REVIEW

Sensory Symptoms in Autism Spectrum Disorders

Eric P. Hazen, MD, Jennifer L. Stornelli, MOT, OTR/L, Julia A. O’Rourke, PhD, MS, MMSc,
Karmen Koesterer, EdM, and Christopher J. McDougle, MD

The aim of this review is to summarize the recent literature regarding abnormalities in sensory functioning in
individuals with autism spectrum disorder (ASD), including evidence regarding the neurobiological basis of these
symptoms, their clinical correlates, and their treatment. Abnormalities in responses to sensory stimuli are highly prev-
alent in individuals with ASD. The underlying neurobiology of these symptoms is unclear, but several theories have
been proposed linking possible etiologies of sensory dysfunction with known abnormalities in brain structure and
function that are associated with ASD. In addition to the distress that sensory symptoms can cause patients and
caregivers, these phenomena have been correlated with several other problematic symptoms and behaviors associ-
ated with ASD, including restrictive and repetitive behavior, self-injurious behavior, anxiety, inattention, and gastro-
intestinal complaints. It is unclear whether these correlations are causative in nature or whether they are due to shared
underlying pathophysiology. The best-known treatments for sensory symptoms in ASD involve a program of occupa-
tional therapy that is specifically tailored to the needs of the individual and that may include sensory integration
therapy, a sensory diet, and environmental modifications. While some empirical evidence supports these treatments,
more research is needed to evaluate their efficacy, and other means of alleviating these symptoms, including possible
psychopharmacological interventions, need to be explored. Additional research into the sensory symptoms associ-
ated with ASD has the potential to shed more light on the nature and pathophysiology of these disorders and to open
new avenues of effective treatments.
Keywords: autism spectrum disorder, pervasive developmental delay, sensory integration, sensory overresponsitivity,
sensory processing

A
bnormalities in sensory responsivity have been ob-
served in autism spectrum disorder (ASD) since
Kanner’s first characterization of autism in 1943.1
Children with ASD frequently demonstrate significant
differences in the ways that they respond to sensory stimuli.
Despite the high frequency of sensory symptoms in ASD,
in the past these symptoms have been viewed as peripheral
to the disorder rather than as a core feature. In recent years,
however, the central significance of sensory symptoms in
ASD has been increasingly recognized. A growing body of
research has demonstrated the frequency of these symptoms
and the role that they can play in contributing to the features
and functional impairments in ASD.
From Harvard Medical School (Drs. Hazen, O’Rourke, and McDougle); Di-
vision of Child and Adolescent Psychiatry (Drs. Hazen and McDougle),
Lurie Center for Autism (Ms. Stornelli, Drs. O’Rourke and McDougle, and
Ms. Koesterer), and Laboratory of Computer Science (Dr. O’Rourke),
Massachusetts General Hospital, Boston, MA; Spaulding Outpatient Center
for Children, Lexington, MA (Ms. Stornelli).
Original manuscript received 28 February 2013, accepted for publication
subject to revision 7 May 2013; revised manuscript received 3 June 2013.
Correspondence: Eric Hazen, MD, Massachusetts General Hospital, 55
Fruit St, YAW 6A, Boston, MA 02114. Email: ehazen@partners.org
© 2014 President and Fellows of Harvard College
DOI: 10.1097/01.HRP.0000445143.08773.58
This newly recognized importance of sensory symptoms
in ASD has led some to propose that these symptoms may
be more than just a peripheral phenomenon and that they
may represent, instead, a fundamental feature of the disor-
der itself, rooted in the same pathophysiology and contrib-
uting to the broader developmental and behavioral issues
observed in ASD, including social and linguistic impair-
ments and repetitive behaviors. This shift in thinking is
reflected in the inclusion of sensory symptoms as part of
the ASD diagnosis in the new edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5), in
contrast to the DSM-IV, under which they were not consid-
ered part of the diagnostic criteria for autism.2 In this article,
we will review the recent literature regarding abnormalities
in sensory functioning in those with ASD, including recent
evidence regarding the neurobiological basis of these
symptoms, their clinical correlates, and their treatment.
Journal articles for this systematic review were identified
using the electronic databases PubMed and PsycINFO. The
databases were searched using the following search terms:
sensory AND autism, sensory AND pervasive developmental
delay, sensory AND Asperger’s. Abstracts were then reviewed,
and articles were included in this review, if they were relevant
to the topic of this review and they met the following cri-
teria: (1) publication in a peer-reviewed journal, (2) full-text

112 www.harvardreviewofpsychiatry.org Volume 22 • Number 2 • March/April 2014

Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.

article available in English, (3) related to sensory functioning
in individuals with an autism spectrum disorder, including
autism, pervasive developmental disorder not otherwise
specified (PDD-NOS), and Asperger’s disorder. Articles were
excluded if they were based on animal models or if their
full text was not available in English. A manual review of
relevant authors and the bibliographies from selected
articles was later performed to identify additional articles
for inclusion if they met the above criteria.
NATURE AND FREQUENCY OF SENSORY
SYMPTOMS IN ASD
Individuals with ASD have been found to have high rates of
abnormalities of sensory functioning. Abnormalities in all
sensory modalities have been reported in ASD, and a broad
range of disturbances may be observed.3 Published studies
using standardized rating scales of sensory symptoms in
individuals with ASD have consistently shown a high fre-
quency of sensory symptoms at least one standard devia-
tion from standardized norms, with prevalence estimates
varying from 69% to 95%.4–7 The broad range of preva-
lence estimates may be due to differences in methodology
and also to differences in the study populations, including
differences in age and specific diagnoses.
Among the most common sensory symptoms observed
and studied in ASD are disorders of sensory modulation,
which can be defined as abnormal responses to sensory stim-
uli leading to functional impairment.8 Sensory-modulation
disorders fall into three categories. The first is sensory
overresponsivity (SOR), in which an individual experiences
distress or displays an exaggerated negative response to sen-
sory input, often leading to avoidance and hypervigilance
related to the stimulus.8 For example, a child may be espe-
cially sensitive to tactile sensations associated with particular
items of clothing or with particular features, such as tags,
on clothing. This sensitivity may lead the child to become
extremely upset or anxious when wearing such an item, to
have an outburst when wearing certain clothes, or to refuse
to wear certain clothes.
The second category of sensory-modulation disorder is
sensory underresponsivity, in which an individual may
seem to be unaware of, or slow to respond to, a stimulus
that would normally be expected to elicit a response.8 Some
children, for example, have been found to be underrespon-
sive to pain, which can lead to injury when a child continues
to engage in a behavior, such as touching a hot stove, which
would normally elicit a strong pain response.
The third category of sensory-modulation disorder is
sensory-seeking behavior in which an individual exhibits
an unusual craving for, or preoccupation with, certain sen-
sory experiences.8 For example, a child may repeatedly
sniff his fingers or put nonfood items in his mouth.
Much of the research related to sensory symptoms in
individuals with ASD has focused on SOR. One likely rea-
son for this focus is that these symptoms are often the most
Harvard Review of Psychiatry
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Sensory Symptoms in ASD
noticeable to caregivers. Another is that recent evidence
suggests that SOR in ASD is connected with anxiety and
other difficulties, which we will discuss later in this article.
Indeed, SOR is highly prevalent in individuals with ASD,
with estimates from studies in children ranging from 56%
to 70%.4,9 However, a 2009 meta-analysis that looked at
14 studies of sensory-modulation symptoms in individuals
with ASD suggested that sensory underresponsivity may
be the most common symptom type in this population.10
Many individuals with ASD suffer from a combination of
underresponsive and overresponsive symptoms.4
With regard to sensory modality, while it is clear
from numerous studies that any sensory modality may
be affected, some evidence suggests that individuals with
ASD appear to have a greater frequency of sensory impair-
ments in the domains of taste and smell,11,12 as well as tac-
tile sensitivity,13 when compared to others with sensory
dysfunction.
MEASURES OF SENSORY SYMPTOMS
Several standardized assessment instruments are available
for evaluating suspected sensory-processing difficulties.
One of the most commonly used instruments in both re-
search and clinical settings is the Sensory Profile,14 which
is designed for children 3 to 10 years of age. One of the
advantages of this instrument is ease of use, as it consists
of a straightforward checklist filled out by a child’s care-
givers. The measure yields a report that compares the child’s
score across various domains, including sensory modality, to
normative data. These norms come from a sample of 1200
children; no published norms are available for children with
autism. Other variations of the measure have been developed
including the more abbreviated Short Sensory Profile,14 the
Sensory Profile for Infants and Toddlers,15 and the Adolescent/
Adult Sensory Profile.16
Perhaps the gold standard of standardized assessments
for sensory dysfunction is the Sensory Integration and
Praxis Test (SIPT).17 This tool provides a comprehensive
assessment of sensory functioning for children ages 4 years
to 8 years, 11 months old. The SIPT involves direct observa-
tion of a child’s behavior rather than relying on checklists.
