743456

research-article2017
OTJXXX10.1177/1539449217743456OTJR: Occupation, Participation and HealthKashefimehr et al.

Article

OTJR: Occupation, Participation and

The Effect of Sensory Integration Therapy

Health
2018, Vol. 38(2) 75­–83
© The Author(s) 2017
on Occupational Performance in Children Reprints and permissions:
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With Autism DOI: 10.1177/1539449217743456

https://doi.org/10.1177/1539449217743456
journals.sagepub.com/home/otj

Babak Kashefimehr1, Hülya Kayihan2, and Meral Huri2

Abstract
Sensory processing problems and related dysfunctions are among the most common conditions in children with autism
spectrum disorder (ASD). This study examined the effect of sensory integration therapy (SIT) on different aspects of
occupational performance in children with ASD. The study was conducted on an intervention group (n = 16) receiving SIT
and a control group (n = 15) with 3- to 8-year-old children with ASD. The Short Child Occupational Profile (SCOPE) was
used to compare the two groups in terms of the changes in their occupational performance and the Sensory Profile (SP)
was used to assess sensory problems. The intervention group showed significantly greater improvement in all the SCOPE
domains, as well as in all the SP domains, except for the “emotional reactions” and “emotional/social responses” domains,
(p < .05). The effectiveness of SIT in improving occupational performance in children with ASD as a health-related factor is
supported by our findings.

Keywords
autism spectrum disorder, occupational performance, sensory integration therapy

