A Systematic Review of Sensory Processing Interventions for Children With Attention Deficit

Overview: Sensory Integration/Sensory Processing Treatment (SI/SP-T) for ASD Is A Widely-Implemented Intervention Arroyo but with An Emerging but Limited Bear witness Base

The goal of this article is to provide a review of sensory integration/sensory processing treatment (SI/SP-T) in Autism Spectrum Disorder (ASD), an intervention used widely in schools and clinics, to generate a framework and teaching for systematically testing behavioral interventions for children with disabilities. That is, nosotros view SI/SP-T equally one of several potential interventions for children with developmental disabilities which tin be evaluated using widely accepted testify-based standards and which can be considerately tested using clinical trial approaches to optimize an intervention for children with disabilities. Because in that location is considerable variation in classification, and many researchers and clinicians have shifted from using "sensory integration" to "sensory processing," (see Miller et al., 2009) we volition be including both of these terms designated as "SI/SP-T" in our review. This combination is utilized because the term "sensory integration" continues to exist included in the literature and in clinical practice along with the term "sensory processing." Big scale intervention studies are needed considering, despite widespread implementation, especially for children with Autism Spectrum Disorder (ASD), Downwardly Syndrome, attention deficit hyperactivity disorder (ADHD), and other developmental disabilities, SI/SP-T has an emerging but express prove base of operations in the literature (run into, for example, Pfeiffer et al., 2018), necessitating additional large-scale studies. Therefore, the review herein will include a description of the origins of SI/SP-T, current evidence, considerations for conducting off-white clinical trials, a review of how to control for potential cofounds, a description of how to examination for generalized changes in SI/SP using multisensory integration approaches, a case instance of how confounds can impact clinical intervention studies of SI/SP-T, suggestions for future enquiry directions, and clinical implications.

Evidence-Based Practice: Levels of Evidence

There have long been universal protocols for evaluating treatment efficacy and effectiveness in medicine and in behavioral interventions (Reynolds, 2008). These procedures arose, in part, from the long-standing persistence of treatments in clinical settings that, when tested adequately, proved to be ineffective or even harmful. For example, chelation, an established biomedical treatment for acute exposure to pb and other toxic metals, was hypothesized to be an constructive "detox" for children with ASD (run into James et al., 2015). This treatment was based on an unproven presumption that considering ASD was caused, at least in part, by exposure to mercury, chelation would better autism symptoms (come across Davis et al., 2013). Moreover, there have been many testimonials and qualitative case studies suggesting that the approach was effective. Only, when tested using clinical trials, chelation not only failed to meliorate symptoms of ASD, simply too caused agin reactions, including expiry, in some cases (Baxter and Krenzelok, 2008). Of course, the overwhelming majority of treatments for autism do not include death as a potential side outcome, but at that place are certainly many treatments that despite having limited data that conform to show-based practice guidelines (Weiss et al., 2008; Guldberg, 2017), are nonetheless widely implemented.

It must exist stated explicitly that a limited evidence base does not mean that a treatment is ineffective; when tested, an emerging treatment may later be validated when large scale studies are conducted. However, ethical practice guidelines include preferentially delivering treatments that currently have credible evidence over those that do not. There is an extensive evidence base showing moderate to large effect sizes for improving a wide range of ASD symptoms using behavioral intervention procedures that do non directly target SI/SP (e.g., Naturalistic Developmental Behavioral Interventions, NDBI; run into Sandbank et al., 2020). That is, SI/SP-T can be conceptualized and tested every bit a naturalistic behavioral intervention and conditions such equally ASD can yield off-white tests of the approach. Because of this, inside the framework of widely used treatment efficacy and effectiveness evaluation procedures that include group and unmarried case (single subject) designs, emerging approaches require systematic evaluation and levels of prove that meet or exceed those of existing interventions (eastward.chiliad., NDBI) to be included in validated treatment options.

Broadly, evidence-based rubrics classify "show" forth a weak to strong continuum (see Brighton et al., 2003). The lowest level of testify includes case presentations and case series studies. These are descriptive and ofttimes include qualitative indices such as goal attainment scaling with limited or no experimental control of bias. Information technology should be noted, nevertheless, that these studies are indeed evidence and that there have been important discoveries that originated with instance reports and example series studies. On the other manus, a lack of control and potential for bias impacting results, are considered weak evidence (Brighton et al., 2003) and there take been many treatments that showed initial hope in case reports that did not evidence benign when more controlled studies were completed. Instance-control studies are like to case reports and case series studies simply include a control/comparison patient (or patients). Although almost are retrospective (a group of similar patients wherein some improved and some did not), this arroyo tin yield fifty-fifty stronger evidence when implemented as prospective single subject/single case design control procedures (encounter Kennedy, 2005; Maggin et al., 2019). The adjacent highest level of testify includes prospective cohort studies, which essentially can be used to determine whether there are differential pre-post- gains in qualitative and/or quantitative benchmarks such as goal attainment scaling and standardized assessments. These also include express or no experimental control of bias but are quite useful. The next level, randomized command trial (RCT), is considered the highest level of evidence when randomization and blinding are implemented. Unblinded and/or subjective qualitative RCTs (e.thou., Goal Attainment Scaling) are viewed as credible bear witness, merely weaker than blinded RCTs. The "ultimate" level of show includes a meta-analysis of aggregated strong RCTs showing consistently meaningful effect sizes across studies. Our assay of SI/SP-T in ASD is predicated on this widely used evidence rubric. Comport in mind that patient and clinician testimonials are not considered evidence.

