Perceptualand Motor Skills, 2008, 106,415-422.

O Perceptual and Motor Skills 2008

A SENSORY INTEGRATION THERAPY PROGRAM O N SENSORY

PROBLEMS FOR CHILDREN WITH AUTISM '
YESIM FAZLIOGLU
Trakya University, Edirne

AND

GULEN BARAN
Ankara University, Ankara

Summary.-The study was planned to investigate the effect of a sensory integration therapy program on sensory problems of children with autism. This study was
conducted at the Trakya University Training and Research Center for Mentally and
Physically Handicapped Children in Turkey. The children were separated into two
groups, each comprising 15 children between 7 and 11 years of age with autism, according to DSM-IV criteria. The children in each group 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.

A normally developing child is born with a complete sensory system,

which continues to develop during life (17); however, some disorders like
autism affect the integration of sensory experiences. Such sensory processing
abnormalities are not specific to autism, although their prevalence in autism
is relatively high (12).
Children with autism sometimes are unreactive to sounds, an expression
of their closedness to environmental stimulation. In addition, abnormalities
have been described in perception of vision, touch, taste, and smell, as well
as in kinaesthetic and proprioceptive sensations. These include hyper- and
hyposensitivity to stimulation (25).
Modulation of activity refers to the brain's regulation of mental, physical, and emotional behaviour (22). Disturbances in modulation are a main
problem seen in autism. Although children with autism show various sensory
reactivity, they usually use the senses of smell and touch. They sometimes
discover objects by touching, smelling, or licking; some children with autism
like to touch and be touched, while others do not (18, 21). Of the sensory
modalities, those most affected by autism seem to be not smell and touch
but auditory and visual modalities. Some authors have suggested that auditory abnormalities should be included among the diagnostic criteria of the
disorder (15, 16). These sensory problems affect virtually all aspects of adaptive, cognitive, social, and academic functioning, so it is important to ad-

'Address correspondence to Yegim Fazl~oglu,Trakya Universitesi Egitim Fakdtesi, Okuloncesi

Egitim A.B.D., Edirne, Turkey or e-mail (yfazli@hotmail.com).

DO1 10.2466/PMS.106.2.415-422

dress sensory problems. Sensory and motor interventions have been used
with children having autistic symptoms (12). The purpose of this study was
to develop a program of sensory integration therapy for use in assessment
and treatment of autistic children.

This study was conducted with 30 low functioning children with autism
(diagnosed according to DSM-IV), who attended the Trakya University
Training and Research Center for Mentally and Physically Handicapped Children. Consent was obtained from the children's parents. Participants were
selected by searching the files to eliminate those who had previously been
part of any sensory integration program or who had epileptic seizures. The
selected group was between 7 and 11 years of age.
The majority of the children could not use language to communicate
and were part of the special education program at the center. They were randomly assigned to a treated group and control group based on a stratification procedure to ensure equivalence of groups. Children were assigned to
experimental and control groups randomly, matching on age and sex as possible. Fifteen children (12 boys, 3 girls) were in the experimental group, and
15 children (12 boys, 3 girls) with similar characteristics were in the control
group. These two groups were matched for age, sex, and level of function.

Measure
The Sensory Evaluation Form for Children with Autism was used for
assessing sensory problems seen in these children. The items were developed
by the authors based upon data reported previously (12, 23, 24, 25). In a pilot study, the evaluation form's validity and reliability were studied with 50
children with autism at the age of seven or above (age M=9.4 yr., SD=2.5).
To assess whether the scale had discriminative validity, the form was also applied to 50 typical children of similar age and sex. Scores of children with
autism and typical children differed statistically; children with autism had
higher scores than nonautistic children. Reliability of the scale was assessed
as internal consistency and in item analysis. Cronbach coefficient alpha was
.74. The item analysis included a test-retest correlation of .96 ( p < .05) over a
2-wk. period.
Following these pilot results, a form of 42 items (cf. Table 1) measured
sensory problems of hearing-speaking, seeing, taste-smell, touch, balance,
muscular tonus, attention, and behaviour characteristics of children with autism (13). Three response alternatives for each response were 1: Not true, 2:
Sometimes true, and 3: Usually true. High scores indicated more sensory
problems.

