Division on Autism and Developmental Disabilities
Evaluation of the Effects of Sensory Integration-Based Intervention by a Preschool Special
Education Teacher
Author(s): Penelope Wong Bonggat and Laura J. Hall
Source: Education and Training in Autism and Developmental Disabilities, Vol. 45, No. 2
(June 2010), pp. 294-302
Published by: Division on Autism and Developmental Disabilities
Stable URL: http://www.jstor.org/stable/23879813
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Education and Training in Autism and Developmental Disabilities, 2010, 45(2), 294-302
© Division on Autism and Developmental Disabilities
Evaluation of the Effects of Sensory Integration-Based
Intervention by a Preschool Special Education Teacher
Penelope Wong Bonggat and Laura J. Hall
San Diego State University
Abstract: This study addresses the call for increased research on common public school practices and progress
monitoring by public school teachers. An alternating treatment design was implemented by a preschool teacher
to evaluate the effect of sensory-integration based activities compared with an attention control on the on task
behavior of three participants with disabilities. The preschool participants were observed during one-to-one
teaching sessions and completing maintenance tasks in an independent workstation during the second half of
a school year. The results revealed no differences in the estimated percentages of time on-task when either
condition was used for all three participants. More time on task occurred when the participants were working
in one-to-one activities. The design used in this study serves as a model that can be used by teachers and
occupational therapists working in a public school.
The process of sensory integration is sup- and environmental stimuli is ongoing (Anza
ported by a theoretical construct that de- lone & Williamson, 2000; Baranek, Parham, &
scribes the relationship between the neurobi- Bodfish, 2005; Wilbarger & Stackhouse), oc
ology of an individual and the environment cupational therapists are actively recommend
(Fisher & Murray, 1991). Theorizing about ing practices to address atypical behavior by
the interaction between the sensory and mo- individuals identified with disabilities thought
tor systems and the environment has been a to be a result of problems with sensory inte
focus of the field of occupational therapy gration processing (Mailloux & Smith-Roley).
(Mailloux & Smith-Roley, 2004; Wilbarger & Reviewers of research on practices based on
Stackhouse, 2005). Current theories build semory integration theory have conciuded
upon the work of Dr. Jean Ayres who devel- that there is either little or no evidence to
oped a theory of sensory integration and de- suppon such practices when used for children
scribed intervention practice for individuals wlth leami disabilities (Hoehn & Baumeis.
fr 1972; Ayres & Tickle, ^ ig94; n Polatajk0) Wilson, & Faris,
1980). Although theory development regard
, . . , , , . r , 1993), language and learning disorders
ing the interaction between behavior of the
(Griffer, 1999), mental retardat
individual, the sensory and motor systems,
MacLean, & Baumeister, 1988), and autism
spectrum disorders (Goldstein, 2000; Rogers
& Ozonoff, 2005). Although most reviewers
This study would not have been possible without . , ,r .
,, ..... ,, . n ■ ■ i r n identify methodological weaknesses in the de
the support of Kim Kossyta, Principal of Rowen ' "
Elementary School and the families of the three s'§n as one °f the main reas
preschool students. We are particularly grateful to elusions, there also is a lack
Mary Scott, the classroom Special Education Tech- between any changes in beh
nician who acted as the primary observer through- posed dysfunctional sensory
out the study. We would also like to acknowledge (Baranek, 2002; Dawson & W
Gretchen Stadnik Grundon who used her many Many of these authors caU f
talents in assistance of this manuscript. Correspon- ,
, . ,. ,, , on the outcomes of this approach (Dawson &
dence concerning this article should be addressed rr
to Laura j. Hall, Department of Special Education, Watling; Goffe
San Diego State University 5500 Campanile Drive lack of evidence
San Diego, California, 92182-1170. Email: ljhall® tivities continu
mail.sdsu.edu pational therapists and used by educators in
294 / Education and Training in Autism and Developmental Disabilities-June 2
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public schools (Rogers & Ozonoff). Parents evaluate the use of therapy ball for children
have reported (Smith & Antolovich, 2000) with autism spectrum disorders and found
and authors have speculated (Kaplan et al.) that children were more engaged when using
that interventionists perceive that children im- the therapy ball than when using alternative
prove as a result of sensory integration-based forms of seating (chair, bench, carpet square
therapy or that positive changes in behavior on floor). These single-subject designs could
are attributed to the sensory integration strat- be used by public school personnel to evaluate
egies. intervention outcomes if the proper controls
Several strategies that are put together in are incorporated,
order to modulate arousal, attention, affect Educators and thera
and action for an individual can be referred to lie schools are curren
as a "sensory diet" (Anzalone & Williamson, dence-based" practi
2000; Baranek, 2002). Some of the strategies The importance of m
included in a typical "sensory diet" may be using data to guide t
enjoyable for both the student and the educa- been emphasized b
tor. Massaging with lotion is an example. Es- occupational therap
calona and her colleagues found that children son, 2000; Baranek e
with autism who received massage from their Tickle-Degnen, & Hasse
parents at bedtime exhibited less stereotypic selkus, previous editor
behavior and showed more on-task behavior of Occupational Ther
during play at school compared with those dence can be determi
children with autism read a Dr. Seuss story tal designs including
(Escalona, Field, Singer-Strunck, Cullen, & (Ottenbacher et al.).