Origins of SI/SP-T: A Brief Overview of Sensory Integration/Sensory Processing Handling Approaches

Ayres (1972, p. 4) described sensory integration dysfunction every bit a problem in the ability to "organize sensory information for use" and along with motor operation, as a key element of intervention (see also Ayres, 1963; Ayres and Robbins, 2005). In addition to her clinical work, Ayres published many studies focused on the assessment and treatment of SI, and she developed assessments for SI (due east.g., Ayres, 1989, 1996). Ayres' definition encompasses a broad range of behaviors and includes disruptions in social interaction and behavioral regulation (Miller et al., 2007a). While acknowledging that many sensory-based approaches comprise motor operation in accordance with Ayres' framework (Ayres, 1979), we will be focusing the review on sensory parameters. A recent definition of SI derived from a nosology of sensory integration disorder includes "difficulty detecting, modulating, interpreting and/or responding to sensory experiences, which is severe enough to disrupt participation in daily life activities and routines and learning" (Miller et al., 2007a). Several subtypes are proposed in 1 or more sensory systems, including auditory, visual, gustatory (sense of taste), olfactory (smell), somatosensory (proprioception and affect), vestibular, and interoceptive (the sense involved in the detection of internal regulation, such as heart rate, respiration, hunger, and digestion) domains. In 2009, Miller et al. (2009) suggested a modify in classification from "sensory integration" to "sensory processing" disorder while maintaining the foundational sensory elements. Thus, these viii sensations are the central targets of many SI/SP-T sessions. Moreover, SI/SP-T is posited to directly improve attentional, emotional, motoric, communication, and/or social difficulties (see Miller et al., 2014). Difficulty in sensory integration/sensory processing is hypothesized to outcome in challenges related to initiating or sustaining peer interactions, developing engaged relationships, participating in activities of daily living, and regulating arousal behaviors. Specific developmental domains, such equally linguistic communication development (due east.m., Ayres and Mailloux, 1981; Mauer, 1999), are also hypothesized to be impacted and to thus incidentally benefit from SI/SP-T. The impact of these sensory parameters on quantitative indices of domains such equally language evolution is direct testable using well-established experimental approaches.

Within this theoretical framework, common manifestations of sensory integration/sensory processing deficits in children with developmental disabilities, such as ASD and ADHD when sensory symptoms are displayed including responses to stimulation more rapidly, more intensely, and for a longer elapsing than do typically developing individuals. Information technology should be noted that SI/SPD is not exclusive to ASD, ADHD or any other developmental condition and not every child with ASD, ADHD or any other developmental condition should exist diagnosed with SI/SPD. Examples in everyday life include extreme responses to stimuli such as noise in a classroom, odors in a restaurant, the bear upon of clothing, the clipping of finger and toenails, the move of playground equipment, and/or the sight of cluttered environments. Behavioral responses are proposed to include a range of "fight, flight or freeze" reactions such as aggression, withdrawal, or preoccupation with the expectation of sensory input. Secondary social effects seen in preschoolers with SI/SPD include astringent difficulty forming and maintaining peer relationships and/or extreme efforts to control events in the surround by over-reliance on routines. Hypothesized correlates include profound behavior regulation problems, including temper tantrums, outbursts, hitting, boot, biting, spitting, and other maladaptive behaviors, and profound withdrawal from groups.