Introduction the child’s ability to process and integrate sensory informa-

Autism spectrum disorder (ASD) is a complex developmen-
tal disorder that can lead to dysfunctions in cognition, emo-
tion regulation, and the communication skills (American
Psychiatric Association, 2013b). In recent years, ASD has
become highly prevalent and has thus become the subject of
extensive research, as one in every 68 children aged 8 is
diagnosed with ASD (Baio, 2014).
Children with ASD tend to exhibit different behaviors that
affect their ability to engage in daily occupations, including
inflexible behaviors, habits, and play patterns. In addition to
sensory–motor problems such as excessive rocking and spin-
ning, they have also preoccupations with personal interests,
sensitivity to certain foods or clothes, and a strong attach-
ment to certain objects (Myles, 2007; Pfeiffer, Koenig,
Kinnealey, Sheppard, & Henderson, 2011). These behaviors
can diminish the child’s functional capabilities, including his
sense of purposefulness, social interactions, participation in
activities, and ultimately his overall health (World Health
Organization [WHO], 2001). Based on Ayres’ sensory inte-
gration theory (Ayres, 1972), the reduced ability to process
and integrate sensation may be one of the underlying reasons
for the behavioral and/or functional problems prevailing in
ASD (Bundy, Lane, & Murray, 2002; Case-Smith, Weaver,
& Fristad, 2015).
Sensory integration therapy (SIT) based on Ayres’ (1972)
theory (Ayres Sensory Integration© [ASI]) is a commonly
used method of therapy by occupational therapists to increase
tion and thereby demonstrate more organized and adaptive
behaviors (Case-Smith et al., 2015). Different sensory pat-
terns in children with ASD have been revealed (Ben-Sasson
et al., 2009) and also the positive effect of SIT on child’s
performance has been reported in a comprehensive review
by Case-Smith et al. (2015). In addition, a review of 27 stud-
ies on children with sensory processing and integration prob-
lems by May-Benson and Koomar (2010) showed that SIT
can positively affect motor skills, socialization, attention,
behavior control, reading skills, participation in game activi-
ties, and the achievement of personal goals. The resulted
gains in gross motor skills, self-esteem, and reading skills
lasted from 3 months to 2 years.
In one case report, Schaaf, Hunt, and Benevides (2012)
revealed changes in the participation level and adaptive
behavior of a child with ASD following an intensive 10-week
intervention using a manualized protocol based on sensory
integration principles. They administered the Sensory
Integration and Praxis Test (SIPT) as a pre–post measure and
observed improvements in the child’s SIPT scores and in the
1
Tabriz University of Medical Sciences, Iran
2
Hacettepe Health Sciences University, Ankara, Turkey
Corresponding Author:
Babak Kashefimehr, Department of Occupational Therapy, Faculty of
Rehabilitation, Tabriz University of Medical Sciences, Tavanir Street,
Valiasr, Tabriz 5157635411, Iran.
Email: babakkashefi@yahoo.com
76
Figure 1. The diagram of the study.
Note. SP = Sensory Profile; SIT = sensory integration therapy; OT= occupational therapy.
child’s participation in school; home and family interactions
also yielded improvements in individual goals according to
the score obtained on the Goal Attainment Scale (GAS) com-
pleted by the parents.
In a more recent study, Schaaf, Benevides, et al. (2014)
used a randomized trial for the assessment of a manualized
OT/SI (sensory integration based occupational therapy)
intervention based on ASI for 4- to 8-year-old children.
Using GAS, they reported that the intervention group, receiv-
ing 30 sessions of occupational therapy, showed significantly
higher scores in the level of caregiver assistance in self-care
and also socialization compared with the control group that
received only the routine care.
To evaluate treatment outcomes, a variety of standardized
tests are regularly used in pediatric occupational therapy; the
most frequently used ones, however, may not be the most
appropriate for measuring the outcomes achieved by occupa-
tional therapy (Payne, 2002). Occupation-focused outcome
measures stand in contrast to those that focus solely on
impairment. Occupation-focused outcome measures provide
a structured format for practitioners to assess the overall abil-
ities or difficulties that affect a patient’s involvement in
activities and participation (Bowyer, Lee, Kramer, Taylor, &
Kielhofner, 2012). The concept of occupation in occupa-
tional therapy and model of human occupation (MOHO)
which defines the human as an occupational being are in line
with the International Classification of Functioning,
Disability and Health (ICF) and reflect the patients’ health
status (Grieve & Maskill, 2013). Given that the goal of
OTJR: Occupation, Participation and Health 38(2)
occupational therapy is to improve the child’s participation
in occupations and that there are limited studies of ASI that
utilize occupation-based outcome measures, the aim of this
study was to investigate the effect of SIT on occupational
performances of ASD children.
Materials and Methods
The present study was conducted as a randomized con-
trolled trial and both control (waiting list) and interven-
tion groups were homogeneous in terms of age and also
were diagnosed as “required very substantial support”
(Level 3) of ASD as per the Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-5; American
Psychiatric Association, 2013a). The evaluator of children
was blinded to grouping. The research project was
approved by the Noninvasive Clinical Research Ethics
