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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy


CRITICALLY APPRAISED TOPIC (CAT)
Focused Question:
Does Ayres' sensory integration (SI) treatment increase engagement and improve play skills in
children with autism/PDD and sensory deficits?
Prepared By:
Marissa Elder, OTS
Ot16.marissa.elder@nv.touro.edu
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014
Marissa Stendel, OTS
Ot16.marissa.stendel@nv.touro.edu
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014
Under the supervision of: Donna Costa, Donna Costa, DHS, OTR/L, FAOTA, Touro University
Nevada, donna.costa@tun.touro.edu
Date Review Completed:
10/8/2015
Clinical Scenario:
Autism Spectrum Disorder (ASD) is defined by the American Psychiatric Association as
being a complex developmental disorder that can cause problems with thinking, feeling,
language and the ability to relate to others (2015, para 1). The Center for Disease Control
(CDC) estimates that 1 out 68 children living in the United States has some form of ASD.

Researchers for the organization also speculate that ASD is found five times more in males than
females (CDC, 2015). Because the condition is categorized on a spectrum, there are various
types and severities of ASD, from more mild forms (occasionally referred to as Aspergers
Syndrome) or more severe cases. Another condition related to ASD is Pervasive Developmental
Disorder-Not Otherwise Specified (PDD-NOS). Children with ASD and PDD-NOS typically
experience deficits in a wide variety of skills, such as social, behavioral, executive, and sensory
integration skills. Engaging in these aspects of daily life is particularly challenging for an
individual with ASD. Watling and Dietz (2007) reported that children with ASD are less engaged
in important occupations than there typical developing counterparts. They advocate the use of
intensive participation in therapeutic activities in order to support children with these deficits. As
the number of children being diagnosed with ASD and PDD-NOS grows, the need for
occupational therapy services becomes more apparent.
Because children with ASD and PDD-NOS experience difficulty with socializing, behaving
appropriately, executive functioning and sensory-integrative skills, many of their meaningful
occupations can be compromised. The impairments experienced by children with ASD and PDDNOS impact nearly every occupation, with activities of daily living (ADL), instrumental
activities of daily living (IADL), education, and play being primary occupations impacted.
Deficits in play are some of the most apparent to outside parties and tend to be a priority of
treatment for children with ASD or PDD-NOS. Because engagement, behavioral and social skills
are typically a major areas for improvement in children with ASD or PDD-NOS, play is one of
the most difficult occupations for children with ASD or PDD-NOS to participate in on a regular
basis. Play, or lack thereof, is also the primary occupation that can serve as a catalyst for
behavioral outbursts. Watling and Dietz (2007) identified unwanted behaviors as being
aggression, aimlessness, self-injuring, and atypical motor movements and these can occur when
a child is frustrated or when he/she struggles to play like his/her peers. As a child with ASD or
PDD-NOS ages and progresses, the focus of treatment may shift from play to work, leisure, and
educational pursuits.
Treatment for children with ASD or PDD-NOS varies depending on the severity of each
individual childs deficits as well as the field of practice for professionals involved in the childs
treatment. Currently, there is no one pharmacological treatment for children with ASD or PDDNOS. However, according to the CDC (2015), medications that influence energy levels, mood,
and attention may be appropriate for a child with ASD or PDD-NOS, depending on his/her
individual impairments. Other treatments for children with ASD or PDD-NOS focus on lifestyle
changes or supports that can improve everyday functioning. Therapies, including physical
therapy, speech therapy, and occupational therapy, can help minimize undesired behaviors or
impairments and maximize positive support systems. The occupational therapy profession
believes that health and well-being is established through engagement in meaningful activities
(AOTA, 2008). One technique used by occupational therapists to address deficits seen in

