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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 auditory integration therapy is any more effective than placebo (Best & 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 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 [citing 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 sensory integration therapy for attention-deficit hyperactivity disorder, and identified only one study (by 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 sensory integration therapy 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 sensory integration therapy 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 AAP (2001) stated that research data supporting the effectiveness of sensory integration therapy in managing autistic children is scant. The NAS (2001) concluded that there is insufficient evidence of the effectiveness of auditory integration therapy 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. In a systematic review, Sinha and colleagues (2006) evaluated the effectiveness of AIT and other sound therapies in people (adults or children) with autism spectrum disorders (ASD). A total of 6 randomized controlled trials 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 two outcome measures used by three 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. Three 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, one 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 ASD. 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.
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