Critique of COT Briefing Paper
Section 1: Introduction
'The sensory needs of a person change with time; so a child's sensory processing will mature as they
get older'
This statement alludes to the belief that children may grow out of their sensory difficulties which is
contradictory to what has been reported by many individuals and also reported in the adult population
studies which have been conducted in relation to sensory processing. High and consistent levels of
impairing sensory problems have been identified from childhood to adulthood in almost all individuals
diagnosed with classic autism (Klintwall’s, 2010)
'It is well accepted that people experience sensations differently....sensitive to noise, light, touch,
smell or movement, while others may under respond to such sensations'
This is a very limited explanation of how individuals experience sensation. ‘Noise’ is different to ‘sound’,
with noise alluding to a sound that is particularly loud. However, it may not be the loudness but rather the
difficulties gating/filtering background sounds (Davies, 2007). Touch sensitivities typically occur in response
to light and unexpected touch due to the neuroscience which links this to autonomic nervous systems
reactions (Ayres, 1972)
'Not universally accepted as effective remediation approaches for occupational performance''
This is a misleading statement and a claim that is presumptuous of other countries. It also does not
acknowledge that there is in general very little evidence for use by professionals when working with people
with disability. Reasons for this include the level of investment and resources required to produce robust
research studies when many of those practicing in the UK are within the NHS and have limited funding for
studies and many barriers to overcome in terms of ethics. It is estimated that 30-40% of healthcare
interventions are not able to be guided by evidence (Novak et al., 2013). However, this does not mean that
these interventions cannot be practiced in conjunction with closely monitored person-centred outcome
measures.
Occupational therapy using sensory integration is one of the most frequently sought out interventions to
address difficulties with functional skills and associated maladapative behaviours (Goin-Kochel et al,
2009;Green et al, 2006 & Mandell et al, 2005)
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Section 1: Introduction
This section offers no clarity for the reader regarding the different terms used: Sensory Integration Theory,
Sensory Integration Therapy, Sensory Integration Dysfunction, Sensory Processing and Sensory
Processing Disorder. There are academic papers available which provide explanations but were not
referred to in this briefing.

Ayres (1972) theorised that impaired sensory processing may result in functional problems which
she referred to as Sensory Integration Dysfunction.

Sensory Integration Theory refers to how the brain processes sensation and the resulting motor,
behaviour, emotion and attention problems (Bundy, Lane & Murray,2002) and is regarded as a
frame of reference primarily by occupational therapists.

Sensory Integration therapy or Ayres Sensory Integration (ASI) as trade marked by the Baker/Ayres
Trust, (2007) refers to specific therapy that evolved from the work of Jean Ayres (1972).
The term Sensory Integration has been used outside of occupational therapy and can be applied to
neurophysiological cellular process rather than a behavioural response as proposed by Ayres. The
proposed Nosology (Miller, 2007) supports the continued use of the terms, Sensory Integration Theory,
Sensory Integration Therapy but proposed a new diagnostic categorisation for individuals who present with
sensory-processing challenges. This was to distinguish the disorder from the theory as well as from the
cellular processes (Miller et al, 2007)
Section 3: What is Sensory processing disorder?
'Sensory processing as a distinct diagnosis, however, failed to be included in the DSMV...there is
also a lack of consensus over how sensory processing can be identified and measured'
The panel for the DSM have requested additional evidence to support the inclusion of this diagnosis,
therefore more research is required. This does not suggest that the panel were dismissive of the research
presented to them, but instead requested more of it. In 2010, Schaaf and Davies described the problem for
the children and adolescents with difficulties processing and integrating sensory information, but highlighted
further robust brain research was needed before it would be possible to clearly differentiate those with
sensory processing difficulties alone, as distinct and separate from those with the sensory processing
difficulties that can and often co-occur with other disorders including Autism, ADHD, Tourette’s and OCD.
