forms of sensory interventions, sensory integration therapy and sensory-based intervention, for children with autism spectrum disorders and concurrent sensory processing problems. A total of 19 studies were reviewed: 5 examined the effects of sensory integration therapy and 14 sensory-based intervention. The studies defined sensory integration therapies as clinic-based interventions that use sensory-rich, child-directed activities to improve a childs adaptive responses to sensory experiences. Two randomized controlled trials found positive effects for sensory integration therapy on child performance using Goal Attainment Scaling (effect sizes ranging from .72 to 1.62); other studies (Levels IIIIV) found positive effects on reducing behaviors linked to sensory problems. Sensory-based interventions are characterized as classroom-based interventions that use single-sensory strategies, for example, weighted vests or therapy balls, to influence a childs state of arousal. Few positive effects were found in sensory-based intervention studies. Studies of sensory-based interventions suggest that they may not be effective; however, they did not follow recommended protocols or target sensory processing problems. Although small randomized controlled trials resulted in positive effects for sensory integration therapies, additional rigorous trials using manualized protocols for sensory integration therapy are needed to evaluate effects for children with autism spectrum disorders and sensory processing problems.
Keywordssensory integration therapy, sensory processing, systematic review
The Ohio State University, USA
Corresponding author:Jane Case-Smith, Division of Occupational Therapy, The Ohio State University, 406 Atwell Hall, 435 West 10th Avenue, Columbus, OH 43210, USA. Email: [email protected]
517762 AUT0010.1177/1362361313517762AutismCase-Smith et al.research-article2014
Review
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2 Autism
2009; Rogers and Ozonoff, 2005), suggesting impairment in sensory modulation across systems (Dahlgren and Gillberg, 1989). Specific sensory modulation problems reported by people with ASD (e.g. Grandin, 1992; Williams, 1995) include hyperreactivity to touch or sounds, hyporeactivity to auditory input, and unusual sen-sory interests. The most common type of sensory modula-tion problem in ASD appears to be hyporeactivity, particularly in social contexts (Baranek et al., 2006). A meta-analysis of sensory modulation symptoms in ASD found that effect sizes for the differences between children with and without ASD were greatest for hyporeactivity (d = 2.02) but also notable for hyperreactivity (d = 1.28) and sensory-seeking (d = .83) (Ben-Sasson et al., 2009). Although sensory processing problems appear to be greater in childhood (Ben-Sasson et al., 2009), they are self-reported to be lifelong (Grandin, 1995).
Sensory processing problems in ASD are believed to be an underlying factor related to behavioral and/or func-tional performance problems. Ornitz (1974) hypothesized that sensory modulation problems are related to the stereo-typic or repetitive behaviors displayed by children with ASD, and that the stereotypic behaviors reflect the childs attempt to lower arousal (self-calm) or increase arousal (sensory-seeking). Researchers have attributed repetitive movements, such as rocking, twirling, or spinning behav-iors, to sensory processing problems (Ornitz et al., 1978; Rogers et al., 2003; Schaaf et al., 2011). Joosten and Bundy (2010) found that a sample of children with ASD and ste-reotypical behaviors had significantly greater sensory pro-cessing problems (d = 2.0) than do typical children. Rigid behaviors (e.g. refusing to transition to a new activity, pre-ferring a rigid routine) or preference for sameness may also be motivated by hyper- or hyporeactivity (Lane et al., 2010).
Sensory processing problems in ASD may also influ-ence a childs functional performance in daily activities, such as eating, sleeping, and daily routines, including bath time and bedtime behaviors (Schaaf et al., 2011). Children with selective eating often have olfactory and/or gustatory oversensitivities that can cause aversion to certain foods (Leekam et al., 2007; Paterson and Peck, 2011). Hyperreactivity or aversion to tastes or smells can lead to anxiety or rigidity about eating and these states can evolve into disruptive and stress-producing behaviors at mealtime (Cermak et al., 2010). Sensory processing problems can also disrupt childrens sleeping patterns; Reynolds et al. (2012) found that children with ASD and sensory modula-tion problems have poor sleeping patterns, specifically have difficulty falling asleep, and that these problems appear to relate to sensory modulation. Between 50% and 80% of children with ASD have sleeping difficulties (Richdale and Schreck, 2009) that seem to relate, at least in part, to sensory processing problems (Klintwall et al., 2011; Reynolds and Malow, 2011).
Sensory processing problems have also been linked to anxiety in children with ASD. Green and Ben-Sasson (2010) proposed a model to explain how hyperreactivity in children with ASD can be characterized as hyper-attention to sensory stimuli and overreaction to those stimuli. Hyperreactivity can lead to overarousal, difficulty regulat-ing negative emotion, and avoidance or negative responses to everyday sensory stimuli. Over time, poor regulation of arousal may result in anxiety (Bellini, 2006) and may be particularly stressful for the nonverbal child who lacks communication skills to express his or her anxiety (Green and Ben-Sasson, 2010). In a large sample of children with ASD and gastrointestinal problems, sensory hyperreactiv-ity correlated with anxiety levels, and hyperreactivity and anxiety uniquely contributed to gastrointestinal symptoms (Mazurek et al., 2012).
Although studies have demonstrated that sensory pro-cessing problems can influence the behavior of children with ASD, the relationships among sensory-driven behav-iors, arousal, self-regulation, attention, activity levels, and stereotypic behaviors are not well understood. When sen-sory processing problems are believed to influence a childs behavior, interventions that use sensory modalities to support self-regulation, promote optimal arousal, improve behavioral organization, and lower overreactivity are often recommended.
Interventions for sensory processing disorders
Despite wide recognition of sensory processing problems and their effects on life participation for individuals with ASD, sensory interventions have been inconsistently defined and refer to widely varied practices. As found in the literature and in practice, sensory interventions use a variety of sensory modalities (e.g. vestibular, somatosen-sory, and auditory), target behaviors that may or may not be associated with sensory processing disorder, involve a continuum of passive to active child participation, and are applied in different contexts. These interventions arise from different conceptualizations about sensory integra-tion and sensory processing as neurological and physio-logical functions that influence behavior. Furthermore, they use a variety of methods (e.g. sensory integration therapy (SIT) (Ayres, 1972), massage (Field et al., 1997), and auditory integration training (Bettison, 1996)). This variation in sensory interventions combined with incon-sistent use of terminology has resulted in considerable confusion for parents, practitioners, and researchers. With disparate and sometimes conflicting rationale for using sensory interventions for ASD, researchers have hypothe-sized that they can inhibit stereotypical behaviors (e.g. Davis et al., 2011), reduce self-injurious behaviors (e.g. Devlin et al., 2009; Smith, et al. 2005), improve attention to task (e.g. Watling and Dietz, 2007), increase sitting time
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Case-Smith et al. 3
(e.g. Hodgetts et al., 2010; Schilling and Schwartz, 2004), elicit adaptive responses (Schaaf et al., 2013), and improve sensory motor performance (Fazlioglu and Baran, 2008). Although researchers have applied sensory interventions to improve behaviors hypothesized to reflect self-regula-tion, most studies did not use neurophysiological measures and many did not include sensory processing measures (e.g. Bonggat and Hall, 2010; Kane et al., 2004). Despite inconsistency in the research literature, sensory interven-tions are among the services most requested by parents of children with ASD (Green et al., 2006). Over 60% of chil-dren with ASD receive sensory interventions, often in combination with other therapies, making it one of the most common types of service for ASD (Green et al., 2006). With incomplete and contradictory findings from research, the field lacks consensus as to what sensory interventions families should seek and practitioners can recommend.
To increase understanding of the different types of sen-sory interventions and to assess the evidence, we distin-guish SIT, a clinic-based, child-centered intervention originally developed by Ayres, that provides play-based activities with enhanced sensation to elicit and reinforce the child adaptive responses, and sensory-based interven-tion (SBI), structured, adult-directed sensory strategies that are integrated into the childs daily routine to improve behavioral regulation.
