Sensory integration: A review of

the current state of the evidence

Nancy Pollock

Sensory integration, sensory integrative dysfunction, is defined as “the organiza-

sensory processing disorder, sensory modulation, sen- tion of sensory informa-
sory diets; all somewhat confusing terms for many occu- tion for use” (p.1). It is a
pational therapists, other health professionals, and edu- neurological process that
cators. Imagine how most families must feel! In the 45 enables us to make sense
years since Jean Ayres presented her Eleanor Clark Slagle of our world by receiving,
Lecture (Ayres, 1963) introducing her concept of sensory registering, modulating, or-
integration, the field of sensory integration research ganizing, and interpreting
and practice has seen tremendous growth and contin- information that comes to
ues to engender strong reactions within and outside our brains from our senses.
the field of occupational therapy. The controversy has Ayres (1972) hypothesized
About the author –
recently moved from the professional literature to the that some children have Nancy Pollock, MSc, OT
lay press. Time Magazine (December 10, 2007) featured an impairment in sensory Reg (Ont) is an Associate
an article entitled “Is this Disorder for Real?” reporting on integration which manifests Clinical Professor in the
the controversy surrounding the move to have sensory in difficulties observed in School of Rehabilitation
Science and an Investiga-
processing disorder included in the next revision of the purposeful behaviours. This
tor at the CanChild Centre
Diagnostic and Statistical Manual. dysfunction in sensory in- for Childhood Disability
Given the controversial nature of sensory integra- tegration may explain why Research at McMaster
tion, it is important to ensure that practitioners are some children have trouble University in Hamilton,
up to date on the current state of the literature and learning new skills, organiz- Ontario.
the evidence. Part of the mandate of the CanChild ing themselves, regulating
Centre for Childhood Disability Research located at Mc- their attention, participating in school or play ac-
Master University in Hamilton, Ontario, is to provide tivities, and engaging in positive social experiences.
synthesized reviews to assist in translating knowledge Ayres, and many who have followed her, have worked
from research to practice. Available on our website to establish the validity of this theory through clinical
www.canchild.ca, these reviews are called Keeping and basic science research.
Current and are written so that families, service pro- Through these past decades, researchers and
viders, and researchers can access them. The Keeping clinicians have explored many aspects of sensory
Current in Sensory Integration, last updated in 2006, integration in a variety of populations including
remains one of the most frequently accessed titles on typically developing children, children with learning
the website, with an average of 650 hits per month. disabilities, autism, Aspergers, and attention deficit
As it is now time to update it, we thought it could also hyperactivity disorder (ADHD). As well, assessments of
be an important contribution to this special issue of sensory integration have been developed and treat-
OT Now. In this article, I will review the discussions ment strategies evaluated. Through all of this work,
and debates about terminology, identification and different ideas and understandings about sensory
diagnosis, review the evidence for the effectiveness of integration have evolved and authors have begun to
sensory integration interventions, and provide some use different terms to describe their perspectives of
suggestions for clinicians and families. sensory integration and propose new models.
Roley, Mailloux, Miller-Kuhanek, and Glennon (2007)
Defining sensory integration describe the rationale for the recent move to trademark
Sensory integration is a theory. As with all theories, the term Ayres Sensory Integration©. They suggest that
sensory integration has a set of assumptions underly- the use of this term denotes the adherence to the core
ing it that propose to explain observed phenomena. principles of Ayres original theoretical framework and
As first described by Ayres (1972), sensory integration distinguishes it from other sensory-based theories and

