Specific Sensory Techniques and Sensory
Environmental Modifications for Children and Youth
With Sensory Integration Difficulties: A
Systematic Review
Stefanie C. Bodison, OTD, OTR/L, is Assistant
Professor of Research, Chan Division of Occupational
Science and Occupational Therapy, University of Southern
California, Los Angeles; bodison@usc.edu
L. Diane Parham, PhD, OTR/L, FAOTA, is Professor,
Occupational Therapy Graduate Program, School of
Medicine, University of New Mexico, Albuquerque.
The American Journal of Occupational Therapy
Stefanie C. Bodison, L. Diane Parham
This systematic review examined the effectiveness of specific sensory techniques and sensory environmental
modifications to improve participation of children with sensory integration (SI) difficulties. Abstracts of
11,436 articles published between January 2007 and May 2015 were examined. Studies were included
if designs reflected high levels of evidence, participants demonstrated SI difficulties, and outcome measures
addressed function or participation. Eight studies met inclusion criteria. Seven studies evaluated effects of
specific sensory techniques for children with autism spectrum disorder (ASD) or attention deficit hyperactivity
disorder: Qigong massage, weighted vests, slow swinging, and incorporation of multisensory activities into
preschool routines. One study of sensory environmental modifications examined adaptations to a dental clinic
for children with ASD. Strong evidence supported Qigong massage, moderate evidence supported sensory
modifications to the dental care environment, and limited evidence supported weighted vests. The evidence is
insufficient to draw conclusions regarding slow linear swinging and incorporation of multisensory activities
into preschool settings.
Bodison, S. C., & Parham, L. D. (2018). Specific sensory techniques and sensory environmental modifications for children
and youth with sensory integration difficulties: A systematic review. American Journal of Occupational Therapy, 72,
7201190040. https://doi.org/10.5014/ajot.2018.029413
S ensory integration (SI) difficulties of children have been studied and treated
by occupational therapy practitioners since the 1960s, when the term sensory
integrative dysfunction was coined by A. Jean Ayres (1969, 1971). This term
referred to children who had difficulty organizing and using sensory in-
formation to accomplish everyday activities yet did not have a medical history,
intellectual disability, or a history of environmental deprivation that could ac-
count for their behavioral, learning, or motor coordination challenges (Ayres,
1972, 2005). Over subsequent decades, a variety of terms have been used to
refer to this population, including children with differences in sensory processing
abilities (Dunn, 1997) or children with sensory processing disorders (Miller, Anzalone,
Lane, Cermak, & Osten, 2007). In this article, we refer to this population as
children with SI difficulties.
Regardless of the term used, occupational therapy researchers have agreed
that children with SI difficulties may be characterized as falling into several
different subgroups, such as children with dyspraxia or children with modulation
difficulties involving overreactivity. Moreover, ongoing efforts are directed to-
ward designing interventions that will effectively help children with SI difficulties
to participate more fully and successfully in everyday activities.
Prevalence estimates have suggested that a substantial number of children
experience SI difficulties. Ahn, Miller, Milberger, and McIntosh (2004) estimated
7201190040p1
that the prevalence for SI difficulties among typically de-
veloping kindergartners is about 5%. Difficulties with SI are
thought to be much more common among children across
a wide variety of developmental or behavioral conditions,
such as autism spectrum disorder (ASD) and attention
deficit hyperactivity disorder (ADHD). For example, within
the population with ASD, prevalence estimates of SI diffi-
culties range from about 40% to more than 90% (Baranek,
Little, Parham, Ausderau, & Sabatos-Devito, 2014).
Occupational therapy practitioners have historically
been the leading professionals in evaluating and treating SI
difficulties of children and youth. They use both remedial
and compensatory intervention strategies to help children
with these difficulties function better and participate more
fully at home, in school, and in their communities. For
example, Ayres Sensory Integration® (ASI) intervention is
a remedial approach that is designed to improve child-
ren’s SI functioning and, ultimately, their participation in
daily life activities. ASI involves a course of individually
administered, intensive occupational therapy sessions in
which children engage in tailored activities that challenge
their weak areas of SI functioning to build competencies
and mastery (Ayres, 2005; Bundy, Lane, & Murray,
1991; Parham & Mailloux, 2015).
In ASI intervention, specific sensory techniques are
frequently embedded within therapy sessions to support
the child’s performance in the immediate situation (Parham
et al., 2011). For example, the therapist might introduce a
slow swinging activity to calm a child who is in an overly
excited state. In this example, slow rhythmic vestibular
stimulation is used to reduce the child’s arousal level,
thereby improving attention so that the child is prepared to
respond to a challenge such as timing the action of throw-
ing a ball at a target while swinging or figuring out how to
move through a novel obstacle course. Other examples of
specific sensory techniques that are often embedded in ASI
intervention to evoke an immediate response include pro-
viding tactile stimulation to either calm or alert the child,
adding resistance to activities to enhance body awareness, or
altering the speed and trajectory of a swing the child is
sitting on to elicit improved postural responses.
Throughout individual ASI intervention, it is cus-
tomary for the occupational therapist to regularly consult
with parents, caregivers, and teachers to suggest ways in
which sensory experiences can be embedded or modified
in daily routines as compensatory efforts that will immedi-
ately support the child’s participation (Ayres, 2005; Parham
& Mailloux, 2015). This approach might include applying
specific sensory techniques, such as wearing a weighted vest
periodically at school, and making modifications to the
child’s sensory environment at home or at school by, for
7201190040p2
example, changing the texture of dining chair seats at home
or the lighting in the classroom so that the child can im-
mediately function more optimally.
However, occupational therapy practitioners also
use specific sensory techniques or sensory environmen-
tal modifications as compensatory interventions without
providing ASI intervention. For example, the occupational
therapist might collaborate with the teacher to have the
child sit on a therapy ball while at the desk rather than a
chair to generate gentle vestibular input to support at-
tention. Although leaders in the field have advocated the
use of multiple intervention methods as the most desirable
approach to help children with SI difficulties (Reynolds
et al., 2017), some practitioners use specific sensory tech-
niques or sensory environmental modifications as the sole
occupational therapy intervention.
Specific sensory techniques sometimes involve sys-
tematic application of sensory stimuli as stand-alone re-
medial interventions. For example, the Wilbarger brushing
protocol (also known as the deep pressure proprioceptive
technique) involves brushing the child’s arms and legs with
a surgical scrub brush using stroking motions in a partic-
ular direction and sequence, followed by manual com-
pression of specific joints, every 2 hours (Wilbarger &
Wilbarger, 1991). This protocol is thought to gradually
improve the child’s physiological capacity to tolerate and
process tactile information, resulting in positive changes in
emotion and behavior. The Astronaut Program (Kawar,
Frick, & Frick, 2005) is a protocol involving a sequence of
activities in which rotary and other types of vestibular in-
put, combined with specific visual and auditory stimuli, are
applied to support attention, behavior, and development of
postural control.
With regard to sensory environmental modifications,
occupational therapy practitioners may make compensa-
tory changes to environments to support the successful
functioning of children and youth who are not necessarily
receiving ASI intervention. An example is provided by a
study in which classroom modifications were made for
teen students with ASD. Lighting was changed and
soundproofing was installed to reduce harsh and dis-
tracting visual and auditory stimuli. These changes made
the environment less disturbing and enabled students to
focus on academic schoolwork more successfully and
comfortably (Kinnealey et al., 2012).
This systematic review was designed to contribute
knowledge that will inform occupational therapy prac-
titioners regarding the effectiveness of specific sensory
techniques and sensory environmental modifications in
improving the functional performance or participation of
children and youth with SI difficulties. In this article, specific
January/February 2018, Volume 72, Number 1
sensory technique is defined as the application of particular
sensory stimuli, or the provision of materials and activities
that provide particular types of sensory stimuli, by direct
application to the child’s body (such as brushing the child’s
arms, having the child listen to music while wearing head-
phones, or having the child wear compression garments) or
by the child’s body being placed directly on or in an object
or device, such as sitting on a therapy ball or kneeling
within a compression device. Specific sensory techniques may
be provided as discrete protocols, as in a brushing or swinging
protocol, or they may be embedded within customary daily
routines at home or in school, as in sitting on a therapy ball or
wearing a weighted vest in the classroom. The intent of these
interventions is to support child functioning and participation
through either compensation or remediation.
Sensory environmental modification is defined in this
article as a compensatory intervention in which a change
is made in the intensity, complexity, or quality of one or
more sensory elements in the ambient physical environ-
ment surrounding the child to support child functioning
and participation. Examples include alterations in room
lighting, soundproofing of a room, elimination of extra-
neous visual stimuli in a room, or changes to the sensory
features of furniture or objects in a room. Environmental
changes that are introduced for primarily aesthetic, cog-
nitive, or communication reasons, such as visual cue cards
with words or pictures, are not considered sensory envi-
ronmental modifications in this review. In this article, we
examine specific sensory techniques and sensory envi-
ronmental modifications provided outside the context of
individual ASI intervention sessions.
Despite the widespread use of specific sensory tech-
niques or sensory environmental modifications, little is
known as to whether children’s participation improves
measurably after receiving these interventions. The purpose
of this systematic review is to synthesize recent outcomes
research related to the effects of these interventions on the
participation of children and youth who have SI difficulties.
Its specific aims are to generate information that will sup-
plement previously published American Occupational Ther-
apy Association (AOTA) practice guidelines for children
with SI difficulties in general (Watling, Koenig, Davies, &
Schaaf, 2011) and for children with ASD (Tomchek &
Koenig, 2016). Children with ASD are given particular
attention because SI difficulties are very common in this
population (Baranek et al., 2014).
Method
This systematic review was completed under the guidance
of AOTA’s Evidence-Based Practice (EBP) Project, as one
The American Journal of Occupational Therapy
in a series of several systematic reviews on diverse occu-
pational therapy interventions for children with SI diffi-
culties. It was designed to be an extension of a previous
review on the effectiveness of occupational therapy in-
terventions other than ASI for children and youth with SI
difficulties (Polatajko & Cantin, 2010). Note that the
population of interest in the earlier review, as well as in
this one, includes children with concomitant diagnoses
such as ASD and ADHD. The earlier review included
articles published from 1986 to 2006 on outcomes of
specific sensory techniques (which the authors called
sensory-based approaches), as well as cognitive-based ap-
proaches. This review updates the earlier findings on
specific sensory techniques by including articles published
from 2007 through May 2015. In addition, we sought
outcome studies of sensory environmental interventions
because these interventions also involve applications of
sensory input, but with sensory changes directed toward
the physical environment surrounding the child rather than
directly in contact with the child’s body. Cognitive inter-
ventions were designated for a separate systematic review.
Accordingly, our Population, Intervention, Com-
parison, Outcomes (PICO) research question was “What
is the effectiveness of occupational therapy interventions
that use specific sensory techniques or sensory environ-
mental modifications to support function and participa-
tion of children and youth who have SI difficulties?” In
our question, the population of interest is children and
youth (ages 2–21 yr) with SI difficulties. Two kinds of
interventions are addressed: specific sensory techniques
and sensory environmental modifications that are within
the practice domain of occupational therapy. The com-
parison component of our question is an alternative
condition (e.g., an alternative treatment, wait-list control,
or no-treatment control). Outcomes are measures of the
children’s functional performance or participation.
Building on the original search strategy developed by
Arbesman and Lieberman (2010), the literature search
process was designed to cast a broad net that would capture
articles relevant to all of the AOTA-sponsored systematic
reviews of diverse SI-related interventions (ASI; cognitive,
parent or teacher coaching, and occupation-based inter-
ventions; specific sensory techniques; and sensory envi-
ronmental modifications) for children with SI difficulties
who might also have a diagnosis such as ADHD or ASD.
The original search was guided by Arbesman and Lieberman,
who have had more than 10 years of experience guiding
AOTA’s EBP Project, and search terms were finalized after
consultation with all review authors contributing to this ef-
fort. The authors of this article supplemented the primary
search with additional searches using terms specific to ASD
7201190040p3
to ensure that all articles pertinent to this population would
be located. The additional ASD searches spanned 2013–
2015 to build on the most recent systematic review of
sensory interventions (Watling & Hauer, 2015) that in-
formed the current occupational therapy practice guidelines
for children and adolescents with ASD (Tomchek &
Koenig, 2016). See Supplemental Table 1 (available online
at http://otjournal.net; navigate to this article, and click on
“Supplemental”) for search terms used to locate studies of
children with SI difficulties published in 2007–2015 and
Supplemental Table 2 (also available online) for search
terms used to probe for additional studies of children with
ASD published in 2013–2015. A medical research librarian
experienced in completing systematic review searches con-
ducted all searches.
Databases and sites searched included MEDLINE,
PsycINFO, CINAHL, ERIC, and OTseeker. In addition,
consolidated information sources providing peer-reviewed
summaries of journal articles, such as the Cochrane Database
of Systematic Reviews, were included in the search. Refer-
ence lists from articles included in the systematic reviews
were examined to locate additional articles, and journals and
books in the authors’ personal files were searched for ap-
propriate research studies that met inclusion criteria.
Inclusion criteria were closely aligned with the pur-
poses and aims of the study. Articles were included only if
they were peer-reviewed scientific literature published in
English. In keeping with the role of the study as part of the
ongoing AOTA EBP Project, the review included only
studies published between 2007 and May 2015. To be
included, an article also needed to examine outcomes of
a specific sensory technique or a sensory environmental
modification that is within the scope of occupational therapy
practice and meets our definitions of these interventions, as
stated earlier in this article. To ensure that all included studies
addressed our research question, additional inclusion criteria
were (1) that participants had to demonstrate SI difficulties
that were documented through a preintervention evaluation
or through pre- and posttreatment measures of SI func-
tioning and (2) that intervention outcomes had to include
measures of participants’ functional performance or partic-
ipation. Finally, studies were included in the review only if
the research designs involved group comparisons, as de-
termined by Levels I, II, and III in the evidence hierarchy
delineated by the AJOT Guidelines for Systematic Reviews
(AOTA, 2014). These levels of evidence are modeled
closely after the work of Sackett, Rosenberg, Gray,
Haynes, and Richardson (1996) and the Oxford Centre for
Evidence-Based Medicine—Levels of Evidence (Howick
et al., 2009). In the AOTA guidelines, studies using
single-subject designs (also called single-case experimental
7201190040p4
designs) were designated as Level IV and were therefore not
included in this review.
Articles were excluded if they examined the outcomes
of only ASI intervention or any other intervention that did
not meet our definition of specific sensory technique or
sensory environmental modification. They were excluded
if they were not published after a formal peer-review process
or if they were published before 2007 or after May 2015.
We also excluded articles if the study design was Level IV or
V, if SI difficulties were not clearly documented for at least
one group of participants, or if outcome measures did not
directly address functional performance or participation.
For example, we excluded studies with outcome measures
that were restricted to physiological measures, measures of SI
functions, or performance on laboratory-controlled tasks.
The methodological consultant to the AOTA EBP
Project completed the first step in the review process by
eliminating unrelated articles on the basis of a review of
article titles and citations that were generated in the da-
tabase searches. Both authors then independently screened
all remaining titles and abstracts to determine whether a
full-text review of an article was warranted to evaluate
whether the article met all inclusion criteria. In cases in
which one author selected an abstract and the other did
not, the article was included for full-text review. Full-text
reviews were independently performed by each author to
determine which articles met all inclusion criteria, with no
cause for exclusion. Any disagreements were discussed in
depth until a consensus was reached as to whether the
article should be included in the final review.
Included studies are summarized in Supplemental
Table 3 (online), which presents level of evidence, research
design, intervention and control conditions, outcome
measures, and results. AOTA staff and an EBP Project
consultant reviewed this evidence table to ensure quality
and consistency with parallel EBP-sponsored evidence
reviews on interventions for children with SI difficulties
(see Miller Kuhaneck & Watling, 2018; Pfeiffer, Frolek
Clark, & Arbesman, 2018; and Schaaf, Dumont, Ar-
besman, & May-Benson, 2018, this issue).
Next, each article included in the review was further
evaluated by each author independently for scientific rigor
and risk of bias, using the methods described by Higgins
Altman, Gøtzsche, et al. (2011; Supplemental Table 4,
online). Several disagreements between authors on risk
factors for individual studies were identified and resolved
through discussion until a consensus was reached.
The evidence produced by the included studies was
evaluated for overall strength of evidence using guidelines
adapted from the U.S. Preventive Services Task Force
(2016). In these guidelines, strong evidence indicates consistent
January/February 2018, Volume 72, Number 1
results from well-conducted studies, usually at least 2
randomized controlled trials (RCTs); moderate evidence
indicates 1 RCT or 2 or more studies with lower levels of
evidence; limited evidence indicates few studies, flaws in
the available studies, and inconsistency in findings across
studies; mixed evidence indicates that findings were in-
consistent across studies in a given category; and in-
sufficient evidence indicates that the number and quality of
studies were too limited to make any clear classification.
Results
The initial search of the literature yielded 11,619 research
studies. After the removal of 205 duplicates, we hand-
searched additional resources and added 22 research
studies for a total of 11,436 abstracts to be screened. After
the review of abstracts, 24 research studies met initial
inclusion criteria for comprehensive review (Figure 1).
Using our preestablished inclusion criteria, 16 studies
were excluded either because the study did not clearly
indicate that participants had SI difficulties or because
outcomes did not clearly measure child functional per-
formance or participation.
Six Level I studies of specific sensory techniques
met all inclusion criteria and were further analyzed
(Buckle, Franzsen, & Bester, 2011; Dunbar, Carr-Hertel,
Lieberman, Perez, & Ricks, 2012; Murdock, Dantzler,
Walker, & Wood, 2014; Silva, Schalock, Ayres, Bunse, &
Budden, 2009; Silva, Schalock, & Gabrielsen, 2011; Silva
et al., 2015), as was as 1 Level II study (Silva & Schalock,
Figure 1. Preferred Reporting Items for Systematic Reviews and
Meta-Analyses flow diagram.
Figure format from “Preferred Reporting Items for Systematic Reviews and
Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff,
and D. G. Altman; The PRISMA Group, 2009, PLoS Medicine, 6(6), e1000097.
https://doi.org/10.1371/journal.pmed.1000097
The American Journal of Occupational Therapy
2013). Only 1 study of sensory environmental modifications
(Cermak et al., 2015) met inclusion criteria. Supplemental
Table 3 summarizes the included studies, which provide
evidence at Levels I, II, or III for four specific sensory tech-
niques and one environmental modification intervention:
Qigong massage, weighted vests, slow linear swinging, in-
corporation of multisensory activities into daily preschool
routines, and sensory modifications to a dental care envi-
ronment. The quality of each study was further analyzed and
summarized in a risk-of-bias table (Supplemental Table 4).
Specific results for each intervention are summarized next.
Qigong Massage
The most robust positive outcomes, indicating strong
evidence of effectiveness for young children with ASD,
were found for the Qigong sensory treatment (QST), a
massage protocol developed and studied by Silva and
colleagues (Silva & Schalock, 2013; Silva et al., 2009,
2011, 2015). Specifically, 3 Level I studies (RCTs with
Ns 5 46–103) and 1 Level II study (N 5 129) indicated
that a program of daily Qigong massage, delivered by
