School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE WORKSHEET

Name: Orah Kabaei & Sara Silverberg

Date: October 8, 2015

Focus Question: Does a sensory integration approach help regulate maladaptive behaviors in children with sensory processing disorders?
Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Articles used to meet the P, I, and O of the focus question included published peer-reviewed articles within the last 15 years and were written in English.
Participants needed to present with sensory processing disorders and participate in sensory interventions administered by an occupational therapist. Outcome
based research for Levels I, II, III, and IV were included. Seminal articles published before 2000 were also included in the review. Articles were excluded if they
were published before1999, were not available in full text, and treatment was administered to participants older than 19 years old.

Author/
Year
Case-Smith
& Bryan
(1999).

Study Objectives

Level/Design/ Subjects

The purpose of the

study was to
determine the
effects of sensory
integration (SI)
intervention with
five preschool
children with
autism.

Level IV
Single Case Design
A multi-baseline singlesubject design was
developed to examine
the effectiveness of
occupational therapy
(OT) utilizing SI. The
children all attended a
one of two half-day

Intervention and
Outcome Measures
Intervention:
Participants engaged in a
three week baseline
phase in which they were
videotaped for 10
minutes in their
classroom during free
play. Interventions began
on the fourth week and
continued for 10 weeks.
The intervention phase
entailed each child

Results

Study Limitations

Implications for OT

Mastery play mean

scores and slopes
during intervention
indicate significant
results for three out
of five participants.
Mastery play was
defined as
functional play and
involved playing
with cars, sand,
matching games, or

Generalization is
very difficult given
the sample size and
design.
Variability in
behaviors made
interpretation of
scores difficult.

Clinical and Community

based practice of OT:
Participation in SI
garnered gains in mastery
(goal-directed) play and
engagement. Frequency of
interactions (both peer and
adult) were minimal at
best.

The length of the

design was limited

Program development:
Implementing direct and

special needs preschool

programs in the
Midwest and received
individualized
educational
programming.
Recruitment:
Convenience Sample
N = 5 boys with Autism
Ages: 4 5 years 3
months
Drop out n = 1 (due to
co-treatment)

receiving direct and

consultative OT with an
emphasis on SI.
Treatment was
administered by the
second author certified in
Sensory Integration and
Praxis Testing (SIPT).
Sessions occurred in a
room adjacent to the
childrens classroom and
incorporated
interventions in line with
SI. Additionally, the
therapist provided
consultation to the
teachers and
recommended
sensorimotor activities
throughout the
intervention phase and
environmental
modifications that
offered specific
therapeutic input during
play.
Play behaviors were
videotaped for 10
minutes during the
intervention phase and
then transferred on to a
master tape in random
order to prevent bias
during scoring. Play

construction.
Four out of five
participants
demonstrated
significant decreases
in non-engaged
behaviors during
intervention.
Specific behaviors
were extinguished
or decreased for
each child during
intervention
(wandering, selfstim).
One of five
participants
demonstrated
improvement in
adult interaction.
All intervention
phase scores
demonstrated high
variability, making
interpretation
difficult.
None of the children
demonstrated
significant
improvement in
peer interaction

due to the
constraints of the
academic school
year.
No follow-up was
performed to
determine if
changes in
performance was
maintained.
Data was
incomplete for one
of the participants.
Utilizing a
convenience sample
introduces bias as
the relationship
between the
participants and
teachers was not
divulged.

consultative SI services
indicate enhanced
outcomes are possible for
mastery play and
engagement.
Societal Needs: Results of
the study suggest that
sensory integration helps
children with autism
develop mastery in play,
however, high variability
with peer and adult
interaction suggests that
further research needs to
be done to determine the
efficacy of SI.
Healthcare delivery and
health policy: Due to the
high variability of results,
interpretations are
difficult, thus they are not
strong enough to inform
policy makers about the
effectiveness of SI for
children with autism.
Education and training for
OT students: The clinical
reasoning and creativity
that are incorporated
within an entry level OT
education, would allow for
future practitioners to

behaviors were randomly

scored by the first author
to evaluate non-mastery
and mastery play, nonengagement, adult
interaction, and peer
interaction.

Devlin,
Healy,
Leader &
Hughes
(2011).

The objective of the

study was to
compare the effects
of sensory
integration and a
behavioral
intervention on rates
of challenging
behavior (including
self-injurious
behavior) in four
children diagnosed
with Autism
Spectrum Disorder
(ASD).

