Research in Developmental Disabilities 47 (2015) 334–351

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review article

Systematic review of sensory integration therapy for

individuals with disabilities: Single case design studies
H.M. Leong *, Mark Carter, Jennifer Stephenson
Macquarie University Special Education Centre, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Sensory integration therapy (SIT) is a controversial intervention that is widely used for
Received 10 December 2014 people with disabilities. Systematic analysis was conducted on the outcomes of 17 single
Received in revised form 22 September 2015 case design studies on sensory integration therapy for people with, or at-risk of, a
Accepted 23 September 2015
developmental or learning disability, disorder or delay. An assessment of the quality of
Available online 23 October 2015
methodology of the studies found most used weak designs and poor methodology, with a
tendency for higher quality studies to produce negative results. Based on limited
Keywords:
comparative evidence, functional analysis-based interventions for challenging behavior
Sensory integration therapy
Outcome studies were more effective that SIT. Overall the studies do not provide convincing evidence for
Developmental disabilities the efficacy of sensory integration therapy. Given the findings of the present review and
Meta-analysis other recent analyses it is advised that the use of SIT be limited to experimental contexts.
Evidence-based practice Issues with the studies and possible improvements for future research are discussed
including the need to employ designs that allow for adequate demonstration of
experimental control.
ß 2015 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
2.1. Study screen and selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
2.2. Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
2.3. Interrater reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3.1. Participants and treatment inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3.2. Outcomes and forms of assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3.3. Treatment and procedural integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3.4. Process scores and structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3.5. Study designs and quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
3.6. Claimed results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

* Corresponding author at: Macquarie University Special Education Centre, Institute for Early Childhood, Macquarie University, NSW 2109, Australia.
E-mail address: danleohanming@gmail.com (H.M. Leong).

http://dx.doi.org/10.1016/j.ridd.2015.09.022
0891-4222/ß 2015 Elsevier Ltd. All rights reserved.
 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351 335

1. Introduction

Sensory integration therapy (SIT) was originally conceived for children with learning disabilities who were thought to
have a sensory integration dysfunction (Ayres, 1972b) or sensory processing disorder (Miller, Anzalone, Lane, Cermak, & Osten,
2007). SIT is now more commonly used by occupational therapists for children with autism (Case-Smith & Miller, 1999;
Goin-Kochel, Myers, & Mackintosh, 2007; Green et al., 2006; Hess, Morrier, Heflin, & Ivey, 2008; Thomas, Morrissey, &
McLaurin, 2007) but has also been explored for an extensive variety of other conditions and populations such as severe
trauma (Alers, 2005) and complex post-traumatic stress disorder (Kaiser, 2007), process schizophrenia (Blakeney, Strickland,
& Wilkinson, 1983), developmental coordination disorder (Davidson & Williams, 2000), institutionalized children (Cermak,
2001; Lin, Cermak, Coster, & Miller, 2005), nursing home residents (Gielow & Hobler, 1986) and dementia (Robichaud,
Hebert, & Desrosiers, 1994).
The rationale for the use of SIT is that it purports to help correct sensory processing disorders, which is claimed to lead to
gains in higher order learning skills (Ayres, 1972b, p. 27) such as language (Ayres & Mailloux, 1981), academic skills such as
reading and writing (Ayres, 1972a), and motor coordination (Ayres, 1977). More recent research on SIT often focuses less on
the effects on language and writing skills and more on the reduction of problem behaviors such as stereotypic behavior and
self-injurious behavior (Smith, Press, Koenig, & Kinnealey, 2005) and poor task engagement (Urwin & Ballinger, 2005).
The main component of SIT involves controlled provision of sensory stimulation (Ayres, 1972b, pp. 114–115) in order to
elicit a response from the student, called an adaptive response. The adaptive response is thought to be an important indicator
of successful modification of the neurological systems that process sensory information (Ayres, 1972b, pp. 125–126). SIT was
suggested to be particularly effective for younger children in the belief that the higher plasticity of their younger brains
would ease the change in the neurological system (Ayres, 1972b).
SIT is usually delivered in dedicated individual or small group sessions, but different practices related to the sensory
integration framework have also been explored (Pollock, 2009). These include the sensory diet, where sensory-based
activities are arranged in the natural environment (Baranek, 2002); the Wilbarger Protocol, which involves a brushing
component and joint compression as well as the sensory diet (Wilbarger & Wilbarger, 1991); and the use of weighted vests
(Olson & Moulton, 2004). Intervention practices which adhere to core principles of Ayres’ original framework have been
trademarked as Ayres Sensory Integration1 (Smith Roley, Mailloux, Miller-Kuhanek, & Glennon, 2007).
In spite of its popularity, the efficacy of SIT is controversial (Pollock, 2009). There have been many descriptive reviews
based on primary sources (Arendt, MacLean, & Baumeister, 1988; Baranek, 2002; Dawson & Watling, 2000; Lang et al., 2012;
Leong & Carter, 2008; May-Benson & Koomar, 2010; Smith, Mruzek, & Mozingo, 2005) and integrative reviews examining
primary sources and/or previous synthesis (e.g., American Academy of Pediatrics, 2012; Hoehn & Baumeister, 1994; Hyatt,
Stephenson, & Carter, 2009; Maine Administrators of Services for Children with Disabilities, 2000; Myers & Johnson, 2007;
National Autism Center, 2009; National Research Council, 2001; Perry & Condillac, 2003; Roberts, Prior, Rodger, & Williams,
2011; Simpson, 2005; Williames & Erdie-Lalana, 2009), but only three published meta-analyses on group design studies
(Leong, Carter, & Stephenson, 2014; Ottenbacher, 1982b; Vargas & Camilli, 1999). Although some reviews have included
single case studies (Case-Smith, Weaver, & Fristad, 2014; Lang et al., 2012; May-Benson & Koomar, 2010), there do not
appear to have been any that have exclusively examined this type of research. Apart from a few dissenting opinions (Case-
Smith et al., 2014; May-Benson & Koomar, 2010; Ottenbacher, 1982b), the consensus of most reviews is that there is only
weak evidence that SIT is an effective intervention for people with disabilities.
Group research designs typically involve between-individual comparisons across groups with large numbers of
participants, who are ideally randomly assigned to conditions. In contrast, single case designs use within-individual
comparisons, employ repeated measures and often compare performance between baseline an intervention phases (Kazdin,
1982; Vannest, Davis, & Parker, 2013). While evidence from randomized group trials is considered the gold standard for
demonstrating the efficacy of an intervention, single case design studies may also prove useful in evaluation. For example, a
substantial body of evidence based on single case research has been accumulated to support many applied behavior analysis
techniques. Single case research offers a number of specific advantages over group studies. High quality research can be
conducted with good control over threats to internal validity with relatively modest resources. In addition, large samples are
not required as single case research designs typically utilize within-subject controls. Finally, single case designs allow
exploration of individual responses to intervention and facilitate adjustment of interventions during treatment phases. Thus,
designs of this type may complement group studies in terms of providing insight into an intervention. In addition,
methodology and quality criteria for evaluating research single case designs are substantially different from those employed
in group designs. Most reviews focus on research using group designs only or a combination of group case studies and single
case designs, and there appear to be no reviews that focus exclusively on single case research. Case-Smith et al. (2014), Lang
et al. (2012), and May-Benson and Koomar (2010) reviewed single case design studies together with group designs and case
studies. The review of May-Benson and Koomar (2010) had a number of important flaws including absence of reliability
checks on article selection and data extraction. The review of Lang et al. (2012), was limited to individuals with autism
spectrum disorder (ASD), and included weighted vests and sensory diets as well as standard SIT. They noted poor research
designs in many of the studies reviewed, and concluded that the studies presented low quality evidence to support the use of
SIT. Case-Smith et al. (2014) included only one single case study (Watling & Dietz, 2007) in their review and concluded more
research was needed. Thus, there is a case for examining single case studies exploring the effects of SIT that extends beyond
participants with ASD.
336 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

