The Efficacy of Sensory Integration Therapy On Children With Asperger's Syndrome and Pdd-Nos

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THE EFFICACY OF SENSORY INTEGRATION THERAPY

ON CHILDREN WITH ASPERGERS SYNDROME AND
PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED
by
Kristen Renee Klyczek
May 4, 2009
A dissertation submitted to the

Faculty of the Graduate School of
the University at Buffalo, State University of New York
in partial fulfillment of the requirements for the
degree of
Doctor of Philosophy
Department of Rehabilitation Science

School of Public Health and Health Professions
UMI Number: 3356047

Copyright 2009 by
Klyczek, Kristen Renee
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The Efficacy of Sensory Integration Therapy
Copyright by
Kristen Renee Klyczek
2009
ii

Acknowledgement
I would like to offer my thanks and gratitude to so many people who have helped
me achieve this goal. First, I would like to thank my husband Mark for his unending
support and dedication to helping me see this through to the end. I never thought we
would get here, but with your help and with many sacrifices along the way, we made it! I
would also like to thank my two beautiful miracles, Andrew and Allison, for allowing
Mommy to spend long hours away from them. I look forward to many years of making
it up to you. To our families, I cannot tell you how much I appreciate all that you have
done for me and for our family over the years. I would not be where I am today if not for
your support. I am truly blessed to have you in my life.
Many people were directly involved in helping me with this process. I would like to
thank my dissertation committee members, Dr. Linda Shriber, Dr. Geralyn Timler and
Dr. Diane Wrisley for your patience throughout the many twists and turns of this process,
for your constant belief in me, and for the many lessons you have taught me along the
way. You have been a pleasure to work with and I look forward to working with each of
you as colleagues. I would also like to thank the Occupational Therapy and Physical
Therapy Departments, as well as the Department of Rehabilitation Science at the
University at Buffalo, for your support and for the generous use of your equipment and
facilities. Dr. Patricia Ohtake, you have helped me see the bigger picture, you have seen
something in me that I couldnt see myself, and you have had a remarkable influence on
my life - thank you. I would also like to thank the faculty at Daemen College for your
support so many years ago, and for your support now, as I stand on the other side of the
podium. I am honored to be a part of your team! I am also grateful to those who have
iii

assisted me in the research process including Kristen Mayrose, Cathy Buyea and the
beautiful children and their families. It was you who made this dream a reality!
Additionally, I would like to express my gratitude to the Mark Diamond Research Fund
for providing funding for this exciting research study.
Finally, to my friends, old and new who have been with me along this journey, I
thank you. Whether it was you who encouraged me to do this, you whose path crossed
mine along the way, or you who stuck with me even when I was too busy to be much of a
friend, I thank you for your role in my life and wish you all the best. I am standing at the
end of a very long road. I am proud of where I have been, but I am so excited about
where I am going. Thank you for being with me along the way!
iv

Table of Contents
Acknowledgement
Table of Contents..
List of Tables
List of Figures...
List of Appendices
Abstract.
iii
v
viii
ix
x
xi
I. INTRODUCTION
Hypothesis....
Conceptual Framework
Neuropathophysiology of Aspergers Syndrome and Pervasive
Developmental Disorder Not Otherwise Specified.
Sensory Integration.....
Sensory Dysfunction...
Sensory Integration Therapy..
Summary..
4
5
5
14
20
23
25
II. LITERATURE REVIEW
27
Characteristics of Children with Aspergers Syndrome and Pervasive

Developmental Disorder Not Otherwise Specified..
Motor Skills of Children with Aspergers Syndrome and Pervasive
Sensory Processing in Children with Aspergers Syndrome and Pervasive
The Effectiveness of Sensory Integration Therapy.
Summary..
36
43
48
III. METHODS.............................
51
Introduction.....
Setting..
Participants..
Human Subject Protection...
Study Design
Instrumentation
Pre-Study Questionnaire.
The Asperger Syndrome Diagnostic Scale.
The Sensory Profile....
Perceived Efficacy and Goal Setting System.....
Clinical Observations.
The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition...
Sensory Integration and Praxis Tests..........
51
51
52
54
56
56
56
57
58
60
61
62
63
27
31

Procedures...
Data Analysis...
Use of Data Collected..
66
72
74
IV. RESULTS...
75
Introduction.
Recruitment.....
Demographics......
Services
Attrition...
Pre-Intervention Findings
The Asperger Syndrome Diagnostic Scale.....
Sensory Profile...
Perceived Efficacy and Goal Setting System.....
Clinical Observations.....
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition......
Sensory Integration and Praxis Tests..........
Post-Intervention Findings..
Interrater Reliability...
The Asperger Syndrome Diagnostic Scale.....
Sensory Processing.
Sensory Integration and Praxis Tests......
Motor Skill Performance
Clinical Observations.
Treatment Fidelity...............
Summary of Results.
75
75
76
77
77
78
78
81
87
87
90
91
94
94
95
98
105
110
115
117
117
V. DISCUSSION..
119
Introduction.
Relationship of the Results to the Stated Hypotheses.
Relationship of the Results to the Conceptual Framework.
Summary of Conceptual Framework...
Relationship of the Results to the Literature...
Recruitment.
Sensory Processing..
Motor Skill Performance.
The Efficacy of Sensory Integration Therapy.
Additional Findings....
Behavioral Changes
Findings Related to The Asperger Syndrome Diagnostic Scale.
Findings Related to The Perceived Efficacy and Goal Setting System..
Findings Related to Clinical Observations.....................
Strengths and Limitations............
Implications for Practice..
119
120
134
145
145
146
147
151
156
161
161
163
164
167
168
172
vi

Implications for Future Research
Conclusion...
References....
Appendices...
vii
176
178
180
199

List of Tables
Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.
Table 8.
Table 9.
Table 10.
Table 11.
Table 12.
Mean Scores and Percentage of Recruited Participants Scoring

Above the Fiftieth Percentile on the Asperger Syndrome Diagnostic
Scale Indicating Impairments in the Given Subcategory.
81
Percentage of Participants Scoring in the Probably Different or

Definitely Different Categories on Sensory Profile Factors
Indicating Impaired Sensory
Processing.
83
Percentage of Participants Scoring in the Probably Different or

Definitely Different Categories on Sensory Profile Sections
Indicating Impaired Sensory
Processing.............................................................
84
Percentage of Participants Whose Bruininks Oseretsky Test of

Motor Proficiency (BOT-2) Composite Scores Fell At or Below the
Eighteenth Percentile Compared to Normative Data Indicating
Impaired Motor Skills..
91
Percentage of Participants Scoring Below One Standard Deviation

From the Mean on the SIPT Subtests Based on a Normative Sample
of Children
93
Summary of Mean Scores and Repeated Measures ANOVA for

Asperger Syndrome Diagnostic Scale
Variables...
96

Sensory Profile Factors
99

Sensory Profile Sections...
101

Sensory Integration and Praxis Test Subtests..
106

Bruininks Oseretsky Test of Motor Proficiency Second Edition
Subtests.
111

Clinical Observations.......
116
Summary Table of Impairments and Areas of Improvement...
118
viii
List of Figures
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Percentage of Participants Whose ASDS Scores Were Above the

Fiftieth Percentile.
80
Percentage of Participants Rated as Having Definite Differences

from the Normative Sample on Sensory Profile Factors..
86
Percentage of Participants Rated as Having Definite Differences

from the Normative Sample on Sensory Profile Sections
86
Percentage of Participants Impaired on Selected Clinical

Observations.
89
Mean Scores on Selected SIPT Items at Pretest, Midtest and

Posttest.
105
ix

List of Appendices
Appendix A:
Approval from the Institutional Review Board...
199
Appendix B:
Sample Request for Support in Recruitment Procedures.
201
Appendix C:
Letters of Support for Recruitment Procedures...
203
Appendix D:
Radio and Written Advertisements..
207
Appendix E:
Parent Information Letter and Invitation.
210
Appendix F:
Parent Informed Consent Form
212
Appendix G:
Childs Assent Form
217
Appendix H:
Pre-Study Questionnaire..
220
Appendix I:
Asperger Syndrome Diagnostic Scale Sample Items..
224
Appendix J:
Sensory Profile Caregiver Questionnaire Sample Items..
226
Appendix K:
Perceived Efficacy and Goal Setting System Sample Items
228
Appendix L:
Clinical Observations Documentation Form...
230
Appendix M: Clinical Observations Worksheet....
234
Appendix N:
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Sample Items ...
238
Sensory Integration and Praxis Tests Descriptions and

Examples..
241
Description of the Sensory Integration and Praxis Tests for

Parents..
244
Appendix Q:
Request For Assistance in Test Administration of Participants .
247
Appendix R:
Treatment Manual
249
Appendix S:
Therapy Session Progress Note and Checklist ...
264
Appendix O:
Appendix P:
Abstract
This research study evaluated the sensory and motor skills of a group of children with
Aspergers Syndrome (AS) and Pervasive Developmental Disorder Not Otherwise
Specified (PDD-NOS). It also examined the efficacy of a 10-week intervention using
sensory integration therapy. In a one-group, pretest-posttest design with a delayed
treatment approach, nine children were assessed using the Asperger Syndrome
Diagnostic Scale, the Perceived Efficacy and Goal Setting System, Clinical Observations,
the Sensory Profile, the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition
and the Sensory Integration and Praxis Tests. Testing was repeated after a five-week
baseline phase during which children and families followed their normal daily routines.
Next, sensory integration therapy was provided twice a week for 10 weeks. A treatment
manual provided treatment options that could be used based on individual client needs.
The tests were repeated after the intervention period and results were analyzed using
repeated measures ANOVA. Prior to intervention, all children were identified as having
sensory and motor impairments that were greater than typically developing children,
particularly in the areas of sensory processing, inattention, distractibility, sensory
modulation, emotional and behavioral responses to sensory input, coordination, praxis
and standing and walking balance. Six children completed the study. Following
intervention, significant improvements were identified in sensory processing, modulation
of sensory input, praxis and balance compared to pre-intervention findings. This
provides preliminary quantitative evidence that sensory integration therapy may be a
useful strategy to improve the sensory and motor skills that are identified in children with
AS and PDD-NOS.
xi
Autism Spectrum Disorders, including Aspergers Syndrome (AS) and Pervasive

Developmental Disorder Not Otherwise Specified (PDD-NOS), have recently become a
topic of considerable interest among pediatric health care providers (Gillberg, 2002,
2004; Newschaffer & Kresch Curran, 2003). Prior to its introduction into the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] (American
Psychiatric Association, 1994), little was known or published about AS, a pervasive
developmental disorder named after Hans Asperger some 60 years ago (Gillberg, 1998).
It wasnt until the 1980s that the first clinical accounts of AS based on descriptions of
Aspergers patients were reviewed and discussed. This was followed in 1991 by the
paper becoming available in English in a translated version (Frith, 1991). Similarly,
changes in the DSM-IV criteria have lead to increased recognition of PDD-NOS as a
diagnosis (Newschaffer & Kresch Curran, 2003). As a result of increased awareness of
these disorders, the past 20 years have seen a tremendous rise in the use and classification
of AS, PDD-NOS, and autism spectrum disorders in general. (Klin & Volkmar, 2003c;
Miller-Kuhaneck, 2004; Newschaffer & Kresch Curran, 2003; Szatmari et al., 2000).
This has encouraged both clinicians and researchers to seek answers regarding the
etiology, the most appropriate diagnostic criteria, and the most effective intervention
techniques for persons with autism spectrum disorders.
Aspergers Syndrome is a pervasive developmental disorder (PDD) which falls on
the autism spectrum; a continuum of social and communicative disorders ranging in
severity from mild to severe (D. R. Walker et al., 2004). Other PDDs include Autism,
Retts Syndrome and Childhood Disintegrative Disorder, along with Pervasive
Developmental Disorder Not Otherwise Specified (PDD-NOS), which often acts as a
The Efficacy of Sensory Integration Therapy 2

catchall diagnosis for children who do not fit the criteria for one of the other[s] (D. R.
Walker et al., 2004, p. 172). Aspergers Syndrome has been described by some as being
on the mild side of the autism spectrum (Frith, 2004). Others argue that AS is
synonymous with other PDDs, such as high functioning autism and PDD-NOS (Klin,
2003; Klin & Volkmar, 2003a; F. Volkmar & Lord, 2007; F. E. Volkmar, 2007). Key
diagnostic features of AS include impairments in social interaction, restricted repetitive
and stereotyped behaviors, and impaired social or occupational functioning (American
Psychiatric Association, 2000). A child with AS is able to interact with others, however
his or her interactions are usually odd and one-sided. Children with AS often have
difficulty following the unspoken social rules of society, such as keeping a certain
distance from others, making eye contact, taking turns during a conversation, and taking
an interest in what someone else is saying. Additional symptoms include being clumsy
and poorly coordinated resulting in impaired gross and fine motor skills, and exhibiting
abnormal responses to sensory experiences (American Psychiatric Association, 1994;
Baranek, Foster, & Berkson, 1997; Case-Smith & Miller, 1999; Church, Alisanski, &
Amanullah, 2000; Dunn, Smith Myles, & Orr, 2002; Frith, 1991; Ghaziuddin, Butler,
Tsai, & Ghaziuddin, 1994; Gillberg, 2002; Miller-Kuhaneck, 2004; Miyahara et al.,
1997; Weimer, Schatz, Lincoln, Ballantyne, & Trauner, 2001).
A diagnosis of PDD-NOS is given to individuals who have symptoms similar to
those of other specific PDDs (ie. Autism, AS) but do not meet all of the diagnostic
criteria specifically. The Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition Text Revision [DSM-IV-TR] (American Psychological Association, 2000) offers
no specific criteria for diagnosing PDD-NOS, except to say that this diagnosis should be

used when impaired social interaction is identified, but the individual is excluded from all
other PDD diagnoses (American Psychiatric Association, 1994). Khouzam and
colleagues (2004) point out that the diagnostic criteria for AS varies as to the nature and
severity of associated symptoms. This variability can make it difficult to distinguish
between AS and PDD-NOS (Klin & Volkmar, 1997; D. Walker et al., 2004). Since
PDD-NOS is a diagnosis of exclusion, reserved for those individuals who do not
precisely meet the diagnostic criteria for a specific disorder, and the most appropriate
criteria for a diagnosis of AS continue to be debated (Klin & Volkmar, 2003b), it is
reasonable to hypothesize that at least some individuals who meet most of the AS criteria,
but fall short in one area or another, are given a more generic diagnosis of PDD-NOS. In
fact, difficulty differentiating between AS and PDD-NOS has caused some clinicians to
use the two interchangeably (Klin, 2003; Klin & Volkmar, 2003a; F. Volkmar & Lord,
2007; D. Walker et al., 2004).
The sensory and motor skill difficulties identified in AS have also been identified
in other autism spectrum disorders (ASDs) (I. M. Smith, 2000; Watling, Dietz, & White,
2001). Evidence suggests that these additional symptoms may be related, however
published research regarding the sensory and motor impairments remains relatively
limited, and research on the treatment of these impairments in children with ASDs is
scarce (Kaplan, Polatajko, Wilson, & Faris, 1993). Sensory Integration (SI) therapy is
one treatment technique used by physical therapists and occupational therapists to
address sensory and motor deficits. Despite anecdotal evidence and many small-scale
studies reporting its effectiveness, few rigorous and well conducted studies have been
performed to support its use (Kaplan et al., 1993; Law, Polatajko, Schaffer, Miller, &

Macnab, 1991; Polatajko, Law, Miller, Schaffer, & Macnab, 1991; Wilson & Kaplan,
1994). Therefore, there is a need to study the effectiveness of SI on various populations
of children with disabilities. This study will evaluate the sensory and motor impairments
observed in children with AS and PDD-NOS, and will assess the effectiveness of SI
therapy on improving the sensory and motor skills of a sample of children who have
these disorders.
The primary objective of this study was to evaluate the assessment and
intervention procedures utilized for the evaluation and treatment of children with ASDs,
specifically AS and PDD-NOS. The specific purposes of this study were: (a) to quantify
the sensory and motor impairments observed in children with AS and PDD-NOS (b) to
determine if children with AS and PDD-NOS demonstrate changes in sensory processing
following SI intervention, and (c) to determine if children with AS and PDD-NOS
demonstrate changes in motor function following SI intervention.
Hypotheses
The hypotheses for this study are that (a) children with AS and PDD-NOS will
demonstrate sensory and motor impairments when compared to normative samples, as
identified on the Sensory Profile, the Sensory Integration and Praxis Tests and the
Bruininks-Oseretsky Test of Motor Proficiency; (b) parents will report an improvement
in the childrens sensory modulation and integration, and the children will exhibit
improved sensory processing following SI therapy as demonstrated by scores on the
Sensory Profile and the Sensory Integration and Praxis Tests, and (c) children will
demonstrate improved motor performance following SI therapy as demonstrated by
higher scores on the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition.

Conceptual Framework
This study is based on the belief that the sensory and motor symptoms
experienced by children with AS and PDD-NOS are the result of abnormalities within the
nervous system. It is also based on the theory of Sensory Integration which provides a
framework for understanding sensory processing dysfunction and for the SI treatment
approach which is described as preparing the body for purposeful interaction with the
environment.
Neuropathophysiology of Aspergers Syndrome and Pervasive Developmental
Disorder Not Otherwise Specified. Literature on the neuropathology of AS and other
related ASDs has identified several structures within the nervous system which seem to
play a role in the physical manifestations of these syndromes. Many researchers have
studied ASDs as a group, therefore, their findings can be considered relevant to a
discussion about the neuropathology of AS or PDD-NOS, as some of the features are
similar. No studies have been identified which examined the nervous systems of persons
with PDD-NOS specifically, and few studies have examined the specific characteristics
associated with PDD-NOS, therefore, because of the similarities in the diagnoses, and the
belief that both AS and PDD-NOS are part of a broader autism spectrum, generalizations
are made that include PDD-NOS in a discussion of the neuropathophysiology. It should
also be noted, that at this time the neurological findings seem to be inconsistent, so
definitive answers regarding the exact location of involvement of structures of the central
nervous system (CNS) in children with ASDs are tentative.
Several studies have implicated the brainstem as playing a role in the symptoms
of ASDs, including AS and PDD-NOS. Since the brainstem has connections to all parts

of the brain, abnormalities here may account for the attention and sensory processing
deficits seen in children with ASDs (Huebner, 1992). In addition, the stereotypic
behaviors often seen in children with PDDs, and soft neurological signs, such as
difficulties with balance, finger-thumb opposition, and tactile discrimination, as well as
incoordination and inadequate sound production, implicate brainstem involvement
(Huebner, 1992; Jones & Prior, 1985). Developmental abnormalities and an altered
inferior olive in the brainstem have been identified in children with autism (Bailey et al.,
1998; Palmen, van Engeland, Hof, & Schmitz, 2004). Auditory brainstem response
abnormalities, including prolonged intervals and abnormal individual waves, have also
been noted, which may result in characteristics associated with autism and AS
(Cederlund, 2004; Huebner, 1992). Since the brainstem is involved in the planning and
production of movement, and in integrating visual and vestibular information with
somatosensory inputs, (Kandel, Schwartz, & Jessell, 1991) it is possible that
abnormalities identified within the brainstem of persons with PDDs could account for the
motor delays identified in AS and PDDs. A prolonged postrotary nystagmus, which is
one indicator of how an individual processes vestibular input and which has been
identified in children with autism, may be related to deficient sensory habituation at the
level of the brainstem (Huebner, 1992).
The basal ganglia appears to play a major role in the sensory and motor symptoms
associated with AS and ASDs in general. It processes information for the planning of
movement, prepares the motor systems to act, forms movement commands and corrects
movement errors. It is therefore involved in praxis, which has been considered an area of
weakness in some children with AS and in PDDs in general. The basal ganglia receives

sensory input from the receptors throughout the nervous system, and influences all
sensorimotor activities. Damage in the basal ganglia may therefore be responsible for the
clumsy movement and sensory dysfunction of children with AS. Decreased movement
control, slow voluntary movements, increased involuntary movements, abnormal
postures and abnormal (increased) muscle tone have all been linked to lesions in the basal
ganglia (Kandel et al., 1991; Leonard, 1998; Zigmond, Bloom, Landis, Roberts, &
Squire, 1999). In addition, increased caudate volumes identified in individuals with
autism have been significantly correlated with overall, ritualistic, repetitive behaviors
when measured by the Autism Diagnostic Interview (Sears et al., 1999). A study done by
Minshew (2004) compared dynamic posturography results from child and adult subjects
with autism who did not have mental retardation to a control group. The subjects with
autism were noted to have delayed postural stability development and an underdeveloped
postural control system. This suggested to the researcher that there was basal ganglia
involvement consistent with an increased caudate volume (Minshew, Sung, Jones, &
Furman, 2004). Dysfunction of the basal ganglia has been linked to some of the clinical
symptoms of autism such as dystonia, motor disturbances, bradykinesia, hyperkinesias
and decreased social communication (Damasio & Maurer, 1978). Soft neurological
signs, such as choreiform movements, and difficulties with balance, finger-thumb
opposition and tactile discrimination (Jones & Prior, 1985), incoordination, and
inadequate speech production (Huebner, 1992) have also been linked to this structure.
Additionally, difficulty controlling the force of movement has been identified in children
who are identified as being clumsy, and who demonstrate these signs of basal ganglia
involvement (Lundy-Ekman, Ivry, Keele, & Woollacott, 1991).

The bulk of the neurological studies completed on subjects with AS has been on
the cerebellum. With extensive connections throughout the nervous system, the
cerebellum is involved in movement and has an effect on postural responses and
proximal stability. Difficulties processing information for planned movement, preparing
motor systems to act, forming commands for movement, and correcting errors can be
linked to a lesion in the cerebellum. Clinically, this may present as difficulty timing
coordinated joint movements, poor precision and control of limb movements, and
decreased coordination. Cerebellar abnormalities may also lead to decreased equilibrium,
an ataxic gait, a wide base of support, abnormal nystagmus, abnormal muscle tone, and
decreased use of vestibular information in an upright position (Kandel et al., 1991;
Leonard, 1998; McAlonan et al., 2002; Zigmond et al., 1999). Impairments such as
dysmetria and dysdiadokinesis have been related to cerebellar dysfunction in children
who are considered clumsy (Lundy-Ekman et al., 1991).
The cerebellum also plays a role in sensory modulation and feedback mechanisms
and has connections with the sensory systems, thus influencing head and eye movements,
body equilibrium, muscle use, visual tracking and the smooth progression between visual
movements. Studies have identified decreased purkinje cell numbers throughout the
cerebellar hemispheres of subjects with autism (Bailey et al., 1998; Huebner, 1992;
Palmen et al., 2004). Volume reductions in the grey matter of individuals with AS have
also been reported (Bailey et al., 1998; McAlonan et al., 2002). Huebners (1992) review
of autism literature reported smaller lobules within the cerebellum, decreased cerebellar
and neuronal size, increased cell density, agenesis of the cerebellar vermis and impaired
startle reflexes. A literature review by Blacher (2003) reported differences in cerebellar

regions between individuals with AS and high functioning autism (HFA), suggesting a
cerebellar link to the disorders.
Abnormalities in the limbic system have also been identified in subjects with
ASDs, particularly in the amygdala. The amygdala plays a role in autonomic responses,
emotional behaviors, and learning requiring coordination of different sensory modalities.
The limbic system also plays an important role in sensorimotor gating [and is used] to
suppress motor responses to irrelevant stimuli (McAlonan et al., 2002, p. 1595). These
processes are deeply involved in the initial stages of the SI process, in which stimuli from
the self and the environment must first be recognized. The system must then determine
what to attend to and how to respond. Increased cell packing in the hippocampus and the
amygdala and a very simple dendrite pattern have been identified in children with autism
(Palmen et al., 2004). In 1999, a functional Magnetic Resonance Imaging (MRI) study
for persons with HFA or AS, found no amygdala activation in subjects with AS during
decoding of the emotional expressions of others (Baron-Cohen et al., 1999). In addition,
Haznedar and colleagues (2000) noted that the left amygdala was larger in the subjects
with AS compared to those with autism, and the increased size was associated with lower
non-verbal communication scores on the Autism Diagnostic Interview. In all of the
subjects with ASD, increased amygdala volume was correlated with a decreased number
of words remembered (Haznedar et al., 2000). In addition, small neurons and increased
cell density in various structures of the limbic system including the amygdala have also
been identified (Huebner, 1992).
The anterior cingulate, with connections to much of the cerebral cortex, has been
determined to be involved in initiating voluntary behavior and movement, and in the

execution of action (Zigmond et al., 1999). Lesions of the anterior cingulate may result
in apathy and inability to express affect, which is a known problem for children with
ASDs (Kandel et al., 1991; Rinehart, Bradshaw, Brereton, & Tonge, 2001). Palmens
(2004) review of the neuropathological findings in autism noted findings of coarse and
poorly laminated anterior cingulate cortices. Haznedars (2000) study of MRI and PET
scans for ASDs, including AS, identified the right anterior cingulate, Brodmanns area,
and the entire cingulate cortex to be smaller. In addition, Haznedar (2000) noted
decreased glucose metabolism in the cingulate gyri in ASDs, with both sides affected in
AS and only the right side affected in autism. The results of Minshews (2004) dynamic
posturography study noted decreased anterior cingulate volume and suggest involvement
of the anterior cingulate region, which is consistent with findings of parkinsonian faces
and decreased initiation of movement. Grey matter deficits in this area were noted by
McAlonan (2002) during a comparison study of MRI and sensorimotor gating in AS.
Finally, Rinehart (2001) assessed movement preparation and movement execution in AS
and autism and determined that both groups had a deficits in movement preparation.
Rinehart concluded that poorly planned movement may explain the clumsiness noted in
AS, implicating the anterior cingulate.
The cerebrum is the highest functioning portion of the brain, with various parts of
it involved in motor planning, task preparation and execution, bilateral motor
coordination, muscle control, posture and voluntary movement (Kandel et al., 1991;
Leonard, 1998; Zigmond et al., 1999). Abnormalities in the cerebrum of individuals with
ASDs have been detected by several researchers (Bailey et al., 1998; Berthier, Starkstein,
& Leiguarda, 1990; Lotspeich et al., 2004; Palmen et al., 2004). Among the findings in

individuals with autism are cortical dysgenesis, a thick cortex and migration
abnormalities (Palmen et al., 2004) and developmental cortical abnormalities (Bailey et
al., 1998). Abnormal cortical gyration bilaterally, and cortical dysplasia, which may
mark abnormal cortical organization and connectivity, have been identified in persons
with AS (Berthier et al., 1990). Lotspiech (2004) performed a case control MRI study on
children and adolescents with and without ASDs, and identified the mean cerebral grey
matter volume among subjects with AS to fall between subjects with autism and controls,
suggesting a true spectrum of disorders. In addition, Lotspiech (2004) noted increased
performance IQ scores associated with increased grey matter volumes in the group with
AS as well as a correlation between performance IQ scores and cerebral white tissue
volume. Rinehart (2001) assessed movement preparation and execution in AS and
autism on a motor reprogramming task and determined both groups deficits in movement
preparation, rather than performance, suggesting supplementary motor cortex
involvement, due to difficulty internally initiating or generating a motor program.
Murphys (2002) in vivo magnetic resonance spectroscopy study noted
significantly increased prefrontal lobe concentrations of N-acetylaspartate, creatine and
phosphocreatine and choline (p=0.002, 0.03, 0.003, respectively). This correlated
significantly (p=0.005) with the severity of obsessive or ritualistic behaviors in a group
with AS, as well as significant correlations (p=0.02) between social impairments on the
Autism Diagnostic Interview - revised and the concentration of choline in the frontal lobe.
These findings suggest a metabolic difference in the prefrontal lobe of children within the
autistic spectrum (Murphy et al., 2002). A review of AS and HFA literature (Blacher,
Kraemer, & Schalow, 2003) identified increased prefrontal lobe metabolic concentrations

and decreased activation of the medial prefrontal cortex, as well as abnormal oculomotor
functions which suggest evidence of prefrontal cortex involvement. Cederlund (2004)
determined that 6 out of 15 male subjects with AS had hypoperfusion of the frontal lobe.
Among other findings, McAlonans (2002) study of adult subjects with AS, found
decreased grey matter volume in the frontal lobe, and left sided white matter frontal lobe
deficits. He concluded that frontostriatal alterations resulted in a startle response that was
not correctly modulated by the preceding stimulus, and suggested that medial frontal lobe
dysfunction results in the clinical symptoms of autism including motor disturbances,
dystonia, brady and hyperkinesias and decreased social communication. In her review of
neuropathological literature of ASDs, Huebner (1992) suggested that frontal lobe
dysfunction may result in stereotyped behaviors, and decreased selective attention. Using
Positron Emission Tomography (PET) in nonhuman primates, Schneider and colleagues
(2007) determined that increased tactile sensitivities, and an exaggerated withdrawal
response were associated with increased neurotransmitter binding in the striatum and
frontal cortex (Schneider et al., 2007).
The parietal lobe may also be involved in individuals with autism spectrum
disorders such as AS and PDD-NOS. This lobe is involved in spatial function, visual
discrimination, and recognizing both sides of the body (Zigmond et al., 1999) and
integrates sensory and motor components of directed attention (Huebner, 1992).
Huebners (1992) literature review of the neuropsychology of autistic disorder has noted
differences in the parietal lobe, which affects selective attention, and may affect bilateral
coordination, vision and spatial awareness.

Blacher (2003) reviewed AS and HFA literature and associated AS more with
right hemisphere dysfunction. This was due to abnormal minicolumnar organization
being detected in some parts of the right hemisphere. These findings support the findings
of Klin, Volkmar, Sparrow, Cicchetti, and Rourke (1995), who found a high degree of
concordance between AS and nonverbal learning disorders, which has already been
associated with right hemisphere dysfunction. Cederlunds (2004) examination of test
results from 100 males with AS revealed that more than 50% had verbal IQ scores that
were above performance IQ scores which is indicative of a non-verbal learning disorder
and right hemisphere dysfunction. Right hemisphere abnormalities have also been
identified on single photon emission computed tomographic imaging studies of
adolescents with AS (McKelvey, et al., 1995). Weimer, et al. (2001) suggest that right
hemisphere dysfunction often results in clumsy behavior, social dysfunction and attention
deficits, which are characteristics commonly seen in individuals with ASDs. Others have
documented left sided neurological signs such as hypertrophy and motor incoordination
(Berthier et al., 1990) in addition to left hemisphere white and grey matter deficits
(McAlonan et al., 2002).
There appears, therefore, to be abnormalities or differences in the neurological
structures of individuals along the autistic spectrum, including AS and PDD-NOS. At
present, no definitive conclusions can be made due to the small sample sizes of the
individuals studied, and variations among the research that has been conducted. It may
be that each individual presents with slightly different neurological abnormalities which
could explain the extreme variability among subjects who have diagnoses that fall along
the autism spectrum. In her review of the neurological literature surrounding autism,

Coleman (2005) confirms this variability, suggesting that many different neurological
areas and abnormalities exist within the nervous systems of persons with autism spectrum
disorders (Coleman & Betancur, 2005). The sensory and motor symptoms of children
with ASDs seem to have the strongest connections to deficits in the basal ganglia,
cerebellum and the brainstem. As Sears (1999) suggests, perhaps it is more a deficit in
the neuronal connections, rather than an abnormality of a specific area of the nervous
system. A study performed by Just, Cherkassky, Kelly and Minshew (2004) supports this
proposal. Results from functional magnetic resonance imaging on persons with high
functioning autism versus controls point to decreased connectivity, and therefore,
decreased integration of the cortical areas of the brain (Just, Cherkassky, Keller, &
Minshew, 2004). Thus it appears that AS and PDD-NOS are abnormalities not only of
certain regions of the central nervous system, but also of the integration of different areas
of the brain.
Since SI theory considers integration at all levels of the nervous system, it may
explain the wide range of symptoms associated with AS, PDD-NOS and other autistic
spectrum disorders. It seems reasonable, therefore to hypothesize that treatments which
work to improve the integration of sensory information in children with AS and PDDNOS would also improve both the sensory processing and the motor functioning of these
children. As a result, childrens clinical performance and both the parent and the childs
perceptions of functioning would be expected to improve.
Sensory Integration. The theories and treatment techniques of SI, which were
developed by A. Jean Ayres in the 1970s and 80s to help explain and treat the various
deficits observed in children with learning disabilities and clumsiness are also being used

as a basis for this study of children with AS and PDD-NOS (Fisher, Murray, & Bundy,
1991). The concepts and applications of SI incorporate three components: the theory, the
evaluation methods for identifying children with SI dysfunction, and SI as a specialized
treatment technique.
The theory of SI is rooted in the belief that all aspects of the nervous system work
together in order for the individual to receive, process and modulate sensory input to
produce a functional response within the environment (Ayres, 1989). Sherrington (as
cited in Bledsoe, 2004), suggests that this process of CNS organization results in the
production of an internal understanding of the surrounding world. This theory also
suggests that appropriate motor and behavioral responses to the environment are possible
only if the child is able to register and process sensory information correctly (Linderman
& Stewart, 1999).
Experts in the field of neurology have proposed more recent theories of motor
control which support the ideas of Ayres. Bernstein (as cited in Thelen, 1995) suggested
that movement is not only a product of the CNS, but rather, is a product of many
components: the environment, body properties, and task demands, which work together
in a heterarchical structure. The nervous system receives sensory information from
various locations within the CNS and is designed to integrate this information. When all
aspects are working at a critical level of function, a child is able to process the properties
of a particular action within the associated environment accurately, and then develop new
adaptive patterns which can be used for higher-level functioning.
A Theory of Neuronal Group Selection (TNGS) has also been proposed, which
states that sensory information is important in adapting movement to the environment.

