Sensory and Auditory Integration Therapy

Number: 0256

Policy

Aetna considers sensory integration therapy and auditory integration therapy (also known as auditory integration training) experimental and investigational for the management of persons with various communication, behavioral, emotional, and learning disorders and for all other indications.  The effectiveness of these therapies is unproven.

Background

Sensory integration refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound and gravity.  It has been postulated that certain behavioral and emotional problems result from the malfunctioning of this process.  Sensory integration therapy (SIT) is a type of treatment usually performed by occupational therapists or physical therapists who provide various sensory stimulation to the patient, often in combination with and within the context of purposeful muscle activities, to improve how the brain processes and organizes sensory information.  This type of therapy requires activities that consist of full body movements employing different kinds of equipment such as textured mitts, carpet squares, scooter boards, ramps, swings, and bounce pads.  It is believed that SIT does not teach higher level skills, but enhances the sensory processing abilities of the subject to acquire them.

Although the use of SIT as a treatment for children with learning disabilities and other behavioral disorders (e.g., autism, attention-deficit disorder, fragile X syndrome, and developmental delay) has been quite popular, there is widespread skepticism regarding its effectiveness.  Kaplan et al (1993) stated that SIT is not more effective than other, more conventional methods of treatment for children with learning disabilities.  Hoehn and Baumeister (1994) reported that SIT is not only an unproven, but also an ineffective, primary or adjunctive remedial treatment for children with learning disabilities and other disorders.

Tharpe (1996) stated that "Although anecdotal reports and testimonials of positive treatment outcomes abound, there remains a dearth of empirical studies designed to scrutinize the claims made by proponents of auditory integration therapy. Until such time that auditory integration therapy technology meets the standards of scientific efficacy, it is best considered to be an experimental treatment...."  Furthermore, the American Speech-Language-Hearing Association declared that auditory integration training is an experimental procedure because it has not yet satisfied standards for effectiveness that would justify the inclusion of this method as a mainstream treatment for a variety of communication, behavioral, emotional, and learning disorders.  The American Academy of Pediatrics (1998) has suggested that auditory integration training should be used for research purposes only.

An assessment of auditory integration therapy (AIT) for autism by the Wessex Institute concluded that trials have produced conflicting results, and it is uncertain whether AIT is any more effective than placebo (Best and Milne, 1997).  A systematic evidence review by Cullen et al (1999) concluded: "Previous claims for the benefits of AIT in reduction of problem behaviors and increases in intelligence quotient (IQ) and adaptive/social skills were not supported by the results. AIT may divert parents' and service providers' resources from better-validated interventions".

An assessment conducted by the National Initiative for Autism (UK) (2003) concluded: "Auditory integration therapy has also recently been subject to careful analysis, and again the results indicate that the effects are no greater than for placebo conditions [Mudford et al, 2000; Dawson and Watling, 2000]."

A meta-analysis of research on sensory integration treatment (Vargas and Camilli, 1999) concluded that more recent studies do not show overall positive effects from sensory or auditory integration therapies.

An assessment conducted by the National Initiative for Autism (UK) (2003) stated: "Experimental data in support of a variety of other treatments, such as Facilitated Communication, auditory or sensory integration programmes, psychoanalytically based interventions or teaching methods such as the Son Rise programme (Option), Walden or Daily Life Therapy (Higashi) did not exist".

An assessment conducted by Hender (2001) for the Centre for Clinical Effectiveness (Monash University) identified no randomized controlled clinical studies of SIT for attention-deficit hyperactivity disorder, and identified only 1 study (Werry et al, 1990), a comparative study with concurrent controls.  Hender (2001) noted the sources of bias that limit reaching definitive conclusions about the effectiveness of SIT for attention-deficit hyperactivity disorder from this single study.

An assessment conducted by the National Academy of Sciences (NAS) (2001) concluded that there is insufficient evidence of the effectiveness of SIT for autism.  The NAS report states that "[t]here is a paucity of research concerning sensory integration treatments in autism…. These interventions have also not yet been supported by empirical studies."  In addition, the American Academy of Pediatrics (AAP, 2001) stated that research data supporting the effectiveness of SIT in managing autistic children is scant.

The NAS (2001) concluded that there is insufficient evidence of the effectiveness of AIT in autism.  The NAS concluded that "auditory integration therapy has received more balanced investigation than has any other sensory approach to intervention, but in general studies have not supported either its theoretical basis or the specificity of its effectiveness."