This process provides a significant advantage, as checklists
may miss more subtle symptoms and may be affected by
the caregiver’s biases and observational abilities. The SIPT
requires administration by a trained, certified occupational
or physical therapist, however, and is more time-consuming
than other measures, with the full battery taking approxi-
mately two hours. Since the SIPT also requires that the child
understand and follow directions, it may not be valid for
children with intellectual impairments.
Several other standardized sensory-assessment instru-
ments have been developed, including the Sensory Pro-
cessing Measure18 and the DeGangi-Berk Test of Sensory
Integration.19 In addition, many standardized measures of
autism-spectrum symptomatology, including the Childhood
www.harvardreviewofpsychiatry.org 113
E. P. Hazen et al.
Autism Rating Scale,20 Autism Behavior Checklist,21 and
Gilliam Autism Rating Scale,22 feature items related to
sensory-processing dysfunction. All of these instruments
have been developed and standardized, however, with pop-
ulations of typically developing children. While many of
these tools have been used in studies of children with ASD,
at present no published instruments have been developed
for, and standardized with, this particular population of
children. Indeed, the heterogeneity of the ASD population
presents a challenge to standardizing such a tool. Nonethe-
less, the absence of an instrument that is tailored specifically
to the ASD population presents a limitation to current re-
search in sensory dysfunction in this population.
DEMOGRAPHICS: RELATIONSHIP OF DIAGNOSIS,
AGE, IQ, AND SYMPTOM SEVERITY
Diagnosis
High rates of sensory-processing problems have been iden-
tified not only in individuals with autistic disorder but
in those with other diagnoses subsumed under the ASD
umbrella—in particular, Asperger’s disorder4,23–25 and
PDD-NOS.4
A study by Baraneck and colleagues4 compared rates
of sensory symptoms among children with an autism diag-
nosis to those in an “other developmental delay” group,
including individuals with Asperger’s disorder and PDD-
NOS. In that study, children with autism had the highest
rates of sensory symptoms, while the “other developmen-
tal delay” group had a significantly greater frequency of
sensory symptoms than a control group of typically devel-
oping children. Similarly, Leekham and colleagues12 found
higher rates of sensory symptoms in children with autism
compared to age- and IQ-matched controls with develop-
mental delay due to other causes.
This finding that individuals with an autism diagnosis
may have higher rates of sensory symptoms than those with
other ASDs, such as Asperger’s disorder and PDD-NOS,
is indirectly supported by a meta-analysis of sensory-
modulation symptoms in ASD, which showed that studies
with a higher percentage of subjects with the specific diag-
nosis of autism showed higher rates of reported sensory
symptoms than studies with relatively higher percentages
of other ASDs in the study group.10
Studies have shown that patients with other neurodevel-
opmental disorders, including fragile X26 and Williams27,28
syndromes, also have high rates of sensory symptoms, though
no studies have directly compared the frequency and nature
of these symptoms to patients with autism.
Chronological Age, Mental Age, and ASD
Symptom Severity
Studies examining the relationship of age and sensory
symptoms in ASD have produced conflicting results, with
some suggesting that symptoms improve somewhat with
114 www.harvardreviewofpsychiatry.org
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
age29 and others showing no relationship with age.4 The
different findings may, in part, be related to significant
variation in the age ranges examined in different studies.
In their meta-analysis of studies of sensory modulation
symptoms in ASD, Ben-Sasson and colleagues10 found
that the frequency of sensory symptoms increased until
reaching a peak at 6–9 years of age and gradually declined
thereafter. The authors suggest that symptoms may peak
at this time in response to the stresses and environmen-
tal changes associated with entering a school setting. It
has been suggested that improvements seen after this age
may be related to children learning coping strategies for
managing their symptoms.29 Nonetheless, the available
evidence indicates that many sensory symptoms continue
to occur commonly and cause significant impairment into
adulthood.12,29–31
Most evidence suggests that individuals with lower IQ
or mental age and more severe ASD symptoms have a
higher frequency of sensory symptoms.4,5,10,12,29,32,33 The
evidence is conflicting, however, concerning the relation-
ship between IQ and sensory symptoms.23,34
NEUROBIOLOGY OF SENSORY SYMPTOMS IN ASD
Psychophysical Studies of Sensory Symptoms in ASD
Studies of physiologic responses to sensory stimuli in indi-
viduals with ASD support the findings from clinical studies
that these individuals frequently have abnormalities in their
processing of, and response to, sensory input.
Multiple studies using electroencephalography (EEG)
and magnetoencephalography have shown that significantly
different patterns of activity occur in primary auditory and
associative cortical areas in response to various auditory
stimuli.35–39
The findings from studies of visual processing in ASD
are conflicting. Some have shown no differences in spatial
contrast sensitivity and in motion and form perception in
subjects with ASD.40,41 Several psychophysical studies,
however, have shown subtle visual-processing abnormali-
ties, including impairments in object boundary detection,42
contrast boundary detection,43 and coherent motion dis-
crimination44 in individuals with ASD.
Despite the frequency of symptoms related to tactile sen-
sitivity in the ASD population, relatively few studies have
been conducted in this area compared to those of auditory
and visual processing.3 Nonetheless, some studies have
shown perceptual differences to certain kinds of tactile
stimuli in individuals with ASD, including increased sensi-
tivity to vibrotactile stimuli.45,46 A recent magnetoenceph-
alography study showed differential responses to various
sensory stimuli in the primary somatosensory cortex of chil-
dren with autism compared to matched controls, including
smaller-amplitude left hemisphere response.47 Similarly, a
functional magnetic resonance imaging study comparing
responses to sensory stimuli in adults with ASD to controls
Volume 22 • Number 2 • March/April 2014

found that the ASD group showed diminished responses
to textures in the parietal somatosensory and association
areas.48 Interestingly, however, the ASD group in this study
showed increased activity in limbic areas in response to
unpleasant textures relative to controls, including increased
activity in the insula, an area associated with the processing
of pain and disgust.
In addition to studies of individual sensory modalities,
some studies have demonstrated deficits in the integration
of stimuli from more than one modality, including difficul-
ties integrating auditory and visual input.49–52 Congruently,
electroencephalography and high-density electrical mapping
studies have demonstrated different response patterns to tasks
requiring audiovisual integration,53 auditory-somatosensory
integration,54 and concurrently presented auditory and visual
stimuli55 in individuals with ASD.
Theories Regarding Pathophysiology
Just as the underlying pathophysiology of ASD remains
unclear, the neurological mechanism responsible for abnor-
mal sensory processing in this population is not known.
Several theories have been proposed. Given the abnormali-
ties observed in the integration and higher-level processing
of sensory input, abnormal functioning in cortical areas
known to play a role in these tasks would be a logical
hypothesis.3 Indeed, neuropathological studies have shown
abnormalities in cellular density in the neocortex in indivi-
duals with autism,56 but these findings are not specific to areas
involved in sensory processing and are also inconsistent across
studies.57 Disruptions in connectivity between discrete cor-
tical and subcortical regions have also been proposed,3 which
might explain why integration of multisensory inputs would
be disrupted; this hypothesis is supported by findings that
show abnormalities in white matter connectivity,58 corpus
callosum volume,59,60 and long-range firing synchrony.61
Hardan and colleagues62 demonstrated an association be-
tween decreases in corpus callosum volume and the severity
of several symptom clusters, including sensory symptoms, in
children with autism. Kern,63 among others, has suggested
that structural and cellular abnormalities in the cerebellum,
which have been associated with ASD in neuroimaging
and post-mortem pathological studies, may be responsible
for the sensory dysfunction seen in these patients; of relevance
here is the role that the cerebellum has relatively recently
been found to play in integrating and modulating sensory in-
put. Mazurek and colleagues,64 citing clinical correlations be-
tween sensory symptoms, gastrointestinal (GI) symptoms, and
anxiety in children with ASD, suggest possible disruptions
in the hypothalamic-pituitary-adrenal axis and the amyg-
dala, which they theorize could explain the connections
between these symptoms. These authors also posit a role
for the immune dysfunction that has recently been ob-
served in many individuals with ASD. Significant structural
abnormalities in the amygdala have also been associated
with autism.57,65
Harvard Review of Psychiatry
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Sensory Symptoms in ASD
CLINICAL CORRELATES OF SENSORY
DYSFUNCTION IN ASD
Sensory symptoms in and of themselves can cause signifi-
cant distress for individuals with ASD and their caregivers.