According to this theory, each action allows the nervous system to organize and become
more efficient, allowing for more goal directed and efficient movements to occur
(Hadders-Algra, 2000; Thelen, 1995). The dynamic systems approach, focuses on the
system as a whole, and holds that any complex system, under certain conditions, will
self-organize to achieve stability. According to the dynamic systems theory, neural
network overproduction occurs first, and is then followed by an elimination of the less
useful connections in performing a particular activity (vonHofsten, 1989)
The full process of SI is segmental. It includes registration that a stimulus
occurred, orientation and attention to it, interpretation of the stimulus, organization of a
response and finally, execution of the response (Williamson, Anzalone, & Hanft, 2000).
Children need to register sensory input (recognize a stimulus), activate their system
(determine what to do with it), and modulate (regulate or adjust to the stimulus) in order
to maintain homeostasis. The ability to complete the full process of SI may vary
depending on the type of sensory input. Success with the entire process is what allows
the child to maintain a state of arousal (Bledsoe, 2004a).
A major premise of SI theory is that there are three major systems involved in
sensory and motor development. These are the tactile, vestibular and proprioceptive
systems, which are considered to be proximal senses. They are the primary and primitive
senses that develop and dominate early in life. Distal senses such as vision and hearing
develop later, as the child matures (Parham & Mailloux, 2001). The tactile system is
essential for the development of motor skills, learning about the environment, knowing
about the body and its boundaries and for emotional well being. It is the primary system
for making contact with the surrounding environment, and is required in order to develop

subsequent skills (Bledsoe, 2004a). Tactile exploration combines with visual
exploration, and together with proprioception, is involved in the development of a body
scheme. Praxis follows in its development, as body scheme and somatosensory inputs
continue to be refined (Brasic-Royeen & Lane, 1991).
The vestibular system develops in utero. It tells us about movement and plays a
key role in balance. The input from this system should result in a feeling of security with
movement. Vestibular input also affects muscle tone, and has a close connection with the
visual system. It is needed to develop perception of space, and plays a role in arousal,
attention and emotion. The vestibular system is involved in the development of the child
by controlling equilibrium and posture (via the visual, tactile, proprioceptive and
vestibular systems), directing eye gaze and compensatory eye movements in response to
head movement, maintaining a constant plane of vision, and regulating arousal and affect
(Bledsoe, 2004a).
Proprioception is the bodys ability to know where it is positioned in space, and
when, where and how quickly to move. It also provides information about how much
force to apply (Fisher et al., 1991). Proprioception allows for the grading of movements
and provides information on the coordination of motor skills (Kranowitz, 1998).
Together with the vestibular system, proprioception provides the basis for the
development of a body scheme and body image by providing a frame of reference for
other forms of sensory input to be interpreted (Fisher et al., 1991). Body scheme is the
bodys internal ability to understand its many components, and how they work together
during motor activities. It allows for motor planning and performance of skilled and
purposeful tasks. The development of a body scheme depends on the bodys ability to

synthesize sensory information from a variety of systems (tactile, proprioception, vision).
According to Ayres (1961), early motor learning is closely associated with the
development of a body scheme. Much of our knowledge of the world begins with
knowledge of our bodies. Without this knowledge, it can be more difficult to develop
number concepts, visual-spatial perception skills and skilled motor tasks (Ayres, 1961).
Proprioception also affects the ability to develop planned sequences or strategies.
Therefore, a deficit in proprioception may make it more difficult to learn a new task
(Anzalone, 1993). Together, it is suggested that the vestibular and proprioceptive
systems work to provide a stable frame of reference, against which other sensory inputs
are interpreted (Fisher et al., 1991).
As a result of the integration of the senses, the child begins to develop some
specific skills. Through the process of tactile, vestibular and proprioceptive system
development, body scheme and praxis, or motor planning, emerge and continue to
develop as the child matures (Brasic-Royeen & Lane, 1991). As the child interacts with
his or her environment, sensory input is processed and integrated, resulting in the
establishment of a body concept (Smith-Roley, Imperatore-Blanche, & Schaff, 2001).
Praxis follows, which is a cognitive process that results in the performance of a
purposeful motor action (Williamson et al., 2000). Praxis includes the stages of ideation
(what to do), planning (how to do it which requires a developed body scheme), and
execution (performing the act) (Bledsoe, 2004a). It allows a child to learn new motor
skills and to adjust skills that have been previously learned in order to achieve success in
a constantly changing environment (Smith-Roley et al., 2001).

It is hypothesized by proponents of SI theory, that human development is related
to SI which is an inherent function of the nervous system. In this process, the sensory
receptors recognize input from pain, touch, vision, gravity, audition, movement,
temperature, smell, and taste. These receptors generate automatic functions such as
posture and balance, bilateral use of the body, homeostasis, reflex maturation,
gravitational security, motor planning and somatosensory awareness, which enhance the
childs spontaneous play. This play results in the development of motor skills, emotional
maturation, and perceptual skills which provide the basis for higher level motor and
cognitive skills (Bledsoe, 2004a).
A childs interest and drive to move results from the need to develop the capacity
to perform skilled motor acts. Movement associated with sensory input is important in
maturing from diffuse to more specific sensory perception and integration. As muscle
strength develops, antigravity movement is achieved, muscle control is developed and
cocontraction and equilibrium follow. Development of anti-gravity movement and
stability allows the child to develop more mature motor patterns which provide
opportunities for a variety of movements. The increased sensory feedback from these
movements results in the development of motor planning (Parham & Mailloux, 2001).
As the child learns to motor plan, movement assumes meaning (Bledsoe, 2004a).
Neuroplasticity literature has suggested that children repeat skills until they are mastered
and then they vary or challenge the skill (Schaff, 1994). From a neurological perspective,
this follows the ideas of Ayres and the Theory of Neuronal Group Selection, in that the
childs actions result in enhanced or modified neuronal pathways which then allow for
more skilled use.

The childs ability to integrate sensory input can be recognized by observing his
or her behavior. In particular, evaluating the childs arousal level (alertness and the
ability to transition between states), attention (focus on a desired stimulus/task), affect
(the emotional component of behavior) and action (engagement in adaptive, goal directed
behavior) can provide a basic understanding of the childs ability to integrate sensory
stimuli (Williamson et al., 2000). Additionally, observing a persons ability to produce a
graded response that is considered appropriate given the presenting stimulus, provides
information about the individuals ability to modulate, or regulate, the sensory input
entering the system (McIntosh, Miller, Shyu, & Hagerman, 1999)
Sensory Dysfunction. Sensory dysfunction occurs when a child does not receive
reliable feedback from his or her body to know what he or she is doing, where he or she
is, and where he or she is going. This makes even the most simple tasks challenging. As
a result, exploration and interaction with the environment, which lays the groundwork
and foundation for future skills, decreases. An inability to effectively interact with the
environment can also result in a state of emotional dysregulation, which, when coupled
with the poor socialization skills of a child with AS or PDD-NOS, can result in an
inability to experience positive interactions with the environment and with others
(Laurent & Rubin, 2004).
Dunn (1999) has identified four categories of sensory processing which are
described as a spectrum of sensory thresholds. A low threshold to a sensory input
indicates that even a small amount of input can be overly stimulating for the person,
whereas a person with a high threshold requires more stimulation than normal for his or
her system to recognize that it has received this input. At the same time, an individual

can respond to his or her threshold in either a passive or an active manner. This results in
four possible situations. The first is low registration, in which the individual has a high
neurological threshold and responds in a passive way. Individuals in this category may
appear highly fatigued, bored or may not notice what is going on around them. The
opposite response to a high neurological threshold is sensation seeking. A person who is
sensation seeking also has a high threshold, but responds in an active manner and tries to
provide him or herself with additional sensory input. This results in the person appearing
hyperactive. The third category is sensory sensitivity, which means that a person has a
low threshold to sensory input and responds by becoming easily distracted by all the
sensations he or she is experiencing. Finally, a person who is sensation avoiding also has
a low threshold, but responds actively, by limiting their participation or creating rituals to
prevent or reduce the amount of stimulation within an environment. As the environment
and the type of stimulation change, an individuals response may also change, such that a
child may be sensory seeking in one situation, while presenting as sensation avoiding in
another situation (Dunn, Saiter, & Rinner, 2002). Successful sensory processing and
integration allows the individual to modulate his or her levels of arousal and attention in
response to sensory input, which in turn, prepares the individual for further sensory
encounters (Anzalone, 1993). Poor sensory processing and integration may result in
abnormal interactions with the environment, including difficulty regulating oneself,
maintaining attention to relevant stimuli, solving problems and communicating. This is
common in AS, and in ASDs in general, where the child is unable to remain actively
engaged, adapt to novel stimuli, and inhibit impulsive reactions while behaving in a
socially appropriate manner, (Laurent & Rubin, 2004, p. 286).

Current best practice relies on research to validate the theories and concepts
surrounding the management of a specific diagnosis. In an effort to validate the theories
associated with sensory processing disorder (SPD), research has emerged which confirms
the presence of physiological differences between individuals who have difficulty
processing sensory information, and those who do not. Davies and Gavin (2007)
conducted a study on 28 children with sensory processing disorders and 25 typically
developing children. Brain processing of auditory stimuli was examined using
electroencephalography (EEG) and event-related potentials (ERPs), to assess the brains
ability to suppress less important or repeated information, as well as to identify how
consistent the brains responses are with respect to organizing the sensory information.
The results of their study confirm that children with sensory processing disorder have
difficulty ignoring irrelevant sensory information, and are less able to organize incoming
sensory information. In addition, the researchers were able to use EEG and ERP results
to distinguish children with sensory processing disorders from typically developing
children with 86% accuracy (Davies & Gavin, 2007).
In a study by McIntosh et al. (1999), childrens skin conductance electrodermal
responses were measured in response to a variety of sensory system inputs. The children
who were referred for occupational therapy due to sensory modulation disorders
responded with either no electrodermal response (underresponsive), or with more
frequent responses and a larger magnitude (overreactive), compared to healthy, control
subjects. In addition, the authors reported a slower habituation rate to sensory stimuli in
children with sensory modulation disruptions compared to controls. These physiological
findings corresponded to parental reports. Those children who experienced abnormal

responses to the stimulation conditions had higher levels of parent-reported behavioral
abnormalities as identified by the Short Sensory Profile (McIntosh et al., 1999).
Together, these findings show support for one of the basic assumptions in SI theory: that
physiological differences exist between children with sensory processing dysfunction as
compared to those who are typically developing.
Recently, new diagnostic terminology has been proposed, using the term Sensory
Processing Disorder rather than Sensory Integration disorder. It is believed that this
will help to clarify the differences between the term as a theory, and an intervention, and
to distinguish the therapy-based use of the term from the neurophysiologic use of the
term which explains the process of integrating the sensory signals within the nervous
system at a more cellular level. The associated subcategories of sensory processing
disorder now include Sensory Modulation Disorder, involving diagnoses of Sensory
Overresponsivity, Sensory Underresponsivity and Sensory Seeking Behaviors; Sensory
Discrimination Disorder, which can be identified for any of the bodys senses; and
Sensory-Based Motor Disorder, which includes Dyspraxia and Postural Disorders (L. J.
Miller, Anzalone, Lane, Cermak, & Osten, 2007). It is recommended that this new
terminology be applied to both research and clinical practice (L. J. Miller, Anzalone et
al., 2007), and as such, subsequent aspects of this document will utilize the new
terminology whenever appropriate.
Sensory Integration Therapy. Sensory integration from a therapy perspective is
rooted in beliefs that the environment impacts the growth and maturation of the nervous
system, which is a changeable structure. This is done through the adaptive responses the
child makes. The main purpose of SI therapy is to improve interaction with the external

environment by encouraging adaptive responses. Adaptive responses are purposeful,
goal directed behaviors that give functional meaning to movement. These responses
follow a developmental sequence, and indicate the degree of integration of the system
(Bledsoe, 2004a) . Adaptive responses also allow for feedback into the nervous system.
As a result, the nervous system matures and organizes itself, which allows for increased
interaction with the environment (Schaff, 1994).
The provision of SI therapy relies on several assumptions. These include: (a) the
ability for the CNS to change with intervention, (b) that sensory processing follows a
developmental sequence, (c) although the brain is made up of a hierarchy of systems, it
functions as a single unit, and any sensory system can affect other systems as well as the
overall state of the individual, (d) that SI can lead to and result from adaptive behaviors,
and (e) people seek sensory integration independently, through an inner drive to perform
purposeful, goal directed activities. It is believed that these assumptions are the reasons
why SI therapy can be effective (Bundy, Lane, & Murray, 2002; Fisher et al., 1991).
In accordance with SI theory, classic SI therapy is based on individual needs as
determined throughout the intervention process. Its goal is to improve the ability of the
nervous system to interpret and organize sensory information. The therapy is child
directed, but requires the therapist to incorporate structure while creating an environment
for self-directed exploration. By providing a sensory rich environment and encouraging
active participation at a level which is neither too easy, nor too difficult, SI therapy
allows the child to create new and more appropriate responses to the external world. A
typical schedule includes 45 to 60 minute intervention sessions two times per week.
Expected outcomes to therapy using an SI approach include an increased frequency or

duration of appropriate responses, improved self confidence and self esteem, and
increased social and occupational participation (Parham & Mailloux, 2001). Parham et
al., (as cited in Watling, 2004) developed an instrument called the Essential
Characteristics of Occupational Therapy Using Sensory Integration Intervention
(ECOTUSII), which assesses whether or not the key aspects of SI intervention are being
followed during a treatment session. According to this tool, ten principles must be met:
(a) the room should be organized to encourage the child to become engaged, (b) the
therapist should ensure safety through equipment placement and by staying in close
proximity to the child, (c) sensory opportunities should be presented, (d) a level of
optimal arousal should be obtained and sustained, (e) adaptive responses by the child and
a challenge which is neither too difficult, nor too hard should be promoted, (f) the
therapist should take care that the child is successful with chosen activities, (g) the
therapist should work to guide self-regulated behaviors by allowing the child to make
choices and plan activities as much as possible, (h) the session should follow a context of
play, (i) the child should have the opportunity to collaborate on choosing activities, and
(j) the therapist should work to create a sense of trust, satisfaction and comfort by the
child. The authors of this tool have developed a scoring system to determine how closely
the principles of sensory integration are being followed (Watling, 2004).
Summary. Two concepts provide the basis for this study. First, neural connection
abnormalities within the CNS of children with AS and PDDs in general have been
identified, and correspond to the sensory and motor symptoms of these children. This
provides objective evidence that children with AS and PDD-NOS do have neurological
differences that may impact their sensory processing and motor function. It also supports

research which will test the effectiveness of treatments aimed at improving sensory and
motor symptoms. Also, SI theory, accompanied by research supporting the use of SI
therapy for children with PDDs and AS, provides the basis for the testing and
intervention techniques which will be utilized in this study. Based on this conceptual
framework, a research study was designed to determine whether or not the sensory and
motor skills of a sample of children with AS and PDD-NOS will be affected by SI
therapy.

Literature Review
Characteristics of Children with Aspergers Syndrome and Pervasive Developmental
Disorder Not Otherwise Specified
As an autism spectrum disorder, the primary symptom of AS is impaired social
skills. Although the diagnostic criteria are still fairly recent, and there remains a lack of
consensus as to what the criteria should include (Green et al., 2002; Mattila et al., 2007),
a review of current diagnostic criteria provides a basis for the most common impairments
in this population. The Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000)
indicates that in order to receive a diagnosis of AS, an individual must display the
following criteria: (a) impairments of social interaction, including impairments in
nonverbal behaviors such as eye-to-eye gaze and body postures; difficulty developing
age-appropriate peer relationships; an inability to participate in the interests of others; and
a lack of social or emotional reciprocity, (b) restricted repetitive and stereotyped patterns,
which include excessive preoccupation with certain topics of interest or parts of an
object, rigid adherence to routine or ritual, and stereotyped and repetitive movements,
and (c) functional impairments resulting from the disorder. In addition, individuals
diagnosed with AS should not have a history of language delays, and should not
demonstrate significant cognitive delays or diminished self-help skills. The literature
also reports motor impairments and abnormal responses to sensory input (Church et al.,
2000; Dunn, Smith Myles et al., 2002; Frith, 1991; Ghaziuddin et al., 1994; Klin &
Volkmar, 1995, 2003c; Miller-Kuhaneck, 2004; Wing, 1981). Finally, the clinician who
determines this diagnosis should have ruled out all other specific pervasive

developmental disorders, as well as schizophrenia (American Psychiatric Association,
2000). It is important to note, however, that there is much variability in the symptoms
associated with AS. While the core characteristics are always present to some degree,
each individual case of AS is slightly different, such that other symptoms may, or may
not be noted. Furthermore, many of the features identified as being present in AS are
found in varying degrees in the normal population (Wing, 1981, p. 120). Possibly due
to the variability in diagnostic criteria for AS, a diagnosis of PDD-NOS, is sometimes
given to a child who meets most of the criteria for AS, but does not meet all of it
(Cummings, 2008; Rourke & Tsatsanis, 2000). An example is a child who has social
impairments and an early language delay, but who fails to meet all other necessary
criteria for AS or autism at the time of evaluation.
Similar to AS, a diagnosis of PDD-NOS is given to a person who experiences
severe difficulty with reciprocal social interaction and communication skills, or who have
stereotyped behaviors, however a person who receives a diagnosis of PDD-NOS does not
meet the specific criteria for another PDD (American Psychiatric Association, 2000).
Since PDD-NOS is a diagnosis of exclusion, without specific diagnostic criteria,
researchers disagree as to how PDD-NOS actually differs from AS and autism, and a
PDD-NOS diagnosis may be overused (Fombonne, 2003; D. Walker et al., 2004). Klin
and Volkmar (2003) report that evidence suggests clinicians are using the terms AS,
PDD-NOS and HFA synonymously, creating even greater confusion. Walker and
colleagues (2004) compared groups of children with autism, AS and PDD-NOS (mean
ages: 8.25 years, 9.77 years and 7.19 years, respectively) on functioning and symptoms of
autism. They determined that the AS and PDD-NOS groups did not differ on measures

of functioning, including communication, daily living and social skills and IQ. With
respect to autistic symptoms, such as repetitive and stereotyped behaviors, children with
PDD-NOS tended to have fewer symptoms than both the AS and the autism groups. The
author concluded that PDD-NOS falls on the autism spectrum, somewhere between the
more severe autism diagnosis, and the more mild AS diagnosis, (D. Walker et al., 2004).
The variability displayed in these individuals makes it difficult to determine the
true prevalence of AS or PDD-NOS. The relatively recent classification of AS as a
diagnosis, coupled with discrepancies in the most appropriate diagnostic criteria, have
resulted in large ranges in prevalence estimates. Current estimates range from 0.1 to 7.1
cases of AS per 1000 individuals, (Khouzam, El-Gabalawi, Pirwani, & Priest, 2004). In a
review of epidemiological studies on AS, Fombonne (2003) determined that based on
ratios of AS to autism diagnoses, a conservative estimate for the prevalence of AS is 2.5
in 10,000 individuals, and an estimate for the prevalence of PDD-NOS is 15/10,000
(Fombonne, 2003). It is not uncommon for children to wait longer before obtaining a
diagnosis of AS. Compared to an average age of diagnosis for autism of 5.5 years, the
average age to obtain a diagnosis of AS was 11 years (Howlin & Asgharian, 1999). Due
to the variability in the nature and severity of symptoms, and the potential delay in
obtaining a diagnosis of AS, there is likely a substantial number of persons with AS who
have not been diagnosed or identified (Khouzam et al., 2004). This hypothesis was
supported by Mattila (2007), who determined that 9/19 participants entered the study
with no AS diagnosis, even though they presented with traits common in persons with
AS, and received an AS diagnosis through testing by experienced clinicians. The number
of children receiving a diagnosis of AS, however, has clearly shown an increase (Klin,

Volkmar, Sparrow, Cicchetti, & Rourke, 1995). Since 1994, the United States Centers
for Disease Control and Prevention [CDC] has reported a nine-fold increase in the
number of children being serviced that have an autism spectrum disorder (ASD) (Centers
for Disease Control and Prevention, 2008). The CDC has predicted that approximately
24,000 children will be diagnosed with ASD each year (Centers for Disease Control and
Prevention, 2006). A recent study on the prevalence of ASDs identifies that their
frequency rate (6.2 per 1000 eight year olds living in South Carolina), is second only to
mental retardation (Nicholas et al., 2008). It has been reported that the rate of individuals
with AS living in the United States is between 700,000 and two million (Safran, Safran,
& Ellis, 2003). The increased incidence of AS since its introduction into the DSM-IV
has been related to an increased awareness brought about by the literature, media and
supporting groups and agencies (Klin & Volkmar, 2003c). A controversy remains,
however, regarding whether more children are being affected by AS, or whether more
children are being diagnosed with the disorder (Miller-Kuhaneck, 2004). With the
increase in the number of children with a diagnosis of AS, it is important that
impairments associated with this disorder are properly understood, and that appropriate
intervention techniques are identified. Compared to other PDDs, PDD-NOS is not often
researched as heavily (Cummings, 2008), in part, due to its vague diagnostic criteria. As
a result, aside from Fombonnes estimate of 15/10,000, prevalence and incidence
estimates for PDD-NOS in the United States are unavailable. These findings are lower
than studies conducted in England and Sweden, which estimate the prevalence of PDDNOS to be 36.1 per 10,000 cases and 23.5 per 10,000 cases, respectively (Chakrabarti &
Fombonne, 2001; Gillberg, Cederlund, Lamberg, & Zeijlon, 2006)

Motor Skills of Children with Aspergers Syndrome and Pervasive Developmental
It is well reported within the literature that motor delays are often present in
persons with PDDs (Freitag, Kleser, Schneider, & Von Gontard, 2007; Molloy, Dietrich,
& Bhattacharya, 2003). As part of an ongoing study for the US Centers for Disease
Control and Prevention, Nicholas and colleagues (2008) reported that 62% of the cases of
ASDs, including children with AS, PDD-NOS and autism, in the study state of South
Carolina have impaired motor skills. Within the diagnostic criteria of the DSM-IV,
motor delays and clumsiness are listed as associated features that are often present in
children with AS, but are not required for diagnosis (American Psychiatric Association,
1994). The same is true for the International Classification of Diseases: Tenth Edition
(ICD-10), which states that while clumsiness is a common characteristic of children with
AS, it is not required for the diagnosis (Ghaziuddin et al., 1994). From the very first case
reports, children with this syndrome have been identified as being motorically awkward,
having poor coordination, and having difficulty with motor skills (Frith, 1991). Children
with AS have also been noted to have delayed motor milestones, poor posture, low
muscle tone, decreased awareness and control of the body, decreased arm swing, stiff
gait, poor rhythm and timing, stiff and clumsy movement patterns, a tendency to break
things, difficulty catching and throwing, and poor handwriting (Frith, 1991; Klin &
Volkmar, 1995, 2003c; Miller-Kuhaneck, 2004; Wing, 1981). Khouzam, El-Gabalawi,
Pirwani and Priest (2004) suggest that motor delays may be one of the first features
recognized in young children, with the more typical AS symptoms presenting later.

In discussing one of his subjects, Asperger stated that the clumsiness was
particularly well demonstrated during physical education lessons. Even when he was
following the group leaders instructionshis movements would be ugly and
angular[his] movements never unfolded naturally and spontaneouslyfrom the proper
coordination of the motor system as a whole. Instead, it seemed as if he could only
manage to move those muscular parts to which he directed a conscious effort of will (as
cited in Frith, 1991, p. 75). Similar signs of motor clumsiness were identified in nearly
75% of Aspergers cases, with another one third reported as having awkward body
language and gait (Hippler & Klicpera, 2003). Of 23 children with AS studied by
Gillberg (1989), 83% demonstrated motor clumsiness based on the Griffiths
Developmental Scales and clinical observation (Gillberg, 1989). In a review of
neuropsychological profiles of children with AS and HFA, Klin, Volkmar, Sparrow,
Cicchetti and Rourke (1995) identified 19 out of 21 subjects with AS as having fine
motor impairments, and all 21 subjects with AS as having deficits in gross motor skills
(Klin et al., 1995). A retrospective chart review performed by Church, Alisanski and
Amanullah (2000), identified 73% of the 40 study participants with AS as being clumsy.
Of these children, greater than 50% had a history of being klutzy, clumsy or awkward
(p. 15) by the age of 11 years, which had been associated with delayed motor skills
during the preschool years. Fifty-eight percent of school age children studied with AS
received occupational therapy services for fine motor deficits, while 33% received
physical therapy services for gross motor delays (Church et al., 2000). A study by
Ghaziuddin and colleagues (1998) compared the motor skills of thirty-six 10 and 11 year
old children: 12 with AS, 12 with PDD-NOS, and 12 with autism. Using the Bruininks

Oseretsky test to measure gross and fine motor performance, the authors identified motor
impairments across all groups, with the group of children with autism performing
significantly worse than the other two groups. Although the group with PDD-NOS was
more impaired in gross motor, fine motor and battery test scores than the group with AS,
the group differences were not statistically significant (Ghaziuddin & Butler, 1998).
As researchers and clinicians become more aware of AS and PDDs, studies that
focus on the motor impairments of these children appear to be increasing in number. The
primary focus of the literature however, has often been to differentiate the motor
problems of ASDs from other disabilities, rather than quantifying the impairments.
Manjiviona and Prior (1995) compared children with AS to children with HFA using the
Test of Motor Impairment Henderson Revision (Stott, Moyes, & Henderson, 1984),
which assesses manual dexterity, balance and ball skills in children. The results of their
study indicated that 50% of the subjects with AS demonstrated motor impairments.
These impairments were typically noted in both gross and fine motor skills. They also
noted that subjects with AS had difficulty with ball skills, had a hard time controlling the
force and direction of the ball, demonstrated laterality confusion, and tended to act either
overly impulsive, or excessively cautious (Manjiviona & Prior, 1995). Miyahara et. al
(1997) noted similar results in a comparison study of the motor coordination of Japanese
children with AS and those with learning disabilities. Using the standardized Movement
Assessment Battery for Children [Movement ABC] (Henderson & Sugden, 1992), this
group identified motor delays in both groups of children, and ball skills that were more
deficient in the subjects with AS. Additionally, Miyahara et al. (1997) noted that the rate
of children with AS who were diagnosed with Specific Developmental Disorder of Motor

Function (SDD-MF) was 42 times above the prevalence of the normative group
(Miyahara et al., 1997). Green et al. (2002) also used the Movement ABC to compare
children with AS to children with SDD-MF, in an effort to quantify the extent and
severity of motor impairment in AS. All of the participants with AS were found to have
motor impairments. In addition, participants from this group accounted for 83% of those
labeled as being most severely impaired.
Ghaziuddin, Butler, Tsai, and Ghaziuddin (1994) utilized the Bruininks-Oseretsky
Test of Motor Proficiency, to determine if AS could be distinguished from high
functioning autism. While the researchers were unable to identify any significant
differences between the groups, they did note that both groups scored below normative
expectations on all four subtests, which include gross motor, fine motor, upper limb
coordination and the battery composite (Ghaziuddin et al., 1994). Similarly, Miller and
Ozonoff (2000) used the Movement ABC to test children with AS and HFA, and
determined that children with AS fell 1.66 standard deviations below the mean for the
normative sample on overall percentile scores which supported subjective findings of
motor impairment made by other researchers. In addition, after controlling for IQ,
children with AS were identified as obtaining lower scores on the Fine Motor component
of the Movement ABC than the HFA group (J. Miller & Ozonoff, 2000).
Although many experts have identified some form of motor deficit in children
with AS, research is limited with respect to understanding the quality of movement and
the specific causes for the awkward and clumsy appearance in this population. Miyahara,
Tsujii, Hori, Nakanishi, Kageyama and Sugiyama (1997) discussed this gap in the
research, stating that at present, we can only provide subjective descriptions of their

movement patterns and a gross estimate of the level of motor skills of children with AS
compared to children who are typically developing. (Miyahara et al., 1997). One
quantitative study (Freitag et al., 2007) utilized the Zurich Neuromotor Assessment to test
the timed performance and adaptive movements of adolescents with AS and HFA, and
IQ-matched controls, while completing alternating movements, static and dynamic
balance activities and stress gaits, which include walking on toes, heels and the inner and
outer borders of the feet. Results identified diadochokinesis and dynamic balance skills
to be most impaired in the AS/HFA group, and identified an association between the
severity of motor impairment and the degree of social withdrawal in all study participants
(Freitag et al., 2007). Smith (2000) suggests that future research should begin to account
for the causes of poor motor coordination in children with AS, rather than simply
identifying differences (I. M. Smith, 2000). Recently, research has begun to shift towards
identifying these causes. For example, one study compared upper extremity movement
kinematics in children with AS and HFA during a writing task on a digitizing tablet. The
researchers determined that both groups had difficulty with the motor planning required
to perform the task, rather than with the actual execution of the task (Rinehart et al.,
2006). Molloy et al. (2003) examined afferent sensory systems of children with ASDs
and children with typical neurodevelopment, and concluded that poor integration of
sensory input results in motor skill impairments in children with ASDs (Molloy et al.,
2003). Even with emerging studies confirming the presence of motor impairments in
children with ASDs and with AS specifically, to date no studies have been published
regarding the issue of how to address the motor impairments that appear in this
population (Green et al., 2002).

Sensory Processing in Children with Asperger Syndrome and Pervasive Developmental
Successful sensory processing allows the individual to modulate his or her levels
of arousal and attention in response to sensory input, which in turn, prepares the
individual for further sensory encounters (Anzalone, 1993). Impairments in sensory
processing and integration have also been identified in children with AS and PDDs. An
impairment in SI can result in difficulty receiving input from the body and the
surrounding environment, processing sensory input and responding appropriately to the
stimulus. Poor SI can also result in abnormal interactions with the environment,
including difficulty regulating oneself, maintaining attention to relevant stimuli, solving
problems and communicating. These problems appear to be common in AS, where the
child is unable to remain actively engaged, adapt to novel stimuli, and inhibit impulsive
reactions while behaving in a socially appropriate manner, (Laurent & Rubin, 2004, p.
286). Case studies and parent reports have suggested definite differences in these skills
when compared to children without AS. It has been indicated that children with AS often
display signs of hypo- or hypersensitivities to light, sound, textures, taste and movement.
Oftentimes there can be a mixed response in a child, such that he or she may be
hyposensitive to one sensory stimulus and hypersensitive to another, or to the same
stimulus at another time (Case-Smith & Miller, 1999; Dunn, Smith Myles et al., 2002;
Frith, 1991; Weimer et al., 2001). Some of the cases described by Asperger (as translated
in Frith, 1991) were identified as having strong likes or dislikes for various fabrics and
sounds, being intolerant to personal grooming and having a fear of movement, which are
signs of hypersensitivity. Others, conversely, demonstrated signs of hyposensitivity,

including a poor sense of personal space, a lack of awareness of objects in the
environment, and preferences for very strong flavors (Frith, 1991). Gillberg (2002),
recognized the relationship between sensory processing difficulties and problems with the
performance of activities of daily living in children and adolescents with AS, such as
bathing, dressing and dental care. He noted that many of these children complained of
pain or discomfort with the water from a shower, hair and nail cutting, and with certain
textures, sounds or scents (Gillberg, 2002).
From as early as the preschool years, children with AS have been identified as
having abnormal responses to sensory stimuli. In a retrospective descriptive study of 40
children with AS, Church, Alisanski and Amanullah (1999) reported that several parents
offered specific comments regarding their childs sensory impairments which resulted in
their child either shut(ting) down completely or becom(ing) very hyper (p. 14).
Similar findings have been reported for children with autism and ASDs in
general. The Center for Autism and Related Disabilities (2005) reports abnormal
responses to various sensory experiences, including visual, auditory, olfactory, oral and
tactile inputs for persons with PDD-NOS. Using the Diagnostic Interview for Social and
Communication Disorders (DISCO) to document sensory abnormalities in children based
on specific sensory domains, Leekam and colleagues (2007) confirmed the presence of
sensory abnormalities in persons of all ages with autism. In this two part study, the
authors noted that children with autism more often experienced abnormalities in several
sensory domains (rather than just one area) than children with language impairment or
developmental disability. Significant differences between groups were identified for
touch and smell/taste domains, and these differences did not change with age or IQ

(Leekam, Nieto, Libby, Wing, & Gould, 2007). In a similar study (Tomchek & Dunn,
2007), which used a parent-rated questionnaire, the Short Sensory Profile, to compare
281 children with ASDs, including 21 children with PDD-NOS and four children with
AS, to age-matched children who were typically developing, 95% of the children with
ASDs were found to have sensory processing dysfunction. The authors also explained
that sensory seeking/underresponsiveness, auditory filtering and tactile sensitivity
sections of the test showed the largest differences between the ASD and control groups
(Tomchek & Dunn, 2007).
Stereotypical and repetitive behaviors are another feature commonly associated
with PDDs and AS. Behaviors might include, but are not limited to: outstretched hands,
hand flapping and shaking of fists (Gillberg, 2002), rocking or pacing (Church et al.,
2000) and jumping, or hitting (Frith, 1991). Some researchers believe that the
stereotyped behaviors observed in children with AS and in ASDs in general, are directly
related to the sensory impairments these children face (Rogers & Ozonoff, 2005).
Baranek, Foster, and Berkson (1997), noted that these behaviors are often present along
with signs of tactile defensiveness, and can present as symptoms of inflexibility to
change. In their study that looked at this relationship, the authors compared teachers
subjective ratings of the presence or absence of abnormal or stereotypical behaviors (as
determined by a yes and no questionnaire), to the students performance on the light
touch subtest of the Tactile Defensiveness and Discrimination Test, the Habituation to
Tactile Stimuli Applied to the Face, and the Touch Inventory for Preschoolers. They
found that children with autism and related developmental disabilities demonstrated more
signs of rigidity and sameness, auditory and repetitive verbalization and abnormally

focused attentions, when they were rated by their teachers as being tactually defensive
(Baranek et al., 1997). Walker and colleagues (2004), using the Autism Behavior
Checklist and the Autism Diagnostic Interview Revised, noted the presence of
repetitive and stereotypical behaviors in all three groups of study participants: children
with AS, children with PDD-NOS, and children with autism.
Due to an apparent inability to successfully integrate and use multimodal
information in a socially acceptable manner, new social situations can also be difficult for
children with ASDs. To cope, they may require unrealistic levels of sameness, engage in
ritualistic or repetitive behaviors, perseverate on topics of interest, overreact to seemingly
minor events, or avoid social interaction altogether (Laurent & Rubin, 2004). Improving
the ability of a child with an ASD to process sensory information effectively will likely
reduce his or her reliance on stereotypical behaviors, rigid environments, and the odd and
awkward behaviors associated with these syndromes (Dawson & Watling, 2000). Smith,
Press, Koenig and Kinnealey (2005) conducted a study that tested this hypothesis and
found that SI intervention reduced the frequency of stereotypical and self-injurious
behaviors in seven children with PDDs or mental retardation, supporting the assumption
that stereotypical behaviors can be related to sensory impairments (S. A. Smith, Press,
Koenig, & Kinnealey, 2005). Only recently, however, has this phenomenon been
recognized and research initiated for children with AS (Dunn, Saiter et al., 2002). In
2002, Dunn, Smith-Myles and Orr conducted a study in which the Sensory Profile, a
parent-reported questionnaire, was administered to parents who had a child with AS.
Their study determined that children with AS had significant impairments in almost all
areas of SI including sensory registration, sensory processing and sensory modulation.