parents to 2- to 7-yr-old children with ASD under the
guidance of a trained occupational therapist, led to im-
provements in self-regulatory behaviors, tactile abnor-
malities, ASD symptoms, and parenting stress.
In 2 of the RCTs, occupational therapists received 50–
60 hr of formal training in QST before initiating the QST
intervention program, in which parents provided daily
15-min Qigong massage sessions to their child with ASD
for 5 mo (Silva et al., 2009, 2015). During the intervention
period, trainers made 20 home visits to the home of each
participating family to teach parents the protocol, demon-
strate how to tailor the intervention to child responses, and
monitor intervention fidelity. In the third RCT (Silva et al.,
2011), occupational therapists completed an 80-hr curric-
ulum in Qigong massage skills, then trained parents in a
3-hr group instructional program to administer daily 15-min
massage sessions for 4 mo. Parents also participated in seven
weekly 30-min clinic-based group support meetings in which
procedures were reviewed. The findings of these RCTs
suggest that a minimum of 50 hr of therapist training in
QST is required before teaching parents this intervention and
supervising parents in administering it at home; the findings
also suggest that 4 or 5 mo of daily Qigong massage with
ongoing therapist supervision can be expected to produce
developmental and behavior benefits for children with ASD.
Weighted Vests
Weighted vests were found to have limited evidence of
effectiveness for children with ADHD. This is supported
7201190040p5
by 1 Level I study, an RCT that demonstrated improved in-
seat behavior and attention of 6- to 9-yr-olds with ADHD
(N 5 30) during classroom activities while wearing vests
individually calibrated to 10% of the body weight of each
child, compared with not wearing a vest (Buckle et al.,
2011). Although encouraging, the results of this study must
be considered with caution because of design limitations
that pose threats to the internal validity of this study (see
Supplemental Table 4). Our search yielded an additional
RCT reporting positive effects of weighted vests on atten-
tion of children with ADHD (Lin, Lee, Chang, & Hong,
2014), but we excluded this study because the outcome
measure was performance on a computerized test of at-
tention in a laboratory environment rather than child
participation within the context of the classroom.
During the search process, we identified a number of
studies that used single-case experimental designs to examine
the effectiveness of weighted vests worn by children with
ASD (e.g., Cox, Gast, Luscre, & Ayres, 2009; Hodgetts,
Magill-Evans, & Misiaszek, 2011; Leew, Stein, & Gibbard,
2010; Reichow, Barton, Sewell, Good, & Wolery, 2010),
but these studies were excluded from our analysis because
they were rated as Level IV evidence. In addition to this
relatively low level of evidence, most of these studies did
not evaluate whether participants had SI difficulties. None
of these studies reported benefits of wearing a weighted vest
for any participating child with ASD. Consequently, in-
sufficient evidence is available at the present time regarding
whether weighted vests are helpful for children with ASD.
Slow Linear Swinging
Vestibular stimulation in the form of slow linear swinging
was examined in 1 Level I study to determine whether it
produced superior on-task behavior of children with ASD
(N 5 30) during tabletop activities immediately after
stimulation compared with a control condition (Murdock
et al., 2014). No significant differences in on-task
behavior were evident between children who experienced
swinging and children in the control group, who watched
a video. However, a weakness of this study is that the
children’s arousal state was not assessed before the in-
tervention. Slow linear swinging is thought to promote
attention by reducing arousal level to reach a calm, at-
tentive state. This may be appropriate for children who
have unusually high arousal levels that interfere with at-
tention, but it would not be appropriate for children
whose arousal levels are already low because it may make
them drowsy and less attentive.
Murdock et al. (2014) reported that only 2 of the 15
participants who received linear swinging demonstrated
7201190040p6
overresponsive behavior (suggesting high arousal), mea-
sured by parent questionnaire responses rather than as-
sessment of the child’s arousal level just before the
treatment session. It is plausible that the researchers found
no effect for linear swinging because most participants were
in a state of low or optimal arousal at the time that they
received the intervention. If this was the case, then slow
linear swinging would likely have been ineffective or con-
traindicated for most participants in this study. We con-
clude that there is currently insufficient evidence for use of
slow linear swinging to improve on-task behavior of chil-
dren with ASD.
Sensory Enrichment in Preschool
The effects of tactile, proprioceptive, and vestibular acti-
vities embedded within preschool daily routines for 12 wk
were evaluated in 1 Level I study (Dunbar et al., 2012).
Preschoolers receiving this sensory enrichment intervention
alone were compared with preschoolers in the same class-
room who received this intervention plus individual oc-
cupational therapy using ASI intervention. After the
intervention phase of the study, no difference was found
between groups, both of which improved in play skills.
However, this study was limited by a very small sample size
(N 5 8) and other design limitations (see Supplemental
Table 4). We conclude that insufficient evidence exists to
support the embedding of tactile, proprioceptive, and
vestibular activities in preschool daily routines.
Other Specific Sensory Techniques
In our search, additional studies were located that examined
other specific sensory techniques commonly used by oc-
cupational therapy practitioners, such as the Wilbarger
brushing protocol (Benson, Beeman, Smitsky, & Provident,
2011), therapy ball chairs (Fedewa & Erwin, 2011), sensory
diets (Hall & Case-Smith, 2007), and auditory stimula-
tion programs including Therapeutic Listening (Hall & Case-
Smith, 2007) and Integrated Listening Systems (Schoen,
Miller, & Sullivan, 2015). These studies were not included
in our review because their research designs fell at lower
levels of evidence (Level IV or V), indicating significant
threats to internal validity that limit the conclusions that
can be drawn from them.
Sensory Environmental Modifications
Although we found only 1 study on sensory environmental
modifications that met our inclusion criteria, it provided
moderate evidence to support the use of sensory adap-
tations in the dental environment to help children with
ASD participate in routine dental cleanings (Cermak
January/February 2018, Volume 72, Number 1
et al., 2015). This Level I RCT examined the effects of
altering the auditory and visual environments of the
dental office while providing the children receiving the
dental cleanings with deep touch pressure via a decorative
weighted wrap. Outcomes included significant improve-
ments in child-reported measures of pain intensity and
sensory discomfort, accompanied by improvements in
participation in dental cleaning for both children with
ASD and those who were typically developing. In addi-
tion, stress and anxiety, as measured by changes in elec-
trodermal responses, showed a moderate to large effect
size after intervention for the children with ASD (ds 5
0.27–0.65), suggesting that reduced physiological stress
likely played an important role in improved participation.
Discussion
The availability of 3 well-designed RCTs on Qigong
massage, all reporting positive outcomes, suggests that
Qigong massage has strong evidence of effectiveness with
preschoolers with ASD (Silva et al., 2009, 2011, 2015). It
is important to bear in mind that the occupational
therapists delivering this intervention had completed 50–
80 hr of training before implementation. During the
intervention period, they provided instruction and on-
going monitoring to parents who provided the massage
on a daily basis. Caution is indicated by the fact that all of
these studies were conducted by the same research group,
raising the possibility that findings might not be gener-
alizable to other groups of practitioners or to other geo-
graphic areas. Very strong confidence in this intervention
would be attained if an independent research group in a
different geographic region replicated these findings.
We found limited evidence in favor of the use of
weighted vests to support classroom participation of chil-
dren with ADHD (Buckle et al., 2011). As noted earlier, we
excluded a large (N 5 110) well-designed RCT that re-
ported significantly positive effects of weighted vests on
attention of children with ADHD because the outcome
measure was performance on controlled laboratory tasks
rather than functional performance in the classroom (Lin
et al., 2014). However, when considered together, these 2
studies suggest that perhaps the deep touch pressure of the
vest supports the ability of children with ADHD to attend
to cognitive tasks, thereby helping them to engage in
classroom activities at school. Future research is necessary
to test this proposition and to evaluate whether weighted
vests can be confidently used to support the participation of
children with ADHD in classroom activities.
Note that this evidence suggesting the effectiveness of
weighted vests applies only to children with ADHD, not
The American Journal of Occupational Therapy
children with ASD. Large, well-designed studies that
provide Level I evidence would be helpful in evaluating
whether weighted vests are helpful for children with ASD.
Given the limited evidence available and the fact that
this limited research generally has not found that these
children benefit from wearing weighted vests, we do not
currently recommend this intervention for children with
ASD.
Our review found insufficient evidence for the ef-
fectiveness of slow linear swinging in producing improved
on-task behavior of children with ASD. This intervention
was not effective in a Level I study (Murdock et al., 2014),
but a flaw of this study is that the arousal state of each
participant was not assessed before intervention. As noted
earlier, slow linear swinging may be appropriate for chil-
dren who have unusually high arousal levels that interfere
with attention. Past research has shown that children with
ASD demonstrate divergent levels of baseline physiologi-
cal arousal; some children have unusually high arousal, and
others have unusually low arousal (Chang et al., 2012;
Schoen, Miller, Brett-Green, & Hepburn, 2008). More-
over, some children with ASD may fluctuate from very low
to very high states of arousal. Because this population is
heterogeneous with regard to baseline arousal states, it is
plausible that vestibular stimulation interventions may be
effective if they are tailored to the individual child’s arousal
state before stimulation is applied. Future research is needed
to examine this possibility.
We also found insufficient evidence for incorporat-
ing specific sensory techniques into daily preschool class
routines for children with ASD. Because the 1 study we
analyzed (Dunbar et al., 2012) was a very small study and
both study groups received the same regimen of sensory
techniques within the classroom, it is unclear whether
improvements in play skills were due to developmental
gains that would have been observed regardless of the
addition of this intervention. It may be useful for future
researchers to further examine the effectiveness of em-
bedding specific sensory techniques into preschool rou-
tines. For example, comparison of this intervention with
standard classroom routines (i.e., without the addition of
specific sensory techniques) might clarify whether the
addition of this intervention promotes developmental
gains that surpass the usual benefits of being in preschool.
Although we found only 1 study on sensory envi-
ronmental modifications that met our inclusion criteria, it
provided moderate evidence to support the use of sen-
sory adaptations in the dental environment to help chil-
dren with ASD participate in routine dental cleanings
(Cermak et al., 2015). The intervention in this RCT
incorporated a specially designed weighted blanket in
7201190040p7
addition to changes in the ambient auditory and visual
environment of the dental clinic, so it is possible that use
of deep-touch pressure as a sensory technique contributed
to the effectiveness of the intervention. Further research
would be helpful in strengthening confidence in the ef-
fectiveness of this intervention.
In this review, we included only studies with high
levels of evidence in which the researchers had verified that
participants had SI difficulties and reported outcomes
reflecting functional performance or participation. These
inclusion criteria contributed to the small number of
studies included in this systematic review. It is noteworthy
that we were unable to locate any published studies at any
level of evidence that examined the effectiveness of some
specific sensory techniques, for example the Astronaut
Program (Kawar et al., 2005). It should be borne in mind
that the absence of evidence does not indicate absence of
effectiveness (Altman & Bland, 1995); however, without
strong evidence to support a particular intervention, we
have limited confidence that the intervention can be
counted on to produce the desired outcomes.
Our review was intentionally delimited to studies that
met stringent inclusion criteria, that is, limited range of
publication dates, high levels of evidence, participants with
verified SI difficulties, particular kinds of sensory inter-
ventions, and outcomes that are functional. This was nec-
essary to meet the purpose and specific aims of the study.
However, a limitation of our systematic review is that we
may not have included some search terms that could have
produced eligible studies. We attempted to generate an
exhaustive list of search terms, as shown in Supplemental
Tables 1 and 2, but perhaps discrete terms such as touch or
tactile, or alternative terms such as therapy ball in addition
to ball chair, would have generated abstracts that our search
did not detect. As with all systematic reviews, reliance on
published peer-reviewed studies raises the possibility that
publication bias could have influenced our conclusions.
Implications for Occupational
Therapy Research
The results of our systematic review revealed several issues
that researchers should address to improve the quality of
future studies of the effects of specific sensory techniques
or sensory environmental modifications on the partici-
pation of children with SI difficulties. First, the strongest
research design that is feasible should be used to evaluate
the effectiveness of these interventions. Most of the pub-
lished studies of these interventions used research designs
with relatively low levels of evidence, which severely limits
confidence in the findings.
7201190040p8
Second, researchers should articulate the underlying
mechanism for why the intervention being studied is
expected to enhance child participation. For example, slow
linear swinging usually reduces arousal level and is
therefore expected to have a calming effect that may support
sustained attention in children with heightened arousal. It
would be helpful to design studies in which the outcome
measures are aligned with the underlying mechanism of the
treatment (e.g., decrease in arousal level after slow linear
swinging) as well as the primary participation outcome (e.g.,
improved sustained attention during classroom activities).
This would allow researchers to test the underlying theory of
why the intervention is thought to be helpful, as well as
the intervention’s effectiveness in supporting child partici-
pation. Research results will ultimately lead to deeper un-
derstanding of the conditions under which a particular
intervention is or is not effective in supporting participa-
tion. Once the underlying mechanism is better understood,
the inclusion or exclusion criteria for future study partici-
pants can be tailored to ensure that only children who are
appropriate candidates for the intervention are eligible to
participate.
To our knowledge, no studies of specific sensory
techniques or sensory environmental modifications have
reported on adverse events associated with the intervention.
Although such events are probably rare, they should be
systematically documented and reported in research pub-
lications because this information could be a critical factor in
clinical decision making. Cost–benefit analyses comparing
these interventions with alternative procedures would also
contribute valuable information for decision making.
Implications for Occupational
Therapy Practice
Our review highlights several important considerations for
occupational therapy practitioners. First, for practitioners
to best implement specific sensory interventions or sensory
environmental modifications, postprofessional training in
SI is strongly recommended. This training will ensure that
practitioners have an adequate knowledge base for eval-
uating and selecting children who are good candidates
for particular interventions and for monitoring child
responses to intervention. To ascertain whether a child’s
sensory characteristics make him or her a good candidate
for particular interventions, evaluation of SI should be
completed prior to initiating any sensory intervention. It
is incumbent on the practitioner to use caution when
considering an intervention that has limited or no re-
search evidence; such interventions should be used only
after considering interventions with stronger evidence
January/February 2018, Volume 72, Number 1
that may be appropriate for the particular situation. Reg-
ular monitoring of child responses to intervention is im-
perative to ensure that the intervention is benefiting the
child and to avoid undesirable effects. Additional recom-
mendations specific to the five interventions identified in
this study are as follows:
• Preschoolers with ASD and tactile overreactivity may
be particularly appropriate for Qigong massage, which
has moderate to strong evidence to support its effec-
tiveness when provided as QST.
• The evidence for the effectiveness of weighted vests
with children with ADHD is limited, and it is insuf-
ficient for children with ASD. Occupational therapy
practitioners should cautiously consider using weighted
vests to support attention in the classroom for elemen-
tary school-age children with ADHD.
• The evidence for slow linear swinging is insufficient
with respect to immediate effects on attention. Occu-
pational therapy practitioners should not expect that
slow linear swinging will immediately improve atten-
tion of preschoolers with ASD during tabletop activities.
• Insufficient evidence supports the effectiveness of reg-
ularly incorporating specific sensory techniques into
classroom routines for preschoolers with ASD, so oc-
cupational therapy practitioners should consider the
use of this intervention cautiously.
• Moderate evidence supports sensory modifications to
the dental care environment. Occupational therapy prac-
titioners who serve children with ASD should consider
collaborating with dental professionals to explore using
this new intervention. s
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Supplemental Table 1. Search Terms for AOTA Systematic Reviews of ASI®, Specific Sensory Techniques, Sensory Environmental
Modifications, and Coaching, Cognitive, and Occupation-Based Interventions for Children With Sensory Integration Difficulties (2007–2015)
Category Search Terms
Diagnoses and clinical conditions included clumsy child syndrome; developmental coordination disorder; developmental dyspraxia; disorder of
attention, motor, and perception; fine motor deficits; gross motor deficits; learning disabilities; nonverbal
learning disorder, perceptual motor deficits; regulatory disorder; sensory integrative dysfunction; sensory
modulation disorder; sensory modulation dysfunction; sensory motor deficit; sensory processing
disorder
Diagnoses and clinical conditions (only if a agoraphobia, anxiety, attention deficit disorder, attention deficit hyperactivity disorder, bipolar disorder,
sensory–motor or perceptual–motor component child abuse, childhood eating and feeding disorders, children with handwriting problems, deprivation—
is included in the study) sensory deprivation (excluding deafness and blindness), Down’s syndrome, dyslexia, fetal alcohol
syndrome, fragile X syndrome, learning disabilities, mood disorders, panic disorders, prematurity,
PTSD, schizophrenia, specific language disorder, Williams syndrome
Interventions activities of daily living, activity, activity groups, adaptive behavior, adaptive equipment, assistive
technology, astronaut training, attention, auditory integration training, augmentative communication,
Ayres Sensory Integration®, ball chairs, bilateral coordination, bilateral intervention, coaching, cognitive
intervention, cognitive–behavioral therapy, consultation, context, contextual, CO-OP, decision-making
skills training, early intervening, early intervention, emotional regulation, employment, environment,
environmental modification, executive function, exercise, family centered care, family coping/coping
skills, family interaction/participation, friendship, friendship group, functional approaches, handwriting,
instrumental activities of daily living, integrated listening systems, job coaching, job training, Kawar
protocol, leisure, life coaching, massage, motor planning, multisensory integration, natural environment
intervention, neurodevelopmental treatment, neuromotor occupational therapy, occupation-based,
occupational therapy, ocular motor skills, oral sensorimotor programs, parent/teacher mediated, parent
training, peer group, peer interaction, peer mediated, perceptual motor learning, play, praxis, pressure
vest, prevocational, priming, problem-solving skills training, relationship-based intervention, rest,
routines-based interventions, self-care, self-management, sensory diet, sensorimotor integration,
sensory integration, sensory integrative, SI, sleep, social competence, social participation, social skills
training, social stories, strengths-based, supported education, supported employment, tactile stimula-
tion, therapeutic listening, time management, touch pressure, transitioning, transitions, vestibular
stimulation, weighted blankets, weighted items, weighted materials, weighted vests, Wilbarger protocol,
work, yoga
Study and trial designs appraisal, best practices, case control, case report, case series, clinical guidelines, clinical trial, cohort,
comparative study, consensus development conferences, controlled clinical trial, critique, cross over,
cross-sectional, double-blind, epidemiology, evaluation study, evidence-based, evidence synthesis,
feasibility study, follow-up, health technology assessment, intervention, longitudinal, main outcome
measure, meta-analysis, multicenter study, observational study, outcome and process assessment, pilot,
practice guidelines, prospective, random allocation, randomized controlled trials, retrospective, sampling,
scientific integrity review, single subject design, standard of care, systematic literature review, systematic
review, treatment outcome, validation study
Note. AOTA 5 American Occupational Therapy Association; ASI 5 Ayres Sensory Integration; CO-OP 5 Cognitive Orientation to daily Occupational Performance;
PTSD 5 posttraumatic stress disorder; SI 5 sensory integration.

