Occupational Therapy Using Sensory Integration to Improve Participation of a Child With Autism: A Case Report

Participant

D.Y. is a 5-yr, 5-mo-old boy who has been diagnosed with ASD and attention deficit hyperactivity disorder (ADHD). Autism diagnosis was confirmed using the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2000) Module 3 (Fluent Speech) as part of screening for this study. On the Gotham, Pickles, and Lord (2009) severity index, he rated a severity score of 7 out of possible 10, and he had a Full Scale IQ of 106 on the Stanford–Binet, fifth edition (Roid, 2003). He was randomized to the treatment group for this study. D.Y.’s mother provided parental permission for him to participate in this study in accordance with Thomas Jefferson University institutional review board procedures. His initials have been changed to maintain confidentiality.

A detailed history gathered from the child’s mother revealed that D.Y. was born by cesarean section after a full-term uncomplicated pregnancy. His medical history is nonsignificant, and his overall health is described as good. D.Y.’s ADHD-related symptoms have been managed with 10 mg methylphenidate hydrochloride extended release (Metadate CD) taken daily. He also takes 5 mg of melatonin nightly to help manage sleep difficulties. D.Y. resides with both of his parents and older brother in a suburban area. He attends public school with a half-day placement in an autism program and a half-day in a mainstream classroom with a 1:1 aide for behavioral support.

D.Y.’s mother was interviewed to determine areas of strength and need related to participation in home, school, and community activities. D.Y.’s mother described him as “very affectionate and super smart” but expressed concerns about his high activity level, distractibility, impulsivity, and clumsiness, stating that he was a safety risk at home and on the playground. She also described him as being “rigid,” getting “stuck” in activities, and having a hard time shifting his focus to engage in other activities, characteristics that make it difficult for him to play with his brother or other children. She indicated that he had difficulty generating ideas for play, stating that “he likes to play with other kids, but he doesn’t seem to know how” (D.Y.’s mother, personal communication, September 3, 2010). Moreover, she reported difficulty with his bedtime routine, stating that he engaged in rigorous rocking in a rocking chair for 20–30 min to help him fall asleep. He was also unable to dress himself, especially managing fasteners and orienting clothing.

Assessments

In addition to performing the detailed parent interview, an independent evaluator completed a series of assessments, as described in the sections that follow. The assessments included measures of sensory processing to determine whether D.Y.’s difficulties were related to poor sensory processing and praxis as well as behavioral assessments to evaluate adaptive skills and behaviors. All assessments, except for the Sensory Profile, were completed before randomization as well as within 2 wk after finishing treatment.

Assessment Findings

Results from the pretest and posttest SIPT and SEQ are displayed in Figures 1 and 2. These results, along with the findings on the pretest Sensory Profile, confirmed the hypothesis that deficits in sensory processing and praxis were affecting D.Y.’s ability to participate in social, play, home, and community activities. Briefly, D.Y. demonstrated hyperresponsivity to auditory, tactile, and oral–tactile sensory inputs (startles easily; shows distress during loud conversations; shows distress with grooming of the face, touching certain textures, and being touched by another person; is described as a picky eater, almost always refusing new foods). He also showed poor auditory filtering (difficulty responding to his name when called; frequently tunes out loud noises in his environment), hyporesponsivity to painful tactile input (frequently does not respond to painful stimuli), and seeking of vestibular input (seeks out movement activity that interferes with daily routine). SIPT scores indicated difficulty with tactile and kinesthetic processing, in particular Manual Form Perception (–2.70). He also demonstrated difficulty in motor planning ability as measured by Design Copy (–1.87), Postural Praxis (–1.56), Oral Praxis (–1.55), Sequencing Praxis (–2.02), and Motor Accuracy (–2.69). On the VABS–II, the subdomains of Receptive Communication, Personal Daily Living Skills, Play and Leisure Time Skills, and Gross and Fine Motor skills were rated as low, and Expressive Communication, Interpersonal Relationships, and Coping Skills were rated as moderately low.

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Figure 1.

Pretest and posttest scores on the Sensory Integration and Praxis Tests (SIPT).

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Figure 2.

Preintervention and postintervention scores on the Sensory Experiences Questionnaire (SEQ).