Board of University.
Study Procedure
All children were assessed by the therapist of University’s
occupational therapy clinic using the instruments described
below. The therapist/evaluator was blinded to study group-
ing. The participants were randomly divided into the control
and intervention groups. The interventions were performed
by researchers trained in sensory integration. The post inter-
vention assessments were performed by the independent
therapist/evaluator for both groups (Figure 1).
Kashefimehr et al.
Table 1. Gender and Age Distribution.
Gender Age
Male Female
Group n % n % M SD
Intervention 15 93.8 1 6.3 5.37 1.82
Control 13 86.7 2 13.3 5.53 1.67
Total 28 90.3 3 9.7 — —
Study Participants
The parents of 35 3- to 8-year-old children diagnosed with
ASD by the psychiatry committee were introduced to the
occupational therapy clinic of University. They all were
informed of this research and declared their willingness to
participate by signing a consent form. The children under-
went an initial examination and a sensory screening and
four were excluded as they did not show sensory problems
on screening with the Sensory Profile (SP; described
below). A total of 31 children entered the study. The gender
and age distribution is shown in Table 1. These children
were diagnosed with autism and showed sensory process-
ing problems (defined as having “definite difference with
normal”) in two or more subscales of the SP developed by
Dunn (1999). The remaining participants were randomly
assigned to an intervention group (n = 16; boys = 93.8%;
mean age = 5.37 ± 1.82) and a control group (n = 15; boys
= 86.7%; mean age = 5.53 ± 1.67) using a random number
table (Figure 1).
Assessments
Dunn’s SP was used as the screening tool and also as the
primary sensory evaluation. The findings from the SP were
used to develop a hypothesis about the sensory characteris-
tics affecting the child’s performance. The SP is a standard-
ized tool in the assessment of sensory capabilities and their
effect in daily life and functional performance in 3- to
10-year-old children. Parents or caregivers’ were asked to
answer the 125 questions of the SP that draw up a child’s
sensory profile in three main domains, including sensory
processing, behavioral, and emotional responses and modu-
lation, and also nine factors, including sensory seeking, emo-
tional reaction, low endurance/tone, oral sensory sensitivity,
inattention/distractibility, poor registration, sensory sensitiv-
ity, sedentary, and fine motor/perceptual. Dunn (1999)
reported a significant correlation between sensory profile
and school function assessment and a good internal consis-
tency (α = .47-.91) along with construct and content validity
for this profile. Also a study conducted to translate SP into
Turkish (Kayihan et al., 2015) obtained Cronbach’s α values
ranging from .63 to .97 and a high 1-week test–retest reli-
ability for the scale (intraclass correlation [ICC] > .90). In
77
the present study, an acceptable overall Cronbach’s alpha
(α = .91) was obtained.
The researchers used The Short Child Occupational
Profile (SCOPE, version 2.2) to assess the children’s occupa-
tional performance as functional capabilities. The SCOPE
p
domains were evaluated individually for each child; majority
.804 of the problems were in the area of communication and inter-
— action skills, and the next prevalent difficulty was the “pro-
— cess skill” (Table 2).
SCOPE measures occupational performances in six
domains as defined in Kielhofner’s (2002) MOHO. MOHO
seeks to explain how the occupations are motivated, pat-
terned, and performed and offers a broad and integrative
view of human occupation (Kielhofner, 2002). So this profile
offers a comprehensive insight into the child’s participation
level and identifies the facilitators and barriers to his partici-
pation from birth to the age of 21 years old. It includes client-
centered and occupation-focused principles of the human
occupation theory and further demonstrates the patient’s pat-
tern of strengths and weaknesses in occupational perfor-
mance and can be used to design appropriate intervention
programs. The results obtained from this tool specify six
concepts including volition, habituation, interaction and
communication skills, process skills, motor skills, and envi-
ronment and a total for the overall score, which can be used
in planning interventions and making comparisons. Of all the
available tools, very few have identified the concepts of
occupational performance with such clarity, brevity, and
comprehensiveness (Bowyer et al., 2008).
In a study, the Turkish version of this scale was found to
have an acceptable internal consistency with Cronbach’s
alpha values ranging from .944 to .948 in each factor and
reported as .94 for the overall scale. The test–retest reliability
was assessed using the correlation coefficient, which was
obtained as .56 to .97 for each factor and as r = .92 for the
entire scale (p < .001). As for the validity of the scale, the
scores obtained by the children diagnosed with the disease
differed significantly from the scores obtained by their nor-
mally developing peers (p < .001). The factor analysis showed
that the six factors explained 79.28% of the variance (Huri
et al., 2016). In this study, the reliability of the Turkish trans-
lation of this scale fell within the acceptable range (α = .79).
Intervention
Each participant in the intervention group received 24 SIT
(two per weak), each 45 min in length with an additional 15
min devoted to parent education (as described below).
The SIT is a clinic-based intervention that uses play activ-