Hartshorn, 2001). The authors state that the tional Children Task
underlying mechanism for enhancing atten- tors for Special Edu
tiveness is not known but they speculate that agrees that the use of
massage therapy has been noted to enhance with a set of criteria can
parasympathetic activity that is correlated with effectiveness of a p
attentiveness. the following study, a single-subject alternat
Case-Smith and Bryan (1999) used a single- ing treatment design was us
subject AB design to evaluate the effects of effects of sensory integratio
sensory integration based therapy on the en- on the on-task behavio
gagement, play and social behaviors of pre- with developmental disabiliti
school children with autism or pervasive de- implemented by a presc
velopmental disorders. Although they found credential in early chil
increases in play behavior and engagement tion.
for three of the five participants, baseline mea
sures were obtained following the winter ,
,
°
•
„
Method
break, a time the authors des
resulting in regression of sk
Participants
on the generalization of play
lacking. Two boys with developmental delay (Jose and
Reilly, Nelson, and Bundy (1983) used an Marco) and one boy
alternating treatment design to evaluate a 30- participants in this
minute sensory integration-based intervention old boy of Mexican
compared with a fine motor activity on the intervention serv
vocalizations of 18 children with autism. Con- the study. He receiv
trary to predictions they found that the fine occupational therap
motor activity resulted in more vocalization by played some signs
participants, however, there was a history of and inconsistent
positive reinforcement for vocalizations dur- tions by screaming
ing fine motor activities. Schilling and asked to work one-on
Schwartz (2004) used a withdrawal design to ting. Jose was an acti
Evaluation of Sensory Integration
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four word sentences at the time of the study. form fine motor tasks. Dante displayed
He showed signs of appropriate play skills parallel play skills during free play, and at the
(turn-taking, sharing, and eye contact with time of the study showed limited age-appro
verbal reminders), however, the majority of priate play and/or social skills, except for
the time he played along side his peers (par- greetings and saying "sorry" when he was told
allel play) and did not seem to attend to any he had hurt someone. Dante enjoyed wres
activity during play or recess for more than tling and movement activities,
five to ten minutes.
Marco was a four-year eleven-month old boy Preschool Teacher
of Mexican decent who began early interven
tion services at an early age. He transitioned The classroom teacher, and first author of this
into this preschool classroom at the age of research, held a B.A. in psychology and her
three years. Some of the behaviors Marco ex- teaching credential in Early Childhood Spe
hibited in the classroom were: resistance to cial Education. She was enrolled in an ad
being touched by the staff, crying and scream- vanced degree program and this st
ing if anyone left the classroom, hitting his filled one of the requirements for th
head when angry, frustrated, and/or sad, and She had worked as a classroom aide f
closing his eyes or covering his eyes with his and as a home program tutor for ten
arm to avoid task demands. Marco's occupa- She was trained to use discrete tri
tional therapy assessment also concluded methods, structured TEACCH activit
signs of "tactile defensiveness". Unlike Jose, bov & Howley, 2003) including in
Marco had Individualized Educational Plan work stations, Pivotal Response Tra
(IEP) goals and objectives written to address child lead approach based on the pr
this issue. Marco also displayed oral motor applied behavior analysis (Koegel,
difficulties, such as low tone around his Carter, 1999), and sensory integration
mouth and drooling, and it was at the sugges- activities. The sensory activities wer
tion of the occupational therapist that oral strated by an occupational therapist who
swipes and oral massage be performed on worked for the district. The teacher had ar
Marco as part of his "sensory diet". ranged a class-wide data collection system
In addition, Marco had difficulties in the prior to commencement of the study,
areas of fine motor, self-help, and strength/
coordination. Marco was nonverbal and dem
Observers
onstrated his liking of Jose by walking hand
in-hand with him, sitting next to him during Two observers were trained for this st
table activities, and helping him with class- primary observer was the Special
room chores such as pulling the wagon and Technician (SET or aide) currently
cleaning up toys. Marco also approached two in the classroom and the secondary
or three of the typical peers in his after school was the second author and the univ