The diagnosis of SPD/SID is yet to appear in the ICD or the DSM, however it is referred to in the
‘Diagnostic Classification of Mental Health and Developmental Disorder of Infancy and Early Childhood’
(2005) as ‘Regulation Disorders of Sensory Processing’. Ongoing research continues to be conducted
and developed to provide further evidence that this is a disorder in its own right. Evidence is emerging in
the neuroscience literature linking behaviour and physiological measures in children such as cortisol levels,
electro dermal activity (Schoen et al 2009, Lane & Schaaf, 2009) and vagal tone (Schaaf et al 2010).
Reduced white matter microstructural integrity, predominantly in the posterior cerebral tracts has been
found in children with atypical unimodal and multisensory integration behaviour (Owens et al, 2013).
Secondary sensory and motor symptoms have been proposed as early indicators of brain vulnerability with
sensory and motor symptoms being reported across a wide range of psychopathologies, much before the
full blown disorder (Levit-Binnun, Davidovitch & Golland, 2013).
This briefing has no mention of the recent inclusion in the DSMV or the NICE guidelines for Autism.
Research has supported the inclusion of sensory processing in the DSMV clearly articulated as ‘minor’
diagnostic criteria for Autism – included within domain 2 - Repetitive, Restricted Behaviours. The DSMV
refers to ‘Hyper or Hypo reactivity to sensory input or unusual interest in sensory aspects of the
environment’. The DSM acknowledges that these responses to sensation together limit and impair
everyday functioning. In addition the NICE guidelines for the assessment, diagnosis and
Critique of COT Briefing Paper
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management/intervention for children, young people and for adults with ASD (2012) also recommend the
assessment of hyper- and hypo-responsivity and adaptations of the physical environment for people with
atypical sensory responses.
'The American Academy of Pediatrics ...recommended that paediatricians should not use the term
sensory processing disorder as a diagnosis'
This statement misrepresents what was recommended as The American Academy goes on to state the
reason being that it has not yet been demonstrated that SID exists as a separate disorder distinct from
other developmental disabilities. However, despite these challenges in defining SI Therapy, the treatment
of sensory processing difficulties may possibly be helpful to children who have problems identified in
sensory processing measures. It also acknowledged that 'standardised measures have been developed to
classify a child's sensory deficits and to quantify how much these developmental and behavioural
differences affect the child's functional performance of the daily activities of childhood'.
This briefing has no mention of the wealth of research regarding the prevalence of proposed sensory
processing disorders. Individuals with Borderline Personality Disorder have shown increased sensory
sensitivity & avoiding responses (Brown, Shanker, 2009). Strong relationships between sensory sensitivity,
childhood ritualism and adult OCD have been found, suggesting oral and tactile hypersensitivity in
childhood may be strong indicators for adult OCD (Dar, Kahn & Carmeli, 2012). Children with Foetal
Alcohol Syndrome present with prevalence of up to 90.9% showing definite differences on SSP & 81.8%
some problems or definite dysfunction on the SPM (Hansen & Jirikowic, 2013).
Children with Developmental Coordination Disorder have shown 80% in one clinical sample demonstrated
strong association between maternal stress and sensory processing (Allen & Knott, 2013)
Individuals with Schizophrenia have shown to have higher scores on Adult Sensory Profile in Sensory
Avoiding and Low Registration, lower on Sensory Seeking than typical population (Brown et al, 2002).
Children with ADHD have been shown to have a prevalence of SOR in 54% of cases (Lane, 2010) and
significant impairments in 11 out of 14 sections and 6 out of 9 factors of the sensory profile (Shimizu V ,
Bueno O, Miranda M, 2014)
When comparing children with Asthma to healthy children 90% of the healthy children were reported to
actively seek sensory stimuli, only 53% of the asthmatic children showed this trend. 25.7% of the children's
scores reflected abnormal sensory performance, compared to 0% of the controls (Engel-Yeger B ,Almog M,
Kessel A, 2014)
4.0 Should an OT assessment focus only on sensory issues.
An OT’s domain of concern is a person’s occupational participation and performance. The literature on SI
provides evidence of the impact of sensory processing and integration difficulties on play & leisure, ADL,
Sleep, education/work and social participation (Koenig and Rudney, 2010). Bagby, Dickie and Baranek’s
(2009) study with families of children with ASD revealed how significantly a child’s sensory experiences
affect their family’s occupation. Parents hope SI will help their children develop- self-understanding,
frustration tolerance and self-regulation (Cohn et al, 2014). Kinnealey et al (2011) found adults with
additional sensory over reseponsivity to have lower scores on quality of life measures and higher incidence
of affective mental ill health such as anxiety and depression. This research supports that sensory
processing should be considered within an OT’s assessment.