The American Journal of Occupational Therapy, January/February 2018, Volume 72, Number 1 1
Supplemental Table 2. Search Terms for AOTA Systematic Reviews of ASI®, Specific Sensory Techniques, Sensory Environmental
Modifications, and Coaching, Cognitive, and Occupation-Based Interventions for Children With Autism Spectrum Disorder (2013–2015)
Category
Diagnoses and clinical conditions (only if
a sensory–motor or perceptual–motor
component is included in the study)
Interventions
Search Terms
autism spectrum disorder (including autism, Asperger syndrome, and pervasive developmental disorder)
activities of daily living, activity, activity groups, adaptive behavior, adaptive equipment, assistive tech-
nology, astronaut training, attention, auditory integration training, augmentative communication, Ayres
Sensory Integration®, ball chairs, bilateral coordination, bilateral intervention, coaching, cognitive in-
tervention, cognitive–behavioral therapy, consultation, context, contextual, CO-OP, decision-making skills
training, early intervening, early intervention, emotional regulation, employment, environment, environ-
mental modification, executive function, exercise, family centered care, family coping/coping skills, family
interaction/participation, friendship, friendship group, functional approaches, handwriting, instrumental
activities of daily living, integrated listening systems, job coaching, job training, Kawar protocol, leisure, life
coaching, massage, motor planning, multisensory integration, natural environment intervention, neuro-
developmental treatment, neuromotor occupational therapy, occupational therapy, occupation-based,
ocular motor skills, oral sensorimotor programs, parent/teacher mediated, parent training, peer group,
peer interaction, peer mediated, perceptual motor learning, play, praxis, pressure vest, prevocational,
priming, problem-solving skills training, relationship-based intervention, rest, routines-based interven-
tions, self-care, self-management, sensory diet, sensorimotor integration, sensory integration, sensory
integrative, SI, sleep, social competence, social participation, social skills training, social stories, strengths-
based, supported education, supported employment, tactile stimulation, therapeutic listening, time man-
agement, touch pressure, transitioning, transitions, vestibular stimulation, weighted blankets, weighted items,
weighted materials, weighted vests, Wilbarger protocol, work, yoga