Level III
The study was
conducted in the format
of an alternating
treatments design, with
initial baseline and final
best treatment phase. SI
and Behavioral
Interventions were
alternated across daily
sessions, the sequence
of treatments
randomized for each of
the participants.
Recruitment
N=4

Outcomes:
Engagement scale
Mastery play
Nonengagement
Adult
interaction
Peer interaction
Intervention:
A sensory diet was
recommended for each of
the 4 participants based
on techniques that would
facilitate vestibular,
proprioceptive, and
tactile input along with
Wilbargers joint
compression and
brushing. Vestibular
input included swinging
on a net swing, jumping
on a trampoline, rocking
and rolling on a peanutshaped ball.
Proprioceptive input
involved wrapping the
participant in a lycra

from baseline to
intervention phases.
However, mild
improvements were
reported in two of
the five participants.

Results for each

participant varied
since interventions
were aimed at
treating different
deficits. Overall, the
findings of this
study demonstrate
the effectiveness of
behavioral
interventions over
sensory based
interventions.
Participant 1: On the
SI days, target
behaviors were
observed to occur at
a relatively high rate
(mean = 16

implement the SI approach

in practice.
Refinement, revision, and
advancement of factual
knowledge or theory: The
results are not strong
enough due to the small
sample size and the design
of the study, thus further
research should be
conducted with a
randomized control trial.

Representative of
sample:
Small
sample size

Possible sources of
bias:
-

The nature
of the design
used in the
current study,
where the
treatments were
randomly
alternated
across daily
sessions,

Clinical and communitybased practice of OT: The

findings of this study
demonstrate the
effectiveness of a
behavioral intervention
over a sensory based
intervention in treating
challenging behavior.
Program development:
Behavioral interventions
that are designed based on
a functional analysis or
assessment of the problem
behavior presented are
more successful in
reducing and eliminating
the target behavior in

Four boys, ages 6 to 10

years, were selected
from a school using
applied behavior
analysis as treatment
and demonstrated
history of aggressive
behavior and self-injury.

blanket and pressing a

large ball on the body to
deliver deep pressure
along with crawling
using elbows on a soft
mat. Tactile input
involved tapping areas of
the body with a light lean
bag. Oral-motor control
included chewing on a
chewy tube and massage
of the lips and cheeks.
Joint compression was
delivered by manually
compressing shoulders,
elbows, wrists and hips.
Outcomes:
- Daily Frequency
of Challenging
Behavior
- Behavioral
Function
Measure
- Stress Measure

occurrences per
day). In comparison,
on the behavioral
intervention days,
target behaviors
occurred at a much
lower rate (mean =
6 occurrences per
day).
Participant 2: Data
patterns for this
participant clearly
indicates a low rate
of challenging
behavior on the
behavioral
intervention days.
More specifically,
target behaviors
were observed to
occur at a much
higher rate on the SI
days (mean = 6.8)
than on behavioral
intervention days
(mean = 2.6).
Participant 3: Data
from the alternating
treatment phase
demonstrates
behavioral
intervention was
more effective for
the treatment of
challenging

presented
limitations to
the potential
therapeutic
value of the
sensory
integration
treatment.

comparison to SI therapy
where techniques are
applied without an analysis
of the behavior under
investigation.
Societal needs:
Implications of the study
limit results from being
generalized to a societal
level.
Healthcare delivery and
health policy: Despite the
lack of evidence for SIs
efficacy, it still remains a
popular treatment among
various consumers.
However, more research is
necessary
Education and training of
OT students: Upon
completion of the childbased semester, OT
students have a general
knowledge on behavioral
interventions, and can
apply this in entry level
practice.
Refinement, revision, and
advancement of factual
knowledge or theory:
Given the implications

Jorge, de
Witt &
Franzen
(2013).

The study
investigated the
effectiveness of a
two-week program
of parent education
and a sensory diet to
reduce signs of
fussiness in infants
identified with
Regulatory Sensory
Processing Disorder
(RSPD).

Level III
The study design was a
quantitative, descriptive
study using a pre and
post-intervention
checklist to determine
the effect of a program
of a sensory diet and
parent education on
infants who met the
diagnostic criteria for

Intervention:
The intervention
consisted of 2 parts,
namely parent education
and the provision of the
sensory diet. Parents
were educated about
RSPD and sensory
modulation. The two
week sensory diet home
program was prescribed
for each infant and

behavior than the SI

intervention. In fact,
there was no
difference in the rate
of SI behavior and
challenging
behavior between
the baseline phase
(mean = 8.4) and
the rate of target
behaviors observed
when SI was in
place.
Participant 4: A
mean occurrence of
4.2 was observed on
behavioral
intervention days,
whereas a mean
occurrence of 7.4
incidents was
observed on SI
days.
Results of the ITSC
total sample
analysis revealed a
significant decrease
in the mean ITSC
behavioral domains
of the test and total
scores for the entire
sample at the end of
the two-week
intervention period
(P<0.00). A large

found with this study, it is

imperative that more
comparative studies are
conducted within this area.