engagement in occupations for children with ASD or PDD-NOS is sensory integration. Sensory
integration (SI) treatment is based on the assumption that neurological processes associated with
sensation can be disrupted, causing abnormal behavioral responses. The goal of this treatment
tool is to elicit an adaptive motor response through the use of controlled sensory experiences
(Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson, 2011, Level I). Sensory integration has the
potential to be a cost-effective means of addressing deficits in occupation, particularly in play,
for children with ASD or PDD-NOS who experience problems integrating their senses (Pfeiffer,
Koenig, Kinnealey, Sheppard & Henderson, 2011, Level I). By decreasing undesirable behaviors
and encouraging engagement, treatments rooted in sensory integration theory may improve
meaningful, occupational participation in children with ASD or PDD-NOS.
Summary of Key Findings:
Summary of Levels I, II and III:
Level I studies determined the following:
The OT-SI group made gains that were significantly greater than the children in
the placebo and regular activity groups on the Goal Attainment Scale (GAS)
(Miller, Coll, & Schoen, 2007, Level I).
o OT-SI group also increased significantly more than the other groups on
Attention and on the Cognitive/Social Composite of the LeiterR
assessment (Miller, Coll, & Schoen, 2007, Level I).
Attainment of parent goals in the GAS and a decrease in autistic mannerisms
were seen in significant amounts in the SI treatment group, but all other results
on the Sensory Processing Measure (SPM), Vineland Adaptive Behavior Scales,
2nd edition (VABS-II),and Quick neurological screening test (QNST-II) for this
group proved insignificant (Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson,
2011, Level I).
Those who received SI treatment scored significantly higher on the GAS (p
value of .003) (Schaaf, Benevides, Mailloux, Faller, Hunt, Hooydonk, & Kelly,
2013, Level I).
Children who received SI treatment also had a decrease in caregiver assistance in
self-care and social skills (p value of .039), as defined by the Pediatric
Evaluation of Disability Inventory (PEDI) (Schaaf, Benevides, Mailloux, Faller,
Hunt, Hooydonk, & Kelly, 2013, Level I).
Level II studies determined the following:
Results indicated an improvement for both the SI treatment and control groups in
their overall play skills within the context of pre-school over a short 12 week
period (Dunbar, Carr-Hertel, Lieberman, Perez & Ricks, 2012, Level II).
No Level III studies were reviewed.

Summary of Level IV and V:


Level IV studies determined the following:
Based on categories of the Engagement Check, the results indicated that mastery
play revealed significance for four out of five children with ASD after they
received SI treatment. However, none of the children received significant scores
in peer interaction (Case - Smith, & Bryan, 1999, Level IV).
Significant improvements were noted in the areas of social interaction, approach
to new activities, response to holding and hugging, and response to movement in
two children with ASD under the age of three. Participants also demonstrated
significant gains in all functional behaviors observed in the context of the home
(Linderman & Stewart, 1999, Level IV).
Visual inspection revealed improvements in Sensory Profile scores for four male
children aged three to four with a diagnosis of ASD who received SI treatment.
However, no statistical data or evidence was provided (Watling & Dietz, 2007,
Level IV).
Level V studies determined the following:
Researchers used a pre and post t-test to determine improvements in
occupational performance and sensory integration in a five year old male with
ASD and ADHD who received SI treatment. None of the data proved significant
or generalizable (Schaaf, Hunt, & Benevides, 2012, Level V).
Contributions of Qualitative Studies:
Not included in this review
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:


The clinical and community-based practice of OT:
Evidence has shown that mastery play can be an area of focus during OT/SI interventions
(Case - Smith, & Bryan, 1999, Level IV).
Education and Sensory Integration (Dunbar, Carr-Hertel, Lieberman, Perez & Ricks,
2012, Level II)
o SI has now been introduced into other practice settings, such as in educational
institutions.
o Teaching SI principles to other professionals who work with children with ASD or
PDD-NOS, such as teachers, can be helpful in expanding the richness of a sensory
environment for those children with sensory deficits.
Supports the role of consultation in occupational therapy.