Tochel (2003) performed a structured evidence review of SIT and AIT for the Wessex Institute.  Regarding SIT, the assessment concluded that "[w]e have found insufficient evidence about the clinical effects of sensory integration therapy in children with autistic spectrum disorders."  Regarding AIT, the report found "[w]eak evidence from limited research suggests that AIT is unlikely to be more effective than unprocessed music in children with autistic spectrum disorders, although both AIT and unprocessed music may be associated with similar improvement in some scores from baseline.  However, the clinical importance of these changes is unclear."

Sinha et al (2004) reported on the results of a structured evidence review for the Cochrane Collaboration of AIT for autism.  The investigators reported that there is "[n]o clear evidence yet for auditory integration therapy's effect on autism."  The investigators explained that "[s]ix relatively small studies met the inclusion criteria for AIT.  These largely measured different outcomes and reported mixed results.  Suggestion of benefit in two outcomes requires corroboration by further research using well-designed trials with long-term follow-up."  The review also concluded that more research is needed to inform parents', carers' and practitioners' decision making about this therapy for individuals with autism spectrum disorders (ASDs).

In a systematic review, Sinha and colleagues (2006) evaluated the effectiveness of AIT and other sound therapies in people (adults or children) with ASDs.  A total of 6 randomized controlled trials (RCTs) of AIT, including 1 cross-over study, were identified, with a total of 171 participants aged 3 to 39 years; 17 different outcome measures were used, with only 2 outcome measures used by 3 or more studies.  Meta-analysis was not possible owing to very high heterogeneity or presentation of data in unusable forms.  Three studies did not show any benefit of AIT over control conditions; 3 studies reported improvements at 3 months in the AIT group for total mean scores of the Aberrant Behavior Checklist (ABC), which is of questionable validity.  Of these, 1 study also reported improvements at 3 months in the AIT group for ABC subgroup scores.  No significant adverse effects of AIT were reported.  The authors concluded that currently there is insufficient evidence to support the use of AIT for individuals with ASDs.

Parham et al (2007) evaluated the validity of sensory integration outcomes research in relation to fidelity (faithfulness of intervention to underlying therapeutic principles).  These investigators identified core sensory integration intervention elements through expert review and nominal group process.  Elements were classified into structural (e.g., equipment used, therapist training) and therapeutic process categories.  They analyzed 34 sensory integration intervention studies for consistency of intervention descriptions with these elements.  They reported that most studies described structural elements related to therapeutic equipment and interveners' profession.  Of the 10 process elements, only 1 (presentation of sensory opportunities) was addressed in all studies.  Most studies described fewer than half of the process elements.  Intervention descriptions in 35 % of the studies were inconsistent with one process element, therapist-child collaboration.  The authors concluded that the validity of sensory integration outcomes studies is threatened by weak fidelity in regard to therapeutic process.  They stated that inferences regarding sensory integration effectiveness can not be drawn with confidence until fidelity is adequately addressed in outcomes research.

A systematic evidence review prepared for BMJ Clinical Evidence judged auditory integration training and sensory integration training to be of "unknown effectiveness" for the treatment of autism (Parr, 2006).  The assessment stated that they found no clinically important results about the effects of sensory integration training or auditory integration training on autism in children.

Fazlioglu and Baran (2008) examined the effect of a SIT program on sensory problems of children with autism (according to DSM-IV criteria).  Subjects were separated into 2 groups, each comprising 15 children aged 7 to 11 years.  They were assessed initially on a checklist, Sensory Evaluation Form for Children with Autism, developed to evaluate sensory characteristics of children with autism, and at the end of the study, participants were assessed again on the checklist.  Statistically significant differences between groups indicated that the sensory integration therapy program positively affected treated children.  It is unclear whether these effects are clinically significant.  The findings of this study need to be validated by more research.

Hess et al (2008) noted that the Autism Treatment Survey was developed to identify strategies used in education of children with ASD in Georgia.  Respondents of the web-based survey included a representative sample of 185 teachers across the state, reporting on 226 children with ASD in grades pre-school to 12th.  The top 5 strategies being used in Georgia (Gentle Teaching, sensory integration, cognitive behavioral modification, assistive technology, and Social Stories) are recognized as lacking a scientific basis for implementation.  Analysis revealed the choice of strategies varied by grade level and classroom type (e.g., general education, special education).  Results highlight clear implications for pre-service and in-service educator training, and the need for continued research to document evidence-based strategy use in public schools for students with ASD.