Additionally, preschool children with SI/SPD are also reported equally being slow to respond to sensation, showing reduced or absent-minded responses, and/or requiring more intense stimuli to respond to the demands of the situation. Examples include not responding to one's name being called and failing to notice when hurt, thirsty, or hungry (see the examples in Miller et al., 2014). Some children with SI/SPD are also reported to have an insatiable need for awareness, well beyond that which is typical, frequently to the extent that safety is a concern. These children derive corking pleasure from "crashing and falling" and have great difficulty sitting still. Parents and peers may describe such children as being "in my face and in my infinite," "constantly touching people or objects," and demanding significant fourth dimension and attention (Miller et al., 2007a; Ben-Sasson et al., 2019). These impulsive and hyperactive behaviors may adversely touch student outcomes. Lastly, preschool children with SI/SPD nowadays with motor delays sometimes categorized as "associated symptoms" (Ming et al., 2007) that are purportedly due to an underlying harm in the ability to translate sensations (Roley et al., 2015). Examples include difficulty initiating, planning, sequencing, and edifice repertoires of action plans, all of which are essential to motor planning to accomplish multi-footstep daily routines. This SI/SPD framework is ofttimes practical to symptoms of conditions such equally ASD when delivering SI/SP-T. Simply it is of import to annotation that the aforementioned features of ASD have also been addressed without utilizing sensory activities and then that there are alternative perspectives as to the nature and extent of SI/SP features in ASD interventions (see the review and meta-analysis in Sandbank et al., 2020).

Thus, despite widespread implementation of SI/SP-T based services, there is an extensive portion of the assessment and intervention literature for children with disabilities that does not translate these behaviors through the lens of sensory integration or sensory processing, relying instead upon some other operant/practical behavioral assay and/or physiological foundations (as examples, see Sappok, 2019; Sandbank et al., 2020). Theoretically motivated, hypothesis-driven studies within the context of off-white clinical trials of SI/SP-T are needed to resolve this disparity in the theoretical ontogenesis of sequelae of developmental disabilities such as ASD. This will shed calorie-free on best practices for intervention in atmospheric condition such as ASD. Moreover, there continues to be considerable heterogeneity in the field regarding treatment and the underlying theories driving these interventions (see for case, Sandbank et al., 2020). Importantly, the "fair evaluation" of an intervention must be faithful to the unsaid or explicit theory of alter for that intervention. Because of this, it is important to briefly review a representative theory of change for SI/SP-T.

Theory of Change for Sensory Integration/Sensory Processing Treatment

Hundreds of publications have described SI/SP-T since 1964, though the literature continues to incorporate relatively few big-scale randomized trials straight testing the intervention (Ayres, 1972; Kimball, 1993; Kinnealey and Miller, 1993; Parham, 1998; Miller et al., 2001, 2007b; Bundy et al., 2002; Pfeiffer et al., 2011, 2018; Schaaf et al., 2014, 2018). Most of the literature on this topic includes inconsistent terminology between studies likewise as limited high-quality show, and design limitations (see Miller et al., 2007c; Schaaf et al., 2018). Additionally, because authors often utilize terminology, theoretical constructs, and observational frameworks that are inconsistent (see Schaaf and Davies, 2010), it can be difficult to aggregate studies and to specify consistent outcome measures. Thus, although some studies provide credible testify of treatment furnishings, SI/SP-T does non however take a strong evidence-base. For case, Schoen et al. (2019) conducted a systematic review of Ayres Sensory Integration (ASI) handling and found but two studies that met a bulk of quality indicators and i boosted study that met a "plurality" of quality metrics. In contrast, reviews of NBDIs include dozens or even hundreds of studies (due east.g., Sandbank et al., 2020). For purposes of this review, we are using the SI/SP-T nosology by Miller et al. (2007a), and we accept adapted the conceptual theory of change from Miller et al. (2001) as an example of a testable SI/SP-T framework (see Table 1). To be sure Ayres Sensory Integration (due east.g., the review of ASI in Watling and Hauer, 2015; Schoen et al., 2019) or any other well-defined arroyo within the wide rubric of SI/SP-T could too exist tested, we utilize the framework of Miller et al. (2001) herein as an example of how this can exist accomplished.

Table 1. Hypothesized social and behavioral effects of sensory disruptions.

The model in Figure i suggests that sensory function is foundational to motor ability, social skill, and a broad range of behavior. Thus, when a disruption occurs in sensory abilities (including disruption in modulation, bigotry, and integration of sensory input), testable cascading effects are posited for several "higher-level" domains, such as social skills. These disruptions are believed to translate to problems with participation at home, at school, and in the community (see Table 1). A Model of Change using SI/SP-T equally articulated above relates to proposed changes in motor, social, and behavioral challenges. It is noteworthy that SI/SP-T tin be implemented in a manner that is consistent with the model inside the context of a blinded RCT with primary and third measures of hypothesized effects. Thus, the SI/SP-T theory of change can be measured using a fidelity of treatment calibration following evidenced-based standards for all behavioral interventions. The construction and delivery of SI/SP-T are founded on the incorporation of tactile (touch), proprioceptive (pressure, position, and muscle exertion), and vestibular (movement and residue) activities in a naturalistic, play-based intervention session. These sensory events can all be operationally defined and reliably measured using observational coding.

Figure 1. Theory of modify for sensory integration/sensory processing (SI/SP) therapy.