Representative of
sample:
Small
Sample Size.
Possible sources of
bias:
Test of
sensory
functions
should be
administered by

The clinical and

community-based practice
of OT: The results of this
study contribute to the
emerging understanding of
the potential benefits of a
sensory diet as an early
intervention to reduce
fussiness in infants.
Program development: A
sensory diet should be

RSPD.
Recruitment
N = 12
The study sample
consisted of 12 infants,
between the ages of 7 to
24 months. Participants
were included based on
meeting two of four
criteria: sleep
disturbances,
difficulties in selfconsoling, feeding
disorders, and hyperarousal by sensory
input. Of the 12
participants included in
the study, seven of the
participants were male
and five were female.
Six participants were
aged between 7 and 12
months and six were
between 13 and 24
months.

designed to address each

infant participants
specific sensory and
behavioral dysfunction
based on information
obtained from the ITSC.
Outcomes:
Infant Toddler Symptom
Checklist (ITSC)

effect size of 1.47,

according to
Cohens calculation
was found post
intervention which
indicates a 73.1%
improvement within
the group and places
the difference
between the pre and
post intervention
scores on the 93rd
percentile.

an occupational
therapist
instead of
parents.

applied early for babys

who meet the diagnostic
criteria for RSPD to
enhance outcomes.
Societal needs: Infants
presenting with high
attachment and poor selfregulation scores will
benefit from parent
education and a sensory
diet home program to
manage RSPD.
Healthcare delivery and
health policy: Results
should be considered
preliminary. Further
research is required on this
intervention in this
population because the
sample size is not large
enough to generalize
results.
Education and training of
OT students: OT students
are well educated on
formulating sensory diets
to promote the just right
challenge.
Refinement, revision and
advancement of factual
knowledge or theory: The

Linderman
& Stewart
(1999).

The purpose of the

study was to
explore the effects
of sensory
integrative-based
occupational
therapy provided in
an outpatient clinic
on the functional
behaviors of two
young children with
pervasive
developmental
disorder (PDD) at
home.

Level IV
The study used a singlesubject design which
included a baseline (A)
and a treatment (B)
phase.
Recruitment
N=2
Participant 1: 3 yr 9 mo
boy indicating
symptoms associated
with mild autism.
Participant 2: 3 yr 3 mo
boy diagnosed with
autism.
Potential participants
were pre-school age
children with PDD who
were referred to the
occupational therapy
department at a health
center in Tacoma,
Washington. The
children referred to this
study had participated

Intervention:
Therapy in the clinic was
child directed, with each
participant actively
making choices and then
engaging in enjoyable,
sensory-based activities.
Gradually, the participant
was encouraged to
participate in
nonthreatening activities
that involved movement
through space and
multimodality input.
Outcomes:
Direct
observation
Parent interview
Revised Functional
Behavior Assessment for
Children with Sensory
Integrative Dysfunction

Participant 1:
Demonstrated major
improvements in the
areas of social
interaction,
approach to new
activities (p < .002),
and response to
holding and hugging
during the treatment
phase.
Participant 2:
Displayed
significant, but
gradual, gains in the
measures of social
interaction and
response to
movement during
the treatment phase
in comparison to the
severity of
symptoms he
displayed at the
outset of the study.

Representative of
sample:
Small
sample size.
Possible sources of
bias:
Participant
s were
receiving other
forms of
interventions at
the time of the
study.

results of the study

demonstrate that
implementing a sensory
diet program can be an
effective strategy for
reducing RSPD.
Clinical and communitybased practice of OT:
Clinical importance of the
results support conclusions
made that the application
of SI based occupational
therapy may enhance the
behavioral responses of
children with autism.
Program development:
Carefully graded therapy
programs provided by an
experienced clinician
provides improvements in
functional behaviors, and
will result in enhanced
outcomes.
Societal needs: A program
of Sensory and integrativebased occupational
therapy, when used with
persons with PDD, may
lead to improved
functional behavior in the
natural context of the
home. Further research is
required to determine if

in a multidisciplinary
evaluation by the Health
Centers
Neurodevelopmental
Group. Children who
received or were
receiving a program of
consistently applied
sensory integrativebased occupational
therapy approaches or
who demonstrated,
during the initial
evaluation, an inability
to tolerate the therapy
technique or the
repeated measurement
design, were excluded
from participating in
this study.

Miller,
Coll, &
Schoen
(2007).

