Running Head: AYRES SI FOR CHILDREN WITH ASD 1

Evaluating the Effects of Ayres’ Sensory Integration on Occupational Participation in Children

with Low-Functioning Autism

Bailey Knudsen and John Barker

Department of Occupational Therapy, University of Utah

April 26, 2020

Running Head: AYRES SI FOR CHILDREN WITH ASD 2

Introduction

Rationale

Symptoms of Autism Spectrum Disorder (ASD) generally appear during the first two

years of a child’s life and can be diagnosed at any age. It is a developmental disorder as well as a

spectrum disorder because it has a variety of differing symptoms and levels of severity. The

severity of ASD can range from low, moderate, to high and can cause difficulty processing and

integrating sensory information (National Institute of Mental Health, 2018). Sensory functions

transcend a broad range of aspects in a child's life. Difficulty processing and regulating sensory

information in children with ASD may cause unusual and routine behaviors, inappropriate

behavior, impact the ability to appropriately regulate emotions, cause difficulties with social and

communication skills, and impact many domains of a child’s life at home, school, and in the

community. These deficits have the potential to disrupt a child’s development and can cause

difficulty in their participation in daily life activities (Preis & McKenna, 2014). ASD affects

many children and adults worldwide. According to the Centers for Disease Control and

Prevention (CDC), 1 out of 59 children are diagnosed with ASD with a prevalence rate of 16.8

cases per 1,000 children. Prevalence is higher in white non-Hispanic and black non-Hispanic

populations in comparison to the Hispanic population and is 4 times more prevalent in males

than females (2019).

Occupational therapists (OT) often work with individuals with ASD and implement a

variety of interventions such as expressive therapy groups, self-awareness training, cognitive-

behavioral therapy, and neurodevelopmental therapy. One of the most applied interventions is

Ayres’ Sensory Integration (Cole, 2012, p. 255). Ayres’ Sensory Integration (SI) was developed

by A. Jean Ayres in the 1960’s and 1970’s. Ayres theorized that when a child experiences
Running Head: AYRES SI FOR CHILDREN WITH ASD 3

different sensory inputs, their behavior will change as well. Sensory processing is a neurological

process that includes “detection, assimilation, organization, interpretation, and use of sensory

information that allows an individual to interact adaptively within the environment in daily

activities at home, at school, and in other settings” (Roley, Bissell, & Clark, 2009). In short, a

sensory stimulus that is experienced by an individual may be linked to their behavioral output

(Boyt Schell & Gillen, 2019).

According to research, 45 to 96% of children with ASD have sensory processing and

integration difficulties. SI therapy is often used by OTs in children and adults who have sensory

processing deficits. For example, OTs can deliver SI in school settings when a child has an

individualized education plan (IEP) (Roley et al, 2009). Although there is some positive

evidence of its usefulness, there is a lack of research about whether SI therapy is effective when

implemented specifically with children who have ASD (Schaaf, Hunt, & Benevides, 2013).

Research on whether SI produces positive outcomes in children who have ASD in their

engagement in daily life occupations such as play, education, social relationships, and home-life

could provide OT and other practitioners evidence that may assure its effectiveness when applied

in a clinical setting.

Objective

This systematic review aims to investigate evidence on SI when implemented in children

with low-functioning ASD. The research will seek to determine its level of effectiveness for

sensory processing ability, functional skills, and behaviors, which in turn may affect

participation in daily life occupations.

Running Head: AYRES SI FOR CHILDREN WITH ASD 4

Methods
Search Strategy

CINAHL and PubMED were the electronic databases utilized for this systematic review.

Research was based on the following PICO question: In children with low-functioning autism,

does Ayres’ sensory integration affect participation in daily life occupations? Searches were

conducted using keywords such as sensory integration, autism spectrum disorder, autism, child

development disorders, pervasive, and Ayres. AND and OR Boolean operators were used to

broaden or narrow keyword searches, parentheses and quotation mark Boolean operators were

used to combine keywords together, and TI and AB Boolean operators were used to ensure that

the keywords would be present in article titles and/or abstracts. MeSH terms were also utilized to

include articles indexed in the databases as pertaining to the keywords. Results from the searches

were exported into EndNote to be reviewed for eligibility. Article duplicates across the two

databases were removed. A few additional articles found through article reference pages were

exported into EndNote for further review. Once all articles were present in Endnote, they were

screened by title, abstract, and full text (see Table 1). Articles were excluded at each screening

according to inclusion and exclusion criteria.