SIT
SIT is a clinic-based intervention that uses play activities and sensory-enhanced interactions to elicit the childs adaptive responses. The therapist creates activities that engage the childs participation and challenge the childs sensory processing and motor planning skills (Ayres, 1972; Koomar and Bundy, 2002; Parham and Mailloux, 2010). Using gross motor activities that activate the ves-tibular and somatosensory systems (Mailloux and Roley, 2010), the goal of SIT is to increase the childs ability to integrate sensory information, thereby demonstrating more organized and adaptive behaviors, including increased joint attention, social skill, motor planning, and perceptual skill (Baranek, 2002). The therapist designs a just-right skill challenge (i.e. an activity that requires the childs highest developmental skills) from the childs rep-ertoire of emerging skills and supports the childs adaptive response to the challenge (Vygotsky, 1978; Watling et al., 2011). Traditional SIT is provided in a clinic with specially designed equipment (e.g. swings, therapy balls, inner tubes, trampolines, and climbing walls) that can provide vestibular and proprioceptive challenges embedded in playful, goal-directed activities.
A widely used fidelity measure defines the active ingre-dients or essential elements of clinic-based SIT (Parham et al., 2007, 2011). Each element is individualized to the
child and targets specific objectives. The 10 essential ele-ments are as follows: (a) ensuring safety, (b) presenting a range of sensory opportunities (specifically tactile, pro-prioceptive, and vestibular), (c) using activity and arrang-ing the environment to help the child maintain self-regulation and alertness, (d) challenging postural, ocular, oral, or bilateral motor control, (e) is challenging praxis and organization of behavior, (f) collaborating with the child on activity choices, (g) tailoring activities to pre-sent the just-right challenge, (h) ensuring that activities are successful, (i) supporting the childs intrinsic motiva-tion to play, and (j) establishing a therapeutic alliance with the child (Parham et al., 2007, 2011).
In addition to working directly with the child, the thera-pist reframes the childs behaviors to the parent or clinician using a sensory processing perspective (Bundy, 2002; Parham and Mailloux, 2010). Explaining the possible links between sensory processing and challenging behaviors, then recommending strategies that target the childs hyper- or hyporeactivity, can help caregivers and other treatment providers develop different approaches to accommodate the childs needs. By modifying the childs environments or routines to support self-regulation, the child can more fully participate in everyday activities. Recommended modifica-tions to the childs daily routines or environments often pro-mote a balance of active and quiet activities and opportunities for the child to participate in preferred sensory experiences (e.g. swinging in the backyard or neighborhood playground, climbing on a gym set, supervised trampoline jumping, and quiet rhythmic rocking in a low lit bedroom).
SBIs
SBIs are adult-directed sensory modalities that are applied to the child to improve behaviors associated with modula-tion disorders. SBIs require less engagement of the child and are intended to fit into the childs daily routine. For the purposes of this review, similar to Lang et al. (2012) and May Benson and Koomar (2010), only SBIs that activate somatosensory and vestibular systems and are believed to promote behavioral regulation were included, for example, brushing, massage, swinging, bouncing on a therapy ball, or wearing a vest. As in SIT, these interventions are based on the hypothesis that the efficiency with which the childs nervous system interprets and uses sensory information can be enhanced through systematic application of sensa-tion to promote change in arousal state (Parham and Mailloux, 2010). SBIs, like SIT, are based on neuroscience models (e.g. Kandel et al., 2000; Lane, 2002) and clinical observations (Mailloux and Roley, 2010) supporting that certain types of sensory input, for example, deep touch and rocking, are calming and organizing, and that rhythmic application of touch (e.g. brushing) or vestibular sensation (e.g. linear swinging) has an organizing effect that pro-motes self-regulation (Ayres, 1979; Parham and Mailloux,
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4 Autism
2010). A key feature of these techniques is that they are designed to influence the childs state of arousal, most often to lower a high arousal state such as agitation, hyper-activity, or self-stimulating behaviors.
Most SBIs, such as weighted blankets, pressure vests, brushing, and sitting on a ball, are used in the childs natu-ral environment (rather than a clinic), are integrated into the childs daily routine (i.e. used as needed according to the childs arousal), and are applied by family members, teachers, or aides (i.e. an occupational or physical therapist does not administer) (e.g. Wilbarger and Wilbarger, 2002). SBIs have evolved from therapists observing how children respond to the sensation (Ayres, 1972; Koomar and Bundy, 2002); therefore, the sensory techniques have not been systematically developed through research into a manual-ized intervention. Most research studies on SBIs have examined the effects of a single-sensory strategy on behav-iors that reflect the childs arousal or self-regulation.
For purposes of this systematic review, we define SBIs as those that (a) are based on specific assessment of the childs performance, development, and sensory needs; (b) include stated goals of self-regulation and related behavio-ral outcomes; and (c) require the childs active participa-tion. Examples of sensory interventions that meet these criteria include sitting on a therapy ball, swinging, and wearing a pressure or weighted vest when used to promote calming, enhance self-regulation, or improve behavior. Evidence-based practice guidelines and fidelity measures have not been developed for these interventions. These interventions have been recommended or applied by edu-cators, psychologists, occupational therapists, and para-professionals, often without a specific protocol.
Systematic reviews of SIT and SBI
Previous systematic SIT reviews using samples of children with learning disabilities, attention deficit hyperactivity disorder (ADHD), and developmental coordination disor-der have reported moderate effect sizes for motor and aca-demic outcomes when SIT was compared to no treatment (Polatajko et al., 1992; Vargas and Camilli, 1999). These reviews concluded that SITs were as effective as alterna-tive treatments (e.g. no different than perceptual motor activities) (Vargas and Camilli, 1999).
For SIT with children with ASD, three relevant system-atic reviews examined sensory motor (Baranek, 2002), occupational therapy interventions (Case-Smith and Arbesman, 2008), and SBIs (Lang et al., 2012). The two former reviews defined SIT and SBI broadly, including auditory integration therapy (electronically filtered music through high-resolution head phones) and motor activity/exercise (Baranek, 2002; Case-Smith and Arbesman, 2008), that are excluded in the current review. Using these more inclusive definitions of SIT and SBI, Case-Smith and Arbesman (2008) and Baranek (2002) found low-level
evidence (Levels III and IV) that these interventions improved social interaction, increased purposeful play, and reduced hyperreactivity in young children. Each review concluded that the evidence for SIT and SBI was uncertain, noting that sensory intervention studies demon-strated methodological constraints, including convenience samples, observer bias, and inadequate controls (Baranek, 2002; Case-Smith and Arbesman, 2008). These research-ers recommended that future SIT/SBI research focus on functional outcomes (in addition to sensory processing measures), link physiological and functional measures, and include long-term outcomes. In a recent review that combined SIT and SBI, Lang et al. (2012) appraised 25 studies of SIT (n = 5) and SBI (n = 20 (10 examined use of a weighted vest)). Like the other reviews, the majority of findings were suggestive given that 19 studies used sin-gle-subject design (Level IV evidence).
The current systematic review updates these reviews, focuses on interventions that activate the somatosensory and vestibular systems, and differentiates between SIT, based on the original work of Ayres and manualized by Parham et al. (2011), and SBI, that applies specific types of sensory input hypothesized to effect self-regulation. This review also dif-fers from Lang et al. (2012) by including only studies in which the participants had evidence of sensory processing problems (eliminating research that applied SBIs to behav-iors that were not linked to sensory processing measures).
Purpose of this study
Given the evidence for co-occurring sensory processing problems in children with ASD and the need to identify the evidence base for sensory interventions, this systematic review examined the following research question: What is the effectiveness of SIT and SBIs for children with ASD and co-occurring sensory processing problems on self-regulation and behavior?
Methods
Literature search
Several strategies were used to identify studies for this review. A computerized search of references published between 2000 and 2012 was conducted using the follow-ing electronic databases: WorldCat (Social Sciences Abstracts, Academic OneFile, and Academic Search Complete); MEDLINE, ERIC, CINAHL, and the Psychology & Behavioral Sciences Collection. Reference lists from identified articles, systematic reviews, and prac-tice guidelines for SBIs (Watling et al., 2011) were hand searched to ensure that a comprehensive list of relevant articles was considered for inclusion.