The present study was a systematic review of research which examined SIT using single case research designs for people
with, or at-risk of, a developmental disability, disorder, or delay. This review extends the scope of previous reviews (Lang
et al., 2012; May-Benson & Koomar, 2010) by including an evaluation the integrity of intervention, and a more rigorous
systematic analysis of study quality criteria relevant to single case designs.

2. Method

2.1. Study screen and selection

The literature search procedure was similar to that described by Leong et al. (2014). A summary of the article selection
process is provided in Fig. 1 with interrater reliability where available. A literature search was conducted in August 2013 in
the ERIC, A+ Education, Psycinfo, CINHAL, and MEDLINE databases using the search terms ‘‘sensory integrat*’’, ‘‘Wilbarger
Protocol’’, ‘‘sensory diet’’ and ‘‘weighted vest*’’, where ‘‘*’’ represents truncation. The abstracts of articles from this literature
search were examined by two authors to determine if the studies examined the effects of SIT (or specific related
interventions including sensory diet, Wilbarger Protocol, and weighted vests). Further examination for reported empirical
outcome data for participants was conducted by the first author and either the second or third author. The full texts of papers
that fulfilled those criteria were obtained for further review. In addition, 11 studies not previously found through the
database search were identified from the reference lists of five major reviews on sensory integration therapy (Baranek, 2002;
Dawson & Watling, 2000; May-Benson & Koomar, 2010; Ottenbacher, 1982b; Vargas & Camilli, 1999), and the full texts of
these articles were also obtained for further review.
Full text articles were examined in two stages by two authors. For the first stage, studies were included if the study
reported empirical outcomes for participants and classic forms of SIT were used. Classic forms of SIT were defined as
interventions that were sensory based, were identified by the authors of the study as SIT based on Ayres’ theoretical
framework, and were implemented in a clinical setting. A total of 108 studies potentially appropriate studies were identified.
For the second stage, the remaining 108 studies were systematically reviewed to determine if they employed an
acceptable single case design and if they reported outcomes of the use of classic SIT for participants who had, or were at-risk
of, a developmental or learning disability, disorder, or delay. Criteria for acceptable single case design included within
subject comparisons of outcomes, the presentation of repeated measures data in phases, and experimental control over
timing of phases. Studies that did not have an acceptable single case design were excluded. For example, the study by Ayres
and Mailloux (1983) had features of single case design but the researcher did not have control over the timing of phases and
it was therefore excluded. Similarly, for the study by Wells and Smith (1983), one of the outcomes was excluded as the
second ‘A’ phase in an ABAB design was not planned and was not under the experimenters’ control. The 17 studies remaining
after both screening processes were used in the final coding process.