Only Modulation of Visual Input Affecting Emotional Responses and Activity Level was
identified as being within normal limits compared to children without disabilities. In
addition, deficits in integration and modulation were identified for all sensory systems
(Dunn, Smith Myles et al., 2002).
In a pilot study (Klyczek, Shriber, Timler, & Ohtake, 2005) in which children
with AS were evaluated using clinical observations and the Sensory Profile, many similar
findings were noted. All parents reported poor sensory registration, and 75% identified
concerns with emotion, low endurance or tone, and distractibility. Clinical observations
confirmed findings of low tone and distractibility, and also identified difficulty with
visual tracking, and maintaining prone extension and supine flexion positions. While
most children were not identified as being tactually defensive using Clinical
Observations, 60% or more had difficulty with motor planning or execution, and with
equilibrium or righting reactions (Klyczek et al., 2005). These findings suggest the
possibility of poor sensory modulation in children with AS.
Research has suggested a connection between the sensory and motor impairments
seen in children with ASDs. Poor coordination and a general appearance of clumsiness
can occur when the sensory systems are not functioning properly and may become
apparent when observing motor skills and activities of daily living (Murray-Slutsky,
2004). Prudhomme White and colleagues (2007) examined this connection in a group of
68 children with a sensory processing disorder (SPD), and of 68 children with typical
development. They found that children with atypical sensory processing scored
significantly lower on the Assessment of Motor and Process Skills (AMPS) in both
Activity of Daily Living and Process Measures, and also identified a connection between

low Sensory Profile scores and difficulty performing functional tasks, as reflected by the
AMPS scores (Prudhomme White, Mulligan, Merrill, & Wright, 2007).
It seems important to understand that one way the sensory and motor systems are
related, is through proprioception. Proprioception, which involves understanding where
the body and the joints are in space (Parham & Mailloux, 2001), is recognized as being
important for motor function. There is some evidence that suggests that the motor
clumsiness associated with AS may be related to deficits in the processing of
proprioceptive and kinesthetic information (Weimer et al., 2001; Molloy, Dietrich, &
Bhattacharya, 2003). A child who appears to be clumsy and awkward with simple
activities of daily living may not be adequately receiving or processing information about
the position of his or her body (Parham & Mailloux, 2001). Gepner and Mestre (2002)
compared children with AS to a group of children with autism, and to a control group of
normal children using the motor subtest of the Psychoeducational Profile. Their results
indicated that children with AS were often overly sensitive to visual motion and had
increased postural instability, indicating that they had difficulty using proprioceptive
information for balance (Gepner & Mestre, 2002). In 1996, Smyth compared the reaction
times of a group of children identified as being clumsy to a control group using Gubbays
Test of Motor Proficiency. Smyth determined that the group identified as being clumsy
demonstrated longer reaction times, suggesting that kinesthetic information was being
processed too slowly in this population (Smyth, 1996). Weimer et al. (2001) conducted a
study on children with AS, in which children were asked to complete a battery of gross
and fine motor tasks, including finger tapping, grooved pegboard, and tests of apraxia,
ataxia and visuomotor integration. They found that children had the greatest difficulty in

tests of apraxia, one leg standing balance with eyes closed, tandem walking and finger
opposition compared to children with normal development. It was noted that each of
these tests required intact proprioception in order to succeed. This suggests that motor
dysfunction in children with Aspergers may really be a disorder of the sensory pathways
(Weimer et al., 2001). Parham and Mailloux (2001) suggest that the child with decreased
proprioception can also be rejected or avoided by others and labeled as clumsy or
accident-prone. In addition, he or she may also seek additional sensory input in socially
inappropriate ways, such as leaning on another person in an effort to obtain the needed
proprioceptive input (Parham & Mailloux, 2001).
Another possible cause for the clumsiness observed in children with AS may be
poor sensorimotor planning or somatodyspraxia. Dyspraxia that is related to sensory
processing can present as a difficulty with bilateral sequencing, poor sensorimotor
processing, or visuodyspraxia. It occurs when the child is unable to correctly process and
integrate the sensory information presented (Fisher et al., 1991). As with decreased
proprioception, somatodyspraxia may cause the child to appear clumsy or poorly
coordinated, and therefore have difficulty completing gross motor activities (Parham &
Mailloux, 2001).
Molloy, Dietrich and Bhattacharya (2003) performed a case control study on eight
children with ASDs, including AS and PDD-NOS, as well as eight children who were
typical and matched for age, gender and race. A force platform was used to measure
postural stability and compared the responses of different sensory systems. The authors
found that compared to control participants, children with ASDs relied more heavily on
vision to maintain their balance, which suggests difficulty using proprioceptive

information. Additionally, they identified a pattern of sway response that suggested
difficulty with integrating sensory input, rather than a deficit of any one sensory system
(Molloy et al., 2003).
Although it appears that based on the literature, there is some evidence for
sensory impairments in AS and ASDs, they are not included within any set of the
diagnostic criteria. In addition, the sensory issues that have been suggested in AS and
PDD-NOS have not been well studied (Frith, 1991; Smith Myles, Tapscott Cook, Miller,
Rinner, & Robbins, 2000). There also remains a gap in the literature with respect to
objective measurements of the sensory deficits in this group of children. As a result,
similar to motor skills, the sensory modulation and integration skills of children with AS
and PDD-NOS have not been clearly defined, making comparison and generalization
between individuals and studies difficult. It also appears that a best practice treatment
approach for persons with AS or HFA has not been identified (Toth & King, 2008), and
no studies to date have examined the effects of SI treatment techniques at improving the
sensory processing or motor skills of children with AS or PDD-NOS.
The Effectiveness of Sensory Integration Therapy
Occupational therapy using sensory integration is a commonly reported treatment
approach for children with ASDs (Stahmer, Collings, & Palinkas, 2005). Despite the
relatively large number of studies performed assessing the effectiveness of SI, this
treatment technique is still under examination, since many of the studies that are available
are dated and many have not used the most appropriate research protocols. A review of
the SI literature reveals that some of the most common problems with these studies are
that they utilized small samples with no control groups, did not adequately describe the

treatment protocols, and studied too many variables to notice a difference in function post
treatment (Vargas & Camilli, 1999). In addition, studies of this type have been subject to
participant variability and ethical dilemmas regarding a no-treatment control group
(Kaplan et al., 1993).
In some studies involving children with PDDs, who have some similarities to
children with AS, SI therapy has been shown to be effective, and has resulted in
improvements in motor coordination, behavior and play. Ayres and Tickle (1980)
performed a study on ten children with autism who received SI treatment two times each
week for more than 11 months. They reported that all but one child showed some
improvement in the areas observed. These included reduced self-stimulatory behaviors,
increased interactions with the environment, and improved test scores (Ayres & Tickle,
1980). Another study provided SI therapy to four children with AS (Watling & Dietz,
2007). While immediate play skills and behaviors were not significantly impacted as a
result of SI therapy, subjective reports suggested that areas of engagement, such as
transitions, eye contact, socialization and behavior, may have shown improvement
(Watling & Dietz, 2007).
Wilson and Kaplan (1994), followed a group of children with autism for two
years after SI treatment, and determined that their gross motor performance continued to
be better than that of the control group who had only received tutoring. In a multiple
baseline study on five, four and five year old boys with autism, Case-Smith and Bryan
(1999) provided ten weeks of therapy based on an SI approach. Their study revealed that
preschool children with autism demonstrated more appropriate goal-directed play,
improved motor planning and fewer unnecessary stereotypical behaviors following

treatment. Linderman and Stewart (1998) provided classical SI therapy to two preschool
boys with autism. After one-hour sessions once a week for seven and eleven weeks, the
boys demonstrated improvements in attention, initiating and leading social interactions,
tolerating new activities, participating in parent-child hugging, and social awareness.
Finally, in a study by Case-Smith and Miller (1999) who surveyed occupational
therapists who had an interest in SI and autism, it was determined that those who used SI
approaches with their children believed that their clients made the greatest improvements
in their ability to process sensory information.
Other studies have examined the effectiveness of SI on children with other
developmental disorders. Although classical SI therapy was not used in their study, Paul
and colleagues (2003) utilized a sensory motor activities program based on SI theory for
31 preschool children. After 12 weeks of therapy, five days a week, the experimental
group, which included 15 children with impairments in typical preschool skills showed
greater improvement than the comparison group using the DeGangi-Berk Test of Sensory
Integration and significantly greater improvement on the Miller Assessment for
Preschoolers (Paul et al., 2003). In a retrospective study of 37 children with
developmental coordination disorder, the effectiveness of a 10-week combined SI and
perceptual motor training program was assessed (Davidson & Williams, 2000). After a
12-month follow-up period, they determined that there was a statistically significant
improvement in fine- and visual motor skills (p=0.034 and 0.002, respectively) for the
children who participated. In a study of the long term effects of SI therapy and tutoring
(three years after intervention), a more sustained improvement in the gross motor skills of
the SI group was observed when compared to the children who had received tutoring

(Wilson & Kaplan, 1994). Another study by Law, Polatajko, Schaffer, Miller and
Macnab (1991) that used a randomized controlled trial for six to nine year old children,
compared the effects of six and nine months of SI therapy (n=34), or perceptual motor
training (n=33) to no treatment (n=13). The results of their study did not find significant
motor improvements among groups of children with learning disabilities and SI
dysfunction. The authors, however, noted that some children improved a great deal,
while others did not. It was suggested, therefore, that SI intervention may be effective for
certain subgroups of children.
In an effort to improve the scientific rigor of SI effectiveness studies, Miller and
colleagues (2007) have utilized a randomized controlled pilot study to examine the
effectiveness of sensory integration for 3 to 11.6 year old children with sensory
modulation disorders. Twenty four children with sensory modulation disorder were
randomly assigned to one of three groups: a SI group, which provided children with
classical SI therapy two times a week, for 10 weeks; an Alternate Placebo treatment
group, which provided adult attention and table-top play activities; and a No-Treatment
control group, which utilized a 10-week wait list plan. The results from this study
suggested that SI was more significantly more beneficial than the other treatments with
respect to attention (p = 0.03 compared to no treatment and p = 0.07 compared to an
alternate treatment), cognition (p = 0.02 compared to the alternate treatment), and in
meeting personalized goals (p < 0.001 compared to both groups). In addition, positive
trends in favor of the SI treatment were noted on parental reports of sensory processing
and sympathetic nervous system responses to sensory challenges (L. J. Miller, Coll, &
Schoen, 2007).

One of the beliefs regarding SI therapy is that it will enhance the childs ability to
regulate the sensory input received by the body, and in so doing, will improve the childs
ability to interact with the environment in a socially appropriate manner. Roberts and
colleagues (2007) examined behavior regulation in one, three-year-old child with sensory
modulation disorder, following occupational therapy which employed a SI frame of
reference. The therapy was provided individually, for one hour sessions, three times per
week, using an A-B-A-B protocol. Significant decreases in aggression, oral selfstimulation, and teacher input, as well as improved engagement skills were noted during
the weeks that the child received therapy (Roberts, King-Thomas, & Boccia, 2007).
Similarly, a case report of a four-year-old child with poor sensory processing who
received SI therapy revealed improvements towards goals in motor planning and
participation, motor skills, decreasing fear of movement, reducing oral sensitivity, and
improving social development (Schaff & Nightlinger McKeon, 2007). In addition, parent
reports on the Sensory Profile and the Goal Attainment Scale indicated that the childs
occupational performance and participation improved following the SI intervention
(Schaff & Nightlinger McKeon, 2007).
A review of the meta-analyses that have been done on SI (Mulligan, 2003;
Ottenbacher, 1982; Vargas & Camilli, 1999) suggests mixed results in regards to its
effectiveness and a confirmation of the lack of consensus with respect to the effectiveness
of the therapy. The first meta-analysis, performed by Ottenbacher (1982), concluded that
although only a small number of studies were reviewed, SI was an effective treatment
technique with a moderate effect size (mean d-index = .79) (Ottenbacher, 1982). Vargas
and Camilli (1999) performed an extensive meta-analysis of all SI efficacy studies

performed between 1972 and 1994 and among other findings, determined that earlier
studies were more likely to show significant improvement after SI intervention than
studies that were conducted after 1984. They also determined that significant
improvement was more likely in studies which compared SI to no treatment, as opposed
to those which compared SI to an alternative treatment. Both Ottenbacher (1982) and
Vargas and Camilli (1999) noted that SI interventions have had the greatest effects on
motor and psychoeducational variables, as opposed to language, academic performance,
or behavior. In addition, Mulligan (2003) reviewed studies that had been performed from
1980 until 2003 which used treatments based on the general principles of SI theory. She
concluded that as a result of poor scientific rigor, the effectiveness of SI therapy remains
unclear (Mulligan, 2003). It is important to consider however, that there is most likely no
intervention that would be ideal for all individuals with a particular diagnosis, and that
interventions need to be individually based (Baranek, 2002). Although there has been
several years of research in the area of SI effectiveness, some suggest that it is still in the
early phases of determining its true effectiveness (Cool, 1995). While studies on SI
therapy may not have provided consistent evidence of statistically significant
improvements following intervention, positive changes have been noted, resulting in
increased comfort with sensory and motor experiences, and more freedom to engage in
social interactions (Siegel, 1996).
Summary
In addition to problems in communication and social skills, many children with
AS and PDD-NOS can have difficulties with sensory and motor skills which often go
undetected or untreated. While some studies and anecdotal evidence support the

presence of these deficits, there is still a great need for research in this area. Decisions
need to be made regarding the most appropriate diagnostic criteria for identifying these
children, and research is needed to clarify the symptoms of this disorder. It is important
however to address the needs of these individuals now, rather than waiting for these
clarifications to be made (Klin & Volkmar, 2003c, p. xiv). Clearly, it must be determined
which treatment techniques will be most effective for children with ASDs who have
sensory or motor deficits. Even though it is documented that children with these
diagnoses frequently display signs of poor sensory processing and modulation which can
possibly effect their motor skills, can negatively impact their relationship with their
family, and can interfere with their ability to succeed in social and educational activities,
no research has been published on the effectiveness of SI therapy in children with AS or
PDD-NOS. One can hypothesize that if SI has been effective in populations displaying
similar characteristics, such as children with autism or difficulty with sensory
modulation, it might also be a useful intervention with this group of children. Therefore,
in order to contribute to an understanding about the sensory processing and motor skills
of children with AS and related PDDs, and to assess the effectiveness of SI treatment, an
intervention program based on the theories of SI was implemented for children with AS
and PDD-NOS. The purposes of this study were: (a) to objectively quantify the sensory
and motor impairments observed in children with AS and PDD-NOS, (b) to determine if
children with AS or PDD-NOS demonstrate changes in sensory function following SI
intervention as quantified by the Sensory Profile, the Sensory Integration and Praxis
Tests (SIPT) and Clinical Observations, and (c) to determine if children with AS or PDD-

NOS demonstrate changes in motor function following SI intervention as quantified by
the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition.

Methods
This research study was a preliminary study which was intended to examine the
efficacy of SI therapy on the sensory and motor skills of children with AS and PDDNOS. Utilizing a one-group pre-test post-test design with a delayed treatment approach,
it sought to provide evidence regarding the level of sensory and motor skills observed in
children with this syndrome. An additional purpose was to determine if SI therapy had
an effect on improving any specific deficits that were identified in this group.
Setting
The evaluation and intervention of the participants recruited for this study took
place in an occupational therapy laboratory within a University setting which contained
equipment necessary to provide SI therapy. An additional, adjacent classroom, which
contained tables and chairs, was also used to conduct testing, when room conflicts or
child distractibility were identified. The occupational therapy laboratory is a 50x35 foot
room which includes equipment such as suspended swings, mats, ramps, scooters and
textured equipment. The room contains two doors for entry and exit, two sinks and a set
of cupboards on one wall and several long tables for completing seated activities, which
can be moved out of the way as needed. The room is equipped with fluorescent light
fixtures and the floors are constructed of vinyl asbestos tiles which are free from damage.
Windows and additional cabinetry line one wall of the room, however since the room is
located in the basement of the building, windows only provide views of a grassy hill, and
shades can be drawn to eliminate distractions or light interference. The ceilings are nine
feet high. Small toys are stored in the drawers, cabinets and portable shelving units

within the room. Mats and other large equipment are stored off the floor, or off to the
sides of the room, leaving a 35 x 24 foot space for treatment to occur.
Due to room conflicts which could not be resolved, a second therapy room with a
large, open area was used for the treatments of one participant for two weeks during the
intervention phase of the study. No suspended equipment was available in the alternate
room, however other equipment in the room was similar to that of the actual treatment
room. Additionally, mobile pieces of equipment were relocated from the original room
to maintain consistency. With the exception of the suspended activities, all other
treatment activities were consistent with the activities listed in the treatment manual.
Participants
Prior to recruiting participants, approval from the Universitys Children and
Youth Institutional Review Board was obtained (see Appendix A). At the time of the
study, participants were required to be five to nine years old, with a diagnosis of AS, and
could not be receiving other therapy that utilized an SI approach. After several weeks of
recruitment, permission to accept a diagnosis of PDD-NOS was requested and approved
by the review board, due to difficulty obtaining participants with a definitive AS
diagnosis. Since SI treatment relies on the presence of SI deficits, an additional inclusion
criterion was that participants had SI deficits as determined by initial testing done by the
researcher. Therefore, only children with SI deficits based on initial testing for the study
were eligible to participate in the intervention phase of the research. In order to meet the
standards for the selected battery of tests, subjects were required to be English speaking,
see clearly with or without corrective lenses, and be free of other neurological diagnoses.
An English speaking parent or guardian who was literate and able to provide

transportation to and from the testing and treatment sessions was also required. In order
to account for vacations and illness, subjects were expected to attend at least 17 of the 20
treatment sessions (85%) that were scheduled.
The article entitled The Effects of Occupational Therapy with Sensory Integration
Emphasis on Preschool-Age Children with Autism (Case-Smith & Bryan, 1999) was used
to determine the appropriate sample size for this study. This article evaluated the
effectiveness of a SI treatment protocol on some of the typical behaviors associated with
autism and SI, including mastery play and interaction. Based on an alpha level of .05,
and applying the data from the study, a very large effect size (2.05) was calculated using
the common standard deviation and the mean difference from a paired t-test. A power
table for 80% power indicated that eight subjects were necessary. At the time of study
development, there were approximately 186 children with ASDs between the ages of four
and eleven years, who were being serviced in the county in which the study was
conducted (New York State Office of Vocational and Educational Services for
Individuals with Disabilities (VESID), 2004). Based on an autism to AS ratio of 5:1
(Fombonne & Tidmarsh, 2003), it was conservatively estimated that approximately 37
children with a diagnosis of AS, who were between the ages of 4 and 11 years were being
serviced in the countys school districts. Since not all children with AS or PDD-NOS
receive services, and diagnosis may be delayed beyond age 11, it was recognized that this
was likely a low estimate of the number of children with AS. As a result of the relatively
small number of potential subjects locally, all potential participants who met the
inclusion criteria, and who agreed to participate by completing consent and assent forms,
were enrolled in the study. During the recruitment period, it was decided to include

children with PDD-NOS, since obtaining study participants who met all study criteria for
AS was becoming difficult. A goal of at least ten subjects was set, based on the power
table described previously and taking into account the possibility of attrition.
Human Subject Protection
Participants were recruited from a University-based clinic that provides speech
and communication services to children with PDDs, and from local psychiatrists, schools
and health care workers who provide services to children with AS or PDD-NOS.
Recruitment of participants also occurred via written advertisements posted at the
University and in offices and schools. Additionally, written fliers were distributed to
parent members of groups and organizations that are affiliated with AS or PDDs. Prior to
the study, a written request for support in recruitment procedures was sent to facilities
and individuals to identify a willingness to assist with the recruitment of participants (see
Appendix B). Letters of support from local service providers can be found in Appendix
C. Appendix D contains radio and written advertisements which were also used to
obtain additional study participants.
The service providers and referral sources who agreed to assist in recruitment
were requested to provide parents of children with AS or PDD-NOS who were between
the ages of five and nine years with an information letter and invitation to participate (see
Appendix E). Written advertisements (see Appendix D) were used to inform the public
of the study. The initial information letter and advertisements explained that this was an
intervention study assessing the effectiveness of SI therapy for children with AS. This
was later revised to include children with PDD-NOS, due to the difficulty in recruiting
children within the age range who had a specific AS diagnosis. Parents were informed

that they could respond, if they were interested in having their child participate, by
calling or contacting the researcher via email to discuss the study details and to schedule
initial testing. At that time, parents who did not already have a copy of the information
letter and invitation were provided with one, and contact information was obtained so that
further parent contact could take place via telephone or mail as necessary. Prior to
testing, parents signed an informed consent form (see Appendix F), accepting the terms
of the study and agreeing to have their child participate. The consent form also indicated
their right to withdraw their child from the study if they wished to do so at any time. The
participants with AS or PDD-NOS were asked to sign an assent form (see Appendix G)
prior to participating, which informed them about what they were expected to do, and
about their right to withdraw from the study.
Information collected for study purposes including the childs test scores and
other private information, was recorded on the score forms in such a way that both the
parents and their childs identities remained confidential. Since the researcher needed to
formulate a treatment plan for each child based on his or her test results, the researcher
needed to know the childs name. Since both the researcher and another therapist
conducted the testing during various phases of the research, the childs first name only
was used during test sessions. The other therapist who administered some of the test
procedures was asked to leave identifying information forms blank, so that code numbers
could be entered by the researcher in order to maintain confidentiality. Once test forms
were returned to the researcher, a code number was assigned to that child. The code
number, rather than the childs name was used on all testing and treatment paperwork. In
the case that a parent or the tester put the childs name on the testing forms, the

researcher removed the name with white out, and that childs code number was put in its
place, in order to identify each participant. With respect to dispersion of study
information, any information regarding this study is and will be reported so that there is
no way that the child can be identified. All forms have and will continue to be stored in a
locked file cabinet in the office of the researcher for seven years, after which time they
will be destroyed.
Study Design
This research study utilized a one-group pre-test post-test design with a delayed
treatment approach. At the initiation of the study, pretesting was conducted using the
pre-study questionnaire, the ASDS, the Sensory Profile, the PEGS, Clinical Observations,
the BOT-2 and the SIPT. To allow subjects to act as their own control, a 5-week
baseline phase, in which no intervention was provided, took place prior to the start of SI
therapy. Midtesting was conducted using the ASDS, the Sensory Profile, the PEGS,
Clinical Observations, the BOT-2 and the SIPT. Sensory integration therapy was
provided for 10 weeks. Therapy sessions took place two days per week, for 45-60 minute
sessions. Post-testing occurred following the 10-week intervention period, and all of the
testing procedures that were followed in the mid-testing phase were repeated.
Instrumentation
Several instruments were used for the collection of data for this study.
Pre-study Questionnaire. Prior to formal testing, a Pre-study Questionnaire (see
Appendix H) was given to the parents during the initial phase of testing. This
questionnaire included demographic data such as the childs age, gender, AS
characteristics, perceived sensory processing impairments, school setting, and other

services the child was receiving. It was also used to establish that the participant was
English speaking, was able to see clearly with or without corrective lenses, and that he or
she was free of other neurological diagnoses.
The Asperger Syndrome Diagnostic Scale. The Asperger Syndrome Diagnostic
Scale (ASDS) (Myles, Bock, & Simpson, 2001) was completed by parents at all three
testing phases to provide more in-depth information on their childs AS symptoms, with
respect to language, social and adaptive behaviors, cognition and sensorimotor skills (see
Appendix I). This standardized, norm-referenced test is based on diagnostic criteria from
the DSM-IV, the ICD-10 and an extensive literature review. It has been designed for
children ages 5-18 years. The normative sample used in developing this test included
115 children from throughout the U.S., who were 5-18 years of age, and diagnosed with
AS. The ASDS contains five separate subscales. The first subscale is the Language
Subscale, which addresses receptive and expressive language function. The second
subscale is the Social Subscale, which addresses the childs eye contact, gestures,
friendships and interactions with others. Next, is the Maladaptive Subscale which
identifies psychological concerns, repetitive behaviors, general behavior and responses to
changes in routine. The Cognitive Subscale addresses memory, intelligence and interests,
and the Sensorimotor Subscale examines the childs gross and fine motor coordination, as
well as sensory integrative abilities. A test form and a pencil are the only items necessary
to complete the test (Myles et al., 2001).
This assessment was developed to assist in identifying individuals with AS and to
identify changes in AS characteristics over time. In administering this test, parents are
asked to identify observed behaviors which are listed. Subscale scores are added to yield

an AS quotient. This quotient provides the likelihood of a child having AS with 85%
accuracy and has an internal consistency of .83. Higher ASQ scores correspond with
more symptoms of AS, and therefore, a greater likelihood of having a diagnosis of AS.
Cronbachs alpha of .83 was determined for the ASDS, indicating a very high correlation
between test items and the AS quotient. Subscale consistencies are as follows: Language:
.72, Social: .83, Maladaptive: .80, Cognitive: .64, and Sensorimotor: .67. The interrater
reliability was reported to be high with a correlation coefficient of .93. Content validity
was established, with discrimination coefficients ranging from .47-.67, indicating that
individual items correlate with the total domain measured by the scale. Item construct
validity has also been established by comparing the ASDS to the Gilliam Autism Rating
Scale, identifying a .46 correlation between the two scales (Myles et al., 2001). This
supports the construct validity of the ASDS demonstrating that although the diagnoses
are similar, the ASDS is not screening for autism.
The Sensory Profile. The Sensory Profile (Dunn, 1999) is a parent completed
questionnaire, which assesses the childs sensory processing and sensory modulation. It
helps to determine areas of sensory processing deficits that may contribute to problems in
completing daily life activities. It was given to the parents to complete at the start of the
study, five weeks into the study, and at the end of treatment (See Appendix J). The
instrument was norm referenced on a group of more than 1,000 children between the ages
of 3 and 10, with and without disabilities. To complete this questionnaire, caregivers
need a score sheet and a pencil.
The Sensory Profile is comprised of 125 questions arranged in a Likert scale.
Low scores on the scale indicate frequent or undesirable behavior that is sensory based.

High scores indicate behavior similar to that of a typically developing child. The test is
made up of three sections. The first section assesses the childs ability to process sensory
information and is broken down by sensory systems which include: auditory, visual,
vestibular, touch, multisensory and oral. The second section is used to assess the childs
ability to modulate more than one type of sensory input at a time. This section includes
modulation related to endurance and tone, body position and movement, movement
affecting activity level, input affecting emotional responses, and visual input affecting
emotional responses and activity level. The final section assesses behavioral and
emotional responses, and includes emotional/social responses, behavioral outcomes of
sensory processing and thresholds of response categories. Scores are added for each
section and then used to determine summary scores. Results from the questionnaire also
yield factor summaries that provided information on the childs sensory seeking
behaviors, emotional reactivity, low endurance or tone, oral sensory sensitivity and
inattention or distractibility, as well as the presence of poor registration, sensory
sensitivity, sedentary behaviors and fine motor and perceptual abilities.
Internal consistency measures for the Sensory Profile ranged from .47-.91, and
standard errors of measurement have been reported to be between 1.0 and 2.8, suggesting
parental scores that are similar to true scores. Content validity was established during
test development. Items were reviewed by a panel of eight experts in SI theory and
practice, and placement of items into categories was agreed upon by 80% of a panel of
155 occupational therapists who were members of the special interest section on SI
through the American Occupational Therapy Association. Thirty-seven items were
identified as being categorized incorrectly, and in those cases, new categories were

developed. By comparing the Sensory Profile to the School Function Assessment (SFA)
(Coster, Deeney, Haltiwanger, & Haley, 1998), moderate to large correlations (.54 to .80)
were identified between the Sensory Profile and the SFA on behavioral regulation and
sensory perception, suggesting convergent validity. Discriminant validity was also
established, with low correlations on specific performance items of the SFA and the
Sensory Profile, suggesting that the Sensory Profile examines sensory processing as a
whole, rather than measuring specific tasks, as the SFA does (Dunn, 1999).
Perceived Efficacy and Goal Setting System. The Perceived Efficacy and Goal
Setting System (PEGS) (Missiuna, Pollock, & Law, 2004) is a picture-based tool which
measures a childs perceived abilities with respect to functional, daily activities, and
allows a child to assist in creating intervention goals (See Appendix K). The test was
designed for children ages six to nine years, but has been used with five year olds
according to correspondence with the tests first author. In order to include the childrens
point of view, and to establish a rapport with each child, the PEGS was administered as
the first child-based test at all three phases of testing.
Based on the All About Me (Missiuna, 1998), which measures childrens
perceived abilities on motor tasks, and utilizing cards depicting pictures of children
performing age-appropriate tasks, the PEGS assesses perceptions of performance
primarily on gross and fine motor skills by asking the child to identify which picture most
closely resembles his or her performance on a particular task, and how similar his or her
performance is to the selected card. For example, a child is shown two pictures: one with
a child kicking a ball, and one with a child missing the ball. The pictures are described,
and the child is asked which picture looks like him/her and then, whether or not the

picture is a lot like him/her or a little like him/her. The childs response corresponds to a
four point rating scale, with one indicating that the child rates him/herself as being very
bad at a particular skill, and four indicating that the child believes he or she is very good
at the skill. Parent and teacher forms are also available, but were not used for the study.
Reliability and validity were established for the PEGS based on an earlier version,
the All About Me, and on a standardization study of 117 six to nine year old children.
Internal consistency of the All About Me identified a Cronbachs alpha coefficient of
0.85 for both the gross and fine motor scales, and 0.91 for the total measure. Test-retest
reliability of the All About Me was found to have Pearson coefficients of 0.79, 0.76 and
0.77 for the fine motor items, gross motor items and total score, respectively. A
moderate correlation (r=.73) was established between the All About Me and the
Bruininks-Oseretsky Test of Motor Proficiency, (Missiuna et al., 2004).
Clinical Observations. It is generally recommended that clinical observations of
neuromotor performance be used to supplement formal testing in an effort to obtain
additional qualitative information about the childs functioning (Ayres, 1989; Fisher et
al., 1991). Clinical Observations (see Appendix L), were used in conjunction with the
Sensory Profile and the SIPT at all three phases of the study, to provide this additional
subjective information based on clinical judgment. The Clinical Observations that were
used in this study were adapted from Fisher, Murray and Bundy (1991) and from Ayres
Clinical Observations (as cited in Shriber, 2004). The test battery includes items that are
commonly used to provide information on a childs sensory modulation, primitive
reflexes, muscle tone, posture, body awareness, bilateral sequencing, motor planning,
coordination and vision (Fisher et al., 1991). In order to guide the examiner through

these items, and to maintain testing consistency between examiners, a Clinical
Observations Worksheet (Appendix M) containing the specific clinical observations,
brief instructions, and possible findings was also used, and the information was then
applied to the Clinical Observations Form for scoring. Although scores on these
observations have not been tested against a normative sample, scoring guidelines are
available that correspond with how the child responds.
The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition. The
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) (Bruininks &
Bruininks, 2005), was also used to obtain information on the participants (see Appendix
N). This test, which was administered to the children at the beginning of the study, five
weeks into the study, and at the end of the intervention phase of the study, measures the
gross and fine motor performance of individuals, ages 4 to 21 years. The test is broken
down into four composites, each with two subtests. The Fine Manual Control composite
examines fine motor precision and integration. The Manual Coordination composite
assesses manual dexterity and upper-limb coordination. A third composite: Body
coordination, assesses bilateral coordination and balance. Finally, running speed and
agility and strength are assessed in the Strength and Agility composite. The scores from
these subtests are added up to determine a Total Motor Composite Score which can be
used to determine percentile ranks. All composites can also be used to determine age
equivalents, which are broken down by gender, based on data from a normative sample of
1,520 children, ages 4 to 21, representative of the 2001 United States Census and the
Twenty-sixth Annual Report to Congress, in 2004.