Various combinations of the following key words and search terms were used to identify pertinent articles:
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Case-Smith et al. 5
sensory integration, sensory processing, sensory-based, sensory, psychiatry, psychology, self-regulation, mental health, occupational therapy, developmental disorder, and autism. Inclusion criteria were as follows: (a) peer-reviewed studies published in English, (b) participants were youth aged 321 years, (c) an SIT or SBI was stud-ied, (d) participants were diagnosed with ASD, and (e) the intervention systematically (i.e. was based on stated goals) targeted self-regulation and arousal state.
A total of 1540 references were identified through the original search process (see Figure 1). Based upon title and abstract screening, 1450 articles were excluded as they did not meet inclusion criteria #13. The remaining 90 abstracts were reviewed. Of those, 71 were excluded because they did not meet inclusion criterion #4 or 5. The remaining 19 studies were selected for full text review by J.C.-S. and L.L.W.
Analysis
J.C.-S. and L.L.W. analyzed the studies that met inclu-sion criteria and extracted the following data: (a) research objectives, (b) research design, (c) participant characteristics, (d) intervention, (e) outcome measures,
and (e) findings. We used criteria developed for both rehabilitation and psychology research as these studies are published in the medical, education, and psychology literature. Overall rigor of the methodology was rated according to PEDro scale (De Morton, 2009), com-monly used in occupational therapy (the field most likely to provide sensory interventions) or physical therapy to judge the rigor of clinical trials (see Center for Evidence-Based Medicine Levels of Evidence (http://www.cebm.net) and Physiotherapy Evidence Database (http://www.pedro.org.au)). The PEDro scale has 10 criteria that are scored 1 for yes or 0 for no and summed as x/10. We also used the psychology guidelines for evidence-based treatments (Chambless and Hollon, 1998; Nathan and Gorman, 2007) to rate rigor of each study (Types 16). The authors rated the studies independently, compared and discussed scores, and agreed on consensus scores. Table 1 presents the criteria used to analyze the studies.
Study characteristics are summarized in Table 2. Findings were synthesized in terms of type of intervention and effects on targeted outcomes. An average effect size was not calculated, as 15 of 19 studies used single-subject or case report designs.
Titles/Abstracts idenfied and assessed for inclusion (N = 1540)
Excluded (n = 1450) Did not meet inclusion criteria #1-3:
- Peer-reviewed- Ages 3-21- Studied SIT or SBI
Excluded (n = 71) Did not meet inclusion criterion #4, 5
- Diagnosed with ASD- Targeted self-regulaon
Full-Text Review (n = 19)5 SIT studies 14 SBI studies
Abstracts eligible for review (n = 90)
Figure 1. Flow diagram outlining results of published literature search and included studies.SIT: sensory integration therapy; SBI: sensory-based intervention; ASD: autism spectrum disorder.
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6 Autism
Table 1. Common systems to describe levels of evidence and criteria used to analyze studies in psychology and occupational therapy.
Randomized controlled trial (RCT) criteria (Chambless and Hollon, 1998; Nathan and Gorman, 2007)
Types of studies (Chambless and Hollon, 1998; Nathan and Gorman, 2007)
PEDro scale (Physiotherapy Evidence Database), scores range from 0 to 10
Levels of evidence (Center for Evidence-Based Medicine)
Should include: Comparison groups with
random assignment Blinded assessments Clear inclusion and
exclusion criteria Standardized assessment Adequate sample size for
statistical power Intervention manual Fidelity measure Clearly described statistical
methods Follow-up measures
Type 1: most rigorous, randomized, prospective clinical trial that meets all criteria
Type 2: clinical trial, at least one aspect of the Type 1 study is missing
Type 3: clinical trial that is methodologically limited, for example, a pilot study or open trial
Type 4: review of published data, for example, meta-analyses
Type 5: reviews that do not include secondary data analyses
Type 6: case studies, essays, and opinion papers
Random allocation used Allocation concealed Groups comparable at
baseline Blinding of participants Blinding of all study
therapists Blinding of all assessors
who measured at least one key outcome
Outcome measures obtained from more than 85% of the initial sample
Intent-to-treat analyses used
Between-group statistical comparisons reported
Pre/post-measures and measures of variability reported (or effect sizes reported)
Level I: systematic review (of RCTs) or RCT conducted
Level II: systematic review of cohort studies; low-quality RCT; individual cohort study; outcomes research
Level III: systematic review of case-control studies; individual case-control study
Level IV: case series; poor quality case-control studies
Level V: expert opinion without explicit critical appraisal
Center for Evidence-Based Medicine (http://www.cebm.net) (Chambless and Hollon, 1998; Nathan and Gorman, 2007); Physiotherapy Evidence Database PEDro scale (http://www.pedro.org.au).
Results
A total of 19 studies published since 2000 met inclusion criteria. Five examined the effects of SIT and 14 examined the effects of a SBI on children with ASD and sensory pro-cessing problems (see Table 2).
SIT effects
Two of the five SIT studies were randomized controlled trials (RCTs); one RCT compared SIT to usual care, one compared SIT to a fine motor activity protocol, and one was a case report. All five studies used participants with ASD and sensory processing disorders and applied a man-ualized SIT approach based on the original work of Ayres (1972, 1979). Four studies (Pfeiffer et al., 2011; Schaaf et al., 2012; Schaaf et al., 2013; Watling and Dietz, 2007) documented high fidelity using the published fidelity measure described earlier (Parham et al., 2007). RCT results suggest that SIT is associated with positive effects as measured by the childs performance on Goal Attainment Scaling (GAS) (Pfeiffer et al., 2011; Schaaf et al., 2013), decreased autistic mannerisms (Pfeiffer et al., 2011), and improved (i.e. less caregiver assistance required) self-care and social function (Schaaf et al., 2013). Treatment effects on GAS, as rated by a blinded
therapist who interviewed the parents, were moderate to high (Pfeiffer et al. ( = .36) and Schaaf et al. (d = 1.17)), reflecting child improvement on targeted goals as meas-ured by teachers and parents. Schaaf and her colleagues also demonstrated moderate effects on sensory perceptual behaviors (d = .6).
In the nonrandomized SIT trial, seven children with low-functioning ASD who exhibited self-injurious and self-stimulating behaviors received alternating SIT and behavioral intervention conditions (Smith et al., 2005). The children showed fewer problem behaviors 1 h after SIT than 1 h after behavioral interventions (p = .02) and problem behaviors declined from weeks 1 to 4 (p = .04), suggesting that in children with sensory processing prob-lems, SIT may reduce self-injurious and self-stimulating behaviors more than behavioral interventions. In the case report by Schaaf et al. (2012), a 5-year-old with ASD and ADHD improved in ritualistic behaviors, resistance to change, specific fears, and individualized goals as meas-ured by the GAS. Using an ABAB single-subject design with four preschool children, Watling and Dietz (2007) examined the immediate effects of SIT compared to a baseline condition on engagement and behavior during a tabletop activity but found no effect for SIT. These authors noted that a ceiling effect limited their ability to detect change in performance.
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Case-Smith et al. 7
Tab
le 2
. Su
mm
ary
of t
he e
vide
nce
exam
inin
g th
e ef
ficac
y of
sen
sory
inte
grat
ion
ther
apy
(SIT
) an
d se
nsor
y-ba
sed
inte
rven
tions
(SB
Is)
for
child
ren
and
adol
esce
nts.
Stud
yO
bjec
tives
Rat
ing/
desi
gn/p
artic
ipan
tsIn
terv
entio
n an
d ou
tcom
e m
easu
res
Res
ults
Inte
rpre
tatio
n
SIT
Pfei
ffer
eta
l. (2
011)
To
dete
rmin
e fe
asib
ility
, ide
ntify
ap
prop
riat
e ou
tcom
e m
easu
res,
an
d ad
dres
s ef
fect
iven
ess
of S
I in
terv
entio
ns in
chi
ldre
n w
ith
ASD
Typ
e 3:
pilo
t R
CT
(ra
ndom
as
sign
men
t, si
ngle
blin
d); P
EDro
sc
ore
= 6
/10;
CEB
M L
evel
I
Inte
rven
tion:
Expe
rim
enta
l gro
up: S
I as
defin
ed b
y Pa
rham
et
al.