For an intervention to exist evaluated fairly, these enhanced sensory integration experiences must be selected specifically to fulfill the needs and behaviors of the individual kid and measured systematically. For example, if a kid displays an unusual sensory profile marked by tactile over-responsivity, so SI/SP-T activities should provide systematic exposure to different tactile sensations (Miller et al., 2014). Systematic exposure to tactile activities is hypothesized to not only subtract tactile over-responsivity but too to improve the behaviors and skills disrupted by tactile over-responsivity, which can all be measured objectively using event coding and/or rating scales. Again, each of these links changes exist tested directly.

Additionally, SI/SP-T is hypothesized to do good children with reduced tactile discrimination. A child who does non translate (discriminate) tactile sensations delivered to her fingers, hands, and feet, may have trouble participating in activities requiring accurate tactile interpretation (e.yard., difficulty buttoning, writing, and manipulating small objects). Once again, this functional relationship is testable.

Testing Behavioral Treatments

For this review, behavioral treatment is defined broadly equally interventions that employ clinician-kid or parent-child interaction excluding pharmacological agents (due east.thousand., as in Hampton and Kaiser, 2016). This includes naturalistic play-based interventions and highly structured operant conditioning treatment methods (Sandbank et al., 2020). Although some have argued that only operant "discrete trials" should be identified as "behavioral" or exclusively falling inside the telescopic of "applied behavioral analysis," behavioral interventions take long been extended to include play-based "naturalistic" treatments (McLean and Snyder-McLean, 1978). As an example, Sid Bijou, one of the founders of the applied behavioral analysis field, adapted Kantor (1977) linguistic theory for study within a behavioral rubric, including conversational elements (see Bijou et al., 1986; Ghezzi, 2010). This framework has been widely practical to written report conversational based interventions (see every bit examples, Koegel et al., 1987; Camarata, 1993; Camarata et al., 1994; Gillum and Camarata, 2004). Table 2 provides a theory of change for a naturalistic behavioral intervention (Pivotal Response Grooming, Koegel et al., 2016) within a behavioral framework. The cardinal point herein is that SI/SP-T tin can be examined—and tested—inside a behavioral framework similar to those applied for naturalistic interventions (e.g., NDBIs).

Table 2. Elements of an example transactional "ABA" treatment (pivotal response instruction).

Current Evidence Base for SI/SP Treatment

Given the widespread delivery of SI/SP based assessment and handling, 1 would look an all-encompassing strong bear witness base of operations in the literature. Earlier delving into the current evidence on SI/SP-T, it is important to mention that practices are often widely provided to students with disabilities even in the absence of extensive supporting data-driven evidence. As an example, music therapy is a very common approach provided to children with ASD despite its currently limited evidence base (come across Lense and Camarata, 2020). Although problematic, an absenteeism of bear witness, unto itself, cannot exist construed as invalidating.

Our review indicated that to engagement, there accept been modest scale studies of several isolated sensory-based procedures, such as weighted vests or "brushing" programs, which usually propose the procedures are not effective (eastward.chiliad., Lang et al., 2012; Taylor et al., 2012). And at that place are a limited number of studies showing positive furnishings on goal attainment scaling (see the reviews in Schaaf et al., 2018; Schoen et al., 2019). But there are also several systematic reviews indicating inconsistent, weak, and/or inconclusive evidence. For example, Lang et al. (2012) reported, "Overall, iii of the reviewed studies suggested that SI/SP-T was effective, viii studies institute mixed results, and 14 studies reported no benefits related to SI/SP-T" (p. 1004). The majority of the studies reviewed past Lang et al. (2012), nevertheless, tested simply ane sensory-based procedure (eastward.chiliad., a weighted vest or sensory brushing) merely not a comprehensive grade of SI/SP-T, in which a multi-component approach is implemented. Thus, a fair test of SI/SP-T necessitates the delivery of multiple elements rather than piecemeal testing of isolated sensory-based procedures and tools (e.grand., wearing a weighted belong).

A critical review published in Pediatrics provides a comprehensive view that more accurately represents the handling (Johnson and Myers, 2007): "The goal of [SI/SP-T] is not to teach specific skills or behaviors merely to remediate deficits in neurologic processing and integration of sensory information to allow the child to interact with the environment more adaptively." This perspective is highlighted in a contempo review by Case-Smith et al. (2015) who concluded:

Studies of sensory-based interventions suggest that they may non be effective. However, these studies did not follow recommended protocols or target specific sensory processing problems. Although small randomized controlled trials resulted in positive effects for [SI/SP-T], boosted rigorous trials using manualized protocols for [SI/SP-T] are needed to evaluate effects for children with [ASD] and sensory processing issues (p. 133).