Internal consistency reliability has been obtained using Pearson correlations for
subtests and a stratified alpha method for composite scores, and has been reported to
range from moderate to excellent with subtest and composite correlation coefficients
ranging from .60-.97. Test-retest reliability has been established based on a time frame
of 7 to 42 days, with Pearson correlation coefficients averaging .78 (subtest) and .83
(composite) for children ages four to seven years, .76 (subtest) and .83 (composite) for
children ages 8-12, and .69 (subtest) and .77 (composite) for children 13-21 years of age.
Interrater reliability Pearson correlation coefficients range from .86 to .99 for all of the
BOT-2 subtests and composites. In addition, content and construct validity have been
established from a national tryout study conducted by test developers, which
demonstrated validity between subtest score and chronological age. A BOT-2 test kit is
required to administer the test in the standardized manner, and test completion takes
approximately one hour (Bruininks & Bruininks, 2005).
Sensory Integration and Praxis Tests. The children who participated in the study
completed the Sensory Integration and Praxis Tests (SIPT) (Ayres, 1989), at the
beginning of the study, five weeks into the study, and at the end of the intervention phase
(see Appendix O). This series of 17 tests designed for children ages 4 to 8 years, 11
months, extensively assesses their ability to plan and carry out motor actions as well as
various sensory processing abilities. The SIPT is a norm-referenced test based on a
normative sample of 1,750 children from a variety of ethnic backgrounds. There are four
categories of tests, each designed to assess a specific aspect of sensory integration and
praxis. The first category assesses form and space perception. These tests include Space
Visualization, Figure-Ground Perception, Manual Form Perception, and Motor Accuracy

subtests. The second category of tests assess somatic and vestibular sensory processing,
and includes the Kinesthesia, tactile tests (including: Finger Identification, Graphesthesia,
and Localization of Tactile Stimuli), Postrotary Nystagmus, and Standing and Walking
Balance subtests. The third category assesses praxis via the Design Copying, Postural
Praxis, Praxis on Verbal Command, Constructional Praxis, Sequencing Praxis and Oral
Praxis subtests. The final category assesses the childs ability to perform bilateral
integration tasks and to sequence various tasks. The Bilateral Motor Coordination
subtest, as well as the previously mentioned Oral Praxis, Sequencing Praxis,
Graphesthesia, and Standing and Walking Balance subtests are used to assess this
component of sensory processing. This test is said to be able to be administered in as
little as 1 hours, however experience indicates that approximately three hours are
necessary to complete the entire test battery. If necessary, the test can be given in two
parts in an effort to maintain the childs attention and endurance for test taking. A SIPT
test kit is required to administer this test, and extensive training and testing is required to
become certified in test administration. The SIPT Manual provides a general description
of the test which was provided to parents by the researcher (See Appendix P).
Validity of the tests construct has been demonstrated with factor and cluster
analyses in 293 children with and without sensory dysfunction. A subsequent cluster
analysis by Mulligan (2000) was performed on 1,961 children, and resulted in five cluster
profiles being identified. These included: Generalized Sensory Dysfunction and
Dyspraxia, Severe Dyspraxia, Generalized Sensory Integration Dysfunction and
Dyspraxia-Moderate, Low Average Bilateral Integration and Sequencing, and Average
Sensory Integration and Praxis. Tests of concurrent validity have yielded correct

classification of 83-88% of children to whom the test was administered with learning
disabilities or SI dysfunction, based on multiple discriminant analysis. Each of the tests
demonstrated significant ability to discriminate between normal and abnormal sensory
function (p<.01). Test-retest reliability coefficients have been determined for each
component of the 17 subtests. For this testing, subjects repeated testing 1-2 weeks after
the initial test. The test-retest reliability coefficients that were obtained are as follows:
Space Visualization: .62, Figure-Ground Perception: .54, Manual Form Perception: .69,
Kinesthesia: .33, Finger Identification: .75, Graphesthesia: .72, Localization to Tactile
Stimuli: .54, Praxis on Verbal Command: .88, Design Copying: .94, Constructional
Praxis: .67, Postural Praxis: .88, Oral Praxis: .89, Sequencing Praxis: .84, Bilateral Motor
Coordination: .77, Standing and Walking Balance: .80, Motor Accuracy: .84, Postrotary
Nystagmus: .47. The average reliability coefficient for the SIPT was .74, indicating a
moderate test-retest reliability (Ayres, 1989). The Postrotary Nystagmus subtest is one
subtest that has demonstrated poor test-retest reliability during psychometric testing,
however this same test has yielded more favorable results (.79 to .83) on earlier versions
of the SIPT which utilized identical protocols (Ayres, 1989). As a result of the intensive
training and certification process required to administer the SIPT, interrater reliability has
previously been demonstrated with total accuracy ranging from .94 to .99 for all tests
(Ayres, 1989). Overall the SIPT is the most comprehensive and standardized
performance test available for assessing SI and praxis.
A previous version of the SIPT, the Southern California Sensory Integration Tests
(Ayres, 1972) was not found to be appropriate for test-retest purposes in efficacy studies.
As a result, it had been the position of Sensory Integration International, which until

recently, was the organization that certified individuals in the administration and
interpretation of the test, to discourage using the SIPT to measure change (Bledsoe,
2004b, 2004). Preliminary evidence suggests, however, that the SIPT may be more
sensitive to change than its earlier version, and may therefore be a useful tool in studies
aimed at assessing the effectiveness of SI therapy (Giencke-Kimball, 1990). Since testretest reliability has been established, and since this is currently the best tool available to
assess all aspects of SI, the SIPT was utilized to assess change as a result of the
intervention provided to the children. Because of the discrepancy in information
regarding the use of the SIPT for test-retest purposes, it is acknowledged that the results
may need to be interpreted with some caution.
Procedures
Following approval from the Children and Youth Institutional Review Board (see
Appendix A), recruitment for participants took place using three separate methods. First,
clinicians and agencies that had agreed to assist in recruiting participants were asked to
contact the parents or guardians (hereafter referred to as parents) of children who may fit
the study criteria and provide them with a parent information letter and invitation to
participate. This letter provided a general description of the study and inquired about
their interest in having their child participate (see Appendix E). Radio and written
advertisements were also used to recruit potential participants, and were offered to
interested parties of parent support groups (see Appendix D). Parents who contacted the
researcher as a result of the advertisements were given the same parent information letter
and invitation that was provided by the clinicians and agencies. Parents who responded
to the invitation and whose children met the study criteria were provided with an

Informed Consent Form (see Appendix F) that provided further details about the study.
After a signature on the consent form was obtained, the parents completed pre-study
testing regarding their child to determine his or her eligibility and to confirm the presence
of AS symptoms and SI symptoms. Pre-study testing included information obtained from
the parents who were asked to complete a brief pre-study questionnaire (see Appendix
H), the ASDS (See Appendix I), and the Sensory Profile (see Appendix J) to determine if
all inclusion criteria was met. These questionnaires were administered by the researcher
during pre- and mid-study testing. Post-testing was administered by another experienced
occupational therapist certified in administering the SIPT, who had agreed to participate
in this process by responding to a written request to assist in the test administration
process (see Appendix Q). Each parent was instructed by the researcher on how to
complete the Sensory Profile and the ASDS based on the directions from the test
manuals. Parents were also asked to complete the questionnaires based on their childs
function at that particular point in time. Once all of the parents questions were
addressed, they were asked to complete the pre-study questionnaire, the ASDS and the
Sensory Profile. Children who were reported by their parents as meeting basic study
criteria, who scored an AS quotient of at least an 80 on the ASDS, and who were
determined to have at least one factor or section that indicated a Probable Difference on
the Sensory Profile were identified as being appropriate for the study. Recruitment of
participants was discontinued when all recruitment resources had been exhausted.
Children with AS or PDD-NOS whose parents provided consent were provided
with an assent form (see Appendix G) that provided information about the study in a
manner that could be easily understood by the children. Following receipt of the childs

assent, pre-testing of the child occurred. Each child was assessed using the PEGS (see
Appendix K), Clinical Observations (see Appendices L and M), the BOT-2 (see
Appendix N) and the SIPT (see Appendix O). Pre-testing took place over two to three
sessions. Since the researcher needed to know all test results in order to develop a
treatment plan for each individual child, and there were a limited number of clinicians
who are certified to administer the SIPT, it was deemed appropriate by her advisors for
the researcher to conduct pre- and mid-study testing. Therefore, all pre- and mid-study
testing was performed by the researcher, and all post-testing was completed by an
occupational therapist who had previously been trained and certified to administer the
tests. The order of the test administration to the children was as follows: First, the PEGS,
and then Clinical Observations were administered in order to establish a working
relationship with the child and to obtain initial information. Next, the BOT-2 was given.
It was expected that most children would be able to complete this test in one session,
however completion in the second session was allowed for those children who displayed
difficulty in completing the test in session one. In the second testing session, the SIPT
was administered. Due to the length and level of concentration necessary for this test, a
third session was available for subjects who were unable to complete the SIPT in one
day. Rest periods were provided throughout the testing sessions as needed by each child.
For some children, all testing was completed in one day, with an extended lunch break
used to separate testing sessions. Each phase of testing took place over the course of no
more than a seven day period.
Interrater reliability between the researcher and the second examiner was
established for Clinical Observations, the BOT-2 and the SIPT. Within the time frame of

the study, the examiner tested one study participant whose parents had provided consent,
and who had signed an assent form. Clinical Observations, the BOT-2 and the SIPT were
administered to the child. Both examiners were present during this testing process and
simultaneously scored the child.
Upon completion of the first round of testing, participants entered a 5-week
baseline period during which no study-related interventions took place and the families
were instructed to carry on with their typical routines. Approximately two and one half
weeks into the baseline phase, the family was contacted via telephone to ensure that there
were no significant changes in routine, to answer any questions, and to schedule the
second round of testing. Following the baseline period, the ASDS, the Sensory Profile,
the PEGS, Clinical Observations, the BOT-2 and the SIPT were administered for a
second time, using the same protocol as the one used for pre-study testing. The
researcher administered the mid-study tests to the parents and the children five weeks
after the initial testing took place. Midtesting began within one week of the conclusion of
the baseline phase.
Once testing had been completed for the second time, and within one week of the
completion of midtesting, the 10-week intervention phase began. This consisted of oneon-one sessions, two days per week, for approximately 45-60 minutes in duration, as
recommended by Fisher, Murray and Bundy, (1991). Upon arrival to each session, the
parent of the child was asked to provide any information that might be useful in
providing optimum therapy that day, such as whether or not the child was feeling well, or
if any abnormal activity or circumstance took place since the last session. After this
information was obtained, the session began.

The researcher, who has been trained and certified in SI evaluation and
intervention, conducted all treatment sessions. Sessions followed a SI frame of reference,
which provides the child with specific sensory input in a child-directed activity in order
to improve the childs ability to process and integrate the input and produce a more
appropriate adapted behavior, (Fisher et al., 1991). Using the results from pre and midstudy testing, treatment plans were developed based on activities listed in the treatment
manual (see Appendix R). The activities offered during each session were based on
specific areas of weakness identified for each child prior to and during the intervention.
The treatment area was arranged in a way that would entice the child into selecting
appropriate activities. Whenever possible, the child was given the opportunity to select
which activity would be performed, and to provide the guidelines for the activity. For
example, a child might decide to use the net swing for the next activity, and would guide
the therapist as to what game would be played (bean bags, rings, rope pull, knocking
into objects). At that point, a theme was agreed upon by the child and the examiner.
Examples include flying on a hot air balloon, building a predetermined structure, such as
a house, and having a treasure hunt.
Every attempt was made to maintain treatment fidelity throughout the study.
Sensory integration theory requires intervention to be highly individualized based on
previous testing and observations made during the session. Therefore, prior to initiation
of the study, a Treatment Manual (see Appendix R) was created by the researcher based
on documented treatment recommendations provided by experts in the field of SI and
was utilized by the researcher throughout the study. The manual incorporates the
theoretical basis for treatment, guidelines for treating, and acceptable activities. A list of

sample treatment activities was provided for each area of concern so that treatment
protocols between children and from session to session remained similar. A list of
acceptable activities was developed for each possible area of need in order to standardize
the treatment and allow for replication of the study. Examples include activities
involving suspended equipment, weights and deep pressure, pushing and pulling,
climbing, jumping and hitting, heavy and resistive activities, and resistive manipulative
activities using materials such as therapy putty (Bundy et al., 2002; Fisher et al., 1991;
Huebner, 2001; Watling, 2004). A checklist and progress note was completed by the
therapist-researcher at the end of every session indicating how the treatment was
conducted (see Appendix S). The progress note included documentation of the specific
order of activities, and was completed at each activity transition during the sessions. The
checklist, which was based on the ECOTUSII, developed by Parham, Cohn, Koomar and
Miller (Watling, 2004), provided a means for evaluating whether or not the key principles
of SI were followed during each session. The researchers advisor served as an outside
examiner and observed five random interventions. She also completed the progress
checklist to assess for treatment adherence and therapist competence.
Following completion of the 10-week intervention period, posttesting took place.
This phase of testing began within one week of the final intervention session. Parents
completed the ASDS, and the Sensory Profile, and children completed the PEGS,
Clinical Observations, the BOT-2, and the SIPT. In order to minimize researcher bias,
post-testing was conducted by a licensed occupational therapist trained and certified in
test administration, and who was blind to initial test scores and treatment activities. The

study was considered complete once all posttesting had been completed. Data analysis
followed.
Neither participants, nor their parents were financially compensated for their
participation in this study. As a way of expressing thanks and wishing the child well,
each child received a small trinket of less than ten dollars in value at the end of the study.
Examples include a gift card to a restaurant, or a favorite toy used during the study.
Other than travel expenses to and from the testing and treatment site, no additional costs
were incurred by the participants. Assessment and treatment services were provided free
of charge. Child-specific results from final testing were offered to the parents of the
participants in the form of a summary report following post-testing. Overall results of the
study will be made available to the parents following data analysis and interpretation of
the study results.
Data Analysis
All data was recorded and analyzed in SPSS version 15. Descriptive statistics
were used to report demographic data such as such as age, gender, diagnosis and other
services the child was receiving. To test hypothesis one to determine if children with AS
and PDD-NOS have sensory and motor impairments, the scores achieved by the subjects
on the ASDS, the Sensory Profile, the BOT-2 and the SIPT were compared to established
norms. Based on the information provided in the procedural manuals for each of the
instruments, specific criteria was selected for each test to determine if the participants had
greater impairments than typically developing children. Frequencies of findings were
determined for the ASDS, the Sensory Profile, the BOT-2 and the SIPT, as well as for

Clinical Observations in order to identify the impairments most commonly reported and
identified for the children in the study.
To test the second and third hypotheses, which tested if children with AS and
PDD-NOS demonstrate improvements in sensory processing or motor skills following SI
intervention, scores for the ASDS, Sensory Profile, BOT-2 and the SIPT were analyzed
using repeated measures analysis of variance (ANOVA) in order to compare changes
within individual participant scores across test sessions. Additionally, individual Clinical
Observations item scores were added together in meaningful groups to form subcategory
total scores which were then compared using repeated measures ANOVA. A p value of
less than .05 was considered to be significant. Post hoc testing using pairwise
comparisons was performed to determine whether improvements were related to
intervention. If significant differences were evident from pretest to posttest, or from
midtest to posttest that were not present from pretest to midtest, the hypotheses that
sensory processing or motor skills will improve following SI therapy would be accepted.
The researcher conducted all of the testing during the pretest and midtest phases
of the study. In order to prevent researcher bias, a second examiner conducted the
posttesting for each child who completed the intervention phase. This second examiner
was trained and certified to administer the tests, and was blind to the purposes of the
study, the childrens test scores and the goals and activities performed during
intervention.
Interrater reliability testing was completed for one child during the post-testing
phase. The child was selected based on convenience with scheduling, and the posttesting
phase was selected for reliability testing in order to prevent bias by the second examiner.

The child completed the typical testing protocol for Clinical Observations, the BOT-2
and the SIPT. Both of the examiners observed and scored the tests simultaneously. Their
scores were then compared using the intraclass correlation coefficient (ICC) model three
for a single measurement (Portney & Watkins, 2000). An ICC of at least .75 is
considered good interrater reliability. Since the ASDS and the Sensory Profile are
parent-rated, and the PEGS is child-rated, it was not necessary to determine the rate of
agreement between the two examiners for these instruments.
Use of Data Collected
Data from this study provides preliminary, quantifiable information regarding the
sensory and motor impairments observed in children with AS and PDD-NOS. Analysis
provides initial information on the efficacy of SI therapy in a group of children with AS
and PDD-NOS as determined by results on the Sensory Profile, Clinical Observations,
the SIPT, and the BOT-2. The results from this study can be used to support a larger
clinical trial of the efficacy of SI treatment on the sensory and motor skills of children
with AS and PDD-NOS.

Results
Introduction
This chapter will present the results obtained from this study. The study had three
primary purposes. It was designed to quantitatively assess the presence of sensory
impairments and the presence of motor impairments in children with AS and PDD-NOS,
and to determine if the sensory and motor skills of these children improved following a
10-week intervention utilizing SI therapy. First, background information, information
regarding recruitment of the participants and demographic data and will be reported. The
second section will report the results obtained prior to intervention. This information will
include pretest data, which was obtained upon initial enrollment of the children in the
study, as well as midtest data, which was obtained five weeks later, just prior to the onset
of intervention. The next section in this chapter will describe the data obtained during
post-testing, which was conducted after the 10-week intervention phase. Finally, a
description of the interrater reliability between the researcher and the post-test examiner
will be provided.
Recruitment
Initial contact was made with the parents of 25 children. From this group, seven
families declined participation. Two primary reasons were given. Either families were
unable to commit to the time requirements, or they were looking for specific programs
such as day programs or social groups. Of the remaining 18, two children had no
diagnosis, and three children had diagnoses of autism, cerebral palsy or attention deficit
hyperactivity disorder that excluded them from the study. Three additional children were
already receiving therapy that provided sensory-based treatment, and one child was a

participant in a different study involving children with Aspergers Syndrome, making
these four children ineligible to participate in this research. The remaining nine children
were enrolled in the study. Six children completed all three testing phases of the study.
An initial criteria for inclusion in the study was for each child to have a known or
suspected diagnosis of AS. After several months of recruitment, it became apparent that
many children between five and nine years of age were either not given a specific
diagnosis, or were given a diagnosis of PDD-NOS. Several parents contacted the
researcher expressing interest in the study, but indicated that their child had a diagnosis
of PDD-NOS with characteristics of AS. Therefore, after approval from the Children and
Youth Institutional Review Board, the inclusion criteria for the study was broadened to
include both a diagnosis of AS and a diagnosis of PDD-NOS with symptoms of AS. In
either case, children who were accepted into the study were required to meet established
scoring criteria on the Sensory Profile and the Asperger Syndrome Diagnostic Scale, in
order to confirm the presence of sensory symptoms and symptoms of AS. All nine of the
initial participants met these requirements.
Demographics
Eight out of the nine participants originally recruited were male, and their ages
ranged from 58 to 111 months, with an average age of 81.9 months (6.8 years).
Participant diagnoses varied. Thirty-three percent of the children (3/9) had a diagnosis of
AS, while 55% (5/9) had a diagnosis of PDD-NOS with characteristics of AS. One child
was reported by a psychologist to have characteristics of AS, but had not received an
official diagnosis at the time of the study.

Services
Sixty-seven percent of the participants (6/9) were receiving occupational therapy
that did not utilize sensory based techniques. In most cases, children were receiving
occupational therapy for handwriting activities or muscle tone issues. With parental
permission, contact was made with the occupational therapist either directly or indirectly
through the parent, to confirm that the therapist was not using a sensory-based treatment
approach. One childs therapist reported use of suspended equipment and tactile
activities at the end of some sessions, as a reward to the child for good behavior and
agreed to avoid use of these activities during the study. Another child had not received
any therapy over the summer months just prior to the start of his enrollment in this study.
His mother requested a change in his Individualized Education Plan for the first part of
the school year, until his involvement in the study ended. One child was receiving
physical therapy at the time of the study, and seven out of nine of the children (77.8%)
were receiving speech therapy services.
Attrition
Over the course of the study, three participants withdrew from the study, resulting
in a total of six children who completed the study. One child withdrew prior to midtesting, due to the time commitment necessary. Another childs mother withdrew him
during mid-testing, as he was having an especially difficult time with the rigorous testing
protocol. A third child withdrew five weeks into the intervention phase because of
unresolved medical issues that were not related to the study, and because of time
commitment concerns. All six of the children who completed all three phases of the
study were male and they ranged in age from 58 to 101 months with a mean age of 79.7

months (6.6 years). Three of the children had a diagnosis of AS, two had a diagnosis of
PDD-NOS and one child had characteristics of AS. Five of the six children were
receiving occupational therapy, one child was receiving physical therapy and four
children were receiving speech therapy.
Pre-intervention findings
Pre-intervention data was collected in order to address the first study hypothesis
which was to determine if children with AS and PDD-NOS have sensory or motor
impairments. The following section describes the data obtained on the participants
before any intervention was provided. Information about the baseline sensory and motor
impairments that exist in children with AS and PDD-NOS is described.
All of the participants who were enrolled in the study underwent two phases of
testing prior to the intervention phase. Upon enrollment, pretesting was conducted to
obtain initial data. All nine participants completed this phase. Children then underwent a
five-week baseline phase, in which the child and his or her family were asked to maintain
all typical, daily activities and routines. After five weeks, participants returned for a
second phase of testing which is referred to as the midtest phase. This phase of testing
took place just prior to the onset of the intervention phase. One child withdrew during
this phase, and therefore the data from eight participants was included in the midtesting
data analyses.
The Asperger Syndrome Diagnostic Scale (ASDS). The ASDS was completed by
the parent of each child at pretesting and again at midtesting, which took place just prior
to intervention. The ASDS is used as a screening tool to determine the likelihood of
having a diagnosis of AS. It addresses several areas that are typically impaired in persons

with a diagnosis of AS. A higher score in an ASDS subtest is indicative of greater
impairment in that subcategory. The scores from each of the subtests are added together
and used to determine the Asperger Syndrome Quotient (ASQ). To be eligible for
enrollment in the study, the participants were required to obtain an ASQ value of at least
80, which indicates that the child has a possible diagnosis of AS. Quotient scores above
90 suggest a likely diagnosis of AS and correspond to a percentile rank of 21%. Scores
above 110 correspond to a percentile rank of greater than 77% and indicate that it is very
likely that the child has a diagnosis of AS. Therefore, a high percentile ranking suggests
more symptoms that are indicative of AS. Children whose scores were above the 50th
percentile were considered to have impairments that were greater than children who are
typically developing. At least half of the participants scored above the 50th percentile on
the Language, Social, Maladaptive Behavior and Cognitive subscales, and more than half
of the participants scored below the 50th percentile on the ASQ (See Figure 1). Even
though parents were unaware of the specific scoring criteria for inclusion, all participants
received ASQ scores above 80. Pretest and midtest ASQ scores for all children ranged
from 88 to 122, with a mean ASQ score for the two test phases of 106.3 (see Table 1).
120%
Percentage (%)
100%
80%
60%
Pretest
Midtest
40%
20%
SQ
Se
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or
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Subtest
Figure 1. Percentage of Participants Whose ASDS Scores Were Above the 50th
Percentile.

Table 1
Mean Scores and Percentage of Recruited Participants Scoring Above the Fiftieth
Percentile on the Asperger Syndrome Diagnostic Scale Indicating Impairments in the
Given Subcategory
Subtest
Mean
Pretest
Midtest
(N=17)
(N=9)
(N=8)
Pragmatics)
6.8
6 = 67%
4 = 50%
Social (Interactions with others)
9.1
5 = 56%
5 = 63%
behaviors)
8.2
8 = 89%
8 = 100%
Cognitive (Memory and thinking)
8.2
6 = 67%
6 = 75%
Sensorimotor (Sensory and motor skills)
3.6
6 = 67%
3 = 38%
106.3
7 = 78%
7 = 88%
Language (Expressive Language and
Maladaptive (Abnormal or immature
Asperger Syndrome Quotient (ASQ)
Note. Mean is calculated using pretest and midtest scores.

Sensory Profile. The Sensory Profile was given to the parents to identify areas of
sensory processing that they perceived to be affected in their child. This questionnaire
was completed by parents at the pretesting phase, and again at midtesting which occurred
five weeks after the pretest but prior to any intervention. Subtest scores are used to
identify if the child is typical, probably different from, or definitely different from other
children who are typically developing. Children who scored in the probable difference or
definite difference ranges were considered to have sensory processing impairments that

were greater than those of children who are typically developing. Parental responses on
the Sensory Profile suggested that every child in the study was perceived to have
impairments in multiple areas of sensory processing. Out of the 23 areas investigated by
the Sensory Profile, more than 50% of the parents perceived sensory processing
impairments in 21 of those areas including seven of the nine Sensory Profile Factors (see
Table 2) and all 14 of the Sensory Profile Sections (see Table 3). All of the parents rated
their children as being emotionally reactive and easily distracted. All of the parents also
reported their children as having atypical emotional responses, and rated their children as
being unable to modulate sensory input, which in turn, affected their emotional
responsivity levels. Additionally, all of the parents reported abnormal behavioral
outcomes associated with sensory processing. The Sensory Profile further categorizes a
childs performance as being definitely different from the normative data or probably
different from the normative data. Figures 1 and 2 identify the percentages of children
reported as being definitely different from typically developing children (see Figures 2
and 3).
Table 2
Percentage of Participants Scoring in the Probably Different or Definitely Different
Categories on Sensory Profile Factors Indicating Impaired Sensory Processing
Subtest
Sensory Seeking (actively seeks additional sensory input)
Pretest
Midtest
(N=9)
(N=8)
8 = 89%
8 = 100%
Emotionally Reactive (excessive emotional reaction to

sensory input)
9 = 100% 8 = 100%
Low Endurance/Tone (tires easily or shows signs of low tone)
6 = 75%a
5 = 63%
mouth)
6 = 67%
5 = 63%
Inattention/Distractibility (easily distracted or inattentive)
9 = 100% 8 = 100%
Oral Sensory Sensitivity (overly sensitive in and around the
Poor Registration (difficulty receiving and processing sensory

input)
8 = 89%
8 = 100%
Sensory Sensitivity (overly sensitive to sensory input)
3 = 33%
3 = 38%
Sedentary (often inactive)
4 = 44%
3 = 38%
6 = 67%
5 = 71%b
Fine Motor/Perceptual (detailed motor skills such as

handwriting)
a
Complete data available for eight participants due to a missing response. bComplete
data available for seven participants due to a missing response.

Table 3
Percentage of Participants Scoring in the Probably Different or Definitely Different
Categories Indicating Impaired Sensory Processing
Subtest
Pretest
Midtest
(N=9)
(N=8)
Auditory Processing (sound)
9 = 100%
7 = 88%
Visual Processing (vision)
7 = 78%
7 = 88%
Vestibular Processing (movement)
9 = 100%
7 = 88%
Touch Processing
9 = 100%
6 = 75%
experiences)
8 = 89%
7 = 88%
Oral Sensory Processing (mouth)
6 = 67%
6 = 75%
Sensory Processing Related to Endurance/Tone
6 = 75%a
5 = 63%
6 = 67%
6 = 75%
9 = 100%
6 = 75%
9 = 100%
8 = 100%
and Activity Level (use of vision in personal interactions)
9 = 100%
7 = 88%
Emotional/Social Responses (inappropriate behaviors)
9 = 100%
8 = 100%
Multisensory Processing (multiple, simultaneous sensory
Modulation Related to Body Position and Movement (levels

of fear with respect to movement of the body)
Modulation of Movement Affecting Activity Level
(frequency of movement)
Modulation of Sensory Input Affecting Emotional Responses
(personal hygiene and interactions with others)
Modulation of Visual Input Affecting Emotional Responses

Table 3 (continued). Percentage of Participants Scoring in the Probably Different or
Definitely Different Categories Indicating Impaired Sensory Processing
Subtest
Pretest
Midtest
(N=9)
(N=8)
Behavioral Outcomes of Sensory Processing (efficiency in

tasks such as writing and tolerance to change)
9 = 100% 7 = 100%b
Items Indicating Thresholds for Response (reactions to

smell, participation in play)
a
9 = 100% 8 = 100%
Complete data available for eight participants due to a missing response. bComplete data
available for seven participants due to a missing response.
nt
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120
100
80
60
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Factor Category
Figure 2. Percentage of Participants Rated as Having Definite Differences from the

Normative Sample on Sensory Profile Factors.
Midtest
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Figure 3. Percentage of Participants Rated as Having Definite Differences from the

Normative Sample on Sensory Profile Sections.

Perceived Efficacy and Goal Setting System (PEGS). Each child completed the
PEGS in order to obtain his or her personal perspective regarding his or her ability to
perform a variety of motor skills. The PEGS was administered to each child at pretest,
and again five weeks later at midtest, just prior to the start of intervention. Individual
item scores range from one which indicates very poor performance on a given item, to
four which suggests very good performance on an item. These individual scores are
summed to yield a total score. The highest possible total score on the PEGS is a 96,
which would indicate that the child rated himself or herself as very good
(corresponding with a score of four) on every item. Out of a possible 96 points, pretest
scores ranged from 59 to 95 and midtest scores ranged from 50 to 96. In order to obtain
these high total scores, children would have had to rate themselves as being good or very
good on most items. Generally speaking, the childrens individual total scores were not
similar between the two test phases.
Clinical Observations. Clinical observations, which were adapted from Fisher,
Murray and Bundy (1991) and from Ayres Clinical Observations (as cited in Shriber,
2004), were done on each child at pretest, and also at midtest just prior to the start of
intervention, in order to obtain additional information regarding the development and
maturity of his or her nervous system. These Clinical Observations were grouped
according to the type of skills that were assessed. Sensory modulation items assessed
very basic responses to sensory input, such as the ability to react appropriately to changes
in body position and sensory experiences, as well as moving on the floor. One hundred
percent of the participants were able to react appropriately to items involving changes in
body position and various sensory experiences, and most children (89% and 88% at

pretest and midtest, respectively) tolerated movement on the floor without difficulty. Just
over half of the participants (56% at pretest and 63% at midtest) reacted appropriately to
tactile input. Clinical Observations indicated that approximately 60% of the participants
had inappropriate levels of activity for the situation at both pretesting and midtesting.
Only 22% were able to maintain prone extension during pretesting and 13% of
participants were able to maintain prone extension during midtesting. Approximately
half of the participants were able to appropriately stabilize their bodies in a quadruped
position. The participants ability to maintain appropriate muscle tone in extended
positions ranged from 44% at pretest to 63% at midtest. Bilateral integration was
assessed using a variety of movement sequences and patterns. Most children showed a
hand preference and were able to cross the midline of their body. Approximately half of
the participants demonstrated signs of right-left confusion, and almost all (78% and 100%
at pretest and midtest, respectively) of the participants had difficulty with motor praxis
skills such as catching a bounced ball or hopping. With the exception of in-hand
manipulation, for which approximately 65% of the participants were successful, praxis
(motor planning) was an area of difficulty for the majority of participants. Finger to
thumb touching and supine flexion were especially difficult for these participants. The
percentage of children who were able to correctly touch each finger to his or her thumb
was 11% at pretest and 13% at midtest. In the pretesting phase, 44% of the children were
able to maintain supine flexion, however only 25% maintained this position during
midtesting. The percentage of children who demonstrated associated movements was
78% at pretest and 87% at midtest. At pretesting, 33% of the children were able to
accurately touch their finger to their nose and 38% of the participants were able to

perform this movement at midtesting. Approximately 33% of the participants were able
to perform slow ramp movements at pretesting, 63% of the participants successfully
performed slow ramp movements at midtesting. At pretesting, 44% of the participants
were successfully able to automatically protect themselves from falling forward,
backwards and sideways in long sitting, tall kneeling and standing. Seventy-five percent
of the participants demonstrated protective extension in these positions at midtesting.
While 67% and 63% of the participants were able to visual track objects at pre and
midtesting, respectively, only 44% of the children were able to converge and diverge
their eyes to follow an object at pretest. The ability to converge and diverge was reduced
to 38% at midtest. Just under 56% of the children were able to perform quick
localization movements with their eyes at pretest, and 63% were able to perform quick
localization movements at midtest. (see Figure 4).
120%
Percentage (%)
100%
80%
Pretest
60%
Midtest
40%
20%
os
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Clinical Observation Items
Figure 4. Percentage of Participants Impaired On Selected Clinical Observations

Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). The
BOT-2 was administered to obtain quantitative information about the participants
abilities to perform gross and fine motor skills. This test was given to the participants at
pretesting, and also at midtesting, which occurred just prior to the start of intervention.
Composite scores are obtained by summing the scores of different subtests within the
BOT-2, providing a broader picture of motor skill performance. On all of the composite
scores of the BOT-2 during pretest and midtest, the children demonstrated difficulties in
motor skill performance. Subtest and composite scores can be used to obtain percentile
ranks based on age and gender referenced norms. Scores that are equal to or below the
18th percentile are equivalent to one standard deviation below the mean. Therefore, a
percentile score of 18 was used to identify children whose impairments were greater than
typically developing children. More than half of the children in the study scored below
the normative values on the Fine Manual Control, Manual Coordination and Body
Coordination Composites (see Table 4).

Table 4
Percentage of Participants Whose Bruininks Oseretsky Test of Motor Proficiency
(BOT-2) Composite Scores Fell At or Below the Eighteenth Percentile Compared to
Normative Data Indicating Impaired Motor Skills
BOT-2 Composite Scores
Pretest
Midtest
(N=9)
(N=8)
5 = 56%
5 = 63%
Coordination)
6 = 67%
4 = 50%
Body Coordination (Bilateral Coordination and Balance)
8 = 89%
7 = 88%
4 = 44%
3 = 38%
Fine Manual Control (Fine Motor Precision and Fine

Motor Integration )
Manual Coordination (Manual Dexterity and Upper-Limb
Strength and Agility (Running Speed and Agility and

Strength)
Sensory Integration and Praxis Tests (SIPT). The SIPT was completed by each
participant in order to obtain quantitative data regarding his or her sensory skills. This
test utilizes a computer-based scoring system which provides subtest scores up to three
standard deviations above or below the mean. A score of one standard deviation below
the mean was used to identify an impairment that was greater than that of a typically
developing child. At both the pretest and the midtest phases of the study which were
completed prior to initiation of intervention, participants demonstrated scores below one
standard deviation from the mean on all 17 subtests of the SIPT. There was a wide
variability in the frequencies of children performing below one standard deviation on

each subtest. All of the children scored below one standard deviation from the mean on
the standing and walking balance subtest, at both the pretest and the mid-test phases of
the study. More than 50% of the children scored below one standard deviation from the
mean on either the pretest or the midtest for the following subtests: Location of Tactile
Stimulation, Praxis on Verbal Command, Design Copying, Postural Praxis, Oral Praxis,
and Graphesthesia (see Table 5).

Table 5
Percentage of Participants Scoring Below One Standard Deviation From the Mean on
the SIPT Subtests Based on a Normative Sample of Children
SIPT Subtest
Pretest
Midtest
(N=9)
(N=8)
Space Visualization
1 = 11%
2 = 29%
Figure Ground
1 = 11%
2 = 29%
Manual Form Perception
4 = 44%
1 = 14%
Kinesthesia
2 = 22%
5 = 71%
Finger Identification
4 = 44%
2 = 29%
Graphesthesia
4 = 44%
4 = 57%
Location of Tactile Stimuli
5 = 56%
3 = 43%
Praxis on Verbal Command
5 = 56%
3 = 43%
Design Copying
5 = 56%
2 = 29%
Constructional Praxis
3 = 33%
2 = 29%
Postural Praxis
6 = 67%
4 = 57%
Oral Praxis
7 = 78%
6 = 86%
Sequencing Praxis
4 = 44%
2 = 29%
Bilateral Motor Control
2 = 22%
1 = 17%
Standing Walking Balance
9 = 100%
7 = 100%
Motor Accuracy
4 = 44%
2 = 29%
Postrotary Nystagmus
3 = 33%
2 = 29%

Post-intervention findings:
This section will report the data obtained after ten weeks of SI therapy, during the
posttesting phase of the study. Since data analysis in this section compared posttesting
scores to those scores obtained during the pretesting and midtesting phases of the study,
these results provide information regarding the effectiveness of the intervention. Due to
the withdrawal from the study of three of the original participants, post intervention
testing was completed on six children.
Interrater Reliability.
The testing in this study was completed by two different examiners. The primary
researcher conducted the tests during the pretest phase and the midtest phase. The tests
during the posttest phase were administered by a second examiner who was blind to the
purposes of the study, the childrens test scores and the goals and activities performed
during intervention. An Intraclass Correlation Coefficient (3,1) was used to provide
information about the level of agreement between the two examiners on the performance
based tests, which included Clinical Observations, the BOT-2 and the SIPT.
On Clinical Observations, the examiners agreed on 22 out of 24 possible items,
demonstrating consistency with scoring. The interrater reliability for the raters was
ICC=.46 (p<.05), 95% CI (.07, .72). Since the data in Clinical Observations are
dichotomous, a Cohens Kappa was also obtained. The results from a kappa analysis
were Kappa = .45 (p<.05). The raters standard scores for the BOT-2 were also
compared. The raters scored exactly the same on one out of four possible standard
scores, and scored nearly the same on the remaining three. The interrater reliability for
the raters was ICC=.88 (p<.05), 95% CI (.01, .99). An ICC was also obtained for the

SIPT scores. The examiners agreed on 10 out of 17 possible scores. The interrater
reliability for the SIPT was ICC=.55 (p<.05), 95% CI (.11, .81).
The Asperger Syndrome Diagnostic Scale (ASDS). The ASDS provides
information regarding the presence of symptoms that are often present in a person who
has AS. A lower post-test score on the ASDS indicates that the child demonstrated fewer
AS characteristics following intervention. The mean ASQ score at posttest was 99.2.
This is a decrease, and therefore an improvement, from the mean pretest and midtest
score of 106.0 and 106.3, respectively. Analysis using Repeated Measures of ANOVA
indicated that scores showed a tendency to improve after intervention, particularly in the
area of Maladaptive behaviors. These changes however, were not significant (see Table
6).