program and would follow their verbal and visor for the teacher's degree prog
physical directions to play and/or sit with
them. Marco spent the majority of his time
engaged in parallel play and did not demon
strate age appropriate play skills. This Special Education Early Childhood class
Dante was a four-year old boy of African- room is located on the campus of an urban
American decent who transitioned from a less elementary school in San Diego. Located in a
structured class one-and-a-half months prior low-income neighborhood, the majority of the
to the beginning of this study because of his school's population is traditionally underrep
lack of progress and his display of challenging resented and the majority of students are on
behaviors (hitting and pushing others). free and reduced lunch programs. Students
Dante's occupational therapy assessment with Individualized Educational Plans who
identified his greatest areas of need to in- typically have a diagnosis of autism, mental
crease his ability to: attend to tasks and peo- retardation, and/or have sensory deficits
pie, complete transitions smoothly, and per- and/or behavior problems are placed in spe
296 / Education and Training in Autism and Developmental Disabilities-June 2010
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cialized preschool classrooms in this district. via joint compressions, a therapy ball,
Because of the unique needs of the students, weighted vests, weighted pillows, and a blan
the student to staff member ratio is approxi- ket. The following materials were used during
mately one or two students to one adult. attention control activities: puzzles, puppets,
School sessions for the preschool classrooms interactive (music/lights) toys, bubbles,
are three hours and forty-five minutes long books, blocks, and play dough.
with the morning session taking place from The dependent measures for this study
9:00 am to 12:45 pm and the afternoon ses- were: attention to task and disruptive behav
sion taking place from 11:50 to 3:35 pm. jors. Attention to task was selected because it
As the children arrive at school they are was a reported benefit of sensory integration
greeted at the bus and walked to the class- based activities according to the occupational
room where each student checks their sched- therapist and the classroom teacher. For the
ule and proceeds to put their backpack away, purposes of this study, attention to task was
go to the bathroom and participate in their defined as the ability to demonstrate eye con
individualized sensory diets (usually consist- tact with the teacher and appropriate partici
ing of some or all of the following activities: pation in an activity Disruptive behaviors were
brushing, joint compressions, oral swipes, and defined as. screaming (S) or any vocalization
exercises, therapy ball activities, the ham- aboye conversational noise level that demon
mock, and scooter board). Once each student strated the participant.s rejection of a corn
is finished, the students begin their work ro- mand and/or ,ask and kad tQ thdr inabm
tations. These activities include but are not , . , , r . , r
to attend to, and/or perform a task
limited to: discrete trial teaching of pre-aca- , , . . r
° r than two seconds; crying (C) or crying tor
demic skills, structured teaching independent , , , . . , , .
° r more than two seconds that lead to the par
work staüons for maintenance tasks, fine mo
ticipants' inability to attend to, and/or per
form a task; turning away (T) or any physical
movement which was demonstrated by the
services.
participant turning their body and/or head
Two Special Education Technicians (SET's)
away from the task or averting their eye gaze
support these classrooms. Typically these _ , , . , ,
**, . ,, , ,. . , , from the task leading to a lack of attending to,
SET s are not trained by the distnct or by the ° ,
... . , . . and/or perform a task for more than two
special education department in the various r
„ , . i , . . , . . . seconds; running away (R) or any physical
techniques and strategies used in these class- ° ' ' ' tor rotations (writing, cutting, puzzles, beads),
structured play, circle time, art, and specialist
TT, ™T ... , , attempt made by the participant to escape,
rooms. The SEI in this classroom, however, ' 1 1 '
was informally trained by the classroom avoi
teacher in discrete trial teaching, sensory in- thei
tegration-based occupational therapy, over- me
seeing the structured teaching independent the
work stations, and was consistent with the tbe
classroom teacher in how to teach fine motor mor
skills such as prewriting and cutting. The SET
was also trained by the teacher on how to take
data throughout all teaching strategies and avoi
activities. more than two seconds (playing with materi
Materials and Measures
als, staring without movement).