In a pilot study, Miller et al (2007a) examined the effectiveness of occupational therapy using a sensory integrative approach (OT-SI) for children who had sensory modulation disorders (SMDs).  This study evaluated the effectiveness of 3 treatment groups.  In addition, sample size estimates for a large scale, multi-site randomized controlled trial were calculated.  A total of 24 children with SMD were randomly assigned to one of three treatment conditions:
  1. OT-SI,
  2. activity protocol, and
  3. no treatment. 

Pre-test and post-test measures of behavior, sensory and adaptive functioning, and physiology were administered. The OT-SI group, compared to the other 2 groups, made significant gains on goal attainment scaling and on the Attention subtest and the Cognitive/Social composite of the Leiter International Performance Scale-Revised.  Compared to the control groups, OT-SI improvement trends on the Short Sensory Profile, Child Behavior Checklist, and electrodermal reactivity were in the hypothesized direction.  The authors concluded that the findings of this pilot study suggested that OT-SI may be effective in ameliorating difficulties of children with SMD.  They stated that more studies are needed to answer the plethora of questions relating understanding whether OT-SI is an effective intervention, for whom, and under what conditions.

Miller et al (2007b) prepared for a RCT of the effectiveness of OT-SI for children who have sensory processing disorders (SPD).  A one-group pre-test, post-test design with 30 children was completed with a subset of children with SPD, those with SMD.  Lessons learned relate to
  1. identifying a homogeneous sample with quantifiable inclusion criteria,
  2. developing an intervention manual for study replication and a fidelity to treatment measure,
  3. determining which outcomes are sensitive to change and relate to parents' priorities, and
  4. clarifying rigorous methodologies (e.g., blinded examiners, randomization, power). 

The authors concluded that a comprehensive program of research is needed, including multiple pilot studies to develop enough knowledge that high-quality effectiveness research in occupational therapy can be completed.  Previous effectiveness studies in OT-SI have been single projects not based on a unified long-term program of research.

In a review on autism, Levy and colleagues (2009) stated that popular biologically based treatments include anti-infectives, chelation medications, gastrointestinal medications, hyperbaric oxygen therapy, and intravenous immunoglobulins.  Non-biologically based treatments include AIT, chiropractic therapy, cranio-sacral manipulation, facilitated communication, interactive metronome, and transcranial stimulation.  However, few studies have addressed the safety and effectiveness of most of these treatments.

In a systematic review on novel and emerging treatments for ASD, Rossignol (2009) stated that currently, only 1 medication (risperidone) is approved by the Food and Drug Administration for the treatment of ASD.  The use of novel, unconventional, and off-label treatments for ASD is common, with up to 74 % of children with ASD using these treatments; however, treating physicians are often unaware of this usage.  The author performed a systematic literature search of electronic scientific databases was performed to identify studies of novel and emerging treatments for ASD, including nutritional supplements, diets, medications, and non-biological treatments.  A grade of recommendation ("Grade") was then assigned to each treatment using a validated evidence-based guideline as outlined in this review:  Grade A: Supported by at least 2 prospective RCTs or 1 systematic review; Grade B: Supported by at least 1 prospective RCT or 2 non-RCTs; Grade C: Supported by at least 1 non-RCT or 2 case series; and Grade D: Troublingly inconsistent or inconclusive studies or studies reporting no improvements.  Potential adverse effects for each treatment were also reviewed.  Grade A treatments for ASD include melatonin, acetylcholinesterase inhibitors, naltrexone, and music therapy.  Grade B treatments include carnitine, tetrahydrobiopterin, vitamin C, alpha-2 adrenergic agonists, hyperbaric oxygen treatment, immunomodulation and anti-inflammatory treatments, oxytocin, and vision therapy.  Grade C treatments for ASD include carnosine, multi-vitamin/mineral complex, piracetam, polyunsaturated fatty acids, vitamin B6/magnesium, elimination diets, chelation, cyproheptadine, famotidine, glutamate antagonists, acupuncture, AIT, massage, and neurofeedback.  The author concluded that the reviewed treatments for ASD are commonly used, and some are supported by prospective RCTs.  Promising treatments include melatonin, anti-oxidants, acetylcholinesterase inhibitors, naltrexone, and music therapy.  All of the reviewed treatments are currently considered off-label for ASD and some have adverse effects.  The author stated that further studies exploring these treatments are needed.

In a systematic review, May-Benson and colleagues (2010) evaluated the literature on the effectiveness of SIT on the ability of children with difficulty processing and integrating sensory information to engage in desired occupations and applied these findings to occupational therapy practice.  Results suggested the SIT may result in positive outcomes in sensori-motor skills and motor planning; socialization, attention, and behavioral regulation; reading-related skills; participation in active play; and achievement of individualized goals.  Gross motor skills, self-esteem, and reading gains may be sustained from 3 months to 2 years.  Findings may be limited by type II error because of small sample sizes, variable intervention dosage, lack of fidelity to intervention, and selection of outcomes that may not be meaningful to clients and families or may not change with amount of treatment provided.  The authors stated that replication of findings with methodologically and theoretically sound studies is needed to support current findings.