2.2. Coding

The 17 studies included were coded for information relevant to the review. General features of SIT present in the study
were recorded, including whether it was explicitly described as SIT, whether the authors referenced Ayres’ theories, whether
dedicated SIT sessions were provided, the use of vestibular, tactile, and/or proprioceptive stimulation, the use of other
sensory stimulation, the use of other interventions in conjunction with classic SIT, such as the use of sensory diets, weighted
vests or the Wilbarger Protocol (brushing, joint compression and sensory diets), and use of any other SI based strategies.
A common criticism of SIT studies is that the interventions may not have complied with the principles of sensory
integration therapy (Clark & Primeau, 1988; Healy, Hughes, Leader, & Devlin, 2011; Kimball, 1988; Schaaf & Blanche, 2011).
Thus, studies were examined for the presence of the ten essential process elements identified in the instrument developed by
Parham, Roley, Mailloux, Koomar, and Bodison (2011) and Parham, Roley, May-Benson, et al. (2011). In addition, the
procedural reliability measures (manualized treatment, informal procedural reliability checks without data, or formal
checks with data) present were recorded, as well as whether the delivery of the intervention was by an occupational
therapist with training in SIT.
The demographic data recorded were the number of participants; age; and presence of a learning disability, intellectual
disability, pervasive developmental disabilities, and other disabilities. The inclusion criteria used to select participants were
recorded according to whether there was evidence of sensory integrative dysfunction based on a test or a scale such as the
Southern California Sensory Integration Tests (SCSIT) (Ayres, 1980) or Short Sensory Profile (SSP) (Dunn, 1999), evidence of
sensory integrative dysfunction based only on clinical opinion, the presence of sensory seeking behavior or sensory avoiding
behavior, the presence of challenging behavior such as stereotypy or self-injurious behavior, the absence of functional
behavior (developmental delay, poor attending behavior, skill deficits), or whether selection was based on a diagnostic
category only (e.g., participants included only because they were diagnosed with autism spectrum disorders).
Outcomes measures used were coded in three basic areas: sensory integration and perceptual-motor measures; short
term functional measures (short-term behavioral changes up to 2 h post intervention); and long-term functional measures.
It was important to differentiate sensory integration and perceptual motor measures from long-term functional measures, as
sensory integration and perceptual-motor outcomes may be caused by practice effects from the activities rather than from a
change in neurological processing. Furthermore, improvements in sensory integration measures may not indicate
 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351 337

Fig. 1. Search strategy and screening process.

improvements in functional outcomes. Likewise, short-term changes in behaviors such as attention or challenging behaviors
may not be indicative of long-term changes. Of the three types of outcomes, a long-term change in functional outcomes
would be the better indicator of a meaningful change in underlying neurological processing, as suggested by Ayres’
theoretical framework.
The types of assessment used were recorded according to the presence of direct elicited testing of participant
performance; observational assessment by therapist or researcher; observational assessment by third party (e.g., behavior
scale or sensory profile completed by parent); and/or Goal Attainment Scaling. The type of single case research design was
examined, as well as the treatment duration, and the frequency and length of treatment sessions.
 338
Table 1
Quality criteria.

Addison Ayres Case- Devlin Devlin Dura Green Hill Joosten Leemrijse Linderman Mason Ottenbacher Pettit Urwin Watling Wells
et al. and Smith & et al. et al. et al. et al. (1995) (2001) et al. and and (1982a) (1987) and and and
(2012) Mailloux Bryan (2009) (2011) (1988) (2003) (2000) Stewart Iwata Ballinger Dietz Smith
(1981) (1999) (1999) (1990) (2005) (2007) (1983)

Description of participants and setting

Statement of Diagnosis: Statement U U U U U U U U U U U U U U U U U
of diagnosis such as autism, ASD,
Asperger’s syndrome, intellectual
disability, learning disability
(with or without indicating
diagnostic source), age and

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

gender
Diagnostic Instrument Specified:     U    U U       
Diagnostic instrument specified
(e.g., WISC, AAMR diagnostic
criteria, DSM-IV criteria, and
ADOS)
Diagnostic Instrument SPD:  U     U  U    U U U U 
Diagnostic instrument for
sensory processing disorder was
specified
Explicit Criteria SPD: Explicit                 
criteria for diagnosis of SPD
stated
Standardized Assessment Data:  U   U U  U U U  U U U U U 
Standardized assessment data
(e.g., IQ, developmental scale,
achievement test, adaptive
behavior) OR detailed functional
description of general ability.
Disability range (e.g. moderate)
acceptable for intellectual delay
Process Selecting Participants: The        U  U       
process for selecting participants
is described with replicable
precision. MUST describe the
process used to select
participants, not just describe the
participant or their needs. This
would generally include the
criteria the participants must
meet (e.g., 3–5 years, less than
5 spoken words, diagnosis of
autistic disorder) and/or the
process of selecting participants
(e.g., the first 5 children on the
waiting list). Essentially, authors
must explicitly state how/why
participants were selected
Features Physical Setting: Critical U   U U  U  U   U    U 
features of the physical setting
are described with sufficient
precision to allow replication –
should include size or layout or
equipment available of therapy
room