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Research using sensory integration have used occupation based measures to demonstrate the impact of
sensory challenges on function and the impact of ASI on occupational performance and participation
(Miller, 2007 et al, Pfeiffer et al 2011, Schaaf et al, 2013)
Data Driven Decision Making as recommended in The Clinician Guide for Implementing Ayres Sensory
Integration (Schaaf & Mailloux, 2015) provides a framework for reasoning through the occupational therapy
process with a focus on utilization of data to guide and measure outcomes:
1. Identify participation challenges and goals
2. Describe the current level of function.
3. Identify factors that may interfere with participation
4. Conduct standardized and systematic assessments.
5. Identify strengths and barriers to participation.
6. Generate specific hypotheses regarding the factors that affect successful participation
7. Design the intervention.
This model emphasises the importance and focus of occupation with in a sensory integration
assessment/evaluation. SI therapy is based on principles of neuroplasticity SI can also address activity and
participation by adapting the sensory properties of a task and environments to accommodate sensory
processing challenges (WHO,2001)
Section 6: Where is ‘sensory’ placed in occupational therapy interventions?
'Controversy exists as to the definition of what constitutes interventions to dress sensory needs'
This controversy stems from systematic reviews which have ignored issues of fidelity and dosage and have
not clearly differentiated Sensory Integration Therapy from other approaches, therefore concluding that
Sensory integration therapy is ineffective. This briefing makes reference to Lang et al (2012) whose review
actually showed that all 14 of the sensory-related interventions that produced negative results failed to
reflect sensory integration therapy as it is typically performed. Therefore the studies included in Lang’s
paper do not fairly address the question of whether SIT is effective.
'Bottom up approaches apply specific techniques in isolation or out of the occupational context' and
'Sensory base interventions do not directly address a person's occupational performance in daily life
occupations'
Sensory Based Intervention are typically designed to influence the child's state of arousal with goals such
as improved self-regulation and related behavioural outcomes. Does self-regulation not enable
occupational participation and also improve occupational performance?
6.1.1 Ayres Sensory Integration Intervention (ASI)
'Intention is to change the person's sensory processing through intensive input'
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This statement is not referenced, the term intensive is not defined and the premise of SIT is not to provide
'Input' as this would suggest the therapy is done to the individual. “The aim of using a sensory integration
approach is to improve the efficiency of the nervous system in interpreting sensory information for
functional use” Parham & Mailloux (2010)
“SIT uses play activities and sensory-enhanced interactions to elicit the child's adaptive responses “(CaseSmith, 2014).
“The therapist creates activities that engage the child's participation and challenges the child's sensory
processing and motor planning skills” (Parham & Mailloux, 2010)
“The goal of SIT is to increase the child's ability to integrate sensory information, thereby demonstrating
more organised and adaptive behaviours” (Baranek, 2002)
The fidelity measure has 10 essential elements including collaboration with the child on activity choices and
supporting the child's intrinsic motivation to play. Both of which would contradict the term ‘input’ used in the
briefing.
SIT is not solely based in the clinics. It also includes reframing the child's behaviour using a sensory
processing perspective, linking sensory processing to challenging behaviours (Parham & Mailloux, 2010).
Modifying the child's environment or routines to support self-regulation and promote balance of activity
(Case-Smith, 2014) all come within the fidelity measure for Ayre’s SI.
'Post graduate training is necessary; experience and supervision recommended'
This point again is not referenced; however this is one of the structural elements of the fidelity measure.
Post professional training in sensory integration-certification in SI/SITP and minimum of 50 hours in SI
theory and practice e.g. post professional SI or SIP certification or university course (Parham et al, 2011).