(201
1); 1
8 se
ssio
ns, 4
5 m
in e
ach,
ove
r 6-
wee
k pe
riod
.C
ontr
ol g
roup
: FM
add
ress
ing
cons
truc
tiona
l, dr
awin
g an
d w
ritin
g, a
nd F
M c
rafts
. Act
iviti
es d
id
not
prov
ide
full-
body
pro
prio
cept
ive,
ves
tibul
ar,
or t
actil
e se
nsor
y in
put.
Mat
ched
for
cont
act
dura
tion
Both
gro
ups
impr
oved
on
GA
S;
SI g
roup
dem
onst
rate
d m
ore
sign
ifica
nt im
prov
emen
t as
rat
ed
by p
aren
ts (
p <
.01,
effe
ct s
ize
= 0.
125)
and
tea
cher
s (p
< .0
1,
effe
ct s
ize
= 0.
360)
. On
SRS,
SI
grou
p de
mon
stra
ted
few
er a
utis
tic
man
neri
sms
than
FM
gro
up (
p <
.05,
ef
fect
siz
e =
0.13
1). N
o si
gnifi
cant
di
ffere
nces
bet
wee
n ot
her
subs
cale
s of
SR
S or
the
QN
ST-II
. N
o si
gnifi
cant
diff
eren
ces
foun
d on
V
ABS
-2 o
r SP
M
Low
to
mod
erat
e ef
fect
s. D
esig
n in
clud
es r
ando
m a
ssig
nmen
t, bl
inde
d as
sess
men
t, cl
ear
incl
usio
n an
d ex
clus
ion
crite
ria,
sta
ndar
dize
d as
sess
men
t, in
terv
entio
n m
anua
l, fid
elity
mea
sure
, and
cle
arly
des
crib
ed
stat
istic
al m
etho
ds. L
imita
tions
incl
ude
SPM
and
QN
ST-II
not
est
ablis
hed
to
mea
sure
cha
nges
ove
r tim
e; t
ools
wer
e no
t sp
ecifi
cally
des
igne
d fo
r us
e w
ith
child
ren
with
ASD
, and
no
follo
w-u
p m
easu
res
Chi
ldre
n w
ith A
SD; N
= 3
7 (3
2 m
ale,
5 fe
mal
e); a
ges
612
SI g
roup
(n
= 2
0); f
ine
mot
or
(FM
) gr
oup
(n
= 1
7)
Out
com
e m
easu
res:
SPM
, QN
ST-II
, GA
S, V
ABS
-2,
SRS
Scha
af e
tal
. (2
012)
To
inve
stig
ate
the
effe
cts
of
occu
patio
nal t
hera
py u
sing
a
sens
ory
inte
grat
ive
appr
oach
on
one
child
with
ASD
and
sen
sory
pr
oces
sing
diff
icul
ty
Typ
e 6;
cas
e re
port
; m
anua
lized
inte
rven
tion
, fid
elit
y m
easu
re; P
EDro
sco
re
= 3
/10;
CEB
M L
evel
VC
hild
with
ASD
and
AD
HD
, n
= 1
; age
= 6
5 m
onth
s
Inte
rven
tion:
Chi
ld r
ecei
ved
a m
anua
lized
SI/
occu
patio
nal t
hera
py t
reat
men
t. T
wo
OT
s pr
ovid
ed t
he in
terv
entio
n 3
times
per
wee
k fo
r 10
wee
ks. F
idel
ity w
as 9
5.5%
acc
urac
y us
ing
the
OT
/SI f
idel
ity m
easu
re (
Parh
am e
tal
., 20
11)
The
chi
ld im
prov
ed o
n fiv
e ta
ctile
di
scri
min
atio
n ta
sks
and
five
prax
is
test
s of
the
SIP
T. H
e im
prov
ed
on t
he P
DD
BI in
Ritu
alis
ms
and
Res
ista
nce
to C
hang
e, a
nd S
peci
fic
Fear
s. O
n th
e G
AS,
his
T s
core
was
68
, ind
icat
ing
bett
er-t
han-
expe
cted
ac
hiev
emen
ts
Thi
s ca
se s
tudy
pro
vide
d de
scri
ptio
n of
cha
nges
in o
ne c
hild
follo
win
g SI
/O
T fo
r 10
wee
ks. T
he c
hild
mad
e im
prov
emen
ts in
sen
sory
mot
or
perf
orm
ance
and
ada
ptiv
e be
havi
ors.
Fi
ndin
gs fr
om a
cas
e st
udy
are
not
gene
raliz
able
Out
com
e m
easu
res:
goal
att
ainm
ent
scal
es u
sing
in
divi
dual
ized
goa
ls; S
IPT
; PD
DBI
; VA
BS
Scha
af e
tal
. (2
013)
To
eval
uate
the
effe
cts
of S
I in
terv
entio
n on
chi
ldre
n w
ith
ASD
in c
ompa
riso
n to
usu
al
care
Typ
e 3;
RC
T (
rand
om
assi
gnm
ent,
not
blin
ded)
; m
anua
lized
inte
rven
tion,
fide
lity
mea
sure
; PED
ro s
core
= 6
/10;
C
EBM
Lev
el I
Inte
rven
tion:
Chi
ldre
n in
the
inte
rven
tion
grou
p re
ceiv
ed a
man
ualiz
ed S
I/occ
upat
iona
l the
rapy
tr
eatm
ent.
Thr
ee li
cens
ed O
T p
rovi
ded
the
inte
rven
tion
and
met
fide
lity
crite
ria.
The
in
terv
entio
n w
as p
rovi
ded
3 tim
es w
eek
for
10
wee
ks. T
he u
sual
car
e gr
oup
rece
ived
tra
ditio
nal
OT
ser
vice
s in
com
mun
ity s
ettin
g
The
SI/O
T g
roup
impr
oved
si
gnifi
cant
ly m
ore
than
UC
on
Goa
l Att
ainm
ent
Scal
ing
(p =
.003
); ca
regi
ver
assi
stan
ce fo
r Se
lf C
are
and
Soci
al F
unct
ion
(PED
I; p
= .0
08,
p =
.039
). T
he g
roup
s di
d no
t di
ffer
in a
dapt
ive
beha
vior
s as
mea
sure
d by
the
VA
BS. D
iffer
ence
s on
the
PD
DBI
app
roac
hed
sign
ifica
nce
Low
to
mod
erat
e po
sitiv
e ef
fect
s fo
r th
e gr
oup
that
rec
eive
d SI
/OT
acr
oss
two
of fo
ur m
easu
res.
Lim
itatio
ns
incl
ude
lack
of b
lindi
ng (
alth
ough
a
blin
ded
ther
apis
t ad
min
iste
red
the
pare
nt-r
epor
t m
easu
res
(GA
S)),
smal
l sa
mpl
e si
ze, a
nd li
mite
d de
scri
ptio
n of
th
e us
ual c
are
grou
p. F
ollo
w-u
p da
ta
wer
e no
t re
port
ed
Chi
ldre
n w
ith A
SD; (
26 m
ales
, 6
fem
ales
); N
= 3
2; a
ges
568
3SI
gro
up (
n =
17)
usu
al c
are
grou
p (n
= 1
5)O
utco
me
mea
sure
s: go
al a
ttai
nmen
t sc
ales
usi
ng
indi
vidu
aliz
ed g
oals
, PED
I, PD
DBI
, VA
BSSm
ith e
tal
. (2
005)
To
com
pare
the
effe
cts
of S
IT
and
a co
ntro
l int
erve
ntio
n on
se
lf-st
imul
atin
g an
d se
lf-in
juri
ous
beha
vior
s (S
SB a
nd S
BI)
in y
outh
w
ith s
ever
e/pr
ofou
nd P
DD
an
d M
R
Typ
e 3:
tw
o-gr
oup,
no
nran
dom
ized
con
trol
tri
al
(not
blin
ded)
; PED
ro s
core
=
5/1
0; C
EBM
Lev
el II
PD
D
and/
or s
ever
e or
pro
foun
d in
telle
ctua
l dis
abili
ty w
ith s
elf-
stim
ulat
ion
and
self-
inju
riou
s be
havi
ors;
N =
7 (
4 m
ale,
3
fem
ale)
; age
s 8
19
Inte
rven
tion:
eng
age
in S
IT, i
nclu
ding
a v
arie
ty
of t
actil
e, p
ropr
ioce
ptiv
e, a
nd v
estib
ular
inpu
t. (W
eeks
2 a
nd 4
onl
y; 3
0 m
in, 5
tim
es p
er w
eek)
. V
ideo
tak
en fo
r 15
min
pri
or t
o tr
eatm
ent,
for
15 m
in a
fter
trea
tmen
t, an
d fo
r 15
min
1 h
afte
r tr
eatm
ent
Perc
enta
ge o
f SSB
and
SBI
pr
etre
atm
ent,
post
trea
tmen
t, an
d 60
min
aft
er t
reat
men
t w
ere
com
pare
d be
twee
n th
e SI
T g
roup
an
d co
ntro
l gro
up. S
elf-s
timul
atin
g an
d se
lf-in
juri
ous
beha
vior
s re
mai
ned
stab
le fo
r al
l par
ticip
ants
pr
e- o
r po
sttr
eatm
ent;
1 h
post
SIT
, fr
eque
ncy
in S
SB d
ecre
ased
(11
%);
1 h
afte
r th
e co
ntro
l int
erve
ntio
n,
SSB
incr
ease
d (2
%)
Low
effe
cts.