For example, these symptoms have been shown to contrib-
ute significantly to limitations in participation in work,
family, and leisure activities in families of children with
ASD.66 Much of the recent literature related to sensory
symptoms in ASD has focused on the correlation between
these symptoms and other problematic symptoms and
behaviors associated with the disorders. While the causative
nature of these relationships remains unclear, it is evident
that sensory symptoms are closely tied to other features
of ASD.
Repetitive Behaviors
Restricted and repetitive behaviors (RRBs) are part of the
diagnostic criteria in both DSM-IV and DSM-5, and
thus are present in the vast majority of individuals with
ASD. These behaviors comprise a group of heterogeneous
behaviors such as hand flapping, body rocking, covering
eyes and ears, arranging things in certain order, and
insisting on placing items in the same place.67
Despite the heterogeneity of these behaviors, they can be
grouped into several subcategories. Recent factor analysis
of 1825 ASD individuals based on the Repetitive Behavior
Scale–Revised parent questionnaire67 identified five sub-
categories: (1) repetitive sensory-motor/stereotypic behaviors,
(2) ritualistic/insistence on sameness behaviors, (3) compulsive
behaviors, (4) restricted/circumscribed interests, and (5) self–
injurious behaviors.68 The first two subcategories were previ-
ously identified by performing factor analysis of the RRB
items from the Autism Diagnostic Interview–Revised.69
Numerous factor analysis studies found that the repetitive
sensory-motor/stereotypic behaviors subgroup consistently
includes a sensory component,68,70–73 indicating that sensory
processing closely relates to these specific repetitive behaviors.
Repetitive sensory-motor/stereotypic behaviors, which in-
clude body rocking, repetitive use of objects, and sensory-
seeking behaviors, have been shown to be worse in younger
individuals with lower cognitive abilities, and they improve
with age.68,70,74,75 By contrast, ritualistic behaviors, insistence
on sameness, and difficulties with transitions have been found
to be independent of age or cognitive abilities.68,74,75
Children with ASD are more likely to experience repetitive
behaviors if sensory-processing abnormalities are present,5,24,76
and more-severe sensory abnormalities are associated with
more RRBs.24 This association has led some researchers to pro-
pose that stereotypic behaviors have an underlying sen-
sory origin,77,78 and the available evidence suggests that
such behaviors have a self-stimulatory function.79 Charac-
terizing RRBs as solely sensory-based, however, is likely
an oversimplification. Boyd and colleagues80 investigated
how specific RRBs (stereotypy, self-injury, compulsions,
rituals, and restricted interests) are associated with the three
www.harvardreviewofpsychiatry.org 115
E. P. Hazen et al.
types of sensory dysfunctions in 67 children with autism
and 42 children with developmental delay. In that study,
the hyperresponsive sensory score showed some associations
with stereotypy, self-injury, compulsions, and rituals; the
sensory-seeking score suggested a potential association with
stereotypy, self-injury, and rituals; and the hyporesponsive
sensory score was associated with stereotypies. These prelim-
inary findings suggest that stereotypies are associated with
all three types of sensory dysfunctions, although the reasons
for these co-occurrences are likely different.
A recent review of RRBs in ASD suggests that repetitive
behaviors provide coping strategies for children with ASD
to regulate arousal level or to manage anxiety.81 In cases
of hyperarousal, repetitive behaviors might be soothing,
whereas in cases of hypoarousal, repetitive behaviors may
act to increase sensory stimulation. The authors indicated,
however, that the experimental evidence is as yet insufficient
to fully support this conclusion81 and that more research is
needed—utilizing measures with strong psychometric prop-
erties and including assessments of physiological responses,
rather than parent-reported measures.78
Self–Injurious Behavior
Self-injurious behaviors (SIBs) are among the more clinically
challenging features of ASD. These behaviors consistently
present as a separate subgroup of repetitive behaviors in fac-
tor analysis studies.68 SIBs are also highly correlated with
other subgroups of repetitive behaviors, especially with the
repetitive sensory-motor/stereotypic behaviors subgroup.68
SIBs in individuals with developmental disorders are com-
monly frequent and repetitive, closely resembling stereo-
typic movements.82 Based on these observations, Gal and
colleagues83 hypothesized that SIBs represent a more severe
form of stereotypic movements. This hypothesis was, indeed,
supported in their own study of 221 children, including
56 children with autism, in which the presence of SIBs was
contingent on the presence of other stereotypic movements.83
A recent study of 241 individuals with ASD evaluated
the influence of seven factors on SIBs: (1) atypical sens-
ory processing, (2) impaired cognitive ability, (3) abnormal
functional communication, (4) abnormal social function-
ing, (5) age, (6) the need for sameness, and (7) rituals and
compulsions.84 Abnormal sensory processing was the stron-
gest single predictor of SIBs, explaining 12% of the variance.
Several studies of SIBs in ASD have implicated impaired
cognitive ability as a risk factor.84–86 Age is also a factor,
with some indications that SIBs increase during childhood,
peak in adolescence, and decrease in adulthood.72,87 There-
fore, SIBs and the repetitive sensory-motor/stereotypic be-
haviors subcategory of repetitive behaviors are similarly
inversely related to age and IQ, further suggesting that SIBs
represent a more severe form of stereotypic behaviors.
The preliminary findings from the study by Boyd and
colleagues80 indicate that SIBs are more associated with
the hyperresponsive and sensory-seeking sensory types than
116 www.harvardreviewofpsychiatry.org
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
with the hyporesponsive type. These authors have
also reported that only the hyperresponsive and sensory-
seeking types have not correlated with each other, sug-
gesting that these two subtypes do not co-occur in the same
individual.
Problem Behaviors and Adaptive Functioning
Sensory-processing dysfunction in individuals with ASD
is associated with lower levels of adaptive skills13,88 and
more problem behaviors,33,88,89 especially in individuals
with more severe sensory dysfunction.33 Lane and col-
leagues33 found that the Maladaptive Behaviors subscale
from Vineland Adaptive Scales90 was significantly associ-
ated with severe sensory dysfunction. The maladaptive
or problem behavior subscale includes items describing
a wide range of behaviors such as noncompliance, poor
mood regulation, withdrawal, impulsivity, aggression, self-
injurious behaviors, hyperactivity, restricted interests, and
distractive behaviors.
Attention Problems
About a third of children with ASD have symptoms that
support the diagnosis of ADHD91 (though under DSM-IV,
but not DSM-5, diagnostic criteria, a child could be diag-
nosed only with either ASD or ADHD and not both con-
currently). The attention difficulties that are observed in
children with ASD tend to be quite different from those
with ADHD. Generally, whereas children with ADHD
have difficulties staying on task, children with ASD have
trouble shifting attention.
The cognitive process of attention consists of selecting
items for further processing from an array of sensory stim-
uli, thoughts, or courses of action. This selection of items
for further processing might enhance some items while
filtering out others. As such, this selection process re-
quires operations such as attention switching and sustained
attention over time. The difficulty in attention shifting
in individuals with ASD could be attributed to hypo-
sensitivity to external stimuli coupled with low levels of
arousal. Although arousal and the sensory reaction to ex-
ternal stimuli are physiologically different, under-reactivity
often co-occurs with under-arousal.92 Liss and colleagues32
found that the overresponsivity observed in individuals with
ASD was associated with over-focusing attention.
Other studies have found that hyporesponsivity, sensa-
tion seeking, and auditory filtering were commonly associ-
ated with attention difficulties.93,94 A low level of arousal
can lead to difficulty in allocating attention resources for
processing environmental stimuli.11,95 Several neurophysi-
ologic studies indicate that auditory-processing deficits
are likely to arise due to cognitive factors such as reduced
attention and are not due to impaired acoustic encoding
or sound discrimination.3
In addition to difficulties in attention shifting, some chil-
dren with ASD have difficulties in selective attention,
Volume 22 • Number 2 • March/April 2014

which dictates what information in the environment should
be focused on and what information should be ignored.
Individuals with ASD have demonstrated difficulties in se-
lective attention when exposed to a stimulating sensory en-
vironment.3 This difficulty may be apparent when a child
with ASD functions well in a controlled setting but has
a meltdown or runs away in a situation that is sensory chal-
lenging, like a playground or a grocery store. Neurophysio-
logic studies have demonstrated that individuals with ASD
perform well on simple visual or auditory tasks, but as the
complexity of these tasks increases, their performance
degrades, indicating a deficit in the automatic processing
of information. This degradation in performance may also
indicate that individuals are experiencing an overloading
of the attention and working-memory networks.3
Anxiety
Anxiety disorders are highly comorbid in individuals with
ASD, with prevalence rates ranging from 11% to 84%.96
Considering the high rates of anxiety and sensory-processing
difficulties in ASD and the theoretical links between these
two clinical correlates, emerging research has been investi-
gating this relationship.23,97–100 While sensory process-
ing and anxiety hold distinct clinical definitions, studying
their relationship has more than a few challenges.101 The
aspects of anxiety and sensory-processing difficulties that
lend well to theoretical comparisons also create difficulties
when attempting to distinguish these two constructs. The
characteristic behaviors (e.g., avoidance and dysregulation)
overlap, and clinical interpretations are biased by the orienta-
tion of the clinician.101 Also, anxiety and sensory-processing
difficulties may share similar physiological pathways.98 Spe-
cific to the ASD population, communication impairments in
certain cases prevent accurate self-report of symptoms, and
the behavioral overlaps in ASD phenomenology, anxiety,
and sensory processing are difficult to differentiate on behav-
ior checklists.
