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Roseann C. Schaaf, PhD.

, OTR/L, FAOTA
Professor and Vice Chairman
Department of Occupational Therapy, School
of Health Professions
Thomas Jefferson University. Philadelphia PA
Roseann.schaaf@jefferson.edu
Sensory Processing and Autism
Evidence, Research, Future
Directions
PLEASE DO NOT REPRODUCE
ANY MATERIALS
What we Know
Autism is prevalent one in 88 (CDC 2012)
Found throughout the world in all racial, ethnic
and social backgrounds
4 times more common in males
Individuals with autism have participation
challenges (self care, transitions, learning, social
interactions): Occupational Therapy facilitates
participation in daily activities.
Individuals with autism have difficulty processing
and integrating sensory information
Sensory Symptoms in ASD
80 -90% of individuals
with autism experience
atypical sensory
responsiveness that
affects their ability to
participate in daily
activities (APA, 2003; Ornitz,
1989; Courchesne, et al 1994;
Adrien, et al 1992; Volkmar, et al
1986; Dahlgren & Gillberg, 1989;
Tomcheck and Dunn, 2005; Kietz
& Dunn, 1997; Watling, et al,
2001
13%
87%
No SMD
SMD
N = 60
Schaaf & Benevides, 2012
Information (Sensory) Processing
Difficulty
People with autism process
and respond to sensory stimuli
in a much different way
There is an obstruction between the senses
and the mind, or put somewhat differently,
the door to the outside (sensory) world is
blockedincoming information may be
incomplete or distorted (Bryson, SE, 2005 in the
Neurobiology of Autism, 2
nd
ed, p 35)
Sensory Symptoms are More
Prominent in Autism
Review of 48 empirical papers and 27
theoretical or concept papers suggests
that sensory symptoms are more
prominent in children with autism BUT
there is not good evidence to suggest that
they differentiate children with autism from
other clinical groups (fXs, DD).
Rogers, SJ & Ozonoff, S. (2005).
Exact Nature of the problem is
Unclear
While there seems to be an abundance of
literature supporting the existence of
sensory processing abnormalities in
children with autism, it is difficult to
pinpoint the exact areas of difficulty
because of significant individual variability
and lack of objective measures.
Generate Evidence
Use Evidence
Publish Evidence
Evidence Based Interventions
Must be clearly described
Have evidence about outcomes
Have adequate power
Be replicable
Measure Fidelity
Am J Occup Ther. 2011 Mar-Apr;65(2):133-42.
Development of a fidelity measure for research on the effectiveness of the
Ayres Sensory Integration intervention.
Parham LD, Roley SS, May-Benson TA, Koomar J, Brett-Green B, Burke JP, Cohn ES, Mailloux Z, Miller LJ, Schaaf RC.
OBJECTIVE: We developed a reliable and valid fidelity measure for use in research on Ayres Sensory Integration (ASI) intervention.
METHOD: We designed a fidelity instrument to measure structural and process aspects of ASI intervention. Because scoring of process
involves subjectivity, we conducted a series of reliability and validity studies on the process section. Raters were trained to score
therapist strategies observed in video recordings of adult-child dyads. We examined content validity through expert ratings.
RESULTS: Reliability of the process section was strong for total fidelity score (ICC = .99, Cronbach's alpha = .99) and acceptable for
most items. Total score significantly differentiated ASI from four alternative interventions. Expert ratings indicated strong agreement
that items in the structural and process sections represent ASI intervention. CONCLUSION. The Ayres Sensory Integration Fidelity
Measure has strong content validity. The process section is reliable and valid when scored by trained raters with expertise in ASI.
OT/SI: Seven studies
Three are group comparison designs (Pffiefer, 2011;
Fazlioglu & Baran, 2008; Ayres & Tickle, 1980)
Three are single subject designs (Case-Smith &
Bryan, 1999; Linderman & Steward, 1999; Watling &
Dietz, 2007)
One is a case study (Schaaf & Nightlinger, 2007).
Collectively, they report that individuals with ASD who
receive OT/SI demonstrated gains in play, individualized
goals, and social interaction; and a decrease in sensory
symptoms.
Caution: small sample sizes, failure to adequately
characterize the sample, lack of a detailed, replicable
intervention protocol with a fidelity measure, and other
methodological and design flaws.