6 occupational therapy now volume 11.5

treatment approaches. Miller, Anzalone, Lane, Cermak, Several articles have explored the relationship
and Osten (2007) have proposed a taxonomy to enhance between indicators of sensory processing difficulties
diagnostic specificity. They do not suggest a change to and children’s occupational performance (Ahn, Miller,
the term sensory integration to describe the theory or Milberger, & McIntosh, 2004; Baranek et al., 2002;
sensory integration treatment for the intervention ap- Bar-Shalita, Vatine, & Parush, 2008; Bundy, Shia, Qi,
proach, but suggest that the diagnostic term be sensory & Miller, 2007; Dunbar, 1999; White, Mulligan, Mer-
processing disorder (SPD) to distinguish the disorder rill, & Wright, 2007). More recently, researchers have
from the theory. This group has described three subtypes used neurophysiological measures such as electro-
within SPD in their proposed taxonomy which differ encephalography (EEG) (Davies & Gavin, 2007), and
from the subtypes identified through the factor analytic measurement of electrodermal activity (changes in
studies conducted by Ayres and colleagues (Ayres, 1972b; the conductivity of the skin related to nervous sys-
Ayres, 1989). In an article describing fidelity in sensory tem activity) to identify differences between typically
integration intervention research, Parham and col- developing children and those with developmental
leagues (2007) have defined ten core elements that they disorders (Mangeot et al., 2001; Miller et al., 1999;
feel must be present in order for the treatment method Schaaf, Miller, Seawell, & O’Keefe, 2003).
to be truly sensory integration treatment. These varying
perspectives reflect the difficulties in describing and “Parents aren’t very interested in our controversies about
defining a complex phenomena, and indicate that at terminology. They want to understand what is happen-
present, there is no clear consensus. These controversies ing with their child and what to do about it. “
also reinforce the importance of practitioners and re-
searchers being very precise and clear in describing their Clinical assessments, observations, interviews, and more
thinking to colleagues and families when using terms direct measures of neurophysiological activity present a
related to sensory integration. strong case that some children do indeed have differ-
ences in their behaviours that fall into certain patterns.
Identifying sensory integrative dysfunction These children can be clearly identified through the
‘He’s clumsy, and frequently bumps into things.’ ‘She’s clinical and laboratory tools at our disposal. The ques-
a very picky eater.’ ‘He has emotional meltdowns when tions remain though, as to why they show atypical
plans change.’ ‘She insists on wearing the same pair neurological activity and behaviour. Is it because they
of socks everyday.’ ‘He is too rough when he plays with have sensory processing problems? Most occupational
other children.’ ‘She can’t organize her backpack to therapists would answer “yes”. Others outside the field
bring home the right things from school.’ These are of occupational therapy, for example Heilbroner (2005),
all descriptors that parents frequently offer when disagree and suggest that these sensory processing
talking about their children who may be experiencing differences do not represent a distinct disorder but are
difficulties in sensory integration. Parents aren’t very markers of neurodevelopmental immaturity or symp-
interested in our controversies about terminology. toms of anxiety. Ultimately, does it matter what causes
They want to understand what is happening with these patterns of behaviour or only that we can iden-
their child and what to do about it. tify them and describe them? Where it does matter of
Occupational therapists have a number of tools at course, is when we move to the question of what do we
their disposal to help in understanding what might be do about it. If we can identify patterns of behaviour that
happening with these children. Well developed stan- are interfering with the child’s development, learning,
dardized assessments such as the Sensory Profile (SP) play and participation, we need to determine how best
(Dunn, 1999) and the Sensory Integration and Praxis to intervene.
Tests (SIPT) (Ayres, 1989) are frequently used. These mea-
sures help to describe and measure the child’s behav- Sensory integration therapy
iour, either directly, in the case of the SIPT, or indirectly Most of the practitioners who use sensory integra-
through parent completed questionnaires, as in the SP. tion therapy are occupational therapists and, as such,
As norm-referenced measures, the results can be com- the goals of intervention are aimed at enhancing the
pared to the results of typically developing children and child’s ability to participate in the daily occupations
patterns of differences described. Considerable research which are meaningful and satisfying for that child in
has shown that these measures are psychometrically their natural context. The route to achieving that goal
robust and able to discriminate differences across chil- is individually defined, but can be broadly categorized
dren (Ayres, 1989; Dunn & Westman, 1997; 1999; Ermer & as aiming either to remediate underlying impair-
Dunn, 1998; Mulligan, 1998). ments or to enable participation through accom-