ities and sensory-enhanced interactions to elicit the child’s
adaptive responses. In this intervention, the therapist creates
activities that encourage the child’s participation and chal-
lenge his sensory processing and motor planning skills
(Ayres, 1972; Case-Smith et al., 2015). The therapist also
designs a “just-right” challenge (i.e., an activity that requires
78
Table 2. The Most Problematic Domains of SCOPE in the Intervention Group.
Communication and
Volition Habituation
Frequency 2 3
% 12.5 18.75
Note. SCOPE = Short Child Occupational Profile.
the best of the child’s skills and abilities) from the child’s
repertoire of skills and supports his adaptive responses to the
challenge. The SIT is often provided in a specially designed
clinical environment using specific equipment (e.g., swings,
therapy balls, inner tubes, trampolines, and climbing walls)
that can provide tactile, proprioceptive, and vestibular chal-
lenges embedded in goal-directed, purposeful, and playful
activities.
In addition to direct interventions for the child, the thera-
pist offered strategies that target the child’s sensory needs to
the caregiver and provided the caregivers with information
about approaches to interact with the child. By modifying the
child’s environment or routines, supporting self-regulation
and creating opportunities for him to participate in his pre-
ferred sensory experiences, the therapist facilitates the child’s
participation in everyday activities in a more normal manner.
The recommended modifications in the child’s daily routines
or environment often promote his life functions and interac-
tions (e.g., climbing on a gym set, swinging in the backyard
or the neighborhood playground, quiet rhythmic rocking in a
low-lit bedroom, and supervised trampoline jumping) (Case-
Smith et al., 2015). A customized SIT program containing
games and goal-directed activities was designed by the
researchers of the present study for each child based on their
sensory needs. The program also included suggestions to
caregivers to modify the daily routine of the children. This
program was based on the sensory needs as well as their most
problematic Domain on SCOPE (Table 2). The individual
therapy sessions were designed as two 60-min sessions per
week for 3 months plus makeup sessions to ensure that all the
children received their full 24 sessions of therapy. In each
therapy session, 45 min were devoted to direct therapy of the
child and another 15 min to suggest sensory strategies to par-
ents to implement at home and also receiving their report on
the child’s behaviors. Researchers considered Parham’s
10-item Fidelity Measure (Parham et al., 2011) to guide the
principles of ASI. Each element is adapted to each individual
child and targets specific objectives. The 10 essential ele-
ments include (a) ensuring safety; (b) presenting a range of
sensory opportunities (specifically tactile, vestibular, and
proprioceptive); (c) using activities and arranging the envi-
ronment to help the child maintain self-regulation and alert-
ness, (d) challenging postural, ocular, oral, or bilateral motor
control; (e) challenging praxis and the organization of behav-
ior; (f) collaborating with the child on his activity choices;
OTJR: Occupation, Participation and Health 38(2)
Domains
Motor
interaction skills Process skills skills
11 5 3
68.75 31.25 18.75
(g) tailoring activities to represent the “just-right” challenge;
(h) ensuring that the activities are successful; (i) supporting
the child’s intrinsic motivation to play; and (j) establishing a
therapeutic alliance with the child (Parham et al., 2011).
The interventions were performed by experienced
researchers (5 to 20 years) holding the required diplomas in
child occupational therapy and SIT. The therapies were per-
formed in compliance with the principles of SIT and accord-
ing to Ayres’ (1972) theory of providing sensory activities
through games (Roley, Mailloux, Miller-Kuhaneck, &
Glennon, 2007) and Parham et al.’s (2011) fidelity protocol.
Both participant groups continued with their previous special
education programs as well.
Data Analysis
The normality of the data was tested using the Kolmogorov–
Smirnov test (p > .05). The changes in the pretest-and post-
test scores were compared between the intervention and
control groups using a series of 2 (group) × 2 (pre–post)
mixed model analyses of covariance (ANCOVAs). The
analysis technique used for this study had the advantage of
reducing the error variance by referring to pretest or covari-
ate data and providing stronger results by eliminating the
effect of the initial conditions (Dimitrov & Rumrill, 2003).
Results
The preintervention data were collected through the SCOPE
and SP. Results of data comparisons using t Test in two
groups before the intervention are presented in Table 3. No
significant difference was observed in SCOPE domains in
preintervention data but a significant difference was observed
between the two groups in terms of the sensory seeking, sen-
sory sensitivity, and behavioral outcomes (p < .05).
A significantly greater improvement was observed in the
intervention group in all domains of SCOPE including voli-
tion, habituation, communication and interaction skills, pro-
cess skills, motor skills, and environment of occupational
performance and also in the total score of the child (p <
0.001; Table 4).
Of the 35 ASD children participating in the study, 31
(88.6%) showed difference in sensory profile according to
SP. The intervention group showed significantly greater
improvements in all factors and domains of SP, with the
Kashefimehr et al. 79

