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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE
Name: Marissa Elder and Marissa Stendel
Date: 09/16/15
Focus Question: Does Ayres' sensory integration (SI) treatment increase engagement and improve play skills in children with
autism/PDD and sensory deficits?
Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table: Include
articles beginning from 1999-2015, in English, must have diagnosis of Autism Spectrum Disorder, Pervasive Developmental Disorder
with sensory deficits.

Author/
Year

Study
Objectives

Level/Design/
Subjects

Intervention and
Outcome Measures

Results

Study
Limitations

Implications for OT

- Case Smith, J., &


Bryan, T.
(1999).

- Effects of OT
intervention
emphasizing SI
(sensory
integration) with
five pre-school
children with
Autism
Spectrum
Disorder (ASD).

- Level IV, single case


design.
- AB study design
-Established a baseline
for five boys tested
over a three week
period.
- Treatment started
week four and ended
week 10.

- The Engagement Check


was used as an outcome
measure.
- Outcome areas measured
were mastery play, nonengagement, adult
interaction, and peer
interaction.
- Outcome measured six
weeks after treatment

- Mastery play
revealed
significance for four
out of five children.
- One child received
significant score in
adult interaction.
-None of the
children received
significant scores in

- Author of study
was providing
treatment to
participants.
- Small sample size
- All same sex
participants.
- ABA therapy was
provided to one
participant for 40

The clinical and


community-based
practice of OT
-Evidence has shown that
mastery play can be an
area of focus during OT/SI
interventions.
Program development
-Because the Engagement
Check is a valid and

- Participants were five


years of age.
- Attended a special
needs program and had
active individualized
educational program
(IEP).

baseline measured.
- Intervention was provided
by second author certified
in SI and praxis tests and
with extensive training in
SI. One to one services
were provided in adjacent
classroom for 30 minutes.

peer interaction.
- Study was too
small to be applied
to a more general
population.

hours a week
concurrent with SI
treatment.
- Comorbidities in
participants such as
bipolar disorder, and
hearing impairment.

reliable outcome measures,


there is a potential to
utilize the Engagement
Check as a foundation for
a program focused on
improve areas of
engagement in children
with ASD.
Societal Needs
-This study addresses
societal needs because it
focuses on proving the
efficacy of SI treatment to
the general public.
-This can provide parents,
healthcare providers, and
consumers with the needed
information to form an
informed opinion about the
implication of SI treatment
in our society.
Healthcare delivery and
policy
-This evidence promotes
the use of valid and
reliable assessment tools
as a part of healthcare
delivery because it
illustrates the clinical
utility of the Engagement
Check.
Education and training
of OT students
-This study can be sued to
illustrate to OT students

- Dunbar, S.,
Carr-Hertel,
J.,
Lieberman,
H., Perez,
B., Ricks, K.
(2012).

- Differences
between
traditional
individualized SI
treatment and
integrated
sensorimotor
activities for
preschool
children with
ASD.

- Level II, cohort study


- Number of
participants was seven.
There was one dropout
due to illness.
- Six males, and two
females.
- Randomly assigned to
two groups.
- All had diagnosis of
ASD.
- Inclusion criteria of
18-month-old level in
order to follow very
simple verbal directions
and gestures,
demonstrate a sensory

Outcome measures:
Evaluation of Sensory
Processing and the Knox
Preschool Play Scale
- Evaluation of sensory
processing completed by
parents.
- Knox Preschool Play
Scale completed by an
occupational therapist (OT)
before and after
interventions.
Outcome areas: Play along
with the individual
components of sensory
systems including, tactile,
vestibular, proprioception,

- Knox Preschool
Play Scale pre- test
treatment mean
score was 28.5 and
post control mean
score was 32.62.
- Knox Preschool
Play Scale post-test
treatment mean
score was 39.37 and
post control mean
score was 47.40.
- Results indicated
an improvement for
both treatment and
control groups in
their overall play

- Small sample size


with limited ability
to generalize results.
- Used varying
approaches with
help from teachers
integrated in
classroom time that
may have affected
the participants
outcomes.