As these reviews demonstrate, there is currently, at best, an emerging, just limited evidence base on SI/SP-T, with few positive outcomes and some null or negative outcomes.

Moreover, the current state of the evidence for SI/SP-T is accurately characterized in a review past the American Academy of Pediatrics (2012): "… the corporeality of research regarding the effectiveness of [SI/SP-T] is limited and inconclusive" (p. 1186). More recently, Weitlauf et al. (2017) reported in a follow-upwards review:

Some interventions may yield pocket-size short-term (<6 months) improvements in sensory and ASD symptom severity-related outcomes; the show base is small, and the durability of the effects is unclear. Although some therapies may hold hope, substantial needs be for standing improvements in methodologic rigor (p. 347).

Moreover, recent meta-analyses and systematic reviews take consistently highlighted: (a) the paucity of intervention studies in SI/SP-T; and (b) a crucial need for credible intervention studies of SI/SP-T (meet Sandbank et al., 2020). As an case, Pfeiffer et al. (2018) conducted a systematic review of SI/SP-T that yielded five articles coming together inclusion criteria and concluded "Because the number of studies that measured sensory processing or SI challenges were limited, researchers are encouraged to include these measures in future enquiry to understand the touch of a broader range of cognitive and occupation-based interventions" (Pfeiffer et al., 2018, p. ane). Similarly, Pingale et al. (2020) reported "occupational therapists (OTs) use sensory diets to manage sensory processing disorder in children. The electric current evidence is limited. Too, the findings of the studies on the furnishings of sensory diets are mixed" (Pingale et al., 2020, p. ane). Schaaf et al. (2018) reviewed five studies and reported that "The evidence is strong that ASI [Ayres Sensory Integration] demonstrates positive outcomes for improving individually generated goals of functioning and participation as measured using Goal Attainment Scaling for children with autism," merely also reported that "Child outcomes in play, sensory-motor, and linguistic communication skills and reduced caregiver assistance with social skills had emerging but insufficient evidence" (Schaaf et al., 2018, p. ane). In sum, large calibration clinical trials are needed because at that place is prove that SI/SP-T tin improve "near point" proximal measures using qualitative Goal Attainment Scaling, just definitive outcomes for broader objective measures are less clear.

Despite a consensus in the literature on the need for additional evidence, SI/SP-T is currently widely implemented in schools by occupational therapists, speech-language pathologists, and other related services personnel (encounter McIntyre and Zemantic, 2017). For example, Devlin et al. (2011) recently reported that SI/SP-T using Ayres Sensory Integration Arroyo was one of the almost prevalent intervention models in schools, which substantiates previous research findings (Spitzer et al., 1996; Instance-Smith and Miller, 1999; Watling et al., 1999; Roley et al., 2001). A survey of occupational therapists revealed that 82% of respondents reported that they "always" utilize sensory-based handling when working with children with ASD (Watling et al., 1999). Fifty-six percent of parents of children who received applied behavior assay (ABA) treatment noted that their children with ASD had been exposed to sensory treatment also (Smith and Antolovich, 2000, p. 1304; see also McIntyre and Zemantic, 2017). There is no doubt that sensory integration procedures have gained widespread popularity despite the ongoing demand for a stronger prove base. Given that SI/SP-T is "testable" within an prove-based framework, further research is warranted to make up one's mind the efficacy of the arroyo (run across Baker et al., 2008). The post-obit sections describe approaches that could potentially strengthen the evidence base for SI/SP-T if the results of clinical-translational studies reveal unique effects for SI/SP-T.

(Multi)Sensory Perception every bit A Window into SI/Sp-T: Multisensory Integration as A Distal Measure of The Touch on of Sensory-Based Treatment

Multisensory integration is defined as the study of how the brain integrates and interprets input from multiple unisensory systems (Alais et al., 2010). The overlap in nomenclature with sensory integration/sensory processing may exist confusing to clinicians and researchers. Multisensory integration differs from sensory integration/sensory processing in that it does not include intervention recommendations or downstream sequelae of disability while specifically focusing on tightly designed neural and cognitive studies of how specific chief sensory streams are integrated in real-time (eastward.g., auditory and visual). Studies of multisensory integration often arm-twist unisensory responses from two or more than primary senses (east.1000., audience and vision) and so compare the separate responses to effects observed when the inputs are combined (see Stevenson et al., 2014). If the core tenant of SI/SP-T is accurate, namely that SI/SP-T enhances sensory integration, multisensory integration provides a strong test of generalized effects of handling explicitly designed to improve sensory integration. The literature on ASD provides an instance of how one can expect distal multisensory impacts if SI/SP-T is delivered and the theory of change is accurate. As noted above, Sensory Integration Theory and practice was originated past Ayres (1972). Multisensory Integration, a branch of contemporary neuroscience devoted to understanding how the brain synthesizes information from the dissimilar sensory systems, found hit behavioral and perceptual benefits derived from multisensory inputs (run into Stein, 2012) and may provide a neurological test of SI/SP-T.

