Professional Documents
Culture Documents
Sandra Hodgetts
William Hodgetts
Key words
Autism
Sensory stimulation
Mots cls
Pratique de l'ergothrapie
Autisme
Stimulation sensorielle
Abstract
Background. There is considerable evidence that children with autism experience sensory dysfunction, which can affect their
ability to participate in functional activities. Occupational therapists frequently recommend somatosensory stimulation
interventions to mitigate sensory dysfunction and improve a child's ability to function. Purpose. This paper examines the
rationale and evidence supporting somatosensory stimulation interventions for children with autism. Method. A comprehensive
review of the literature specific to somatosensory stimulation was conducted, resulting in six published studies that addressed
interventions feasible within a child's daily routine. Discussion. Although research related to somatosensory stimulation
interventions is becoming more rigorous, empirical support remains limited; therefore, when these interventions are implemented,
they should be systematically evaluated. Practice Implications. To help occupational therapists recommend interventions with
confidence, strategies are provided to (1) utilise best practices to intervene in an area in which evidence is limited, and (2) help
expand the evidence base through clinical research.
Rsum
Description. Il existe beaucoup de donnes permettant d'affirmer que les enfants atteints d'autisme ont des dficits sensoriels
pouvant avoir des effets sur leur capacit de participer des activits fonctionnelles. Les ergothrapeutes recommandent
frquemment des interventions bases sur la stimulation somatosensorielle afin d'attnuer les dficits sensoriels et d'amliorer les
capacits fonctionnelles de l'enfant. But. Cet article examine la raison d'tre et les donnes probantes qui soutiennent les
interventions bases sur la stimulation somatosensorielle auprs des enfants atteints d'autisme. Mthodologie. Une revue
complte de la littrature portant spcifiquement sur la stimulation somatosensorielle a t effectue. Cette recension a permis de
reprer six tudes publies portant sur les interventions qui peuvent s'insrer dans la routine quotidienne de l'enfant. Discussion.
Bien que la recherche associe la stimulation somatosensorielle soit devenue plus rigoureuse, les donnes empiriques demeurent
limites; ainsi, il est important, lorsque ces interventions sont mises en uvre, de les valuer systmatiquement. Consquences
pour la pratique. Afin d'aider les ergothrapeutes recommander des interventions en toute confiance, les auteurs proposent des
stratgies visant (1) utiliser des pratiques exemplaires pour intervenir dans un domaine o les donnes probantes sont limites
et (2) produire davantage de donnes probantes l'aide de la recherche clinique.
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Methods
Searches were conducted using MEDLINE, CINAHL,
PsychINFO, and OTDBase. Intervention studies specific to
children with autism spectrum disorder and published in
English language peer-reviewed journals between 1985 and
2005 were examined. Subject headings and keywords
included general terms related to occupational therapy intervention (occupational therapy, intervention, effectiveness,
evidence-based practice); diagnostic terms (autism, autism
spectrum disorder, pervasive developmental disorder); and
terms broadly related to somatosensory stimulation interventions (sensory integration, sensory modulation, sensory
processing, sensory stimulation, habituation, arousal, attention, touch, pressure). Unpublished Master's theses and conference proceedings were not included in this review, as they
are not accessible to the general public. Studies that addressed
somatosensory stimulation not feasible within the context of
daily activity and not typically available to therapists or
clients (e.g., Grandin's hug machine) were also excluded. A
total of six published studies meeting the inclusion criteria
were found that addressed the effectiveness of somatosensory
stimulation interventions feasible within an inclusive setting.
Table 1 provides a comparative summary of the studies. This
review was not systematic in nature. Articles were reviewed
and synthesized based on the manuscript critique process
outlined in Seals and Tanaka (2000). Our aim was to provide
practicing clinicians with an understandable qualitative
assessment of the current literature in this area.
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Results
Case studies
Case studies are commonly used to introduce new interventions or techniques by exploring individual responses.
Indeed, the first three published studies that reported the
effects of somatosensory stimulation interventions for children with autism were case studies. Larrington (1987)
reported numerous positive responses to a variety of sensory
inputs including some somatosensory stimulation (e.g.,
weighted vests, vibration) for a 15-year-old boy with autism
and severe mental retardation, who had a long-standing
history of destructive behaviours. McClure and Holtz-Yotz
(1991) described decreases in self-stimulatory and self-injurious behaviours, and increases in social interaction and
attention span as a result of pressure and tactile input
provided through bilateral, foam arm splints for a 13-year old
boy with autism and severe mental retardation. Zissermann
TABLE 1
Summary of somatosensory stimulation intervention studies for children with autism
Citation
Age
Design
Intervention
Outcomes Measured
Reported findings
Escalona et al.