The purpose of this

study was to
evaluate the
effectiveness of

Level I
Randomized Control
Trial (RCT)

results are applicable to

other contexts.
Healthcare delivery and
health policy: Functional
outcomes of SI
interventions has important
implications for
reimbursement in health
care.
Education and training of
OT students: Entry level
practitioners have a
generalist knowledge of
Ayres SI theory. Further
certification and
experience in SI is
recommended to apply a
graded therapy program.

Intervention:
OT-SI was administered
twice a week for 10
weeks by OTs in an

The findings
suggest that OT-SI
may be effective in
treating sensory

The small sample

size is a limitation
to this study.

Refinement, revision, and

advancement of factual
knowledge or theory:
Future research is needed
to replicate and extend
findings on SIs
effectiveness since
generalizability of these
results is limited by the
single subject design.
The clinical and
community-based practice:
The study was useful in
developing a standard

three treatment
methods with
children who have
sensory modulation
disorders (SMD).
Treatments
evaluated included:
Sensory Integration,
activity protocol,
and no treatment.
The authors sought
to determine
whether OT-SI was
more effective in
treating attention,
cognitive/social,
sensory or
behavioral problems
than an activity
protocol or no
treatment.

Recruitment:
Participants were
recruited from a local
pediatric outpatient
facility. Of 50 identified
to meet the inclusion
and exclusion criteria,
30 families agreed to
participate.
N = 24
Using Fishers exact
test for categorical
variables and ANOVA
for age, no significant
group difference was
found on age, gender,
mothers education or
ethnicity. Inclusion and
exclusion criteria for
SMD identified a
homogenous sample.
Drop out: n = 6 (due to
moving, vacations,
illness or mothers
pregnancy)

outpatient therapy room

equipped with sensory
activities and toys. The
alternate group was led
by non-OT staff or
graduate students.
Participants engaged in a
variety of tabletop
activities (arts and crafts,
puzzles, blocks, reading
stories and interactive
games).
Baseline measurements
were conducted prior to
treatment. Post outcome
measures were assessed
after 10 weeks of
treatment.
Outcomes:
Leiter
International
Performance Scale
Revised: Parent
Rating Scale (LeiterR)
Short Sensory
Profile (SSP)
Vineland
Adaptive Behavior
Scales
Child Behavior
Checklist (CBCL)
Goal attainment
scale (GAS)

modulation deficits.
Differences among
the treatments were
evaluated with oneway ANOVA.
Those in the SI
group demonstrated
significant gains on
the GAS (p<0.001)
compared to the
other two groups.
Participants in the
OT-SI group
demonstrated gains
in Attention (p = .03
comparted to No
Treatment; p = .07
compared to
Activity Protocol)
and
Cognitive/Social
Composite on the
Leiter R (p = .02
compared to the
Activity Protocol).
While greater
changes were
documented in the
SSP and CBCL
Internalizing
composite, gains
were not significant.
The activity

Lack of statistical
power is another
limiting factor to
consider when
interpreting the
results.

system for participant

inclusion, treatment and
outcome measurement and
testing controls to validate
threats.
Program development:
This research is important
because it develops a
protocol that can be used
in randomized controlled
studies of utilizing SI to
treat SMD.
Societal needs: Children
impacted by sensory
processing disorders have
difficulty interacting with
others and communicating
with adults and peers and
have the potential to be
isolated. Sensory
integration protocol has
the potential to address
these areas of concern.
Healthcare delivery and
health policy: Currently
the cost-to-benefit ratio of
SI is questioned, justifying
the high cost of sensory
integration interventions in
comparison to traditional
interventions is necessary.

Pfeiffer,
Koenig,
Kinnealey,
Sheppard &
Henderson
(2011).

The purpose of the

pilot study was to
establish a model
for RCT research,
identify appropriate
outcome measures
and address the
effectiveness of

Level I
Randomized Control
Trial
Recruitment:
A convenience sample
of 37 children aged 6

Electrodermal
reactivity (EDR)

Intervention:
Participants were
randomly assigned to two
groups; SI or fine motor
(FM). Each participant
received 18 treatments
for 45 minutes over 6
weeks. Treatment

protocol group
made greater, but
non-significant
gains compared to
the other groups in
Socialization on the
Vineland. The no
treatment group
made greater, but
not significant gains
on the CBCL
Externalizing
Composite.
Physiologically, the
OT-SI group
demonstrated
greater decline in
EDR amplitudes
when compared to
the Activity
Protocol and Not
Treatment groups
(OT-SI, n = 4;
Activity Protocol, n
= 3; No Treatment,
n = 4).
The SI group
demonstrated more
significant
improvements than
the FM group in
their GAS scores as
rated by parents (p
< .05) and teachers

Education and training of

OT students: Implementing
OT-SI will require future
practitioners to utilize
clinical reasoning and have
knowledge in
implementing OT-SI
interventions.
Refinement, revision, and
advancement of factual
knowledge or theory: The
small sample size limits
definitive conclusions
made on the effectiveness
of OT-SI. Findings
suggest that SI is effective
in treating SMD, however
it is not certain if results
are by chance and
questions the external and
internal sources of validity.