Eligibility Criteria

Inclusion criteria. Studies included in the systematic review met the following criteria:

● Included human children in the age range from 1-12 years of age

● Included participants had low functioning ASD

● Utilized SI

● Published in English

● Published within year range from 2009-2019

Running Head: AYRES SI FOR CHILDREN WITH ASD 5

Exclusion criteria. Studies with the following characteristics were excluded from the systematic

review:

● Included participants greater than 12 years of age

● Included nonhuman subjects

● Did not utilize SI

● Included participants with high functioning ASD or other conditions

● Not published in English

● Published before 2009 or after 2019

○ All included articles were published between 2011-2019

Running Head: AYRES SI FOR CHILDREN WITH ASD 6

Each article was assessed according to the Oxford 2011 Levels of Evidence. Oxford

Levels of evidence range from 1A being highest level of evidence to 5 being the lowest. Level

1A evidence includes systematic reviews of homogeneous randomized control trials. Level 1B

evidence includes well-designed individual randomized control trials. Level 2B evidence

includes individual prospective cohort studies, low quality randomized control trials, ecological

studies, and two group nonrandomized studies. Level 3A evidence includes systematic reviews

of case-control studies. Level 3B evidence includes individual retrospective case-control studies,

one group nonrandomized pre-posttest studies, and retrospective cohort studies. Level 4 evidence

includes case series, single subject research, and low-quality cohort and case-control studies.

Lastly, level 5 evidence includes case studies and expert opinions without explicit critical

appraisal. All articles included in the systematic were evaluated by the two authors and assigned

level of evidence. Levels of evidence were adjusted according to further investigation and input

given by the authors’ professor (See Table 2).

Running Head: AYRES SI FOR CHILDREN WITH ASD 7
Running Head: AYRES SI FOR CHILDREN WITH ASD 8

Quality Assessment

The research articles were evaluated to determine risk of bias using study quality

assessment tools. The first risk of bias table is used to assess risk of bias in 2 or 2 + group

studies, randomized or nonrandomized (See Table 3). The second risk of bias table is an

assessment tool adapted by the American Occupational Therapy Association (AOTA) from the

National Heart, Lung and Blood Institute (NHLBI) and is used to assess articles for risk of bias

in non-control research studies (See Table 4) (Higgins, 2016 & NHLBI, 2014). Each article was

reviewed individually to determine the risk of bias using the appropriate assessment tool.
Running Head: AYRES SI FOR CHILDREN WITH ASD 9
Running Head: AYRES SI FOR CHILDREN WITH ASD 10

Results

Six quantitative studies included in the systematic review, based on study designs and

implementation, were levels of evidence 2B except for two articles. One article by Xu Yao, and

Liu (2019) was determined to be level 1B. Another article by Sniezyk and colleagues (2015) was

determined to be level 4. Details of each study are found in the evidence table (see Table 2). The

risk of bias assessment determined that all five RCTs were identified to have a low risk of bias

(see Table 3). The assessment determined that the case series had a moderate risk of bias (see

Table 4). The articles in the review examined the effects of SI on many dependent variables

relating to occupational participation. Several articles focused on functional skills as an outcome.

Many articles focused on behaviors. Some behaviors were considered negative behaviors that

children with autism might need to adapt such as stereotypy, social isolation, and inappropriate

communication. Other behaviors were positive, in which children with autism might need to

improve on to effectively participate in occupations such as adaptive behaviors and social

engagement. Lastly, many studies targeted the outcome of sensory processing. The

aforementioned outcomes, in relation to SI and occupational participation in children with low-

functioning autism are summarized below.