Table 3. Baseline Data of Participants.

Control group Intervention group

Items M SD M SD p
Sensory seeking* 58.53 10.02 51 7.22 .022
Emotionally reactive 54.06 13.45 47.31 13.05 .167
Low endurance tone 36.53 8.61 37.18 6.41 .811
Oral sensory sensitivity 30.13 7.92 26.81 9.11 .289
Inattention distractibility 22.20 6.12 21.93 4.21 .890
Poor registration 28.93 6.65 30.25 5.28 .545
Sensory sensitivity 15.00 3.90 11.43 4.17 .021
Sedentary 14.33 3.69 14.06 3.53 .836
Fine motor perceptual 8.86 3.09 7.18 2.94 .132
Auditory processing 26.46 7.36 27.5 3.22 .613
Visual processing 32.86 8.15 34.56 4.70 .480
Vestibular processing 43.33 9.84 41.25 5.06 .461
Touch processing 65.0 15.35 67 8.48 .654
Multisensory processing 23.13 6.28 22.81 5.52 .881
Oral sensory processing 40.73 9.37 37.31 10.60 .350
Sensory processing related to endurance tone 36.53 8.61 37.18 6.41 .811
Modulation related to body position and movement 37.46 8.38 32.93 6.84 .109
Modulation of movement affecting activity level 23.60 5.05 21.56 4.50 .245
Modulation sensory input affecting emotional responses 13.33 2.74 13.25 2.88 .935
Modulation visual input affecting emotional responses and level 14.46 4.42 13.18 2.71 .336
Emotional social responses 59.86 13.88 54.62 14.26 .309
Behavioral outcomes of sensory processing 19.53 5.64 15 6.01 .039
Items indicating thresholds 10.73 2.37 9.93 1.94 .315
Volition 12.20 2.17 11.81 2.00 .610
Habituation 10.60 3.24 9.43 2.33 .260
Communication interaction skills 9.46 3.54 9.12 2.30 .751
Process skills 11.40 3.22 11.06 2.20 .735
Motor skills 12.66 2.66 12.31 2.72 .717
Environment 15.40 3.54 15.56 2.70 .886
Total of SCOPE 71.73 16.04 69.31 10.07 .616

Note. t test. SCOPE = Short Child Occupational Profile.

*Significant at .05.

exception of the “emotionally reactive” factor—F(2, 28) =
1.81, p = .182—and “emotional/social responses” domain—
F(2, 28) = 1.27, p = .295; Table 4.
Discussion
Occupational performance is the ultimate outcome expected in
sensory processing development and occupational therapy pro-
grams (May-Benson & Koomar, 2010), and our study results
support the effectiveness of the SIT in improving occupational
performance of ASD children (Table 4), in keeping with Schaaf,
Benevides, et al. (2014). Occupation is the main focus of occu-
pational therapy (Thomas, 2012) and the various domains
assessed in this study are compatible with the ultimate goals and
principles of occupational therapy and those of the ICF.
The SCOPE is a MOHO-based scale designed to assess
occupational performance. Within MOHO, humans are
conceptualized as being made up of three interrelated
components: volition, habituation, and performance capacity.
Volition refers to the motivation for occupation and indicates
the process of making choices. In childhood, volition can be
regarded as synonymous with the choice of activities to per-
form, habituation deals directly with common functional
activities performed under different physical, cultural, and
time conditions that involve routines, habits, and roles, and
performance capacity refers to the physical and mental abili-
ties that underlie skilled occupational performance. MOHO
also emphasizes that to comprehend human occupation,
understanding the physical and social environments in which
occupation takes place is necessary (Bowyer et al., 2008;
Kielhofner, 2002).
Volition
In the review of the literature, the researchers were unable to
find any study on the effect of the SIT on volition; however,
80 OTJR: Occupation, Participation and Health 38(2)

Table 4. Comparing Score Changes of Dunn Profiles and SCOPE Post Intervention.