Participants lacked
homogeneity which
limited the ability to
interpret
effectiveness of the
intervention.
The interventions

The clinical and

community-based practice
of OT: The study provides
preliminary evidence for
the effectiveness of SI and
provides a guide in the
development of future
RCT studies.

sensory integration
interventions in
children with
Autism Spectrum
Disorder.

12 years old (n = 37)

attending a summer
therapeutic activities
program participated in
the study. This included
32 boys and 5 girls,
identified with a
sensory processing
disorder. Twenty one
were diagnosed with
ASD and 16 were
diagnosed with PDD.
Participants were
randomly assigned to
sensory integration (n =
20) or fine motor (FM;
n = 16) using version 16
of the SPSS, by a
statistician who was not
associated with the
implementation of the
study. Researchers and
parents were blinded to
group assignments
during pre- and posttesting.
Dropouts:
N=4
Four children dropped
out of the study and
were not included in the
37. Two were removed
from the program by

interventions were based

on the individual needs
of each child. The
intervention consisted of
two different groups. The
SI group had ten key
therapeutic strategies to
ensure fidelity of
treatment. Three main
areas encompassed the
ten key therapeutic
strategies: providing the
child with environmental
modifications and
sensory opportunities
during the treatment
session, fostering
adaptive responses and
providing the just rightchallenge and promoting
the therapist-child
relationship.
The FM group was
treated by a graduate
student with
interventions focused on
3 main activity area:
constructional, drawing,
writing, and fine motor
crafts. Fine motor
interventions followed 5
fidelity criteria.
Outcome measurements

(p < . 01).
The SI group
demonstrated
significantly fewer
autistic mannerisms
than the FM group
when looking at
scores of the SRS (p
< .05), indicating
that SI interventions
may have an impact
on core symptoms
of ASD. No
significant
differences were
found between the
other subscales of
the SRS or the
QNST-II.
The QNST-II is the
only test requiring
standardized
administration. A
substantial
proportion of
participants in both
groups (SI: n = 9;
FM: n = 6) were
unable complete the
pretest portion. At
the completion of
intervention 70% of
SI treatment
participants were

were done in a
clinical setting and
may not be
generalizable to
home or community
settings.
Lastly, the small
sample size limits
the generalizability
of the results.

Program development:
Research results supported
the use of more
individualized measures,
such as GAS, to determine
progress and change in
both research and clinical
practice.
Societal Needs: With the
rise in the number of
children diagnosed with
ASD and SI being used as
a primary intervention
technique, it is imperative
to establish its
effectiveness to implement
evidence-based practice.
Healthcare delivery and
health policy: The study
identifies GAS as an
effective outcome measure
when treating children
with ASD.
Education and training of
OT students: Entry level
OT students have been
exposed to outcome
measures utilized in
detecting SPD behaviors.
Refinement, revision and

Roberts,
KingThomas &
Boccia
(2007).

The authors sought

to investigate
behavioral
responses to SI
treatment. They
sought to determine
if self-regulatory
behaviors increased
as a result of SI and
if improvements
generalized to other
areas.

their parents and two

were asked to leave
because of aggressive
behavior.

consisted of pre and post

testing.

Level IV

Intervention:
Therapy was
administered in a clinical
setting by a SIPT
certified OT in a one-onone 1 hr session 3x/wk
for 11 weeks. During
this time the participant
engaged in alternating no
treatment (A) and
treatment (B) conditions
in which he had 2 weeks
of no treatment, 5 weeks
of treatment and 2 weeks
of treatment.
Interventions occurred

Single Subject Design

Recruitment:
N=1
A prospective
longitudinal, single
subject ABAB design
was utilized. Therapy
was administered in a
clinical setting by a
SIPT certified OT in a
one-on-one 1 hr session
3x/wk for 11 weeks.

Outcomes:
Sensory
Processing Measure
(SPM)
Social
Responsiveness
Scale (SRS)
Quick
Neurological
Screening Test II
(QNST-II)
Goal Attainment
Scale
Vineland
Adaptive Behavior
Scale

able to complete
part or all of the
QNST-II compared
to 17% of the FM
group. Those of the
SI group able to
complete the QNSTII showed a
significant change
from pre- to posttest
when compared to
the FM group ((SI:
pretest M = 69.91,
posttest M = 39.36;
FM: pretest M =
33.91, posttest M =
24.60).