Dependent variable
Described with Operational U  U U U   U  U  U U    
Precision: All dependent

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

variables described with
operational precision
Quantifiable Index: Each U U U U U U U U U U U U U U U U U
dependent variable is measured
with a procedure that generates a
quantifiable index
Process Described Replicable U   U U   U  U  U U   U 
Precision: The measurement
process is described with
replicable precision
Repeated Measurement: U U U U U U U U U U U U U U U U U
Dependent variables are
measured repeatedly over time
Reliability Measured: Data are U  U U U U      U    U 
collected on the reliability or
inter-observer agreement (IOA)
associated with each dependent
variable, and IOA levels meet
minimal standards (e.g.
IOA = 80%; Kappa = 60%). Must be
on minimum of 20% of sessions to
be acceptable

Independent variable
Replicable Precision: Independent U   U  U  U    U     
variable is described with
replicable precision
Systematic Replication: U U U U U U U U U U U U U U U U U
Independent variable is
systematically manipulated and
under the control of the
experimenter
Fidelity: Overt measurement of the                 
fidelity of implementation for the
independent variable is
performed. Must be measured on
a minimum of 20% of sessions to
be acceptable

339
 340
Table 1 (Continued )

Addison Ayres Case- Devlin Devlin Dura Green Hill Joosten Leemrijse Linderman Mason Ottenbacher Pettit Urwin Watling Wells
et al. and Smith & et al. et al. et al. et al. (1995) (2001) et al. and and (1982a) (1987) and and and
(2012) Mailloux Bryan (2009) (2011) (1988) (2003) (2000) Stewart Iwata Ballinger Dietz Smith
(1981) (1999) (1999) (1990) (2005) (2007) (1983)

Experimental control
Design: The design controls for U   U U U U     U    U 
common threats to internal
validity (e.g. permits elimination
of rival hypothesis). Acceptable
designs include concurrent
multiple baseline, ABAB and
alternating treatments with

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

counterbalancing. Award no
points: AB, ABA, ABAC, multiple
baseline with probe, non-
concurrent multiple baseline and
changing criterion
Three Demonstrations: Design                 
must meet standard above for
point to be awarded. The design
provides at least three
demonstrations of experimental
effect at different points in time.
Experimental effects must be
unequivocal in relation to
baseline data and trends. Effects
of alternating treatments may be
added, as main comparison is not
with baseline. When there are
more than 3 possible
demonstrations of experimental
control, 75% or more must
actually demonstrate control
unequivocally

Baseline
Stable: A baseline phase provides U   U U U   U U U U U    
repeated measurement of a
dependent variable and
establishes a pattern of
responding that can be used to
predict the pattern of future
performance, if introduction or
manipulation of the independent
variable did not occur. Should
include a minimum of 5 stable
data points. High variability is
acceptable if intervention effects
are ambiguous. Baseline optional
for alternating treatment design.
Two thirds of baselines must be
acceptable
Described Operational: The U   U U U U U  U  U U   U 
procedural characteristics of the
baseline conditions should be
described operationally

External validity
Replication: Experimental effects  U U  U   U U U  U U  U U U
are replicated across participants,
settings, or materials to establish
external validity. At least three
participants, settings or materials
must be present

Social Validity
Important: The dependent variable U U U U U U U U U U U U  U U U U

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

is socially important
Practical Cost Effective:                 
Implementation of the
independent variable is practical
and cost effective. Code if
acceptability, practicality or cost
effectiveness is formally and
directly measured (e.g., via a
questionnaire such as the
Intervention Rating Profile -15,
estimation of treatment costs)
Extended Typical Agent Context:  U U     U    U  U  U U
Social validity is enhanced by
implementation of the
independent variable over
extended rime periods, by typical
intervention agents, in typical
physical and social contexts.
Extended time period would be
several months. Extended follow-
up is acceptable. Only need one
characteristic
Formally Assessed: Social validity                 
of the impact of intervention is
formally assessed (e.g.,
questionnaire to caregivers
addressing perceived
improvement in communication
or quality of life)

Total quality score 37.0 21.6 22.8 37.0 41.5 33.0 24.1 34.0 27.0 34.5 16.3 46.0 30.6 16.6 19.1 37.0 18.8

341
342 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

The studies were scored against quality criteria as described in Table 1. The quality scale was an adaptation of the
measure used by Preston and Carter (2009) and Reynhout and Carter (2011), based on the Horner et al. (2005) criteria. The six
major quality areas were description of participants and setting, dependent variable, independent variable, baseline,
experimental control and social validity. A total of 10 points was allocated to each quality area with the exception of external
validity, for which 5 points were allocated in recognition of the inherent limitations of single case designs in regard to
external validity. Studies received a score between 0 and 65, with greater quality indicated by higher scores. In order for a
study to be given credit for three demonstrations of experimental effect, the experimental effects needed to be in favor of SIT.