Sensory overresponsivity is the most often cited sensory
correlate to increased anxiety in both general102–104 and
ASD populations.23,97,99,100 Green and Ben-Sasson98 propose
three theories supporting the link between sensory overres-
ponsivity and anxiety: (1) SOR is caused by, or is a symptom
of, anxiety (e.g., hypervigilence or hyperarousal focused on
sensory input); (2) anxiety is caused by, or is a symptom of,
SOR (e.g., overreactions to sensory input creates conditioned
behavioral responses); and (3) SOR and anxiety are associ-
ated through a third variable such as a common risk factor
(e.g., common neurophysiological pathways) or overlapping
diagnostic criteria (common symptoms across disorders).
Two studies present results supporting Green & Ben-
Sasson’s primary SOR theory—namely, (2) above, that
SOR precedes anxiety.98 In a sample including children
with ASD, ADHD, and typical development who were
presented with a sensory challenge, the intensity of the phys-
ical response measured with skin conductance mediated
Harvard Review of Psychiatry
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Sensory Symptoms in ASD
the relationship between baseline arousal and anxiety.
The findings suggest that those with greater sensory re-
sponse also had higher levels of anxiety after challenging
sensory stimuli were presented.97 In another study, toddlers
with an ASD diagnosis were assessed over the course of one
year to explore the relationship between SOR and anxiety.
Although SOR remained stable over time, the researchers
found that anxiety increased. Further analysis revealed that
SOR at time 1 predicted anxiety level at time 2, but that
anxiety at time 1 did not predict SOR at time 2. The
findings suggest that SOR may be a precursor to the devel-
opment of anxiety.99
Other investigations offer conflicting results on the gen-
eral association of SOR and anxiety. In an older sample
of children and adolescents with Asperger’s disorder,
researchers found significant associations between sensory
defensiveness, which is a manifestation of overresponsivity,
and anxiety.23 The association between SOR and anxiety
was not replicated in a sample of Japanese children with
ASD. The group characterized as having hypersensitivities
did not differ significantly on the anxiety measure com-
pared to the group with no hypersensitivities.105 Further,
the anxiety and sensory link appears to weaken slightly
with the inclusion of a range of sensory-processing diffi-
culties. Using cluster analysis, three sensory-processing
groups were determined for a sample of toddlers with ASD.
Groups were defined as low frequency (no to mild sensory
abnormalities), high frequency (under- or overresponsivity,
and seeking), and mixed frequency (high under- or over-
responsivity, and low seeking) of sensory processing diffi-
culties. Toddlers in the high-frequency group had higher
rates of parent-reported anxiety than the low-frequency
group. Differences in anxiety did not emerge among all
of the groups, however, possibly because the overall rate
of clinically significant anxiety was low in this sample of
young children (5%).100
Other Correlates
Sensory-processing dysfunction has been implicated in other
temperamental presentations, including negative affect,
withdrawal/depression, and social impairment. In a sample
of children and adolescents with Asperger’s disorder, sensory
hyporesponsivity was found to correlate with depressive
symptoms.23 By contrast, in a sample of Japanese children
with ASD, the hypersensitive group, compared to the non-
hypersensitive group, had more depressive symptoms.105 In
another study, elevations in hypersensitivity, hyposensitivity,
and sensory seeking combined were associated with higher
levels of withdrawal and negative mood.106 Similarly, overall
sensory dysfunction was associated with increased problems
on the Aberrant Behavior Checklist, including irritability
and lethargy/social withdrawal.89 In Ben-Sasson and col-
leagues’ cluster analysis mentioned earlier,100 the toddlers
in the high-frequency (elevated problems in all areas) group
had higher rates of parent-reported negative emotionality,
www.harvardreviewofpsychiatry.org 117
E. P. Hazen et al.
separation distress, and depression/withdrawal symptoms
than the low-frequency group. Compared to the mixed group
(elevated hyper- and hyposensitivity), the high-frequency group
had higher rates of negative emotionality and depression/
withdrawal, and the mixed group had higher levels of nega-
tive emotionality and depression/withdrawal, than the low-
frequency group.
The relationship between gastrointestinal dysfunction
and sensory processing in ASD is an area that has garnered
attention recently. High rates of GI problems are reported
in the ASD population,107 and those with abdominal pain
are more likely to show exaggerated startle reflexes to sen-
sory stimuli.108 Recently, Mazurek and colleagues64 ex-
plored the intersection of chronic GI problems, anxiety,
and sensory processing in a large sample of children and
adolescents with ASD. The authors demonstrated that
both anxiety and sensory overresponsivity predict the
presence of chronic constipation, abdominal pain, bloating,
and nausea.
TREATMENT OF SENSORY ISSUES ASSOCIATED
WITH ASD
Occupational therapy is currently the mainstay of treat-
ment for sensory disorders associated with ASD. Every
individual has a unique sensory profile existing within an
ever-changing environment. Thus, the approach that occu-
pational therapists take must be tailored to the specific
needs and challenges of each individual. Before treatment
can begin, a thorough assessment must take place. The
occupational therapist must look at a person’s unique sen-
sory profile and determine through direct observation and
assessment, as well as by caregiver interview, how these
sensory issues are affecting that individual’s ability to par-
ticipate fully and safely in his or her daily activities and rou-
tines. The therapist also needs to consider how these factors
play out across the contexts of home, school, work, and
community settings, as well as to the interplay between
task, environment, and social context.
Sensory Integration Therapy
Sensory integration therapy is based upon a theory that
describes how the nervous system translates sensory infor-
mation into action.109 Individuals with sensory integration
dysfunction misinterpret everyday sensory information
(touch, sound, movement, etc.), are unable to discriminate
between sensations, or have such unusual or awkward mo-
tor or behavioral responses that it limits participation
in daily activities and interactions.8 Jean Ayres,109 in ex-
plaining the theory of sensory integration, suggested that
if a child is engaged in meaningful, individually tai-
lored sensory-motor activities that offer the “just right
challenge,” the child’s nervous system will be better able
to modulate, organize, and integrate sensory information
in order to produce an adaptive response. The premise of
providing specific input to a sensory system in order to
118 www.harvardreviewofpsychiatry.org
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
elicit the reorganization of cortical maps is central to the
theory of sensory integration. Lacourse and colleagues110
found that, although both physical activity and exposure
to an enriched sensory environment can affect some aspects
of neurogenesis, the importance of active participation is
indeed critical to obtain maximal results. Specifically, they
found that when presented with a novel (non-habitual) mo-
tor task, individuals who engaged in physical performance
of the task saw improvement of 121% versus individuals
who engaged only in mental practice, who saw an improve-
ment rate of 86%.
Active participation is not the only critical ingredient
to sensory integration. Parham and colleagues111 published
a fidelity measure describing the essential components
of sensory integration therapy. These components in-
clude (1) physical safety, (2) enriched sensory opportunities,
(3) strategies to maintain appropriate arousal level/alertness,
(4) challenges to postural, ocular, oral, or bilateral motor
control, (5) opportunities for higher-level praxis and orga-
nization of behavior, (6) collaborating with child in activity
choice, (7) tailoring the activity to present the “just right
challenge,” (8) facilitating success, (9) tapping into the
child’s intrinsic motivation to play/interact, and (10) estab-
lishing a therapeutic alliance. Adhering to these principles,
sensory integration therapy is carried out by a specially
trained occupational therapist with the goals of improving
sensory modulation for improved attention and behavioral
control and of improving the ability to integrate sensory in-
formation across systems as a basis for improved praxis
and higher-level skills.112
An important study by Miller and colleagues92 looked
at how the benefits occupational therapy–sensory integra-
tion (OT-SI) therapy compares to what would be achieved
through active participation in play (non-OT). The study
used randomized, controlled trials to compare OT-SI inter-
vention with children with sensory modulation disorder
to both an active alternative group (e.g., children engaged
in a variety of table-top play with a non-OT staff member
or student; no parent education provided) and a passive
control (children on the waitlist for OT-SI). Children in
the OT-SI group made significantly greater improvements
toward their goals as measured by a goal-attainment scale,
compared to children in the other two groups. Further-
more, the OT-SI group increased significantly more on At-
tention and the Cognitive/Social Composite of the Leiter
International Performance Scale–Revised. These results
provide strong evidence for the effectiveness of OT-SI over
a non-OT, play-based intervention or no intervention at all.