how to structure an ABAB


design study.
-It can also be used to
encourage discussion on
the effectiveness of SI
treatment in practice
versus what the literature
has said about SI
treatment.
Refinement, revision, and
advancement of factual
knowledge or theory
-The study examines how
SI treatment can be utilize
to influence the occupation
of play versus ADL, which
are what is typically
examined.
The clinical and
community-based
practice of OT
- SI has now been
introduced into other
sectors such as in general
education. Teaching SI
principles to others can be
helpful in expanding the
richness of a sensory
environment for those
children with sensory
deficits.
Program development
-Creating more programs
like the one implemented
in this schools system to

issue, and not currently


receiving SI related
intervention.

visual, auditory,
olfactory/taste.
- Intervention was
conducted over 12 weeks in
collaboration with teachers
and OTs.
- Activities included table
tasks, circle, story, art,
sensory, play, computer,
teacher time, independent
work, nap, mealtime, gym,
and playground time.
-The amount of time in
sensorimotor-related
activities was intended to
match the time of the one
hour pull out sessions.
- Four students who
received pull out therapy
were provided with
individualized intervention
to meet needs. Occurred
twice a week for 30
minutes.

skills within this


short 12 week
period.
- The children in the
pull-out intervention
group demonstrated
increases in mean
scores of play skills,
but the control
group also improved
in this area of
function.

increase program
outcomes like this across
the nation.
Societal Needs
-The high rate of incidence
for ASD in this country is
in need for further services
like these where an OT
and teacher combine
forces to help these
children with their needs.
Healthcare delivery and
policy
-Creating policy to better
implement OTs into
classrooms could help to
decrease deficits like these
in children.
Education and training
of OT students
-Gaining hands on
experience in the
classroom with children
and organizing SI
treatment can better help
train students for the work
force.
Refinement, revision, and
advancement of factual
knowledge or theory
-This study advances
typical SI treatment by
moving the application of
its principles from the
setting of an outpatient

-Linderman,
T. M., &
Stewart, K.
B. (1999).

- Explore the
effects of SI OT
treatment on the
performance of
two pre-school
children with
Pervasive
Developmental
Disorder (PDD)
in social
interaction,
communication
during mealtime,
approaches to
new activities,
response to
holding, and
response to
movement.

- Level IV, single case


design.
- Two phases: baseline
and treatment phases.
- Baseline evaluation
completed two weeks
before treatment.
- Targeted behaviors
identified for treatment
phase.
- Participant one was
nine months old with
signs of autism with
symptoms of echolalia,
moderate tactile
hypersensitivity, and
decreased social skills.
- Participant two was
three years old with
autism, severe language
delay, hypersensitivity
to tactile stimuli,
hyposensitivity to
vestibular stimuli, and
excessively spun,
jumped and swing.

- Outcome measures:
Functional Behavior
Assessment for Children
with Sensory Integrative
Dysfunction was used for
duration, quality, and
frequency of behaviors.
- Outcome areas: Social
interaction skills, approach
to new activities, and
response to holding and
hugging for Participant 1
and social interaction skills,
functional communication
during mealtime, and
response to movement for
Participant 2.
- For intervention a wide
range of materials were
used depending on need of
child.
- Each child encouraged to
participate in multimodality
input and movement
through space.
- Novel experiences and
graded sequence of
activities.

- Significant
improvements were
noted in the areas of
social interaction,
approach to new
activities, response
to holding and
hugging, and
response to
movement.
Participants
demonstrated
significant gains in
all functional
behaviors observed
in context of home.
- Tables provided
with more detail.

- Future research
needed to replicated
and extend findings.
- One of participants
had been receiving
SI treatment prior to
study.
- Presence of video
in home of
Participant 2 could
have altered
behavior and thus
the validity of data.
- Authors collected
interrater reliability
of the study.

sensory gym to a local preschool.


The clinical and
community-based
practice of OT
-Creating novel
multisensory experiences
for children may create
functional gains in
children with PDD.
Program development
-This program would need
to be expanded and
researched with a larger
population for
generalizability. Novel
experiences for each child
will be different thus a
sensory gym and many
materials will be needed.
Societal Needs
-Addressing needs of
children who have
hypo/hypersensitivity can
help to merge special
needs clients into
integrated classrooms.
Healthcare delivery and
policy
-Further delivery of these
services and use of
assessments with children
demonstrates the process
of refinement and need for
these OT services within

Miller, L.J.,
Coll, J.R., &
Schoen. S.A.
(2007).