Sensory Processing. Analysis using Repeated Measures of ANOVA was used to
compare Sensory Profile scores at each phase of the study. Sensory Profile results
indicated several improvements in the childrens ability to process sensory information
following SI therapy. Significant improvements (p<.05) were noted from midtest to
posttest in Sensory Seeking behaviors which decreased. Significant improvements were
also noted from midtest to posttest in Auditory Processing, Modulation of Movement
Affecting Activity Level and Modulation of Visual Input Affecting Emotional Responses
and Activity Level (p<.05). Several other areas approached significance. Areas
approaching significance in their improvement included Fine Motor and Perceptual skills
(p=.08), Multisensory Processing (p=.08), and Modulation Related to Body Position and
Movement (p=.08) (see Tables 7 and 8). Additionally, Touch Processing improved
significantly, however the improvement was noted across all phases of the study.

Sensory Integration and Praxis Test. Objective findings of a childs ability to process
sensory information were obtained using the SIPT. Analysis using Repeated Measures of
ANOVA was performed in order to identify any significant SIPT score differences after
intervention. Significant improvements were noted on four subtests which included:
Constructional Praxis, Postural Praxis, Oral Praxis and Standing and Walking Balance
(See Figure 5). Childrens performance significantly decreased following intervention on
the Bilateral Motor Control subtest (see Table 9).
Standard Deviations From the Mean
Pretest
Midtest
Posttest
-1
-2
-3
SIPT Subtests
Constr.
Praxis
Postural
Praxis
Oral
Praxis
Stand/Walk
Balance
Kinesthesia Graphesthesia
Figure 5. Mean Scores on Selected SIPT Items at Pretest, Midtest and Posttest

Motor Skill Performance
Bruininks Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). The
BOT-2 was conducted to assess the motor skills of the study participants. Repeated
Measures of ANOVA was used to analyze data from the BOT-2, in order to identify any
significant score differences following intervention. Several children showed
improvements on their BOT-2 scores after ten weeks of SI therapy. Significant
improvements were noted for the Balance subtest from pretest to posttest, and results for
the Running Speed and Agility subtest approached significance (see Table 10).

Clinical Observations. Each child performed a series of short tests known as
Clinical Observations, which are meant to provide the examiner with information
regarding the maturity and development of the childs nervous system. In an effort to
manage the number of items in Clinical Observations, related items were grouped
together into subcategories which were then analyzed using repeated measures ANOVA.
Praxia, which assesses a childs ability to motor plan through skills such as touching each
finger to the thumb, and alternating supination and pronation of the wrists, approached
significance (p=.05). Bilateral Integration also approached significance (p=.06), which
suggests that when using Clinical Observations as a measure, children also improved in
their ability to correctly use both sides of their body in the performance of a motor skill
(see Table 11).

Treatment Fidelity
On four random occasions, an outside examiner observed the treatment sessions
and also completed the Progress Note and Checklist. Results were compared. The
results from each of the four visits identified that the therapist and the outside examiner
agreed on all aspects of the checklist except for one item. The therapist and the outside
examiner did not agree on the length of time that the intervention was child directed.
Summary of Results
The participants in this study demonstrated impairments in sensory processing
and motor skills. In addition, behaviors such as inattention and abnormal emotional
responses to sensory experiences were identified. A ten-week intervention phase was
effective in improving some areas of sensory processing, some motor skills and some
behaviors (see Table 12). The results from this study provide preliminary evidence to
support the use of SI therapy in children with AS and PDD-NOS.

Table 12. Summary Table of Impairments and Areas of Improvement
Behaviors or Functions
Inattention/Distractibility
Impairments
Improvements
Prior to
Following
Intervention
Intervention
Instrumentation Used
ASDS, Sensory Profile
ASDS, Sensory Profile
Emotional/Social
Responses
ASDS, Sensory Profile,

Behaviors
Clinical Observations
Sensory Profile
SIPT, Sensory Profile
Input
Sensory Profile
Balance
SIPT, BOT-2
Sensory Seeking
Sensory Processing
Modulation of Sensory
SIPT, BOT-2, Clinical

Praxis
Observations
SIPT, BOT-2, Clinical
Coordination
Observations
Strength and Agility
BOT-2

Discussion
Introduction
This was an initial efficacy study which had three primary purposes. First, it was
intended to provide evidence regarding how children with AS and PDD-NOS process
sensory information. Its second purpose was to provide evidence regarding the level of
motor skill performance observed in this group. A third purpose was to determine if SI
therapy had an effect on improving any specific sensory and/or motor deficits that were
identified in this group of children. A one-group pre-test post-test design with a delayed
treatment approach was utilized to test the research hypotheses.
In this chapter, the results of the study will be discussed. It will begin with a
discussion of the relationships between the study results and the proposed hypotheses.
This will provide evidence as to the nature and severity of sensory and motor
impairments in children with AS and PDD-NOS. It will also provide evidence as to the
effectiveness of SI therapy on the sensory and motor skills of the study participants. The
second section will discuss the relationship of the results to the conceptual framework
which provided the basis for the study. Next, relationships between the findings of this
research study and the findings from previous, related research studies will be identified
and discussed. The fourth section will discuss additional findings which were not
included in the study hypotheses, but provide useful information regarding children with
ASDs and SI therapy. The strengths and limitations of the study design and data
collection methods will follow. Finally, implications for practice will be discussed, along
with recommendations for future research as it applies to children with AS and PDDNOS.

Relationship of the Results to the Stated Hypotheses
This study had three primary hypotheses. The hypotheses were (a) children with
AS and PDD-NOS will demonstrate sensory and motor impairments when compared to
normative samples, as identified by the Sensory Profile, the Sensory Integration and
Praxis Tests (SIPT) and the Bruininks-Oseretsky Test of Motor Proficiency, Second
Edition (BOT-2); (b) parents will report an improvement in the childrens sensory
modulation and integration, and the children will exhibit improved sensory processing
following SI therapy as demonstrated by scores on the Sensory Profile and the SIPT, and
(c) children will demonstrate improved motor performance following SI therapy as
demonstrated by higher scores on the BOT-2.
First, it was hypothesized that children with AS and PDD-NOS would
demonstrate sensory and motor impairments when compared to normative samples, as
identified on the Sensory Profile, SIPT and the BOT-2. To address this first hypothesis,
pretest and midtest scores on the Sensory Profile, the SIPT and the BOT-2, were
compared to established age and gender referenced norms.
In order to assess the sensory processing abilities of children with AS and PDDNOS, the parents of the participants were asked to complete the Sensory Profile at the
pretesting and the midtesting phases of the study. The Sensory Profile is a parent-rated
questionnaire which provides a parents perspective as to the nature and severity of his or
her childs ability to process sensory information and use it in daily activities.
Participants whose scores were classified as probably different or definitely different
were on the Sensory Profile were considered to have greater impairments than children
who are typically developing. The participants in this study were identified as being

typically different or definitely different from the normative sample on all 23 subtests of
the Sensory Profile. More than half of the parents reported impairments that were greater
than typically developing children in 21 of those areas. Subjectively, this supports the
hypothesis that children with AS or PDD-NOS have sensory impairments as compared to
normative samples on the Sensory Profile. On both pretest and midtest, which occurred
prior to the start of the intervention phase, 100% of the participants were rated by their
parents to have difficulty in several areas of sensory processing. Some of the most
common sensory impairments in this cohort included Emotional Reactivity, Inattention or
Distractibility, Modulation of Sensory Input Affecting Emotional Responses, Emotional
or Social Responses and Behavioral Outcomes of Sensory Processing. Emotional
reactivity can be described as having an emotional reaction to sensory input that is more
than would typically be expected. A child who is considered emotionally reactive may
be overly sensitive to criticism, may cry easily or may offer more than typical affection
towards others. A poor score on Inattention and Distractibility would be identified in
children who tend to be easily distracted or inattentive. Emotional and Social responses
describe inappropriate or immature behaviors, such as throwing temper tantrums, having
signs of low self esteem or having excessive fears that interfere with daily routines.
Behavioral Outcomes of Sensory Processing are those daily activities that require the
ability to process sensory information, such as writing, performing tasks efficiently and
tolerating changes in routine. It appears from the results that the sensory processing
impairments identified in the children in this study frequently affect their behavior and
their ability to control their emotions. Less common parental concerns, where fewer than
50% of the children were rated as being probably different or definitely different include

Sensory Sensitivity, which describes a child who, for example, is overly fearful of
movements and heights, and Sedentary behaviors which describe preferences toward
quiet activities or activities that do not require much movement.
In addition to the information that was obtained using the Sensory Profile, The
SIPT was also used at the pretest phase and at midtesting, just prior to intervention, in
order to objectively assess the sensory processing abilities of children with AS and PDDNOS. The SIPT is a performance-based test which can provide evidence regarding a
childs ability to process sensory information and plan motor actions. Scores are
computer generated, and output is in the form of standard deviations. Children whose
scores fell below one standard deviation from the mean were considered to have
impairments greater than children who are typically developing. The participants in this
study fell below one standard deviation from the mean on each of the 17 subtests of the
SIPT. All of the children were considered to have greater than typical impairments on
the Standing and Walking subtest, which assesses a childs ability to maintain his or her
balance while performing standing and walking tasks with his or her eyes open or closed.
In addition, more than half of the participants scored below one standard deviation on
either the pretest or the midtest on the following subtests: Praxis on Verbal Command,
Postural Praxis, Oral Praxis, Design Copying, Location of Tactile Stimulation and
Graphesthesia. The Praxis on Verbal Command subtest requires a child to position
himself or herself correctly following only verbal directions. Postural Praxis on the other
hand, requires the child to mirror the body positions made by the examiner when no
verbal cues are given. Oral praxis is similar, however the positions and tasks are limited
to the mouth and tongue. Design Copying involves copying line drawings from a printed

image. Location of Tactile Stimulation requires a child to identify which of his or her
fingers were lightly touched when vision was occluded. Finally, on the Graphesthesia
subtest, the examiner draws a simple set of lines on the back of the childs hand when
vision is occluded, and the child is asked to repeat the drawing with his or her eyes open.
A theme that emerged from these findings was that the children in this study experienced
difficulty with motor planning tasks regardless of the visual or verbal input he or she
received. This was true on more isolated motor tasks such as drawing or oral motor
activities, as well as on whole body tasks such as imitation, standing and walking. In
addition to supporting the parent perceptions on the Sensory Profile, the results from the
SIPT provided quantitative data to support the hypothesis that children with AS and
PDD-NOS have sensory impairments that are greater than typically developing children.
Based on the Sensory Profile and the SIPT, the participants in this study were
impaired in many areas of sensory processing and integration, as compared to normative
data for each of the tests. The hypothesis that the children would demonstrate
impairments is accepted for impairments in Emotional Reactivity, Inattention or
Distractibility, Modulation of Sensory Input Affecting Emotional Responses, Emotional
or Social Responses, Behavioral Outcomes of Sensory Processing, Sensory Sensitivity
and Sedentary behaviors as measured by the Sensory Profile. The hypothesis can also be
accepted for impairments in Standing and Walking Balance, Praxis on Verbal Command,
Postural Praxis, Oral Praxis, Design Copying, Location of Tactile Stimulation and
Graphesthesia as measured by the SIPT. It is important to note that although the
impairments that are listed do not include every area of sensory processing that was

evaluated during the pretesting and midtesting, every area of sensory processing and
integration was impaired in at least one study participant.
Another purpose of the current study was to examine the motor skills of children
with AS and PDD-NOS. In order to identify if motor skill impairments existed in this
group of children, the BOT-2 was administered during the pretest and midtest phases of
the study, prior to the intervention phase. The BOT-2 is a performance-based test which
provides objective information regarding a childs ability to perform gross and fine motor
skills. The scores achieved by the subjects on the BOT-2 were compared to established
age and gender referenced norms. If subjects fell at or below the 18th percentile they
were considered to have greater impairments than children who are typically developing.
Subtest scores are combined to form composite scores in four key areas of motor skill
performance: Fine Manual Control, Manual Coordination, Body Coordination and
Strength and Agility. On all of the composite scores obtained during pretest and midtest,
more than half of the participants were found to score below the 18th percentile for their
age and gender. As a group, the children had the most difficulty with the Manual
Coordination and Body Coordination composites. The Manual Coordination composite
examines a childs manual dexterity in tasks such as sorting cards, stringing blocks and
placing pegs in a pegboard. It also assesses upper-limb coordination through a series of
ball skills using a tennis ball. The Body Coordination composite assesses bilateral
coordination including hand tasks, hand and feet tasks, and whole body skills, as well as
standing balance skills on the floor and on a narrow balance beam. These findings
suggest that perhaps the childrens greatest difficulties with respect to their motor skills is
in their inability to coordinate their bodies to perform fine motor and gross motor

movements. The data obtained provides quantifiable evidence to support the hypothesis
that the children with AS and PDD-NOS in this study had motor impairments as
compared to children in the normative sample of the BOT-2 who were typically
developing. Therefore, the hypothesis is accepted for impairments in Manual
Coordination and Body Coordination. The children were also impaired in other areas of
motor skill performance, including Fine Manual Control and Strength and Agility,
although these impairments were less frequent.
In addition to the data obtained from standardized testing using the Sensory
Profile, the SIPT and the BOT-2, Clinical Observations, which are used as a supplement
to standardized testing, were also completed on the participants at pretesting, midtesting
and posttesting. Through a series of short and simple tasks, the examiner is able to gain
additional information regarding the development and maturity of the childs nervous
system. The Clinical Observations in this study were grouped according to the type of
skills that were assessed. Frequencies of findings were determined for each subtest of the
Clinical Observations in order to identify the impairments most commonly reported for
the children in the study. In the area of sensory modulation, children had the greatest
difficulty maintaining appropriate levels of activity for the testing situation. High levels
of energy were observed in each of these cases. More than half of the children were
found to have difficulty reacting appropriately to tactile stimuli. In other areas of basic
sensory modulation, such as the ability to tolerate changes in body position and
movement, most of the children performed in a typical manner. These findings were
consistent with parent reports on the Sensory Profile, which identified a general ability of

the children to tolerate movement and changes in body position, but difficulties with
attention and distractibility.
Controlling their posture was also relatively difficult for the participants in this
study. A majority of the participants had difficulty maintaining a prone extension posture
at both pretest and midtest, and only about half of the children were able to stabilize their
bodies in a quadruped position. The ability of the children to maintain appropriate
muscle tone varied between pretest and midtest, however it should be noted that at least
40% of the participants showed signs of low muscle tone at both the pretest and midtest
phases. Parents also reported low endurance and tone on the Sensory Profile.
Another area that was assessed through Clinical Observations was Bilateral
Integration. It was assessed using a series of activities that progressed in difficulty. In
general, most children showed a hand preference and were able to cross the midline of
their body. These skills are expected in children who are five to nine years of age.
Typically, children in this age group are able to differentiate between their right and left
sides. Approximately half of the participants in the study showed signs of right-left
confusion. The final observation of bilateral integration involved higher level skills such
as catching a bounced ball, hopping and jumping. In this area, a majority of the
participants demonstrated signs of difficulty. These findings of poor bilateral integration
with higher level skills were confirmed by the results obtained on the subtests of both the
SIPT and the BOT-2 that measured similar skills.
Clinical Observations also provided information about each childs ability to plan
motor actions. The results from Clinical Observations indicated that praxis was another
area of difficulty for the children in this study. While these results may have been related

in part to the childrens low muscle tone, no more than half of the children were able to
assume and maintain a supine flexion position. Although most children were able to
manipulate a small object in their hands, an overwhelming majority of the participants
could not demonstrate smooth finger to thumb opposition without visual assistance. In
addition, no more than half of the children were able to coordinate their hands to rapidly
alternate moving from supination to pronation at either the pretest or the midtest.
Some of the Clinical Observations are designed to assess the maturity of the
central nervous system. These observations, which are expected to be seen in children
five to nine years of age, include touching the finger to the nose with the eyes closed,
performing slow upper extremity (ramp) movements, and automatically protecting
oneself from falling. At both pretest and midtest, more than half of the children had
difficulty touching their finger to their nose with their eyes closed. On the ramp
movement subtest which assesses bilateral integration, praxis and proprioceptive
awareness, the frequencies of children who were able to perform this task varied greatly
between pretest and midtest. Responses on the protective reactions subtest also varied.
On midtest, more than half of the children were successfully able to perform both of these
skills. Associated reactions also fall into the category of Clinical Observations, but they
are expected to be integrated, and therefore not seen during typical activities performed
by children in this age group. More than half of the participants demonstrated associated
movements or fixing patterns during typical activities. Since the ability to perform
activities correctly, without associated movements relies on a mature central nervous
system to process and integrate information from a variety of sensory and motor sources,
the findings of associated movement reactions suggest the possibility of a lack of

maturity within the central nervous system. Caution should be used when interpreting
this however, since formal neurologic testing would be required for confirmation.
Finally, Clinical Observations provide information about a childs ability to move
his or her eyes in a smooth and controlled pattern. Most children in this study were able
to track an object and perform quick localization skills with their eyes. An area of
difficulty for the participants however was in eye convergence and divergence. More
than half of the participants were unable to perform this skill. It should also be noted that
in general, children required the use of their eyes to guide them in the performance of
various tasks. When vision was occluded in activities such as finger to thumb touching,
identifying shapes through touch, and balancing skills, several of the children were either
unable to perform the task, or became anxious or frustrated. The childrens reliance on
vision was noted during all three phases of testing, however their tolerance for
performing skills without the use of their vision seemed to improve following
intervention.
Although Clinical Observations are not standardized, they are a useful supplement
to standardized testing. Since each Clinical Observation is performed to assess a separate
item, it is difficult to make specific conclusions from the findings. Clinical Observations
are said to provide additional information to the therapist regarding nervous system
maturity (Fisher et al., 1991). Overall, it appears that children with AS and PDD-NOS
are able to perform basic skills, such as tolerating simple touch and movement, moving
the eyes for basic tracking, and crossing the midline of the body. This suggests nervous
system maturity at a basic level. As the skills become more challenging however, such as

is needed for prone extension, hopping and finger to thumb touching, performance
declined noticeably, perhaps suggesting signs of an immature nervous system.
In addition to assessing the sensory and motor skills of children with AS and
PDD-NOS, this study examined the effectiveness of SI therapy. The second hypothesis
was that parents would report improvements in their childrens sensory modulation and
integration and the children with AS and PDD-NOS would show improvements in
sensory processing skills following ten weeks of SI therapy. To address this hypothesis,
scores for the Sensory Profile and the SIPT were analyzed using repeated measures
analysis of variance (ANOVA) in order to compare changes within individual participant
scores. Post hoc analysis was completed for those subtests that showed significant
changes in order to identify if the significant improvements were evident following
intervention. If significant differences were evident in the post-test scores that were not
evident between the pre- and mid-tests, the hypothesis that sensory processing would
improve following SI therapy would be accepted.
Nine Sensory Profile factors were analyzed to determine if significant differences
were evident following SI therapy. The Sensory Seeking factor, which describes
childrens responses to sensory input, improved significantly (p<.05) following
intervention. Post hoc analysis identified significant (p<.05) changes between pretest and
posttest, and also between midtest and posttest. This means that parents reported less
frequent attempts by their child to seek out and provide himself or herself with additional
sensory input.
Three sections of the Sensory Profile, which examine how information is
processed by the specific senses, also showed significant improvement following

intervention. These include Auditory Processing, Modulation of Movement Affecting
Activity Level and Modulation of Visual Input Affecting Emotional Responses and
Activity Level (p<.05). Post hoc analysis revealed significant improvements in Auditory
Processing from pretest to posttest (p<.05). Modulation of Visual Input Affecting
Emotional Responses and Activity Level assesses a childs ability to use visual input
appropriately during personal interactions. Examples include the ability to make eye
contact, and the ability to recognize but not visually obsess about the actions of others. In
this subtest, children demonstrated significant improvement from pretest to posttest
(p<.05). Significant differences were also identified for Modulation of Movement
Affecting Activity Level which assesses whether a child is constantly on the move or is
more sedentary. For this subtest however, when post hoc analyses were completed, the
results did not indicate significant differences.
Repeated measures ANOVA approached significance on four other subtests of the
Sensory Profile. These tests included Fine Motor and Perceptual Skills (p=.08),
Multisensory Processing (p=.08) and Modulation Related to Body Position and
Movement (p=.08). An improvement in Fine Motor and Perceptual skills reflects
improvements in a childs ability to perform fine motor skills such as writing and
drawing. An improvement in Multisensory Processing points to improvements in a
childs ability to process information that is entering the body from more than one
sensory system. Finally, the results on the Modulation Related to Body Position and
Movement subtest suggest that following the 10-week intervention phase, the children
were better able to control the amount of movement in which they engaged.

While the Sensory Profile was useful in obtaining the parents perceptions of their
childrens abilities to process sensory information during the various phases of the study,
in order to obtain objective data on the childrens sensory processing abilities, the SIPT
was used. These results indicated that following intervention, significant improvements
were noted on four out of seventeen of the subtests of the SIPT. Participants showed
significant improvements in Constructional Praxis, Postural Praxis, Oral Praxis and
Standing and Walking Balance (p<.05). These findings suggest improvements in three
areas of motor planning which include planning required to construct complex structures
out of blocks, planning required to imitate body positions, and planning required to
imitate mouth and tongue movements. The ability to maintain balance and coordinate the
body during standing and walking tasks also improved significantly following SI therapy.
It should be noted that the areas of praxis and standing and walking balance were the
same areas found to be most impaired in the children prior to intervention. In each of
these subtests, changes were significant from pretest to posttest and from midtest to
posttest, suggesting that the improvements were related to the intervention. Additionally,
Location of Tactile Stimuli, which assesses a childs ability to identify which fingers
were touched when vision was occluded, approached significance (p=.06). This was also
identified as an area of difficulty for more than half of the participants prior to
intervention.
The results of improved praxis and balance are of great interest. In her discussion
of praxis, Ayres (1972) states that the effectiveness of a childs action upon the
environment will reflect accuracy of sensory input (Ayres, 1972, p. 127). Additionally,
Ayres states that higher level sensory processing such as praxis occurs only after more

basic sensory processing occurs (Ayres, 1972). Based on the results from the SIPT, the
children showed the greatest improvements in areas of motor planning even though taskspecific motor planning skills were not addressed in intervention. By providing
opportunities for sensory processing within each of the sensory systems, perhaps the
treatments that were provided during the intervention phase allowed the children
opportunities to receive adequate sensory feedback in order for more refined, and
ultimately higher level sensory processing, such as praxis to occur.
Since parents reported significant improvements following SI therapy, and the
objective findings from the SIPT identified some significant improvements following SI
therapy, the hypothesis that the sensory processing abilities of children with AS or PDDNOS will improve following SI therapy is accepted for improvements in Sensory
Seeking, Auditory Processing, Modulation of Movement Affecting Activity Level and
Modulation of Visual Input Affecting Emotional Responses and Activity Level which
were assessed with the Sensory Profile. It is also accepted for improvements in
Constructional Praxis, Postural Praxis, Oral Praxis and Standing and Walking Balance as
measured by the SIPT. Significant improvements were not identified for Emotional
Reactivity, Low Endurance and Tone, Oral Sensory Sensitivity,
Inattention/Distractibility, Poor Registration, Sensory Sensitivity, Sedentary Behaviors,
and Fine Motor/Perception which were measured by the Sensory Profile. Other areas that
did not show significant improvements following SI therapy that were measured by the
Sensory Profile were Visual, Vestibular, Touch, Multisensory and Oral Sensory
Processing, Sensory Processing Related to Endurance/Tone, Modulation Related to Body
Position and Movement, Modulation of Sensory Input Affecting Emotional Responses,

Emotional and Social Responses, Behavioral Outcomes of sensory processing, and Items
Indicating Thresholds for Response. Improvements were identified but were not
significant for several other subtests of the Sensory Profile. The SIPT subtests that did
not demonstrate significant changes following intervention were Space Visualization,
Figure Ground, Manual Form Perception, Kinesthesia, Graphesthesia, Location of Tactile
Stimulation, Praxis on Verbal Command, Design Copying, Sequencing Praxis and
Bilateral Motor Coordination. Therefore, the hypothesis that the participants would show
improvements in sensory processing following SI therapy is rejected for these areas.
The third and final hypothesis was that children would demonstrate improved
motor performance following SI therapy as demonstrated by higher scores on the BOT-2.
In order to address this hypothesis, posttest scores from the BOT-2 were compared to
pretest and midtest scores using repeated measures ANOVA. The results indicated that
the participants demonstrated significant improvements (p<.05) on the Balance subtest,
with significant changes occurring from pretest to posttest. Additionally, significance
was approached on the Running Speed and Agility subtest (p=.07), which assessed a
childs running speed and ability to perform repetitive stepping and hopping skills. This
means that children demonstrated more success in balancing and coordinating their
bodies to perform complex motor skills following the intervention. Composite scores
were not significantly impacted following intervention. Therefore, since significant or
nearly significant improvements were noted for two subtests of the BOT-2 during posttest
that were not present for pretest or midtest, the third hypothesis is accepted for the
specific areas of balance and running speed and agility. Therefore, it appears that certain
areas of motor function can be improved following SI therapy. It should also be noted

that the participants did not demonstrate significant improvements in Fine Motor
Precision, Fine Motor Integration, Manual Dexterity, Upper-Limb Coordination, Bilateral
Coordination or Strength, which may suggest that some types of motor skills, such as
balance, running and agility may respond better to ten weeks of SI therapy than other
types of motor skills.
Relationship of the Study to the Conceptual Framework
This study was based on two primary concepts. First, it was based on the belief
that the sensory and motor symptoms exhibited by children with AS and PDD-NOS are
the result of abnormalities within the nervous system. It was also based on the theory of
Sensory Integration which suggests that the body must accurately receive and process
sensory input from the environment in order for a person to respond with appropriate and
goal-directed behaviors. This section will investigate the results of the study protocol as
they relate to the conceptual frameworks which served as the foundations for this study.
The first concept to guide the development of this study was that there is a
neuropathophysiological cause to the disorders addressed in this study. Previous research
has reported neural connection abnormalities within the central nervous systems of
children with AS and PDDs in general (Huebner, 1992). These neural connection
abnormalities correspond to the sensory and motor impairments which have previously
been identified in persons with AS and PDDs. It is important to note that this study was
not intended to identify the specific neurological abnormalities within the brain. Internal
abnormalities within the central nervous system however, have been linked to physical
impairments that are observed in children with AS and PDD-NOS (Huebner, 1992).
Therefore, it is worthwhile to review the neurological structures that have been

implicated in AS and PDD-NOS and where appropriate, offer support, albeit indirect, to
the current base of knowledge.
It appeared to be evident through testing and observation that the participants in
this study experienced a variety of sensory and motor impairments. To summarize, their
greatest areas of difficulty appeared to be inattention and distractibility, impaired balance
and praxis and poor bilateral coordination. In addition, the children experienced sensory
processing impairments that seemed to affect their ability to react in a socially and
emotionally appropriate manner within their environment. Several structures within the
brain have been identified as having an influence over these sensory and motor processes.
The brainstem for example, is involved in attention, balance, and coordination (Huebner,
1992). The basal ganglia and the cerebellum are both involved in the planning and
production of motor actions. In addition to its involvement in praxis, the cerebellum is
involved in balance and coordination (Kandel et al., 1991; Leonard, 1998; Zigmond et al.,
1999). The highest functioning portion of the brain, the cerebrum, is involved in motor
planning and execution, bilateral motor coordination, muscle control, posture and
voluntary movement, (Kandel et al., 1991; Leonard, 1998; Zigmond et al., 1999) all of
which relate to impairments that were identified in the participants of the current study.
In addition, metabolic differences within the cerebrum (Murphy et al., 2002) have been
linked to the same types of social impairments and obsessive or ritualistic behaviors that
were reported and observed in the participants in this study. The functions of the parietal
lobe, which include selective attention, and possibly, bilateral coordination, vision and
spatial awareness (Huebner, 1992) also relate to the results of the current study, which
suggested that the participants had impaired attention, bilateral coordination and spatial

awareness, as well as a possible overreliance on vision. The amygdala within the limbic
system is involved in emotional behaviors and it is also involved in learning that requires
multisensory processing. It is also important for attending to relevant stimuli (McAlonan
et al., 2002). While it was not possible, nor was it within the realm of this study to
determine if the participants had abnormalities within the structures of their brains, the
fact that they displayed some significant impairments in sensory and motor skills linked
to these neurological structures may offer some support for the possibility of a
neurological basis for the sensory and motor impairments that are seen in children with
AS and PDD-NOS.
Previous research on the nervous systems of persons with ASDs has identified
several areas that may be implicated. One of the findings of this study was that the
children had impairments in balance, coordination and motor planning, as well as rigid
and emotional behaviors and difficulties with attention. Three structures within the brain
have been indicated to control this unique combination of both motor performance and
behaviors and attention. These include the brainstem, the cerebrum and the parietal lobe.
The impairments observed in the study participants seem to have the strongest
connections to two of these structures. As has been suggested in previous literature
(Bailey et al., 1998; Palmen et al., 2004) the brainstem, with its extensive connections to
and from many of the structures within the brain may not function effectively in children
with AS and PDD-NOS. Therefore, if the neurological messages to and from the
brainstem are not being received and sent correctly, impairments such as decreased
attention, poor balance and incoordination can result. The participants in this study
demonstrated impairments in all three of these areas associated with brainstem function.

The children in this study also appeared to have difficulty with skills that involved
higher-level sensory processing and motor planning. Examples of these skills include
imitation skills, balance skills, hopping and nonreciprocal movements. The cerebrum
which controls these higher level functions may also therefore have an impact on the
deficits observed in the participants. Dysfunction at this level of the brain may account
for the poor motor planning, and impaired bilateral motor coordination that was observed
in the participants. In addition the social impairments and rigid behaviors that were
reported and observed in the participants of this study may be the result of abnormalities
within the cerebrum.
Other neurological researchers have suggested that children with PDDs have
impairments in multiple neurological areas, and that the connections between different
areas of the CNS are most likely impaired (Coleman & Betancur, 2005; Just et al., 2004;
Sears et al., 1999). Although every child in this study demonstrated signs of sensory and
motor impairments, and some similarities were identified, the nature and severity of the
sensory and motor impairments differed between the children. This supports the idea that
their impairments may be due to abnormal connections between several neurological
areas, rather than an abnormality in one specific area. Since SI therapy is intended to
improve neural connections, the findings of some improved sensory and motor skills
following SI intervention also help to offer some support for the concept that providing
opportunities for the nervous system to refine its neural connections may result in
improved function.
In addition to associating the neurological structures of the brains of children with
ASDs to how they function, this study was also based on the theory of Sensory

Integration, which provides a framework for understanding sensory processing
dysfunction and the SI treatment approach. According to SI theory, all aspects of the
nervous system must work together to register and process sensory information in order
for the individual to produce appropriate motor and behavioral responses within his or
her environment (Ayres, 1989; Linderman & Stewart, 1999). Based on this theory, the
sensory processing impairments identified in the participants in this study may have
contributed to the childrens difficulties in behaving appropriately and producing ageappropriate movements.
The process of sensory integration involves several steps. First, the body must
recognize that a stimulus occurred. Next, the body must attend to and interpret the
stimulus. It can then organize and execute a response to the stimulus (Williamson et al.,
2000). When a child is successful in sensory processing, and he or she is able to regulate
the sensory information that is entering the system, an appropriate and graded response
should occur (McIntosh et al., 1999). The process of SI also involves several sensory
systems. It is through the interaction of the three primary sensory systems, which include
the tactile, vestibular and proprioceptive systems, that a childs body scheme and praxis
develop (Brasic-Royeen & Lane, 1991). This internal map of the body, and the ability to
plan motor actions are a requirement for efficient performance of motor skills.
Individually, the children in this study demonstrated impairments in some or all three of
the primary sensory systems through the scores they obtained on the Sensory Profile,
Clinical Observations, and the SIPT. Based on their scores on the SIPT and the BOT-2,
the children also demonstrated difficulty with performing appropriate and graded
responses to a given stimulus. The findings of poor praxis, and difficulty producing

appropriate and graded movements, are the physical manifestations that suggest that the
nervous system may be struggling to make the appropriate connections at one or more
points along the SI pathways. The impairments that were identified in both the sensory
and motor skills of the study participants lend support to the idea that a childs ability to
process sensory information can affect his or her ability to perform motor tasks.
Just as impairments in sensory processing can affect the performance of motor
skills, Laurent and Rubin (2004) described the emotional frustration that accompanies
sensory dysfunction, which occurs as a result of the childs inability to appropriately
interact with his or her environment and with others (Laurent & Rubin, 2004). These
emotional frustrations were noted during the testing sessions, as the tasks involved in the
testing became more difficult. Emotional frustrations were also reported by the parents.
Other theories that have been proposed also provide a conceptual basis for the
current study. For example Bernstein (as cited in Thelen, 1995) states that movement
requires the nervous system to adequately adapt to changes within the environment, to
changes in body properties and to task demands. This may explain why the children in
this study were often able to perform basic skills, but demonstrated signs of increased
frustration and poor performance when the skill level was increased. The Theory of
Neuronal Group Selection (TNGS) suggests that every action is an opportunity for the
nervous system to reorganize and improve its efficiency (Hadders-Algra, 2000; Thelen,
1995). Similarly, the dynamic systems approach supports the idea that the entire system
will self-organize in order to achieve stability (vonHofsten, 1989). Initially, at pretest
and at midtest which occurred just prior to the 10 week intervention, the children were
often inefficient in skills involving motor planning, balance and bilateral coordination.