Although the terms "sensory integration" and "multisensory integration" have divergent theoretical and empirical origins, the hypothesized theory of alter for the SI/SP-T arroyo is directly predicated on disruptions in the ability to integrate sensory and multisensory information. Consequently, multisensory integration assessment is hypothesized to be a useful distal, quantitative approach for testing this aspect of the SI/SP-T approach. Recent studies are developing highly effective methods for characterizing multisensory integration in developing children (Neil et al., 2006; Stephen et al., 2007; Hillock et al., 2011; Hillock-Dunn and Wallace, 2012), and some studies are focused on children with ASD. While there is a potent conceptual link between sensory integration and multisensory integration, there has not as however been a systematic written report of whether sensory-based treatment procedures have an incidental upshot on multisensory integration. Indeed, sensory-based treatments are specifically designed to increase inputs from multiple sensory sources, which would facilitate learning and improve beliefs equally a outcome of improved multisensory integration every bit a consequence of the sensory-based treatment. Although therapists and teachers across many disciplines ofttimes incidentally contain data from multiple sensory modalities during handling in the absence of targeted sensory integration procedures, sensory-based treatments specifically focus on delivering elements across different sensory systems. This arroyo of providing input from multiple sensory modalities is believed to benefit students past facilitating multisensory integration.

Ayres (1972) proposed that multisensory systems play a critical role in establishing a foundation upon which "higher-level" development can occur. Indeed, sensory and multisensory representations are viewed as forming the "building blocks" upon which higher cerebral abilities and learning can occur. Nonetheless, whatever social/behavioral intervention, including sensory-based treatment, must ultimately be founded upon a series of empirically tested and validated procedures (Devlin et al., 2011). The force of these multisensory integration assessments every bit distal upshot measures lies in the fact that SI/SP-T, if valid, should have a differential significant impact on MSI every bit compared to nonsensory comparing intervention conditions which practise NOT include straight sensory-based handling. Thus, a comparing of multisensory abilities betwixt SI/SP-T and fair nonsensory behavioral treatment groups may be used to assess the specificity of treatments aimed at improving multisensory function. As an instance, the aforementioned NDBI recast communication therapy arroyo yields stiff effects on linguistic communication, but, hypothetically should Non improve MSI whereas SI/SP-T is hypothesized to improve language and MSI.

Tests that specifically alphabetize multisensory function are becoming increasingly important tools to provide an empirical evaluation of the integrity of sensory processing in individuals with disabilities (see Kwakye et al., 2011). Much of the work to date has focused on testing the power to discover and discriminate sensory stimuli—both inside and across different sensory modalities—in children and adults with disabilities compared to those considered "typically developing." This work has revealed substantial differences in the manner in which individuals with disabilities, specifically ASD and dyslexia, integrate auditory and visual information. Therefore, there is a strong rationale for including multisensory assessments in future evaluations of the differential touch on of SI/SP-T on individuals with ASD or who are typically developing as a direct link in the theory of change for sensory-based treatment approaches.

Case From ASD and Multisensory Auditory-Visual Integration

Stevenson et al. (2014) reported that the "window" within which the brain integrates and "binds" visual and auditory information—called auditory-visual temporal binding (approximately 100 ms in typically developing school-age children)—is highly variable and often considerably more than latent (up to 500 ms or even more than) in matched participants with ASD. That is, the auditory and visual sensory streams are not "integrated" within the aforementioned fourth dimension frame in people with ASD. This phenomenon is depicted in Figure ii, wherein the temporal binding curve for ASD and matched command participants are overlaid on 1 another. This is also illustrated in Figure 3, which presents a histogram depicting the relative distribution of the temporal bounden window in each group.

Figure 2. Shift in temporal binding window in multisensory integration in autism spectrum disorder (ASD). *Significant departure (p < 0.05).

Effigy 3. Theory of change for tactile sensory stimulation.

We hypothesize that auditory-visual temporal bounden should differentially decrease for ASD under SI/SP-T because the theory of change for sensory-based treatment specifically posits that sensory integration volition be improved post-obit the commitment of these treatments. We also hypothesize that auditory-visual temporal binding volition not be affected in children with ASD who are treated using applied behavioral intervention (due east.g., Pivotal Response Training™; Koegel et al., 2016). A plausible theory of alter including multisensory integration and use of tactile stimulation equally an antecedent treatment ingredient is depicted in Figure 3.