The studies suggest creating novel multisensory experiences for children may create
functional gains in children with PDD (Linderman & Stewart, 1999, Level IV).
The research illustrates how attentional deficits in children with ASD could be addressed
within the confines of SI treatment (Miller, Coll, & Schoen, 2007, Level I).
Goal Attainment Scale (GAS)
o The GAS assessment can be helpful in evaluating if SI treatment has been found
to be useful with the population. However, many other assessments that are meant
to evaluate the same behaviors and did not show any significant differences in
behaviors (Schaaf, Benevides, Mailloux, Faller, Hunt, Hooydonk, & Kelly, 2013,
Level I).
o There is a disparity between parent-made goals and practitioner-made goals on
the GAS.
Therapist can use this information to bridge the gap between parent-made
goals and expected treatment outcomes (Pfeiffer, Koenig, Kinnealey,
Sheppard & Henderson, 2011, Level I).
The results outlined how manualized protocol can be used within the context of OT
practice and SI treatment (Schaaf, Hunt, & Benevides, 2012, Level V).
OTs can utilize the importance of finding subtle nuances in childrens behavior, as
demonstrated in the literature, to refine their current practices and sensory integration
treatment plans (Watling & Dietz, 2007, Level IV).

Program development:
Because the Engagement Check is a valid and reliable outcome measures, there is a
potential to utilize the Engagement Check as a foundation for a program focused on
improve areas of engagement in children with ASD (Case - Smith, & Bryan, 1999, Level
IV).
Creating more programs to be implemented in schools systems can encourage program
outcomes similar to those reported in the literature across the nation (Dunbar, CarrHertel, Lieberman, Perez & Ricks, 2012, Level II).
This program would need to be expanded and researched with a larger population for
generalizability. Because it is known that novel experiences for each child will be
different, sensory gyms and various therapeutic tools will be necessary to start a sensory
integration program that will successfully address the needs of individual children
(Linderman & Stewart, 1999, Level IV).
The evidence lays groundwork for a SI treatment program that addresses the needs of
children with a wide range of diagnoses and disorders (i.e. ADHD, LD, etc.) (Miller,
Coll, & Schoen, 2007, Level I).
o Specifically outlines possible treatment sessions design that can address the needs
of children PDD-NOS (Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson,
2011, Level I).
o SI care has been identified to work better for children than usual care (UC). This

leads to the notion that UC should be improved (Schaaf, Benevides, Mailloux,


Faller, Hunt, Hooydonk, & Kelly, 2013, Level I).
Provided ten core principles of SI that could be used to structure an SI program for
children with ASD and ADHD (Schaaf, Hunt, & Benevides, 2012, Level V).
This study indicates a need to create a legitimate study design that uses statistical analysis
to understand findings in future research (Watling & Dietz, 2007, Level IV).

Societal Needs:
This study addresses societal needs because it focuses on proving the efficacy of SI
treatment to the general public.
o This can provide parents, healthcare providers, and consumers with the needed
information to form an informed opinion about the implication of SI treatment in
our society (Case - Smith, & Bryan, 1999, Level IV).
The high rate of incidence for ASD in this country is in need for further services like
these where an OT and teacher combine forces to help these children with deficits
(Dunbar, Carr-Hertel, Lieberman, Perez & Ricks, 2012, Level II).
Addressing needs of children who have hypo/hypersensitivity can help to merge special
needs clients into integrated classrooms (Linderman & Stewart, 1999, Level IV).
The research attempts to provide justification for the implementation of SI treatment
throughout various clinical settings, particularly hospital-based settings (Miller, Coll, &
Schoen, 2007, Level I).
The literature addressed the need to determine which sensory-related assessment tool is
most appropriate to use when measuring goals for children with PDD-NOS and ASD
enrolled in a SI treatment program (Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson,
2011, Level I).
o UC should be improved in some areas such as sensory deficit care in order to
better serve the community (Schaaf, Benevides, Mailloux, Faller, Hunt,
Hooydonk, & Kelly, 2013, Level I).
This research sets a foundation for future research in SI treatment and OT, which could
benefit society as a whole (Schaaf, Hunt, & Benevides, 2012, Level V).
The creation of programs that address needs of children with all types of SI deficits is
essential (Watling & Dietz, 2007, Level IV).
Healthcare delivery and policy:
This evidence promotes the use of valid and reliable assessment tools as a part of
healthcare delivery because it illustrates the clinical utility of the Engagement Check
(Case - Smith, & Bryan, 1999, Level IV).
Creating policy to better implement OTs into classrooms could help to decrease deficits
in children (Dunbar, Carr-Hertel, Lieberman, Perez & Ricks, 2012, Level II).
Further delivery of SI treatment and use of assessments with children demonstrates the
process of refinement and need for these OT services within the community and home

setting (Linderman & Stewart, 1999, Level IV).