Individual Goals

Goals for D.Y. were established using standardized goal attainment scaling (GAS) as described by Kiresuk, Smith, and Cardillo (1994) and Mailloux et al. (2007). GAS is a quantitative alternative to traditional goals and objectives that allows for individualized goal setting and measurement. The independent evaluator was trained in the GAS methodology and, to increase objectivity for the posttest parent interview, was blinded to the intervention. The GAS process was implemented using the following guidelines:

Intervention

The intervention followed a manualized protocol (Schaaf et al., 2010) based on sensory integration principles (Ayres, 1972, 2005) that is structured to guide the therapist through the assessment and intervention process. The 10 key principles that guided intervention are detailed in the manual and are as follows (Parham et al., 2007):

The intervention was delivered by two registered and licensed occupational therapists with advanced training and certification in sensory integration and who were trained to competence on the approach.

Treatment integrity was measured using the Ayres Sensory Integration® Fidelity Measure (Parham et al., 2011). The measure has 10 items rated on a Likert scale ranging from 1 to 5, with 5 indicating strong agreement that the therapist used a particular component of the approach. A score of 100 indicates perfect adherence to interventions, and a score of ≥80 is considered acceptable adherence to OT–SI principles (Parham et al., 2007). This measure has been found to have an interrater reliability of .98 for total fidelity score, with individual item interrater reliabilities ranging from .94 to .99. Validity has been found to be strong because raters are able to accurately identify and distinguish OT–SI sessions from other intervention approaches with 92% accuracy. All of D.Y.’s treatment sessions were videotaped (N = 30), and independent evaluators who were trained in use of the instrument evaluated a random selection of 20% of available tapes (n = 6).

Results

As shown in Figure 1, D.Y. showed improvements on four of five SIPT tactile discrimination tasks (Finger Identification: pretest = −1.32, posttest = 0.36; Graphesthesia: pretest = −0.73, posttest = 0.36; Manual Form Perception: pretest = −2.70, posttest = −1.93; Kinesthesia: pretest = −1.20, posttest = 0.35). In addition, he improved on five of five praxis tests (Design Copy: pretest = −1.87, posttest = −1.03; Postural Praxis: pretest = −1.56, posttest = 0.49; Oral Praxis: pretest = −1.55, posttest = 0.49; Sequencing Praxis: pretest = −2.02, posttest = 0.21; Motor Accuracy: pretest = −2.60, posttest = 0.42).

SEQ item scores (see Figure 2) showed improvement in D.Y.’s ability to regulate and organize his responses to auditory, vestibular, tactile, and oral sensory input and movement. On the VABS–II, D.Y.’s Motor Skills standard score improved from a score of low to moderately low (from 61 to 75), and his Communication standard score changed from moderately low to adequate (from 78 to 87). His Adaptive Behavior composite score changed from low to moderately low (from 69 to 75). Socialization and daily living standard scores were unchanged.

As shown in Figure 3, all PDDBI scores on the Approach/Withdrawal Problems Scale decreased, indicating positive changes in these behaviors. Specifically, notable decreases (improvements) occurred in two subdomains: Ritualisms and Resistance to Change and Specific Fears. Specific Fears includes items such as fear responses to sensory input (e.g., auditory noises in the environment).

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Figure 3.

Pretest and posttest scores on the Pervasive Developmental Disorder Behavior Inventory (PDDBI).

Parent postintervention rating of D.Y.’s GAS yielded a T score of 68, indicating better-than-expected achievement on goals. 3 The outcome (rating = 2) on his second goal (play with peers) was much better than expected, and the outcomes on the other four goals (rating = 1) were better than expected. Average fidelity ratings were 95.5 of a possible 100, indicating that the therapist’s intervention had high fidelity to OT–SI principles (Parham et al., 2011).

A parent interview conducted at the end of the 10-wk intervention by an evaluator blind to D.Y.’s treatment condition indicated parent-perceived improvement in D.Y.’s adaptive behaviors and participation. D.Y.’s mother described him as a happier child with less-rigid behaviors and increased tolerance of unexpected changes in the routine. She reported being able to go places without having to tell D.Y. ahead of time (more flexibility in his behavior) and being able to make unexpected stops during their outings without him becoming upset. D.Y.’s mother reported a decrease in his activity level, distractibility, and impulsivity, with better safety during play and daily activities. She also reported that D.Y. improved in his play skills, stating that

D.Y. was reported to be able to participate more successfully in dressing, requiring less help from a parent. His bedtime routine changed, and he no longer engaged in excessive rocking before falling asleep. On a few occasions, D.Y.’s mother reported that she was now able to tuck him in his bed and read a book with him before he fell asleep, which was a welcome improvement. Moreover, D.Y.’s teacher reported to his mother that “D.Y.’s attention in the classroom was so much better that he did not need the aide at all for his schoolwork.” D.Y. was reported to be doing well socially at school and was not having any difficulty interacting with his peers (D.Y.’s mother, personal communication, December 30, 2010).