Des
ign
incl
udes
con
trol
co
nditi
on, c
lear
ly d
escr
ibed
sta
tistic
al
met
hods
. Lim
itatio
ns in
clud
e sm
all
sam
ple
size
, sin
gle
clin
ical
site
, no
blin
ding
, and
lack
of p
sych
omet
rics
for
SI In
vent
ory
Rev
ised
For
Indi
vidu
als
with
Dev
elop
men
tal D
isab
ilitie
sCo
ntro
l con
ditio
n: t
able
top
activ
ities
rel
ated
to
clie
nts
educ
atio
nal p
rogr
am (s
ortin
g, c
olor
ing,
an
d w
ritin
g). I
ndiv
idua
l ses
sions
ove
r 4
wee
ks
(wee
ks 1
and
3 o
nly;
30
min
; 5 t
imes
per
wee
k).
Vid
eo t
aken
for
15 m
in p
rior
to
trea
tmen
t, fo
r 15
min
afte
r tr
eatm
ent,
and
for
15 m
in 1
h a
fter
trea
tmen
tO
utco
me
mea
sure
s: th
e SI
Inve
ntor
y R
evis
edF
or
Indi
vidu
als
With
Dev
elop
men
tal D
isab
ilitie
s;
vide
o ta
pes:
15
min
long
pri
or t
o in
terv
entio
n,
15 m
in lo
ng a
fter
inte
rven
tion,
and
15
min
1 h
po
st in
terv
entio
n, r
atin
g se
lf-st
imul
atio
n or
sel
f-in
juri
ous
beha
vior
s at
15-
s in
terv
als
(Con
tinue
d)
at University of Ulster Library on February 2, 2015aut.sagepub.comDownloaded from
http://aut.sagepub.com/
-
8 Autism
Stud
yO
bjec
tives
Rat
ing/
desi
gn/p
artic
ipan
tsIn
terv
entio
n an
d ou
tcom
e m
easu
res
Res
ults
Inte
rpre
tatio
n
Wat
ling
and
Die
tz (
2007
)T
o ex
amin
e w
heth
er
part
icip
atio
n in
Ayr
es
SIT
imm
edia
tely
bef
ore
tabl
etop
tas
ks a
ffect
s th
e ch
ilds
eng
agem
ent
in o
r th
e oc
curr
ence
of u
ndes
ired
be
havi
ors
duri
ng t
able
top
activ
ities
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t de
sign
; PED
ro s
core
=
3/10
; CEB
M L
evel
IVC
hild
ren
with
ASD
; N =
4
(mal
es);
ages
34
Inte
rven
tion:
thr
ee p
hase
sfa
mili
ariz
atio
n,
base
line,
and
tre
atm
ent.
Each
pha
se w
as t
hree
40
-min
ses
sion
s pe
r w
eek.
Eac
h se
ssio
n w
as
follo
wed
by
a 10
-min
tab
leto
p ac
tivity
(da
ta
colle
ctio
n pe
riod
). SI
T s
essi
ons
wer
e ba
sed
on t
he s
enso
ry p
rofil
e re
sults
of e
ach
child
, SI
theo
ry, o
bser
vatio
ns o
f beh
avio
rs, a
nd o
ngoi
ng
clin
ical
rea
soni
ng
Mea
sure
s of
tas
k en
gage
men
t or
un
desi
red
beha
vior
s th
at in
terf
ered
w
ith e
ngag
emen
t di
d no
t im
prov
e.
The
aut
hors
rep
orte
d a
ceili
ng
effe
ct a
cros
s th
e m
easu
res.
No
effe
cts.
Des
ign
incl
udes
tw
o ba
selin
e ph
ases
, cle
ar in
clus
ion/
excl
usio
n cr
iteri
a, s
tand
ard
inte
rven
tion
prot
ocol
, and
a fi
delit
y m
easu
re.
Lim
itatio
ns in
clud
e sm
all s
ampl
e si
ze,
com
plic
atio
ns in
rat
ing
enga
gem
ent,
shor
t du
ratio
n of
A2
phas
es, a
nd n
o bl
indi
ng in
obs
erva
tions
rec
orde
d by
ca
regi
vers
and
stu
dy p
erso
nnel
Out
com
e m
easu
res:
beha
vior
s in
terf
erin
g w
ith
task
eng
agem
ent
and
enga
gem
ent
in p
lay
or
purp
osef
ul a
ctiv
ities
wer
e m
easu
red
thro
ugh
dire
ct o
bser
vatio
nSB
IBa
gate
ll et
al.
(201
0)T
o ex
amin
e th
e ef
fect
of
ther
apy
ball
chai
rs o
n in
-sea
t be
havi
or a
nd e
ngag
emen
t
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t D
esig
n; P
EDro
sco
re =
3/
10; C
EBM
Lev
el IV
Chi
ldre
n in
kin
derg
arte
n to
firs
t gr
ade
with
mod
erat
e to
sev
ere
ASD
; N =
6 (
mal
es);
no a
ge
repo
rted
Inte
rven
tion:
for
4 w
eeks
, chi
ldre
n sa
t on
in
divi
dual
ly s
ized
, inf
late
d th
erap
y ba
ll ch
airs
du
ring
cla
ss c
ircl
e tim
e (fe
et fl
at o
n gr
ound
with
hi
ps a
nd k
nees
at
a 90
an
gle)
No
cons
iste
ncy
of r
esul
ts fo
r in
-sea
t be
havi
or a
nd e
ngag
emen
t. Fo
r th
ree
stud
ents
, no
chan
ges
from
bas
elin
e no
ted;
one
stu
dent
ha
d gr
eate
r in
-sea
t be
havi
or, w
hile
an
othe
r ha
d le
ss (
out-
of-s
eat
beha
vior
not
rec
orde
d fo
r on
e st
uden
t). I
ndiv
idua
l ana
lyse
s su
gges
t th
at a
the
rapy
bal
l cha
ir m
ay b
e m
ore
appr
opri
ate
for
child
ren
who
se
ek v
estib
ular
pro
prio
cept
ive
inpu
t th
an fo
r ot
her
patt
erns
of
sens
ory
proc
essi
ng
No
posi
tive
effe
ct. L
imita
tions
incl
ude
smal
l sam
ple
size
, lac
k of
con
sist
ency
of
cont
ext
and
activ
ity in
whi
ch b
alls
wer
e us
ed, s
hort
stu
dy d
urat
ion,
eva
luat
ion
not
blin
ded,
and
no
fidel
ity m
easu
reO
utco
me
mea
sure
s: to
tal d
urat
ion
of t
ime
out
of
seat
and
/or
not
atte
ndin
g to
tea
cher
or
task
Cox
et
al.
(200
9)T
o ev
alua
te t
he im
pact
of
wei
ghte
d ve
sts
on t
he a
mou
nt
of t
ime
enga
ged
in a
ppro
pria
te
in-s
eat
beha
vior
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
4/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
no
vest
(A
); ve
st, n
o w
eigh
t (B
); w
eigh
ted
vest
(BC
)W
eigh
ted
vest
s, n
on-w
eigh
ted
vest
s, a
nd n
o ve
st a
ll ha
ve a
sim
ilar
effe
ct o
n ap
prop
riat
e in
-sea
t be
havi
or
No
effe
cts.
