The Efficacy of Sensory Integration Therapy on Children With Asperger's Syndrome and Pdd-nos

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THE EFFICACY OF SENSORY INTEGRATION THERAPY

ON CHILDREN WITH ASPERGER’S SYNDROME AND

PERVASIVE DEVELOPMENTAL DISORDER – NOT OTHERWISE SPECIFIED

by

Kristen Renee Klyczek

May 4, 2009

A dissertation submitted to the

Faculty of the Graduate School of

the University at Buffalo, State University of New Yorkin partial fulfillment of the requirements for the

degree of

Doctor of Philosophy

Department of Rehabilitation Science

School of Public Health and Health Professions



UMI Number: 3356047

Copyright 2009 byKlyczek, Kristen Renee

All rights reserved

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The Efficacy of Sensory Integration Therapy

ii

Copyright byKristen Renee Klyczek

2009




iii

Acknowledgement

I would like to offer my thanks and gratitude to so many people who have helped

me achieve this goal. First, I would like to thank my husband Mark for his unending

support and dedication to helping me see this through to the end. I never thought we

would get here, but with your help and with many sacrifices along the way, we made it! I

would also like to thank my two beautiful miracles, Andrew and Allison, for allowing

Mommy to spend long hours away from them. I look forward to many years of “making

it up to you”. To our families, I cannot tell you how much I appreciate all that you have

done for me and for our family over the years. I would not be where I am today if not for

your support. I am truly blessed to have you in my life.

Many people were directly involved in helping me with this process. I would like to

thank my dissertation committee members, Dr. Linda Shriber, Dr. Geralyn Timler and

Dr. Diane Wrisley for your patience throughout the many twists and turns of this process,

for your constant belief in me, and for the many lessons you have taught me along the

way. You have been a pleasure to work with and I look forward to working with each of

you as colleagues. I would also like to thank the Occupational Therapy and Physical

Therapy Departments, as well as the Department of Rehabilitation Science at the

University at Buffalo, for your support and for the generous use of your equipment and

facilities. Dr. Patricia Ohtake, you have helped me see the bigger picture, you have seen

something in me that I couldn’t see myself, and you have had a remarkable influence on

my life - thank you. I would also like to thank the faculty at Daemen College for your

support so many years ago, and for your support now, as I stand on the other side of the

podium. I am honored to be a part of your team! I am also grateful to those who have




iv

assisted me in the research process including Kristen Mayrose, Cathy Buyea and the

beautiful children and their families. It was you who made this dream a reality!

Additionally, I would like to express my gratitude to the Mark Diamond Research Fund

for providing funding for this exciting research study.

Finally, to my friends, old and new who have been with me along this journey, I

thank you. Whether it was you who encouraged me to do this, you whose path crossed

mine along the way, or you who stuck with me even when I was too busy to be much of a

friend, I thank you for your role in my life and wish you all the best. I am standing at the

end of a very long road. I am proud of where I have been, but I am so excited about

where I am going. Thank you for being with me along the way!




v

Table of Contents

Acknowledgement…………………………………………………………………… iii

Table of Contents…………………………………………………………………….. v

List of Tables………………………………………………………………………… viii

List of Figures………………………………………………………………………... ixList of Appendices…………………………………………………………………… x

Abstract………………………………………………………………………….…… xi

I. INTRODUCTION………………………………………………………………… 1

Hypothesis………………………………………………………………………….... 4 Conceptual Framework…………………………………………………………… 5

Neuropathophysiology of Asperger’s Syndrome and Pervasive

Developmental Disorder – Not Otherwise Specified…………………………. 5

Sensory Integration…………………………………………..………………... 14

Sensory Dysfunction…………………………………………………………... 20 Sensory Integration Therapy……………………………………….…………. 23

Summary………………………………………………………………………….. 25

II. LITERATURE REVIEW………………………………………………………… 27

Characteristics of Children with Asperger’s Syndrome and Pervasive

Developmental Disorder – Not Otherwise Specified…………………………….. 27

Motor Skills of Children with Asperger’s Syndrome and PervasiveDevelopmental Disorder – Not Otherwise Specified…………………………….. 31

Sensory Processing in Children with Asperger’s Syndrome and PervasiveDevelopmental Disorder – Not Otherwise Specified……….……………………. 36

The Effectiveness of Sensory Integration Therapy………………………………. 43

Summary………………………………………………………………………….. 48

III. METHODS……………………………………………………............................. 51

Introduction………………………………………………………..……………... 51 Setting…………………………………………………………………………….. 51

Participants……………………………………………………………………….. 52

Human Subject Protection………………………………………………………... 54 Study Design……………………………………………………………………… 56

Instrumentation…………………………………………………………………… 56

Pre-Study Questionnaire………………………………………………………. 56 The Asperger Syndrome Diagnostic Scale……………………………………. 57

The Sensory Profile………………………………………………………….... 58

Perceived Efficacy and Goal Setting System………………………………..... 60

Clinical Observations…………………………………………………………. 61 The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition………... 62