Additional search terms for ASD review: antecedent modification, applied behavioral analysis, behavioral
interventions, behavior modification, comprehensive behavioral programs, differential reinforcement, DIR/
Floortime, discrete trial training, early intensive behavioral intervention, Early Start Denver Model, floor time,
Learning Experiences (An Alternative Program for Preschoolers and Parents), Lovaas, pivotal response
training, positive behavioral intervention, positive behavioral supports, response interruption, token economy,
Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH), SCERTS
Study and trial designs appraisal, best practices, case control, case report, case series, clinical guidelines, clinical trial, cohort,
comparative study, consensus development conferences, controlled clinical trial, critique, cross over, cross-
sectional, double-blind, epidemiology, evaluation study, evidence-based, evidence synthesis, feasibility
study, follow-up, health technology assessment, intervention, longitudinal, main outcome measure, meta-
analysis, multicenter study, observational study, outcome and process assessment, pilot, practice
guidelines, prospective, random allocation, randomized controlled trials, retrospective, sampling, scientific
integrity review, single subject design, standard of care, systematic literature review, systematic review,
treatment outcome, validation study
Note. AOTA 5 American Occupational Therapy Association; ASD 5 autism spectrum disorder; ASI 5 Ayres Sensory Integration; CO-OP 5 Cognitive Orientation to
daily Occupational Performance; SCERTS 5 Social Communication, Emotional Regulation, and Transactional Support; SI 5 sensory integration.