Results indicated a
reduction in
aggressive acts,
mouthing objects,
and intensity of
teacher input, and
an increase in
engagement
associated with the
treatment phases.
Intraclass
correlation
coefficients between
visual teacher
ratings (exact

advancement of factual
knowledge or theory: The
study design, small sample
size and homogeneity of
participants does not allow
generalizability of results
to the home or community
setting.

Major limitations
were the size and
teachers
documenting
observations. Due
to the demands of
the classroom, it is
possible not all
areas were
adequately
recorded.
Additionally, each
teacher may have
individual beliefs of
acceptable or

Clinical and communitybased practice for OT:

This research indicates that
SI can create a significant
reduction in maladaptive
behaviors in multiple
domains when
participating in intensive
therapy (3x/wk) in a
clinical setting.
Program development:
Due to the small sample
size and study design, the
results are not strong
enough to inform OTS to

During this time the

participant engaged in
alternating no treatment
(A) and treatment (B)
conditions in which he
had 2 weeks of no
treatment, 5 weeks of
treatment and 2 weeks
of treatment. Teachers
were asked to observe
and rate behaviors
evaluating
manifestations of SMD
as they occurred during
play and social
interactions. No OT
consultation occurred to
ensure teachers
remained blind to
treatment.
The participant was a 3
year and 5 months old
boy, with no history of
gestational or birth
complications. He
demonstrated an
average nonverbal
intelligence score with
an IQ of 104 and a 10
month-delay in
receptive and
expressive language
skills. He demonstrated
tactile sensitivity, poor

within the occupation of

play.
Outcomes:
Teachers were asked to
observe and rate
behaviors evaluating
manifestations of SMD
as they occurred during
play and social
interactions. Areas of
interest included:
- Aggression
- Engagement
- Mouthing objects
- Teacher intensity

agreement) indicate
each measure was
reliable. Reported
probability
estimates (p-value)
reflect comparison
to the initial notreatment phase.
- Aggression:
ICC = .78 (p < .
001)
- Engagement
ICC = .79 (p < .
001)
- Mouthing
objects ICC = .
94 (p < .001)
- Teacher
Intensity ICC
= .66 (p < .05)
The four dependent
variables were
statistically
analyzed using a
split-middle
technique which
provides estimates
of level (intercept)
and rate of change
(slope) for each
experimental phase.

unacceptable
behavior and they
may be impacted by
contextual
influences (mood,
level of patience,
etc.).
Lastly, while
teachers were
unaware of the type
of therapy being
received and when,
they were aware
therapy was taking
place. It is possible
that teachers may
have anticipated
behavioral changes
and may have made
subtle or overt
changes in their own
behavior which
could have impacted
the participants
behavior.

implement this program as

the sole therapeutic
intervention to remediate
maladaptive behaviors
associated with SMD.
However, it does imply
that intensive clinicalbased therapy alone may
be sufficient enough to
produce behavioral
changes.
Societal needs:
Sensory modulation
disorders impact social,
cognitive and/or sensory
functioning in children
impacted by this disorder.
Devising a treatment
modality that addresses
these deficits will have
global implications.
Healthcare delivery and
policy: The results of this
study are not significant
enough to impact health
care and the way OTs
administer treatment for
SMD.
Education and training of
OT students: The
completion of more
evidence-based and

auditory filtering, and

sensory seeking
behaviors.

Schaaf,
Benevides,
Mailloux,
Faller,
Hunt, van
Hooydonk,
Freeman,
Leiby,
Sendecki &
Kelly
(2013).

This study was twofold. The primary

focus of the study
was to evaluate the
efficacy of OT-SI
utilizing a
manualized protocol
in individualized
goal attainment
when compared to
typical care. The
secondary focus of
the study was to
evaluate the impact
of OT/SI on sensory
behaviors, adaptive
behaviors and
functional skill of
children with
Autism Spectrum

Level I
Randomized control
trial
Recruitment:
Eligible families were
recruited from the
surrounding area and
childrens hospital.
Eligibility requirements
included: (1) between 4
and 7.11 years; (2)
received a diagnosis of
autism from a licensed
psychologist; (3) a nonverbal cognitive score
of >65; (4)
demonstrated difficulty

rigorous research studies

are needed to replicate the
results of this study.