Functional Skills

Many of the included studies focused on variations of functional skills as an outcome.

Functional skills examined in the studies included play skills, social skills, and general functional

skills. Overall, the results were similar across the studies in that most participants improved in

social skills after having SI intervention. Dunbar Carr-Hertel, Perez, & Ricks (2012) found that

SI improves play skills, however there were improvements in both independent variable groups,
Running Head: AYRES SI FOR CHILDREN WITH ASD 11

leaving inconclusive results. Schaaf et al. (2013) found that children in the SI intervention group

improved significantly on their individualized functional skill goals, but other tests resulted in no

significant differences between both the SI and control groups. The SI treatment group displayed

more significant improvement in treatment effects on functional behaviors and social functions than the

control group. Results were mixed in this study, with the standard measures showing no

differences, but there was improvement in the GAS where the items targeted goals specific to the

children. The randomized control trial by Pfeiffer, Koenig, Kinnaley, Sheppard, & Henderson,

(2011) produced similar findings that SI and the fine motor control group showed improvement

in functional behaviors with no significant differences between groups.

Dunbar and colleagues (2012) compared the effectiveness of SI treatment to an integrated

preschool on play skills. The SI treatment group included individualized therapy sessions in

which specific students were pulled out of the preschool classroom and sensory needs were

addressed 2x/week for 30 minute sessions, while the preschool classroom group included general

sensory activities (vestibular, proprioceptive, tactile). Time was matched in both intervention

groups. Results showed that both the pull-out group and sensory integrated classroom group had

improved mean scores of play skills, however no inferential statistics were used to test the

effects.

In another study, the effects of SI as outlined by Ayres were evaluated for 10 weeks

through an RCT with 32 children. At random, 17 children were assigned to an intervention group

receiving SI and 15 children were assigned to a control group. They found that the SI group had

more significant improvement in functional skills such as social, self-care, and mobility than the

control group. The SI group also had significant improvement on their individualized GAS goals,

showed a decrease in negative behaviors, and needed less assistance by caregivers for social and

self-care activities.
Running Head: AYRES SI FOR CHILDREN WITH ASD 12

In a similar study, Pfieffer et al. (2011) assessed the effectiveness of SI in 32 children

with ASD. From the sample, 20 children were randomly assigned to the SI group and 17 children

were randomly assigned to the fine motor (FM) intervention group. Both groups showed

significant improvement in their individualized GAS goals. Improvements were seen across both

groups in sensory processing regulation, functional motor skills, and social-emotional skills.

QNST-II is an evaluation tool to identify possible neurological barriers in learning in children

from kindergarten to the 12th grade. It assesses areas such as visual tracking, tactile perception,

motor skills, praxis, dexterity, and spatial awareness. Subgroups from both the SI and FM groups

were not able to complete the QNST-II in the pre-test phase, but after the 6 week intervention

program 70% of participants in the SI subgroup and 17% of participants in the FM subgroup

were both able to partially complete or finish it. The significant improvements seen in the SI

group were social responsiveness and autistic mannerisms which demonstrated progress in

sensory processing, fine motor skills, and social-emotional function (Pfeiffer et al., 2011).

Behaviors

Some studies examined behaviors such as socially appropriate and adaptive behaviors.

Overall, the results of the studies were mixed about the ability of SI to improve behavior. One

study found that SI improves autistic behaviors such as sensory regulation, language, life

management, and conscious movement (Xu et al., 2019). Sniezyk & Zane, (2015) performed a

case study in 3 children with ASD and found that behaviors improved during SI intervention

phases but also during non-intervention phases. Results in their study displayed that behavior

improved whether SI was implemented or not and that further research was needed (2015). In

contrast, Schaaf et al. (2013) found there was a decrease in autism behaviors in the SI

intervention group.
Running Head: AYRES SI FOR CHILDREN WITH ASD 13

Xu and colleagues (2019) examined the effectiveness of SI in addition to routine

treatment versus routine treatment alone in treating the behaviors of autism using a randomized

control trial. Routine treatment included education and psychotherapy. The study included 102

children diagnosed with autism (ages 2-14). The CARS scale and Autistic Behavior Checklist

(ABC) were used to assess changes in autism behaviors. The investigators found that the

difference in pre and post CARS scores between the groups were statistically significant (the SI

group improved more than the routine care group). They also found that Autistic behaviors

improved in both groups in pre and post CARS scores.