2.3. Interrater reliability

Interrater agreement (see Fig. 1) was independently performed by two authors on study selection for the initial literature
search on title and abstract, the preliminary examination of the full text, and final selection of literature. Interrater agreement
was calculated from the number of studies agreed to be included or excluded divided by the total number of studies and
multiplied by 100. Disagreements were resolved through discussion between all authors. Interrater reliability for article
selection is presented in Fig. 1. Interrater agreement was also independently performed by two authors on the data extraction
process, and calculated from the number of database entries in the areas of general features, other intervention features, process
elements, structure, procedure, outcomes, form of assessment, participants, treatment inclusion criteria, design, intensity, and
quality, with agreement divided by the total number of database entries and multiplied by 100. Interrater reliability for
extraction of data from the articles was 90.2% overall, with a range of 76.5% (for structure) to 98.0% (for intensity).

3. Results

3.1. Participants and treatment inclusion criteria

Participant features and treatment inclusion criteria are reported in Table 2. Ten of the 17 studies included involved
participants aged six years or less, and 11 studies included participants with intellectual disability. Eight studies included
participants with autism spectrum disorders. The most common treatment inclusion criterion was the presence of
challenging behaviors (11 studies).

3.2. Outcomes and forms of assessment

Outcomes and forms of assessments used are reported in Table 3. Researchers primarily focused on short-term functional
outcomes and observational measures of participant performance.

3.3. Treatment and procedural integrity

A summary of intervention features is reported in Table 4. SIT was reported to have been delivered by an occupational
therapist in eight studies, including three studies where it was reported that they had received specialized training in SIT. In
an additional two studies it was stated that the interventionist had specialized training but they were not explicitly
identified as occupational therapists. Approximate treatment durations are reported in Table 5. Total intervention hours
ranged from 3.3 to an estimated 273 h. Only one study (Addison et al., 2012) provided manualized treatment and reported
use of informal procedural integrity checks (with no data provided). Similarly, the use of formal procedural integrity checks
(with data provided) was only reported in a single study (Watling & Dietz, 2007).

3.4. Process scores and structure

Process elements scored are reported in Table 6. The average number of process elements reported in studies was 2.9. The
presentation of sensory opportunities was reported in most studies (14), but the establishment of a therapeutic alliance was
reported in only one study (Addison et al., 2012).

3.5. Study designs and quality

Study designs used are reported in Table 7. In ten studies, weak designs were used that could not allow for three
demonstrations of effect. Strong designs that allowed the possibility of three demonstrations of control were used in six
studies, and in one study both an ABA (weak) and an ABAB (strong) design were used.
The quality criteria met by the studies are reported in Table 1. The average total overall quality score was 29.2 out of 65,
with a standard deviation (SD) of 9.2, and a range of 16.3–46.0. The mean score (out of 10 for all except external validity
which was out of 5), for each category was: 3.9 (SD = 1.6, range of 1.4–7.1) for description of participants and setting; 6.7
(SD = 2.5, range of 4–10) for the dependent variable; 4.3 (SD = 1.6, range of 3.3–6.7) for the independent variable; 5.6
(SD = 4.3, range of 0–10) for baseline; 2.1 (SD = 2.5, range of 0–5) for experimental control; 3.2 (SD = 2.5, range of 0–5) for
external validity; 3.4 (SD = 1.5, range of 0–5) for social validity.
Table 2
Participants and inclusion criteria.

Addison Ayres and Case-Smith & Devlin Devlin Dura Green Hill Joosten Leemrijse Linderman Mason Ottenbacher Pettit Urwin and Watling Wells and
et al. Mailloux Bryan et al. et al. et al. et al. (1995) (2001) et al. and Stewart and (1982a) (1987) Ballinger and Dietz Smith
(2012) (1981) (1999) (2009) (2011) (1988) (2003) (2000) (1999) Iwata (2005) (2007) (1983)
(1990)

Participants
Total 2 4 5 1 4 1 2 19 4 6 2 3 3 1 5 4 4
Mean age 2 4.9 4.93 10.1 9.4 15 31 28.6 6.9 7 3.5 9 8.2 15.3 36.4 3.7 NR
Age range 1–3 4–5.3 4–5.3 10.1 6.6–11 15 28–34 6.3–46.4 5.2–7.3 6.0–8.1 3.3–3.8 3–18 7.8–8.6 NR 28–48 3–4.3 NR
Learning 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0
disabilities
Intellectual 1 1 3 1 2 19 4 3 0 1 5 4

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

disabilities
ASD/PDD 0 5 1 4 1 4 2 0 4 4 0
Others disabilities 2 4 4 6 0 1 3

Inclusion criteria
Evidence of sensory U U U U
integrative
dysfunction
based on test or
scale
Evidence of sensory U
integrative
dysfunction
based therapist
clinical opinion
ONLY
Specific mention of U
Sensory seeking
behavior
Specific mention of U
Sensory avoiding
behavior
specifically
Presence of U U U U U U U U U U U
challenging
behavior
(stereotypy, self-
injurious
behavior)
Absence of U U
functional
behavior
Diagnostic category U U U U
only
Other U U U

343
 344
Table 3
Outcomes and forms of assessment.