(2001)
x = 5.2 yrs
RCT with
alternative
treatment
20
Touch (massage)
therapy vs. reading
attention control
group
On-task behaviour,
stereotypical
behaviour, social
relatedness, sleep
diaries
Field et al.
(1997)
x = 4.5 yrs
RCT with
alternative
treatment
22
Touch (massage)
therapy vs. touch
control group (hold
in lap and play
game)
Off-task behaviour,
touch aversion,
withdrawal
Fertel-Daly et al.
(2001)
2-4 yrs
ABA singlesubject
design
Weighted vest
Attention to task,
number of
distractions, selfstimulatory behaviours
Decreased in number of
distractions, increase in
attention to task, decrease in
self-stimulatory behaviours
Case report
Multi-sensory input
including weighted
vest, vibration and
oral stimulation
Variety of outcomes:
alertness, attention,
play skills, self-abuse,
destructive behaviour
McClure
& Holtz-Yotz
(1991)
Case report
Elbow splints;
followed by elastic
arms wrappings
Self-injurious
behaviour
Decrease self-injurious
behaviour and selfstimulations; increased social
interaction with elastic
bandages
Case report
Pressure gloves
and vest
Self-stimulatory
(hand-hitting)
behaviours
Decrease in self-stimulatory
behaviour with vest
13 yrs
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Single-subject research
Fertel-Daly, Bedell, and Hinojosa (2001) explored the effects
of using a weighted vest to address classroom behaviours for
four preschool-aged children with pervasive developmental
disorder (not specified) and one child with autism.
Measurements were taken of the number of distractions, the
length of focused attention to task, and the duration and type
of self-stimulatory behaviours during a table-top, fine motor
activity. One-pound weighted vests were determined effective
in decreasing the number of distractions, increasing attention to task, and decreasing the duration of self-stimulatory
behaviours in four out of five participants.
The authors chose an ABA single-subject design for their
study, which enables systematic evaluation of behaviours
while allowing for individual variations. The ABA design is
considered more rigorous than case studies (or AB designs)
because it adds increased control through replication of the
baseline phase. However, an ABAB design would have further
strengthened the results by providing increased control
through replication of both the baseline and intervention.
The authors reported that this design was not possible due to
time constraints.
The visual results were presented clearly, however, no
statistical interpretation was used to support the visual interpretation of the graphs (e.g., two standard deviation
approach; Barlow & Hersen, 1988). Of most concern, how396
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ever, is that only one rater was used during the intervention
and return-to-baseline phases. Therefore, rater bias and
observer drift may have influenced the results. Given that the
rater was the first author and, therefore, not blinded to intervention condition or to the expected outcomes of the study,
this concern is noteworthy. The authors did take care that the
time of day for data collection remained consistent for each
child, thus controlling for systematic behaviour fluctuations
during the day. Generalisability was also greatly enhanced, as
the study was conducted in the participants' natural
preschool environment. This study does provide important
preliminary support for an intervention strategy reported to
be used by 82% of occupational therapists who work with
children with autism (Olson & Moulton, 2004).
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There have been three more rigorous studies investigating the effectiveness of various somatosensory stimulation
interventions for children with autism including one singlesubject ABA design (Fertel-Daly et al., 2001) and two randomised controlled trials (Escalona et al., 2001; Field et al.,
1997). The clinician can be more confident in the results suggested by these studies, since they offer more control over
extraneous variables. However, generalisability may still be
limited due to small sample size and a lack of detail provided
about the participants.
Discussion
Variability of interventions
Of the six studies published that relate to somatosensory
stimulation interventions for children with autism, two
investigate the effects of massage therapy, one investigates the
effects of weighted vests, one investigates the effects of a pressure vest and gloves, one investigates the effects of arm splints
and pressure arm wrappings, and one investigates a variety of
sensory stimulation. Can we really compare between all of
these interventions? Although these interventions are based
on the same general assumption that providing somatosensory stimulation will have a calming or organizing effect on
the nervous system, none of these studies address this underlying assumption. We need to test the underlying theorysomatosensory stimulation induces physiological effects on
the nervous system-to see if effects are similar with various
types of somatosensory stimulation. Similar effects with
different types of stimulation can increase one's confidence
that individualised interventions may be effective. In addition, we need to replicate studies that address behavioural
and functional outcomes of commonly used somatosensory
stimulation (e.g., weighted vests) to increase our confidence
that specific interventions are effective.
