**2. Sensory integration therapy**

Current estimates indicate that accompanying sensory processing problems are reported in more than 80% children with autism. Hyper or hypo reactivity to sensory inputs is now a diagnostic criterion for Autism Spectrum Disorders in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [11, 12]. A. Jean Ayres, an occupational therapist, developed the sensory Integration theory [13]. Theory is based on neuroscience, developmental psychol‐ ogy, occupational therapy and education sciences. Sensory integration therapy is a common method used in paediatric occupational therapy. Results of a survey made on occupational therapists working with children with autism report that 99% of therapists stated that they were referring to sensory integration therapy [14]. According to this theory; 1.sensorymotor development is important for learning 2. Individual's interaction with environments shapes brain development 3. Neurological system has plasticity capability. 4. Meaningful sensorymotor activity is a strong mediator of plasticity [15]. Sensory integration is a process of organizing sensory information in brain in order to create an adaptive response. The aim of sensory integration therapy is to provide controlled and meaningful sensory experiences so that the child can spontaneously and appropriately form responses that require integration of those sensations [16].

#### **2.1. The importance of sensation**

According to the theoretical basis of sensory integration vestibular, proprioceptive, tactile, auditory and visual systems as well as olfaction (sense of smell) and gestation (sense of taste) have a significant importance. The tactile/proprioceptive and vestibular/proprioceptive systems interact routinely with the auditory and visual systems to supply the multimodal sensory information needed to make a meaningful motor response. It's reported that sensory integration is a dynamic process that sustains during development and sensory information can be organized as a result of interaction with environment [17].

#### *2.1.1. Tactile system*

meaningful and purposeful activities they have in their daily roles and aims to achieve. They also make use of client-centred and holistic therapeutic interventions both in analysing and evaluating the problems which individuals with autism face and in their treatment and

Occupational therapy interventions, which are designed according to standardized assess‐ ment tests, questionnaires, skilled observations, provide considerable advantage in dealing

This chapter will give information on standardized assessment tests and practices applied in occupational therapy interventions such as sensory integration therapy, auditory integration training, activities of daily living training, play therapy, social skills training, cognitive behavioural therapy, school based intervention, recreational activities and sports and voca‐

Current estimates indicate that accompanying sensory processing problems are reported in more than 80% children with autism. Hyper or hypo reactivity to sensory inputs is now a diagnostic criterion for Autism Spectrum Disorders in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [11, 12]. A. Jean Ayres, an occupational therapist, developed the sensory Integration theory [13]. Theory is based on neuroscience, developmental psychol‐ ogy, occupational therapy and education sciences. Sensory integration therapy is a common method used in paediatric occupational therapy. Results of a survey made on occupational therapists working with children with autism report that 99% of therapists stated that they were referring to sensory integration therapy [14]. According to this theory; 1.sensorymotor development is important for learning 2. Individual's interaction with environments shapes brain development 3. Neurological system has plasticity capability. 4. Meaningful sensorymotor activity is a strong mediator of plasticity [15]. Sensory integration is a process of organizing sensory information in brain in order to create an adaptive response. The aim of sensory integration therapy is to provide controlled and meaningful sensory experiences so that the child can spontaneously and appropriately form responses that require integration of

According to the theoretical basis of sensory integration vestibular, proprioceptive, tactile, auditory and visual systems as well as olfaction (sense of smell) and gestation (sense of taste) have a significant importance. The tactile/proprioceptive and vestibular/proprioceptive systems interact routinely with the auditory and visual systems to supply the multimodal sensory information needed to make a meaningful motor response. It's reported that sensory integration is a dynamic process that sustains during development and sensory information

can be organized as a result of interaction with environment [17].

with the problems individuals with autism and their families face in daily life.

support system.

164 Autism Spectrum Disorder - Recent Advances

tional rehabilitation.

those sensations [16].

**2.1. The importance of sensation**

**2. Sensory integration therapy**

Skin has numerous receptors that perceive touching, pressure, texture, heat, pain and move‐ ment. A signal is transmitted to the related parts of the brain when tactile receptors are stimulated with touch, heat or vibration. Tactile system is a sensory system that affects behaviour both physically and mentally. Sense of touch is quite important for neural organi‐ zation and praxis development [16, 18].

#### *2.1.2. Vestibular system*

Vestibular receptors related with balance and gravity, and located in inner ear consist of semicircular canals, utricle and saccule. Semi-circular canals are responsible for detection of angular, fast, short bursts of motion, and result in phasic limb movements and momentary head righting. Vestibular system is a system that affects balance, eye movements, posture, muscle tonus and attention [16, 19].