In a pilot study, Pfeiffer et al (2011) established a model for randomized controlled trial (RCT) research, identified appropriate outcome measures, and addressed the effectiveness of sensory integration (SI) interventions in children with autism spectrum disorders (ASD).  Children aged 6 to 12 years with ASD were randomly assigned to a fine motor or SI treatment group.  Pre-tests and post-tests measured social responsiveness, sensory processing, functional motor skills, and social-emotional factors.  Results identified significant positive changes in Goal Attainment Scaling (GAS) scores for both groups; more significant changes occurred in the SI group, and a significant decrease in autistic mannerisms occurred in the SI group.  No other results were significant.  The authors concluded that the findings of this study provided preliminary support for using SI interventions in children with ASD, although further research is needed.  Results identified significant progress toward individualized goals and a decrease in autistic mannerisms after SI interventions, although no significant changes were found on the other measures.  Results suggested implementing interventions that are generalized to home and community settings, using tools that allow for individualized sensitive measurement in future studies, and completing future studies with a larger sample

The authors stated that one of the objectives of this pilot study was to provide information to guide the development of future RCTs measuring the effectiveness of SI interventions in children with ASDs.  An important recommendation would be to ensure that subjects are more homogeneous so that the effectiveness of the interventions can be detected and clinically applied.  The use of a measure such as the Autism Diagnostic Observation Scale to establish groups that are more homogeneous in nature was suggested.  The groups in the current study varied greatly in their adaptive behavioral levels.  Although accounted for through statistical analysis in this study, other heterogeneous variables may have affected the outcome of the study specific to the diverse nature of ASD.  As mentioned previously, other considerations in designing future studies include carrying over interventions throughout daily routines, which is more characteristic of occupational therapy services, and using measurement tools that are more individualized because of the diverse nature of individuals with autism.  The GAS allows researchers to measure individualized outcomes but must be used in a method to ensure the greatest amount of reliability and validity.  Another consideration for future studies is the duration and intensity of interventions.  This study focused on intense interventions over a short period of time, 3 sessions/week for 6 weeks.  It is important to determine the most appropriate frequency and duration for interventions to guide intervention planning and funding recommendations.  Although the use of fidelity measures helped ensure consistency and validity of interventions, it is highly recommended that intervention manuals, in conjunction with fidelity measures, be developed for future effectiveness studies.  Finally, an RCT that includes a larger sample size and the establishment of inter-rater reliability of the fidelity measures is needed.

In a Cochrane review, Sinha and colleagues (2011) examined the effectiveness of AIT or other methods of sound therapy in individuals with ASDs.  For this update, these investigators searched the following databases in September 2010: CENTRAL (2010, Issue 2), MEDLINE (1950 to September week 2, 2010), EMBASE (1980 to Week 38, 2010), CINAHL (1937 to current), PsycINFO (1887 to current), ERIC (1966 to current), LILACS (September 2010) and the reference lists of published papers.  One new study was found for inclusion.  Randomized controlled trials involving adults or children with ASDs were included in this analysis.  Treatment was AIT or other sound therapies involving listening to music modified by filtering and modulation.  Control groups could involve no treatment, a waiting list, usual therapy or a placebo equivalent.  The outcomes were changes in core and associated features of ASDs, auditory processing, quality of life and adverse events.  Two independent review authors performed data extraction.  All outcome data in the included papers were continuous.  The authors calculated point estimates and standard errors from t-test scores and post-intervention means.  Meta-analysis was inappropriate for the available data.  They identified 6 RCTs of AIT and 1 of Tomatis therapy, involving a total of 182 individuals aged 3 to 39 years.  Two were cross-over trials; 5 trials had fewer than 20 participants.  Allocation concealment was inadequate for all studies.  Twenty different outcome measures were used and only 2 outcomes were used by 3 or more studies.  Meta-analysis was not possible due to very high heterogeneity or the presentation of data in unusable forms.  Three studies (Bettison 1996; Zollweg 1997; Mudford 2000) did not demonstrate any benefit of AIT over control conditions; 3 studies (Veale 1993; Rimland 1995; Edelson 1999) reported improvements at 3 months for the AIT group based on the Aberrant Behaviour Checklist, but they used a total score rather than subgroup scores, which is of questionable validity, and Veale's results did not reach statistical significance.  Rimland (1995) also reported improvements at 3 months in the AIT group for the Aberrant Behavior Checklist subgroup scores.  The study addressing Tomatis therapy (Corbett 2008) described an improvement in language with no difference between treatment and control conditions and did not report on the behavioral outcomes that were used in the AIT trials.  The authors concluded that there is no evidence that AIT or other sound therapies are effective as treatments for ASDs.  As synthesis of existing data has been limited by the disparate outcome measures used between studies, there is insufficient evidence to prove that this treatment is not effective.  However, of the 7 studies including 182 participants that have been reported to date, only 2 (with an author in common), involving a total of 35 participants, reported statistically significant improvements in the AIT group and for only 2 outcome measures (Aberrant Behavior Checklist and Fisher's Auditory Problems Checklist).  As such, there is no evidence to support the use of AIT at this time.