Variability of outcomes
We were surprised by the variability of outcomes expected
from the interventions used. Can we reasonably expect
somatosensory stimulation interventions to influence all of
these outcomes? Are the outcomes used conceptually congruent with the interventions? In theory, different behaviours are
improved if somatosensory stimulation affects the nervous
system; however, we need to better define our outcomes, both
in research and in clinical practice, to determine if our interventions are truly effective. In the literature and in our own
clinical experience, broad goal statements such as "improved
sensory modulation" are not uncommon. However, what
does this mean? Will a parent or teacher of a child with autism
feel comfortable spending time, money, and energy on an
intervention that will improve sensory modulation? We suggest that a parent or a teacher would be more satisfied if outcomes were specific, for example, increased time on task in the
classroom or decreased self-hitting behaviour. Claims of
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Variability of autism
Empirical research related to intervention effectiveness is also
difficult because autism is comprised of an extremely heterogeneous spectrum of disorders. The course of autism varies
significantly between individuals and within an individual.
For example, a child may seek sensory input one day, then be
sensitive to sensory input the next (Schneck, 2001).
Therefore, it is difficult to determine the effectiveness of an
intervention because it may appear effective for some individuals and ineffective for others, or it may appear effective
for one child one day and ineffective for the same child the
next day. This variability was addressed, in part, by Field and
colleagues (1997) and Escalona and colleagues (2001), who
controlled for intelligence quotient and other factors. Future
research also needs to control for variability in autism in
group designs, or provide detailed documentation of individual profiles in single-subject research. Although limiting
participants initially decreases the generalisability of results,
rigorous replication with various subgroups will strengthen
the confidence that researchers, funders, families, and clinicians can have in recommended interventions.
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Acknowledgements
References
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Escalona, A., Field, T., Singer-Strunck, R., Cullen, C., Hartshorn, K.
(2001). Brief report: Improvements in the behavior of children
with autism following massage therapy. Journal of Autism and
Developmental Disorders, 31, 513-516.
Fertel-Daly, D., Bedell, G., & Hinojosa, J. (2001). Effects of a
weighted vest on attention to task and self-stimulatory behaviors in preschools with pervasive developmental disorders.
American Journal of Occupational Therapy, 55, 629-640.
Field, T., Lasko, P.M., Henteleff, T., Kabat, S., Talpins, S., & Dowling,
M. (1997). Autistic children's attentiveness and responsivity
improve after touch therapy. Journal of Autism and
Developmental Disorders, 27, 333-338.
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Developmental Disorders, 33, 365-381.
Goldstein, H. (2000). Commentary: Interventions to facilitate auditory, visual, and motor integration: "Show me the data". Journal
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(1999). A selective review of treatments for children with
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Johnson, C.E., & Danhauer, J.L. (2002). Handbook of outcomes mea-
Conclusion
Sensory-based interventions, including somatosensory
stimulation, are the most common occupational therapy
recommendation for children with autism. The results of this
review indicate that research investigating the effectiveness of
somatosensory stimulation interventions for children with
autism has become more rigorous over time; however, studies are still few in number and replication is limited.
Although these interventions appear promising, it is still difficult for clinicians to recommend interventions with confidence. Researchers and clinicians are therefore challenged to
systematically investigate the effects of sensory stimulation
interventions for children with autism. Building our knowledge will enable occupational therapists to contribute to
autism intervention and enhance the lives of children with
autism and their families.
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Appendix 1
The following list provides clinical considerations for intervention in an area in which empirical support is limited.
Some of these considerations have been adapted from
Baranek (2002) and Gresham et al. (1999).
1. Have a healthy skepticism of intervention strategies
based only on subjective data and anecdotal evidence.
2. Have a healthy skepticism of any interventions whose
authors or advocates are defensive when their program is
honestly criticized.
3. Obtain baseline data prior to starting any intervention.
4. Control for as many variables as possible when trying to
determine if an intervention is effective. For example, do
not try to measure the success of a new intervention at a
time when the child attends a new school, works with a
new teacher, or becomes ill.
5. Provide interventions in shorter, monitored increments
(e.g., one to three months), documenting progress in a
systematic manner.
6. Be very clear in your rationale for recommending a specific intervention. For example, is a weighted vest recommended to address attention to task, or simply because
they are frequently recommended for children with
autism?
7. Recognize that some new interventions may ultimately
be effective, but have not yet been empirically validated.
8. Remember that sensory stimulation intervention strategies are only one of several options.
9. Remember there is no cure for autism. Not every intervention will work for every child.
10. Be honest with clients and caregivers. Until evidence is
available, it is unethical to declare an intervention has
been proven to work.
Authors
Sandra Hodgetts, MClSc, OT is a Doctoral Candidate,
Faculty of Rehabilitation Medicine, University of Alberta,
2-64 Corbett Hall, Edmonton, Alberta, Canada T6G 2G4.
Tel: (780) 492-8568. E-mail: sandra.hodgetts@ualberta.ca
William Hodgetts, MSc is a Doctoral Candidate, Faculty of
Rehabilitation Medicine, Assistant Professor, Department
of Speech Pathology and Audiology, Faculty of
Rehabilitation Medicine, University of Alberta, 2-16
Corbett Hall, Edmonton, Alberta, Canada, T6G 2G4
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