Discussion

Ayres’ (1972, 2005) Theory of Sensory Integration claims that adequate processing and integration of sensory information is an important foundation for learning and behavior. Following this theory, occupational therapists often use the principles of sensory integration to address the underlying sensory–motor mechanisms that may be affecting adaptive behaviors and participation in daily activities. However, the evidence linking changes in these proposed mechanisms to the observed changes in behaviors is limited. This case report describes one child’s changes in adaptive behaviors; individualized, participation-focused goals; and concurrent changes in objective tests of sensory processing and praxis. Given that the literature has called for systematic investigation of interventions for people with autism—specifically the development and testing of a manualized protocol beginning with case reports (Smith et al., 2007)—this case report provides preliminary data supporting the use of this manualized intervention protocol and its fidelity measure to guide future studies. More important, this study links changes in behavior and participation to changes in the ability to process and integrate sensory information for improved praxis and, as such, provides preliminary evidence for this approach.

A second important contribution of this study is the explication of a systematic method of clinical reasoning that builds on the work of Sugai, Lewis-Palmer, and Hagan-Burke (2000) and Blanche (2001, 2006) and can be used as a model for best practice. Standardized assessment findings and sensory integration theory can be used to generate and test hypotheses about the potential underlying sensory and motor mechanisms contributing to participation limitation. Once the hypotheses and potential underlying mechanisms are identified, the manualized protocol can be used to develop treatment strategies. Finally, measurement of proximal (sensory and motor) and distal (participation-oriented) outcomes provides a strategy for hypothesis testing and validation. This method is displayed in Table 1 and clearly links the changes in D.Y.’s behavior and participation to the sensory–motor mechanisms hypothesized to underlie his difficulties.

Regarding outcome measures, this study builds on the existing evidence showing that GAS is a useful method for quantifying individual outcomes (Mailloux et al., 2007). Not only does GAS provide a means to link proposed mechanisms affecting goal attainment, but it also provides a measure of change on individualized, functional, parent-generated goals. Although the VABS–II and the PDDBI did capture some of these behavioral changes, GAS allowed specific documentation and quantification of changes in these individualized goals and may thus be a useful supplement to other assessments when measuring behavioral outcomes of an intervention for people with ASD.

The SIPT is an objective, standardized assessment of sensory integration and praxis with adequate test–retest reliability (Ayres, 1989). It is important that the SIPT did detect changes postintervention that were consistent with parent-reported behavioral improvements and thus shows promise as an outcome measure for detecting changes in sensory processing and praxis ability that may affect behavioral outcomes. Many of the measures of sensory processing that are available today use parent report and thus may compromise the rigor of the study findings.

Finally, an interesting note is that D.Y. improved in his motor skills as reflected in the VABS–II Motor domain scores. This finding is consistent with the literature that has shown that sensory interventions affect motor skills. For example, in a review of intervention studies using sensory approaches, May-Benson and Koomar (2010) found evidence that motor skills were a positive outcome of sensory integration interventions. This case study further supports their finding and points to the need to measure motor skills as an outcome in future studies.

Although the limitations of a case report include lack of generalizability or ability to distinguish treatment effects from maturation effects, this case report represents 1 child in a larger RCT that is currently ongoing. By highlighting the importance of the systematic data collection processes, the hypothesis generation, and the tailored therapeutic approach to parent and child goals, we have detailed the nuances of the occupational therapy process used in OT–SI.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

Conclusion

This case report provides preliminary evidence of the efficacy of occupational therapy using a manualized protocol based on the principles of sensory integration for a child with autism. Given the relatively brief intervention period of 10 wk, these findings are particularly interesting and may be strengthened even further with a longer intervention period. In addition, this report demonstrates the implementation of a manualized protocol with hypothesis generation and testing and fidelity measurement as a model for best practice.