Pfeiffer and colleagues113 also found support for sensory
integration over other treatments—specifically, OT with a fo-
cus on fine-motor skills. Children with ASD ages 6–12 years
were randomly assigned to one of the two groups. Although
positive outcomes on a goal-attainment scale were achieved
for both groups, the changes seen with the sensory integration
group were greater.
Volume 22 • Number 2 • March/April 2014

Despite the findings discussed above, additional research
is needed to determine whether sensory integration therapy
and related interventions are effective treatments for children
with ASD and other developmental disabilities. Lack of
strong research in this area has come under scrutiny in recent
years, and in May 2012 the American Academy of Pediatrics
issued a policy statement on sensory integration therapy, cau-
tioning therapists to communicate this paucity of supportive
evidence to patients and families prior to treatment and to
encourage the families to determine for themselves if the in-
terventions are reasonable to try for their children.114
Sensory Diet and Complementary Interventions
Another key component to an OT intervention with a child
with ASD is the implementation of a sensory diet—that is,
a regimen of regularly scheduled, sensory-based activities
provided throughout the day so that the child’s sensory
needs are met in a safe, controlled, and socially appropriate
manner. This approach can be especially effective with
children who are “sensory seekers” who often seek out
movement, visual, tactile, or proprioceptive input in ways
that interfere with or disrupt daily routines, or that com-
promise personal safety or the safety of those around them.
A sensory diet needs to be created with the child’s unique
sensory profile in mind. In some cases, strategies are
imbedded in the child’s regular routine, as in sitting on a
small air-filled cushion during meals or using an electric
toothbrush instead of a manual one. In other cases, sensory
diet activities are implemented as breaks from the child’s
routine, as when calming and organizing sensory input is
provided in an effort to increase attention, reduce disrup-
tive or impulsive behavior, and improve participation in
subsequent activities. Many authors have discussed the
calming effects of deep pressure and proprioception, which
are frequently incorporated into sensory diets to increase
organized behavior.115,116
When helping clients and caregivers create and imple-
ment sensory diets, the occupational therapist collaborates
with them to identify what challenges exist that may be
ameliorated by a sensory diet, what sensory strategies
the client seeks, what naturally occurring possibilities exist
or may be included, and when to implement the strate-
gies.117 The exact activities depend on the child but may
include activities such as bouncing on an exercise ball,
jumping on a trampoline, swinging on a swing, getting
deep pressure input through massage or other techniques,
engaging in heavy work (dragging, pushing, or carrying
things to load the muscles), resistive activities (Theraband,
Theraputty), oral-sensory inputs (crunchy, chewy, or sour
snacks), and a variety of auditory and visual stimuli.
Depending on the child’s cognitive ability and age, strate-
gies for self-regulation may be implemented. The Alert Pro-
gram’s How Does your Engine Run? outlines strategies for
children to identify their own arousal levels and to begin to
make connections between various activities and sensory
Harvard Review of Psychiatry
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Sensory Symptoms in ASD
inputs and their bodies’ own reactions to those inputs.117
Visual supports such as an “engine wheel” or “engine meter”
are helpful in allowing some children with ASD to identify
their own “engine” as going “too fast,” “too slow,” or “just
right.” Once they identify their engine speeds (with or with-
out adult assistance), they can experiment with methods to
change those speeds (e.g., through sensory diets).
Some studies have shown that when a sensory diet is
used in conjunction with other complementary interven-
tions, results can be substantial. A study by Hall and
Case-Smith118 found measureable improvement in the sen-
sory processing of children with ASD and other develop-
mental disabilities following a 12-week intervention that
included the implementation of a sensory diet in conjunc-
tion with therapeutic listening. The latter is a sound-
based treatment based on the work of a French physician,
Alfred Tomatis, who believed that the ear functions as
an “integrator” and serves as a critical organ in facilitating
organization at all levels of the nervous system.119 The
subjects in this study averaged a 71-point increase in their
scores on the Sensory Profile (Caregiver Questionnaire),
with improvement seen in 9 out of the 14 subsections.118
The parents of these children reported a number of signifi-
cant behavioral changes following treatment, including
increased attention, greater peer interaction, improved
sleep patterns, better communication, and easier transi-
tions. The results of this study represent a substantially
larger improvement than seen in previous studies utilizing
therapeutic listening alone.
Environmental Adaptation
Occupational therapists play an important role in environ-
mental adaptation, helping the child to function in various
settings. Children who tend to be hyporesponsive to sen-
sory input, for example, may benefit from the use of music
(with a faster beat) to increase arousal level or from the
use of strong scents (scented candles, foods with strong
aromas). Offering these children opportunities to change
their seating or positioning during activities or mealtime
can also be helpful in keeping them engaged.
By contrast, children who tend to be hyperresponsive to
sensory input may need an environment that is calm and
predictable. Reducing background noise and using natural
light in lieu of fluorescent light, keeping home and class-
room well organized with minimal clutter, and selecting
bedding and clothing that the child can tolerate well are
important considerations.
Many children with ASD rely on an environment that is
consistent and on a routine that is predictable. Changes to
routine or physical space can be confusing and disorienting
to some children with ASD. When change is unavoidable,
visual supports can be helpful. Picture schedules depicting
the new chain of events or the use of a Social Story (simple
vignette about a social situation) are strategies commonly
used to facilitate these changes.
www.harvardreviewofpsychiatry.org 119
E. P. Hazen et al.
Task Modification and Activity Analysis
As stated above, modifying a task or tailoring an activity to
present the “just right challenge” is an essential component
to OT intervention. Sometimes activities need to be altered
to avoid aversive sensory responses, as by decreasing
tactile, auditory, or movement input that can lead to over-
stimulation and withdrawal. In other instances the right
type of sensory input needs to be enhanced in order to mo-
tivate the child to participate. Another important consider-
ation in activity selection is the child’s overall state of
arousal or alertness. Maintaining a state of arousal that
supports learning and engagement is an important compo-
nent to intervention.
Social Considerations
In looking holistically at the impact of children’s sensory
impairments on their daily lives, therapists need to look
at their social networks across settings, including how the
children interact with members of their families at home,
how they interact with peers and teachers at school, and
how they integrate into the community. Several important
adjustments should be made in order to foster social partic-
ipation in different contexts. Miller120 suggests that identi-
fying playmates who do not overstimulate the child, who
are sensitive to the child possibly needing more time to re-
spond, and who make an effort to include the child in ac-
tivities can help foster more successful peer interactions.
Miller also emphasizes the importance of sensitivity train-
ing. Educating siblings and classmates about the child’s
sensitivities, difficulties with personal space, and unique
sensory needs can foster greater understanding and toler-
ance during daily interactions.
Psychopharmacological Treatment
To date, there is only a single published study related to
medication management of sensory symptoms in ASD.
This retrospective study by Fung and colleagues121 showed
modest improvement in some sensory symptoms following
treatment with aripiprazole. The authors speculate that
the efficacy of aripiprazole may be related to its modula-
tion of serotonin and dopamine pathways, both of which
have been linked to sensory processing, including sensory-
gating mechanisms. These results should be interpreted
with caution since the study had a retrospective design,
did not have a control group, and had a small sample size
of only 13 subjects. Nonetheless, it raises the interesting
possibility that medications, including others that may
affect serotonergic or dopaminergic pathways, may have
a role in addressing sensory symptoms in ASD.
DISCUSSION
In summary, abnormalities in responses to sensory stimuli
are highly prevalent in individuals with ASD, even when
compared to individuals with other forms of developmen-
tal delay. These abnormalities can include both hypo- and
120 www.harvardreviewofpsychiatry.org
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
hypersensitivity to sensory stimuli, and maladaptive and
repetitive patterns of seeking particular sensory stimuli.
Though the findings are somewhat conflicting, it appears
that rates of sensory symptoms are highest in individuals
with a diagnosis of autistic disorder relative to Asperger’s
disorder and PDD-NOS and that the symptoms may be
most frequent and severe in those with lower mental age
and more severe overall symptomalogy. Some evidence
suggests that these symptoms diminish in later childhood
and adolescence, though they are still common in adults.
The underlying neurobiology of these symptoms is un-
clear but may be related to other abnormalities in brain
structure and function that have been identified in ASD.
Proposed mechanisms include local structural abnormali-
ties in cortical areas such as sensory association areas in-
volved in sensory processing and integration, disturbances
in long-range connectivity between discrete brain areas
(including structural disturbance in the corpus callosum),
and structural and functional impairments in the amyg-
dala, cerebellum, and hypothalamic-pituitary-adrenal axis.