Using the ideas suggested by Bernstein, the TNGS and the dynamic systems approach as
frameworks, one could suggest that the childrens nervous systems were having difficulty
with the process of neural reorganization and refinement. By allowing the children to
guide their own participation in sensory-based activities within a safe and nonthreatening
environment during the study, an opportunity for their nervous systems to potentially
form more efficient neural pathways, which ultimately resulted in improvements in their
sensory and motor skills seemed to occur. It should be noted that the intervention phase
of this study did not involve the repetitive performance of skills which were examined
during testing. In fact, tasks which were similar to the testing situation were specifically
avoided in the intervention phase, so as not to cause a training effect.
Within the realm of SI, how a child processes various forms of sensory input has
also been described. In the specific area of sensory processing, four categories of
processing have been identified. Together, these categories create a spectrum of sensory
thresholds regarding how a person responds to sensory input from the environment.
These thresholds include low registration, sensory seeking, sensory sensitivity and
sensation avoiding. With low registration, the individual requires more sensory input
than is being provided before he or she can recognize its presence. A child who is
sensation seeking, actively attempts to provide him or herself with additional sensory
experiences in order to recognize and feel the input. A child who has sensory sensitivity
becomes easily distracted or overwhelmed by sensory input, and if the child is sensation
avoiding, he or she will set rigid limits on the amount of sensory input that is received
(Dunn, Saiter et al., 2002). These categories of sensory processing have been supported
by physiologic evidence. For example, in a study by Davies and Gavin (2007) which

compared electroencephalography (EEG) and event-related potentials (ERP) in children
with sensory processing disorders and children who were typically developing, the EEG
and ERP results suggested that participants with sensory processing disorders had
difficulty ignoring irrelevant sensory information. They were also less able to organize
incoming sensory information (Davies & Gavin, 2007). Additionally, McIntosh, Miller
and Hagerman (1999), found that children who had sensory modulation disorders
demonstrated either no skin conductance electrodermal response or more frequent
responses and larger magnitudes compared to subjects who were healthy controls.
According to the authors, this suggests either underresponsive or overreactive responses
to sensory stimuli in children with sensory modulation disorder. Additionally, the
participants with sensory modulation disorder demonstrated slower habituation rates to
sensory stimuli and their parents reported more behavioral abnormalities on the Short
Sensory Profile (McIntosh et al., 1999).
The results of the current study suggest that the children who participated can be
described as falling into many or all of the four categories of sensory processing. This
seemed to depend on the situation and the system that received the input. One of the
focuses of the intervention provided in this study was to improve the childrens abilities
to modulate the sensory input from one or a variety of sources, in order to produce a more
appropriate adaptive response. This was accomplished by providing opportunities for
their nervous systems to be able to recognize appropriate incoming stimuli and ignore
irrelevant sensory input. As treatment progressed, the children in this study appeared to
improve in their ability to tolerate and process sensory input from a variety of sources.
They were also able to tolerate a wider variety of intensities of sensory input while

maintaining an active and alert state and engaging in purposeful, goal-directed play.
These findings support the use of SI therapy for children with AS and PDD-NOS. It
seems that the active and frequent participation in sensory-rich experiences allowed the
childrens nervous systems to recognize that sensory input was entering the system and
that it was able to refine its neural connections through active participation and repetition
so that eventually, a more appropriate adaptive response was elicited. With each
successful interaction with the environment that can occur during SI intervention, the
theory suggests that the child will become more comfortable with the sensory experience
and more willing to participate in future interactions with his or her environment. This
appeared to be the case during the posttesting phase of the study, where some participants
demonstrated a new willingness to try the activities, even if they were not yet capable of
performing them correctly.
As has been indicated, the methodology utilized in this study was based primarily
on the SI theory. In accordance with this theory, the study attempted to provide classic SI
therapy, which was based on individual needs as determined throughout the intervention
process. Using a structured environment which was created by the therapist, the children
in this study participated in child-directed, one-on-one therapy sessions that lasted 45-60
minutes. Two sessions were completed each week for a period of 10 weeks. All six
children who completed the post-testing phase participated in at least 17 out of 20
possible sessions. Every effort was made to allow for the child to direct the therapy
session. In some cases however, particularly in the early treatment sessions, more
direction from the therapist was necessary. The children were offered choices to select
from available activities rather than allowing for free reign which may have resulted in

a non-productive session. More specifically, these choices were offered due to the
severity of the childrens sensory processing impairments, their inability to independently
select developmentally appropriate activities, or their desire to engage in activities that
were either too easy or overstimulating for their systems. Equipment was offered in such
a way that over time, each child gained more and more control over what activities he or
she would do. The child was also responsible for selecting the theme for the task, thus
giving additional meaning to the activity. By providing a sensory rich environment and
encouraging active, meaningful participation at a level that was neither too easy, nor too
difficult, the participants in the study had an opportunity to create new and more
appropriate responses to the sensory input provided.
To maintain the use of a sensory integrative approach to the intervention, many
aspects of the treatment that was provided were closely monitored for their fidelity.
Based on observation and discussion with the parents, a Progress Note and Checklist (see
Appendix S) was completed during and after each session by the researcher. The
progress note was used to document subjective and objective information regarding the
childs responses to, and progress in therapy and in functioning. Treatment sessions were
conducted based on a treatment manual which was created for this study (see Appendix
R). During a therapy session, the researcher kept a detailed list of all treatment activities
that were performed, so as not to accidentally alter the order or nature of the activities. A
checklist, which was based on the Essential Characteristics of Occupational Therapy
Using Sensory Integration Intervention (ECOTUSII) (Watling, 2004) was completed
after every session to monitor the researchers fidelity to treatment during the session.
The researcher, in filling out the checklist, provided information that indicated how well

the session met the ten principles of SI therapy. Specifically, the length of the session,
the amount of time in which the session was child directed and the sensory systems that
were addressed were documented. In addition, the researcher indicated if the session was
one-on-one, whether or not the room was organized in a way that encouraged child
participation, and if safety was maintained. Finally, the researcher indicated if an effort
was made to sustain optimal arousal, to support the childs success, and to grade the
difficulty of the activity. In addition it was noted if the child was allowed to choose and
plan activities, maintain a context of play, had active control and self direction, and if a
sense of trust, appreciation and respect was maintained. In an effort to maintain
treatment fidelity, an outside examiner observed four random sessions of intervention and
completed the Progress Note and Checklist. The therapist and outside examiner agreed
on all aspects of the checklist at each session except on whether or not the session was
child-directed. No discussion was made prior to the study to agree upon how this tool
would be completed, and therefore it is possible that this item may have been interpreted
in two different ways. The treating therapist reported child-directed time as any time in
which the child was directly involved in the planning or selecting process of the task,
even if support was offered by the therapist. The outside examiner on the other hand,
limited her reports of child-directed time to only those times when the child was solely
responsible for selecting and directing the activity. As a result, these values varied
greatly between the examiner and the outside examiner. Regardless of the value
indicated, both the therapist and the outside examiner agreed that every effort was made
to allow the child to direct the session as much as possible.

Summary of Conceptual Framework Relationships. Every aspect of this study
was designed with the conceptual framework in mind. Although it did not intend to
identify specific neurological pathologies involved in AS and PDD-NOS, the physical
findings which included deficits in attention, balance, motor planning, and bilateral
coordination appear to be linked to specific neurological structures which have been
identified as being abnormal in persons with ASDs. In particular, the impairments
identified in the participants of this study seem to have the closest connections to the
functioning of the brainstem and cerebrum.
In addition to the neurological framework which supported this study, the theory
of SI provided the basis for the testing and treatment phases of this study. Every effort
was made to adhere to the guiding principles behind SI theory, SI dysfunction and SI
treatment. The results from the study demonstrated some support for the theory of SI.
Participants showed clear signs of sensory dysfunction which impacted their ability to
engage with their environment in an age-appropriate and typical manner. As the children
gained more opportunities to allow their nervous systems to adapt to a sensory-rich
environment, their behaviors and their ability to perform sensory and motor tasks also
appeared to improve.
Relationship of the Results to the Literature
This study was developed based on an extensive review of previous literature and
research on children with pervasive developmental disorders. This section examines the
results of the current study in comparison with the findings of previous studies. The
similarities and differences between this research and earlier research will help to clarify
what has been gained by conducting the current study. This section begins with a

discussion of participant recruitment and the relationships to what has been reported in
the literature about children with AS and PDD-NOS. It will continue with a discussion
regarding the sensory processing skills of the children in the study as they relate to the
research literature. Next, the findings regarding the motor skill performance of the study
participants will be compared to previous research, followed by the results from this
study as they relate to earlier SI efficacy studies.
Recruitment. Despite the reported and estimated numbers of children living in the
area in which the study was being conducted, one major challenge in this study was the
recruitment of children who met the criteria for age and diagnosis. Parents frequently
reported either the absence of any diagnosis, or the absence of a specific AS diagnosis.
In some cases, parents reported a long waiting list to see a specialist for diagnosis. In
other cases, parents reported that their child had signs or symptoms of AS, but did not
meet all diagnostic criteria based on the DSM-IV, and were either diagnosed with PDDNOS or were not given a specific diagnosis. According to Howlin and Asgharian (1999),
the average age of receiving a diagnosis of AS is approximately 11 years, which may
help to explain the shortage of potential participants for this study who had to be between
five and nine years of age. Results from a survey-based study conducted by these
researchers in the United Kingdom, indicated that 77% of the participants did not receive
a diagnosis of AS until they were at least 15 years old (Howlin & Asgharian, 1999).
Additionally, several researchers have pointed to discrepancies within the diagnostic
criteria for AS, which may result in missing or incorrect diagnoses (Klin & Volkmar,
2003a; Mattila et al., 2007). Although no attempts were made in this study to examine
the prevalence or incidence of AS or PDD-NOS, the difficulty in finding participants who

met the initial study criteria, coupled with parent reports supports the information from
previous studies which suggest the difficulties encountered when attempting to come to a
conclusion about a childs diagnosis.
At the time this research was conducted, many of the children in this study had
been receiving therapeutic services for their impairments. For example, 67% percent of
the participants (6/9) were receiving occupational therapy, often to address muscle tone
or handwriting needs. One child was receiving physical therapy. These findings
regarding services were relatively similar to the reported frequency and type of services
in a study by Church, Alisanski and Amanullah (2000). They identified that 58% of the
26 elementary school-aged children with AS were receiving OT services and 33% were
receiving PT services. A larger number of children in the Church and colleagues study
(2000) were receiving Speech Therapy services (96%), compared to a smaller number
receiving those services (78%) in the current study.
Sensory Processing. It has frequently been reported that children with ASDs have
impairments in sensory processing skills. One of the purposes of this study was to
determine if this was true for the children who were the participants in the current study.
For children with AS and PDD-NOS, the sensory impairments reported have included
overresponsiveness and underresponsiveness to textures, sounds, tastes and the
perception of space, as well as impairments in personal grooming tasks resulting from
difficulty with sensory processing (Center for Autism and Related Disabilities, 2008;
Frith, 1991; Gillberg, 2002). The findings of a retrospective chart review by Church,
Alisanski and Amanullah (2000) identified 67% of the preschoolers and 30% of the
children who were in middle school as having sensory overresponsiveness, sensory

underresponsiveness or mixed thresholds. The authors specifically reported signs of
auditory, oral and tactile sensitivity (Church et al., 2000). Similar concerns were
expressed through anecdotal reports from the parents in the current study who reported
that their children became frustrated or had a melt-down in settings that had loud or
excessive noise. Additionally, several parents reported that their children had a very
limited diet due to hypersensitivities to either tastes or textures. Tactile sensitivity in the
form of limited clothing choices and tactile defensiveness were also reported by the
parents. Each of these findings was confirmed during testing and witnessed by the
researcher during the course of this study. Although anecdotal reports cannot
conclusively confirm that a sensory processing problem exists, the reports of these
parents offered support for some of the findings of the Church et. al (2000) study.
Research reported by Leekam and colleagues (2007) also identified findings of
sensory impairments in a group of individuals with autism, using the Diagnostic
Interview for Social and Communicative Disorders (DISCO). Ninety percent of the
participants in their study had sensory impairments, and the majority of those individuals
had sensory processing deficits in more than one sensory system (Leekam et al., 2007).
Even though the Leekam study involved children with a diagnosis of autism, the findings
of multisensory processing deficits were similar in the current study of children with AS
and PDD-NOS. This was indicated by low sensory processing scores on several sections
of the Sensory Profile which were below what would be expected of a child who is
typically developing. This provides support for the evidence that suggests that sensory
processing impairments can occur across the autism spectrum.

To obtain information specifically on the sensory processing of children with AS
and PDD-NOS, the parents in the current study completed the Sensory Profile. This
assessment provides subjective evidence regarding how the parents feel about their
childrens sensory processing. Much like the study done by Dunn and colleagues (2002)
who identified children with AS as being impaired in 22 out of 23 possible areas assessed
by the Sensory Profile (Dunn, Smith Myles et al., 2002), the parents in the present study
reported sensory processing impairments in all 23 areas of sensory processing. More
than 50% of the parents reported impairments in 21 of those areas. Every participant in
the current study was rated by his or her parent on the Sensory Profile as being
emotionally reactive and easily distracted, as having emotional responses that differed
from a typically developing child, and as being unable to modulate sensory input. Every
parent also reported that their child had difficulty with the behavioral outcomes of
sensory processing such as tolerating changes in routine and hand writing. It is important
to understand that the scores on the Sensory Profile correspond to one of three levels of
dysfunction, including typical performance, a probable difference from typically
developing children and a definite difference from children who are typically
developing. More than half of the children in the current study scored in the definitely
different category indicating the most severe form of dysfunction for several of the
subtests. The subtests in which the children were definitely different included Sensory
Seeking, Emotionally Reactive, Low Endurance/Tone, Inattention/Distractibility, Poor
Registration, Auditory Processing, Vestibular Processing, Touch Processing,
Multisensory Processing, Sensory Processing Related to Endurance/Tone, Modulation
Related to Body Position and Movement, Modulation of Sensory Input Affecting

Emotional Responses, Modulation of Visual Input Affecting Emotional Responses and
Activity Level, Emotional/Social Responses and Behavioral Outcomes of Sensory
Processing.
Corresponding with the current studys findings, a study on a cohort of 400
children, including children with AS and PDD-NOS (Tomchek and Dunn, 2007) found
that nearly 84% of the participants with ASDs met the criteria for definite differences
on the total score on an abridged version of the Sensory Profile. More than half of the
participants with ASDs scored in the definitely different category for the Tactile and
Taste/Smell Sensitivity, Underresponsive/Seeks Sensation, and Auditory Filtering
subtests (Tomchek & Dunn, 2007). Although the categories of sensory processing
differed somewhat due to the different versions of the Sensory Profile that were used,
both the current study and the Tomchek and Dunn study indicate that children with ASDs
appear to have a definite difference in several areas of sensory processing from children
included in the normative sample.
The current study is only one of three studies to assess children with AS using the
Sensory Profile, however it supports previous findings obtained using the Sensory
Profile. Dunn and colleagues (2002) and Klyczek and colleagues (2005) both identified
difficulty with modulating sensory input in their samples of children with AS. In a very
different type of study, the purpose of the research of McIntosh, Miller, Shyu and
Hagerman (1999) was to demonstrate this difficulty by testing electrodermal responses in
children who had sensory modulation disorder. Their results indicated that the children
in their study who had difficulty modulating sensory input also had impaired
electrodermal responses. This finding also correlated with greater impairments in

sensory processing as reported by the parents using the Sensory Profile (McIntosh et al.,
1999). Although the current study did not use electrodermal testing, the participants
scores on the Sensory Profile and the SIPT suggest that the children in the current study
had impairments in both sensory processing and sensory modulation. This supports the
previous research which has provided evidence that there is a connection between
sensory processing and sensory modulation, and that these impairments are present in
children with ASDs.
Motor Skill Performance. Another primary purpose of this study was to examine
the motor skills of children with AS and PDD-NOS. The presence of motor skill
impairments in children with AS dates back to the original group of children described by
Asperger himself in the 1940s who said that the children he worked with were poorly
coordinated and moved in an awkward manner (Frith, 1991). In addition, many experts
have identified motor clumsiness or awkwardness in children with autism spectrum
disorders (Freitag et al., 2007; Molloy et al., 2003). Some of the commonly reported
motor impairments include delayed motor milestones, low muscle tone, decreased
awareness and control of the body, stiff and clumsy movement patterns, difficulty with
ball skills, and poor handwriting (Frith, 1991; Klin & Volkmar, 1995, 2003c; MillerKuhaneck, 2004; Wing, 1981). Many of these reported impairments were objectively
supported in the current study through the subtests of Clinical Observations, the BOT-2
and the SIPT, which identified abnormal muscle tone, decreased bilateral coordination,
difficulty with ball skills and impairments in drawing and copying skills. Whereas much
of the literature on motor impairments in persons with PDDs is the result of the use of
non-standardized measurement techniques and indirect methods such as chart reviews

and parental reports, a difference between these studies and the current study is that the
current study utilized the BOT-2 to provide an up-to-date, objective measure of motor
skill performance, This objective and standardized assessment determined that the
participants in the current study have poor coordination and difficulty performing some
motor skills.
Although they did not use the BOT-2, there are a few other studies that have
attempted to objectively quantify the motor impairments in children with AS using more
formal and standardized instruments. Manjiviona and Prior (1995) compared children
with AS to children with HFA using the Test of Motor Impairment Henderson Revision
(Stott et al., 1984). This instrument assesses the manual dexterity, balance and ball skills
in children. In comparison to the current study which identified motor impairments in all
of the study participants, the results of the Manjiviona and Prior (1995) study indicated
that 50% of the subjects with AS demonstrated motor impairments. With an average age
of 11 years, the participants in the Manjiviona and Prior study were older than the
participants in the current study. One possible reason for the difference in the frequency
of motor impairments between the two studies is that motor skills in persons with ASDs
are not consistent over time (Freitag et al., 2007). More conclusive statements however,
cannot be made at this time.
There have been three studies that have used the Movement Assessment Battery
for Children [Movement ABC] (Henderson & Sugden, 1992) on groups of children with
ASDs, including children with AS. In all three of these studies, the researchers identified
motor delays in the participants who had a diagnosis of AS (Green et al., 2002; J. Miller
& Ozonoff, 2000; Miyahara et al., 1997). The motor delays in those studies included

difficulties with ball skills, imitation activities and fine motor skills. The current study,
which utilized the BOT-2 to identify motor impairments and decreased coordination in all
of the study participants, is consistent with the findings from Green et al. (2002) which
reported motor impairments in 100% of the participants with AS. It appears that many
children with AS and ASDs experience difficulties with performing motor skills in a
coordinated fashion. Perhaps this is because of the impairments that have been identified
in sensory processing, sensory modulation and motor planning. If a child is unable to
adequately process or modulate incoming sensory information in order to produce an
appropriate response, and if he or she has difficulty planning motor actions, he or she will
most likely appear clumsy or poorly coordinated.
Similar to the current study, there have been two other studies that have used the
Bruininks Oseretsky Test of Motor Proficiency to examine the motor skills of children
with ASDs. The present study indicated that the BOT-2 test scores fell below the 50th
percentile for children with AS and PDD-NOS, particularly in the areas of manual and
bilateral coordination. This supports the findings of the Ghaziuddin, Butler, Tsai and
Ghaziuddin (1994) and Ghaziuddin and Butler (1998) studies which also identified motor
impairments in children with ASDs based on Bruininks Oseretsky test scores. In contrast
to the Ghaziuddin studies however, the current study utilized a more recent version of the
Bruininks test, the BOT-2, which is based on a more current normative sample. No other
studies have been reported which have used the BOT-2 with this population of children.
As a result, the findings from the current study, which identified impairments in motor
coordination and motor skill performance in the study participants, provide up to date

evidence that children with AS and PDD-NOS are impaired in their ability to perform
some motor skills in an age-appropriate manner.
Another study performed by Freitag et al. (2007) assessed the motor skills of
adolescents with AS, HFA and IQ-matched controls using the Zurich Neuromotor
Assessment. The greatest impairments that were reported for their participants were in
alternating wrist supination and pronation movements and dynamic balance tasks. These
impairments were also found in the children who participated in the current study. In
addition, the findings from this study share an additional similarity to the findings of the
Freitag study in that the children in both studies demonstrated greater ease with more
simple motor movements such as symmetrical, repetitive movements that involve the legs
or hands and balance on two feet with the eyes open, as compared to more complex
motor skills such as alternating leg and hand movements, sequential finger movements
and balance skills on one foot with the eyes closed.
Although it is clear that the SIPT, which was used in this study, focuses on
assessing a childs ability to process and integrate sensory input from a variety of
sources, the test of Postural Praxis within the SIPT assesses a childs ability to motor plan
and imitate postures that are assumed by the examiner. Similar to the praxis tests
administered in the current study, Green and colleagues (2002) used a gesture test to
assess motor planning and postural imitation in a group of children between the ages of 6
years and 11 years who had a diagnosis of AS. Just as in the current study which found
that the participants had difficulty with planning whole body movements as well as oral
movements, Green and colleagues (2002) also identified signs of poor imitation skills in
the study participants. The fact that children in both studies demonstrated impaired

imitation skills, and that the children in the current study were identified as having
additional impairments in Oral Praxis and Praxis on Verbal Command, seems to indicate
that the impaired motor skills evident in these children appears at least in part, due to
their poor motor planning skills. In another study involving children with AS and HFA,
Rinehart et al. (2006) suggested that impaired motor planning was the primary cause for
difficulty with writing tasks, rather than an impairment with the kinematics involved in
performing the movements. The patterns of impairments shown in the children in the
current study also seem to suggest impairments in motor planning skills, as suggested by
poor praxia scores on the SIPT and poor motor skills on the BOT-2. In addition, the
participants in the current study frequently attempted to receive additional proprioceptive
input in the form of deep pressure and resisted activities.
Findings that a motor planning deficit exists in children with AS are also
consistent with a study performed by Weimer and colleagues (2001) which assessed the
motor skills of these children along with a group of typically developing controls. Nonstandardized tests that included balance activities, pegboard skills, finger-to-thumb
opposition and tests of praxis were used. The participants in their study, much like the
participants in the current study, had difficulty with tests of praxis, standing and walking
balance tasks and finger-to-thumb opposition, which again supports the idea that motor
planning and balance tasks may be difficult for these children. Unlike the Rinehart
(2006) study however, Weimer and colleagues (2001) relate impairments in movement to
an underlying deficit in proprioception, rather than impaired praxis. They suggested that
these children exhibit an increased reliance on visual input because of their poor
proprioceptive awareness.

An increased reliance on visual input has been identified by other researchers
(Molloy et al., 2003) as well. To assess the contributions of the sensory systems on
postural stability, Molloy, Dietrich and Bhattacharya (2003) utilized a force platform
with children with ASDs. The results from their study indicated that children with ASDs,
compared to a control group of children relied heavily on their visual sense in order to
maintain their balance and postural stability. This may be consistent with an observation
made in the current study, where some of the children demonstrated either an
unwillingness to close their eyes for testing or frustration when they were required to
close their eyes for testing. In addition, other children in the current study demonstrated
decreased sensory processing such as difficulty identifying where their hand was touched,
or identifying which shape they were feeling in their hand when they were unable to use
their visual system to assist them. Their motor skills were also more difficult for them
when their eyes were closed in activities such as touching their finger to their nose and
walking. Each of these findings on the children in this study support the findings of the
Weimer (2001) and Molloy (2003) studies that suggest that children with ASDs
demonstrate an overreliance on visual input, which may suggest possible impairments in
the ability of the nervous system to integrate input coming from more than one sensory
source.
The Efficacy of Sensory Integration Therapy. Many researchers have utilized a
variety of study designs to evaluate the effectiveness of SI therapy with children who
have disabilities including autism, PDDs and learning disabilities. The results of their
studies have indicated different outcomes. Linderman and Stewart (1998) conducted an
intervention study that provided SI therapy to two three-year-old boys with PDDs.

Therapy was provided for one hour per week for seven weeks and eleven weeks,
respectively. Function was assessed utilizing the Functional Behavior Assessment for
Children with Sensory Integrative Dysfunction. Improvements were identified in social
interaction and responses to touch and movement. Additionally, decreased frequencies of
aggressive or highly active and distracting behaviors were identified following
intervention. Although the current study utilized the Sensory Profile to measure sensorybased functional behaviors rather than the Functional Behavior Assessment, both studies
identified similar improvements in sensory-based functional behaviors. These
improvements indicated fewer disruptive behaviors, improved attention and improved
responses to sensory input. Findings from both studies therefore appear to offer support
for the use of SI therapy as an intervention for these children. A more recent case study
of a four year old boy with poor sensory processing was reported by Schaaf and McKeon
Nightlinger (2007). The results of ten months of individualized SI therapy, provided
once a week, resulted in improvements in Sensory Profile scores and the achievement of
several established occupational performance goals (Schaff & Nightlinger McKeon,
2007). The authors suggested that the results obtained indicated that an improvement
was made in the childs sensory processing as a result of the intervention. The current
study is the second known study to utilize Sensory Profile scores in a pretest-posttest
scenario. In both cases, parents reported via the Sensory Profile that improvements were
seen in their childrens ability to receive, process and integrate sensory information in a
manner that allowed for more appropriate and more efficient performance in daily
activities.

Other researchers have used modified versions of traditional SI therapy in an
effort to measure its effectiveness. In an attempt to measure the outcomes of intervention
using a 10-week Sensory Integration and Perceptual-Motor protocol, Davidson and
Williams (2000) studied the impact of treatment for children with Developmental
Coordination Disorders. Unlike the current study which identified significant
improvements in the Balance subtest and nearly significant improvements in the Running
Speed and Agility composite of the BOT-2, the Davidson and Williams study did not find
significant improvements on tests of motor skills using the Movement Assessment
Battery for Children, and the Beery-Buktenica Developmental Test of Visual-Motor
Integration (Davidson & Williams, 2000). This finding might be explained by four major
differences that existed between these two studies. First, the studies differed in the
diagnosis of the participants. In the Davidson and Williams study, the children had a
diagnosis of Developmental Coordination Disorder, whereas in the current study, motor
impairments were identified in the children with AS and PDD-NOS, but were not a
requirement for enrollment. Second, sensory processing impairments were confirmed for
the children in the current study via sensory testing prior to the initiation of SI therapy.
Another difference between the two studies is that the current study attempted to use a
traditional SI treatment approach, whereas the Davidson and Williams study utilized a
combination of SI and perceptual motor therapy. It is possible that the incorporation of
the perceptual motor component into an SI protocol as in the Davidson and Williams
study resulted in the need for the participants to simultaneously respond to sensory input
and process information at a cognitive level, which may have been too difficult for the
participants to do in an effective and efficient manner. Finally, the SI therapy provided

during the current study was focused on improving sensory processing which was
considered a prerequisite to good motor performance, rather than specifically on motor
skill performance. Perhaps this more focused approach of addressing sensory processing
resulted in improvements in these motor skills that would not have otherwise occurred if
the treatment was focused solely on motor performance.
In a different type of study, Kaplan, Polatajko, Wilson and Faris (1993) reported
the results of two interventions which were conducted simultaneously, and which
assessed the effectiveness of SI therapy compared to tutoring or perceptual motor
training. Motor skills and academic performance were assessed as the outcomes. In both
studies, treatment was provided for at least six months and change was measured using
the Bruininks Oseretsky Test of Motor Proficiency, along with other instruments that
assessed academic and visual motor skills. Overall, all three treatment techniques yielded
positive results for the children although they were not statistically significant.
Therefore, the authors concluded that SI treatment was no more beneficial than tutoring
or perceptual motor therapy in improving academic or motor skills. Explanations for
these findings included the use of a heterogeneous sample (Law et al., 1991), and the
effects of the child interacting with an adult, rather than specific treatment effects
(Wilson & Kaplan, 1994). Even though the SI treatment provided in the current study
was not compared to another type of treatment, the SI intervention provided did result in
significant improvements in some areas of sensory processing and motor skill
performance when compared to a five week baseline phase in which no treatment was
provided. Additionally, the current study utilized a more homogeneous sample than
some of the other studies in that it included a group of children with a specific diagnosis,

who were also confirmed to have sensory and motor impairments. This homogeneity
may have allowed for more positive effects to be identified. Two years following the
original study by Kaplan, Polatajko, Wilson and Faris (1993), Wilson and Kaplan (1994)
repeated the testing procedures on a group of children from the original cohort to
determine if there were any long term effects of the intervention. This time, the group
who received SI therapy showed significantly improved gross motor performance (p<.02)
compared to the group who received tutoring. Their results therefore offered support for
using SI therapy for the improvement of long term motor skill goals. Although long term
effects were not assessed in the current study, the gross motor skill improvements
identified in all three studies suggest the possibility that SI therapy may have some
efficacy in improving motor coordination and motor skills.
Many different assessment tools have been used in SI effectiveness studies. Even
though the SIPT is considered to be one of the best tools to measure a childs ability to
integrate sensory information and plan movements, there has been only one other
reported study that has utilized the SIPT to measure change following intervention. In a
study by Gienke-Kimball (1990), the SIPT was used to assess a group of 19 children
before and after a six month treatment program involving SI intervention that was
provided two times per week. Although results were analyzed differently between the
two studies, both studies were successful in measuring the change in SIPT scores before
and after intervention. In addition, the findings of significant improvements in several
areas of praxis as well as standing and walking balance were similar between the two
studies, providing objective data to support the hypothesis that children with AS and

PDD appear to improve in their ability to process sensory input following SI therapy for
these particular skills.
Additional Findings
Three primary hypotheses were addressed in this study. In addition to the
findings that relate specifically to these three hypotheses however, the testing and
treatment protocol yielded additional data which may provide useful information to
researchers and clinicians. Therefore, this section will discuss the behavioral changes
that were identified following the 10-week intervention phase. Additionally, the results
from the ASDS, the PEGS and Clinical Observations will also be reviewed.
Behavioral Changes. A childs behavior can provide good insight regarding his
or her ability to adequately receive and process sensory information (McIntosh et al.,
1999; Williamson et al., 2000). The ASDS and the Sensory Profile provide specific
information regarding the childs behaviors as they relate to AS and to sensory
processing. Based on the results of administering the ASDS, almost every participant in
the current study was found to demonstrate signs of rigidity, immaturity and obsessive
behaviors on the Maladaptive Behavior subtests at both pretest and midtest phases.
These findings were also supported by the Sensory Profile, where 100% of the parents
reported signs of inattention, distractibility and emotional reactivity in their children. The
importance of sensory processing on emotional regulation is discussed by Laurent and
Rubin (2004). They state that an inability to react in an emotionally appropriate manner,
becoming overly stressed or shutting down, is likely to occur when an individual is
unable to regulate himself or herself internally, and in the context of a social interaction
(Laurent & Rubin, 2004). In addition to the parental reports on the ASDS and the

Sensory Profile, which indicated maladaptive behaviors, emotional reactions to sensory
input and distractibility, some of the children in this study also displayed some of these
behaviors during testing. These behaviors included signs of frustration and either
emotional withdrawal, or emotional meltdowns. The behaviors were seen less frequently
during the intervention sessions, when one of the focuses was on providing opportunities
for self regulation by the children.
Following SI intervention in the current study, there was an improvement in
Maladaptive behavior scores on the ASDS with the analysis revealing results that were
nearly significant (p=.08). These results seem to offer support for the findings of CaseSmith and Bryan (1999) which identified improvements in the level of engaged behaviors
and interaction in a group of five children with PDDs following 10 weeks of one-on-one
SI therapy sessions (Case-Smith & Bryan, 1999). Additionally, the results from the
current study are also consistent with findings from a single-subject study by Roberts,
King-Thomas and Boccia (2007) which noted reduced aggression, an improved ability to
engage within the environment and less frequent teacher involvement to manage the
behaviors of a three year old child with a sensory modulation disorder (Roberts et al.,
2007). In addition, a third study assessing the impact of SI therapy on the behavior of
children with ASDs was conducted by Watling and Dietz (2007). The authors measured
the frequency of undesirable behaviors and levels of engagement immediately after
intervention, in four boys who received alternating phases of treatments including SI
intervention and seated activities at a table. Neither the frequency of undesirable
behaviors, nor the frequency of engagement improved significantly during the SI
treatment phases. Subjective reports from the parents however suggested improvements

in both behavior and engagement after the post-intervention data collection period ended,
rather than immediately following treatment. Subjectively, the results of the current
study suggest similar reports being made by the parents regarding their childs behavior
and engagement. While the children often seemed to leave the therapy sessions
demonstrating no major behavioral changes from the start of therapy, their parents
reported that behavioral changes occurred on the way home or for the remainder of the
day. One parent for example often reported better regulation of activity levels following
the treatment sessions which made the familys evening routine easier to manage.
Therefore the results from the Case-Smith and Bryan (1999) study, the Roberts, KingThomas and Boccia (2007) study, the Watling and Dietz (2007) study and the current
study lend some support to the suggestion that SI therapy may result in improved and
more typical behavioral patterns.
Findings Related to the Asperger Syndrome Diagnostic Scale (ASDS). The
ASDS was administered to the participants at each phase of the study for two primary
reasons. Prior to enrollment, the ASDS was used to determine eligibility for the study.
For the purposes of this study, the pretest, midtest and posttest scores of the ASDS were
compared using repeated measures ANOVA to identify any significant changes in AS
characteristics following 10 weeks of SI therapy. For this test, it is important to
understand that a lower score represents fewer AS characteristics. According to the
scoring criteria for the ASDS, as the ASQ increases, the likelihood of the child having
AS increases. Scores between 80 and 89 suggest a possibility of an AS diagnosis. This
means that a child whose ASQ score is between 90 and 110 is considered likely to have
a diagnosis of AS, and a score above 110 indicates that the child is very likely to have a

diagnosis of AS. Individual subtest scores were summed together to obtain a percentile
score.
At the time of both pretesting and midtesting, all of the children, including those
with a PDD-NOS diagnosis, received an Asperger Syndrome Quotient (ASQ) between 80
and 122, with a mean score of 106.3. Before intervention, the average participant in the
study was rated by his or her parent as having enough signs and symptoms of AS to be
considered likely to have a diagnosis of AS. Based on these percentile scores it was
determined that on every subtest, at both pretest and midtest, at least 50% of the
participants were rated by their parents as having more symptoms of AS than a child who
is developing typically. Upon visual inspection of the data, the scores of the children on
the ASQ was lower following the intervention, suggesting that fewer AS characteristics
were observed by the parents following the treatment. Repeated measures ANOVA
however, indicated no significant changes in the ASQ scores. Following 10 weeks of SI
therapy, the mean score for the children decreased from 106.3 to 99.2, which is indicative
of a reduction of AS signs and symptoms, but not a large enough change to decrease the
reported likelihood of having a diagnosis of AS. Although ASDS subtest scores did not
change significantly following SI therapy, scores on the Maladaptive Behaviors subtest
approached significance (p=.08), which suggests that children demonstrated fewer rigid
or obsessive behaviors and more signs of flexibility to changes in their daily routine.
Findings Related to The Perceived Efficacy and Goal Setting System (PEGS). In
an attempt to obtain the childs perspective on his or her ability to perform various
activities of daily living, the PEGS was administered at all phases of the study. The test
examines self perceptions on 24 different motor skills, with each skill acting as its own

subtest. Using pictures of successful and unsuccessful task performance, children are
asked to identify how similar the picture was to his or her abilities. Based on the childs
answers, a four point scoring system is used. A score of one indicates that the child
perceives himself or herself to be very bad at a particular skill and a score of four
indicates that the child rated himself or herself as being very good at a skill. In an effort
to simplify the findings, the PEGS total score, which is obtained by summing the
individual scores, was used for analysis. Overall, most children rated themselves as
being good or very good on most items at all phases of the study. Out of a possible 96
points, which is achieved by rating yourself as very good at every skill in the test, average
total scores for the pretest, midtest and posttest phases of the study were 72.4, 78.2 and
76, respectively. These findings were very similar to the results from a study on five to
ten year old children with a diagnosis of Developmental Coordination Disorder, which
compared the childrens self perceptions to the perceptions of their parents and teachers,
and to scores on the Movement Assessment Battery for Children (Dunford, Missiuna,
Street, & Sibert, 2005). The PEGS total scores in the Dunford et al. study ranged from
42 to 92, and the mean scores were 71.4 for males and 70.6 for females. This was
different than the range of the participants scores in the current study, which was 50 to
96. This suggests that the children in the current study tended to rate themselves as being
slightly more able to perform motor skills than the children in the Dunford et al. study.
The mean total score from the current study was also similar to that of another study
which utilized the PEGS on a large group of children with a variety of diagnoses
including Attention Deficit Hyperactivity Disorder, Developmental Coordination
Disorder and Physical Disabilities (Missiuna et al., 2004). The mean total PEGS score

for the children in that study was 75.9 with little variability based on diagnosis. Parents
in that study who were also asked to complete the PEGS on their child reported lower
total scores when compared to their childrens ratings. Additionally, the Missiuna,
Pollock and Law study found no correlation between the childrens ratings and their
performance on the School Function Assessment which evaluates performance on schoolrelated tasks as well as the amount and type of support needed. In the current study, the
parents were often able to hear their childs responses to the PEGS as it was being
administered. Although the parent version of the PEGS was not given to them, they
reported to the researcher that their children were not being accurate in their self-reported
ratings. Missiuna and colleagues (2006) suggest that although children consistently
overrate themselves on the PEGS, its primary purpose is for goal-setting, rather than for
use as a pretest-posttest tool. In the current study, the change following intervention was
not significant, suggesting that the childrens perceptions of their abilities to perform
motor skills were not altered after 10-weeks of SI therapy. Knowing that the children in
this study had motor impairments as identified on tests of motor performance, and as
reported by parents anecdotally, it appears that the participants in this study might not
have accurately perceived their true motor abilities. Perhaps the very literal nature of
children with PDDs makes it difficult for them to accurately identify which of two picture
choices for each item in the PEGS is most like himself or herself. A second possible
explanation for the high self-perceived ratings is that children with PDDs often desire to
be good at things in order to fit better in their environments. A third possibility,
suggested by Missiuna and colleagues (2006), is that perhaps these children do not realize
how much external effort is actually being provided to make them successful.