The American Journal of Occupational Therapy, January/February 2017, Volume 72, Number 1 2
 Supplemental Table 3. Studies Included in the Systematic Review of Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory Integration
Difficulties
Level of Evidence/Study
Author/Year Design/Participants/Inclusion Criteria Intervention and Control Outcome Measures Results
Buckle, Franzsen, & Bester Level I Group A received treatment first, then the • In-seat behavior measured 10· by primary At baseline, no significant differences existed
(2011) control condition. Group B received the control investigator on any outcome measure between Group A
Randomized, 2-group longitudinal crossover condition, then treatment. • Task completion speed measured 10· by and Group B.
design classroom teacher
Intervention For in-seat behavior, Group B showed
N 5 30 children with ADHD (21 boys, 9 girls; Children wore weighted vests calibrated to 10% • Attention to task collected 3· by school significant change after intervention (p £ .05).
ages 6–9 yr). counselors
of their body weight 45 min at a time, each day,
for 15 consecutive school days. For task completion, Group A showed
Group A, n 5 15. significant change after intervention (p £ .05).
Group B, n 5 15. Control
For attention to task, both Groups A and B
No intervention.
Inclusion criteria: Definite difference scores showed significant change after intervention
on the Sensory Profile. (ps £ .02 and .01, respectively).