Schaaf, 2010 in Reichow, B., .Volkmar, F Evidence Based Practices in ASD
Pfieffer, et al, 2010
Small trial to examine sensitive outcome
measures for larger RCT
Children in both group made gains in
individual goal attainment scales
Tx > Control.
N= 37; 20 Tx, 17 control
Fidelity measured
significant decrease in autistic
mannerisms in TX group.
Sensory-Based Interventions
Distinguished from OT/SI
They utilize specific sensory stimulation of one
sensory system rather than the integrated
approach that is consistent with OT/SI
4 categories:
Interventions that utilize touch (i.e., massage or touch
therapy): promising
Therapy balls as seating devices: promising
Interventions that utilize weighted vests: unconvincing
Auditory interventions: unconvincing
Sensory diet: unconvincing
Brushing Protocol: unconvincing .
We Need to Generate Evidence!
Progress made
Studies of OT/SI and sensory-based interventions
ASI Fidelity Measure (Parham, et al 2001; 2011)
Evidence Reviews (AJOT; Reichow.Volkmar Book 2011)
Subtype studies: Miller, et al; Davies, 2010)
Physiological studies
Each of you can participate we need more
1. Be systematic in your approach
2. Use systematic clinical reasoning based on theory
3. Articulate hypothesis
Identify participation limitations
Obtain a history to guide systematic assessment
Assess, assess, assess
Use theory to generate hypothesis and underlying mechanisms
Identify outcomes
4. Test Hypotheses by charting outcomes
5. Publish, publish, publish
Be Systematic!
Devlin, et al 2010 JADD
Comparison of the effects of sensory integration
and behavioral intervention for addressing
problem behaviors
N = 4 boys with challenging behaviors
Conclusion: behavioral interventions effective in
reducing problem behaviors but SI was not.
SI: 15 minute access to equipment provided during
school day for approx. 6 times/day
Analysis
(Schaaf & Blanche)
Sensory Integration Therapy
not an accurate representation of the sensory integrative
approach (OT/SI)
Did not use ASI Fidelity Measure
Failure to conduct a systematic assessment to
guide intervention
Inaccurate use of literature
Does not include contemporary or classic literature
Brings up important limitations of OT/SI
Systematic Data Driven
Intervention
Guides practitioners reasoning
Create seamless links from:
Assessment to hypothesis generation
From Hypothesis to Intervention
From Intervention to outcome measures
(Sugari, Lewis-Palmer, Hagan-Burke, 2001;
Blanche, 2006; Frolek-Clark, 2010;
Benevides, personal conversation))
Data Driven Intervention Process (Schaaf,
2011)
Schaaf, RC & Blanche, EI. (2012). Emerging as Leaders in Autism through Data
Driven Intervention. AJOT
Based on work by Sugari, McEwen, Blanche (2006) and conversation with
Benevides (2010)
Identify
participation
challenges
(history,
observation,
discussion)
Identify and
administer
standardized and
non-
standardized
assessment
Create
hypothesis about
the factors
impacting
participation
challenge
Consider:
strengths
Environmental
targets
Implement
intervention
protocol
Identify proximal
and distal
outcomes and
strategies for
measuring and
charting
outcomes
Generate Hypothesis
(Sugari, Lewis-Palmer & Hagan-Burke, 2001; Blanche, 2006)
A summary statement that links assessment findings
to participation restrictions:
1. Identify participation challenge
2. Define factors contributing
Child is not able to sleep for more than 90 minutes
at a time. Gets up and wanders around house.
Based on assessment findings, poor arousal regulation related
to hyper-sensitivity to stimuli are impacting ability to sleep.
Utilize Systematic Intervention
Theory driven
Evidence based
Manuals or protocol that can be
replicated
Describe your intervention so it can
be replicated
Measure Outcomes
Proximal: close to the proposed
factors contributing to partic challenge
Distal: Measures of participation or
goal attainment
Examples
Proximal: Decrease in hyper-responsivity (SEQ)
Improved Arousal Regulation (PDDBI)
Distal: Improved ability to sleep through the night (GAS;
PDDBI; chart # of hours slept)
Chart your Outcomes
Create graphs and
charts to display your
outcome data
Use Goal Attainment
Scaling
Pre-Post
Assessments (SIPT,
PDDBI, PEDI,
Vineland)
Case Report: Improving Handwriting with Social Stories for
Student with ASD
(Perhac, J., Just, C., & Schaaf, R.C)
PDDBI-PX Apporach/Withdrawal Problesm
Lower Scores= Better Performance
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Domain
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Pretest
Post-test
Autism Speaks
(Schaaf, Benevides, Kelly, Freeman, Hunt,
VanHooydonk, Faller, Neuwirth, Mailloux, )
Does a manualized protocol of
occupational therapy using sensory
integration principles improve adaptive
behaviors; participation in activities for
children with Autism Spectrum Disorders?