Addison Ayres and Case-Smith & Devlin Devlin Dura Green Hill Joosten Leemrijse Linderman Mason Ottenbacher Pettit Urwin and Watling Wells and

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

et al. Mailloux Bryan et al. et al. et al. et al. (1995) (2001) et al. and Stewart and (1982a) (1987) Ballinger and Dietz Smith
(2012) (1981) (1999) (2009) (2011) (1988) (2003) (2000) (1999) Iwata (2005) (2007) (1983)
(1990)

Outcome
Sensory integration U U
and perceptual
motor-measures
Short-term U U U U U U U U U U
functional
measures
Long-term U U U U U U
functional
measures

Form of assessment
Direct formal U U
elicited testing of
participant
performance
Observational U U U U U U U U U U U U
assessment of
participant
performance
Observational U U U U
assessment by
third party
Goal Attainment U
Scaling (GAS)
 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351 345

Table 4
Summary of intervention features.

Number of studies % (n)

General intervention features

Explicitly described as SIT 100 (17)
Ayres’ theories referenced 88.2 (15)
Dedicated SI sessions 100 (17)
Vestibular stimulation 88.2 (15)
Tactile stimulation 76.5 (13)
Proprioceptive stimulation 76.5 (13)
Other stimulation 23.5 (4)
Other features (treatment group only) 0 (0)

Other intervention features

Sensory diet, explicitly described 17.6 (3)
Sensory diet, sensory stimulation in the context of 11.8 (2)
activities embedded in the daily routine
Weighted vests 0 (0)
Wilbarger, brushing (correct locations) 17.6 (3)
Wilbarger, joint compression 11.8 (2)
Wilbarger, sensory diet 5.9 (1)
Other SI-based 0 (0)
Delivered by OT 47.1 (8)
Specialized training in sensory integration 29.4 (5)

The dependent variable(s) were described with replicable precision in eight studies and observational reliability of the
dependent variable measures was reported in seven studies. The independent variable was described with replicable
precision in only five studies.

3.6. Claimed results

Of the eight studies where SIT was compared to another intervention (Addison et al., 2012; Devlin, Leader, & Healy, 2009;
Devlin, Healy, Leader, & Hughes, 2011; Dura, Mulick, & Hammer, 1988; Hill, 1995; Leemrijse, Meijer, Vermeer, Ader, &
Diemel, 2000; Mason & Iwata, 1990; Watling & Dietz, 2007), the alternative intervention was found to be more effective in all
but one study (Hill, 1995), in which mixed results were reported. In the nine studies where SIT was researched without
comparison to an alternative treatment (Ayres & Mailloux, 1981; Case-Smith & Bryan, 1999; Green et al., 2003; Leemrijse
et al., 2000; Linderman & Stewart, 1999; Ottenbacher, 1982a; Pettit, 1987; Urwin & Ballinger, 2005; Wells & Smith, 1983),
positive results were reported in all but two studies, where mixed results (Green et al., 2003) and negative results (Pettit,
1987) were reported.

4. Discussion

Overall, the reviewed studies explored the effect of SIT on 70 participants, mostly with intellectual disabilities and autism
spectrum disorders and typically in an attempt to address challenging behavior. The most outstanding feature of this corpus
of research was the poor quality of the studies. The mean overall quality score was 29.2 out of a possible 65. In comparison,
using a very similar quality scale, Preston and Carter (2009) reported a mean quality score for Picture Exchange
Communication System research of 45.1, and Reynhout and Carter (2011) reported a score of 46.1 for Social Stories. Four
studies (Linderman & Stewart, 1999; Pettit, 1987; Urwin & Ballinger, 2005; Wells & Smith, 1983) scored less than 20, and
only two studies (Devlin et al., 2011; Mason & Iwata, 1990) scored higher than 40. It should be noted that in order to be
included in this review, studies needed to meet certain criteria, some of which were also items in the quality scoring
(repeated measure of the dependent variable and experimenter control over the application of the independent variable),
hence all studies were automatically credited in these quality items.
The greatest weaknesses in study quality were in the areas of experimental control, external validity, social validity,
description of participants and settings, and operationalization of the independent variable. Scores on experimental control
were particularly poor, with a mean score of 2.1 out of a possible 10. Eleven studies used weak designs, such as AB designs,
that could not allow the possibility of three demonstrations of effect. It should be noted that two studies (Addison et al.,
2012; Devlin et al., 2011) did in fact use acceptable designs and provided three demonstrations of control but these were in
favor of alternative interventions, rather than SIT. There were five quality criteria where no study received credit: provision
of explicit criteria for a sensory processing disorder, fidelity measures of the independent variable at an acceptable standard
(i.e., 20% of sessions), having at least three demonstrations of a treatment effect (in favor of the SI intervention), inclusion of
information on the practical value and cost effectiveness of the study, and inclusion of a formal assessment of the social
validity of the study.
 346
H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351
Table 5
Estimated treatment duration.