- To find how SI
can better
ameliorate
attention,
cognitive/social,
sensory, or
behavioral
problems

-Level I, RCT.
-24 children
participates total.
-Seven were in the OTSI group, 10 in the
Alternate Placebo
Group, and seven in the
Passive placebo or no

- OT-SI group included


supervised,10 week sensory
integration program at a
childrens hospital
- Active placebo was called
Activity Protocol and
consisted of a variety of
engaging tabletop play

- The OT-SI group,


made gains that
were significantly
greater than the
children in the other
two groups on GAS
- OT-SI group also
increased

- 54% of the data


were unusable
(either pretest or
posttest data were
not of good enough
quality to use on 13
children).
-Sample size too

the community and home


setting.
Education and training
of OT students
-Engaging students during
class time with more
sensory interventions for
certain types of sensory
deficits will help to better
their skill when out in
practice.
Refinement, revision, and
advancement of factual
knowledge or theory
- This study revises typical
SI treatment protocol by
utilizing the Functional
Behavior Assessment for
Children with Sensory
Integrative Dysfunction
instead of the SIPT to
measure improvements in
sensory processing and
quality of motor
movements after
implementing SI
treatment.
The clinical and
community-based
practice of OT
-Illustrates how attentional
deficits in children with
ASD could be addressed
within the confines of SI
treatment

compared to an
active/ Alternate
Placebo
treatment or a
passive placebo.

treatment group.
- Of the 24 children
with diagnosis of
sensory modulation
disorder (SMD), five
had attention deficit
disorder (ADHD), three
with learning
disabilities (LD), and
one with anxiety. 15
had no other diagnosis.

activities (e.g., arts and


crafts, puzzles, blocks,
reading stories, interactive
games).
- Passive placebo/no
treatment group were on a
waitlist for SI treatment
during the 10 weeks
-Primary outcome measures
were the Leiter
International Performance
ScaleRevised: Parent
Rating
Scale (Leiter-R), Short
Sensory Profile (SSP),
VABS-II, Child Behavior
Checklist (CBCL), Electro
dermal reactivity (EDR),
and GAS.

significantly more
than the other
groups on Attention
(p = .03 compared
to No Treatment; p
= .07 compared to
Activity Protocol
[trend toward
significance]) and
on the
Cognitive/Social
Composite of the
LeiterR (p = .02
compared to
Activity Protocol).
-Improvements in
subtest of the other
measures were
greater for the
treatment group but
not significant.

small (revealed via


post hoc power
analysis).
- Homogenous
sample size (most
participants were
Caucasian and
male).

Program development
-Lays groundwork for a SI
treatment program that
addresses the needs of
children with a wide range
of diagnoses and disorders
(i.e. ADHD, LD, etc.)
Societal Needs
-Attempts to provide
justification for the
implementation of SI
treatment throughout
various clinical settings,
particularly hospital-based
settings.
-This would theoretically
bring needed services to an
underserved portion of
society.
Healthcare delivery and
policy
-Demonstrates how the
GAS can be used to assess
a childs goals in relation
to SI treatment plans and
how the process can then
be documented
Education and training
of OT students
- Can provide a real-life
example for students of the
purpose of the Leiter-R as
well as how it can be
implemented into practice.
-Can be used to teach

Pfeiffer,
B.A.,
Koenig, K.,
Kinnealey,
M.,
Sheppard,
M.,
Henderson,
L. (2011).

-Set up a method
for randomized
controlled trials
dealing with SI,
- Point out ideal
outcome
measures
-Discuss the
efficiency of SI
interventions in
children with
ASD.