Sensory Integration and Praxis Tests…………………………………….......... 63




vi

Procedures………………………………………………………………………... 66

Data Analysis……………………………………………………………………... 72 Use of Data Collected…………………………………………………………….. 74

IV. RESULTS………………………………………………………………………... 75

Introduction………………………………………………………………………. 75

Recruitment………………………………………………………………..……... 75

Demographics………………………………………………...…………………... 76 Services…………………………………………………………………………… 77

Attrition……………………………………………………………………….….. 77

Pre-Intervention Findings………………………………………………………… 78 The Asperger Syndrome Diagnostic Scale…………………………………..... 78

Sensory Profile………………………………………………………………... 81

Perceived Efficacy and Goal Setting System………………………………..... 87

Clinical Observations………………………………………………………..... 87

Bruininks-Oseretsky Test of Motor Proficiency, Second Edition……...……... 90 Sensory Integration and Praxis Tests…………………………………….......... 91

Post-Intervention Findings……………………………………………………….. 94 Interrater Reliability…………………………………………………………... 94

The Asperger Syndrome Diagnostic Scale…………………………...……….. 95

Sensory Processing……………………………………………………………. 98 Sensory Integration and Praxis Tests……………………………...…………... 105

Motor Skill Performance……………………………………………………… 110

Clinical Observations…………………………………………………………. 115 Treatment Fidelity………………………………………………………............... 117

Summary of Results………………………………………………………………. 117

V. DISCUSSION…………………………………………………………………….. 119

Introduction………………………………………………………………………. 119 Relationship of the Results to the Stated Hypotheses……………………………. 120

Relationship of the Results to the Conceptual Framework………………………. 134

Summary of Conceptual Framework……………………………………………... 145 Relationship of the Results to the Literature……………………………………... 145

Recruitment………………………………………………………………………. 146

Sensory Processing……………………………………………………………….. 147 Motor Skill Performance……………………………………………….………… 151

The Efficacy of Sensory Integration Therapy……………………….…………… 156

Additional Findings……………………………………………………...………. 161 Behavioral Changes…………………………………………………………… 161

Findings Related to The Asperger Syndrome Diagnostic Scale………………. 163

Findings Related to The Perceived Efficacy and Goal Setting System……….. 164

Findings Related to Clinical Observations……………………..…................... 167 Strengths and Limitations…………………………………………..……….......... 168

Implications for Practice………………………………………..………………… 172




viii

List of Tables

Table 1. Mean Scores and Percentage of Recruited Participants Scoring

Above the Fiftieth Percentile on the Asperger Syndrome Diagnostic

Scale Indicating Impairments in the Given Subcategory……………. 81

Table 2. Percentage of Participants Scoring in the Probably Different or

Definitely Different Categories on Sensory Profile Factors

Indicating Impaired SensoryProcessing……………………………………………………………. 83

Table 3. Percentage of Participants Scoring in the Probably Different orDefinitely Different Categories on Sensory Profile Sections

Indicating Impaired Sensory

Processing……………………............................................................. 84

Table 4. Percentage of Participants Whose Bruininks Oseretsky Test ofMotor Proficiency (BOT-2) Composite Scores Fell At or Below the

Eighteenth Percentile Compared to Normative Data IndicatingImpaired Motor Skills……………………………………………….. 91

Table 5. Percentage of Participants Scoring Below One Standard DeviationFrom the Mean on the SIPT Subtests Based on a Normative Sample

of Children…………………………………………………………… 93

Table 6. Summary of Mean Scores and Repeated Measures ANOVA for

Asperger Syndrome Diagnostic ScaleVariables………………………………………………………….….. 96


Sensory Profile Factors……………………………………………… 99


Sensory Profile Sections……………………………………………... 101


Sensory Integration and Praxis Test Subtests……………………….. 106


Bruininks Oseretsky Test of Motor Proficiency – Second EditionSubtests………………………………………………………………. 111


Clinical Observations……………………………………………....... 116

Table 12. Summary Table of Impairments and Areas of Improvement………... 118




ix

List of Figures

Figure 1. Percentage of Participants Whose ASDS Scores Were Above the

Fiftieth Percentile……………………………………………………. 80

Figure 2. Percentage of Participants Rated as Having Definite Differences

from the Normative Sample on Sensory Profile Factors…………….. 86

Figure 3. Percentage of Participants Rated as Having Definite Differences

from the Normative Sample on Sensory Profile Sections…………… 86

Figure 4. Percentage of Participants Impaired on Selected Clinical

Observations…………………………………………………………. 89

Figure 5. Mean Scores on Selected SIPT Items at Pretest, Midtest and

Posttest………………………………………………………………. 105




x

List of Appendices

Appendix A: Approval from the Institutional Review Board…………………... 199

Appendix B: Sample Request for Support in Recruitment Procedures…………. 201

Appendix C: Letters of Support for Recruitment Procedures…………………... 203

Appendix D: Radio and Written Advertisements……………………………….. 207

Appendix E: Parent Information Letter and Invitation…………………………. 210

Appendix F: Parent Informed Consent Form…………………………………… 212

Appendix G: Child’s Assent Form……………………………………………… 217

Appendix H: Pre-Study Questionnaire………………………………………….. 220

Appendix I: Asperger Syndrome Diagnostic Scale Sample Items…………….. 224

Appendix J: Sensory Profile Caregiver Questionnaire Sample Items………….. 226

Appendix K: Perceived Efficacy and Goal Setting System Sample Items……… 228

Appendix L: Clinical Observations Documentation Form……………………... 230

Appendix M: Clinical Observations Worksheet...………………………………. 234

Appendix N: Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Sample Items… …………………………………………………... 238