Lim
itatio
ns in
clud
e sm
all
sam
ple
size
, eva
luat
ion
not
blin
ded,
an
d no
inte
rven
tion
man
ual.
In-s
eat
beha
vior
is h
ighl
y in
fluen
ced
by
clas
sroo
m a
ctiv
ities
Chi
ldre
n w
ith A
SD; N
= 3
(2
mal
e, 1
fem
ale)
; age
s 5
9O
utco
me
mea
sure
s: ob
serv
ed d
urat
ion
of
appr
opri
ate
in-s
eat
beha
vior
Dav
is e
tal
. (2
011)
To
anal
yze
the
effe
cts
of
a br
ushi
ng p
roto
col o
n st
ereo
type
d be
havi
or o
f a b
oy
with
ASD
Typ
e 3:
sin
gle-
subj
ect;
PED
ro
scor
e =
2/1
0; C
EBM
Lev
el IV
Inte
rven
tion:
bru
shin
g w
as u
sed
follo
win
g ba
selin
e,
5 w
eeks
of b
rush
ing,
and
6-m
onth
follo
w-u
pSt
ereo
typy
rem
aine
d un
chan
ged
acro
ss a
sses
smen
t co
nditi
ons
whe
n br
ushi
ng t
echn
ique
s w
ere
used
No
effe
cts.
Fin
ding
s fo
r on
e ch
ild w
ere
repo
rted
. Lim
itatio
ns in
clud
e us
e of
an
ABA
des
ign
in w
hich
the
inte
rven
tion
was
onl
y ap
plie
d on
ce a
nd la
ck o
f bl
indi
ng
Chi
ld w
ith A
SD; N
= 1
(m
ale)
; ag
e 4
Out
com
e m
easu
res:
ster
eoty
pic
beha
vior
dur
ing
five
asse
ssm
ent
cond
ition
sat
tent
ion,
dem
and,
ta
ngib
le, p
lay,
and
alo
neD
evlin
et
al.
(200
9)T
o in
vest
igat
e th
e co
mpa
rativ
e ef
fect
s of
SIT
and
beh
avio
ral
inte
rven
tions
on
rate
s of
sel
f-in
juri
ous
beha
vior
Typ
e 3:
sin
gle-
subj
ect;
PED
ro
scor
e =
3/1
0; C
EBM
Lev
el IV
Chi
ld w
ith A
SD; N
= 1
(m
ale)
; ag
e 10
Inte
rven
tion:
SBI
sw
ingi
ng, d
eep
pres
sure
s w
ith
bean
bag,
roc
king
, jum
ping
, cra
wlin
g, c
hew
tub
e,
brus
hing
, and
join
t co
mpr
essi
on; b
ehav
iora
l in
terv
entio
nfu
nctio
nal a
naly
sis,
req
uest
s, a
nd
rein
forc
emen
t
Chi
ld e
xhib
ited
few
er s
elf-i
njur
ious
be
havi
ors
duri
ng t
he b
ehav
iora
l in
terv
entio
n th
an d
urin
g th
e SB
I
Effe
cts
of b
ehav
iora
l int
erve
ntio
n w
ere
grea
ter
than
SBI
effe
cts.
Fun
ctio
nal
anal
ysis
and
tai
lori
ng o
f int
erve
ntio
n fo
r th
e be
havi
oral
app
roac
h on
ly.
Lim
itatio
ns in
clud
e sh
ort-
term
in
terv
entio
n (1
6 da
ys),
no b
lindi
ngO
utco
me
mea
sure
s: O
ccur
renc
e of
sel
f-inj
urio
us
beha
vior
s as
mea
sure
d in
10-
s in
terv
als
Dev
lin e
tal
. (2
011)
To
com
pare
the
effe
cts
of S
IT
and
a be
havi
oral
inte
rven
tion
on
rate
s of
cha
lleng
ing
beha
vior
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
4/1
0;
CEB
M L
evel
IVC
hild
ren
with
ASD
; N =
4
(mal
e); a
ges
611
Inte
rven
tion:
SBI
sw
ingi
ng, j
umpi
ng, t
hera
py
balls
, wra
ppin
g in
bla
nket
, joi
nt c
ompr
essi
ons,
de
ep p
ress
ure
with
bea
nbag
, che
w t
ube,
and
br
ushi
ng; b
ehav
iora
l int
erve
ntio
nop
erat
e co
nditi
on b
ased
on
func
tiona
l beh
avio
ral a
naly
sis
Cha
lleng
ing
beha
vior
s w
ere
grea
ter
duri
ng t
he S
BI t
han
duri
ng t
he
beha
vior
al in
terv
entio
n (c
ompa
ring
a
5-da
y ba
selin
e to
10
days
of
inte
rven
tion)
. Cor
tisol
leve
ls w
ere
slig
htly
hig
her
in t
he S
BI c
ondi
tion;
ho
wev
er, t
hese
res
ults
wer
e no
t si
gnifi
cant
Beha
vior
al in
terv
entio
n w
as m
ore
effe
ctiv
e in
red
ucin
g ch
alle
ngin
g be
havi
ors
than
SBI
. Lim
itatio
ns in
clud
e a
shor
t pe
riod
of i
nter
vent
ion
(10
days
), sm
all s
ampl
e (fo
ur p
artic
ipan
ts),
lack
of b
lindi
ng, a
nd d
espe
rate
ap
plic
atio
n of
inte
rven
tion
(beh
avio
ral
inte
rven
tion
used
func
tiona
l ana
lysi
s,
SBI d
id n
ot)
Out
com
e m
easu
res:
Freq
uenc
y of
cha
lleng
ing
beha
vior
; str
ess
leve
ls a
s m
easu
red
by c
ortis
ol
Tab
le 2
. (C
ontin
ued)
at University of Ulster Library on February 2, 2015aut.sagepub.comDownloaded from
http://aut.sagepub.com/
-
Case-Smith et al. 9
Stud
yO
bjec
tives
Rat
ing/
desi
gn/p
artic
ipan
tsIn
terv
entio
n an
d ou
tcom
e m
easu
res
Res
ults
Inte
rpre
tatio
n
Fazl
iogl
u an
d Ba
ran
(200
8)T
o de
velo
p an
d te
st a
pro
gram
of
SIT
for
use
in a
sses
smen
t an
d tr
eatm
ent
of a
utis
tic c
hild
ren
Typ
e 3:
RC
T (
rand
om
assi
gnm
ent,
not
blin
ded)
; PED
ro
scor
e =
6/1
0; C
EBM
Lev
el II
Inte
rven
tion:
bas
ed o
n T
he S
enso
ry D
iet.
In
clud
es a
sch
edul
e of
bru
shin
g an
d jo
int
com
pres
sion
follo
wed
by
a se
t of
indi
vidu
aliz
ed
sens
ory
activ
ities
tha
t w
as in
tegr
ated
into
th
e ch
ilds
dai
ly r
outin
e. B
ehav
iora
l str
ateg
ies
(pro
mpt
ing,
rei
nfor
cem
ent,
and
extin
ctio
n) w
ere
also
use
d to
tea
ch t
arge
ted
mot
or b
ehav
iors
id
entif
ied
by T
he S
enso
ry E
valu
atio
n Fo
rm fo
r C
hild
ren
with
Aut
ism
Stat
istic
ally
sig
nific
ant
inte
ract
ion
effe
cts
on s
enso
ry b
ehav
iors
for
grou
p
tim
e (F
= 1
19.3
8, p
< .0
1)
Stro
ng e
ffect
s. R
esul
ts a
re d
iffic
ult
to
gene
raliz
e. D
esig
n in
clud
es r
ando
m
assi
gnm
ent,
adeq
uate
sta
tistic
al p
ower
. Li
mita
tions
incl
ude
limite
d de
scri
ptio
n of
the
sen
sory
inte
rven
tion,
lack
of
a fid
elity
mea
sure
, use
of a
non
-st
anda
rdiz
ed m
easu
re, n
o bl
indi
ng, a
nd
no fo
llow
-up
Chi
ldre
n w
ith A
SD; N
= 3
0 (2
4 m
ale,
6 fe
mal
e); a
ges
711
Inte
rven
tion
grou
p (n
= 1
5);
cont
rol g
roup
(n
= 1
5)
Out
com
e m
easu
res:
the
Sens
ory
Eval
uatio
n Fo
rm
For
Chi
ldre
n W
ith A
utis
m (
a ch
eckl
ist
crea
ted
by t
he r
esea
rche
rs)
was
use
d to
det
erm
ine
sens
ory
proc
essi
ng p
robl
ems
Fert
el-D
aly
eta
l. (2
001)
To
exam
ine
the
effe
cts
of
wea
ring
a w
eigh
ted
vest
on
atte
ntio
n to
tas
k an
d se
lf-st
imul
ator
y be
havi
ors
of fi
ve
pres
choo
l chi
ldre
n w
ith A
SD
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
3/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
wea
ring
a w
eigh
ted
vest
All
part
icip
ants
sho
wed
dec
reas
ed
num
ber
of d
istr
actio
ns a
nd t
ime
on
task
whi
le w
eari
ng t
he v
est.