The AAP Committee on Children with Disabilities has stated that the scientific legitimacy of SIT has not been established for children with motor disabilities.  The AAP also stated that successful therapy programs are individually tailored to meet the child’s functional needs and should be comprehensive, coordinated, and integrated with educational and medical treatment plans, with consideration of the needs of parents and siblings.  This can be facilitated by primary care pediatricians and tertiary care centers working cooperatively to provide care coordination in the context of a medical home (AAP, 2004).  A statement of re-affirmation for this policy was published on September 1, 2007.

The AAP Council on Children with Disabilities published guidelines for the management of children with ASDs.  Regarding SIT, the guidelines stated that SIT is used alone or as part of a broader program of occupational therapy for children with ASDs.  Unusual sensory responses are common in children with ASDs, but there is not good evidence that these symptoms differentiate ASDs from other developmental disorders, and the effectiveness of SIT has not been demonstrated objectively.  Available studies are plagued by methodological limitations, but proponents of SIT noted that higher-quality SI research is forthcoming (Myers, et al, 2007).

The American Academy of Audiology’s position statement on auditory integration training (AAA, 2010) stated that auditory integration training (by any name) is investigational.  The AAA believes that prospective, systematic research of this technique is needed to determine its effectiveness.

The American Academy of Pediatrics’ position statement on "Sensory integration therapies for children with developmental and behavioral disorders" (2012) stated that "Sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders.  Sensory-based therapies involve activities that are believed to organize the sensory system by providing vestibular, proprioceptive, auditory, and tactile inputs.  Brushes, swings, balls, and other specially designed therapeutic or recreational equipment are used to provide these inputs.  However, it is unclear whether children who present with sensory-based problems have an actual "disorder" of the sensory pathways of the brain or whether these deficits are characteristics associated with other developmental and behavioral disorders.  Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed.  Other developmental and behavioral disorders must always be considered, and a thorough evaluation should be completed.  Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders.  Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan.  However, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive".

The American Academy of Child and Adolescent Psychiatry (AACAP)’s practice parameter for "The assessment and treatment of children and adolescents with autism spectrum disorder" (Volkmar et al, 2014) stated that "There is a lack of evidence for most other forms of psychosocial intervention, although cognitive behavioral therapy has shown efficacy for anxiety and anger management in high functioning youth with ASD.  Studies of sensory oriented interventions, such as auditory integration training, sensory integration therapy, and touch therapy/massage, have contained methodologic flaws and have yet to show replicable improvements".

Schaaf et al (2014) examined a manualized intervention for sensory difficulties for children with autism, aged 4 to 8 years, using a randomized trial design.  Diagnosis of autism was confirmed using gold standard measures.  Results showed that the children in the treatment group (n = 17) who received 30 sessions of the occupational therapy intervention (using sensory integration) scored significantly higher (p = 0.003, d = 1.2) on GAS (primary outcome), and also scored significantly better on measures of caregiver assistance in self-care (p = 0.008 d = 0.9) and socialization (p = 0.04, d = 0.7) than the Usual Care control group (n = 15).  The study showed high rigor in its measurement of treatment fidelity and use of a manualized protocol; it provided support for the use of this intervention for children with autism.  The authors concluded that the findings of this study provided evidence that this intervention may be a useful adjunct to a comprehensive intervention program for individuals with ASD who have functional and behavioral challenges related to difficulty processing and integrating of sensory information.  Moreover, these researchers stated that these findings should be interpreted with cautions until they are replicated in a larger sample size.  Furthermore, in future studies it would be useful to include additional outcome measures that rely on direct observation of goal attainment and sensory behaviors to provide further validation of GAS findings.  It would be important to supplement parent reported data with direct observational measures.  It would also be important to include a longer intervention period in future studies and follow-up testing to examine if the observed changes were maintained.  Finally, although these investigators randomized subjects based on autism severity and cognition, they were unable to include these strata in their analysis due to the small sample size.  These researchers stated that future studies would be strengthened by the inclusion of a larger sample so that impact of potentially confounding variables on treatment outcomes can be evaluated.  Of note, almost all subjects (30 of 32 children, or 94 %) demonstrated high severity of autism, and 22 or 68.75 % also had high IQ.  It would be useful if future studies utilizing this intervention include children with low severity and/or low cognition to examine if the findings from this study could be replicated with this sample.  Similarly, the sample of convenience resulted in a sample with little ethnic diversity and future studies should include subjects from more diverse backgrounds.