The Efficacy of Occupational Therapy
using Sensory Integration Principles
for Children with Autism
Roseann Schaaf, PhD, OTR/L, FAOTA
Teal Benevides, MS, OTR/L
Thomas Jefferson University, Phila, PA
Patricia Faller, MS, OTR/L, Joanne Hunt,
OTR/L, Elke van Hooydonk, OTR/L Childrens
Rehabilitation Hospital, Toms River NJ
Zoe Mailloux, OTD
Example of Data Driven Intervention
One of first RCT of OT/SI
Funded by the Autism Speaks Foundation
Inclusion Criteria
4-8 years of age
Diagnosed with ASD using ADOS and ADI-R
Non-Verbal IQ >70
No other co-morbid genetic or developmental
conditions (i.e. Fragile X, CP)
Demonstrate difficulty processing and
integrating sensory information as measured
by the SP or the SIPT
Design &
Methods
Children who do not
meet inclusion criteria
excluded
Phenotypic Evaluation for
Eligibility
ADOS, ADIr, IQ, SSP, SIPT
Informed Consent
Pre-Test Assessments
Randomization
Control Group
Usual Care, 10 weeks
Experimental Group OT/SI
3 - 1 hr. sessions/week for 10 weeks =
30 sessions
Referral
& Screening
Analysis of Assessment Data
Goal writing with Parent: GAS
Post Test
SIPT, SEQ, Vineland, PEDI, QOL, PDDBI
Post GAScale Interview
Vineland- II
PEDI, PDDBI
WHO-QOL
SEQ
Data Driven Intervention Table
Hypothesis generation
Phase 1 n = 10
Phase 2 n = 30
Total n = 40
Assessment Data
History and occupational profile
Evaluations and Assessments
Sensory processing and praxis
Sensory Integration and Praxis Test (SIPT): PRAXIS
Sensory Profile
Sensory Experiences Questionnaire (SEQ)
Adaptive behavior and participation
Vineland Adaptive Behavior Scales (Vineland-II)
Pediatric Evaluation of Disability Inventory (PEDI)
Pervasive Developmental Disorder Behavior Inventory
(PDDBI)
Intervention Delivery
Active, individually-
tailored sensory motor
activities designed to
address underlying
factors affecting
participation.
10 weeks 3X/weeks
Follows manualized
protocol
Fidelity is tested with
validated measure
(Parham, et al 2010)
Intervention Manual Authors
Draft 3 - November, 2010
Roseann C. Schaaf, PhD., OTR/L, FAOTA
Erna Blanche, PhD., OTR/L, FAOTA
Zoe Mailloux, MS, OTR/L, FAOTA
And the Sensory Integration Research Collaborative
Janice P. Burke, PhD., OTR/L, FAOTA
Ellen Cohn, PhD., OTR/L, FAOTA
Shelly Lane, PhD., OTR/L, FAOTA
Jane Koomar, PhD., OTR/L, FAOTA
Teresa May-Benson, ScD, OTR/L, FAOTA
Lucy Jane Miller, PhD., OTR/L, FAOTA
Diane Parham, PhD., OTR/L, FAOTA
Stacey Reynolds, PhD., OTR/L
Sarah Shoen, PhD., OTR/L
Teal Benevides, MS, OTR/L
Susanne Smith Roley, MS, OTR/L, FAOTA
Intervention Based on Core Elements of Sensory
Integration Intervention (Ayres, 1972, 1979; 1989; Parham and
Mailloux, 2001; Schaaf, Schoen, Lane, et al, 2010).