Intervention:
Intervention protocols
were not detailed,
however, reader is
referenced to sources for
an in-depth description.
Interventions took place
three times per week in
1-hr sessions for ten
weeks in a sensory gym
utilizing Sensory
Integration principles.
Outcomes:
Goal Attainment
Scale
Pediatric
Evaluation of
Disability Inventory

To assess goal
attainment between
the two groups a
two-tailed
independent t-test
was conducted.
Results showed a
significant
difference between
the treatment
(M=56.53,
SD=12.38, n = 17)
and UC (usual care;
M=42.71,
SD=11.21, n = 14)
groups on the GAS
with the treatment
group attaining
significantly higher
scores (t(23) =

The small sample

size is a limitation
to the study design.
Parent report was
not substantiated by
observational
measures.
Additionally,
researchers note
that while they
randomized subjects
based on severity of
autism and
cognition, they were
not able to include
this in their analysis.
Subsequently, a
larger sample size

Refinement, revision, and

advancement of factual
knowledge or theory:
Future studies should
include a larger sample
size attending to children
with average intelligence.
Additionally, ensuring
fidelity measures are
implemented will limit
bias.
The clinical and
community-based practice
of OT: This study
demonstrated preliminary
support for a manualized
intervention aimed at
addressing sensory
processing and integration
deficits in children with
ASD.
Program development:
Utilizing a manualized
protocol when
administering SI in
comparison to usual care
will allow for enhanced
outcomes.
Societal needs: Behaviors

Disorder (ASD).

processing and
integrating sensory
information as
measured by the
Sensory Profile; and (5)
parents were willing to
participate in 3 weekly
sessions for 10 weeks
and refrain from
initiating any new
treatments, including
medications.
Convenience sample
n = 32

Treatment group: n
= 17
Control group: n =
15

(PEDI)
Pervasive
Developmental
Disorders Behavior
Inventory (PDDBI)
Vineland
Adaptive Behavior
Scales II (VABS II)

-3.23, p = 0.002, ES
= 1.2).
To assess the effect
of treatment on
functional
behaviors,
researchers
compared the
change from
baseline to the end
of treatment for
each of PEDI
subscales assessed
using the Wilcoxon
Rank sum test.
Significantly greater
improvements for
the treatment group
where noted in SelfCare Caregiver
Assistance (p =
0.008) and Social
Function Caregiver
Assistance (p=
0.039) when
compared to the UC
control group.
To assess the effect
of treatment on
sensory/perceptual
approach behaviors,
arousal regulation
and

would allow
researchers to
consider
confounding
variables impacting
outcomes.

associated with difficulty

processing and integrating
sensory information create
social isolation for parents
and their children,
resulting in barriers to
participation in activities
of daily living.
Subsequently,
interventions aimed at
addressing these deficits
will enhance engagement
in daily activities for
parents and children.
Healthcare delivery and
health policy: Although
results from the study are
preliminary, they are
statistically significant
enough to impact
healthcare and the way OT
treat children with SPD.
Education and Training of
OT students: Entry level
practitioners have general
knowledge on Ayres SI
theory and can implement
this in practice.
Refinement, revision and
advancement of factual
knowledge or theory: The
study demonstrates

ritualism/resistance
to change, a
comparison of
baseline to posttreatment scores
were compared
using the Wilcoxon
Rank Sum test. No
significant
differences in
autism behaviors
were noted at posttreatment between
the groups. Sensory
Perceptual
Behaviors
approached
significance at posttreatment (p =
0.064).
To assess the effect
of treatment on
adaptive behaviors,
pre and posttreatment scores
from the VABS II
were evaluated
using the Wilcoxon
Rank Sum test.
Although the
treatment group
made more
improvements in
adaptive behaviors

precision in its
measurement of treatment
fidelity and use of a
manualized protocol, and
provides support for the
use of this intervention for
children with ASD.

Schaaf &
Nightlinger
(2007).

To document
changes in
occupational
performance of
children with
sensory processing
disorder during and
after 10 months of
occupational
therapy using a
sensory integrative
approach.

Level IV
A single subject case
study was conducted,
documenting the results
of a four year old male
(n = 1).
Recruitment
Participant was born
full-term, with no birth
or early infancy
complications.

Intervention:
Direct OT-SI was
administered once per
week with frequent
consultation and
collaboration with the
patients mother and
preschool teacher.
Therapy was administer
in an OT-SI clinic.

Participant displayed
deficits in expressive
language, social skills,
emotional/behavioral,
motor and sensory
processing.
Participant was sensory
avoidant and
hypersensitive to
sensation.

Outcomes:
Sensory Profile
Goal Attainment
Scale

compared to the UC
Control group, no
significant
differences were
noted.
The participant
demonstrated gains
in each of his GAS
goals.
Improvements were
documented in:
- motor planning
- participation in
age-appropriate
activities,
- decreased fear
reactivity to
movement
- participation in
age-appropriate
playground
equipment,
- decreased oralsensitivity
- expanded his
food repertoire
and
participation
with family and
peers at
mealtime,
- improved social
development
and began to
initiate social
play with peers

Sample size is the

primary concern of
this study as it does
not allow for
generalization of
findings.