Recording sheets were created to sc
occurrence of dependent variables
For the sensory diets that all participants re- dent measures were sc
ceived, a surgical brush was used as well as a val time sampling
specialized brush designed for oral swipes for minute activity) with
Marco who was given oral swipes after joint and 5 seconds record
compressions. Vestibular equipment was also ruptive behavior oc
used and included: a hammock, swing, and interval, the type of b
scooter board. Proprioceptive input was given circling the letter cod
Evaluation of Sensory Integration /
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Design and Analysis and swung in the hammock (stretched out,
stomach down). If Marco received the senso
An alternating-treatments design (Barlow & integration intervention, h
Hersen, 1984; Cooper, Heron, & Heward, would also include oral swipes
200?) was used to evaluate the effects of sen- preSsions and wheelbarrow walk
sory integration-based occupational therapy tance of ten feet
and an attention control on activity engage- when participants received
ment and disruptive behaviors. The two treat- control they were exposed tQ a
ments or conditions of sensory integration ac- teractive activities with a staf
ti vi ties and attention control activities were rdated R) the sensor^. integrati
implemented for one to two weeks in a coun- their "sensoly diets") for the sa
terbalanced order within each single subject time that they would have s
(Cooper et al.). their "sensory diets". An example
period might include the participant choos
Procedure an 'n,eractive story to read then, completing a
series of puzzles or turn-taking games with
Training of the observers took place prior to bubbles or a ball.
beginning the observations. The observers Dante and Marco also received additional
scored videotapes of the participants in vari- sensory integrative-based occupational ther
ous activities (the same activities that they apy for half-an-hour three and four times a
would be observed in during the treatment month respectively with a trained occupa
phase) until the criterion of an inter-observer tional therapist who worked specially on occu
agreement rating with the classroom teacher pational therapy goals (from the student's
of a minimum of 80% over three consecutive IEP). Sessions were typically held every Friday
observations was obtained for each observer. at 9:00 am and 9:30 am, however, for the
During intervention, participants were ran- purposes of this study, occupational therapy
domly assigned to a sensory integration or services were rescheduled to occur after data
attention control schedule that alternated ev- had been collected during two targeted activ
ely one or two weeks. Sensory diets or atten- ities following intervention. Occupational
tion control activities were implemented upon therapy sessions were designed to develop fine
the participants' arrival at school and lasted motor skills, attending, and transitions for
for about ten minutes. The observers were not Dante, and fine motor skills, toileting, feed
in the classroom at the time of intervention to ing, and dressing for Marco,
ensure that they were blind to the interven- Observations were made during the two ed
tion or condition the participants had re- ucational activities (independent workstations
ceived. The SET took the non-participating and one-on-one activity) that were scheduled
students to the restroom and the second ob- directly following the intervention sessions,
server did not arrive on the school grounds Independent workstations were modeled
until after the intervention had been pro- from the structured teaching approach from
vided. the TEACCH program (Mesibov & Howley,
The sensory integration intervention con- 2003) where stude
sisted of the participant being brushed via the on a series of mast
Wilbarger deep pressure and proprioceptive completed all the
technique (DPPT) - brushing each arm, back, sion. Activities in a o
and each leg using long, firm strokes for a classroom staff in
count of ten per body part, given joint com- taught with a discre
pressions - applying firm pressure to the activities such as cu
shoulders, elbow, wrists, fingers, hips, knees, itation of simple p
and ankles for a count of ten per joint, use of rotated through th
a therapy ball (rolled on front of entire body minute sessions fol
for a count of ten - except on face and on top attention activi
stomach down, pushing and pulling legs for a corded one child
count of ten) (Wilbarger & Wilbarger, 1991), samples with th
298 / Education and Training in Autism and Developmental Disabilities-J
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domly conducted. All observations were made curred only once for Dante (session 9) with
within the 30-minute period following the in- the second highest session scored during the
tervention activity. During intervention, 43 ob- attention control condition (session 23).
servations were recorded for Jose, 40 for Marco scored both the highest and lowest per
Marco, and 46 for Dante. centages under the sensory condition during
the independent work activity. Marco had
, . . . greater variability of on task performance
Inter-Observer Agreement ° , ' .r ,
when the sensory condi
Two observers scored 63% of all observa
including both conditions (sensory and a
tion) throughout the study. Interobserv
agreement scores were calculated using t
formula: the number of agreements divi
by the number of agreements plus the num
ber of disagreements divided by 100 (Sul
Azaroff & Mayer, 1991). The overall mea
inter-rater agreement was 91% with a r
from 69% to 100%. The lowest agreeme
score occurred during a day with a fire dr
(day 6). The mean inter-rater agreement
for Jose was 93% (range = 69% to 100%),
Marco 92% (range = 70% to 100%), and f
Dante 89% (range = 75% to 100%). Marco, 10 and 55% for Dante and 5 and 40%
for Jose. Jose was scored as "crying" during two
sessions (with 10% & 45%). "Running" from
Results
the station was observed for Dante for 5 to
The percentage of on-task behaviors during 10% during nine sessions and by Mar
two separate activities (independent vs. one- 5% of two sessions. "Other" types of off t
on-one) and across two conditions (sensory vs. behaviors were recorded in thirteen (Jos
attention) for each of the three participants twenty (Marco) of the observations a
appear in Figure 1. The diamond represents tween 5 and 65% (Jose & Marco) of t
the percentage of attention to task following sion when the participants were in th
the sensory integration-based condition and pendent work stations.