#### *2.1.3. Proprioseptive system*

This system is related with position and movement. Pushing and pulling activities related with muscles and joints are activities that provide maximum stimulation for this system. Proprio‐ ceptive system provides information on postural and oculomotor control, position in space and balance together with vestibular and visual system. In terms of the problems reported in vestibular and proprioceptive system, difficulties in good body scheme and laterality devel‐ opment, poor balance, poor postural control and difficulties in coordinated movements are observed in children with autism [2, 16-18].

Children who are hypo responsive against proprioceptive stimulation have weak propriocep‐ tive discrimination and awareness and fail to use proprioceptive input correctly. Therefore they tend to break their toys easily and have low postural tonus. Bites, pushes, hits, scratches, bumps, hurls, hangs and aggressive behaviours as well as self stimulatory and hyperactive behaviours such as banging head, biting hands are observed in children seeking for proprio‐ ceptive inputs [20].

#### *2.1.4. Auditory system*

The sound information from each ear goes to auditory cortex of opposite hemisphere. The relation between the auditory system and valgus nerve is important in sensory modula‐ tion [16].

#### *2.1.5. Visual system*

The light received stimulates retina in order to send sensory input to the processing centre in the brain. Integration of visual inputs with different senses provides our awareness about our environments. Visual and vestibular systems work together for perceptual motor integration and visual perception [16, 18].

#### *2.1.6. Gustatory sense*

Different senses of tastes ensure that we like the food we eat and distinguish those that may be harmful [16].

#### *2.1.7. Olfactory sense*

Smell is directly processed via limbic system and creates memories and associations that influence some of our choices and preferences [16].

It's reported that sensory processing problems observed in individuals with autism are associated with behavioural and/or functional performance problems and specifically stereo‐ typical or repetitive are associated with self-calm or sensory seeking [21]. The studies show that repetitive behaviours, behaviours such as climbing, turning and twirling may indicate existence of sensory processing behaviours [12].

Sensory registration, modulation, discrimination and praxis defined as motor behaviour planning capability are performance components, which are important for sensory integration. Sensory registration is receiving different stimulus from body or environment [17]. Sensory registration process is important for the individual to perform effective function by paying attention. Children with autism who have sensory registration problems fail in creating appropriate adaptive responses against pain, touch, movement, taste, smell, light and sound [22]. Sensory modulation is defined as "capacity to regulate and organize the degree, intensity, and the nature of responses to sensory input in a graded and adaptive manner" [17]. Sensory discrimination is important for development of motor functions, postural tonus and postural adjustment. Different sensory modulation problems such as hyporesponsivity, hyperrespon‐ sivity, sensory avoiding or sensory seeking are reported in children with autism. Hypersen‐ sitivity is the most common auditory and tactile defensiveness. High pain tolerance is the most significant indicator of hypo responsiveness in children with autism [2].

Difficulty in starting and sustaining a social interaction and relation, delays in speaking or communication disorders such as echolalia, repetitive stereotypical plays, visually focusing on any object, cognitive deficits and confusions in impacts and results of behaviours are common sensory integrative – related behaviours in children with autism spectrum disorder. Poor sensory processing affects the child with autism in successful involvement in daily life activities such as playing and participating in social activities with peers, tooth brushing, eating, self care etc. [23].

#### **2.2. Sensory integration assessment and intervention**

*"The Occupational Therapy Practice Framework: Domain and Process (AOTA, 2002)"* which is a comprehensive guideline of assessment and intervention is used in the assessment of individuals with autism and in occupational therapy interventions. Accordingly, occupa‐ tional profile should be initially defined, occupational performance should be assessed, intervention plan should be designed, objectives and goals should be identified and documented, intervention should be implemented and results of intervention should be assessed and documented [24].

#### *2.2.1. Assessment*

*2.1.6. Gustatory sense*

166 Autism Spectrum Disorder - Recent Advances

*2.1.7. Olfactory sense*

eating, self care etc. [23].

assessed and documented [24].

influence some of our choices and preferences [16].

existence of sensory processing behaviours [12].

be harmful [16].