AUTISM AND SENSORY INTEGRATION TIIERAPY

-.

TABLE 1
SENSORY
EVALIJATION
FORMFORCHILDREN
WITHAUTISM:~ T E MCONTENT
.-

1.
2.
3.
4.

--

Can answer when his name is uttered

Cannot express self by pointing out or signalling
Needs commands to be repeated
Cannot give answers to simple questions asked (such as, "What is your name?" and
"How old are you?")
5. Unable to understand concepts such as Upward/Downward, BefordAfter, Inside/
Outside
6. Cannot use pronouns in a sentence appropriately (uses "he" instead of "I")
7. Has difficulty in understanding concepts such as big/small, long/short, woman/man
8. Cannot use 'Yes' or 'No' for a specific purpose
9. Looks are either void or thoughtful
10. Unable to copy figures and lines (such as /, ----,0, +, X)
11. Cannot write letters on a line
12. Has difficulty distinguishing colours
13. Has difficulty distinguishing numbers
14. Cannot match two identical objects
15. Has difficulty with single piece
16. Has difficulty with single and double piece puzzle
17. Often bites either the straw or the glass while drinking water or fruit juice
18. Overreacts to wet clothes or tissues
19. Nonreactive to pain
20. Has difficulty walking on the walking board
21. Has difficulty walking on the balance board
22. Has difficulty mimicking gross motor skills (such as clapping and swaying his head)
23. Has difficulty mimicking gross motor skills (such as hitting his index finger)
24. Unsuccessful in mimicking oral motor skills (such as opening and closing his mouth and
sticking out his tongue)
25. Unable to synchronize two targeted movements in coordination (swinging a rope while
jumping)
26. Has a different walking style (such as tip-toeing, walking on his heels, hopping, and
skipping)
27. Cannot use scissors for a specific purpose
28. No specific preference about right or left hand use durin activities (such as writing
sometimes with right hand or sometimes with left h a n 8
29. Has fears about climbing
30. Looks anxious on the playground (avoids getting on a swing or see-saw)
31. Cannot ride a bike
32. Weak in catching objects with both hands (such as catching a ball)
33. Does not pay much attention when he drops something from his hand
34. Has poor posture while standing or sitting
35. Has difficulty grasping objects (such as holding them too tight or too loose)
36. Unsuccessful pulling and pushing objects
37. Not interested in his environment
38. Cannot concentrate on a specific subject (even on the activities he likes)
39. Unsuccessful in playing games with rules
40. Has anger attacks
41. Nonreactive to others' feelings
42. Resorts to self-stimulative behaviors
(suchas swaying, watching his hands, and clapping)
---Not~.-Rating scale has 3 points-1: Not true, 2: Sometimes true, 3: Usually true.
-

Procedure
The sensory integration program is based on "The Sensory Diet," a
popular modern version of a sensory integration program in which the child
is provided a home or classroom program of sensory-based activities aimed
at fulfilling the child's sensory needs (10). A schedule of frequent and systematically applied somatosensory stimulation (i.e., brushing with a surgical
brush and joint compression) is followed by a prescribed set of activities designed to meet the child's sensory needs and integrated into the child's daily
routine (3). There were 13 target behaviours to somatosensory stimulation in
addition to hearing, seeing, tasting, smelling, touching, balancing, moving
(fine motor, gross motor, oral motor), and proprioception. This program has
68 activities to achieve 13 target behaviors. For example, when reduction of
the child's intolerance to touching of different textures was the goal, the
program procedure included exercises of touching different textures (play
dough, finger paint, water, rice, vibrating toys, sandpaper, feathers), playing
with these materials, and perceiving and feeling different textures.
The program was practiced in a specially arranged room in the center,
called the sense room, in which were siecial materials such as different kinds
of brushes, lotions, a massage table, massage instruments, pipes, musical instruments, a mirror, a trampoline, balls, and a touch board.
In the beginning, the families were informed about the aim and duration of the study, and importance of continuity in the program was emphasized. A physiotherapist who helped develop the motor items evaluated muscular tonus, motor development, and posture.
A study plan showing the days and hours of application was prepared
for every child, and the children were taken to the sensory integration sessions individually. Before a session, a special educator prepared the required
materials and informed the child about the order of activities and the beginning and the finishing times of the session.
In the beginning, children were given permission to freely touch the
materials so that they became familiar with the environment and materials.
During the session, if children became overstimulated, activity was stopped
for a while. Activity was separated into small skills and given step by step.
Objective and symbolic reinforcements were used for motivation. Several
types of prompts were used: verbal, modeling, physical, and gestural position cues. When new skills were taught to a child, the strategy began with a
full physical prompt for the desired response, then was faded to a gesture or
model, and finally to only a verbal instruction. After children gave responses,
cues were eliminated over time (extinction). The performances of the children during each session were recorded and placed in their files. Performances were coded for each session as full physical prompt, verbal instruc-