Cermak et al. (2015) Level I Half of the participants received the Primary outcome measure: Physiological EDA showed moderate effect size after
intervention first, then the control condition; stress and anxiety as measured by EDA intervention in the TD group (ds 5 0.30–
https://doi.org/10.1007/ Randomized, 2-group crossover design other half received the control condition first, 0.46) and a moderate to large effect size in
s10803-015-2450-5 Secondary outcome measures: Behavioral the ASD group (ds 5 0.27–0.65).
N 5 22 children with ASD (18 boys, 4 girls; then the intervention. distress, pain intensity, sensory discomfort,
M age 5 8.2 yr, SD 5 1.9) and 22 TD Intervention and measures related to the cost of dental All behavioral measures showed statistically
children (10 boys, 12 girls; M age 5 8.3 yr,
1 dental cleaning administered using an SADE. procedures significant group effects (ps < .03).
SD 5 2.1). Adaptations were made to the auditory and
visual characteristics of the environment. In The child-reported measures of pain intensity
Inclusion criteria: For all participants, English-
addition, each child was provided with deep and sensory discomfort were significantly
or Spanish-speaking parents; children who improved in both groups with the SADE
had ³1 prior oral cleaning but not in the pressure via a wrap shaped like a butterfly.
intervention (ASD group, p 5 .05; TD group,
previous 4–6 mo; no significant motor Control p 5 .09).
impairment or genetic, endocrine, or
1 dental cleaning administered in a standard
metabolic dysfunction. For patients with ASD, dental environment. To measure cost savings, the number of