In addition to the distress that sensory symptoms can
cause for patients and caregivers, these symptoms have
been correlated with several other problematic symptoms
and behaviors associated with ASD, including restrictive
and repetitive behavior, self-injurious behaviors, anxiety,
attentional problems, and GI complaints. It is unclear
whether these correlations are causative in nature or whether
they are due to the same underlying neurological under-
pinnings. It appears that some of these comorbid symptoms
are associated with specific patterns of sensory symptoms.
For example, anxiety symptoms are more associated with sen-
sory hyperresponsivity, whereas problems with attention and
hyperactivity are closely related to sensory hyporesponsivity
and sensory-seeking behaviors. These patterns raise the
possibility that endophenotypes in ASD might be eluci-
dated through patterns of sensory symptoms and related
comorbidities.
The best-known treatments for sensory symptoms in
ASD involve a program of OT that is specifically tailored
to the needs of the individual and that may include sensory
integration therapy, a sensory diet, and environmental mod-
ifications. While further outcomes research is needed to sup-
port the efficacy of these interventions, at present they
appear to be the most effective treatments available.
The growing recognition of the centrality of sensory
symptoms in ASD opens several promising avenues for
future investigation. More research is needed on the under-
lying neurophysiology of those symptoms and on the
relationships between them and the symptoms and comor-
bidities related to ASD. Despite the distress caused by such
symptoms, little research has been conducted regarding
their treatment. Further research into the efficacy of sen-
sory integration therapies would be useful, and the role of
psychiatric medications in treating sensory symptoms has
not been adequately explored. A single study showing the
Volume 22 • Number 2 • March/April 2014

efficacy of aripiprazole raises the possibility that psycho-
pharmacology may have an adjunctive role.
In addition to such additional research, greater efforts
should be made to train psychiatrists and other mental
health professionals working with the ASD population to
evaluate patients for sensory symptoms. In addition to
helping clinicians better understand their patients’ experi-
ence and enabling them to frame better treatment strate-
gies, the ability to take an effective history of sensory
symptoms will become essential to making an accurate
diagnosis of ASD under the revised DSM-5 criteria. While
much is still unclear about sensory symptoms and their
relationship to ASD, it seems that understanding more
about these symptoms and their treatment may not only
help us improve the quality of life of individuals with
ASD; it may shed light on the nature of these disorders.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the article.
REFERENCES
1. Kanner L. Autistic disturbances of affective contact. Nerv
Child 1943;2:217–50.
2. Volkmar FR, Reichow B, McPartland J. Classification of
autism and related conditions: progress, challenges, and
opportunities. Dialogues Clin Neurosci 2012;14:229–37.
3. Marco EJ, Hinkley LB, Hill SS, Nagarajan SS. Sensory
processing in autism: a review of neurophysiologic findings.
Pediatr Res 2011;69:48R–54R.
4. Baranek GT, David FJ, Poe MD, Stone WL, Watson LR.
Sensory Experiences Questionnaire: discriminating sensory
features in young children with autism, developmental delays,
and typical development. J Child Psychol Psychiatry 2006;47:
591–601.
5. Baker AE, Lane A, Angley MT, Young RL. The relationship
between sensory processing patterns and behavioural
responsiveness in autistic disorder: a pilot study. J Autism
Dev Disord 2008;38:867–75.
6. Klintwall L, Holm A, Eriksson M, et al. Sensory abnormalities
in autism. A brief report. Res Dev Disabil 2011;32:795–800.
7. Tomchek SD, Dunn W. Sensory processing in children with
and without autism: a comparative study using the short
sensory profile. Am J Occup Ther 2007;61:190–200.
8. Miller LJ, Anzalone ME, Lane SJ, Cermak SA, Osten ET.
Concept evolution in sensory integration: a proposed
nosology for diagnosis. Am J Occup Ther 2007;61:135–40.
9. Ben-Sasson A, Cermak SA, Orsmond GI, et al. Extreme
sensory modulation behaviors in toddlers with autism
spectrum disorders. Am J Occup Ther 2007;61:584–92.
10. Ben-Sasson A, Hen L, Fluss R, Cermak SA, Engel-Yeger B,
Gal E. A meta-analysis of sensory modulation symptoms in
individuals with autism spectrum disorders. J Autism Dev
Disord 2009;39:1–11.
11. Schoen SA, Miller LJ, Brett-Green BA, Nielsen DM.
Physiological and behavioral differences in sensory
Harvard Review of Psychiatry
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Sensory Symptoms in ASD
processing: a comparison of children with autism spectrum
disorder and sensory modulation disorder. Front Integr
Neurosci 2009;3:29.
12. Leekam SR, Nieto C, Libby SJ, Wing L, Gould J. Describing
the sensory abnormalities of children and adults with
autism. J Autism Dev Disord 2007;37:894–910.
13. Rogers SJ, Hepburn S, Wehner E. Parent reports of sensory
symptoms in toddlers with autism and those with other
developmental disorders. J Autism Dev Disord 2003;33:
631–42.
14. Dunn W. The Sensory Profile manual. San Antonia, TX:
Psychological, 1999.
15. Dunn W. The Infant/Toddler Sensory Profile manual. San
Antonio, TX: Psychological, 2002.
16. Brown CD, W. Adolescent/Adult Sensory Profile manual.
San Antonio, TX: Psychological, 2002.
17. Ayers AJ. Sensory Integration and Praxis Tests manual. Los
Angeles: Western Psychological Services, 1989.
18. Parham LDE, C.J. Sensory Processing Measure manual. Los
Angeles: Western Psychological Services, 2007.
19. DeGangi G, Burk RA. DeGangi-Burk Test of Sensory
Integration (TSI). Los Angeles: Western Psychological
Services, 1983.
20. Schopler E, Reichler RJ, DeVellis RF, Daly K. Toward
objective classification of childhood autism: Childhood
Autism Rating Scale (CARS). J Autism Dev Disord 1980;
10:91–103.
21. Krug DA, Arick J, Almond P. Behavior checklist for
identifying severely handicapped individuals with high
levels of autistic behavior. J Child Psychol Psychiatry
1980;21:221–9.
22. Gilliam JE. Gilliam Autism Rating Scale. Austin, TX:
PRO-ED, 1995.
23. Pfeiffer B, Kinnealey M, Reed C, Herzberg G. Sensory modu-
lation and affective disorders in children and adolescents with
Asperger’s disorder. Am J Occup Ther 2005;59:335–45.
24. Chen YH, Rodgers J, McConachie H. Restricted and
repetitive behaviours, sensory processing and cognitive
style in children with autism spectrum disorders. J Autism
Dev Disord 2009;39:635–42.
25. Siaperas P, Ring HA, McAllister CJ, et al. Atypical movement
performance and sensory integration in Asperger’s syndrome.
J Autism Dev Disord 2012;42:718–25.
26. Baranek GT, Roberts JE, David FJ, et al. Developmental
trajectories and correlates of sensory processing in young
boys with fragile X syndrome. Phys Occup Ther Pediatr
2008;28:79–98.
27. Riby DM, Janes E, Rodgers J. Brief report: exploring
the relationship between sensory processing and repetitive
behaviours in williams syndrome. J Autism Dev Disord
2013;43:478–82.
28. John AE, Mervis CB. Sensory modulation impairments
in children with Williams syndrome. Am J Med Genet C
Semin Med Genet 2010;154C:266–76.
29. Kern JK, Trivedi MH, Garver CR, et al. The pattern of
sensory processing abnormalities in autism. Autism 2006;
10:480–94.
30. Billstedt E, Gillberg IC, Gillberg C. Autism in adults:
symptom patterns and early childhood predictors. Use of
the DISCO in a community sample followed from childhood.
J Child Psychol Psychiatry 2007;48:1102–10.
31. Crane L, Goddard L, Pring L. Sensory processing in adults
with autism spectrum disorders. Autism 2009;13:215–28.
32. Liss M, Saulnier C, Fein D, Kinsbourne M. Sensory and
attention abnormalities in autistic spectrum disorders. Autism
2006;10:155–72.
www.harvardreviewofpsychiatry.org 121
E. P. Hazen et al.
33. Lane AE, Young RL, Baker AE, Angley MT. Sensory
processing subtypes in autism: association with adaptive
behavior. J Autism Dev Disord 2010;40:112–22.
34. Kientz MA, Dunn W. A comparison of the performance of
children with and without autism on the Sensory Profile.
Am J Occup Ther 1997;51:530–7.
35. Ferri R, Elia M, Agarwal N, Lanuzza B, Musumeci SA,
Pennisi G. The mismatch negativity and the P3a components of
the auditory event-related potentials in autistic low-functioning
subjects. Clin Neurophysiol 2003;114:1671–80.