Ensure physical safety
Present sensory opportunities
Facilitate childs self-regulation of arousal level, attention
and emotion
Challenge postural, ocular and bilateral motor
development
Promote praxis and organization of behavior
Tailor activities to provide the just-right-challenge
Collaborate with the child on activity choices
Ensure success
Create a context of play
Foster a therapeutic alliance with the child
MODULE 1: Developing the therapeutic Alliance
MODULE 2: Addressing Sensory Responsivity to Decrease Problem Behaviors
MODULE 3: Developing Sensory Perception and Discrimination
MODULE 4: Developing Praxis: The Somatomotor Adaptive Response
MODULE 5: Developing Self Initiation & Purposeful Play
MODULE 6: Educating the Family
Sensory Integration Treatment
Manual Treatment Overview
Sample Concept Map
(Adapted from Blanche, 2009)
Adequate
sensory
Modulation?
No
Yes
Are there
identifiable
sensory
triggers?
Level
of
arousal
is high
Level
of
arousal
is low
Provide
inhibitory, or
modulatory
sensory motor
activities
(see Table 1)
Provide
facilitatory
sensory motor
activities
(see Table 1)
Monitor changes in behavior/outcomes
Findings
Phase 1 Feasibility
Phase 2 - RCT
Feasibility Study
Schaaf, Benevides, Kelly, Mailloux - submitted
Treatment is Safe
No reported injuries
Treatment is Acceptable
Parents and Therapist rate positively
Treatment is Feasible
Feasible for parents to attend 3X/week
Feasible for therapists to provide tx and obtain fidelity
Fidelity
Therapists deliver intervention with good fidelity (M =
81).
RCT:
Preliminary
Results
GAScale
N = 20 (11 treatment; 9 control)
T = -3.343; p = .045*
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PDDBI
Ritualisms Sensory Behaviors
N = 15 (10 treatment; 6 control)
(lower score indicates better functioning).
SIPT scores Pre/Post
SIPT Scores
-4
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Subtest
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Pre
Post
Case Report - DY
5 year 5 month old
male with Dx of ASD
Autism diagnosis
ADOS 3 Module 3
Severity score of 7
out of possible 10
Full Scale IQ of 106
on the Stanford Binet-
5.
Attends public school with a
half-day placement in an
autistic program
Physiological Evidence
Characterizing Sensory Behavior
Biomarker of Response to Intervention
Spaceship Lab Sensory
Challenge Protocol
Designed to be fun and
non-threatening
Short- child in spaceship
chair for ~30 minutes
Non-invasive: Measure
influence of vagus nerve on
heart rate and sweat
responses
The Sensory Challenge Protocol
Obtain Baseline data before and after (sitting in
chair for 2 minutes)
Eight contiguous trials in each of six sensory
systems
olfactory (wintergreen oil)
auditory (siren and tones, prolonged tone)
visual (strobe light)
tactile (feather on face)
vestibular (chair tilted backwards)
KID Foundation
Mindware
Sympathetic Measures:
Electrodermal Activity (EDA)
and Pre-ejection Period
KID Foundation
EDA -measures
responsiveness to
stimuli by changes in
the skin.
PEP: time from depolarization of the heart to
the time when blood enters the aorta. Greater
sympathetic activation is indexed by shorter PEP (i.e.
faster time to contraction) (Newlin & Levenson, 1979).
PEP is measured using impedance cardiography, a non-
invasive method of calculating blood flow resistance at
the sino-atrial node over time
Parasympathetic Measure: High
Frequency Heart Rate Variability
Vagus nerve
influence on heart
rate variability
EDA in Children with Autism
(Miller, et al, 2001)
Patterns
Problems in Adaptive
Behavior also noted
Typical Reaction to Sensation
-1
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1
Time (Seconds)
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Hyperreactivity to Sensation
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Under Reactive to Sensation
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Time (Seconds)
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Children with Autistic Spectrum Disorder
Compared to Children with Fragile X Syndrome
0
0.01
0.02
0.03
0.04
0.05
0.06
1 2 3 4 5 6 7 8
Trials
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Typical
FXS
Autism
Miller et al., 2001
KID Foundation
Difference in VT during SCP
5.4
5.6
5.8
6
6.2
6.4
6.6
6.8
7
Baseline Tones** Visual Siren Olfactory Tactile** Movement Recovery Prolonged
Tones
SCP Domain
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TYP (n=35)
AUT (n=33)
Children w/ AUT had Lower
Parasympathetic Activity/HRV
(Schaaf & Benevides, unpublished)
Tones, p = .023
Tactile, p= .029
Differences between TYP and AUT on
SSP (p<.001 for all domains; Schaaf & Benevides, unpublished)
-4
-3
-2
-1
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1
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TYP (n=38)
AUT (n=39)
Significant Differences between AUT vs.