Addison Ayres Case-Smith Devlin Devlin Dura Green Hill Joosten Leemrijse Linderman Mason Ottenbacher Pettit Urwin Watling Wells
et al. and & Bryan et al. et al. et al. et al. (1995) (2001) et al. and and (1982a) (1987) and and and
(2012) Mailloux (1999) (2009) (2011) (1988) (2003) (2000) Stewart Iwata Ballinger Dietz Smith
(1981) (1999) (1990) (2005) (2007) (1983)

Duration in weeks 0.8 NR 10 NR 1.4 3 4 26–52 8 17.3 11, 7 NR 20 52 4 6.8 22.3

Frequency of 35 NR 1 20 13.8 3.3 2, 3 21 2 1 1 NR 3 3 2 3 5
sessions per week
Length of sessions 0.2 0.8 0.5 0.5 0.3 0.3 0.5, 0.8 0.3 0.5 1 1 0.3 0.8 0.5 0.4 0.7 0.5
(hours)
Total intervention 4.5 74.1 5 10 6.9 3.3 4, 10 137–273 8 17.3 11, 7 8.8 50 78 3.4 13.6 55.6
hours
Table 6
Intervention process elements.

Addison Ayres Case-Smith Devlin Devlin Dura Green Hill Joosten Leemrijse Linderman Mason Ottenbacher Pettit Urwin Watling Wells

H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

et al. and and et al. et al. et al. et al. (1995) (2001) et al. and and (1982a) (1987) and and and
(2012) Mailloux Bryan (2009) (2011) (1988) (2003) (2000) Stewart Iwata Ballinger Dietz Smith
(1981) (1999) (1999) (1990) (2005) (2007) (1983)

Safety U U
Presents sensory U U U U U U U U U U U U U U
opportunities
Helps the child to U U U
attain & maintain
appropriate
levels of alertness
Challenges U U U U
postural, ocular,
oral, or bilateral
motor control
Challenges praxis U U U
and organization
of behavior
Collaborates in U U U U
activity choice
Tailors activity to U U U U U U U U
present just-right
challenge
Ensures that U U U U U U U
activities are
successful
Supports child’s U U U
intrinsic
motivation to
play
Establishes a U
therapeutic
alliance

347
348 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351

Table 7
Study designs.

Design

Addison et al. (2012) ABCBC

Ayres and Mailloux (1981) AB
Case-Smith and Bryan (1999) AB
Devlin et al. (2009) Alternating treatments
Devlin et al. (2011) Alternating treatment
Dura et al. (1988) Alternating treatment
Green et al. (2003) ABAB and ABA
Hill (1995) AB and ABC
Joosten (2001) AB
Leemrijse et al. (2000) ABC
Linderman and Stewart (1999) AB
Mason and Iwata (1990) Multiple baseline
Ottenbacher (1982a) AB
Pettit (1987) AB
Urwin and Ballinger (2005) ABA
Watling and Dietz (2007) ABAB
Wells and Smith (1983) AB

Studies on SIT have been heavily criticized for poor research methodology issues for over 20 years (see Arendt et al., 1988;
Schaffer, 1984). Originally, the authors of the present article had intended to conduct a single case meta-analysis on the
results of the studies, but the weak designs and serious flaws identified were such that an analysis was deemed
inappropriate. It is disappointing that poor quality studies continue to appear in the literature in spite of numerous early
criticisms concerning quality of research (Arendt et al., 1988; Schaffer, 1984). A number of studies also employed
questionable or inappropriate statistics tests, including application of parametric tests to single case data (e.g., Joosten,
2001).
The existence of sensory processing disorder as a valid and discrete diagnosis has been questioned and it has been
suggested that may simply be part of broader underlying developmental disability (American Academy of Pediatrics, 2012).
Nevertheless, if the existence of the purported disorder were accepted, presumably the presence of an assessed sensory
processing disorder would be required to determine the suitability of SIT. Only four studies in the current review, however,
included participants based on evidence of sensory integrative dysfunction from a test or scale, and only one study included
participants based on a clinical opinion of the presence of sensory integration dysfunction. Researchers in four studies
selected participants based on a diagnostic category only. The most common criteria for being included in the studies
reviewed was the presence of challenging behaviors, but the better quality studies generally indicated techniques based on
the principles of applied behavior analysis were more effective for such issues. In addition, the relationship between the
assessment results and the treatment were often opaque. That is, it was unclear how the assessment data informed the
selection and implementation of treatment. This area of research would be improved if a consensus could be reached on clear
criteria for participant selection, which would indicate who may possibly benefit from SIT.
Only eight studies described the dependent variable with operational precision, and only five studies described the form
of treatment used with replicable precision. The lack of clear descriptions of the treatment used and the outcome measures
are concerning, considering that procedural integrity measures were rarely taken (one manualized treatment, one informal
check without data, one formal check with data, with no study performing overt measurement of fidelity of implementation
of treatment on at least 20% of sessions). Future researchers should utilize the fidelity tool developed by Parham, Roley, May-
Benson, et al. (2011), which sets guidelines for which process elements of sensory integration principles should be reported.
Also, consistent with the findings of Parham et al. (2007), there were numerous issues with the interpretation of what is
acceptable as SIT in the research context, as the studies reviewed here only reported on average 2.9 (range of 0–5) of the
process elements outlined by Parham et al., and in many cases key features of SIT were missing or unreported. It should be
stressed that the absence of features does not necessary imply that they were absent from the intervention but rather that
they were not present in the often fleeting descriptions of the intervention. In most cases, the forms of SIT used were often
not sufficiently well described to enable replication and, as noted above, fidelity of implementation was rarely measured. In
this regard, the continued efforts to improve the fidelity of research in SIT (Parham, Roley, Mailloux, et al., 2011; Parham,
Roley, May-Benson, et al., 2011) are a positive step. Whilst the tool is not strictly an operational measure, it is apparently
acceptable to sensory integration researchers (Case-Smith et al., 2014; Miller, Coll, & Schoen, 2007b; Miller, Coll, & Schoen,
2007c; Schaaf et al., 2014) and as such has the potential to circumvent criticisms of research for failing to adhere to the
appropriate treatment techniques.
One positive feature of the reviewed research was that all but one study examined socially important outcome measures.
Although all the studies failed to assess the practicality and cost effectiveness of the intervention as well as formally assess
the social validity of the outcomes, it is commendable that research outcomes included functional outcomes and were not
limited to sensory integration and perceptual motor measures, such as postrotary nystagmus (Ottenbacher, 1982a).
Nevertheless, sensory processing and physiological measures are important to establish a logical causal link between
 H.M. Leong et al. / Research in Developmental Disabilities 47 (2015) 334–351 349