419

AUTISM AND SENSORY INTEGRATION THERAPY

tion, and independent. When children learned one skill to independence,

another skill was begun. Each child attended the 45-min. sensory integration
sessions two days a week for 24 sessions.
In this part of the study, the children with autism in the control group
did not participate in the sensory integration program but attended their regularly scheduled special education classes at the center. After the administration of the sensory integration program, children in both groups were reassessed on the evaluation form and pre- and posttest scores were compared.

RESULTS
Pre- and Posttest scores were analysed using SPSS (Version IO.O), using
a two group analysis of variance for repeated measures. Pretest and posttest
means and standard deviations for the two groups are shown in Table 2.
Children's scores in the experimental group and control group showed
changes over time; however, the scores were significantly lower for the treated group attending sensory integration therapy.
TABLE 2
PRE- AND POSTTEST
MEANSAND STANDARD
DEVIATIONS
FORTWOGROUPS(ns = 15)
- -

Group
Treated
Control

Pretest

SD

98.2
95.8

19.3
17.0

66.5
97.3

Posttest
--

SD
11.4
17.8

There was a statistically significant main effect for group in total scores
(F1,*,=5.84,p < .05) as well as a main effect of test time (pre- and posttest)
(F,,*,= 98.38, p < .01). Sensory problems observed in children with autism
were reduced after the sensory integration program. The interaction of group
and time was also significant (F,,*,=119.38, p<.OI). In addition, when pretest scores were the covariation in analysis of covariance, the mean difference
at posttest for the groups was statistically significant (F,,*, = 167.16, p < .01).
DISCUSSION
In this study, after a sensory integration program the sensory problems
of children with autism improved as has previously been noted with various
sensory training for children with sensory problems (20, 27). Field, et al.
(14) measured the effects of touch therapy (massage) on attentiveness and
responsivity in 22 preschool children with autism. Massage was provided for
15 minutes per day, two days per week for four weeks (i.e., eight sessions).
The children showed positive changes posttreatment on all observational variables (i.e., touch aversion, off-task behaviour, orienting to sound, stereotypies), but those given touch therapy showed significantly greater changes in
responsiveness to sound and reduced stereotypies as well as significant improvement in measures of social communications.