Demonstrates how the GAS can be used to assess a childs goals in relation to SI
treatment plans and how the process can then be documented (Miller, Coll, & Schoen,
2007, Level I).
Articulated a possible duration and frequency of SI treatment that effectively addressed
of the needs of each individual participant.
o This was done by proving that the suggested duration and frequency was
inefficient (Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson, 2011, Level I).
Increases in SI care and decrease or improvements to UC interventions and
implementation among healthcare professionals may benefit society as a whole (Schaaf,
Benevides, Mailloux, Faller, Hunt, Hooydonk, & Kelly, 2013, Level I).
The results suggests an appropriate frequency and intensity for SI treatments in practice
(Schaaf, Hunt, & Benevides, 2012, Level V).
The research suggests that practitioners ensure that healthcare delivery of SI treatment is
legitimate and backed by objective assessments (Watling & Dietz, 2007, Level IV).

Education and training of OT students:


This study can be used to illustrate to OT students how to structure an ABAB design
study. It can also be used to encourage discussion on the effectiveness of SI treatment in
practice versus what the literature has stated about SI treatment (Case-Smith & Bryan,
1999, Level IV).
Gaining hands on experience in the classroom with children and organizing SI treatment
can better help train students for the work force (Dunbar, Carr-Hertel, Lieberman, Perez,
Ricks, 2012, Level II).
Engaging students during class time with more sensory interventions for certain types of
sensory deficits will help to better their skills when out in practice (Linderman & Stewart,
1999, Level IV).
Can provide a real-life example for students of the purpose of the Leiter-R as well as how
it can be implemented into practice. Can be used to teach students the components of a
true RCT study (Miller, Coll, & Schoen, 2007, Level I).
Provided real-life examples for students/educators/readers of what activities are included
in a SI treatment program versus a fine motor program (Pfeiffer, Koenig, Kinnealey,
Sheppard, Henderson, 2011, Level I).
Train OT students how to incorporate more SI principles in their UC to facilitate better
outcomes (Schaaf, Benevides, Mailloux, Faller, Hunt, Hooydonk, & Kelly, 2013, Level
I).
Teaches students how to run a pre and post t-test to determine improvements in
performance (Schaaf, Hunt, & Benevides, 2012, Level V).
Educate on task engagement for children with ASD using multimodal means of
intervention (Watling & Dietz, 2007, Level IV).

Refinement, revision, and advancement of factual knowledge or theory:


The research examines how SI treatment can be utilized to influence the occupation of
play versus ADLs, which are what is typically examined. By examining occupations
outside of ADLs, the study refines the implementation of SI treatment (Case - Smith, &
Bryan, 1999, Level IV).
This study advances typical SI treatment by moving the application of its principles from
the setting of an outpatient sensory gym to a local pre-school (Dunbar, Carr-Hertel,
Lieberman, Perez & Ricks, 2012, Level II).
This study revises typical SI treatment protocol by utilizing the Functional Behavior
Assessment for Children with Sensory Integrative Dysfunction instead of the SIPT to
measure improvements in sensory processing and quality of motor movements after
implementing SI treatment (Linderman & Stewart, 1999, Level IV).
The research attempts to expand SI theory to address areas of executive functioning in
addition to motor praxis and sensory modulation (Miller, Coll, & Schoen, 2007, Level I).
The research provides information to guide future higher level research studies on SI,
specifically a model of how SI treatment studies involving RCTs should be conducted
(Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson, 2011, Level I).
This study seeks to advance knowledge on what usual care is defined as amongst
healthcare professionals involved in the treatment of children with ASD (Schaaf,
Benevides, Mailloux, Faller, Hunt, Hooydonk, & Kelly, 2013, Level I).
This research advocates using the theoretical background behind the SIPT in conjunction
with theories supporting other sensory-related outcome measures (Schaaf, Hunt, &
Benevides, 2012, Level V).
This study seeks to advance the use of the Sensory Profile as a diagnostic tool for
sensory-related deficits as well as an assessment tool to track a child with ASD progress
over time after receiving SI treatment (Watling & Dietz, 2007, Level IV).
Review Process:

PICO area chosen; preliminary search done to ensure literature support of question and
need for systematic review.
Focus Question identified; submitted to instructor for review
Revised and finalized focus question; submitted to instructor
Finalized focus question approved by instructor
Inclusion/exclusion criteria identified and approved by instructor. The articles which did
not meet PICO of focused question were removed; articles which matched PICO were
pulled from systematic reviews and systematic reviews eliminated.
Development of medical subject headings (MeSH) terms and non-MeSH key words
Thorough Literature Search conducted; submitted to instructor by discussion board for
feedback; no additional articles found

Full text articles were then reviewed


Evidence Table created and submitted to instructor
Summarized results to create critically appraised topic (CAT)
CAT worksheet submitted to instructor

Procedures for the Selection and appraisal of articles:


Inclusion Criteria:

Articles were peer reviewed, and written in English


Articles must be published between 1999-2015
Must include play as means for intervention
Must include elements of PICO question
Must have diagnosis of Autism Spectrum Disorder, and/ or Pervasive Developmental
Disorder with sensory deficits.
Level I-V of research

Exclusion Criteria:

Any articles outside of our requested year published


Non-English written articles
Persons over the age of 21 years
Must not be receiving SI treatment from other therapy sources while enrolled in study
Dissertation or master thesis

Search Strategies:
Categories
Patient/Client Population

Intervention

Outcomes

Key Search Terms


Child; children; autism spectrum disorder; pervasive
developmental disorder; ASD; PDD; sensory deficit; children
with autism; sensory integration and children with autism;
randomized control trial and sensory and autism.
Ayres sensory integration; sensory integration; sensory
integration treatment; sensory treatment; treatment for sensory
deficits; Ayres sensory integration with children; Ayres
sensory integration children with autism; sensory integration
with pervasive developmental disorder.
Play skills; increase play; sensory play; play in children.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Databases and Sites Searched


Cumulative Index of Nursing and Allied Health Literature (CINHAL), SAGE Publications
(SAGE), Occupational Therapy Search Database (OT Search), OTDbase, Google Scholar, AOTA
(website utilized to research American Journal of Occupational Therapy (AJOT) articles), and
additional a hand searching of bibliographies was performed.
Quality Control/Peer Review Process:

The focus question was created by two Touro University Nevada Master of Occupational
Therapy students.
Faculty reviewed the focused question and provided feedback: 07/21/2015
Search terms developed by the student based on PICO.
An exhaustive search of multiple databases (6) using the identified search terms was
completed by the students.
Hand searching of bibliographies of articles which partially match PICO was performed;
two additional articles were found.
Comprehensive literature search table was reviewed by faculty; no additional articles
were found: 09/16/2015.
Faculty review of evidence table: 10/08/2015
Articles synthesized on Critically Appraised Topic worksheet for review by faculty.
Independent consultation with faculty occurred throughout the process to answer any
questions that arose.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I
II
III
IV

Study Design/Methodology of Selected Articles


Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g., cohort,
case-control)
One group, nonrandomized (e.g., before and after,
pretest, and posttest)
Descriptive studies that include analysis of outcomes

Number of Articles
Selected
3
1
0
3

(single subject design, case series)


Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Qualitative Studies
TOTAL:

V
Other

1
0
8

Limitations of the Studies Appraised:


Levels I, II, and III

Small sample size with limited ability to generalize results. Article used varying
approaches with help from teachers integrated in classroom time that may have
affected the participants outcomes (Dunbar, Carr-Hertel, Lieberman, Perez,
Ricks, 2012, Level II).
54% of the data was unusable (either pretest or posttest data were not of good
enough quality to use on 13 children). Sample sizes were too small (revealed via
post hoc power analysis), and contained a homogenous sample size (most
participants were Caucasian and male) (Miller, Coll, & Schoen, 2007, Level I).
This study did not demonstrate carrying over of interventions into the daily
routine of the child. The authors did not account for all variables that could have
influenced the results, and overall a very short period of time for interventions
was allotted (Pfeiffer, Koenig, Kinnealey, Sheppard, Henderson, 2011, Level I).
Although this study examined objective measures over many assessments their
sample size, sample diversity, and lack of additional assessments to support the
GAS limit their outcomes significance (Schaaf, Benevides, Mailloux, Faller,
Hunt, Hooydonk, & Kelly, 2013, Level I).