treatment and effect. Although sensory integration and perceptual motor measures are useful in establishing a possible
change in sensory processing, socially important outcome measures are crucial in establishing that the change also resulted
in functional outcomes.
Considering the poor overall quality of the studies in general, the results from these studies may be generally regarded as
uninterpretable. Only seven studies (Addison et al., 2012; Devlin et al., 2009, 2011; Dura et al., 1988; Green et al., 2003;
Mason & Iwata, 1990; Watling & Dietz, 2007) used designs which allowed for the possibility of three demonstrations of
experimental effect (i.e., multiple baseline, ABAB, alternating treatment), and six of these studies (Addison et al., 2012;
Devlin et al., 2009, 2011; Dura et al., 1988; Mason & Iwata, 1990; Watling & Dietz, 2007) had a quality score higher than 30.
Dura et al. (1988) (quality score 33.0) found that SIT involving vestibular stimulation only lowered rates of self-injurious
behaviors during intervention compared to attention control, but had no effect on self-injurious behaviors during post-
treatment observation. None of the process elements outlined by Parham, Roley, Mailloux, et al. (2011) and Parham, Roley,
May-Benson, et al. (2011) were identified in this study. All the remaining studies (Addison et al., 2012; Devlin et al., 2009,
2011; Mason & Iwata, 1990; Watling & Dietz, 2007) provided evidence that other interventions were more effective than SIT.
Mason and Iwata (1990) (quality score 46.0) found that behavioral interventions were successful in reducing the self-
injurious behaviors of three individuals where a form of sensory integration intervention had failed. The SIT intervention
used by Mason and Iwata did not involve interaction between the therapist and the participants, and it has been questioned
whether it accurately represented SIT: Only two out of ten of the process elements outlined by Parham, Roley, Mailloux, et al.
(2011) and Parham, Roley, May-Benson, et al. (2011) were reported in the study. Watling and Dietz (2007) (quality score
37.0) reported that Ayres’ sensory integration had no immediate effects on undesirable behaviors or task engagement when
used with three participants with autism spectrum disorders. Addison et al. (2012) (quality score 37.0) found that escape
extinction plus noncontingent reinforcement was more effective than sensory integration in increasing acceptance of food,
decreasing inappropriate behavior, and increasing amount consumed for two children with feeding problems. Devlin et al.
(2011) (quality score 41.6) found that function-based behavioral interventions were more effective than sensory integration
therapy in reducing challenging behaviors in four children with autism spectrum disorders. Devlin et al. (2009) (quality score
37.0) had also found that behavioral interventions were clearly more effective than sensory integration therapy in reducing
rates of self-injurious behaviors in a boy with autism. Thus, although the quality of studies was low for the most part, the
better-conducted studies still did not provide support for the efficacy of SIT on the whole.

5. Conclusion

When the findings of this review are put together with the results from the meta-analysis of group design studies (Leong
et al., 2014) and other recent reviews (Lang et al., 2012; Roberts et al., 2011), the evidence base for the efficacy of SIT is seen to
be weak. Based on these results, and consistent with the recommendations of previous reviewers (Lang et al., 2012; Leong
et al., 2014; Roberts et al., 2011), it is advised that the use of SIT be limited to experimental contexts. Considering the poor
quality of the studies reviewed, it is also recommended that new studies meet minimal methodological requirements to be
considered for publication. In particular, single case studies should use research designs that allow for at least three
demonstrations of effect (e.g., multiple baseline, ABAB); offer explicit criteria for sensory processing disorder; describe the
dependent variable with operational precision; and provide clear documentation of the features of intervention, including
verification of procedural reliability.

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