In the literature, sensory problems have been associated with sensory

processing in the vestibular and tactile systems (5, 6, 7 , 9, 19, 28). CaseSmith and Brayn (8) emphasized that sensory perceptual abnormalities in
people with autism could be improved by sensory integration therapy. Ayres
and Tickle (2) noted that children with autism were reactive to touch, and
changes in movement and gravity. Connor (11) emphasized the importance
of programs which develop motor skills, noting that such programs were effective in reducing perceptual overselectivity. These programs develop skills
related to discrimination of sensory input and play an important role in attention and concentration (4,12).
Dawson and Watling (12) reviewed evidence regarding the prevalence
of sensory and motor abnormalities from sensory integration therapy, traditional occupational therapy, and auditory integration training. Researchers
noted that sensory integration therapy positively affected development of motor skills. For this reason, play skills should be supported by a sensory integration approach. With a well-planned program, opportunity to interact with
peers could be provided (1, 9, 29).
Case-Smith and Miller (9) studied five boys over a 3-wk. baseline phase
and a 10-wk. intervention which consisted of a combination of classical sensory integration treatment and consultation with teachers. Independent coding of videotaped observations of free play indicated that three of the five
boys significantly improved in their mastery play. For only one boy were significant improvements evident in interaction with adults, and none changed
in amount of peer interaction. Outcome measures more directly related to
intrinsic features of the intervention (e.g., individual mastery play) appeared
more improved than measures not directly addressed in treatment (e.g., peer
interaction). Although it is possible that the positive results could be attributed to factors other than the intervention (i.e., maturation, care-giving effects), the authors noted that the behaviours did not change systematically
across all outcome measures.
Results of many studies seem to parallel present findings of a significant
difference between treated and control groups, plus reduction in sensory
problems after the sensory integration treatment. This implies that such a
program could be used as an intervention for sensory and motor problems
of children with autism.
Stagnitti, Raison, and Ryan (26) described a 5-yr.-old boy with severe
sensory defensiveness who underwent a treatment program consisting of
brushing followed by joining sessions of three to five times daily for two
weeks. The program included integration of appropriate sensory activities interspersed throughout the child's daily activities and routines and was carried out by the parents at home under the supervision of a therapist trained
in these methods. Following the initial improvements, the treatment program

AUTISM AND SENSORY INTEGRATION TIIERAPY

42 1

was repeated several months later as the child's behaviours seemed again to
deteriorate. Posttreatment parental reports suggested improvements in tolerance of tactile stimulation, fewer temper tantrums, an increase in activity,
and better coordination.
It is through their sensory experience that children develop connectedness with the world. When children show sensory dysfunction, it is harder
for them to interact and learn about the world. Sensory integration therapy
should be fun and inviting for children, stimulating the brain, so sensory
and motor skills can develop more fully and functionally.
Most children with autism are treated with special classes at public or
private schools in Turkey, but autism is accepted as a psychiatric and developmental problem in Turkey so both psychiatric and educational treatment
are carried out in special education centers. In this process behaviour therapy is more common than sensory treatment. It seems reasonable that the
present study be extended psychometrically and temporally.
REFERENCES
1. AMATO,J., BARROW,
M., &DOMINGO,
R. (1999) Symbolic play behaviour in very young verbal and nonverbal children with autism. The Trans Dtjciplinary Journal, 9, 185-194.
2. AYRES,A. J., &TICKLE,L. S. (1980) Hyper-responsivity to touch and vestibular stimuli as
predictor of positive response to sensory integration procedures by autistic children.
American journal of Occupational Therapy, 34, 375-381.
G. T. (2002) Efficacy of sensory and motor interventions in children with au3. BARANEK,
tism. Journal of Autism and Developmental Disorders, 32, 397-422.
4. BARANEK,
G. T., FOSTER,L. G., & BERKSON,
G. (1997) Sensory defensiveness in persons
with developmental disabilities. The Occupational Thc,rapy Journal of Research, 17, 173185.
5. BARKELL,
D. E. (1996) Auditory integration for individuals with autism. Education and
Training in Mental Retardation and Developmental Disabilities, 31, 66-70.
6. BETTISON,S. (1996) The long term effects of auditory training on children with autism.
Journal of Autism and Developmental Disorders, 26, 361-372.
7. CARR,E., &CARLSON,
J. (1993) Reduction of severe behaviour problems in the community
using a multi component treatment approach. lourndl of Applied Behavior Analysis, 26,
157-172.
8. CASE-SMITH,
J., & BRAYN,
1: (1999) Effects of occupational therapy with sensory integration emphasis on preschool aged children with autism. Anzerican Journal of Occupational
Therapy, 53, 489-497.
9. CASE-SMITH,
J., &MILLER,H. (1999) Occupational therapy with children with pervasive
developmental disorders. American journal of Occupational Therapy, 53, 506-513.
10. CHARA,K. A,, CHARA,l? J., J R . , &CHAM, C. l? (2004) .Ymsoy smarts: a book for kids wzth
A D H D or autirm spectrum disorder,- stniggling with sensoy, integration problems. London:
Jessica Kingsley.
11. CONNOR,E (1990) Combating stimulus over selectivity: physical education for children
with autism. Teaching Exceptional Children, 23, 30-33.
12. DAWSON,
G., &VATLING,
R. (2000) Intervention to facilitate auditory, visual, and motor integration in autism: a review of the evidence. Journal of Autirm and Developmental Dzsor&r.s, 30, 415-425.
13. FAZLIOCLU,
Y.,&BARAN,G. (2004) Duyusal entegrasyon programznzn otzzmli Gocuklarzn duyusal up davrany problemleriUzerine ctkisinin incelenmesi. Ankara: Ankara Universitesi Ev
Ekonomisi Yuksek Okulu Bilimsel Aragt~rrnave Incelemeler Yayln No. 7.
14. FIELD,T., LASKO, P. M., HENTELEFF,
T., KABAT, S., TALPINS,S., &DOWLING,M. (1997) Brief