TYP groups on Adaptive Behavior
p< .001 for all domains and ABC
0
20
40
60
80
100
120
Communication** Daily Living** Socialization** Composite**
VABS Domain
S
t
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TYP (n=21)
AUT (n=19)
Higher SSP scores are significantly related
to better Adaptive Behavior
0
20
40
60
80
100
120
-6 -4 -2 0 2
SSP (total Z-score)
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n=19 (AUT=10, TYP= 9)
(r=.571, p = .011)
Miller, et al; and Schaaf &
Benevides, unpublished)
Differences in Sensory Behaviors

<.0001 -3.8 0.8 0.8 28 1.4 -3.1 60 Total Score


<.0001 -2.4 0.7 1.0 28 1.5 -1.4 60 Visual/Auditory Sensitivity
<.0001 -3.9 1.3 0.9 28 2.0 -3.0 60 Underresponsive/Seeking
<.0001 -2.4 1.8 1.1 28 2.7 -1.2 60 Taste/Smell Sensitivity
<.0001 -2.4 0.6 0.5 28 1.7 -1.8 60 Tactile Sensitivity
0.0043 -1.2 0.4 0.3 28 6.5 -1.5 60 Movement Sensitivity
<.0001 -2.6 0.3 0.2 28 2.4 -2.4 60 Low Energy
<.0001 -3.6 1.2 0.4 28 1.5 -2.9 60 Auditory Filtering
p-value
age-adj
dif sd mean n sd mean n
Typical ASD
HRV: ASD (n = 59) vs TYP
(n = 20)
Differences in Severe Sensory
Dysfunction Group vs TYP
The Severe group demonstrated significantly lower mean HRV than the TYP children for
baseline (p = .026); tones (p =.020), and prolonged auditory stimuli (p = .04) during the
Sensory Challenge Protocol. From: Schaaf, R.C., Benevides, T., Blanche, E., Brett-
Green, B., Burke, J.P., Cohn, E., Schoen, S. (2010). Parasympathetic functions in children
with sensory processing disorder. Frontiers in Neuroscience, 4(4), 1-11.
Summary
Children with autism have a different
physiological response to sensory stimuli
than typically developing children (tone
and tactile are significantly different
(lower).
Suggests that children with ASD have
poor regulation of reactivity that is related
to autonomic nervous system
dysregulation
Summary
S
U
M
M
A
R
Y
To Emerge as Leaders we must
train Advanced Practitioners who:
Articulate our unique expertise
Understand best practice in Autism
Use a systematic, data-driven
approach
Publish
Thank You
Roseann.schaaf@jefferson.edu
http://www.jefferson.edu/health_professions/occup
ational_therapy/programs/certificate_Autism.cfm
http://www.jefferson.edu/jchp/jshp/
ot/AutismCertificate.cfm
Advanced Practice Certificate in
Autism at Thomas Jefferson University
12 credits/4 courses
Can be applied toward OTD
On-Line learning
Contemporary issues in autism
Course 1: Autism: The state of the Field
Course 2: Best Practice Assessment
Course 3: Evidence Based Intervention
Course 4: Data Driven Intervention
http://www.jefferson.edu/health_professions/occ
upational_therapy/programs/certificate_Autism
.cfm
Evidence for Sensory Based
Interventions with ASD
Inconclusive
No strong evidence
Corbett
Bettison
Auditory
Inconclusive
No strong evidence
Reichow, B
Fertel-Daly,D
Kane, A
WT Vests
Emerging
Variable intervention;
no control group
no fidelity
T. Field
Silva
Massage
Touch Therapy
Limitations Key
Authors
Intervention
Evidence for Sensory Based
Interventions
Promising Deitz, J
Schilling
Schwartz
Therapy
Balls
Very weak
No subject descriptions
No report of statistical
significance
Kimball, J
Wilbarger, P
Brushing