The fidelity measure is now taught within the UK requiring that therapists who provide ASI are suitably
qualified.
'In an attempt to evaluate the effectiveness of ASI, Parham et al (2011) outline criteria which they
proposed should be used in order to be described as ASI'
This briefing has failed to refer to a more recent publication by May-Benson et al (2014). Results of this
study show that the structural section of the ASIFM, along with the process section (Parham et al., 2011), is
reliable and valid for use in effectiveness studies to ensure that interventions claiming to provide OT–SI are
congruent with the underlying principles of this intervention. Moreover, the structural elements identified in
the ASI Fidelity Measure may provide a tool to guide therapists who intend to provide OT–SI so that they
can acquire the necessary professional qualifications, provide comprehensive evaluations, engage in active
collaboration with families and other professionals, and deliver the intervention in a safe and adequately
equipped therapeutic space.
There is also now available the text 'Introduction to Ayes SI Guidebook for Children with Autism' (Roseann
C. Schaaf & Zoe Mailloux, 2015).
Research into the effectiveness of ASI to date is inconclusive...'
Other examples of intervention studies for sensory difficulties such as those relating to sensorimotor
interventions have similar methodological flaws such as varied research designs and outcome measures
therefore limiting the generalisation of the findings. All studies examined in Polatajko & Cantin’s (2010)
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review highlighted the need for well-designed studies exploring the efficacy of well-defined interventions
with homogenous populations, in order to link specific outcomes to specific interventions. The evidence
base for SI is addressing these recommendations in the most recent research and demonstrating positive
outcomes.
SI therapy has been criticised for being no more effective than other interventions for children with ASD
(Lang, 2012). However, Jane Case Smith (2014) in her systematic review has provided a more
comprehensive exploration and critique of the existing research. Her synthesis of the research evidence
suggests that the SI approach may result in positive outcomes in the areas of sensori-motor skills and
motor planning, socialisation, attention, behavioural regulation, reading and reading related skills. SI has
shown to have better outcomes than those associated with the no treatment groups in many studies and
was just as effective than alternative treatments such as perceptual motor and tutoring/academic based
(May Benson & Koomar 2010 and Pfeiffer, 2011 ). To note an intervention that is ‘as effective’ as other
interventions does not mean it is ineffective.
Fazlioglu and Baran(2008) were referenced as completing an RCT within the Ayres SI section. This is
incorrectly located within the brief as Fazlioglu & Baran (2008) used sensory diets with children with ASD
as part of their RCT.
'The small sample size, variable intervention dosage, lack of fidelity to intervention, selection of
outcomes which are not meaningful to the person and limited results on standardised outcome
measures, limit the usability of the finding’
This statement does not reflect the more recent research published which attempts to address the
methodological flaws often highlighted in regards to efficacy studies using SIT.
Schaaf’s (2013) RCT has addressed many of the limitations previously acknowledged in the research
methodology in SI. The study shows high rigor in its measurement of the treatment fidelity and use of a
manualised protocol. GAS was able to capture change in function/participation that may be linked to
changes in sensory processing as a result of the intervention. This study supports more recent thinking that
short bursts with high intensity (2 to 3 sessions/ week for 6-10 weeks) can provide significant results. The
children receiving ASI scored significantly better on measures of caregiver assistance in self care
(p=.008,d=0.9) and socialisation (p=.04, d=0.7).
Goal Attainment Scaling is a standardised way to capture the diversity of meaningful and functional
outcome which are individualised for the child and the families (Kiresuk & Sherman, 1968). This contradicts
the comment that outcomes of Ayre’s SI therapy are not meaningful or standardised. Many of the goals
within this study were occupation based, including self-care, play, participation in daily routines, sleep and
meal preparation.