15.
16.

17.
18.
19.
20.
21.
22.
23.
24.
25.

26.
27.
28.
29.

report: autistic children's attentiveness and responsivity improve after touch therapy. ]ournal of Autism and Developmental Disorders, 27, 333-339.
GILLBERG,
C. (1990) Autism and pervasive developmental disorders. Journal of Child Psychology and Psychiatry, 3 1, 99-119.
GILLBERG,
C., EHLERS,S., SCHAUMANN,
H., JACOBSSON,
G., DAHLGREN,
S. O., LINBLOM,
R.,
BAGENHOLM,
A., TJUUST,T., & BLIDER,E. (1990) Autism under age three years: a clinical
study of 28 cases referred for autistic symptoms in infancy. Journal of Child l'rychology
and Prychzatry, 31, 921-934.
GRANDIN,
T. (1996) Brief report: res onse to National Institutes of Health report. Journal
, 185-187.
of Autism and Developmental ~ i s o r L r s 26,
GRANDIN,
T. (1998) Teaching tips from a recovered autistic. Focus on Autistzc Behaviour,
3, 1-8.
GREENSPAN,
S. I. (1992) Reconsiderin the diagnosis and treatment of very young children
with autistic spectrum or pervasive dgevelopmental disorders. Zero to Three, 13, 1-9.
KERN,J. K., TRIVEDI,
M. H., GRANNEMANN,
B. D., GARVER,
C. R., JOHNSON,
D. G., ANDREWS,
A. A,, SAVLA,
J. S., MEHTA,J. A,, &SCHROEDER,
J. L. (2007) Sensory correlations in autism. flutzsm, 11, 123-134.
KIENTZ,M. A,, &DUNN,W. (1997) A comparison of the performance of children with and
without autism on the sensory profile. The Amerzcan ]ournal of Occupatzonal Therapy, 51,
530-537.
KRANOWITZ,
C. S. (1998) The out-of-sync child: recognizing and coping with sensory integration dv\function. New York: Skylight Press.
M., &HILL,D. (1996) Moving on: autism and movement disturbance. Mental ReLEARY,
tardation, 34, 39-53.
MATSON,J., BENAVIDEZ,
D., &COMTON,L. (1996) Behaviour treatment of autistic persons:
a review of research from 1980 to the present. Research in Developmental Disabilities, 17,
433-465.
O'NEILL,M., &JONES,R. P. (1997) Sensory- erceptual abnormalities in autism: a case for
more research? Journal of Autism and ~ e v e & m e u t a lDisorders, 27, 283-293.
STAGNITTI,
K., RAISON,P., &RYAN,I? (1999) Sensory defensiveness syndrome: a pediatric
perspective and case study. Australian Occupational Therapv Journal, 46, 175-187.
VANVUCHELEN,
M., ROEYERS,
H., & D E WEERDT,W. (2007) Nature of motor imitation problems in school-aged boys with autism: a motor or a cognitive problem? Autzsm, 11, 225240.
WATERHOUSE,
L., FEIN,D., & MODAHL,C. (1996) Neurofunctional mechanism in autism.
P.sychologicalReview, 103, 457-489.
WILLIAMS,
E.,REDDY,V, & COSTALL,
A. (2001) Taking a closer look at functional play in
children with autism. Journal of Autirm and Developmental disorder.^, 31, 67-77.

Accepted February 28, 2008