read full colour version @ www.caot.ca 7

 modation and adaptation; essentially two different flaws (Miller, Schoen, James, & Schaaf, 2007; Parham et
roads to one place. In the former category is sensory al., 2007). They highlight weaknesses in study design
integration therapy (SIT) as originally developed by related to the inclusion criteria for the study samples,
Jean Ayres (1972). This form of therapy is sometimes fidelity to sensory integration treatment principles
referred to as classical SIT (Parham & Mailloux, 2005) and limitations in the outcome measures to detect a
or now, according to the trademark, as Ayres Sensory difference. A recent randomized controlled trial con-
Integration© therapy. This treatment approach aims ducted by some of these same authors showed some
to provide the child with various sensory experiences. positive outcomes, but again suffered from many of
These experiences are matched during therapy with the methodological flaws they were critical of in other
studies (Miller, Coll, & Schoen, 2007).
“Over the past four decades, dozens of research studies There has been more effectiveness research
have been carried out to evaluate the effectiveness of conducted on sensory integration therapy than any
SIT using a wide variety of study methods and designs other intervention in the field of occupational therapy.
(Deams 1994; Miller, 2003).” To date, the evidence of its effectiveness is weak at
best. We can continue to argue that the supportive
a “just right” challenge, an activity that requires the evidence is limited due to methodological limitations
child to give an adaptive response. SIT is an active and attempt to address these weaknesses in future
therapy. The child must be motivated and engaged trials, or we can accept that the results are valid and
in the choice of activities; hence, play is the medium that classical SIT, used with the populations that have
of choice. Activities usually involve large pieces of been studied, is not supported by the evidence.
equipment such as big rolls and balls, trampolines, Occupational therapists use other forms of
and suspended equipment that provide intense intervention which are based on sensory integra-
proprioceptive, vestibular, and tactile experiences. The tion theory, but which differ from classical SIT. These
child is encouraged to explore the equipment and approaches use a sensory integration framework to
the therapist sets up the activities and the environ- help understand and explain children’s behaviour, but
ment to challenge the child to use the sensory input rather than trying to remediate an underlying impair-
to organize an adaptive response. It typically involves ment, these methods are embedded in the child’s
one-to-one direct intervention in an environment daily routines and focus on working with the children,
that has a variety of specialized equipment. parents, and educators to adapt the child’s environ-
Over the past four decades, dozens of research ment in ways that will facilitate the child’s ability to
studies have been carried out to evaluate the effec- participate. This approach may include such things
tiveness of SIT using a wide variety of study methods as modifications to the child’s clothing, altering room
and designs (Deams 1994; Miller, 2003). Additionally, configurations, noise or light levels, experimenting
there have been two meta-analyses (Ottenbacher, with food textures, adapting tools and materials,
1982; Vargas & Camilli, 1999) and four research re- changing program demands, and so on. These ap-
views (Arendt, MacLean, & Baumeister, 1988; Hoehn proaches are designed to help children function to
& Baumeister, 1994; Polatajko, Kaplan, & Wilson, 1992; the best of their ability given their sensory process-
Shaffer, 1984). The majority of studies have focused on ing capabilities as opposed to trying to change their
the use of “classical” SIT with children with learning underlying neurological functioning. In this way, they
disabilities and has aimed at improving motor skills, are distinct from classical SIT.
academic performance, behavioural performance Most of the effectiveness research on these types
and/or sensory and perceptual skills. The results from of approaches has been preliminary in nature. While
studies published in the 1970s and early 1980s were some positive results have been found, for example,
very promising; however as research methodologies in the use of specific interventions such as weighted
have become more rigorous, the results have been less vests (Fertel-Daly, Bedell, & Hinojsa, 2001; Vandenburg,
favourable for SIT. The more recent meta-analysis con- 2001), the research designs have been less rigorous,
cluded that children receiving SIT improved no more such as single-subject designs, case studies, and qua-
than children who received alternate treatments or, si-experimental designs. The population being stud-
in fact, no treatment at all (Vargas & Camilli, 1999). ied has also shifted with many of these studies being
Research reviews, particularly those done outside conducted with children with autism. Case-Smith
of the field of occupational therapy have been very and Arbesam (2008) in a review of interventions for
critical. Proponents of SIT argue that the studies done children with autism cite some positive findings, but
to date have not been valid due to methodological again conclude that the evidence for sensory integra-