Four
ou
t of
five
par
ticip
ants
sho
wed
de
crea
sed
self-
stim
ulat
ion
and,
for
two
child
ren,
rem
aine
d de
crea
sed
whe
n in
terv
entio
n w
as r
emov
ed.
Self-
stim
ulat
ion
incr
ease
d du
ring
in
terv
entio
n fo
r on
e pa
rtic
ipan
t
Mod
erat
e ef
fect
s. D
esig
n in
clud
es
cont
rol c
ondi
tion;
cle
arly
des
crib
ed
stat
istic
al m
etho
ds. L
imita
tions
incl
ude
smal
l sam
ple
size
, use
of v
est
in o
ne
sett
ing,
and
eva
luat
ion
not
blin
ded
Out
com
e m
easu
res:
time
on
task
, num
ber
of d
istr
actio
ns,
and
self-
stim
ulat
ory
beha
vior
s w
ere
mea
sure
d th
roug
h di
rect
ob
serv
atio
n
Chi
ldre
n w
ith A
SD; N
= 5
(3
mal
e, 2
fem
ale)
; ag
es 2
3
Hod
gett
s et
al.
(2
011)
To
inve
stig
ate
the
effe
cts
of
wei
ghte
d ve
sts
on s
tere
otyp
ed
beha
vior
s in
chi
ldre
n w
ith
ASD
and
to
test
the
effe
cts
of
wei
ghte
d ve
sts
on h
eart
rat
e
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
5/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
(a)
wea
ring
a w
eigh
tless
ves
t w
ith
Styr
ofoa
m b
alls
in p
lace
of w
eigh
ts, (
b) v
ests
w
eigh
ed a
t 5%
10
% o
f chi
lds
bod
y w
eigh
t
Am
ong
all p
artic
ipan
ts, m
otor
ic
ster
eoty
ped
beha
vior
s or
hea
rt
rate
did
not
dec
reas
e. H
eart
rat
e in
crea
sed
for
one
part
icip
ant.
One
ch
ild d
emon
stra
ted
decr
ease
d ve
rbal
ste
reot
ypy
No
effe
cts.
Stu
dy s
ugge
sts
that
whe
n us
ing
wei
ghte
d ve
sts,
the
follo
win
g m
ust
be c
ompl
eted
: a fu
nctio
nal
anal
ysis
of t
arge
t be
havi
or a
nd
desi
red
outc
omes
def
ined
a p
rior
i an
d m
onito
red
syst
emat
ical
ly. D
esig
n in
clud
es b
lindi
ng o
f rat
ers/
child
ren
to t
reat
men
t co
nditi
on. L
imita
tions
in
clud
e no
func
tiona
l ana
lysi
s of
be
havi
ors
and
smal
l sam
ple
size
Chi
ldre
n w
ith s
ever
e A
SD; N
=
6 (5
mal
e, 1
fem
ale)
; age
s 4
10O
utco
me
mea
sure
s: vi
deot
aped
ses
sion
s w
ere
code
d fo
r st
ereo
typy
and
hea
rt r
ate
mon
itor
was
use
d fo
r m
easu
ring
hea
rt r
ate
Hod
gett
s et
al.
(201
0)T
o ex
amin
e w
heth
er t
ouch
-pr
essu
re s
enso
ry in
put
thro
ugh
a w
eigh
ted
vest
dec
reas
es
off-t
ask
beha
vior
and
incr
ease
s si
ttin
g tim
e; t
o ev
alua
te w
heth
er
teac
hers
and
edu
catio
nal
assi
stan
ts v
iew
wei
ghte
d ve
sts
as a
too
l to
enab
le c
hild
ren
with
ASD
to
func
tion
mor
e pr
oduc
tivel
y
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
5/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
(a)
wea
ring
a w
eigh
tless
ves
t w
ith
Styr
ofoa
m b
alls
in p
lace
of w
eigh
ts, (
b) v
ests
w
eigh
ed a
t 5%
10
% o
f chi
lds
bod
y w
eigh
t
No
effe
ct o
n tim
e in
-sea
t fo
r th
ree
part
icip
ants
. Ves
ts w
ere
effe
ctiv
e in
dec
reas
ing
off-t
ask
beha
vior
for
thre
e pa
rtic
ipan
ts a
nd in
effe
ctiv
e fo
r fiv
e pa
rtic
ipan
ts. C
GI-T
sco
res
did
not
corr
espo
nd w
ell w
ith v
ideo
ob
serv
atio
ns
Low
effe
cts.
Wei
ghte
d ve
sts
may
be
a su
itabl
e co
mpo
nent
of i
nter
vent
ion
for
som
e ch
ildre
n, b
ut s
houl
d no
t be
the
sol
e ap
proa
ch t
o im
prov
ing
adap
tive
beha
vior
. Des
ign
incl
udes
co
ntro
l con
ditio
n an
d ra
ter
blin
ding
. Li
mita
tions
incl
ude
smal
l sam
ple
size
, inv
estig
ated
onl
y se
lect
tar
get
beha
vior
s, h
omog
enou
s sa
mpl
e, p
hase
le
ngth
pre
dete
rmin
ed, a
nd n
o fo
llow
-up
Chi
ldre
n w
ith m
oder
ate
to
seve
re A
SD; N
= 1
0 (8
mal
e, 2
fe
mal
e); a
ges
310
Out
com
e m
easu
res:
dire
ct o
bser
vatio
n w
as
used
to
mea
sure
off-
task
beh
avio
r an
d tim
e in
-sea
t. T
he 1
0-ite
m C
GI-T
was
use
d to
rat
e re
stle
ssne
ss, i
mpu
lsiv
ity, a
nd e
mot
iona
l lab
ility
Kan
e et
al.
(200
4)T
o ev
alua
te t
he e
ffect
s of
w
eari
ng a
wei
ghte
d ve
st o
n st
ereo
typy
and
att
entio
n to
tas
k
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
2/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
wea
ring
a w
eigh
ted
vest
, a n
on-
wei
ghte
d ve
st, o
r no
ves
tO
ccur
renc
e of
ste
reot
ypy
and
atte
ntio
n to
tas
k di
d no
t va
ry a
s a
func
tion
of w
eari
ng a
ves
t
No
effe
cts.
Lim
itatio
ns in
clud
e a
shor
t in
terv
entio
n tim
elin
e (t
hree
ses
sion
s),
smal
l sam
ple
(four
par
ticip
ants
), an
d la
ck o
f blin
ded
asse
ssm
ent
Chi
ldre
n w
ith A
SD; N
= 4
(2
mal
e, 2
fem
ale)
; age
s 8
11O
utco
me
mea
sure
: occ
urre
nce
of s
tere
otyp
y an
d at
tent
ion
to t
ask
duri
ng t
en 1
-min
inte
rval
s
(Con
tinue
d)
Tab
le 2
. (C
ontin
ued)
at University of Ulster Library on February 2, 2015aut.sagepub.comDownloaded from
http://aut.sagepub.com/
-
10 Autism
Stud
yO
bjec
tives
Rat
ing/
desi
gn/p
artic
ipan
tsIn
terv
entio
n an
d ou
tcom
e m
easu
res
Res
ults
Inte
rpre
tatio
n
Leew
et
al.