Sniezyk & Zane (2015) followed 3 children, ages 2-3.5 who were diagnosed with ASD.

The purpose of the study was to evaluate SI and its effectiveness in treating stereotypic or

repetitive behaviors often seen in children with ASD. The study concluded that there were no

significant results and that findings were inconsistent with what is found in literature. Behaviors

in children decreased both during intervention and when no intervention was implemented. No

link could be established on whether SI influenced stereotypy or target behaviors. In the

randomized controlled trial by Schaaf et al. (2013), results revealed no significant difference in

improvement between both groups and that they both improved on the effects on autistic

behaviors such as sensory and perceptual approach behaviors, adaptive behaviors, resistance to

change, and sensory regulation.

Sensory Processing and Integration

Many of the studies measured outcomes related to sensory processing and integration.

Overall, the results were mixed. One study found that SI improves sensory processing in all

domains, except emotional reactivity (Kashefimehr, Kayihan, & Huri, 2018). Another study

found that there was improvement in autistic mannerisms in the intervention groups, but that
Running Head: AYRES SI FOR CHILDREN WITH ASD 14

there were no significant differences in the sensory processing scores of either (Pieffer et al.,

2011). Schaff et al. (2013) found that there was a decrease in autistic behaviors in the

intervention group. Although there were no significant differences in the post-intervention scores

of sensory regulation, there were improvements in the participant’s ability to process and

modulate sensory inputs which facilitated improvement in the regulation of behavior.

Kashefimehr et al. (2018) examined the effectiveness of SI vs control (wait list) on

sensory processing and occupational performance in children with autism using a randomized

control trial. Sensory processing was assessed with Dunn’s Sensory Processing Screening tool.

From a sample of 31 children, 16 were randomly assigned to the intervention group in which

they were given SI for 45 minutes, twice per week and their parents received education about it.

The other 15 children were randomly assigned to the waitlist control group. The intervention

group also showed significant improvements in all domains of sensory processing, except the

“emotionally reactive” factor.

Schaaf et al. (2013) found that there was no significant difference in post-testing scores

between the SI group and control group in sensory regulation. Post-intervention results for the SI

group found that the tailored interventions developed to target GAS goals improved the

children’s ability to modulate sensory information which in turn allowed them to better regulate

behavioral responses to the sensory input around them (2013). Pfeiffer et al. (2011) similarly

implemented individualized GAS goals that focused on the area of sensory processing and

sensory regulation. The Sensory Processing Measure (SPM) assesses processing issues in the

sensory systems of visual, tactile, auditory, vestibular and proprioceptive senses as well as social

participation and praxis. There were no significant differences in improvement between both the

SI and FM group in sensory processing scores post-intervention.

Running Head: AYRES SI FOR CHILDREN WITH ASD 15

Discussion

This systematic review sought to find evidence on the effectiveness of SI on sensory

processing ability and occupational participation when implemented in children with low-

functioning autism. Overall, the evidence is mixed regarding the effects of SI on functional

skills, sensory processing, and behaviors, but there were no results particularly about

participation in occupations in children with low-functioning autism. However, the outcomes

mentioned are important aspects of occupational participation.

Effectiveness of SI and Functional Skills

Dunbar et al. (2012) found improvement in play skills in both the sensory classroom and

individualized SI pull-out group. Both intervention groups incorporated sensory activities and

there was no control group receiving a non-sensory intervention. Since the researchers did not

compute inferential statistics to test potential differences between groups, the results of the

studies were unclear, with no clear patterns of significance. It is also important to note that the

study only had a sample size of 7, which makes it difficult to extract meaningful findings. In one

level 2B RCT, it was found that both intervention groups improved in functional skills, but there

were no significant differences. Both interventions were similar in nature, which could explain

their similarities in functional skill improvement (Pfieffer et al., 2011).