Different senses of tastes ensure that we like the food we eat and distinguish those that may

Smell is directly processed via limbic system and creates memories and associations that

It's reported that sensory processing problems observed in individuals with autism are associated with behavioural and/or functional performance problems and specifically stereo‐ typical or repetitive are associated with self-calm or sensory seeking [21]. The studies show that repetitive behaviours, behaviours such as climbing, turning and twirling may indicate

Sensory registration, modulation, discrimination and praxis defined as motor behaviour planning capability are performance components, which are important for sensory integration. Sensory registration is receiving different stimulus from body or environment [17]. Sensory registration process is important for the individual to perform effective function by paying attention. Children with autism who have sensory registration problems fail in creating appropriate adaptive responses against pain, touch, movement, taste, smell, light and sound [22]. Sensory modulation is defined as "capacity to regulate and organize the degree, intensity, and the nature of responses to sensory input in a graded and adaptive manner" [17]. Sensory discrimination is important for development of motor functions, postural tonus and postural adjustment. Different sensory modulation problems such as hyporesponsivity, hyperrespon‐ sivity, sensory avoiding or sensory seeking are reported in children with autism. Hypersen‐ sitivity is the most common auditory and tactile defensiveness. High pain tolerance is the most

Difficulty in starting and sustaining a social interaction and relation, delays in speaking or communication disorders such as echolalia, repetitive stereotypical plays, visually focusing on any object, cognitive deficits and confusions in impacts and results of behaviours are common sensory integrative – related behaviours in children with autism spectrum disorder. Poor sensory processing affects the child with autism in successful involvement in daily life activities such as playing and participating in social activities with peers, tooth brushing,

*"The Occupational Therapy Practice Framework: Domain and Process (AOTA, 2002)"* which is a comprehensive guideline of assessment and intervention is used in the assessment of individuals with autism and in occupational therapy interventions. Accordingly, occupa‐ tional profile should be initially defined, occupational performance should be assessed, intervention plan should be designed, objectives and goals should be identified and documented, intervention should be implemented and results of intervention should be

significant indicator of hypo responsiveness in children with autism [2].

**2.2. Sensory integration assessment and intervention**

It is important to identify sensory responsiveness (over, under or labile) and sensory prefer‐ ences (likes and dislikes) praxis and sensory processing problems that affect involvement in daily life activities in the assessment of sensory integration in children with autism [25].

Numerous tests like given below are used for assessment of sensory integration in occupational therapy.

**Sensory Integration and Praxis Test (SIPT):** It is developed to identify sensory integration problems. Test is standardized for use in children 4 –8 : 11 years of age. SIPT assesses sensory and neurological process, which leads to behavioural, learning, language and praxis problems. It consists of 17 subtests, which assess tactile, vestibular proprioceptive processing; form and space perception, visual-motor coordination, praxis, bilateral integration and sequencing, and it takes nearly 90 minutes to complete the test [26].

**Southern California Sensory Integration Test (SCSIT):** It is developed by Ayres for use in physically and mentally normal children with specific learning disorder. It is standardized for children 4-8:11 years of age. It takes nearly 75-90 minutes to complete the test [27].

**Southern California Postrotary Nystagmus Test (SCPNT):** This test developed by Ayres to evaluate of nystagmus to field of occupational therapy. This test measures the amplitude of the eye's side to side excursion and the total duration in seconds of ocular movements following rotations [28].

**Sensory Profile:** The Sensory Profile is a caregiver questionnaire, which measures children's responses to sensory events in everyday life for children 3-10 years of age. 5-point likert scale (nearly never, seldom, occasionally, frequently, almost always) is used for assessment [29].

**Evaluation of sensory processing:**This questionnaire is intended to identify behaviors thought to be indicative of sensory processing problems [30].

Tests such as *Developmental Test of Visual Motor Integration* [31]*, Motor Free Visual Perception Test* [32]*, Test of Visual Perceptual Skills* (Non motor) [33] are used for the assessment of visual perceptual skills.

Besides standardized assessments, many occupational therapists refer to clinical observations for assessment of sensory and praxis functions. Clinical observation of postural control, behaviour organization and vestibular functions offer significant information in addition to sensory tests. It's important to observe playing skills, social interaction and other relevant behaviours of the child in child's natural settings [23]. *Clinical Observations of Motor and Postural Skills* is a screen tool for motor deficits and assessment of cerebellar function, postural control and motor coordination [34]. It's reported that Goal Attainment Scale (GAS) can used in measurement of results in sensory integration studies [35].

#### *2.2.2. Intervention*

It's reported that sensory integration therapy should be individually implemented with the consideration of the "inner drive" of the child, based on the sensory experience, challenge and interest and in a structured environments with active participation of the child [16, 22]. More effective feed-forward mechanism required for optimum adaptive response are created with child-directed actions. In responding children with autism, it is important to use controlled and meaningful sensory stimulus to create organized behaviour and to make environmental adaptations when needed. Due to the problems in body awareness, a child with autism fails in receiving sufficient tactile, proprioceptive and vestibular inputs from his/her body. There‐ fore, environmental arrangements should be adjusted according to motor planning and body awareness required for praxis. It's important to refer to sensory experiences that motivate and please the child with complex motor planning, social interaction and language skills. Therapist should integrate activities that contain sensory experiences required by the child into daily routine in cooperation with the family, caregivers and teachers [23]. Validity of the results in sensory integration studies are reported to be influenced by different practices in the inter‐ vention process and it's further reported that "Ayres Sensory Integration Fidelity Measure" which is a reliable and applicable verification measure for studies on sensory integration disorders should be used [36, 37].