8 occupational therapy now volume 11.5

 tion and sensory-based interventions for children occupation and participation levels of function.
with autism is weak and requires further study. 5. Involve the family as partners and think about the
These research findings are of course concerning for changes you can make in the tasks and the environ-
those therapists and parents who believe that they see ment that will benefit the child more immediately.
positive changes in the children treated using SIT and 6. If you want to use SIT, clearly explain to the fam-
for those who want to base their practices on strong evi- ily the state of the evidence so they are making an
dence. Sensory integration as an explanatory framework informed choice.
has intuitive appeal. We have strong evidence that there If parents and therapists decide to use SIT, it
are children who present with behaviours and neuro- should always be approached as a trial. Clear, measur-
logical responses consistent with hypothesized sensory able, and functional outcomes should be established.
processing challenges. We also have strong evidence A baseline period of measurement should be under-
that these children have difficulties in their daily oc- taken prior to the initiation of treatment. Education
cupations. The question remains, how do we help these of families, teachers, and other team members should
children? The evidence for the types of interventions we always accompany the therapy. Re-assessment using
have studied to date is weak, yet a significant proportion the pre-established outcomes should take place after
of occupational therapists report that they continue 8 - 10 weeks of intervention. If SIT is going to be an
to use sensory integration as a primary intervention effective intervention, some positive benefits will be
approach (Brown, Rodger, Brown, & Roever, 2007; Rodger, evident by then. If these benefits are not apparent,
Brown, & Brown, 2005). We need to be careful that the another approach should be investigated.
appeal of a treatment approach that, unlike many of our
References
“Remember that you are occupational therapists, not Ahn, R.R., Miller, L.J., Milberger, S., & McIntosh, D.N. (2004). Prevalence
of parents’ perceptions of sensory processing disorders among
sensory integration therapists. Focus first and foremost kindergarten children. American Journal of Occupational Therapy,
on the occupations identified by the child and family that 58, 287-302.
are of concern.” Arendt, R.E., MacLean,W.E., & Baumeister, A.A. (1988). Critique of sensory
integration therapy and its application in mental retardation.
American Journal on Mental Retardation, 92, 401-411.
approaches, was developed by an occupational therapist, Ayres, A. J. (1963). Eleanor Clark Slagle Lecture. The development of
doesn’t overshadow our commitment to evidence-based perceptual motor abilities: A theoretical basis for treatment of
practice and to the provision of the highest quality of dysfunction. American Journal of Occupational Therapy, 17, 221-225.
Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles,
care to our clients. SIT is a resource-intensive interven- CA: Western Psychological Services.
tion and the time and resources devoted to this therapy Ayres, A. J. (1972b). Types of sensory integrative dysfunction among dis-
mean that the child is not receiving another type of abled learners. American Journal of Occupational Therapy, 26, 13-18.
intervention that may potentially have greater benefits. Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles, CA:
Western Psychological Services.
In summary, the topic of sensory integration
Baranek, G.T., Chin, Y.H., Hess, L.M., Yankee, J.G., Hatton, D.D., & Hooper,
remains contentious. Its theoretical underpinnings, its S.R. (2002). Sensory processing correlates of occupational perfor-
existence as a distinct disorder, and the effectiveness mance in children with Fragile X syndrome: Preliminary findings.
American Journal of Occupational Therapy, 56, 538-546.
of treatment approaches based on the theory are still
Bar-Shalita, T., Vatine, J., & Parush, S. (2008). Sensory modulation disor-
under debate. Given the current state of the evidence, der: A risk factor for participation in daily life activities. Develop-
here are a few suggestions: mental Medicine & Child Neurology, 50: 932-937.
1. Remember that you are occupational therapists, Brown, G.T., Rodger, S., Brown, A., & Roever, C. (2007). A profile of Cana-
dian pediatric occupational therapy practice. Occupational Therapy
not sensory integration therapists. Focus first and in Health Care, 21, 39-69.
foremost on the occupations identified by the child Bundy, A. C., Shia, S., Long Qi, L., & Miller, L.J. (2007). How does sensory
and family that are of concern. processing affect play? American Journal of Occupational Therapy
61, 201-208.
2. In your occupational analysis, be sure to consider
Case-Smith, J. & Arbesman, M. (2008). Evidence-based review of inter-
multiple hypotheses for why the child might be ventions for autism used in or of relevance to occupational therapy.
having difficulties. Keep an open mind. Remember American Journal of Occupational Therapy, 62, 416-429.
the old adage “If the only tool you have is a ham- Davies, P.L. & Gavin, W. J. (2007). Validating the diagnosis of sensory
processing disorders using EEG technology. American Journal of Oc-
mer, you’ll view every problem as a nail”. cupational Therapy 61, 176-189.
3. If you hypothesize in your clinical reasoning that Daems, J. (1994). Reviews of research in sensory integration. Torrance, CA:
sensory factors may be impacting on this child, use Sensory Integration International.
psychometrically sound measures to support or Dunbar, S. B. (1999). A child’s occupational performance: Consideration
of sensory processing and family context. American Journal of Oc-
refute your hypothesis. cupational Therapy, 53, 231-235.
4. Set specific and measurable goals that target the Dunn, W. (1999). The Sensory Profile. San Antonio, TX: PsychCorp.