A case study in the RCT by Schaaf, Hunt, & Benevides et al., (2012), found significant

improvement in functional skills following SI compared to the control group. The case study

describes a child during the 10 week program who improved in the functional skill areas such as

decreased excessive rocking to go to sleep, improved completing 3 step tasks in dressing

routines, participation in play, safety awareness, and fine motor skills. However, there was

limited evidence of a causal link between the improvement and the intervention. The
Running Head: AYRES SI FOR CHILDREN WITH ASD 16

improvement could have been due to confounds such as the use of personalized GAS goals, not

SI itself. Additionally, since parents were not blind to the intervention, interpretation of GAS

scores needs to be analyzed with caution (Schaaf, et al., 2013). Due to the lack of control,

internal validity could have been compromised in the studies examining the relationship between

SI and functional skills.

Effectiveness of SI and Behaviors

The ability of children with low functioning autism to display appropriate and adaptive

behaviors in many ranges of situations can play an integral role in occupational participation.

The RCT by Xu and colleagues (2019) found significant differences in autistic behaviors

between the SI group and the control (routine) group. Some autistic behaviors listed relate to

language, life management, etc., which arguably contribute to occupational participation. Since

the SI group had more significant improvements, it may show that while routine treatment

(education and psychoeducation) can be beneficial, it is not the most effective when used alone

(Xu et al., 2019). SI in combination with routine treatment can have many benefits, including

increased attention, awareness, and quality of life. The basic improvements resulting from SI can

potentially improve many aspects of the life of children with autism (Xu et al., 2019).

The case series by Sniezyk & Zane (2015) provided evidence that was not consistent with

literature about the effectiveness of SI in children with ASD. The behaviors of the 3 children

decreased whether an intervention was implemented or not, so a link could not be established

from the intervention to the target behavior being assessed. Being a low-quality cohort study

with only 3 participants demonstrates that this study does not reflect strong enough evidence to

come to confident conclusions. Interventions in this study only focused on one target behavior

per child and not holistically in other behavioral areas. This may have contributed to the poorer
Running Head: AYRES SI FOR CHILDREN WITH ASD 17

outcomes in their study and SI may not have been the contributing factor to the lack of

improvement.

Effectiveness of SI and Sensory Processing/Integration

According to the studies related to sensory processing outcomes, the child’s ability to

process and regulate sensory input affects other aspects of occupational participation such as

behavioral output and functional skills. Improvements in these sensory systems provide mixed

evidence that SI may be effective for children with ASD who have negative behaviors, struggle

with processing sensory input, sensory regulation, interacting with their environment, and who

have deficits in social & communication skills. The overall results provided information that SI

may be more likely to be effective when measured with GAS goals. GAS goals have the ability

to target specific goals that may not appear in standard assessments, but further research is

needed.

Study limitations

While some studies provided useful information regarding the effect of SI in children

with low-functioning autism, many of the studies had notable limitations, indicating that more,

higher level evidence research is needed on the topic. Researchers concluded that in studies

resulting in significant improvement there seemed to be research design flaws. They suggest that

future research is needed to develop more reliable protocols for the testing of sensory integration

(Sniezyk & Zane, 2015). Future research should utilize larger sample sizes to increase external

validity and clarity of the results. Longer intervention periods and follow-up testing after the

studies should additionally be implemented to improve SI interventions’ external validity

(Schaaf et al., 2013). Future studies should use control groups as well to increase internal validity

of results.
Running Head: AYRES SI FOR CHILDREN WITH ASD 18

Conclusion

With increasing interest in SI, it is of utmost importance that OTs and healthcare

professionals review reliable evidence prior to incorporating SI (Mailloux & Miller-Kuhaneck,

2014). In conclusion, based on the review of these studies, evidence is unclear regarding the

effectiveness of Ayre’s SI in children with low-functioning ASD in improving aspects of

occupational participation. Due to the scarcity of higher-level evidence in research, the external

and internal validity of Ayres’ SI remains at a moderate level and cannot improve until higher

quality evidence is acquired.