Fidelity measure consists of 10 essential elements is used in clinic based sensory integra‐ tion treatment. These essential elements are as follows: a) ensuring safety b) presenting a range of sensory opportunities (specifically tactile, proprioceptive, and vestibular) c) Using activity and arranging the environment to help the child maintain self regulation and alertness d) challenging postural, ocular, oral, or bilateral motor control e) is challenging praxis and organisation of behaviour f) collaborating with the child on activity choices g) tailoring activities to present the " just –right challenge", h) ensuring that activities are successful, i) supporting the child's intrinsic motivation to play, and j) establishing a therapeutic alliance with the child [37].

#### **Activities for proprioceptive system**

Proprioception is defined as a cornerstone in sensory integration therapy. Muscle movements against resistance or gravity, traction, compression, movements related with muscles and joints provide proprioceptive stimulus and are used to improve motor coordination, to increase body awareness and to help arousal level modulation [2, 20].Practices like jumping on trampoline, climbing a mountain of bolster and crash onto mats, jumping games, roller skating, bicycle riding, throwing and catching a heavy ball, wheelbarrow walking, pulling and pushing activities, carrying or moving heavy objects, imitating animal walks that require heavy work (crab, bear), swinging from trapeze bar, wearing a weighted west, weighted blanket, wearing ankle or wrist weights in activities stimulates proprioceptive system [23, 38]. (Figure 1)

#### **Activities for tactile system**

Activities like playing with dough or clay type materials, drawing on mirror with shaving cream, finger painting, drawing shapes with fingers in sand, foam etc, massage, vibrating toys, using different textures for playing and bathing, playing hide and seek games in dried beans or rice, asking the child to define shapes drawn on this/her back with fingers, finding objects from a bag full of rice or beans etc. can be used to improve tactile awareness [23, 38].

**Figure 1.** Activity examples for proprioseptive and vestibular system stimulation

#### **Activities for auditory system**

interest and in a structured environments with active participation of the child [16, 22]. More effective feed-forward mechanism required for optimum adaptive response are created with child-directed actions. In responding children with autism, it is important to use controlled and meaningful sensory stimulus to create organized behaviour and to make environmental adaptations when needed. Due to the problems in body awareness, a child with autism fails in receiving sufficient tactile, proprioceptive and vestibular inputs from his/her body. There‐ fore, environmental arrangements should be adjusted according to motor planning and body awareness required for praxis. It's important to refer to sensory experiences that motivate and please the child with complex motor planning, social interaction and language skills. Therapist should integrate activities that contain sensory experiences required by the child into daily routine in cooperation with the family, caregivers and teachers [23]. Validity of the results in sensory integration studies are reported to be influenced by different practices in the inter‐ vention process and it's further reported that "Ayres Sensory Integration Fidelity Measure" which is a reliable and applicable verification measure for studies on sensory integration

Fidelity measure consists of 10 essential elements is used in clinic based sensory integra‐ tion treatment. These essential elements are as follows: a) ensuring safety b) presenting a range of sensory opportunities (specifically tactile, proprioceptive, and vestibular) c) Using activity and arranging the environment to help the child maintain self regulation and alertness d) challenging postural, ocular, oral, or bilateral motor control e) is challenging praxis and organisation of behaviour f) collaborating with the child on activity choices g) tailoring activities to present the " just –right challenge", h) ensuring that activities are successful, i) supporting the child's intrinsic motivation to play, and j) establishing a

Proprioception is defined as a cornerstone in sensory integration therapy. Muscle movements against resistance or gravity, traction, compression, movements related with muscles and joints provide proprioceptive stimulus and are used to improve motor coordination, to increase body awareness and to help arousal level modulation [2, 20].Practices like jumping on trampoline, climbing a mountain of bolster and crash onto mats, jumping games, roller skating, bicycle riding, throwing and catching a heavy ball, wheelbarrow walking, pulling and pushing activities, carrying or moving heavy objects, imitating animal walks that require heavy work (crab, bear), swinging from trapeze bar, wearing a weighted west, weighted blanket, wearing ankle or wrist weights in activities stimulates proprioceptive system [23, 38].