Findings Related to Clinical Observations. Since Clinical Observations can be a
useful supplement to standardized testing, the pretest, midtest and posttest scores of
Clinical Observations were also compared in this study in order to identify any
significant changes following the intervention. In an effort to manage the number of
items in this test, related items were grouped together into subcategories which were then
analyzed using repeated measures ANOVA. Two subtests approached significance for
improvement. These two tests were Praxia (p=.05), which suggests that the children
improved in their ability to plan coordinated movements, and Bilateral Integration
(p=.06), which suggests that the participants also improved in their ability to recognize
and coordinate the two sides of their bodies in order to perform a motor skill. These two
subtests were indicated earlier as being two of the areas that were most challenging for
children at the pretest and midtest phases of testing. In addition, similar impairments at
pretest and midtest, and similar improvements at posttest were noted in these areas on the
SIPT and the BOT-2, which supports the study findings overall that sensory and motor
impairments are present in children with AS and PDD-NOS, and that SI therapy can
improve the sensory processing and motor skills in this population. As indicated
previously, many of the items included in Clinical Observations assess nervous system
development and maturity at a very basic level. Based on the pretesting and midtesting
findings from Clinical Observations, it appears that many of these basic skills, such as
tolerating simple sensory experiences, were not as impaired as the higher level skills,
such as hopping and reciprocal jumping, which involved bilateral coordination and motor
planning. Since Clinical Observations were only scored as typical or impaired,
improvement is only possible if the child was originally performing below the

expectations for a child his or her age. This may help to explain why the participants
made the greatest improvements in these particular sections of Clinical Observations.
Strengths and Limitations
Several strengths have been identified in this research study. First, this research
utilized standardized, performance based tests of sensory function. Previous research had
focused primarily on more subjective ratings such as observations and parent reports.
This objective and quantitative evidence of sensory impairments provides support to the
subjective reports that have previously identified sensory impairments in children with
AS and PDD-NOS. Additionally, this is the first known study to report SIPT scores for
children with AS and PDD-NOS. As the current gold standard for assessing sensory
processing and praxis skills, the SIPT has provided strong evidence to support that
children with ASDs have sensory impairments that may impact their function.
Similar to other studies, this study adds to the limited knowledge regarding the
motor impairments that have been identified in children with AS and PDD-NOS. What
distinguishes this study from others, however, is that it utilized the BOT-2 which is the
most recent version of this test, thus updating the evidence that children with ASDs
exhibit impairments in motor skills. Additionally, since both sensory and motor
impairments were assessed on the same group of children, some connections can be made
regarding the relationship between sensory and motor skills in this population.
An additional strength of this study is that it is the first reported study to assess
the effectiveness of SI as an intervention for children with AS. Evidence regarding the
most effective treatment techniques for children with ASDs has been severely lacking,
especially with respect to treatment that addresses the sensory and motor impairments in

this population. Therefore, the positive results from this study provide initial pilot
evidence to support the use of SI therapy for children with AS and PDD-NOS. It also
offers a starting point for future research in this area. Critics of SI research often report
the absence of reported treatment protocols in studies that assess the effectiveness of SI
intervention as well as a lack of treatment fidelity during intervention. The therapy
provided in this study was administered based on a treatment manual that can be
reproduced for future research. The therapy sessions were well documented to allow for
a specific sequence of activities to be repeated by others who might wish to further study
this population. Treatment was also monitored for compliance to the key aspects of SI
intervention using a worksheet that was developed based on the Essential Characteristics
of Occupational Therapy Using Sensory Integration Intervention (Watling, 2004).
An additional strength in this study was that it utilized a variety of assessment
tools to measure sensory processing, motor skills and behaviors that are often associated
with sensory processing disorders and ASDs. By using subjective and objective
measurements, assessments based on parental report, child report and clinician report,
and both standardized and non-standardized instruments, the study provides a
comprehensive overview of the sensory and motor impairments that were present in the
participants. The relationships and connections between the findings from the tests add
validity to the results from any individual instrument by itself. In addition, the fact that
the testing instruments identified similar areas of improvement following SI therapy even
though they were assessing different items in different manners, supports the claim that
SI was effective in improving certain sensory and motor skills of the children who
participated in this study. Besides demonstrating improvements in sensory and motor

skills following SI therapy, the children in this study also were reported and observed to
demonstrate reductions in inappropriate or immature behaviors that are often identified in
children with ASDs. These findings also offer support for the use of SI intervention as a
treatment technique for children with AS and PDD-NOS for improving sensory
processing and motor skill performance.
This study is also acknowledged to have limitations. A major limitation was the
small sample size. While ten children began participation in the study, six children
completed all phases of the study. Four children who were recruited withdrew prior to,
or during intervention. Randomized controlled testing with large sample sizes is
generally recommended for obtaining greater validity and confidence regarding the
outcomes. Given the heterogeneity of children with sensory processing disorders, the
relatively low number of children with a diagnosis such as AS or PDD-NOS who could
participate, and the amount of time required to conduct such an intervention study
indicates that conducting a large-scale study would be difficult without having prior
evidence to support it. Since research in this area is still in the early stages, effectiveness
with a small sample such as the sample used in this study can be used to provide support
for larger studies in the future.
An additional limitation in the study was the lack of a control group. Limited
recruitment and ethical restrictions regarding withholding treatment from a child were the
two primary reasons for not having participants assigned to be controls. In order to
account for the absence of a control group however, a five week baseline phase was
implemented just after initial testing. In this way, the participants themselves acted as
their own controls. After five weeks of no study-related activities, midtesting was

performed to ensure that changes were not related to maturation. Following midtesting,
the ten-week intervention phase took place, and the results of posttesting following
intervention were compared to pretest and midtest scores to identify any significant
improvements.
During the development of the study, it was recognized that the SIPT is not
generally used in research to identify change before and after intervention, and that this
may be a limitation in the study. Currently however, the SIPT is the best tool available to
objectively measure sensory processing skills, and preliminary research has supported its
use in this manner. The findings from this study are in agreement with the findings from
Kimball (1990) which suggested that the current version of the SIPT may be a useful tool
for assessing change following intervention. In addition, since the SIPT scores during
each phase of testing corresponded to the subjective ratings by the parents, and the
observations made by the examiners during Clinical Observations, the results suggest that
greater confidence in using the SIPT in this manner is something to be considered.
A final study limitation relates to the low values for interrater reliability. It has
been suggested that ICC values that are greater than .75 are indicative of good reliability
and ICC values below .75 are indicative of poor or moderate reliability (Portney &
Watkins, 2009). Although the results from ICC testing for the BOT-2 can be considered
indicative of good reliability (ICC=.88), testing for Clinical Observations and the SIPT
yielded moderate results for interrater reliability (ICC=.46 and ICC=.55, respectively).
The results from the reliability testing should be considered with caution however, for
two reasons. First, because of the small sample size, reliability testing was only
performed on one child, and therefore, data for the analysis was limited. Having a single

subject sample may result in a lack of variability which can negatively impact the values
obtained when using Intraclass Correlation Coefficients. Another consideration is the
type of data collected. The data for Clinical Observations was dichotomous in nature.
For each item, a child could earn either a score of zero if the skill was incorrect or
inappropriate for his or her age, or a score of one if he or she demonstrated ageappropriate performance. For reliability testing, both examiners scored the child the
same on 22 out of 24 items, which yielded an ICC of only .46. Similarly, scores on the
SIPT spanned a narrow range, from -3.00, which indicated that the childs score was
three standard deviations below the mean, to 3.00 which indicated that the childs score
was three standard deviations above the mean. Even though the examiners were exactly
the same on 10 out of 17 items, and less than .30 standard deviations different on four
additional subtests, the ICC was .55. Even though there was agreement between most of
the examiners scores, this is not evident by the interrater reliability values obtained.
Therefore although the results regarding the interrater reliability of the examiners should
be considered with some caution, the similarities between the examiners scores seem to
offer support that the findings from this study can be considered with confidence.
Implications for Practice
As more children and adults are being diagnosed with AS and other PDDs such as
PDD-NOS, it is critical that a better understanding be developed of the common
symptoms they display and the most effective methods for treating them. The clinical
implications from this research study span across clinical settings. First, all clinicians
need to be aware of the relatively new, and still somewhat novel, diagnoses of AS and
PDD-NOS. It is also important that all rehabilitation professionals and educators

recognize that although sensory and motor impairments are not required for a diagnosis
of any ASD, their presence in children with ASDs is very real. One hundred percent of
the children in this study demonstrated impairments in sensory and motor skills which
can impact their ability to participate in the home and school settings. Still, only 67% of
the children were reported by their parents and therapists to be receiving occupational
therapy, and this therapy was not focused on their sensory impairments. In addition, only
one child was receiving physical therapy at the time of the study. Even though it is
recognized that social impairments are one of the key features in these diagnoses, it is
important that the presence of sensory and motor impairments not be overlooked. Those
who assess individuals with PDDs should, at a minimum, screen for the presence of
sensory and motor impairments. For the children in this study, the most frequent and
most severe impairments were in the areas of inattention or distractibility, emotional and
social responses and behaviors, modulation of sensory input from a variety of sensory
systems, praxis and coordination. It is believed that impairments in these areas can affect
an individuals ability to interact appropriately and efficiently with the surrounding world
at home and at school, and that this may lead to coping mechanisms and social responses
that are viewed as inappropriate or immature. Therefore, any professional who works
with a child who has an ASD should consider the presence of sensory and motor
impairments and should take steps to ensure that the childs needs in these areas are
addressed.
In regards to the assessment instruments utilized in this study, they did
demonstrate that they were useful in identifying impairments in this group of children.
Provided they have received appropriate training, the results obtained from the study

suggest that clinicians should consider using the tools described when examining children
with ASDs. It is important to recognize, however, that the battery of tests administered
during this research study were quite rigorous and very time consuming. In the clinical
setting, administration of all of these tests would not be practical. Therefore, care should
be taken to select the instruments which best meet the needs of the child, the clinician and
the facility.
Anecdotal evidence is and has historically been useful from a clinical perspective.
Soon after the study, one parent proudly reported observable successes in her childs
tolerance for sensory input and his ability to maintain balance and coordinate motor
skills. In addition, three of the six parents whose children completed the study contacted
the researcher after the research period to indicate significant improvements in their
children following their participation in the study. One parent reported receiving very
positive reports from the childs school for the first time in a long time. Another parent
reported significant reductions in tactile and oral sensitivity which began during the
intervention and continued with the implementation of a sensory-based occupational
therapy treatment program with another therapist after the conclusion of the study. A
third parent reported school assessment scores that were in the 13th to 34th percentiles
approximately two years before the study and an improvement to the 47th to 97th
percentiles in the year following intervention. Although the reasons for this improvement
cannot be certain, this parent attributed at least part of the childs success to the intensive
therapy he received during the study.
Although not measured during the course of the study, two anecdotal observations
were also made by the researcher that may be of interest to clinicians. First, the children

responded exceptionally well to oral input in the form of resistive oral motor activities as
a means for calming and organizing them. In addition, in some children, whole body
tone appeared to improve following these oral activities. As a result, the importance of
the oral area to development and organization should be considered. In this study
resisted oral activities were often used as a way to prepare the entire body for work,
which in some cases was effective. It was also noted that most children required a
combination or a sequence of proprioceptive and vestibular activities in order to maintain
an appropriate state of arousal and organization. Although it is not known how previous
therapy had been provided by other therapists, some of the participants therapists have
anecdotally identified that input to either the childs vestibular system or his or her
proprioceptive system independently resulted in signs of poor sensory modulation, such
as becoming hyperactive or melting down. During the intervention phase of the current
study, it appeared that the children could tolerate a greater variety of sensory experiences
when the activities incorporated either simultaneous proprioceptive and vestibular
experiences, or they provided consecutive proprioceptive and vestibular input. It seemed
that the proprioceptive input provided the childrens bodies with the information needed
to feel more secure for moving through space during the activities that involved the
vestibular system.
It is acknowledged that a great debate remains as to the effectiveness of SI
therapy. The results of this pilot study suggested that it was effective in improving some
areas of sensory processing, motor skills and behaviors of children with AS and PDDNOS. It followed the principles of classical SI therapy. It was child-directed and it
provided therapy in a one-on-one environment that was rich in sensory experiences.

Sessions were conducted two times per week for 45 minutes to one hour. Although each
session was based on the individual needs of each child at that particular time, a treatment
manual was utilized to maintain consistency with the activities performed during each
session. The most notable improvements following intervention were seen in the areas of
sensory processing, modulation of sensory input, praxis, standing and walking balance
and running speed and agility and reductions in inattention and distractibility. Further
research is needed to continue the examination of the effectiveness of SI therapy. This
study however provides some initial evidence to support the use of SI for children who
have AS and PDD-NOS with associated sensory and motor impairments.
Implications for Future Research
For years, researchers have reported the presence of sensory impairments in
ASDs. Their claims have largely been based on observation and subjective measurement
tools. This study provided some initial objective evidence to support the existence of
sensory impairments in ASDs. Future research should continue to objectively measure
sensory impairments in this population, and to compare the objective results with the
subjective findings that are more commonly reported. This research should occur for all
diagnoses in the autism spectrum, not necessarily to identify differences between
diagnoses, but rather to confirm their presence so that sensory impairments can be
recognized within the diagnostic criteria for ASDs.
A second recommendation is for continued research on the motor impairments
associated with ASDs. This study supports previous research that confirms the presence
of motor skill impairment in children with AS and PDD-NOS. At this point, more
specific and more refined analyses should be considered. For example, specific task

analysis may be useful in identifying which motor skill components are most impaired.
Researchers are also encouraged to continue searching for the causes of the motor
impairments, and to continue searching for the link between the sensory impairments and
the motor impairments that are seen as a result. A more definitive understanding of this
connection can serve to guide intervention choices and techniques.
Like other studies which have been completed over the past 40 years using SI as a
treatment approach, this study provides some support for the use of SI therapy on a small
group of children with AS and PDD-NOS. The dependent variables in this study were
sensory processing abilities and motor skills. In addition, the tools utilized in this study
indirectly assessed behaviors, however this was not the focus of the research. Based on
the theory of SI, there appears to be a connection between improvements in sensory
processing skills and improvements in motor, social and behavioral skills (Ayres, 1989;
Linderman & Stewart, 1999). Previous researchers have examined these sensory skills
indirectly, by identifying the dependent variables to be other areas of function, such as
learning, behaviors and motor skills. A third recommendation is for future research to
focus on the sensory processing abilities by testing sensory processing itself, rather than
by assessing other functional skills which may provide indirect evidence of sensory
processing. To do this, objective and performance-based measurements of sensory
processing and the integration of sensory input as assessed with the SIPT should be used.
Studies with larger sample sizes are required in order to confirm the findings of
smaller studies such as this, and in order to allow for generalization to occur. The
possibilities for areas of SI research are seemingly endless. First, further research will be
needed to replicate this study in hopes of confirming the effectiveness of SI therapy for

children with AS and PDD-NOS. In addition, research should also involve other
populations in which sensory impairments are frequently identified. Rather than using a
sample of persons within the broad category of sensory processing disorders, which will
likely involve a wide variety of diagnoses and levels of severity, a more homogeneous
sample may be obtained by selecting a specific diagnosis which often involves sensory
impairments, such as AS or autism.
Finally, it is recommended that researchers investigate the presence of sensory
and motor impairments in other populations of persons with ASDs, such as adolescents
and adults. If sensory and motor impairments affect persons with ASDs throughout their
lifespan, then perhaps age-appropriate interventions will be required to address these
needs.
Conclusion
This research study was conducted to answer two primary questions. First, it
addressed the question of whether or not children with AS and PDD-NOS have sensory
or motor impairments that are greater than those of typically developing children. The
results from the Sensory Profile and the SIPT, along with supporting evidence from
Clinical Observations provide evidence that sensory and motor impairments do exist in
children with AS and PDD-NOS. The children in this study demonstrated impairments
in attention and behavior, sensory processing and modulation, praxis, balance and
coordination. The second purpose of this study was to address the question of whether
or not sensory processing or motor skills improve following SI therapy. Following 10weeks of SI therapy, children demonstrated improvements in behavior, sensory
processing and modulation, balance and praxis (See Table 12). This provides initial

evidence that SI therapy may be an appropriate treatment technique for children with AS
and PDD-NOS. As more children are being diagnosed with ASDs, it is critical that
researchers and clinicians address all of their needs, including those that involve sensory
processing and motor skill performance. This research study provides preliminary
evidence on the efficacy of SI therapy for children with AS and PDD-NOS.

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Appendix A
Approval from the Institutional Review Board
Appendix B
Sample Request for Support in Recruitment Procedures

University at Buffalo
Kimball Tower, Room 515
3435 Main Street
Buffalo, New York 14214
Date
To Whom It May Concern:

My name is Kristen Klyczek. I am a physical therapist and a graduate student at the University at
Buffalo. I am pursuing a Ph.D. in Rehabilitation Science. As part of my dissertation, I am
planning to conduct a study entitled: The Effectiveness of Sensory Integration Therapy on the
Sensory and Motor Skills of Children with Aspergers Syndrome. I would like to request your
support by allowing me to recruit participants from your facility for this study.
For my study, children who have Aspergers Syndrome will receive free Sensory Integration
treatment, and the effect of this intervention will be measured by pre-, mid-, and post-study
testing. As you may know, research to support the use of Sensory Integration Therapy is greatly
needed. The role of you and your facility, would simply be to allow me to post fliers within your
facility. Additionally, if you agree, I would attend a parent group, briefly present my research,
and distribute fliers to persons indicating their interest. You will incur no costs by agreeing to
assist me, and only those persons interested would be given the flier.
I am including a copy of the flier for you to review. I will contact you in approximately two
weeks to see if you can provide assistance in my recruitment of participants. Feel free to contact
me by telephone at 716-639-9201, or via email at krarent@buffalo.edu if you wish to discuss this
matter, or if you have other ideas regarding how you might be able to help. I look forward to
working with you, and sincerely appreciate your consideration.
Sincerely,
Kristen Klyczek, PT
PhD Student
Enclosure
Appendix C
Letters of Support for Recruitment Procedures
Appendix D
Radio and Written Advertisements

Script for Radio Announcement
A study is being conducted at the University at Buffalo for children with Aspergers
Syndrome, to determine if children with this disorder benefit from Sensory Integration
Therapy. To be eligible for the study, children must be between the ages of 5 and 9 years
at the time the study is being conducted. Participants will receive 10 weeks of free
therapy sessions under the direction of a qualified physical or occupational therapist that
include fun activities which incorporate movement and the senses of the body. Both
participants and their parents will be required to complete pre-, mid- and post-study
testing which involves both sensory and motor questionnaires and tests. The testing and
intervention will take place on UBs South Campus at 3435 Main Street. For more
information, please contact Kristen Klyczek at (716) 639-9201, or by email at
krarent@buffalo.edu.

Written Advertisement
Free Testing and Treatment for

Children with Aspergers
Syndrome
Why? A study is being conducted for children with
Aspergers Syndrome, to determine if they benefit from
Sensory Integration Therapy
Where? University at Buffalo, 3435 Main Street,

South Campus
Who? Children ages of 5 and 9 years who have

Aspergers Syndrome, and their parents
What does it involve? Participants will receive

10 weeks of free therapy sessions that include fun
activities which incorporate movement and the senses
of the body. Participants and their parents will also
complete pre-, mid- and post-study testing using
sensory and motor tests
How do I sign up? For more information, please

contact Kristen Klyczek at (716) 639-9201 or
email her at krarent@buffalo.edu
Appendix E
Parent Information Letter and Invitation

Date
Dear Parent:
My name is Kristen Klyczek. I am a graduate student at the University at Buffalo, and a licensed
physical therapist in New York State. I am pursuing a Ph.D. in Rehabilitation Science. As part
of my dissertation, I am planning to conduct a study that will determine how effective sensory
integration therapy is for children with Aspergers Syndrome. You have been identified by your
childs service provider or physician as someone who may be interested in having your child
participate in this study.
This study will offer free testing and treatment for children ages 5 to 9 years, who have
Aspergers Syndrome, and who are not already receiving sensory integration therapy. It involves
10 weeks of therapy sessions which include fun activities in a one-on-one setting, allowing your
child to move and explore his or her senses in a non-threatening and safe environment. As part of
the study, you would be required to complete parent questionnaires, and your child would
participate in a series of clinical assessments including the Sensory Integration and Praxis Tests.
This would occur three times over the course of the study in order to determine the effectiveness
of treatment. While you would be required to travel to and from UBs Main Street Campus, you
would incur no additional expenses for your childs participation in this study. Your childs test
results, and the results from the study will be made available to you at the end of the study.
Please note that confidentiality is a high priority, and any information obtained from this study
will be kept confidential. This means that your childs name will not appear on any reports
regarding the final results of the study.
An index card is enclosed with this letter. The index card will simply give me, Kristen Klyczek,
permission to contact you in order to determine if your child is eligible to participate. In the
event that your child is selected to participate, a separate consent form would be provided before
beginning the testing and treatment. If you are interested in learning more about this study, or if
you are interested in having your child be considered for the study, please provide your name,
address and phone number on the attached index card and either return it to your service provider
or return it to me in the enclosed self addressed, stamped envelope. You can also contact me by
telephone at 716-639-9201 or email me at krarent@buffalo.edu.
Your permission for me to contact you does not obligate you to have your child participate in the
study. If your child will be participating, you will receive a separate consent form that will
provide further explanation regarding the study and about your childs rights as a participant. I
will look forward to hearing from you and sincerely appreciate your consideration of having your
child participate.
Sincerely,
Kristen Klyczek, PT
PhD Student
Enclosure
Appendix F
Parent Informed Consent Form

THE EFFECTIVENESS OF SENSORY INTEGRATION THERAPY ON THE
SENSORY AND MOTOR SKILLS OF CHILDREN WITH ASPERGERS
SYNDROME
CONSENT FORM
INTRODUCTION
The purpose of this consent is to provide you with enough information to make an
informed decision as to whether you will agree to have your child be a subject in research
that take place during the 2007 calendar year. You and your child have been invited to
participate in this study because your child was identified by his or her clinician as
having Aspergers Syndrome, being between 5 and 9 years of age, and being free of any
other neurological diagnoses.
PURPOSE
Kristen Klyczek, hereafter referred to as the researcher, is conducting this study to
determine if children with Aspergers Syndrome have any difficulty with sensory
integration, which is the ability to process information from the senses. Another purpose
is to see if sensory integration therapy is an effective treatment for children with
Aspergers Syndrome. To conduct the study, your child will take part in a therapy
program designed around his or her specific needs, in order to improve his or her ability
to take in information from his or her senses, process that information and then use it to
complete play skills and daily activities. The body has many sensory systems including
touch, vision, movement and an awareness of where the body is in space. Sometimes,
when these systems overreact or do not react enough, people have difficulty behaving or
moving in ways that are considered typical. Sensory integration therapy may help these
systems to work together more easily, in order for your child to behave and perform daily
skills without difficulty.
PROCEDURES
This study will be conducted at the University at Buffalo, in a room designed to provide
sensory integration therapy. Since the procedures can be done at a time convenient for
you and your child, there will be no interruption to your childs school day. With your
consent, you will be asked to complete a short questionnaire. It will provide information
about your child, such as his or her age, gender and the services he or she is receiving.
You will also be asked to complete the Sensory Profile, and the Aspergers Syndrome
Diagnostic Scale, caregiver questionnaires which will provide additional information
about your childs diagnosis and his or her sensory systems. Together, these
questionnaires will determine whether or not your child is eligible for the study. If your
child is identified as being eligible to participate, and if you provide consent, and your
child agrees, he or she will participate in three tests to measure how he or she uses his or
her sensory and motor skills. These tests include: Clinical Observations, the Perceived

Efficacy and Goal Setting System, the Bruininks-Oseretsky Test of Motor Proficiency, 2nd
Edition, and the Sensory Integration and Praxis Tests.
Next, a five-week period of no testing or intervention will take place. During this time,
your child will not receive any study-related intervention, and you and your child will be
instructed to follow a typical family and school routine. After five weeks, you and your
child will be asked to return for testing which will include giving your child the Sensory
Profile, the Aspergers Syndrome Diagnostic Scale, Clinical Observations, the Perceived
Efficacy and Goal Setting System, the Bruininks-Oseretsky Test of Motor Proficiency, 2nd
Edition, and the Sensory Integration and Praxis Tests.
After the second phase of testing has been completed, your child will participate in a 10week therapy program consisting of two individualized sessions per week, for
approximately 60 minutes per session. During the sessions, your child will be involved
in a series of activities designed to meet his or her specific needs. Sessions will include
activities on the floor and on special therapy equipment designed to provide input to your
childs sensory systems. Activities may include skills such as running, jumping,
climbing and swinging, which will often be incorporated into games, challenges and
obstacle courses. All equipment will be used with mats placed on the floor, assistance
will be provided, and precautions will be taken to ensure your childs safety.
Following the 10-week intervention phase, you and your child will complete a final round
of testing. You will be asked to complete the Aspergers Syndrome Diagnostic Scale and
the Sensory Profile, and your child will be tested using Clinical Observations, the
Perceived Efficacy and Goal Setting System, the Bruininks-Oseretsky Test of Motor
Proficiency, 2nd Edition, and the Sensory Integration and Praxis Tests. Once you and
your child have completed this testing, the study will be complete.
TIME COMMITMENT
The study is expected to be implemented and continue through the 2007 calendar year.
Your childs participation will require one 60-minute session two days per week, for 10
weeks. In addition, both you and your child will be required to complete three phases of
testing. These will take place upon initial enrollment into the study, five weeks after
study enrollment, and again at the completion of the 10-week intervention phase. Each
phase of testing will take two to three sessions, depending on your childs ability to
maintain his or her interest and endurance. Each test session will take approximately 2 to
3 hours, with breaks given as necessary.
RISKS
There are minimal risks involved in this study. Risks are similar to those present when
your child participates in gym class or playground activities. Although these risks are
present, all procedures will be followed to ensure your childs safety. These procedures
include: a) measuring the equipment to your childs size so that his or her hands or feet
can touch the floor, b) placing mats beneath and around the equipment and c) having an

adult present at all times. Using these precautions, it is unlikely that your child would fall
onto a mat or sustain a minor injury. If this occurs however, acute medical care will be
provided by the researcher or examiner and follow up action will be taken, which will
include contacting you and your childs physician. The State University of New York at
Buffalo does not provide for medical care or compensation for medical care in the event
of injury as a result of participation in a research project. This is not, however, a waiver
or release of your legal rights.
BENEFITS
The information from this study will provide initial evidence as to whether sensory
integration therapy is a beneficial intervention for children with Aspergers Syndrome.
Although the outcome of this study is not known, if the results indicate that sensory
integration therapy is useful in improving the childrens ability to plan and perform play,
school and daily skills, your child may benefit directly.
CONFIDENTIALITY
The information obtained during the study regarding your childs ability to receive,
process and use sensory information will be recorded on the test forms in such a way that
both you and your childs identity will remain confidential. This means that a code
number, rather than your childs name will be used. Licensed physical and occupational
therapists who have the proper certification to administer the tests will complete the
assessments with your child. Upon receipt of the test sheets, the researcher will remove
your childs name and replace it with the code number assigned to your child. If any
information collected is printed in a report or used in a presentation, it will be reported so
that there is no way your child can be identified. All forms will be stored in a locked file
cabinet for seven years in the office of Dr. Linda Shriber, primary advisor to the study, at
the State University of New York at Buffalo. The researcher will destroy all written
records after seven years.
PAYMENT
There will be no direct compensation to you or your child for participating in the study,
however all testing and treatment procedures will be provided to you and your child at no
cost. If you wish to receive a summary of the results of the study upon its completion,
record your full name and address on the index card provided to you and return it to the
researcher. A summary of the results will be mailed to you upon the studys completion.
VOLUNTEERING FOR THE STUDY
Your permission to have your child participate in this study is completely voluntary. If
you do not want your child to participate, there will be no penalty or loss of benefits to
which you or your child are otherwise entitled. If you choose to have your child
participate, but then decide to withdraw him or her, you may do so at any time by
contacting Kristen Klyczek at 639-9201. In addition, if your child demonstrates signs of

discomfort during the testing or treatment sessions, the tester or the researcher may
request withdrawal from the study. If someone other than yourself initiates the
withdrawal, you will be notified by the researcher immediately and services to which you
or your child are entitled will not be effected.
If you should have any questions about your childs rights as a subject in a research
study, you should contact (anonymously, if you wish) the Children and Youth
Institutional Review Board, Women and Childrens Hospital of Buffalo, 219 Bryant
Street, Buffalo, NY 14222, or by phone at (716) 878-7859, to speak with the Patient
Representative about questions regarding patient rights.
SUBJECT STATEMENT
I have read the explanation provided to me. I have had all my questions answered to my
satisfaction, and voluntarily agree to allow my child to participate in the study.
I HAVE BEEN GIVEN A COPY OF THIS CONSENT FORM.
SIGNATURE OF PARENT/GUARDIAN
DATE
I certify that I obtained the consent of the subject whose signature is above. I understand
that I must give a signed copy of the informed consent form to the subject, and keep the
original copy in my files for 3 years after the completion of the research project.
SIGNATURE OF INVESTIGATOR
(OR PERSON OBTAINING CONSENT)
DATE
SIGNATURE OF WITNESS
DATE
Appendix G
Childs Assent Form

THE EFFECTIVENESS OF SENSORY INTEGRATION THERAPY ON THE
SENSORY AND MOTOR SKILLS OF CHILDREN WITH ASPERGERS
SYNDROME
CHILDS ASSENT FORM
WHO AM I?
My name is Kristen Klyczek and I am a Physical Therapist. I go to school at the
University at Buffalo.
WHY ARE WE HERE?
I want to tell you about a study for children like you. A study is like a school project, and
I would like to see if you want to be in the study too.
WHY ARE WE DOING THIS STUDY?
Sometimes, children need extra help playing and doing different activities at school and
home. Physical therapists and occupational therapists work with these children to help
them. I am doing a study to see if a kind of therapy, called sensory integration will help
you to play and move better.
WHAT WILL HAPPEN TO YOU IF YOU ARE IN THE STUDY?
If you want to be in this study, you will do many things. Here is a list:
1. First, you will meet with me or someone else, who is also a therapist. We will
meet two or three times and will be together for two or three hours. You will take
four tests that are like games to see how your body works. Some parts are easy
and some are harder. You should try your best, but dont worry if you cannot do
something. Its okay.
2. Next, you will wait for five weeks before you come back. You will take the tests
again.
3. After that, you will come to work with me two times each week for 10 weeks.
You will spend about one hour working with me each time. We will work on
things that you might do in gym class or on the playground. Most times it will
probably feel like we are playing.
4. After 10 weeks of working with me, you will do the same tests one more time.
5. Once you are done with the tests, we will be done working together.
WHAT MIGHT HAPPEN IF YOU ARE IN THE STUDY?
Whenever people exercise and play, there is a chance they might fall or get hurt. We will
be very careful to make it safe for you so that you do not get hurt. The things we use will
be set up just for you, to make it safer. An adult will always be near you, and there will

be mats set up in case you lose your balance or fall. You might feel like you are playing
when you come to therapy. If this therapy helps you, it might be easier to play and move.
DO YOU HAVE TO BE IN THE STUDY?