Case-Smith et al (2015) stated that children with ASDs often exhibit co-occurring sensory processing problems and receive interventions that target self-regulation.  In current practice, sensory interventions apply different theoretic constructs, focus on different goals, use a variety of sensory modalities, and involve markedly disparate procedures.  Previous reviews examined the effects of sensory interventions without acknowledging these inconsistencies.  This systematic review examined the research evidence (2000-2012) of 2 forms of sensory interventions, SIT and sensory-based interventions, for children with ASDs and concurrent sensory processing problems.  A total of 19 studies were reviewed: 5 examined the effects of SIT and 14 sensory-based interventions.  The studies defined SIT as clinic-based interventions that use sensory-rich, child-directed activities to improve a child's adaptive responses to sensory experiences.  Two RCTs found positive effects for SIT on child performance using Goal Attainment Scaling (effect sizes ranging from 0.72 to 1.62); other studies (Levels III to IV) found positive effects on reducing behaviors linked to sensory problems.  Sensory-based interventions are characterized as classroom-based interventions that use single-sensory strategies (e.g., weighted vests or therapy balls) to influence a child's state of arousal.  Few positive effects were found in sensory-based intervention studies.  Studies of sensory-based interventions suggested that they may not be effective; however, they did not follow recommended protocols or target sensory processing problems.  The authors concluded that although small RCTs resulted in positive effects for SIT, additional rigorous trials using manualized protocols for SIT are needed to evaluate effects for children with ASDs and sensory processing problems.

In a systematic review, Watling and Hauer (2015) evaluated the literature published from January 2006 through April 2013 related to the effectiveness of Ayres Sensory Integration (ASI) and sensory-based interventions (SBIs) within the scope of occupational therapy for people with ASD to improve performance in ADLs and occupations.  Of the 368 abstracts screened, 23 met the inclusion criteria and were reviewed.  Moderate evidence was found to support the use of ASI; the results for sensory-based methods were mixed.  The authors recommended that future research should include performing higher level studies with larger samples, using the fidelity measure in studies of ASI, and using carefully operationalized definitions and systematic methods in examination of SBIs.

Leong and colleagues (2015) noted that SIT is a controversial intervention that is widely used for people with disabilities.  Systematic analysis was conducted on the outcomes of 17 single-case design studies on SIT for people with, or at-risk of, a developmental or learning disability, disorder or delay.  An assessment of the quality of methodology of the studies found most used weak designs and poor methodology, with a tendency for higher quality studies to produce negative results.  Based on limited comparative evidence, functional analysis-based interventions for challenging behavior were more effective than SIT.  Overall, the studies did not provide convincing evidence for the effectiveness of SIT.  Given the findings of the present review and other recent analyses it is advised that the use of SIT be limited to experimental contexts.  Issues with the studies and possible improvements for future research were discussed including the need to employ designs that allow for adequate demonstration of experimental control.

Li and co-workers (2018) noted that RCTs have reported an inconsistent relationship regarding the use of AIT in children with ASD among Chinese.  In a meta-analysis, these investigators examined the efficacy of AIT for children with ASD compared with those in control group.  Relevant trials published were identified by an electronic search of PubMed, CENTRAL, Embase, WanFang, CNKI, and SinoMed databases up to December 31, 2017.  Outcome of interest included childhood autism rating scale (CARS), autism behavior checklist, IQ, and autism treatment evaluation checklist (ATEC).  Standardized mean difference (SMD) with 95 % confidence intervals (CIs) was calculated using a random-effect model.  A total of 13 RCTs with 976 children with ASD were included for analysis.  The pooled SMD showed that children with ASD had significantly lower ABC scores [summary SMD = -0.58, 95 % CI: -0.79 to -0.38] and ATEC scores [summary SMD = -0.75, 95 % CI: -1.05 to -0.45] in AIT group compared with that in control group.  The analysis of pooled statistics put forward AIT could increase the IQ score when compared with that in control group [summary SMD = 0.59, 95 % CI: 0.41 to 0.77].  A negative association was found about CARS scores between AIT group and control group.  No publication bias was found and no single study had essential effect on the pooled results.  The authors concluded that AIT could reduce the score of autism behavior checklist and ATEC and could increase the IQ score among children with ASD in Chinese.  Thus, it is recommended for Chinese children with ASD to receive AIT.  These findings need to be validated in other ethnic groups.