-Level I, RCT.
-37 participants, 32
males and five females,
after losing four
participants to drop out.
- Children with PDD
not otherwise specified
(NOS) and children
with ASD (excluding
Aspergers syndrome).
between the ages of 612

-18 treatment sessions


lasting 45 minutes for six
weeks
-Treatments for SI group
were based on individual
deficits using established
core concepts of SI
-Treatment for fine motor
(FM) control group focused
on crafts, constructional
activities, and
drawing/writing.
- Outcome measures used
were the Sensory
Processing Measure (SPM),
Goal Attainment Scale
(GAS), Vineland Adaptive
Behavior Scales, 2nd edition
(VABS-II),
Quick neurological
screening test (QNST-II)
Social responsiveness scale
(SRS).

- None of the
categories in the
various measures
were significant,
expect for the
attainment of parent
goals in the GAS
and a decrease in
autistic mannerisms
(measured in a
subscale of the
SRS).

-Not carrying over


interventions into
daily routine.
-Not accounting for
all variables that
could have
influenced the
results.
-Short period of
time for
interventions.

students the components of


a true RCT study.
Refinement, revision, and
advancement of factual
knowledge or theory
-Attempts to expand SI
theory to address areas of
executive functioning in
addition to motor praxis
and sensory modulation.
The clinical and
community-based
practice of OT
-Provides information
regarding the disparity
between parent-made goals
and practitioner-made
goals
-Therapist can use this
information to bridge the
gap between parent-made
goals and expected
treatment outcomes.
Program development
-Outlines possible
treatment sessions design
that can address the needs
of children PDD-NOS
Societal Needs
Addressed the need to
determine which sensoryrelated assessment tool is
most appropriate to use
when measuring goals for
children with PDD-NOS

Schaaf, R.,
Benevides,

- Evaluate the
efficacy of

- Level I, RCT
- N = 32

- SI treatment provided by
three OT with certification

- Those who
received SI

- Sample size,
sample diversity,

and ASD enrolled in a SI


treatment program.
Healthcare delivery and
policy
-Articulated a possible
duration and frequency of
SI treatment that
effectively addressed of
the needs of each
individual participant.
-This was done by proving
that the suggested duration
and frequency was
inefficient
Education and training
of OT students
-Provided real-life
examples for
students/educators/readers
of what activities are
included in a SI treatment
program versus a fine
motor program.
Refinement, revision, and
advancement of factual
knowledge or theory.
-Provides information to
guide future higher level
research studies on SI.
-Provided a model of how
SI treatment studies
involving RCTs should be
conducted.
The clinical and
community-based

T., Mailloux,
Z., Faller, P.,
Hunt, J.,
Hooydonk,
E., Kelly, D.
(2013).

OT/SI in
comparison to
usual care (UC).

- Two dropouts
Total # - 30

in SI.
- UC treatment defined as
speech, language,
behavioral, and educational
programs that can be
replicated in practice.
-Outcome measures:
Autism Diagnostic
Interview- Revised (ADIR), Autism Diagnostic
Observation Schedule
(ADOS), Stanford-Binet V,
Different Abilities Scale-II,
Weschseler Preschool and
Primary Scale of
Intelligence III, Sensory
Integration and Praxis Tests
(SIPT), Sensory Profile,
Global Assessment Scale
(GAS).
-Secondary measures
comprised of Pediatric
Evaluation of Disability
Inventory (PEDI),
Pervasive Developmental
Disorder Behavior
Inventory (PDDBI), and
Vineland Adaptive
Behavior Scales-III

treatment scored
significantly higher
on the GAS (p value
of .003).
- Children who
received SI
treatment had a
decrease in
caregiver assistance
in self-care and
social skills (p value
of .039), as defined
by the PEDI.

and lack of
additional
assessments to
support the GAS.

practice of OT
-The GAS assessment can
be helpful in evaluating if
SI treatment has been
useful. However, many
other assessments that are
meant to evaluate the same
behaviors did not show
any significant differences
in behaviors.
Program development
-SI care has been identified
to work better for children
than UC. This leads to the
notion that UC should be
improved.
Societal Needs
-UC should be improved in
some areas such as sensory
deficit care in order to
better serve the
community.
Healthcare delivery and
policy
-Increase SI care and
decrease or improve UC
interventions and
implementation among
healthcare professionals.
Education and training
of OT students
-Train OT students how to
incorporate more SI
principles in their UC to
facilitate better outcomes.