Clinical and communitybased practice of OT: The

findings support the
theoretical basis of SI;
improvement in the ability
to process and integrate SI
will influence adaptive
behavior and occupational
performance.
Program development: SI
should be applied in
occupational therapy
treatments when treating
children with SPD to
enhance sensory
processing, behavior and
occupational behavior.
Societal needs: Since this
is a single case study,
further research is needed
to generalize the findings
to societal needs.
Healthcare delivery and
health policy: Further
accumulation of evidence
with a larger, more
representative sample is

participation in
age-appropriate
fine and visualmotor and play
activities.

necessary.
Education and training of
OT students: Entry level
practitioners have a
general knowledge on
Ayres SI approach.

Improvements were
evident across
contexts (home,
community and
clinic).

Smith,
Press,
Koening &
Kinnealley
(2005).

The purpose of the

study was to
compare the effects
of occupational
therapy, using a SI
approach and a
control intervention

Level III study

Within subject reversal
Participants participated
in a four week study
utilizing alternating

Intervention:
During SI intervention,
the subject engaged in
sensory based treatment
that included a variety of
tactile, proprioceptive,
and vestibular input

The Sensory Profile

was conducted after
10 months of
intervention to
determine if further
areas of need
existed. He showed
typical performance
in all but 3 subtests
which only
indicated probable
difference,
suggesting poor
sensory processing
was no longer a
factor.
Results provided
evidence that
sensory integration
intervention was
effective in reducing
self-stimulating and
self-injurious

Refinement, revision and

advancement of factual
knowledge or theory:
Further studies with more
stringent protocols are
needed. Randomized
control trials are ideal.

Representative of
sample size:
-small sample size
-no control group
present to compare
results.

The clinical and

community-based practice
of OT: Activities that are
rich in vestibular, tactile,
and proprioceptive input
addressing an individuals
sensory processing needs

of tabletop
activities, on the
frequency of selfstimulating
behaviors in seven
children 8-19 years
of age with
pervasive
developmental
delay and
intellectual
disabilities.

treatment methods.
Treatments took play
daily five times a week
for 30 minutes. Weeks
two and four
encompassed SI
interventions and weeks
one and three
encompassed table top
interventions.
Recruitment
A convenience sample
of four boys and three
girls (n = 7) aged 8 to
19 years of age with a
diagnosis of PDD or
severe profound mental
retardation engaging in
self-stimulating or selfinjurious behaviors.

based on their unique

sensory needs.
The control intervention
consisted of tabletop
activities related to each
clients specific
individualized education
program goals. These
tasks included activities
such as sorting by color
or shape, writing
activities, puzzles and/or
placing pegs in a peg
board.
Outcomes:
The Sensory Integration
Inventory Revised For
Individuals With
Developmental
Disabilities
(Inventory has four
sections: tactile,
vestibular,
proprioception, and
general reactions)
Likert Scale (1-5)

behaviors in the
classroom, which
interferes with
function and
participation. The
percentage of selfstimulating
behaviors was
reduced 1 hour after
sensory integration
intervention when
compared to the
pretreatment and
post 0 min
percentages
(p=0.01).
-Teachers reported
fewer selfstimulating and
repetitious vocal
sound behaviors
during the sensory
integration weeks
compared to the
control weeks (p<
0.05).

Possible sources of
bias:
-use of a single
clinical site and lack
of psychometric
properties for the
Sensory Integration
Inventory Revised

are most beneficial in

reducing maladaptive
behaviors in comparison to
tabletop activities.
Program development:
Sensory integration
interventions should be
applied in the classroom
for children with PDD to
reduce self-injurious
behaviors.
Societal needs: SI is
effective in reducing selfstimulating and selfinjurious behaviors in the
classroom which interferes
with function and
participation, thus
allowing students to
participate in more
functional activities.
Healthcare delivery and
health policy: Further
research needs to be
conducted to further
demonstrate the efficacy of
SI in order for this
treatment to be recognized
universally within the
healthcare system.
Education and training of

OT students: OT students
are equipped with a
generalist knowledge on
sensory integration.
Refinement, revision, and
advancement of factual
knowledge or theory:
Continued research is
indicated in this area to
further examine the
effectiveness of sensory
integration intervention on
reducing self-injurious
behaviors and increasing
positive participation in
educational behaviors and
work settings for people
with intellectual
disabilities.

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