The authors stated that this study had re several drawbacks.  First, although most of the diagnostic criteria of ASD were DSM-IV, different diagnostic criteria were employed in the included RCTs.  This may affect the pooled results of SMD and 95 % CI.  However, sensitivity analysis did not support this opinion.  Second, only 2 RCTs were conducted to assess the association for CARS scores and ATEC scores using the treatment of AIT, and these researchers found a negative relationship in CARS scores.  Hence, more related RCTs are needed to confirm AIT in children with ASD in CARS and ATEC rating scale.  Third, 2 RCTs with no training, 1 with music therapy, 6 with routine rehabilitation training, 2 with guided education training, and 2 with comprehensive treatment were used in the control group.  Different treatment of the control group could have increased the heterogeneity between studies.  In this meta-analysis, the authors found significant heterogeneity in the results of ALT for autism behavior checklist scores.  Thus, different treatment of the control group may be an influencing factor on the significant heterogeneity.

Seiverling and associates (2018) compared a behavioral feeding intervention with and without pre-meal SIT in 2 boys with ASD and severe food selectivity.  For both participants, child bite and drink consumption and total intake increased to similar levels with corresponding decreases in inappropriate mealtime behavior (IMB) in both conditions.  The SIT condition was then discontinued and both participants continued to exhibit high levels of bite and drink consumption with corresponding low levels of IMB during a non-SIT phase.  Care-givers of both participants were then trained in the behavioral feeding intervention.  Follow-up data were collected for 1 subject for 2 months following intervention and showed maintenance of treatment gains over time.

Tzang and colleagues (2019) stated that parents of children with attention deficit hyperactivity disorder (ADHD) have been found to prefer SIT rather than guideline-recommended ADHD treatment.  These investigators examined if SIT for children with ADHD was associated with a reduced risk of subsequent mental disorders.  From children less than 8-year old newly diagnosed with ADHD in a nationwide population-based dataset, these investigators established a SI cohort and a non-SI cohort (n =  1,945) matched by propensity score.  Incidence and hazard ratios (HRs) of subsequent psychiatric disorders were compared after a maximum follow-up of 9 years.  The incidence of psychiatric disorders was 1.4-fold greater in the SI cohort, with an adjusted HR of 1.41 (95 % confidence interval [CI]: 1.20 to 1.67), comparing to the non-SI cohort.  Risks were elevated for emotional disturbances, conduct disorders, and adjustment disorders independent of age, gender, or comorbidity.  Among children with only psychosocial intervention, the incidence of psychiatric disorders was 3.5-fold greater in the SI cohort than in the non-SI cohort.  The authors concluded that to their knowledge, this was the first study to report an increased risk of developing psychiatric disorders for children with ADHD who received SIT compared to those who did not.  They stated that potential adverse effects of SIT for ADHD children should be carefully examined and discussed before practice.

Furthermore, an UpToDate review on "Evaluation and treatment of speech and language disorders in children" (Carter and Musher, 2018) states that "Investigational therapies – Facilitated communication, auditory integration training (AIT), sensory integration (SI) therapy, and Fast ForWord are examples of controversial practices that have not been validated in large, controlled trials".