The American Journal of Occupational Therapy, January/February 2018, Volume 72, Number 1
diagnosis using the ADOS. hands required to restrain the child during
cleaning was evaluated and found to be
significantly reduced in the SADE
intervention, with an effect size of 0.42 in the
ASD group.

Dunbar, Carr-Hertel, Level I Intervention Overall play age as assessed by the Revised Both treatment and control groups improved
Lieberman, Perez, & Ricks 12 wk of ASI treatment was administered Knox Play Scale. Areas assessed included in overall play skills after the 12-wk
Randomized, 2-group pilot study
(2012) individually for 30 min 2·/wk by OTs certified space and material management and intervention and control conditions.
N 5 8. in the Sensory Integration and Praxis Tests. pretense–symbolic and participation areas Specifically, participants had more purposeful
http://nsuworks.nova.edu/ Authors note ASI fidelity descriptions were of play. environmental exploration in the space
ijahsp/vol10/iss3/6/ Intervention group, n 5 4 boys used to verify adherence to ASI treatment, but management category.
(M age 5 4.5 yr) who received both the no formal assessment was done.
intervention and control conditions.
Control
Control group, n 5 4 (2 boys, 2 girls; 12 wk of daily sensory-rich classroom
M age 5 4.4 yr). experiences that included opportunities for
(Continued )

3
 Supplemental Table 3. Studies Included in the Systematic Review of Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory
Integration Difficulties (cont. )
Level of Evidence/Study
Author/Year Design/Participants/Inclusion Criteria Intervention and Control Outcome Measures Results
Inclusion criteria: All children had to have a vestibular, tactile, and proprioceptive inputs
diagnosis of ASD, be functioning at ³18-mo after consultation and collaboration with the
level, be able to follow very simple verbal OT.
directions and gestures, have sensory issues
on the Evaluation of Sensory Processing, and
not currently be receiving sensory integration
intervention.

Murdock, Dantzler, Walker,
& Wood (2014)
https://doi.org/10.1177/108
8357613509838
Level I Pretesting: 5-min tabletop tasks that included During a 5-min tabletop activity, 4 behaviors Analyses revealed no significant differences
stringing beads, coloring, or doing a puzzle. were coded in 10-s intervals. Behaviors between the treatment and control groups
RCT Children were then randomly assigned to either included on task vs. off task; engaged vs. before or after intervention for any of the 4
N 5 30 (26 boys, 4 girls; age the intervention or the control condition. disengaged; stereotyped vs. not stereotyped; behaviors coded during the 5-min tabletop
range 5 30–77 mo), 22 with ASD and 8 with Posttesting: Another 5-min tabletop task. repetitive behaviors vs. no repetitive behaviors. tasks.
PDD–NOS.
Intervention
Intervention group, n 5 15. 5-min sensory break of vestibular stimulation
Control group, n 5 15. that included swinging in a slow, linear motion
on a platform swing.
Inclusion criteria: Diagnosis of either ASD or
PDD–NOS; probable or definite difference in Control
³1 area on the Sensory Profile. 5-min non–sensory break; included watching a
movie.

Silva & Schalock (2013) Level I Intervention • SSC Posttreatment results indicated Qigong
Daily parent-delivered Qigong massage for 5 • APSI massage treatment resulted in significant
RCT with wait-list control mo and weekly therapist support through QST. • Therapist report of children’s responses to improvement of tactile impairment, self-
N 5 129 children with ASD (104 boys, 25 touch on different areas of the body regulatory delay, and parenting stress (p <

The American Journal of Occupational Therapy, January/February 2017, Volume 72, Number 1
girls; ages 3–6 yr) and their parents.
Intervention group, n 5 97 children.
Control group, n 5 32 children.
Inclusion criteria: Age <6 yr; confirmation of
autism via DSM–IV criteria; receiving early
intervention services for ASD.
Control .001 on all paired t tests).
Wait-list comparison group.
The effect size estimate (partial h2 values) for
treatment effects on self-regulatory
difficulties was in the large range (0.213).
The effect size estimate for abnormal tactile
response was in the medium to large range
(0.114), and the effect size estimate for
parenting stress was in the medium range
(0.093).
(Continued )