Activities like playing with dough or clay type materials, drawing on mirror with shaving cream, finger painting, drawing shapes with fingers in sand, foam etc, massage, vibrating toys, using different textures for playing and bathing, playing hide and seek games in dried beans or rice, asking the child to define shapes drawn on this/her back with fingers, finding objects

from a bag full of rice or beans etc. can be used to improve tactile awareness [23, 38].

disorders should be used [36, 37].

168 Autism Spectrum Disorder - Recent Advances

therapeutic alliance with the child [37].

**Activities for proprioceptive system**

(Figure 1)

**Activities for tactile system**

The child may be asked to listen his/her favourite soft music on headphones in order to reduce auditory sensitivity [23].

#### **Activities for vestibular system**

Activities such as linear swinging on a swing or ball on facedown position, throwing and catching objects while swinging, sliding down a slide, climbing, using scooter board or skateboard, jumping games, rolling activities, toys like rocking horse can be used to reduce sensitivity against vestibular senses. The child tolerates linear vestibular stimulus more than rotational stimulus [23, 38].

#### **Activities for ocular-motor control**

Toys and pens with lights, throwing balls at a target while swinging, games of ball throwing and catching, bubble blowing can be used to improve ocular-motor control [23, 38].

#### **Activities for postural control and motor skills**

Ball catching games can be played on the floor or on a ball or while sitting in different positions on a swing [23, 38].

#### **Activities for bilateral motor coordination and praxis**

Activities such as creating shapes by tearing papers with both hands, making shapes with play dough, cutting papers etc. with scissors, making necklace by placing beads through a string, closing/opening clothe fasteners, ball catching and throwing and clapping type hand games[23, 38].

#### **Activities for praxis and behaviour organization**

Therapeutic activities, which are for sensory processing and facilitate skills such as initiation, sequencing, bilateral coordination, timing and imitation can be used [5]. Activities of clapping and rhythm patterns hand games, building obstacle courses, activities that require whole body movements and timing such as kicking a rolled ball, hitting a ball with a bat, imitation of animal postures etc. can be used to improve motor planning [23, 38].

#### **2.3. Researches about sensory integration therapy**

Sensory integration therapy is a clinical based intervention that uses play activities and sensory integration principles to increase adaptive responses of children [12]. In a systematic review research by Benson and Koomar, 27 studies on the impact of sensory integration approach on children were reviewed. It's reported that sensory integration approaches are effective in terms of sensory-motor skills, motor planning, socialization, attention and behavioural regulation, skills related with reading, active participation in plays and personal goal attainment, however, the findings are limited due to small sample size, different practice dosages, therapy duration and result measurements not being appropriate [39].

Schaaf *et al* implemented sensory integration protocol for 10 weeks on a case with autism and consequently an increase was reported in sensory processing and home, school and family activities measured with Goal Attainment Scale [40]. Another study by Schaaf *et al* reviewed the safety, validity and applicability of sensory integration and occupational therapy in children with autism. 10 children with autism at 4-8 years of age were under therapy for 3 days a week for 6 weeks and an assessment was made with Ayres Sensory Integration Fidelity Measure. Sensory integration approaches in children with autism were reported to be a safe and applicable intervention [41]. Sensory integration therapy of 10 weeks for pre-schooler children with autism resulted with a decrease in non-engagement behaviours and an im‐ provement in purposeful behaviours [42].

Pfeiffer *et al* reviewed the impact of fine motor activity with sensory integration therapy in 37 children between the ages of 6 and 12 with autism spectrum disorders in randomized con‐ trolled studies. Consequent to practice of 18 sessions, each for 45 minutes for six weeks, a significant improvement was reported in the sensory integration group. In sensory integration group, positive changes in sensory processing, motor skills and social functions and decrease in stereotypical and self-stimulating behaviours were reported [43]. A study by Smith *et al* reports that self-stimulating and self-injurious behaviours remain stable in children with pervasive developmental disorders as a result of sensory integration therapy [44]. Sensory integration and sensory based treatments resulted in increase in engagement in plays and social interaction, proper adaptive response, decrease in stereotypical and self-stimulating behaviours, decrease in sensitivity against touching and movement in hyper responsive children and decrease in sensory vulnerability. Sensory integration therapy improves skills of engagement in social interaction and modulating behaviours [45, 46].

Some studies report that sensory integration therapy does not have a positive impact due to small sample size, short therapy duration, no fidelity measure, study design and due to the fact that assessments are not blinded [47-51].

The last systematic review study by Smith et al. on sensory integration notes that evidence based studies where blinded evaluation, larger samples and randomised trial are used should be conducted [12].