You do not have to be in the study. No one will be mad at you if you do not want to do
this. You can change your mind later if you decide you dont want to be in the study
anymore.
WHO WILL KNOW THAT YOU ARE IN THE STUDY?
No one will know that you are in the study except your mom or dad.
DO YOU HAVE QUESTIONS?
Do you have any questions right now? You can always ask us questions, now or later.
You can talk to me, my teacher or someone else anytime. Here are some telephone
numbers for you or your parents to call us:
Kristen Klyczek
Dr. Linda Shriber
(716) 639-9201
(716) 829-3141 extension 129
If you would like to be in my study, please sign or print your name on the line below:
Signature of Child: ______________________________________ Date: _____________
Signature of Parent/Guardian: _____________________________ Date: _____________
Signature of PI or Designee: ______________________________ Date: _____________
Signature of Witness: ___________________________________ Date: _____________
Appendix H
Pre-Study Questionnaire

THE EFFECTIVENESS OF SENSORY INTEGRATION THERAPY ON THE SENSORY
AND MOTOR SKILLS OF CHILDREN WITH ASPERGERS SYNDROME
PRE-STUDY QUESTIONNAIRE
Dear Parent,
Thank you for consenting to participate in this study with your child. What follows is a brief
questionnaire that will help to determine your childs eligibility for the study, and will also
provide general information for proper reporting. Please understand that this information will be
kept strictly confidential, and that your childs name will be replaced by a code number on all
study-related paperwork.
Please take a few moments to complete this questionnaire to your best ability. It is
important that no questions are left blank or unanswered. Feel free to ask any questions
you may have, and to add any additional information which you feel is pertinent at the end
of the questionnaire.
CONTACT INFORMATION:
Your Childs Name __________________________________________________________
Your Name _________________________________________________________________
Address _____________________________________________________________________
Telephone ___________ Emergency Contact Name _______________ Number ___________
DEMOGRAPHIC INFORMATION PERTAINING TO THE STUDY PARTICIPANT:
Date of Birth: __________________ Sex: M / F
School Setting:
Grade in School: ___________
Private / Public
Regular Classroom / Special Education Classroom / Inclusion Classroom
Other
_________________________________________________________
Services My Child is Receiving: PT / OT / Speech Therapy / Special Education / Tutoring

Other
_________________________________________________________
May we contact your childs therapist?
Yes _____
No _____
If Yes: Name _____________________ Telephone Number: ______________
Is your child receiving Sensory Integration Therapy as part of any services he or she is
receiving? Yes / No
Language preference: English / Spanish / Other: ______________________
Child uses: Glasses / Contact Lenses / Neither and CAN / CANNOT see clearly

Other medical diagnoses: _______________________________________________________
My child has a history of: Seizures / Cerebral Palsy / Neurological diagnosis: ____________
Please list why YOU would consider your child to have a diagnosis of Aspergers
Syndrome: ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Circle all that apply to, or are descriptive of your child:
Impaired social interaction
Rigid adherence to routine or ritual
Impaired eye contact with people
Stereotyped and repetitive motor

movements
Impaired eye contact with activities

Limited facial expressions
Impaired functioning (social,

occupational)
Abnormal body postures
Language delays
Use of abnormal gestures
Academic delays
Difficulty developing peer relationships
Unable to help him/herself in daily

activities
Decreased social or emotional exchanges

with others
Accident Prone
Clumsy or poorly coordinated
Repetitive and stereotyped patterns of

behavior
Excessive preoccupation with topics or
objects
Extreme like for certain sounds, flavors,

textures, movements
Extreme dislike for certain sounds,
flavors, textures, movements
Please comment on any noteworthy or unusual ways in which your child responds to:
Taste: ________________________________________________________________________
Sound: _______________________________________________________________________
Touch: _______________________________________________________________________
Sight: ________________________________________________________________________
Movement: ___________________________________________________________________
Appendix I
Sample Items

Sample Items
Language Subscale:
Observed
Not Observed
Speaks like an adult in an academic or

bookish manner and/or overly uses correct
grammar
Social Subscale:
Has little or no ability to make or keep friends
Maladaptive Subscale:
Exhibits a strong reaction to a change in his or
her routine
Cognitive Subscale:
Lacks organizational skills
Sensorimotor Subscale:
Has a restricted diet consisting of the same
foods cooked and presented in the same way
Appears clumsy or uncoordinated
Selected From: Myles, B. S., Bock, S., & Simpson, R. (2001). Asperger Syndrome
Diagnostic Scale Examiners Manual. Texas: Pro-Ed, Inc.
Appendix J
Sensory Profile Caregiver Questionnaire
Sample Items

Sensory Profile Caregiver Questionnaire
Sample Items
Sensory Processing:
Always
Frequently Occasionally Seldom
Responds negatively to
unexpected or loud noises
Covers eyes or squints to
protect eyes from light
Seeks all kinds of movement
and this interferes with daily
routines (for example, cant
sit still, fidgets)
Reacts emotionally or
aggressively to touch
Has difficulty paying
attention
Picky eater, especially
regarding food textures
Modulation:
Poor endurance/tires easily
Seems accident-prone
Takes excessive risks during
play
Is overly affectionate
Behavior and Emotion
Responses:
Is sensitive to criticisms
Has temper tantrums
Poor frustration tolerance
Doesnt express emotions
Selected From: Dunn, W. (1999). Sensory Profile: Users Manual San Antonio:
Psychological Corporation.
Never
Appendix K
Perceived Efficacy and Goal Setting System
Sample Items

Perceived Efficacy and Goal Setting System
Sample Items
Item
A Lot
A Little
A Little
A Lot
Catching balls good

Catching balls not good
Tying shoes difficult
Tying shoes - easy
Playground does not like to
try new things
Playground likes to try new
things
Drawing not neat
Drawing neat and clear
Selected From: Missiuna, C., Pollock, N., & Law, M. (2004). The Perceived Efficacy and
Goal Setting System Manual. San Antonio: Psych Corp; Harcourt Assessment.
Appendix L
Clinical Observations Documentation Form

Clinical Observations
Adapted from:
Fisher, A.G., Murray, E., & Bundy, A. (1991). Sensory Integration Theory and Practice.
Philadelphia: F.A. Davis Company.
Shriber, L. (2004). "Sensory Integration and Neurodevelopmental Therapy Course."
The following is a list of activities to be observed outside of formal testing. This list
serves as an example of activities, as some items may not be observed, while other
items not on this list may be noted during the session:
Sensory Modulation:
Reaction to changes in body position
Normal Reaction
Gravitational Insecurity in the form of excessive fear
Responses to movement
Tolerates movement well
Demonstrates signs of discomfort (nausea, vomiting, dizziness)
Reaction to tactile stimuli
Tolerates many forms of touch and textures
Overreacts of demonstrates discomfort with touch or textures
Reaction to sensory experiences
Actively seeks new challenges and activities
Avoids new activities or sensory stimuli
Distractibility
Able to attend to activity at hand
Difficulty attending to the task
Level of Activity
Appropriate levels of activity for the situation
Abnormally high or low levels of activity for the situation or difficulty with
transitions from one activity to the next
Posture:
Prone Extension
Able to hold 10-20 seconds
Difficulty assuming a prone extension position
Quadruped
Able to stabilize trunk and extremities
Unable to maintain with proper stability or locking at joints
Muscle Tone
Normal tone in extended positions
Increased or decreased tone observed in the extremities or at the low back

Bilateral Integration:
Hand Preference
Consistently uses preferred hand
Inconsistent with hand use
Crossing Midline
Easily brings extremities past midline
Avoids crossing the midline of the body
Right-Left Confusion
Demonstrates understanding of right and left
Confuses right and left
Motor Skills (Catching bounced ball, hopping, skipping, Symmetrical and reciprocal
stride jumping, stepping over a moving object)
Demonstrates ability to plan and execute a smooth pattern of movement
Unable to execute a smooth movement or demonstrates difficulty with the task
Praxia:
Supine Flexion
Able to hold 10-20 seconds
Difficulty assuming a supine flexion position
Finger-Thumb touching
Demonstrates smooth finger thumb opposition without visual assistance
Unable to touch thumb to fingers in smooth pattern
In-Hand Manipulation
Able to move objects within the hand
Requires both hands or setting the object down to manipulate an object
Pronation/Supination of the Upper Extremity
Able to execute a smooth sequence of palmar to dorsal hand slaps
Unable to alternate hands between palm and dorsal surface
Central Nervous System Maturity:
Associated Movements
No additional movements or fixing noted with age-appropriate skills
Additional movements or fixing patterns observed with age-appropriate skills
Finger to Nose
Able to touch finger to nose in an smooth, alternating pattern
Unable to touch finger to nose in an smooth, alternating pattern
Slow (Ramp) Movements
Mirrors flexion and extension of elbows in a smooth, symmetrical manner
Unable to flex and extend elbows smoothly and symmetrically
Protective Extension and Equilibrium Reactions (In Quadruped, Sitting, Kneeling and
Standing)
Demonstrates ability to extend body on weight bearing side to maintain balance
or catch himself or herself when falling
Unable to maintain balance with reaching out of center of balance, does not
extend limb to catch himself or herself, or demonstrates flexion on the weight
bearing side
Eye Movements:
Visual Tracking
Follows small object with eyes across midline, along diagonals and in a circular
pattern
Unable to follow small object in a smooth and controlled pattern
Convergence or Divergence
Able to follow object with eyes when brought to the nose and then moved away
Unable to coordinate eye movements when an object is brought to the nose and
back again
Quick Localization
Appendix M
Clinical Observations Worksheet
Clinical Observations Worksheet

Name: ___________________________________
DOB: __________________
Handedness:
Test Date: _______________
1. Muscle Tone: Sitting in chair; forearm supination; 90 degree shldr flexion; thumb
in hand
Hypertonic
Normal
Slightly hypotonic
Hypotonic
Right/Left Differences:
2. Eye Dominance:
3. Eye Movements:
4. Ramp Movements:
Ring made by fingers:

Paper Hole:
Kaleidoscope:
R / L
R / L
R / L
Independent Eye Closure:
Able / Unable
Across Midline:
Normal
Pursuits:
Normal
Convergence:
Normal
Quick Localization:
Normal
Smooth
5. Pronation/Supination:
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slightly Irregular
Jerky/Too Fast
Right: ___
Normal
Left: ___
Normal
Both: ___
Normal
6. Finger-Thumb Touching:
Hand: R / L
Hand: R / L
Hand: R / L
Right: ___
Normal
Left: ___
Normal
Both: ___
Normal
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor

7. In Hand Manipulation:
(using penny)
8. Tongue to Lip Movements:
Right: ___
Normal
Left: ___
Normal
Upper Lip:
Normal
Lower Lip:
Normal
Sides:
Normal
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
9. Cocontraction: (90 degrees shldr flexion, elbows slightly bent, hands fisted)
Elbow:
Normal
Slight Irregular
Poor
Neck: (rotation, downward pressure, sidebending)
Normal
Slight Irregular
Poor
Trunk: (rotation with examiners hands at shoulders)
Normal
Slight Irregular
Poor
10. Postural Insecurity:
(Balance board; long sit; lean backwards)

Normal
Slight Irregular
Poor
11. Equilibrium Reactions:

(reaching for pencil)
Quadruped:
Normal
Long Sitting:
Normal
Kneeling:
Normal
Standing:
Normal
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Poor
Slight Irregular
Slight Irregular
Slight Irregular
Poor
Poor
Poor
12. Protective Extension:

Long Sitting: Normal
Kneeling:
Normal
Standing:
Normal

13. Schilders Arm Extension: (90 degrees shldr flexion; eyes closed, pt. counts
to 10)
Arm Raising: R / L
Elbow Hyperextension: R / L
Coreoathetosis:
None
Slight
Definite
Position Changes of arms: None
Slight
Definite
(Eyes open; passive rotation of the head)
Trunk Rotation:
None
Slight
Definite
Head Resistance:
None
Slight
Definite
Discomfort:
None
Slight
Definite
14. Righting Reactions:
(standing)
Eyes Open: Normal
Eyes Closed: Normal
Absent
Absent
15. Prone Extension:
______ seconds
_______effort
16. Symmetrical TNR:
(quadruped)
No change in joint flexion or extension
Slight change in joint position
Definite change in joint position
17. Asymmetrical ATNR: Quadruped: No flexion with passive head turn

Slight flexion with passive head turn
Definite flexion or head resistance
Reflex Inhibiting Posture: (quadruped; hand on hip;
contralateral leg extended; snap finger and have pt.
look at you on the side of the hand on hip)
Assumes and maintains balance
Assumes with great difficulty
Cannot assume
18. Supine Flexion:
_____ seconds
19. Postural Background Movements:
______ effort
Normal
Slight Irregular
Poor
Appendix N
Sample Items

Sample Items
Fine Manual Control Composite
Motor Precision Subtest
Drawing Lines through Paths without touching the lines
Folding paper along a line
Fine Motor Integration Subtest
Copying a Circle
Copying a Star
Manual Coordination Composite
Manual Dexterity Subtest
Transferring Pennies from the desk to a box
Stringing Blocks
Upper-Limb Coordination Subtest
Catching a Tossed Ball Both Hands
Dribbling a Ball - Alternating Hands
Body Coordination Composite
Bilateral Coordination Subtest
Jumping Jacks
Tapping Feet and Fingers Opposite Sides Synchronized
Balance Subtest
Walking Forward on a Line
Standing on One Leg on a Line Eyes Closed
Standing Heel-to-Toe on a Balance Beam

Strength and Agility Composite
Running Speed and Agility Subtest
Shuttle Run
One-Legged Stationary Hop
Strength Subtest
Standing Long Jump
Sit-Ups
Selected From: Bruininks, R. H., & Bruininks, B. D. (2005). Bruininks-Oseretsky Test of

Motor Proficiency (2nd Edition). Circle Pines, Minnesota: AGS Publishing.
Appendix O
Sensory Integration and Praxis Tests
Descriptions and Examples

Sensory Integration and Praxis Tests
Descriptions and Examples
Subtest
Description
Space
Visualization
The child is asked to select which

of two shapes fits the given hole
Figure-Ground
Perception
The child is asked to identify three

figures within a more complex
picture
Standing and
Walking Balance
The child is asked to balance and

walk with eyes open and eyes
closed
Example
Offering an egg shape and a
diamond which fits the eggshaped hole?
Stand heel to toe

Stand, balance left foot, eyes
closed
Design Copying
The child is asked to copy abstract

drawings
Postural Praxis
The child is asked to imitate a static

position performed by the examiner
One hand on the side of the

head, other hand on the hip,
the head and trunk are leaning
Bilateral Motor
Coordination
The child is asked to imitate a

sequence of hand movements
Tap: Right hand, left hand,

right hand, left hand
Praxis on Verbal
Command
The child is asked to follow the

instructions for movement
Put both hands on your head

and bend your knees
Constructional
Praxis
The child is asked to build a

complex structure that is the same
as the given block structure
Postrotary
Nystagmus
The child sits on a spinning board

with his or her head forward 30
degrees. He or she is spun 10 times
in one direction and 10 times in the
other direction within 20 seconds
each time.
Motor Accuracy
The child is asked to trace a line

without leaving the line
Sequencing
Praxis
The child is asked to imitate a series Clap, Clap

of
progressively
difficult
Clap, Clap, Tap both hands
movements with hands and feet
Clap, Clap, Tap both hands,
Tap both hands
Oral Praxis
The child is asked to imitate oral Touch tongue to the upper

movements made by the examiner
lip, then the lower lip, two
times
Manual Form
Perception
The child is asked to identify the Circle

picture
or
the
shape
that
corresponds to a shape that was Star
placed in his or her hand with vision
Hexagon
occluded
Kinesthesia
The childs finger is moved from

one position to another, and he or
she is asked to return to the original
location with vision occluded
Finger
Identification
The child is asked to identify which Left ring and left little fingers
fingers were touched when vision are touched simultaneously
was occluded
Graphesthesia
The child is asked to use one finger An X is drawn on the back

to copy a line that was drawn on his of the hand
or her hand when vision was
occluded
Location of
Tactile
Stimulation
The child is asked to identify the

exact spot he or she was touched on
the hand or lower arm
Selected From: Ayres, A. J. (1989). Sensory Integration and Praxis Tests Manual. Los
Angeles: Western Psychological Services.
Appendix P
Description of the Sensory Integration and Praxis Tests for Parents
Appendix Q
Request For Assistance in Test Administration of Participants

University at Buffalo
Kimball Tower, Room 515
3435 Main Street
Buffalo, New York 14214
Date
To Whom It May Concern:

My name is Kristen Klyczek. I am a graduate student at the University at Buffalo, and I am
pursuing a Ph.D. in Rehabilitation Science. As part of my dissertation, I am planning to conduct
a study titled: The Effectiveness of Sensory Integration Therapy on the Sensory and Motor Skills
of Children with Aspergers Syndrome. I would like to request your assistance in testing study
participants.
For my study, a minimum of eight children who have Aspergers Syndrome will receive Sensory
Integration treatment, and the effect of this intervention will be measured by pre-, mid-, and poststudy testing. Clinical testing will include the Sensory Integration and Praxis Tests, the
Bruininks Oseretsky Test of Motor Proficiency, Second Edition, the Perceived Efficacy and Goal
Setting System, and Clinical Observations. It will also require parents to complete a demographic
survey, the Sensory Profile and the Asperger Syndrome Diagnostic Scale. I plan on conducting
much of the pre- and mid- study testing personally, however for study validity, it is important to
have an outside examiner perform post-study testing. I would greatly appreciate any time you
could offer for this purpose. Unfortunately, I do not have funding to compensate you for your
time, however I will cover the costs for all testing materials, and your generous work will be
recognized in my dissertation and in any subsequent publications or presentations should you
provide consent.
I am sure you can appreciate how critically important it is to support research that involves
treatment of children with disabilities. Completing smaller studies, such as this will hopefully
lead to larger-scale studies regarding the efficacy of treatment of children with Aspergers
Syndrome. I would appreciate your contacting me by telephone at 716-639-9201, or via email at
krarent@buffalo.edu to discuss this matter further. I will contact you in approximately two
weeks to see if I can provide any additional information and to obtain your decision. I will look
forward to speaking with you, and sincerely appreciate your consideration.
Sincerely,
Kristen Klyczek
PhD Student
Appendix R
Treatment Manual

The Effectiveness of Sensory Integration Therapy on the Sensory and Motor Skills
of Children with Aspergers Syndrome
Treatment Manual
Goals for Treatment:

The primary goal of SI therapy is to improve the ability of the nervous system to
interpret and organize sensory information. This can be accomplished by providing
child-centered sensory experiences at a just-right level of challenge that promote
interpretation and organization of sensory input within the childs nervous system in
order to improve the childs ability to interact with his or her environment.
Mode of Delivery:
The activities within this treatment manual are designed for a ten-week treatment
period using direct, one-on-one therapy. Sessions are designed to be provided for 45-60
minutes each. The provider, will be a licensed physical therapist who is trained and
certified in SI evaluation and intervention, and will conduct all treatment sessions. A
sensory integration frame of reference will be followed at all times.
Session activities will be child-directed whenever possible, however the types of
activities offered to the child will be based on the needs of the child, identified during
pretesting, previous sessions and that session itself. A list of treatment options has been
provided.
Equipment Specifications:
The following equipment is available for use during the study:
Suspended equipment: New swing, Platform swing, disc swing
Therapy Balls: Assorted sizes and shapes
Mats and Landing Cushions: Six mats: 910x 6 x 3
Mat Tables: Two: 7x 5 raised 21 off the floor, and two: 6x 4, 18 off the floor
Panel Mats: Three: 4 panels each
Wedges: Assorted sizes and shapes
Bolsters: Assorted sizes and shapes
Scooter boards
Tilt boards
T-stools
Adjustable benches
Ramp: 22 wide, extending 57
Mirrors: full length
Mini-trampoline
Floor balance beam: 8 x 4 x 1 high
Elevated balance beam
Tunnels: Rigid, flexible, and resistive tunnels
Weighted equipment: vests, toys, cuff weights
Blankets, elastic fabrics and resistive vests

Large manipulative toys and accessories including: Balls, hula hoops, ropes, theraband
Small toys including: plastic cones, bean bags, textured balls and objects, puzzles
Tactile toys and accessories including: rice buckets, bean buckets, creams (shaving), play
dough/clay, textured objects
Treatment Options:
What follows is a list of basic treatment options, which have been taken from
published lists that have been provided by experts in the field of SI. In addition,
modifications to treatment suggestions and additional ideas have been listed, in order to
properly utilize the available equipment and resources. The options listed provide a
framework for intervention with basic activity descriptions. Each activity will tailored to
match the childs interests or the intended functional purpose. For example, a prone
activity on a suspended swing, in which the child is throwing beanbag gold into a
basket might be altered by having the child ring hula hoop sprinkles around ice cream
cones (plastic cones) instead. Options are listed based on the primary need the activity
might address, however treatments that are on this list may also be appropriate for other
purposes. An example is a vestibular activity such as jumping on a trampoline, which
may also be used to provide increased proprioceptive awareness to a child. Therefore, as
long as the activity is listed, it may be used during intervention. The therapist will make
every attempt to use only those activities listed in this manual, however if an activity is
performed which is not listed, the therapist will describe both the activity and its purpose
in writing.

Vestibular Input
Purpose
Activity
Calming
Slow, rhythmic movements

Slow, linear swinging
Eyes in line with the horizon
Minimal visual stimulation
Alerting
Quick, unpredictable movements

Swinging in an angular pattern
Quick changes in direction
Visually stimulating environment
Use of suspended equipment
Activities with the body position
altered from neutral
Generalized Vestibular Input

(Useful for promoting eye contact,
Weight shifting quickly

Rolling or rocking activities (roll
up in
blankets, rolling obstacle course,
rock back
and forth while sitting and holding
hands)
Using the head in various positions
to move a ball
Rocking while seated on a bolster
or therapy ball
Rolling on the floor, or down an
incline
Swinging in prone, supine flexion,
sitting or standing (the therapist or
child initiates
the movement by holding ropes,
hoops, or objects, or by keeping
hands on the floor)
Walking up and down inclines, on
a balance beam, on rough surfaces,
with assistance as needed
Slides close to the floor with mats
Scooter Board (supine, prone,
sitting, or kneeling; on the floor, or
prone down an incline)
Being pulled on a piece of
cardboard while trying to maintain
extension, muscular cocontraction,

improving postural or gravitational security,
promoting improved equilibrium)

balance (prone, sitting, kneeling,
standing)
Tilt board (supine, prone, sitting,
kneeling, standing)
Movement activities to music
Bouncing on the floor, on a
trampoline, on a therapy ball or
Hippity-Hop toy
Turning, rotating, spinning
(independently, or using equipment
such as a Sit n Spin)
Gravitational Insecurity
Purpose
Activity
Prone activities on the ground
Rolling on the floor or mat
Rolling in a barrel
Proprioceptive activities
Linear activities such as swinging
on suspended equipment, or using a
scooter board (may have child knock
something over in the backwards
direction if he or she has a fear of
backwards movement)
Quadruped activities such as an
obstacle course
Reducing gravitational insecurity
Poor Posture
Purpose
Activity
Often low tone, poor postural stability, poor equilibrium reactions, decreased prone
extension, poor supine flexion together, indicate vestibular and proprioceptive
processing deficits
Facilitating extension against gravity
(Cocontraction of extensor muscles)
Prone propping activities

Supported prone activities using
extension of the neck and upper back
(activities that are in prone on
elbows)
Weight shifting in prone (on
extended elbows)
257
Obstacle course activities in

quadruped
Activities involving prone
extension of the body (such as being
prone in net swing or on a scooter
board with linear movement)
Prone extension with full support
of body weight (such as prone on a
swing, or climbing horizontally hand
over hand up ropes held by a
therapist)
Graded resistance activities (such
as pushing) in a prone position
Wheelbarrow walking with
proximal or other necessary support
Facilitating supine flexion
(Cocontraction of flexor muscles
Generalized activities to improve posture
Flexion of head and upper trunk

(such as
supine on a wedge, flexing the neck
to
blow bubbles)
Whole body flexion (supine on
wedge, flex legs to kick a ball
usually leads to lifting head to see
ball)
Provide resistance into flexion or
sustained flexion
Activities on a disc swing requiring
flexion to hold on
Scooter board activities in a
modified sitting position
Flexion against gravity and
resistance (supine on scooter - pull
across suspended rope, trapeze)
Elicit subtle reactions in various
positions (any moving activity or
reaching)
Platform swing activities
Therapy ball activities
Tilt board activities
Sit in swing, reach for beanbags, sit
up and throw
Scooter with two ropes about
258
6 feet apart pull on one to get near

the other one, grab turn and go back
Rolling in a barrel steamroll
over objects
Alternating flexion and extension
activities
(pump a swing)
259
Proprioceptive Input
Purpose
Calming
Activity
Slow, steady activities
Resistance activities
Slowly alternating pushing and
pulling
Firm, deep pressure: tight wraps,
blankets,
mats
Alerting
Quick, jerky movements

Activities involving stopping and
starting quickly
Generalized Proprioceptive Input
Firm, deep pressure: tight wraps,

blankets,
mats
Weights (provided via clothing,
(Useful for producing a calming effect,

promote body awareness, enhance motor
toys, cuff
planning, improve balance, alter muscle tone)
weights, weighted blankets)

Joint compression or traction
Scrubbing activities (using brushes,
sponges, washcloths)
Weight bearing and weight shifting
activities (in prone, quadruped,
sitting, kneeling, standing)
Locomotor activities: rolling,
crawling, hopping, skipping,
marching, stomping, clapping,
Therapy ball activities (prone on
hands, bouncing on the ball, pushing
or bouncing balls)
Bumping into and knocking down
objects
Hitting or punching activities
(balls, balloons, pillows)
Stair climbing
Heavy work: pushing, pulling,
carrying
heavy objects, lifting
260
Races pushing or carrying therapy

balls, medicine balls, weighted
objects
Tug of War
Resistance tunnels
Climbing activities up incline, or in
net
Jumping (on the floor, on a
trampoline, onto a soft surface)
Wheelbarrow walking (on hands)
or crawling
Push-ups, sit-ups
Tactile Input
Purpose
Activity
The following guidelines should be followed when providing tactile experiences to a

child with
poor tactile processing or integration:
1. Input should be child administered (choosing activities and the amount of
pressure and time)
2. Deep pressure is usually more tolerable, but some children prefer quick or light
touch, so determine what is appropriate for each child based on response
3. Input to the arms and legs (also back) is usually sufficient no need for whole
body
4. Apply input in the direction of hair growth or go back and forth
5. Provide proprioception first, then more tactile
6. Try enclosed spaces for providing new tactile/proprioceptive experiences
Calming
Warm temperatures
Deep touch pressure
Rolling balls, bolsters or other
objects over the child
Compression of the child with
mats, toys, hugging, wraps
Weight bearing activities
Smooth textures
Alerting
Rough textures
Cold temperatures
Light, inconsistent, unexpected or
pressure point touch
Touch in direction opposite of hair
growth
261
Touch to the face

Generalized Tactile Input
(Useful in improving acceptance of touch
and tactilely defensive situations)
Textured surfaces on equipment

(carpet, satin, corduroy, sheepskin)
Pulling child on various surfaces
Brushes
Vibrators
Dry textured objects and materials
(balls, toys, rice, beans fabrics, sand,
powder)
Ball bath
Writing with chalk, erasing with
hand
Wet textured objects and materials
(play dough or clay, grass, slimey,
sticky or gooey objects, finger paint,
water, bubbles, shaving cream,
lotion)
Obstacle courses that incorporate a
variety of textures
Enhancing sensory modulation

(decrease defensiveness)
Deep pressure
Weighted vests, backpacks, hats
Large pillows and mats for
burrowing
Large therapy balls roll over
child or child pushes against w/
therapist
Activities requiring the child to
move heavy objects such as pulling
on end of rope, barrels, therapist on
equipment
Theraband wrapped on skin
Proprioceptive activities
Jumping, bouncing
Vibration to arms and legs
Textured coverings on equipment
Textured mitts on skin
Searching for objects in boxes of
tactile experiences (beans, rice)
Ball pits
Resistance activities for the mouth,
such as sucking through a straw
(sour = organizing)
262
Toys, food, gum for chewing

Enhancing sensory discrimination
Tactile experiences
Identifying unseen objects
Have child describe or discriminate
various textures
Practic (Motor Planning) Disorders

Purpose
Activity
Ideation
Motor activities with familiar

objects or properties that respond to
slight actions (balls, blocks)
Obstacle course
Encourage the child to think of
new ideas for familiar equipment or
activities
Provide physical guidance for a
motor activity
Model the activity
Provide thorough instructions,
prompts or cues
Bilateral Limb Use
Activities involving both sides of

the body, such as pushing or pulling
activities using both sides of the
body
Volleyball activities with a balloon
Scooter board activities using both
arms or both legs, followed by
reciprocal movements
Sequenced activities (simon
says, games requiring a new skill to
be added to the series)
Activities on equipment involving
alternating movements of the arms or
legs (side to side or front to back)
Obstacle course
Active propulsion on equipment
while holding a stable or unstable
object (hula hoop or stick held by
therapist, a suspended rope)
Swinging side to side while child
holds on
263
Activities involving alternating

flexion and extension of the arms
Activities that require the child to
aim at specific targets (throwing,
touching, kicking, squirting) while
on a stable or moving surface
Whole body activities progressing
to movement of specific body parts
Resistance activities
Counting or singing a song while
performing an activity to keep the
rhythm
Create new activities with old
skills (jump onto mats one day and
into a hula hoop the next
Jumping, hopping, jumping jacks,
skipping, stride jumping
Stepping over moving objects
References
Bundy, A. Lane, S. & Murray, E. (2002). Sensory Integration Theory and Practice (2nd
Edition). Philadelphia, PA: F.A. Davis Company.
Fisher, A.G., Murray, E. & Bundy, A. (1991). Sensory Integration Theory and Practice.
Philadelphia, PA: F.A. Davis Company.
Huebner, R.A. (1992). Autistic Disorder: a neuropsychological enigma. The American
Shriber, L. (2004). Sensory Integration and Neurodevelopmental Therapy Course.
young children with autistic spectrum disorders. University of Washington.
Appendix S
Therapy Session Progress Note and Checklist
264
265
Therapy Progress Note and Checklist

Code Number: ____________________
Date of Session: _______________
Subjective:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Objective:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Assessment:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Plan:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
List All Activities Performed During The Session:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Additional Comments:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
266
1. Circle which items were targeted during this session:

Gustatory
Tactile
Olfactory
Auditory
Proprioceptive Bilateral CoordinationKinesthesia
2. Was the session one-on-one? Yes / No
Minutes
Vestibular
Praxis
Length of Session: __________
3. Approximately how many minutes were child directed? _____ Therapist

directed?_____
4. Did the therapist set up the equipment or arrange the room to entice the child into
choosing and engaging in an activity?
Yes / Somewhat / No
Comments:________________________________________________________
5. Did the therapist ensure physical safety of the child either through placement of
equipment or through therapists proximity and actions?
Yes / Somewhat / No
Comments:
_____________________________________________________________
6. Did the therapist work to sustain an optimal level of arousal?
Yes / Somewhat / No
Comments:
_____________________________________________________________
7. Did the therapist present or support activities in which the child could be successful in
response to the challenge?
Yes / Somewhat / No
Comments:
_____________________________________________________________
8. Did the therapist adjust the activity in response to the child, so that the activity was
neither too difficult, nor too easy?
Yes / Somewhat / No
Comments:
_____________________________________________________________
9. Did the therapist support the childs Self-organization of behavior by giving the child
chances to make choices and plan activities?
Yes / Somewhat / No
Comments:
_____________________________________________________________
10. Did the therapist maintain a context of play throughout the session?
Yes / Somewhat / No
Comments:
_____________________________________________________________
11. Did the therapist allow for active control and self direction by the child as much as
possible?
Yes / Somewhat / No
267
Comments:
_____________________________________________________________
12. Did the therapist work to connect with the child, build a sense of trust, convey a sense
of appreciation of the childs capabilities, respect the childs signs of distress and
assist in regaining a sense of comfort and competence?
Yes /
Somewhat / No
Comments:
_____________________________________________________________
This checklist has been adapted from work published in:
young children with autistic spectrum disorders: University of Washington.

The Efficacy of Sensory Integration Therapy On Children With Asperger's Syndrome and Pdd-Nos

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The Efficacy of Sensory Integration Therapy On Children With Asperger's Syndrome and Pdd-Nos

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NOTE TO USERS

Page(s) missing in number only; text follows. The

pgs. 223, 255, 256

This reproduction is the best copy available.

THE EFFICACY OF SENSORY INTEGRATION THERAPY

A dissertation submitted to the

Department of Rehabilitation Science

UMI Number: 3356047

The Efficacy of Sensory Integration Therapy

The Efficacy of Sensory Integration Therapy

The Efficacy of Sensory Integration Therapy

The Efficacy of Sensory Integration Therapy

II. LITERATURE REVIEW

Characteristics of Children with Aspergers Syndrome and Pervasive

The Efficacy of Sensory Integration Therapy

The Efficacy of Sensory Integration Therapy

The Efficacy of Sensory Integration Therapy

Mean Scores and Percentage of Recruited Participants Scoring

Percentage of Participants Scoring in the Probably Different or

Percentage of Participants Scoring in the Probably Different or

Percentage of Participants Whose Bruininks Oseretsky Test of

Percentage of Participants Scoring Below One Standard Deviation

Summary of Mean Scores and Repeated Measures ANOVA for

Summary of Mean Scores and Repeated Measures ANOVA for

Summary of Mean Scores and Repeated Measures ANOVA for

Summary of Mean Scores and Repeated Measures ANOVA for

Summary of Mean Scores and Repeated Measures ANOVA for

Summary of Mean Scores and Repeated Measures ANOVA for

Summary Table of Impairments and Areas of Improvement...

The Efficacy of Sensory Integration Therapy

Percentage of Participants Whose ASDS Scores Were Above the

Percentage of Participants Rated as Having Definite Differences

Percentage of Participants Rated as Having Definite Differences

Percentage of Participants Impaired on Selected Clinical

Mean Scores on Selected SIPT Items at Pretest, Midtest and

The Efficacy of Sensory Integration Therapy

Approval from the Institutional Review Board...

Sample Request for Support in Recruitment Procedures.

Letters of Support for Recruitment Procedures...

Radio and Written Advertisements..

Parent Information Letter and Invitation.

Parent Informed Consent Form

Childs Assent Form

Asperger Syndrome Diagnostic Scale Sample Items..

Sensory Profile Caregiver Questionnaire Sample Items..

Perceived Efficacy and Goal Setting System Sample Items

Clinical Observations Documentation Form...

Appendix M: Clinical Observations Worksheet....

Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Sensory Integration and Praxis Tests Descriptions and

Description of the Sensory Integration and Praxis Tests for

Request For Assistance in Test Administration of Participants .

Therapy Session Progress Note and Checklist ...

The Efficacy of Sensory Integration Therapy

The Efficacy of Sensory Integration Therapy

Autism Spectrum Disorders, including Aspergers Syndrome (AS) and Pervasive

The Efficacy of Sensory Integration Therapy 2

The Efficacy of Sensory Integration Therapy 3

The Efficacy of Sensory Integration Therapy 4

The Efficacy of Sensory Integration Therapy 5

The Efficacy of Sensory Integration Therapy 6

The Efficacy of Sensory Integration Therapy 7

The Efficacy of Sensory Integration Therapy 8