4
 Supplemental Table 3. Studies Included in the Systematic Review of Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory
Integration Difficulties (cont. )
Level of Evidence/Study
Author/Year Design/Participants/Inclusion Criteria Intervention and Control Outcome Measures Results
Silva, Schalock, Ayres, Level I Intervention • Parent and teacher report on the PDDBI Large effect sizes were found on parent-report
Bunse, & Budden (2009) QST; therapists met with families for 20 • SSC measures of PDDBI (0.328) and SSC (0.346) for
RCT training sessions over 5 mo, providing a QST intervention vs. control groups.
https://doi.org/10.5014/ massage treatment to the child, then trained
ajot.63.4.423 N 5 46 children randomized to intervention No significant treatment effect was found on
or control group. the family to provide the same massage daily
until the next session. the PDDBI measure of maladaptive
Intervention group, n 5 25 (19 boys, 6 girls; classroom behavior, with both intervention
M age 5 65.3 mo). Control and control groups improving significantly on
Wait-list comparison group. pre- and postintervention measures.
Control group, n 5 21 (18 boys, 3 girls;
M age 5 53.3 mo).
Inclusion criteria: Age <6 yr; eligible for early
intervention services for autism; no
complicating medical diagnosis or chronic
medication.

Silva, Schalock, & Gabri- Level I
elsen (2011)
RCT with wait-list control
https://doi.org/10.5014/
N 5 47 children with ASD (33 boys, 14 girls; supplemented with DVD, booklet, and chart and
ajot.2011.000661
ages 3–6 yr) and their parents. 5 children
dropped out.
Intervention group, n 5 24.
Control group, n 5 18. 15 also provided data
postintervention.
Intervention • ABC Intervention group improved with medium to
QST; 15-min home program provided by • PDDBI large effect sizes.
parents daily for 4 mo after 3-hr training • SSC
No changes were found in wait-list control
• APSI
7 weekly 30-min support sessions. group.
Large effect sizes were found on parent-
Control
Wait-list comparison group. report measures: PDDBI (0.59 and 0.66), SSC
subtests (0.79 and 0.85), and APSI (0.74).
Small effects were found for language and
social abilities (0.27).

The American Journal of Occupational Therapy, January/February 2018, Volume 72, Number 1
Inclusion criteria: Age <6 yr; receiving early
intervention services for ASD.

Silva et al. (2015) Level I
https://doi.org/10.1155/ Multisite, randomized, single blind controlled
2015/904585 trial with wait-list control
N 5 103 children with ASD (ages 2–5) and
their parents. 28 children dropped out.
Intervention group, n 5 42 children (36 boys,
6 girls).
Control group, n 5 42 children (39 boys,
3 girls).
Intervention • Childhood Autism Rating Scale, 2nd Edition Participants in the treatment and control
Daily parent-delivered Qigong massage for 5 • PLS–5 conditions did not differ on outcome
mo plus 20 sessions of therapist-delivered • Vineland Adaptive Behavior Scales, 2nd measures or age.
massage after QST. Edition
• ABC Children in the treatment group experienced a
Control • SSC 38% decrease in abnormal sensory response;
Wait-list comparison group. 49% decrease in abnormal oral–tactile
• APSI
response; 34% decrease in self-regulatory
difficulties; and 32% decrease in autistic
behavior. Parents of these children
experienced a 44% decrease in stress
responses.
(Continued )

5
 Supplemental Table 3. Studies Included in the Systematic Review of Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth With Sensory
Integration Difficulties (cont. )
Level of Evidence/Study
Author/Year Design/Participants/Inclusion Criteria
Inclusion criteria: Age between 2 and 5 yr;
receiving early intervention services;
confirmation of autism via DSM–IV criteria.
Intervention and Control Outcome Measures Results
Children with both mild to moderate and
severe autism experienced significant
improvements in receptive language as
measured by PLS–5 Auditory Language
(ts 5 24.26 and 24.29, ps 5 .0001
and .0003, respectively).

Note. ABC 5 Autism Behavior Checklist; ADHD 5 attention deficit hyperactivity disorder; ADOS 5 Autism Diagnostic Observation Schedule; APSI 5 Autism Parenting Stress Index; ASD 5 autism spectrum disorder; ASI 5
Ayres Sensory Integration®; DSM–IV 5 Diagnostic and Statistical Manual of Mental Disorders (4th ed.); EDA 5 electrodermal activity; M 5 mean; OT 5 occupational therapist; PDDBI 5 Pervasive Developmental Disorders
Behavior Inventory; PDD–NOS 5 pervasive developmental disorder–not otherwise specified; PLS–5 5 Preschool Language Scale, 5th Edition; QST 5 Qigong Sensory Training (a manual therapy providing somatosensory
stimulation through patting, shaking, and pressing movements to 12 areas of the body); RCT 5 randomized controlled trial; SADE 5 sensory-adapted dental environment; SD 5 standard deviation; SSC 5 Sense and Self-
Regulation Checklist; TD 5 typically developing.
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2018 by the American Occupational Therapy Association. It may be freely reproduced for
personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.
Suggested citation. Bodison, S. C., & Parham, D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: A systematic review (Suppl. Table 3).
American Journal of Occupational Therapy, 72, 7201190040. https://doi.org/10.5014/ajot.2018.029413

The American Journal of Occupational Therapy, January/February 2017, Volume 72, Number 1
6
 Supplemental Table 4. Risk-of-Bias Table
Attrition Bias Incomplete
Selection Bias Outcome Data
Random Sequence Allocation Performance Bias: Blinding of Detection Bias: Blinding of Short-Term Long-Term Reporting Bias: Selective
Citation Generation Concealment Participants and Personnel Outcome Assessment (2–6 wk) (>6 wk) Reporting
Buckle, Franzsen, & Bester (2011) 1 ? 2 2 1 N/A 1
Cermak et al. (2015) ? ? 1 2 N/A 1 1
Dunbar, Carr-Hertel, Lieberman, Perez, ? ? 2 ? N/A 1 1
& Ricks (2012)
Murdock, Dantzler, Walker, & Wood 1 1 2 1 N/A N/A 1
(2014)
Silva & Schalock (2013) ? ? 1 ? N/A ? ?
Silva, Schalock, Ayres, Bunse, & Budden 1 1 1 1 N/A 1 1
(2009)
Silva, Schalock, & Gabrielsen (2011) 1 1 1 1 N/A 1 1
Silva et al. (2015) 1 1 1 1 N/A 1 1
Note. Categories for risk of bias are as follows: 1 5 low risk of bias; ? 5 unclear risk of bias; 2 5 high risk of bias. N/A 5 not applicable.
Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J. P. T.
Higgins and S. Green (Eds.), 2011. London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org. Copyright © 2011 by The Cochrane Collaboration.
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2018 by the American Occupational Therapy Association. It may be freely reproduced for
personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.

Suggested citation. Bodison, S. C., & Parham, D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: A systematic review (Suppl. Table 4).
American Journal of Occupational Therapy, 72, 7201190040. https://doi.org/10.5014/ajot.2018.029413

The American Journal of Occupational Therapy, January/February 2018, Volume 72, Number 1
7
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