Running Head: AYRES SI FOR CHILDREN WITH ASD 19

References

Autism spectrum disorder. (2012, March). National Institute of Mental Health.

https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml

Boyt Schell, B., A., Gillen, G. (2019). Willard and Spackman’s Occupational therapy 13th

Edition. Philadelphia PA: Wolters Kluwer.

Cole, M. B, (2018). Group Dynamics in Occupational Therapy: The Theoretical Basis and

Practice Application of Group Intervention. Thorofare, NJ: Slack.

Data and statistics on autism spectrum disorder. (2019, September 23). Centers for Disease

Control and Prevention. https://www.cdc.gov/ncbddd/autism/data.html

Dunbar, S. B., Carr-Hertel, J., Perez, B., & Ricks, K. (2012). A pilot study comparison of

sensory integration treatment and integrated preschool activities for children with

autism. Internet Journal of Allied Health Sciences and Practice, 10(3), 1–8.

Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I, Reeves B, Eldridge S.

A revised tool for assessing risk of bias in randomized trials In: Chandler J, McKenzie J,

Boutron I, Welch V (editors). Cochrane Methods. Cochrane Database of Systematic

Reviews 2016, Issue 10 (Suppl 1). dx.doi.org/10.1002/14651858.CD201601.

Kashefimehr, B., Kayihan, H., & Huri, M. (2018). The effect of sensory integration therapy on

occupational performance in children with autism. OTJR: Occupation, Participation and

Health, 38(2), 75–83. doi: 10.1177/1539449217743456

Mailloux, Z., & Miller-Kuhaneck, H. (2014). Evolution of a theory: How measurement has

shaped Ayres Sensory Integration®. American Journal of Occupational Therapy, 68(5),

495–499. doi: 10.5014/ajot.2014.013656

Running Head: AYRES SI FOR CHILDREN WITH ASD 20

Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness

of sensory integration interventions in children with autism spectrum disorders: A pilot

study. American Journal of Occupational Therapy, 65(1), 76–85. doi:

10.5014/ajot.2011.09205

National Heart Lung and Blood Institute. Quality assessment tool for before-after (pre-post)

studies with no control group. 2014. Retrieved from https://www.nhlbi.nih.gov/health-

topics/study-quality-assessment-tools

Preis, J., & McKenna, M. (2014). The effects of sensory integration therapy on verbal expression

and engagement in children with autism. International Journal of Therapy &

Rehabilitation, 21(10), 476–486. https://doi.org/10.12968/ijtr.2014.21.10.476

Roley, S. S., Bissell, J., & Clark, G. F. (2009). Providing occupational therapy using sensory

integration theory and methods in school-based practice. American Journal of

Occupational Therapy, 63(6), 823–842. doi: 10.5014/ajot.63.6.823

Schaaf, R., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., Hooydonk, E., Freeman, R., Leiby,

B., Sendecki, J., & Kelly, D. (2014). An intervention for sensory difficulties in children

with autism: A randomized trial. Journal of Autism & Developmental Disorders, 44(7),

1493–1506. https://doi.org/10.1007/s10803-013-1983-8

Schaaf, R. C., Hunt, J., & Benevides, T. (2012). Occupational therapy using sensory integration

to improve participation of a child with autism: A case report. American Journal of

Occupational Therapy, 66(5), 547–555. https://doi.org/10.5014/ajot.2012.004473

Sniezyk, C. J., & Zane, T. L. (2015). Investigating the effects of sensory integration therapy in

decreasing stereotypy. Focus on Autism and Other Developmental Disabilities, 30(1),

13–22. doi: 10.1177/1088357614525663

Running Head: AYRES SI FOR CHILDREN WITH ASD 21

Xu, W., Yao, J., & Liu, W. (2019). Intervention effect of sensory integration training on the

behaviors and quality of life of children with autism. Psychiatria Danubina, 31(3), 340–

346. doi: 10.24869/psyd.2019.340