the square represents the percentage of on The highest category of off task beha
task behavior when the attention control was scored during one-on-one sessions we
used. "turning away" for all participants with esti
The data indicated that there were no dif- mated percen
ferences in the trend as a result of treatment as between 5 and 25% and for Dante as be
intervention or by condition across all three tween 5 and 50% of a session. Dante was a
participants (see Figure 1). The only differ- scored as "crying" for 5% of one sessio
enees observed were for the type of activity, "Other behaviors", were recorded in low per
with the participants maintaining a higher centages during one-to-one sessions for
level of on task behavior when working in a participants and following both conditio
one-on-one activity than when in an indepen- with the exception of Jose who scored
dent activity (see Figure 1 - lower graph). This tween 0% and 15% in this category during fiv
difference could be a result of the skilled staff sessions,
that were familiar with the participants and
thus, were able to prevent off task behaviors Discussion
during the one-to-one sessions.
Dante and Marco's highest percentage of This study investigated the effects of therapist
on task behavior during the independent recommended sensory integration-based ac
work activity occurred under the sensory con- tivities on the on-task behavior in preschool
dition, however, this high percentage oc- children with disabilities. Results indicated
Evaluation of Sensory Integration / 299
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100
Marco - Independent
50
^
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
100
■
50
Marco - One-to-one
0 r T T T T * T 1 T I T T T T T T T ; r—
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
A Sensory
Figure 1. The estimated percentage of time on task for the three participants during independent and
one-to-one activities following the two conditions of sensory integration based activities (triangle)
and attention control activities (square).
that sensory integration activities had no bet- behaviors than attention control activities. All
ter effect on the participants' ability to remain three participants chosen for this study had
on task and reduce the number of disruptive been prescribed "sensory diets" by an occupa
300 / Education and Training in Autism and Developmental Disabilities-June 2010
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tion therapist for sensory defensiveness, and progress monitoring by their occupational
difficulty with attention, yet there was no ob- therapy staff.
vious benefit to starting their day with a "sen- Limitations to this study include the limited
sory diet" compared with an attention control time frame in which data was collected. This
activity. Similar to results from the alternating study was conducted at the later half of the
treatments design used by Reilly and col- school year when participants were accustom
leagues (1983), the sensory integration-based to the staff, routine, and classroom environ
condition did not have a greater effect on ment and the data may have looked different
targeted outcomes. if the study was conducted at the beginning of
What seemed to make the most significant the school year. Follow-up data for Jo
difference in the participants' on task behav- sensory-based occupational therap
iors was the individualized attention they re- were discontinued would have yie
ceived in a one-on-one educational activity esting information on the maintena
versus an independent activity setting. The on-task behavior.
high percentage of on task behavior for all This study serves as a model for c
participants during the one-to-one activities outcome data on interventions use
demonstrated the effectiveness of using sound lie school classroom. Teachers ar
teaching strategies along with motivating ma- develop a data collection system and
terials to maintain on task behavior. ment student progress. Clearly, it is also im
This study was organized and implemented portant for occupational therapists to become
by a preschool teacher working in a public accountable for the strategies they recom
school with the assistance of her classroom mend and to provide research indicating that
aide. Collecting the data on the student's be- those strategies are evidence-based. Classroom
havior provided important information. The teachers are expected to know the purpose for
preschool teacher became aware that she had implementing any strategy and be able to
incorrectly attributed some positive changes identify the intended outcome. Teachers us
in student behavior to the sensory integration- ing ongoing progress monitoring systems can
based activities, an occurrence speculated by make data-based decisions regarding modifi
Raplan and colleagues (1993) to be common. cations or discontinuation of interventions in
Review of the data by the occupational ther- a timely manner in order to provide maxi
apist and the Individualized Education Plan mum benefit for their students with disabili
(IEP) team resulted in the decision to remove ties.
the "sensory diet" forjóse and to place him in
a less restrictive environment for the following
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Final Acceptance: 22 July 2009
302 / Education and Training in Autism and Developmental Disabilities-June 2010
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