*3.2.1. Purpose of the technique*

Ayers Sensory Integration Intervention® (ASII) is a clinical procedure grounded in sensory integration theory [19]. The intervention focuses on aiding clients to register, process, integrate and adequately respond to internal and external sensations that occur within the clients' daily life, contexts, and relationships. Sensory integration has been defined as "the neurological process that organizes sensations from one's own body and from the environment and makes it possible to use the body effectively in the environment" ([20], p. 11). ASII is aimed at remediating integration disruptions and increasing participation and performance among individuals who experience sensory disturbances or a sensory processing disorder. An internet survey identifying treatments used for children with ASD indicated that Sensory Integration (a broadly used term) was the third most commonly requested intervention requested by caregivers [21].

#### *3.2.2. Overview of the technique*

Intervention guided by sensory integration theory [19] has been reported to be commonly used by therapists who work with children with various types of developmental delays and medical and behavioral conditions [22, 23]. ASII includes the following steps within the standardized intervention protocol:


#### *3.2.3. Review of the evidence*

Pfeiffer, Koenig, and associates conducted a randomized-control trial with 37 children diagnosed with ASD who were between the ages of 5–12 years of age [26]. Seventeen participants were assigned to a control group focused on fine motor intervention and 20 participants were assigned to the experimental group who received ASII. The study reported no significant differences in the subjective perception of sensory processing difficulties via the Sensory Processing Measure and objective ratings on the Quick Neurological Screening Test, 2nd Edition, between the control and experimental groups. Yet the authors reported a significant difference between groups in the reduction of autistic mannerisms and social responsiveness as measured by the Social Responsiveness Scale. Both groups demonstrated statistically significant improvement with Goal Attainment Scaling (focused on sensory processing, motor skills, & social functioning). However, there was a higher effect size in the ASII group than in the fine motor group.

has something to do with "sensory features" [18]. The inability to accurately process sensory information impacts all areas of child development, so approaches directed towards remedia-

Ayers Sensory Integration Intervention® (ASII) is a clinical procedure grounded in sensory integration theory [19]. The intervention focuses on aiding clients to register, process, integrate and adequately respond to internal and external sensations that occur within the clients' daily life, contexts, and relationships. Sensory integration has been defined as "the neurological process that organizes sensations from one's own body and from the environment and makes it possible to use the body effectively in the environment" ([20], p. 11). ASII is aimed at remediating integration disruptions and increasing participation and performance among individuals who experience sensory disturbances or a sensory processing disorder. An internet survey identifying treatments used for children with ASD indicated that Sensory Integration (a broadly used term) was the third most commonly requested intervention

Intervention guided by sensory integration theory [19] has been reported to be commonly used by therapists who work with children with various types of developmental delays and medical and behavioral conditions [22, 23]. ASII includes the following steps within the stan-

**2.** present active sensory opportunities (tactile, proprioceptive & vestibular),

**10.** establish therapeutic alliance between the client and the therapist [24, 25].

Pfeiffer, Koenig, and associates conducted a randomized-control trial with 37 children diagnosed with ASD who were between the ages of 5–12 years of age [26]. Seventeen participants

**3.** help the client attain and maintain appropriate levels of alertness,

**6.** collaborate between the client and the therapist on activity choice, **7.** tailor the activities to present a just right challenge for the client,

**4.** challenge postural, ocular, oral and/or bilateral motor control,

**5.** challenge praxis and organization of behavior,

**9.** support the child's intrinsic motivation to play, and

tion of sensory processing deficits are often used by both occupational therapists.

**3.2. Ayres sensory integration intervention**

8 Occupational Therapy - Therapeutic and Creative Use of Activity

*3.2.1. Purpose of the technique*

requested by caregivers [21].

*3.2.2. Overview of the technique*

dardized intervention protocol:

**1.** ensure physical safety of the client,

**8.** ensure that activities are successful,

*3.2.3. Review of the evidence*

Another randomized-control trial evaluated the efficacy of ASII among 32 children aged 4–8 years old, diagnosed with ASD [27]. In this trial, the experimental group using ASII (*n* = 17) scored significantly higher at posttest in the areas of self-help skills and socialization, than did the control group (*n* = 15) who received standard care. Additionally, the authors reported that children in the ASII group were better able to reach specific goals than the control group when measured using Goal Attainment Scaling. Children in the ASII group also experienced greater decreases in sensory related behaviors than the control group.