read full colour version @ www.caot.ca 9

 Dunn, W. & Westman, K. (1997). The sensory profile: The performance Therapy, 52, 819-828.
of a national sample of children without disabilities. American Ottenbacher, K. (1982). Sensory integration: Affect or effect? American
Journal of Occupational Therapy 51, 25-34. Journal of Occupational Therapy, 36, 571-578.
Ermer, J. & Dunn, W. (1998). The sensory profile: A discriminant analysis Parham, L.D., Cohn, E.S., Spitzer, S., Koomar, J.A., Miller, L.J., Burke, J.P.,
of children with and without disabilities. American Journal of Oc- Brett-Green, B., Mailloux, Z., May-Benson-T.A., Roley, S.S., Schaaf, R.C.,
cupational Therapy, 52, 283-290. Schoen, S.A., & Summers, C.A. (2007). Fidelity in sensory integration
Fertel-Daly, D., Bedell, G., & Hinojsa, J. (2001). Effects of a weighted vest intervention research. American Journal of Occupational Therapy,
on attention to task and self-stimulatory behaviors in preschool- 61, 216-227.
ers with pervasive developmental disorders. American Journal of Parham, L.D., & Mailloux, Z. (2005). Sensory Integration. In J. Case-Smith
Occupational Therapy, 55, 829-840. (Ed.) Occupational therapy for children (5th edition), pp 356-411. St.
Hoehn, T. & Baumeister, A. (1994). A critique of the application of Louis, MO: Elsevier Inc.
sensory integration therapy to children with learning disabilities. Polatajko, H.J., Kaplan, B.J,. & Wilson, B.N. (1992). Sensory integration
Journal of Learning Disabilities, 27, 338-350. treatment for children with learning disabilities: Its status 20 years
Mangeot, S.D., Miller, L.J., McIntosh, D.N., McGrath-Clarke, J., Simon, J., later. Occupational Therapy Journal of Research, 12, 323-341.
Hagerman, R.J., & Goldson, E. (2001). Sensory modulation dysfunc- Rodger, S., Brown, G.T., & Brown, A. (2005). Profile of pediatric occu-
tion in children with attention-deficit hyperactivity disorder. Devel- pational therapy practice in Australia. Australian Occupational
opmental Medicine and Child Neurology, 43: 399-406. Therapy Journal, 52, 311-325.
Miller, L.J. (2003). Empirical evidence related to therapies for sensory Roley S.S., Mailloux, Z,. Miller-Kuhanek, H., & Glennon, T. (2007). Under-
processing impairments. Communiqué, 31, 34-37. standing Ayres Sensory Integration. OT Practice, 12(17): Suppl. (CE1-7).
Miller, L.J., Anzalone, M.E., Lane, S.J., Cermak S.A., & Osten E.T. (2007) Schaaf, R.C., Miller, L. J., Seawell, D., & O’Keefe, S. (2003). Preliminary study
Concept evolution in sensory integration: A proposed nosology for of parasympathetic functioning in children with sensory modula-
diagnosis. American Journal of Occupational Therapy, 61, 135-140. tion dysfunction and its relation to occupation. American Journal
Miller, L.J., Coll, J.R., & Schoen, S.A. (2007). A randomized controlled pilot of Occupational Therapy, 57, 442-449.
study of the effectiveness of occupational therapy for children with Schaffer, R, (1984). Sensory integration therapy with learning disabled
sensory modulation disorder. American Journal of Occupational children: A critical review. Canadian Journal of Occupational
Therapy, 61, 228-238. Therapy, 51, 73-77.
Miller, L.J., McIntosh, D.N., McGrath, J., Shyu, V., Lampe, M., Taylor, A.K., VandenBerg, N. (2001). The use of a weighted vest to increase on task
Tassone, F., Neitzel, K., Stackhouse, T., & Hagerman, R. (1999). Elec- behavior in children with attention difficulties. American Journal of
trodermal responses to sensory stimuli in individuals with Fragile Occupational Therapy, 55, 621-628.
X syndrome: a preliminary report. American Journal of Medical
Vargas, S., & Camilli, G. (1999). A meta-analysis of research on sensory
Genetics, 83, 268-279.
integration treatment. American Journal of Occupational Therapy,
Miller, L.J., Schoen, S.A., James, K. & Schaaf, R.C. (2007). Lessons learned: A 53, 189-198.
pilot study of occupational therapy effectiveness for children with
Wallis, C. (2007, December 10). Is this disorder for real? TIME, pp.46-48.
sensory modulation disorder. American Journal of Occupational
Therapy, 61, 161-169. White, B. P., Mulligan, S., Merrill, K., & Wright, J. (2007). An examination
of the relationship between motor and process skills and scores on
Mulligan, S. (1998). Patterns of sensory integration dysfunction: A
the sensory profile. American Journal of Occupational Therapy, 61,
confirmatory factor analysis. American Journal of Occupational
154-160.

10 occupational therapy now volume 11.5