6.1.2 Sensory Based Interventions
Sensory Based interventions should be clearly differentiated from Ayres SI as they do not reflect the theory
of SI and do not adhere to the fidelity of ASI. These sensory-based techniques usually provide passive
sensation to one sensory system rather than the holistic, child-directed, playful approach contextualised
within a professional framework that is the hallmark of the SI approach (Schaaf & Mailloux, 2015)
'Sensory-based interventions do not directly address a person's occupational performance in daily
life occupations''
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This is however a generalising statement. Therapy ball’s have been shown to have a positive effect on in
seat behaviour for children who have the most extreme vestibular-proprioceptive seeking behaviours,
however those with poor postural stability were less engaged (Bagatelle, 2010). This study highlights the
importance of accurate assessment and recommendation of appropriate sensory based interventions. It is
also demonstrates positive impact on a child’s occupational participation (engagement in school work).
Results from a recent study by Reynolds, Lane & Mullen (2015) showed that wearing a ‘Vayu Vest’ which
provided deep pressure stimulation for even short periods of time reduced sympathetic arousal and non–
stimulus-driven electrical occurrences. Concomitant increases in parasympathetic arousal were found.
Performance improvements were noted after wearing the Vayu Vest, potentially because of changes in
arousal. The study concluded that deep pressure stimulation is capable of eliciting changes in autonomic
arousal and may be a useful modality in diagnostic groups seen by occupational therapy practitioners.
Despite one study’s findings suggesting weighted blankets had no significant effect on sleep the subjective
findings from the sample group showed that parents and children preferred the weighted blankets to the
placebo blanket and requested to keep them. Deep pressure has been hypothesised to have a calming
effect on people with ASD, especially those with high levels of arousal and anxiety. They have been used in
acute mental health care settings and have been found to provide feelings of safety, relaxation and comfort
to those using them (Mulligan, Champagne & Krishnamurthy, 2008). Ruling out an intervention based on
one study is not advised. The results of a research study will only be based on the outcome measures they
selected and the hypothesis they were testing. This will not capture other outcomes which may have
occurred yet may not have been measured. Again, ignoring the reports of service users is not advised. As
therapists and in research it is important to be aware of changes that occur that are not being measured,
the consequential outcomes that are often overlooked such as the individual’s quality of life or their stress
levels.
'Effectiveness of these sensory-based interventions into sensory diets is also limited and or low
quality' (e.g Devlin et al, 2011; Fazlioglu & Baran, 2008)
The first of these references does not appear in the reference list. This statement misrepresents the
findings of this study. The sample group were not assessed using a measure of sensory
processing/responsivity and the intervention was designed independent of the results of any functional
assessments completed. Not completing an assessment contradicts what is recommended in Ayres SI
which requires that therapists engage in a data driven decision making process in terms of the assessment,
goals and the intervention for each service user. The intervention title Sensory Integration Therapy would
not comply with the fidelity measure, the treatment phase was over 10 days and only 4 of these days used
SI, therefore less frequent than in the studies which showed good results. The study investigated the
impact of the 2 interventions on challenging behaviours displayed by the children, however, there were no
sensory basis proposed for the presentation of these behaviours, therefore no justification for the use of
sensory integration therapy.
The second reference again is misrepresented in terms of the study’s findings. Their findings showed
statistically significant differences between the control group and the Sensory Integration Therapy group,
indicating that a SI therapy program positively affected treated children.
6.2 Performance –Orientated approaches
Again the key points in this section are not referenced.
It would be again useful to differentiate Ayres SI to Sensory strategies. These are based on SI theory but
do not meet the fidelity criteria of Ayres SI.
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Additional evidence has been omitted from this briefing supporting the use of sensory strategies. The
results of 3 studies addressing consultation as an intervention have been deemed to be ‘particularly
promising’ (Polatjajko & Cantin, 2010).
7.0 Summary and implications
Within this summary Ayres SI and sensory-based strategies have misleadingly been put together. This
needs to be separated as they are not the same. Segal and Beyer (2006) are referring to the
Therapressure/Willbarger Approach not Ayres SI, yet this has been put together and referred to as
burdensome.
Since 2011 there have been over 700 professionals completing SI one ‘Foundations in Neuroscience’ and
over 500 therapists have gained their SI Practitioners status. A therapist with increased knowledge of the SI
framework may draw on their greater understanding of sensation to develop innovative therapy
programmes for a diverse range of clients/populations in order to support engagement in meaningful
activities (Watling, 2011).
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