Tests of between-subjects effects Differences between

Profiles (sensory two groups mean
and scope) Items F Significance Sum of squares df M2 improvement
Sensory profile
Sensory seeking 18.18 .000 1,528.71 2 764.35 9.47
domains Emotionally reactive 1.81 .182 574.67 287.33 4.92
Low endurance tone 58.97 .000 1,099.66 549.83 1.98
Oral sensory sensitivity 11.11 .000 785.24 392.62 6.76
Inattention distractibility 17.23 .000 397.18 198.59 3.52
Poor registration 9.248 .001 446.66 223.33 3.08
Sensory sensitivity 14.07 .000 191.97 95.98 3.49
Sedentary 10.64 .000 191.77 95.88 1.30
Fine motor perceptual 8.17 .002 94.63 47.31 0.66
Auditory processing 26.61 .000 732.44 366.22 3.90
Visual processing 43.53 .000 925.29 462.64 1.54
Vestibular processing 31.91 .000 1,121.23 560.61 4.96
Touch processing 22.10 .000 2,459.35 1,229.67 6.17
Multisensory processing 21.91 .000 442.70 221.35 1.75
Oral sensory processing 11.24 .000 951.93 475.96 8.2083
Sensory processing related to 58.97 .000 1,099.66 549.83 1.98
endurance tone
Modulation related to body position 35.00 .000 1,042.42 521.21 5.58
and movement
Modulation of movement affecting 5.92 .007 221.04 110.52 1.94
activity level
Modulation of sensory input affecting 15.55 .000 148.99 74.49 0.3
emotional responses
Modulation of visual input affecting 8.88 .001 48.39 24.19 3.26
emotional responses and level
Emotional social responses 1.27 .295 475.58 237.79 4.17
Behavioral outcomes of sensory 4.08 .028 188.50 94.25 2.25
processing
Items indicating thresholds 22.14 .000 85.38 42.69 0.9
SCOPE domains Volition 61.26 .000 146.25 2 73.12 10.64
Habituation 65.27 .000 187.73 93.86 1.42
Communication interaction skills 111.67 .000 263.36 131.68 1.75
Process skills 43.77 .000 146.49 73.25 1.13
Motor skills 36.00 .000 120.50 60.25 1.07
Environment 18.88 .000 123.88 61.94 2.45
Total score 97.82 .000 4,471.23 2235.61 2.81

Note. ANCOVA. SCOPE = Short Child Occupational Profile; ANCOVA = analysis of covariance.