Controlling for Developmental Confounds

Fair and unbiased evaluation of SI/SP-T requires delivery of SI/SP-T procedures in an advisable social and communicative developmental context (see Bialer and Miller, 2011; Miller et al., 2014), not decontextualized applications of sensory equipment, activities, and/or personal appliances such as weighted or pressure vests. While acknowledging the validity of this perspective, there exist challenges to testing the unique contributions of SI/SP-T procedures in a context that includes known active ingredients that are causally linked to developmental growth. For example, the aforementioned NDBI recast treatment involves linguistic communication transactions that are ubiquitous in clinician-child interactions. That is, SI/SP-T conducted in naturalistic play contexts with supportive clinicians contains many known efficacious NDBI recast teaching events in addition to sensory events. As stated straight, social and communication elements themselves without enhanced tactile, proprioceptive, or vestibular enhancements are well established (and powerful) agile ingredients in a plethora of naturalistic behavioral interventions (see Koegel et al., 1987; Carve et al., 2015; Sandbank et al., 2020) that do non include SI/SP activities. Thus, it will be important to test whether unique treatment effects are arising from SI/SP activities and/or whether there are synergistic "value-added" contributions for SI/SP activities when implemented within the context of naturalistic social and communication intervention such every bit NDBIs.

As a specific instance, it is well-established in the treatment literature that transactional communication exchanges facilitate linguistic communication and social skills evolution (encounter National Academies of Sciences, Technology and Medicine, 2016). The theory of change for recast treatment is based upon a naturalistic ABA approach to transactional developmental modeling (come across Camarata and Yoder, 2002). Primal elements for the theory of change in this naturalistic ABA arroyo include reinforcing attempts using social attention and natural reinforcers and pairing educational activity models inside meaningful communication interactions.

Recast treatment and other transactional approaches (e.one thousand., pivotal response handling, Koegel and Koegel, 2019) contain transactional elements such every bit reinforcing and pairing in handling sessions (see Figure 4). Stahmer et al. (2010) describe pivotal response training or pivotal response treatment as a class of naturalistic behavioral intervention based on the principles of ABA, an arroyo soundly supported by the scientific literature (National Inquiry Quango, 2001). Thus, transactional intervention fits within the wide rubric of prove-based naturalistic ABA interventions that include the design, utilize, and evaluation of ecology modifications and interventions to produce socially significant comeback in man beliefs. ABA uses antecedent stimuli (events that happen before a behavior occurs, such equally a instructor asking a child what color a crayon is) and consequences (events that happen later on a beliefs occurs, such every bit giving the kid the crayon later he or she names the color), to produce changes in behavior. Tabular array 2 (from Stahmer et al., 2010) describes the fundamental elements in the intervention.

Figure 4. Example of language transaction.

Because of this, there is a potential confound within SI/SP-T that must be considered when conducting handling trials; namely, off-white implementation of SI/SP-T includes numerous communication transactions that are known drivers of development in typical children and in diverse populations of children with disabilities, so the unique touch on of SI/SP procedures should exist tested. The question is whether handling gains associated with SI/SP-T are differentially associated with the sensory ingredients or, more broadly, to the transactional ingredients.

Therefore, it is important to discriminate the furnishings of sensory ingredients from those of transactional ingredients. A potential solution could be to deliver SI/SP-T while omitting transactions, but experts in SI/SP-T agree that this type of socially unusual intervention—wherein the clinician does not interact with a child in a normal fashion—may unfairly bias the results against SI/SP-T. Another solution is to comport an RCT wherein ane arm includes delivery of transactional handling with sensory events, every bit compared to transactional intervention without sensory ingredients. This alternative arroyo is both practical and feasible and tin exist conducted with high fidelity of implementation and to exam for synergistic "value-added" furnishings from SI/SP-T.

Equally a instance, for example, which we acknowledge is a weak form of show, but none the less a useful analogy of this point, consider the following patient. A male, historic period vi; three, with ASD displayed salient facial rubbing. Within the SI/SP-T theoretical framework, an OT diagnosed "sensory seeking" type sensory processing disorder and prescribed treatment using contingent sensory brushing wherein brushing on the forearm was delivered in response to facial rubbing events. Note that facial rubbing and delivery of sensory brushing are both highly salient events that were coded from video records with 100% concordance between independent coders. In addition to the sensory brushing, the clinician incidentally delivered communication transactions while sensory brushing (i.due east., she interacted verbally with the kid while brushing him). A counterfactual condition, wherein transactions were delivered in the absenteeism of brushing, was developed and subjected to video coding for the allegiance of treatment. Naturally, coders concurred that at that place were no sensory events in this condition with 100% accuracy, and the concordance for communication transaction delivery was 92% (which is inside the usual range of fidelity for transactional treatment, see Davis et al., 2016 as an instance).