Iwanaga et al. utilized a quasi-experimental design to explore the use of ASII on 20 preschool aged children with high functioning autism [28]. It was reported that the children in the experimental group, who received ASII, demonstrated significantly higher total post test scores on the Miller Assessment of Preschoolers when compared to the control group. Significant improvements were noted specifically in the areas of motor coordination, nonverbal cognitive abilities, and sensory motor abilities following ASII treatment.

Case-Smith et al. conducted a systematic review on sensory integration with standardized administration protocols that occurred in clinics that used sensory-rich, child directed activities to improve a child's adaptive responses to sensory experiences [15]. They found and reviewed two randomized controlled trials, which reported positive effects for ASII on the participants (children with ASD) using Goal Attainment Scaling (with reported effect sizes ranging from .72 to 1.62); the additional studies analyzed included Level III–IV research studies, that reported positive effects on reducing challenging behaviors linked to sensory processing difficulties.

Kashefimehr et al. reported improvement in a sensory integration intervention group (*n* = 16) over a control group (*n* = 15) among children with ASD. The authors reported that the participants in the intervention group demonstrated significant improvements in the subjective measures of the Short Child Occupational Profile and the Sensory Profile. Of significant note the authors reported improvements not only in sensory processing domains (tactile processing, vestibular processing, etc.) but also in occupational performance based upon the Model of Human Occupation [29, 30].

It is important to make a clear distinction between ASII and other sensory-based interventions, as ASII has strict implementation protocol that may not always be followed accurately. In a review of more than 70 published research articles examining the efficacy of ASII, it was found that only three adhered to the theory and intervention protocols [25, 29, 30]. The reason for this disparity is that research conducted (in occupational and speech therapy, special education and psychology) generally did not report if the researchers designed the intervention to represent Ayres' original therapeutic principles. Furthermore, it was not noted if the researchers monitored intervention delivery during the studies to ensure that a high degree of fidelity to the ASII was maintained [30–32]. This is an important notation when evaluating the efficacy of ASII, as the majority of the research claiming to be examining the effects of sensory integration treatment may really be evaluating sensory-based and sensorymotor-based interventions.

**3.4. Weighted blankets**

*3.4.1. Purpose of the technique*

*3.4.2. Overview of the technique*

*3.4.3. Review of the evidence*

exacerbates behavioral problems during the day [47].

allow the individual to be better able to fall asleep and stay asleep.

Sleep and rest disturbances are important self-care challenges that are commonly faced by many children with ASD, with 44–83% of individuals reporting some form of sleep disturbances [45]. Humphreys and associates found that children between the ages of 18 months and 11 years with ASD slept 17–43 min less each night than their typically developing matched peers, with decreased sleep patterns found to be most pronounced in children between the ages of 30 and 42 months [46]. Additionally, Malow and associates found that children with ASD who slept poorly showed an average decrease in rapid eye movement sleep, possibly providing a partial explanation for their finding that disordered sleep in children with ASD

Occupational Therapy's Role in the Treatment of Children with Autism Spectrum Disorders

http://dx.doi.org/10.5772/intechopen.78696

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As sleep is important for overall wellbeing, occupational therapists may work with individuals to establish healthy sleep routines in their clients, commonly including children with ASD and their families. They often assist such children in obtaining adequate sleep by experimenting with different sleep routines, using cognitive and behavioral interventions, and/or implementing sensory-based interventions [48]. Weighted blankets are an example of a sensory-based intervention commonly used in helping children with autism spectrum disorders attain adequate sleep participation. The underlying theory behind their use is that weighted blankets provide deep pressure touch without movement restrictions. This deep pressure, in turn, releases endorphins and serotonin to relax and calm the individual and help the individual to modulate sensory input [49, 50]. These relaxing sensations, it is hypothesized,

Typically, weighted blankets are applied to children during sleep-time activities (nighttime and naps). The weight of the blankets used anecdotally is 10% of the child's body weight. The blankets size is large enough to cover the child's body, not including face and/feet. The intention is that the blanket will remain on top of the child throughout the duration of sleep.

The evidence to support the efficacy of using weighted blankets is scarce. Creasey and Finlay were unable to find any relevant primary or secondary evidence exploring the effectiveness of weighted blankets' impact on sleep in children with ASD [51]. Despite this lack of evidence, there is parental/caregiver anecdotal support of use, and as such, many advocate for the use of weighted blankets. One study published after Creasey and Finlay's review studied 73 children, aged 5–16 years, all of whom had an autism spectrum disorder diagnosis and reported sleep disturbances [52]. Using a crossover design, study participants were given a weighed blanket to sleep with for 2 weeks, followed by a period during which they slept with a nonweighted blanket that was provided by the researchers. The core findings were that weighted blankets were no more effective than a typical blanket in helping children with ASD improve