36. Martineau J, Garreau B, Barthelemy C, Lelord G. Evoked
potentials and P300 during sensory conditioning in autistic
children. Ann N Y Acad Sci 1984;425:362–9.
37. Bruneau N, Bonnet-Brilhault F, Gomot M, Adrien JL,
Barthelemy C. Cortical auditory processing and communication
in children with autism: electrophysiological/behavioral
relations. Int J Psychophysiol 2003;51:17–25.
38. Oram Cardy JE, Flagg EJ, Roberts W, Roberts TP. Auditory
evoked fields predict language ability and impairment in
children. Int J Psychophysiol 2008;68:170–5.
39. Roberts TP, Khan SY, Rey M, et al. MEG detection of
delayed auditory evoked responses in autism spectrum
disorders: towards an imaging biomarker for autism. Autism
Res 2010;3:8–18.
40. Koh HC, Milne E, Dobkins K. Spatial contrast sensitivity in
adolescents with autism spectrum disorders. J Autism Dev
Disord 2010;40:978–87.
41. de Jonge MV, Kemner C, de Haan EH, Coppens JE, van den
Berg TJ, van Engeland H. Visual information processing
in high-functioning individuals with autism spectrum disor-
ders and their parents. Neuropsychology 2007;21: 65–73.
42. Vandenbroucke MW, Scholte HS, van Engeland H, Lamme
VA, Kemner C. A neural substrate for atypical low-level
visual processing in autism spectrum disorder. Brain
2008;131:1013–24.
43. Sanchez-Marin FJ, Padilla-Medina JA. A psychophysical test
of the visual pathway of children with autism. J Autism Dev
Disord 2008;38:1270–7.
44. Ronconi L, Gori S, Ruffino M, et al. Decreased coherent
motion discrimination in autism spectrum disorder: the role
of attentional zoom-out deficit. PloS One 2012;7:e49019.
45. Blakemore SJ, Tavassoli T, Calo S, et al. Tactile sensitivity in
Asperger syndrome. Brain Cogn 2006;61:5–13.
46. Cascio C, McGlone F, Folger S, et al. Tactile perception
in adults with autism: a multidimensional psychophysical
study. J Autism Dev Disord 2008;38:127–37.
47. Marco EJ, Khatibi K, Hill SS, et al. Children with autism
show reduced somatosensory response: an MEG study.
Autism Res 2012;5:340–51.
48. Cascio CJ, Moana-Filho EJ, Guest S, et al. Perceptual and
neural response to affective tactile texture stimulation in adults
with autism spectrum disorders. Autism Res 2012;5:231–44.
49. Foss-Feig JH, Kwakye LD, Cascio CJ, et al. An extended
multisensory temporal binding window in autism spectrum
disorders. Exp Brain Res 2010;203:381–9.
50. Kwakye LD, Foss-Feig JH, Cascio CJ, Stone WL, Wallace MT.
Altered auditory and multisensory temporal processing in
autism spectrum disorders. Front Integr Neurosci 2011;4:129.
51. Donohue SE, Darling EF, Mitroff SR. Links between
multisensory processing and autism. Exp Brain Res 2012;
222:377–87.
52. Collignon O, Charbonneau G, Peters F, et al. Reduced
multisensory facilitation in persons with autism. Cortex
2013;49:1704–10.
53. Brandwein AB, Foxe JJ, Butler JS, et al. The development of
multisensory integration in high-functioning autism: high-
122 www.harvardreviewofpsychiatry.org
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
density electrical mapping and psychophysical measures
reveal impairments in the processing of audiovisual inputs.
Cereb Cortex 2013;23:1329–41.
54. Russo N, Foxe JJ, Brandwein AB, Altschuler T, Gomes H,
Molholm S. Multisensory processing in children with autism:
high-density electrical mapping of auditory-somatosensory
integration. Autism Res 2010;3:253–67.
55. Courchesne E, Lincoln AJ, Kilman BA, Galambos R. Event-
related brain potential correlates of the processing of novel
visual and auditory information in autism. J Autism Dev
Disord 1985;15:55–76.
56. Casanova MF, Buxhoeveden DP, Brown C. Clinical and
macroscopic correlates of minicolumnar pathology in autism.
J Child Neurol 2002;17:692–5.
57. Palmen SJ, van Engeland H, Hof PR, Schmitz C.
Neuropathological findings in autism. Brain 2004;127:
2572–83.
58. Billeci L, Calderoni S, Tosetti M, Catani M, Muratori F.
White matter connectivity in children with autism spectrum
disorders: a tract-based spatial statistics study. BMC Neurol
2012;12:148.
59. Prigge MB, Lange N, Bigler ED, et al. Corpus callosum area
in children and adults with autism. Res Autism Spectr
Disord 2013;7:221–34.
60. Frazier TW, Hardan AY. A meta-analysis of the corpus
callosum in autism. Biol Psychiatry 2009;66:935–41.
61. Just MA, Cherkassky VL, Keller TA, Kana RK, Minshew
NJ. Functional and anatomical cortical underconnectivity
in autism: evidence from an FMRI study of an executive
function task and corpus callosum morphometry. Cereb
Cortex 2007;17:951–61.
62. Hardan AY, Pabalan M, Gupta N, et al. Corpus callosum
volume in children with autism. Psychiatry Res 2009;174:
57–61.
63. Kern JK. The possible role of the cerebellum in autism/PDD:
disruption of a multisensory feedback loop. Med hypotheses
2002;59:255–60.
64. Mazurek MO, Vasa RA, Kalb LG, et al. Anxiety, sensory
over-responsivity, and gastrointestinal problems in children
with autism spectrum disorders. J Abnorm Child Psychol
2013;41:165–76.
65. Schumann CM, Amaral DG. Stereological analysis of
amygdala neuron number in autism. J Neurosci 2006;26:
7674–9.
66. Schaaf RC, Toth-Cohen S, Johnson SL, Outten G, Benevides
TW. The everyday routines of families of children with autism:
examining the impact of sensory processing difficulties on
the family. Autism 2011;15:373–89.
67. Bodfish JW, Symons FJ, Parker DE, Lewis MH. Varieties
of repetitive behavior in autism: comparisons to mental
retardation. J Autism Dev Disord 2000;30:237–43.
68. Bishop SL, Hus V, Duncan A, et al. Subcategories of restricted
and repetitive behaviors in children with autism spectrum
disorders. J Autism Dev Disord 2013;43:1287–97.
69. Rutter M, Le Couteur A, Lord C. Autism diagnostic interview-
revised (ADI-R). Los Angeles: Western Psychological Services,
2003.
70. Cuccaro ML, Shao Y, Grubber J, et al. Factor analysis of restricted
and repetitive behaviors in autism using the Autism Diagnostic
Interview–R. Child Psychiatry Hum Dev 2003;34:3–17.
71. Lam KS, Aman MG. The Repetitive Behavior Scale-Revised:
independent validation in individuals with autism spectrum
disorders. J Autism Dev Disord 2007;37:855–66.
72. Esbensen AJ, Seltzer MM, Lam KS, Bodfish JW. Age-related
differences in restricted repetitive behaviors in autism spectrum
disorders. J Autism Dev Disord 2009;39:57–66.
Volume 22 • Number 2 • March/April 2014

73. Mirenda P, Smith IM, Vaillancourt T, et al. Validating
the Repetitive Behavior Scale-revised in young children
with autism spectrum disorder. J Autism Dev Disord 2010;
40:1521–30.
74. Bishop SL, Richler J, Lord C. Association between restricted
and repetitive behaviors and nonverbal IQ in children with
autism spectrum disorders. Child Neuropsychol 2006;12:
247–67.
75. Szatmari P, Georgiades S, Bryson S, et al. Investigating the
structure of the restricted, repetitive behaviours and interests
domain of autism. J Child Psychol Psychiatry 2006;47:582–90.
76. Gabriels RL, Agnew JA, Miller LJ, et al. Is there a relationship
between restricted, repetitive, stereotyped behaviors and inter-
ests and abnormal sensory response in children with autism
spectrum disorders? Res Autism Spectr Disord 2008;2:660–70.
77. Lovaas I, Newsom C, Hickman C. Self-stimulatory behavior
and perceptual reinforcement. J Appl Behav Anal 1987;
20:45–68.
78. Rogers SJ, Ozonoff S. Annotation: what do we know about
sensory dysfunction in autism? A critical review of the empirical
evidence. J Child Psychol Psychiatry 2005;46: 1255–68.
79. Cunningham AB, Schreibman L. Stereotypy in autism: the
importance of function. Res Autism Spectr Disord 2008;
2:469–79.
80. Boyd BA, Baranek GT, Sideris J, et al. Sensory features and
repetitive behaviors in children with autism and developmental
delays. Autism Res 2010;3:78–87.