(201
0)T
o ex
amin
e w
heth
er t
he u
se
of w
eigh
ted
vest
s fa
cilit
ated
an
incr
ease
in jo
int
atte
ntio
n in
to
ddle
rs
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
4/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
wea
ring
a w
eigh
ted
vest
Wei
ghte
d ve
sts
did
not
decr
ease
pr
oble
m c
ompe
ting
beha
vior
s or
in
crea
se jo
int
atte
ntio
n in
tod
dler
s w
ith A
SD. C
hang
es in
PM
I wer
e no
t si
gnifi
cant
for
thre
e ou
t of
four
m
othe
rs
No
effe
cts.
Lim
itatio
ns in
clud
e sm
all
sam
ple
size
, ves
ts u
sed
in t
he s
tudy
m
ay n
ot p
rovi
de a
mou
nt o
f dee
p pr
essu
re n
eede
d fo
r op
timal
effe
ct o
n ne
rvou
s sy
stem
, and
lack
of f
idel
ity a
nd
follo
w-u
p m
easu
res
Out
com
e m
easu
res:
the
PMI
mea
sure
d pa
rent
ing
mor
ale.
D
irec
t ob
serv
atio
n w
as u
sed
to m
easu
re jo
int
atte
ntio
n an
d be
havi
ors
that
com
pete
with
jo
int
atte
ntio
n
Chi
ldre
n w
ith a
utis
m; N
= 4
(m
ale)
; age
s 27
33
mon
ths
Rei
chow
et
al.
(201
0)T
o ex
amin
e th
e us
e of
a
wei
ghte
d ve
st o
n en
gage
men
t of
yo
ung
child
ren
with
aut
ism
or
deve
lopm
enta
l del
ay
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
4/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
thr
ee c
ondi
tions
wer
e co
mpa
red:
w
eari
ng a
wei
ghte
d ve
st, a
ves
t w
ith n
o w
eigh
t, an
d no
ves
t
The
re w
ere
no s
yste
mat
ic
diffe
renc
es in
eng
agem
ent,
ster
eoty
pic
beha
vior
, or
prob
lem
be
havi
or fo
r on
e pa
rtic
ipan
t be
twee
n co
nditi
ons.
In t
he o
ther
ch
ild, p
robl
em b
ehav
ior
incr
ease
d an
d st
ereo
typi
c be
havi
or d
ecre
ased
w
hen
the
vest
was
wor
n. T
he v
ests
w
ere
not
effe
ctiv
e fo
r in
crea
sing
en
gage
men
t fo
r th
e pa
rtic
ipat
ion
duri
ng t
able
act
iviti
es
Mix
ed e
ffect
s fo
r on
e ch
ild a
nd n
o ef
fect
s fo
r on
e ch
ild. O
ne c
hild
had
fe
w p
robl
em o
r st
ereo
typi
c be
havi
ors.
Li
mita
tions
incl
ude
smal
l sam
ple,
lack
of
pote
ntia
l var
ianc
e in
beh
avio
r, a
nd la
ck
of b
linde
d as
sess
men
t
Chi
ldre
n w
ith A
SD; N
= 2
(m
ale)
; age
5O
utco
me
mea
sure
s: be
havi
or w
hen
wea
ring
the
ve
st o
r th
e co
ntro
l con
ditio
ns: (
a) e
ngag
emen
t, (b
) no
neng
agem
ent,
(c)
ster
eoty
pic
beha
vior
, (d)
pr
oble
m b
ehav
ior,
and
(e)
una
ble
to s
ee c
hild
Schi
lling
and
Sc
hwar
tz
(200
4)
To
inve
stig
ate
the
effe
cts
of t
hera
py b
alls
as
seat
ing
on e
ngag
emen
t an
d in
-sea
t be
havi
or
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
3/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
with
draw
al d
esig
n us
ing
an
indi
vidu
ally
fitt
ed t
hera
py b
all f
or s
eatin
gR
esul
ts in
dica
te t
hat
all p
artic
ipan
ts
disp
laye
d m
arke
d im
prov
emen
t in
en
gage
men
t an
d in
-sea
t be
havi
or
duri
ng u
se o
f the
the
rapy
bal
ls
Hig
h ef
fect
s. D
esig
n in
clud
es c
ontr
ol
cond
ition
. Lim
itatio
ns in
clud
e sm
all
sam
ple
size
, ass
ignm
ent
to t
reat
men
t co
nditi
on, e
valu
atio
n no
t bl
inde
d, a
nd
lack
of f
idel
ity a
nd fo
llow
-up
mea
sure
sC
hild
ren
with
ASD
; N =
4
(mal
e); a
ges
34
Out
com
e m
easu
res:
mom
enta
ry r
eal-t
ime
sam
plin
g w
as u
sed
to m
easu
re s
ittin
g an
d en
gage
men
t be
havi
ors
Van
Rie
and
H
eflin
(20
09)
To
dete
rmin
e w
heth
er
ther
e is
a fu
nctio
nal
rela
tions
hip
betw
een
sens
ory
activ
ities
and
co
rrec
t re
spon
ding
Typ
e 3:
mul
tiple
bas
elin
e si
ngle
-su
bjec
t; PE
Dro
sco
re =
3/1
0;
CEB
M L
evel
IV
Inte
rven
tion:
sw
ingi
ng o
r bo
unci
ng o
n an
exe
rcis
e ba
ll fo
r 5
min
bef
ore
a ta
rget
ed a
ctiv
ityC
orre
ct r
espo
ndin
g to
aca
dem
ic
task
s w
as n
ot r
elat
ed t
o se
nsor
y st
imul
atio
n pr
ior
to t
he a
cade
mic
ta
sk
Mix
ed e
ffect
s. F
or o
ne p
artic
ipan
t bo
unci
ng o
n th
e ba
ll re
late
d hi
gher
co
rrec
t re
spon
ding
; for
tw
o pa
rtic
ipan
ts, s
win
g w
as a
ssoc
iate
d w
ith h
ighe
r co
rrec
t re
spon
ding
; for
on
e pa
rtic
ipan
t, th
e SB
I had
no
effe
cts.
Li
mita
tions
incl
ude
smal
l sam
ple,
sh
ort
time
fram
e, la
ck o
f blin
ding
, and
de
sper
ate
mea
sure
s ac
ross
par
ticip
ants
Chi
ldre
n w
ith A
SD; N
= 4
(m
ale)
; age
s 6
7O
utco
me
mea
sure
: cor
rect
res
pond
ing
to
acad
emic
tas
ks
SI: s
enso
ry in
tegr
atio
n; A
SD: a
utis
m s
pect
rum
dis
orde
rs; R
CT
: ran
dom
ized
con
trol
led
tria
l; C
EBM
Lev
el: l
evel
of r
igor
bas
ed o
n gu
idel
ines
from
the
Cen
ter
for
Evid
ence
-Bas
ed M
edic
ine
(201
1); G
AS:
Goa
l Att
ainm
ent
Scal
ing;
SR
S: S
ocia
l Res
pons
iven
ess
Scal
e; Q
NST
-II: Q
uick
Neu
rolo
gica
l Scr
eeni
ng T
est;
VA
BS: V
inel
and
Ada
ptiv
e Be
havi
oral
Sca
les;
SPM
: Sen
sory
Pro
cess
ing
Mea
sure
; OT
: occ
upat
iona
l the
rapi
st; S
IPT
: SI a
nd P
raxi
s T
ests
; PD
DBI
: Per
vasi
ve D
evel
opm
enta
l Dis
orde
r Be
havi
oral
Inve
ntor
y; A
DH
D: a
tten
tion
defic
it hy
pera
ctiv
ity d
isor
der;
UC
: usu
al c
are;
PED
I: Pe
diat
ric
Eval
uatio
n of
Dis
abili
ty In
vent
ory;
SSB
: sel
f-stim
ulat
ory
beha
vior
; M
R: m
enta
l ret
arda
tion;