Sensory integration was a term coined by A Jean Ayres. Ayres (1972) described sensory integration as ‘the organisation of the senses for use.’ Throughout her lifetime, Ayres developed assessment tools and a treatment approach informed by her theory of sensory integration. This approach is still widely used by paediatric occupational therapists today. As the ultimate aim of sensory integration treatment is to support and develop brain connections, it is considered to be a ‘bottom-up’ approach.
What is sensory integration therapy? Development of fidelity measure
Many of the early systematic reviews looking at sensory integration, especially within education literature, included all research describing ‘sensory integration.’ Within this research, there was no robust definition of what constituted sensory integration treatment. This issue has frequently been identified by sensory integration researchers.
To address the problem, Parnham et al (2007) published the Ayres Sensory Integration (ASI) fidelity measure. This fidelity measure outlines the core features of ASI treatment. The measure includes details regarding the level of training therapists must have completed, and descriptions of the space and the equipment that should be used during Ayres Sensory Integration treatment. It also outlines criteria that describe what therapy sessions should look like. One essential criterion of ASI treatment is that it is child-led. A second essential criterion is that the child must be actively engaging in sensory experiences. The fidelity measure aims to ensure that there is consistency across studies claiming to use the ASI treatment approach.
The outlined criteria mean that Ayres Sensory Integration (ASI) treatment is very different from the use of sensory strategies, such as wobble cushions, fidget toys or weighted vests, commonly used in schools. It is also very different from techniques such as brushing or listening therapies, where the child is not actively engaged. Whilst these strategies and techniques are informed by the sensory integration theoretical model, they are not considered to be sensory integration treatment when scored using the ASI fidelity measure.
If you are reading any research on sensory integration treatment, it is important to check if the authors have used this fidelity measure to define their treatment approach. Unfortunately, despite the existence of this measure for over ten years, newly published studies continue to incorrectly use the term ‘sensory integration therapy’ to describe their interventions. An example of this would include Mohammed and Karim (2017), who compared sensory integration treatment with the use of console games. These authors did not use the ASI fidelity measure despite saying they were using ‘sensory integration treatment.’ This was disappointing as their research demonstrated greater improvements in the group engaged in therapy vs those in the console game group.
The most recent systematic review of Ayres Sensory Integration (ASI) with children with autism was completed by Schaaf, et al. (2018). These authors only included studies that used the fidelity measure to quantify sensory integration treatment. Three randomised controlled trials, one retroactive analysis and one single-subject ABA design report were identified. The authors found emerging but insufficient evidence to support the use of ASI to improve play, sensory-motor and language skills. A moderate degree of evidence was found to support the use of ASI to help to improve behaviours and increase independence with self-care activities. There was, however, strong evidence that ASI treatment provides positive outcomes for improving function and participation goals in children with autism. These goals were individualised depending on the child’s needs.
Whilst results are not yet available, an exciting piece of research is currently being completed at Cardiff University. Radell et al (2019) are running a randomised control trial comparing sensory integration treatment against usual care in children with autism. The researchers aim to recruit 216 children within the UK to participate in the trial. The study includes sites in South Wales, Cornwell and more recently Buckinghamshire. Both private clinics and NHS centres are involved. Children involved in sensory integration therapy will receive two sessions a week for ten weeks.
The control group will receive the usual care provided. All sensory integration therapy will be scored against the fidelity measure. The study aims to provide high-quality evidence on the clinical and cost-effectiveness of Ayres Sensory Integration. It is being funded by the National Institute for Health Research (reference 15/106/04) and the results should give clear data on the true effectiveness of ASI for children with autism.
Bringing it all together
Since its inception in the 1970s, sensory integration has always garnered attention. Whilst there was significant support for the model in the 70s and early 80s it was more heavily criticised in the late 80s and throughout the 90s. This coincided with a move towards a more top-down approach within education and therapies. A significant problem with much of the research at this time was that sensory integration treatment was poorly defined. This meant that systematic reviews were effectively comparing apples with oranges and watermelons.
Over the last fifteen years sensory integration researchers have strived to ensure that their research is robust and that there is a clear definition of what constitutes Ayres Sensory Integration treatment. There is now strong evidence that ASI treatment provides positive outcomes for improving individualised function and participation goals in children with autism and emerging evidence it help to support other areas. It is hoped that the ongoing research will provide further support for this treatment model.
Kim @Griffin_OT is a trained occupational therapist. She has extensive experience working with children who have sensory and/ or motor skill challenges, including those with autism. Her current focus is on creating online sensory resources, training and motor skill development programmes for schools, teachers and parents. View her site at www.GriffinOT.com/eduk1.
Ayres, A.J. (1972). Sensory Integration and Learning Disorders. Western Psychology Services: Los Angles.
Mohammed AH, Karim AElSA (2017) Gamification Does Not Replace Sensory Integration Training in Autistic Children. Autism Open Access 7:214. doi:10.4172/2165-7890.1000214.
Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J. A., Miller, L. J., Burke, J. P. et al. (2007). Fidelity in sensory integration practice intervention research. American Journal of Occupational Therapy, 61, 216–227.
Randell, R. et al (2019) Sensory integration therapy vs usual care for sensory procesing difficulties in autism spectrum disorder in children: study protocol for a pragmatic randomised control trial. BMC Trials. https://doi.org/10.1186/s13063-019-3205-y
Schaaf, R. C., Dumont, R. L., Arbesman, M., & May-Benson, T. A. (2018). Efficacy of occupational therapy using Ayres Sensory Integration®: A systematic review. American Journal of Occupational Therapy, 72, 7201190010. https://doi.org/10.5014/ ajot.2018.028431.