the present study showed a significant improvement in the
intervention group in this domain as measured by the
SCOPE. This finding is in keep with Dunn’s theory of sen-
sory processing which states that SIT can increase children’s
social and environmental interactions and improve their
motivation (Dunn, 2001).
Given that an individual’s volition is influenced by expe-
riences and information (Duncan, 2011) and involves his
perceived causation, values, and interests (Kielhofner, 2002)
and that SIT provides opportunities for individually designed
sensory rich experiences, the finding from this study sup-
ports link between volition and sensory integration.
Kuhaneck and Britner (2013, p. 164) support this idea
showing preliminary evidence that sensory problems are
related to “tend[ency] to play the same activities over and
over, rather than shift[ing] to new activities when given the
chance.” Furthermore, a review study conducted by Lord
(Gayle & Magill-Evans, 1994) showed that ASD children
have greater delays in initiating playing and interactions dur-
ing play time, and Sherman (Gayle & Magill-Evans, 1994)
found that ASD children have diminished social motivation
and pay little attention to their playmates compared with
mentally challenged or healthy children. Reduced social
motivation also reduces the accumulation of life experiences
(Taylor et al., 2009) and may affect the child’s performance.
In summary, children with ASD have well documented
Kashefimehr et al.
difficulties in the area of volition, and this study suggests that
SIT may be helpful to improve these.
Habituation
The significant greater gain in the habituation of the inter-
vention group is indicative of the effectiveness of SIT in the
modulation and modification of nonfunctional habits.
Children with ASD tend to have problems in their functional
habits, including social habits (Ingersoll, 2008), sleeping
(Malow et al., 2009) and eating, and stereotypic movements
(Johnson, Handen, Mayer-Costa, & Sacco, 2008). The
researchers found no specific studies conducted on the effect
of SIT on this domain. However, based on Dunn’s theory,
inappropriate and nonfunctional habits can occur due to sen-
sory processing problems suggest problems in habitation
may co-occur with sensory processing difficulties.
Communication and Interaction Skills
In the present study, the performed SIT interventions resulted
in significant improvements in the communication skills of the
intervention group, which is similar to the findings of Schaaf,
Benevides, et al. (2014). Some studies have reported a specific
relationship between the different patterns of sensory process-
ing and social, emotional, and behavioral performance in chil-
dren with ASD (Kuhaneck & Britner, 2013; Matsushima &
Kato, 2013). The SIT has positive effects on the main problem
with which ASD children have to deal (i.e., establishing com-
munication) and may help to improve their social performance
and thus participation as a health factor (WHO, 2001).
Processing Skills
The significant improvements made in the intervention
group in the present study suggest the effectiveness of SIT
for improving processing skills. Processing skills imply
planning activities, utilizing the correct tools and materials
and adapting to problems (Case-Smith & Arbesman, 2008).
ASD has been defined as an executive disorder because it is
associated with a number of executive function deficiencies,
especially in the domain of cognitive flexibility, planning,
and working memory (Geurts, Verté, Oosterlaan, Roeyers, &
Sergeant, 2004). This improvement may be the result of the
better and integrated use of environmental sensory informa-
tion for planning activities.
Motor Skills
In this study, the intervention group gained significantly
higher scores in motor skills. Motor skills imply movement
by the individual or his movement of an object to perform a
certain activity (Bowyer et al., 2008). A study by White,
Mulligan, Merrill, and Wright (2007) showed that children
with abnormal sensory processing profiles have greater
81
difficulty in motor processing and daily life activities. Based
on Ayres’ (1972) theory, sensory processing and integration
disorders lead to impaired motor skills and apraxia (Roley
et al., 2007). Amel and Amira (2015) also reported that SIT
improves fine and gross motor skills, and the findings from
this study support this.
The Environment
The intervention group in our study obtained significantly
higher scores in the emergence and use of environmental
opportunities. This domain of the SCOPE examines the sup-
port provided by the environment (Bowyer et al., 2008). Based
on the philosophy of occupational therapy (Amini et al., 2014),
occupational therapists use environmental adaptation to
improve occupational skills. This is mainly due to the fact that
environmental conditions affect occupational performance
(French, 2005). Environmental stimuli could also affect sen-
sory processing related reactions and behavioral skills (Dunn,
2007). As Piller and Pfeiffer (2016) have suggested, the sen-
sory aspects of the environment are both inhibitory and facilita-
tory to participation of preschool children with ASD. In the
present study, the training of caregiver for better integration of
environmental stimuli and related home programs could have
resulted in better conducive opportunities that affect the child’s
interactions with his caregivers and the environment (Case-
Smith et al., 2015; Schaaf, Benevides, et al., 2014).
In the present study, 88.6% of the children showed sen-
sory information processing difficulty. Some studies have
reported sensory processing disorders in 45% to 96% of chil-
dren with ASD (Schaaf, Benevides, et al., 2014). These find-
ings could denote the urgent need for sensory evaluations
and interventions in ASD children. Also, this study is in line
with a report by the Turkish Ministry of Health (2008) and
some clinical studies that reported a higher frequency of
ASD in males (Yeargin-Allsopp et al., 2003); boys com-
prised the dominant gender group (90%) in this study. Given
the significant effect of age on the outcomes of interventions
(Corsello, 2005), the two groups were completely homoge-
neous for age in this study.
Conclusion
This study has demonstrated that SIT interventions could
improve occupational performance and sensory processing
abilities in ASD children. The SIT can therefore be proposed
as a useful approach of occupational therapy, and the thera-
pists could consider it as an effective customizable therapy
for improving the occupational performances and subse-
quently the health status of ASD children.
Limitations and Recommendations
This study used parent-report measures which could complicate
the blinding process of the study; therefore, future studies should
82
use more objectives scales. Although the SP is not adequate for
the outcome measure, the SP pre–post scores (Table 4) suggest
that the occupational therapy interventions may have led to
improvement in sensory processing skills. As another limitation,
this study fulfilled the fidelity concepts only informally to guide
treatment and did not specifically measure fidelity.
Authors’ Note
This study was approved by Noninvasive Clinical Research Ethics
Board of Hacettepe University with No: B.30.2.HAC.028.00.00/3008
on March 12, 2012. The authors declare that this manuscript is orig-
inal, has not been published before, and is not currently being con-
sidered for publication elsewhere. No significant financial support
for this work that could have influenced its outcome.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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