Levels IV and V

Limitations of this article include the authors of study providing treatment to


participants, and a small sample size. Other limits include all same sex
participants, and applied behavioral analysis (ABA) therapy being provided to
one participant for 40 hours a week concurrent with the studies SI treatment.
Other notes that might be considered limitations are comorbidities in participants
such as bipolar disorder, and hearing impairment (Case-Smith & Bryan, 1999,
Level IV).
Further research is needed to replicate and extend findings. Several limits within
the study include that one of participants had been receiving SI treatment prior to
study, and the presence of a video camera in the home of participant two could
have altered behavior and thus the validity of data. The authors also collected
interrater reliability of the study themselves (Linderman & Stewart, 1999, Level

IV).
This study was limited by a small sample size of only one child, hindering the
generalizability of the studies outcomes. Also, the authors cited research
conducted by themselves from other studies which can be indicated as bias in
justification for research. Lack of statistical significance limits implications for
future research and practice (Schaaf, Hunt, & Benevides, 2012, Level V).
This research was limited by a lack of statistical support utilized to analyze the
significance of findings. It was also limited by subjective testing bias related to
the questionnaire nature of the Sensory Profile, and by a small sample size of
only four children (Watling & Dietz, 2007, Level IV).
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:


Case - Smith, J., & Bryan, T. (1999). The effects of occupational therapy with sensory
integration emphasis on preschool-age children with autism. American Journal of
Occupational Therapy, 53, 489-497. doi:10.5014/ajot.53.5.489
Dunbar S, Carr-Hertel J, Lieberman H, Perez, B., Ricks K. A pilot study comparison of sensory
integration treatment and integrated preschool activities for children with autism. The
Internet Journal of Allied Health Sciences and Practice, 10(3), 1-8.
Linderman, T. M., & Stewart, K. B. (1999). Sensory integrative-based occupational therapy and
functional outcomes in young children with pervasive developmental disorders: A singlesubject study. American Journal of Occupational Therapy, 53, 207-213.
doi:10.5014/ajot.53.2.207
Miller, L.J., Coll, J.R., & Schoen. S.A. (2007). A randomized controlled pilot study of the
effectiveness of occupational therapy for children with sensory modulation disorder.
American Journal of Occupational Therapy, 61, 228-238. doi:10.5014/ajot.61.2.228
Pfeiffer, B.A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Research
scholars initiativeeffectiveness of sensory integration interventions in children with
autism spectrum disorders: A pilot study, American Journal of Occupational Therapy, 65,
76-85. doi:10.5014/ajot.2011.09205
Schaaf, R., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., Hooydonk, E., Kelly, D. (2013). An
intervention for sensory difficulties in children with autism: A randomized trial. Journal
of Autism and Developmental Disorders, 44, 14931506. doi:10.1007/s10803-013-1983-8

Schaaf, R. C., Hunt, J., & Benevides, T. (2012). Occupational therapy using sensory integration
to improve participation of a child with autism: A case report. American Journal of
Occupational Therapy, 66, 547555. doi:10.5014/ajot.2012.004473
Watling, R. L., & Dietz, J. (2007). Immediate effect of Ayress sensory integrationbased
occupational therapy intervention on children with autism spectrum disorders. American
Journal of Occupational Therapy, 61, 574583. doi:10.5014/ajot.61.5.574
Other References:
Autism spectrum disorder: Data and statistics. (2015, August 17). Retrieved September 29, 2015.
From: http://www.cdc.gov/ncbddd/autism/index.html
Help With Autism Spectrum Disorder. (2015, January 4). Retrieved September 27, 2015. From:
http://www.psychiatry.org/patients-families/autism