Two different treatments–sensory brushing plus incidental communication transaction and advice transaction WITHOUT brushing–were delivered to this example using an alternate treatment design within the rubric of a unmarried-instance design (see Kennedy, 2005). Sensory brushing plus transaction was delivered get-go, followed by a return to baseline (no treatment) phase, so a transactional merely phase, then another render to baseline (no treatment) phase, and finally, some other sensory brushing stage. The results are depicted in Figure 5. The bluish dots and lines stand for the session counts for the "sensory seeking" facial rub events and the red squares depict the number of sensory brushing events in the session. Both conditions included an average of ii communication transactions per minute. As seen in the figure, the high baseline count for facial rubbing before initiating treatment decreased during sensory brushing treatment atmospheric condition. After each handling condition was completed, facial rub counts speedily increased during the render to baseline phases.

Figure 5. Case example illustrating confounds in sensory and transactional handling elements.

It is perchance useful to examine the first baseline and handling phases, which included sensory brushing. Every bit can be seen, no brushing was delivered during baseline, during which fourth dimension the participant exhibited a very loftier level of facial rubbing, ranging from 33 to 52 events per 1-h session. In the first handling phase, the behavior decreased dramatically, falling to fewer than 20 confront rubs in every session and to zero in 6 of the 22 sessions. A clinician keeping these data could certainly conclude that the sensory brushing was highly effective! The render to baseline phase provides further confirmation of handling efficacy because the facial rub count immediately increased to a higher place the levels observed in treatment. However, it is of import to carry in listen that sensory brushing was non the only "ingredient" delivered during this phase; incidentally, an average of 2 transactional events per minute during the session was provided as well when the clinician verbally interacted with the child while brushing him.

Note that in the second treatment phase, the aforementioned clinician delivered NO sensory brushing (meet the cherry squares in phase 2) while continuing to deliver communication transactions at the aforementioned rate. As tin can be seen by the blue circles and line, the number of face rub events mirrored the frequency of behaviors observed in phase ane; these events decreased precipitously to below 20 per session, and on two occasions, between zero and ten events were recorded (the numbers were a piffling disruptive without nouns) there were ii at zero and six that were less than ten (but higher than null). Once again, a return to baseline yielded an increase to nearly baseline frequency of behaviors, and reinstatement of the sensory brushing treatment replicated the results from phase 1, except for a spike in face up rub events during sessions 7–9. One could fence that these results suggest that communication transactions were driving the decrease in facial rub events rather than the sensory brushing. This case graphically illustrates the need to command for confounds when testing SI/SP-T.

Summary, Conclusions, and Hereafter Directions

SI/SP-T is a widely-used arroyo for treating individuals with diverse conditions and symptomology. A currently express simply emerging evidence base of operations necessitates fair, unbiased clinical studies comparing SI/SP-T procedures to those of other established handling approaches. This review included a presentation of 1 such validated NDBI handling: Recast Treatment, which is based on a broader transactional intervention framework. Also, multisensory integration, broadly, and auditory-visual integration specifically, were discussed as promising approaches to differentially test the SI/SP-T theory of modify. The article also includes a case presentation wherein misreckoning factors could potentially account for treatment effects that may be inaccurately attributable to an SI/SP procedure, sensory brushing, which more plausibly could be attributed to conversation transactions.

SI/SP-T is testable within the context of rigorous treatment studies, and key ingredients tin exist measured. Chiefly, these trials should be conducted fairly and without bias to empirically evaluate the efficacy of SI/SP-T. Moreover, there has been an ongoing need for fair clinical trials of SI/SI-T. The review herein indicates that such trials tin exist conducted using the highest quality standards of implementation and employing objective quantitative proximal and distal measures in addition to more qualitative indices such as goal attainment scaling. Finally, these studies must be conducted using procedures that are not only faithful to the accurate implementation of SI/SP-T simply also control for misreckoning factors. These studies should be conducted with all populations posited to benefit from SI/SP-T such equally ASD, ADHD, Linguistic communication Disorders, and Down Syndrome. Calls for off-white studies have been appearing in the literature for more than 2 decades; these must be conducted shortly.

Author Contributions

SC and MTW accept collaborated on the multi-sensory processing research described in this article. LM and SC have collaborated on behavioral issue coding for evaluation of sensory based treatments described herein and on developing a measurable theory of alter for testing sensory based intervention approaches. All authors contributed to the article and approved the submitted version.

Funding

This inquiry was supported in part by a grant from the Wallace Research Foundation and by 1R34DC010927-01 from the National Establish on Deafness and Other Communication Disorders (SC and MTW, MPI). The Scottish Rite Foundation of Nashville also provided back up.

Conflict of Interest

The authors declare that the research was conducted in the absence of whatsoever commercial or financial relationships that could be construed as a potential conflict of interest.

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