Camarata et al (2020) noted that for more than 50 years, "Sensory Integration" has been a theoretical framework for diagnosing and treating disabilities in children under the umbrella of "sensory integration dysfunction" (SID).  More recently, the approach has been reframed as "the dimensions of sensory processing" or SPD in place of SID.  These investigators described this collective framework as sensory integration/sensory processing treatment (SI/SP-T) for ASD; this review was not focused on diagnosis of SI/SPD.  Broadly, the SI/SPD intervention approach views a plethora of disabilities such as ADHD, ASD, and disruptive behavior as being exacerbated by difficulties in modulating and integrating sensory input with a primary focus on contributions from tactile, proprioceptive, and vestibular systems which are hypothesized to contribute to core symptoms of the conditions (e.g., ASD).  SI/SP intervention procedures include sensory protocols designed to enhance tactile, proprioceptive, and vestibular experiences.  SI/SP-T procedures utilize equipment (e.g., lycra swings, balance beams, climbing walls, and trampolines), specific devices (e.g., weighted vests, sensory brushes) and activities (e.g., placing hands in messy substances such as shaving cream, sequenced movements) hypothesized to enhance sensory integration and sensory processing.  The approach is reviewed to provide a framework for testing SI/SP-T using widely accepted clinical trials and event coding methods used in applied behavior analysis (ABA) and other behavioral interventions.  Furthermore, a related but distinct neuroscientific paradigm, multi-sensory integration, was presented as an independent test of whether SI/SP-T differentially impacted sensory integration and/or multi-sensory integration.  Finally, because SI/SP-T activities include many incidental behavioral events that are known as developmental facilitators (e.g., contingent verbal models/recasts during verbal interactions), there is a compelling need to control for confounds to study the unique impact of sensory-based interventions.  Note that SI/SP-T includes very specific and identifiable procedures and materials, so it is reasonable to expect high treatment fidelity when testing the approach.  A patient case was presented that illustrated this confound with a known facilitator (recast intervention) and a method for controlling potential confounds in order to conduct unbiased studies of the effects of SI/SP-T approaches that accurately represent SI/SP-T theories of change.

These researchers stated that SI/SP-T is testable within the context of rigorous treatment studies, and key ingredients can be measured.  More importantly, these trials should be conducted fairly and without bias to examine the efficacy of SI/SP-T.  Moreover, there has been an ongoing need for fair clinical trials of SI/SI-T.  This review indicated that such trials can be conducted using the highest quality standards of implementation and employing objective quantitative proximal and distal measures in addition to more qualitative indices such as goal attainment scaling.  Finally, these studies must be conducted using procedures that are not only faithful to the authentic implementation of SI/SP-T but also control for confounding factors.  These studies should be conducted with all populations posited to benefit from SI/SP-T such as ASD, ADHD, language disorders, and Down syndrome.  Calls for fair studies have been appearing in the literature for more than 20 years; these must be conducted soon.

Wuang et al (2020) examined the sensory integration and perceptual-motor performances in elementary school children (5 to 12 years) with ASD in Taiwan.  The impacts of comprehensive body functions on activity participations in ASD were also examined to provide evidence for clinical applications and further study.  A total of 117 children with ASD (42 girls; aged 5 to 13 years, average age of 8 years 3 months) were recruited.  All subjects were evaluated with standardized measures of body functions and activity participations.  The body function measures included Bruininks-Oseretsky of Motor Proficiency - 2nd Edition, Sensory Profile, Test of Sensory Integration Functions, and Test of Visual Perception Skills - 3rd Edition.  The activity participation measures included the Chinese versions of both Vineland Adaptive Behavior Scale and School Function Assessment.  School-aged children with ASD had different levels of impairments on body function measures.  Most subject scores fell within the impairment range on 13 to 15 items out of the total 19 sensory and perceptual-motor measure subtests, with worst performance on coordination-related motor task and most sensory integrative dimensions.  The results indicated a significant main effect for age and sex on some body functions and activity participations.  Correlation analyses indicated strong associations between body function and activity participation across settings in ASD.  The authors concluded that the findings of this study characterized the developmental continuum of body functions of school-aged children with ASD and showed their associations with adaptation and participation.  While emphasizing the development of functional skills to facilitate age-appropriate activity participation in multiple scenarios, interventions aiming to improve body functions were indispensable.

These researchers stated that there were several drawbacks with respect to the lack of control group and intellectual functioning measures.  For further study, these investigators recommended the completion of longitudinal studies with various subtypes (e.g., Asperger’s, high-functioning autism) and intellectual functioning to examine the effects of maturation and individual differences on sensory integration and perceptual-motor skills in ASD school-aged individuals.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes not covered for indications listed in the CPB:

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

F43.20 - F43.29 Adjustment disorders
F80.9 Developmental disorder of speech and language, unspecified [communication disorder]
F81.0 - F81.9 Specific developmental disorders of scholastic skills
F84.0 - F84.9 Pervasive developmental disorders
F90.0 - F90.9 Attention-deficit hyperactivity disorders
F91.0 - F91.9 Conduct diorders
F93.0 - F93.9 Emotional disorders with onset specific to childhood
Q99.2 Fragile X chromosome
R62.50 Unspecified lack of expected normal physiological development in childhood
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out [observation for suspected mental health condition]

The above policy is based on the following references:

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