81. Leekam SR, Prior MR, Uljarevic M. Restricted and repetitive
behaviors in autism spectrum disorders: a review of research
in the last decade. Psychol Bull 2011;137:562–93.
82. Matson JL, Hamilton M, Duncan D, et al. Characteristics of
stereotypic movement disorder and self-injurious behavior
assessed with the Diagnostic Assessment for the Severely
Handicapped (DASH-II). Res Dev Disabil 1997;18:457–69.
83. Gal E, Dyck MJ, Passmore A. The relationship between
stereotyped movements and self-injurious behavior in chil-
dren with developmental or sensory disabilities. Res Dev
Disabil 2009;30:342–52.
84. Duerden EG, Tannock R, Dockstader C. Altered cortical
morphology in sensorimotor processing regions in adolescents
and adults with attention-deficit/hyperactivity disorder. Brain
Res 2012;1445:82–91.
85. Richman DM, Barnard-Brak L, Bosch A, Thompson S,
Grubb L, Abby L. Predictors of self-injurious behaviour
exhibited by individuals with autism spectrum disorder. J
Intellect Disabil Res 2013;57:429–39.
86. Dominick KC, Davis NO, Lainhart J, Tager-Flusberg H,
Folstein S. Atypical behaviors in children with autism and
children with a history of language impairment. Res Dev
Disabil 2007;28:145–62.
87. Baghdadli A, Pascal C, Grisi S, Aussilloux C. Risk factors for
self-injurious behaviours among 222 young children with
autistic disorders. J Intellect Disabil Res 2003;47:622–7.
88. Jasmin E, Couture M, McKinley P, Reid G, Fombonne E,
Gisel E. Sensori-motor and daily living skills of preschool
children with autism spectrum disorders. J Autism Dev
Disord 2009;39:231–41.
89. O’Donnell S, Deitz J, Kartin D, Nalty T, Dawson G. Sensory
processing, problem behavior, adaptive behavior, and cognition
in preschool children with autism spectrum disorders. Am J
Occup Ther 2012;66:586–94.
90. Sparrow SS, Balla DA, Cicchetti DV. Vineland Adaptive
Behavior Scales: interview edition survey form manual.
Circle Pines, MN: American Guidance Service, 1984.
91. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T,
Baird G. Psychiatric disorders in children with autism
Harvard Review of Psychiatry
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
Sensory Symptoms in ASD
spectrum disorders: prevalence, comorbidity, and associated
factors in a population-derived sample. J Am Acad Child
Adolesc Psychiatry 2008;47:921–9.
92. Miller LJ, Coll JR, Schoen SA. A randomized controlled
pilot study of the effectiveness of occupational therapy for
children with sensory modulation disorder. Am J Occup
Ther 2007;61:228–38.
93. Ermer J, Dunn W. The sensory profile: a discriminant analysis
of children with and without disabilities. Am J Occup Ther
1998;52:283–90.
94. Watling RL, Deitz J, White O. Comparison of Sensory
Profile scores of young children with and without autism
spectrum disorders. Am J Occup Ther 2001;55:416–23.
95. Schell AM, Dawson ME, Rissling A, et al. Electrodermal
predictors of functional outcome and negative symptoms
in schizophrenia. Psychophysiology 2005;42:483–92.
96. White SW, Oswald D, Ollendick T, Scahill L. Anxiety in
children and adolescents with autism spectrum disorders.
Clin Psychol Rev 2009;29:216–29.
97. Lane SJ, Reynolds S, Dumenci L. Sensory overresponsivity
and anxiety in typically developing children and children
with autism and attention deficit hyperactivity disorder:
cause or coexistence? Am J Occup Ther 2012;66:595–603.
98. Green SA, Ben-Sasson A. Anxiety disorders and sensory
over-responsivity in children with autism spectrum disorders:
is there a causal relationship? J Autism Dev Disord 2010;
40:1495–504.
99. Green SA, Ben-Sasson A, Soto TW, Carter AS. Anxiety and
sensory over-responsivity in toddlers with autism spectrum
disorders: bidirectional effects across time. J Autism Dev
Disord 2012;42:1112–9.
100. Ben-Sasson A, Cermak SA, Orsmond GI, Tager-Flusberg H,
Kadlec MB, Carter AS. Sensory clusters of toddlers with
autism spectrum disorders: differences in affective symptoms.
J Child Psychol Psychiatry 2008;49:817–25.
101. Ben-Sasson A, Cermak SA, Orsmond GI, Carter AS, Fogg L.
Can we differentiate sensory over-responsivity from anxiety
symptoms in toddlers? Perspectives of occupational
therapists and psychologists. Infant Ment Health J 2007;
28:536–58.
102. Ben-Sasson A, Carter AS, Briggs-Gowan MJ. Sensory over-
responsivity in elementary school: prevalence and social-
emotional correlates. J Abnorm Child Psychol 2009;37: 705–16.
103. Goldsmith HH, Van Hulle CA, Arneson CL, Schreiber JE,
Gernsbacher MA. A population-based twin study of parentally
reported tactile and auditory defensiveness in young children.
J Abnorm Child Psychol 2006;34:393–407.
104. Aron EN, Aron A. Sensory-processing sensitivity and its
relation to introversion and emotionality. J Pers Soc Psychol
1997;73:345–68.
105. Tsuji H, Miyawaki D, Kawaguchi T, et al. Relationship of
hypersensitivity to anxiety and depression in children with
high-functioning pervasive developmental disorders. Psychiatry
Clin Neurosci 2009;63:195–201.
106. Brock ME, Freuler A, Baranek GT, Watson LR, Poe MD,
Sabatino A. Temperament and sensory features of children
with autism. J Autism Dev Disord 2012;42:2271–84.
107. Buie T, Campbell DB, Fuchs GJ 3rd, et al. Evaluation,
diagnosis, and treatment of gastrointestinal disorders in
individuals with ASDs: a consensus report. Pediatrics
2010;125 suppl 1:S1–18.
108. Bakker MJ, Boer F, Benninga MA, Koelman JH, Tijssen
MA. Increased auditory startle reflex in children with
functional abdominal pain. J Pediatr 2010;156:285–91.e1.
109. Ayers AJ. Sensory integration and learning disorders. Los
Angeles: Western Psychological Services, 1972.
www.harvardreviewofpsychiatry.org 123
E. P. Hazen et al.
110. Lacourse MG, Turner JA, Randolph-Orr E, Schandler SL,
Cohen MJ. Cerebral and cerebellar sensorimotor plasticity
following motor imagery-based mental practice of a
sequential movement. J Rehabil Res Dev 2004;41:505–24.
111. Parham LD, Cohn ES, Spitzer S, et al. Fidelity in sensory
integration intervention research. Am J Occup Ther 2007;
61:216–27.
112. Baranek GT. Efficacy of sensory and motor interventions for
children with autism. J Autism Dev Disord 2002; 32:397–422.
113. Pfeiffer BA, Koenig K, Kinnealey M, Sheppard M,
Henderson L. Effectiveness of sensory integration interventions
in children with autism spectrum disorders: a pilot study.
Am J Occup Ther 2011;65:76–85.
114. Section On Complementary and Integrative Medicine;
Council on Children with Disabilities; American Academy
of Pediatrics; Zimmer M, Desch L. Sensory integration
therapies for children with developmental and behavioral
disorders. Pediatrics 2012;129:1186–9.
115. Edelson SM, Edelson MG, Kerr DC, Grandin T. Behavioral
and physiological effects of deep pressure on children with
124 www.harvardreviewofpsychiatry.org
Copyright @ 2014 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.
autism: a pilot study evaluating the efficacy of Grandin’s
Hug Machine. Am J Occup Ther 1999;53:145–52.
116. Zissermann L. The effects of deep pressure on self-stimulating
behaviors in a child with autism and other disabilities. Am J
Occup Ther 1992;46:547–51.
117. Williams M, Shellenberger S. How does your engine run? A
leader’s guide to the Alert program for self-regulation.
Albuquerque, NM: Therapy Works, 1994.
118. Hall L, Case-Smith J. The effect of sound-based intervention
on children with sensory processing disorders and visual-
motor delays. Am J Occup Ther 2007;61:209–15.
119. Thompson BM, Andrews SR. An historical commentary on
the physiological effects of music: Tomatis, Mozart and
neuropsychology. Integr Physiol Behav Sci 2000;35:174–88.
120. Miller LJ. Sensational kids: hope and help for children with
sensory processing disorder. New York: Penguin, 2006.
121. Fung LK, Chahal L, Libove RA, Bivas R, Hardan AY. A
retrospective review of the effectiveness of aripiprazole in
the treatment of sensory abnormalities in autism. J Child
Adolesc Psychopharmacol 2012;22:245–8.
Volume 22 • Number 2 • March/April 2014