Schaaf, R.
C., Hunt, J.,
&
Benevides,
T. (2012).

-To establish the


effectiveness of
SI treatment in
the context of
OT.
-Documented
and analyzed the
changes in one
child after he
received SI
treatment.

- Level V, case study


design.
- The sample included
one five-year old male
with ASD and ADHD.
-Information was not
provided as far the
means of recruitment is
concerned.

- Researchers used
manualized protocol based
on SI principles (ten).
-Interventions were
administered by two
registered OTs certified in
SI.
-The therapy was a 10
week, intensive treatment
with 30 sessions per week.
-Outcome measures used
were the Vineland Adaptive
Behavior
Scales, Second Edition, the
Pervasive Developmental
Disorder Behavioral
Inventory (PDD-BI)
Sensory Integration and
Praxis Tests (SIPT), the
Sensory Profile, and
Sensory Experiences
Questionnaire
(SEQ)

-Researchers used a
pre and post t test to
determine
improvements in
performance.
- No p values were
significant at the .05
level.
-The studys results
were an individuals
performance and
cannot be
generalized.

-Limited by small
sample size of only
one child, hindering
generalizability.
-Citing research
conducted by the
authors of the study
indicated bias in
justification
research.
- Lack of statistical
significance limits
implications for
future research and
practice.

Refinement, revision, and


advancement of factual
knowledge or theory
- This study seeks to
advance knowledge on
what usual care is defined
as amongst healthcare
professionals involved in
the treatment of children
with ASD
The clinical and
community-based
practice of OT
-Outlines how manualized
protocol can be used
within the context of OT
practice and SI treatment
Program development
-Provided ten core
principles of SI that could
be used to structure an SI
program for children with
ASD and ADHD
Societal Needs
-Sets a foundation for
future research in SI
treatment and OT, which
could benefit society as a
whole
Healthcare delivery and
policy
-Suggests an appropriate
frequency and intensity for
SI treatments in practice.
Education and training

Watling, R.
L., & Dietz,
J. (2007).

-To analyze the


how SI impacts
behavior and
task engagement
for individual
children with
ASD.
-Provide a
guideline for
future research.

-Level IV, ABAB


design
-Four male children
ages three to four with
a diagnosis of ASD
-Recruited from a local
neurodevelopmental
center.

-Included activities that


supported Ayres SI that
were specific to each childs
needs.
-Researchers used each
childs Sensory Profile
score to pinpoint deficits.
-Delivered by an OT with a
solid foundation in SI
methods used clinical
reasoning to guide
treatment.

-Visual inspection
was used to analyze
findings
- No statistical
measures were run
-Leads to lack of
generalizability.

- Limited by a lack
of statistical support
utilized to analyze
the significance of
findings.
- Limited by
subjective testing
bias related to the
questionnaire nature
of the Sensory
Profile.
-Limited by a small
sample size of only
four children.

of OT students
-Teaches students how to
run a pre and post t test to
determine improvements
in performance.
Refinement, revision, and
advancement of factual
knowledge or theory
-Advocated for using the
theoretical background
behind the SIPT in
conjunction with theories
supporting other sensoryrelated outcome measures.
The clinical and
community-based
practice of OT
-OTs could analyze and
find aspects of article that
may emphasize the
importance of finding
subtle nuances in
childrens behavior as
demonstrated in the
context of therapy and
outside the context of
therapy.
Program development
-Design a legitimate study
design that uses statistical
analysis to understand
findings.
Societal Needs
-Create programs that
address needs of children

with all types of SI


deficits.
Healthcare delivery and
policy
-Ensure that healthcare
delivery of SI treatment is
legitimate and backed by
objective assessments.
Education and training
of OT students
-Educate on task
engagement for children
with ASD using
multimodal means of
intervention.
Refinement, revision, and
advancement of factual
knowledge or theory
-This study seeks to
advance the use of the
Sensory Profile as a
diagnostic tool for
sensory-related deficits as
well as an assessment tool
to track a child with ASDs
progress over time after
receiving SI treatment.

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