Appendix O: Sensory Integration and Praxis Tests Descriptions and

Examples………………………………………………………….. 241

Appendix P: Description of the Sensory Integration and Praxis Tests for

Parents…………………………………………………………….. 244

Appendix Q: Request For Assistance in Test Administration of Participants …. 247

Appendix R: Treatment Manual………………………………………………… 249

Appendix S: Therapy Session Progress Note and Checklist …………………... 264




xi

Abstract

This research study evaluated the sensory and motor skills of a group of children with

Asperger’s Syndrome (AS) and Pervasive Developmental Disorder – Not Otherwise

Specified (PDD-NOS). It also examined the efficacy of a 10-week intervention using

sensory integration therapy. In a one-group, pretest-posttest design with a delayed

treatment approach, nine children were assessed using the Asperger Syndrome

Diagnostic Scale, the Perceived Efficacy and Goal Setting System, Clinical Observations,

the Sensory Profile, the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

and the Sensory Integration and Praxis Tests. Testing was repeated after a five-week

baseline phase during which children and families followed their normal daily routines.

Next, sensory integration therapy was provided twice a week for 10 weeks. A treatment

manual provided treatment options that could be used based on individual client needs.

The tests were repeated after the intervention period and results were analyzed using

repeated measures ANOVA. Prior to intervention, all children were identified as having

sensory and motor impairments that were greater than typically developing children,

particularly in the areas of sensory processing, inattention, distractibility, sensory

modulation, emotional and behavioral responses to sensory input, coordination, praxis

and standing and walking balance. Six children completed the study. Following

intervention, significant improvements were identified in sensory processing, modulation

of sensory input, praxis and balance compared to pre-intervention findings. This

provides preliminary quantitative evidence that sensory integration therapy may be a

useful strategy to improve the sensory and motor skills that are identified in children with

AS and PDD-NOS.



The Efficacy of Sensory Integration Therapy 1

Autism Spectrum Disorders, including Asperger’s Syndrome (AS) and Pervasive

Developmental Disorder – Not Otherwise Specified (PDD-NOS), have recently become a

topic of considerable interest among pediatric health care providers (Gillberg, 2002,

2004; Newschaffer & Kresch Curran, 2003). Prior to its introduction into the Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] (American

Psychiatric Association, 1994), little was known or published about AS, a pervasive

developmental disorder named after Hans Asperger some 60 years ago (Gillberg, 1998).

It wasn’t until the 1980s that the first clinical accounts of AS based on descriptions of

Asperger’s patients were reviewed and discussed. This was followed in 1991 by the

paper becoming available in English in a translated version (Frith, 1991). Similarly,

changes in the DSM-IV criteria have lead to increased recognition of PDD-NOS as a

diagnosis (Newschaffer & Kresch Curran, 2003). As a result of increased awareness of

these disorders, the past 20 years have seen a tremendous rise in the use and classification

of AS, PDD-NOS, and autism spectrum disorders in general. (Klin & Volkmar, 2003c;

Miller-Kuhaneck, 2004; Newschaffer & Kresch Curran, 2003; Szatmari et al., 2000).

This has encouraged both clinicians and researchers to seek answers regarding the

etiology, the most appropriate diagnostic criteria, and the most effective intervention

techniques for persons with autism spectrum disorders.

Asperger’s Syndrome is a pervasive developmental disorder (PDD) which falls on

the autism spectrum; a continuum of social and communicative disorders ranging in

severity from mild to severe (D. R. Walker et al., 2004). Other PDDs include Autism,

Rett’s Syndrome and Childhood Disintegrative Disorder, along with Pervasive

Developmental Disorder – Not Otherwise Specified (PDD-NOS), which often acts as a




“catchall diagnosis for children who do not fit the criteria for one of the other[s]” (D. R.

Walker et al., 2004, p. 172). Asperger’s Syndrome has been described by some as being

on the mild side of the autism spectrum (Frith, 2004). Others argue that AS is

synonymous with other PDDs, such as high functioning autism and PDD-NOS (Klin,

2003; Klin & Volkmar, 2003a; F. Volkmar & Lord, 2007; F. E. Volkmar, 2007). Key

diagnostic features of AS include impairments in social interaction, restricted repetitive

and stereotyped behaviors, and impaired social or occupational functioning (American

Psychiatric Association, 2000). A child with AS is able to interact with others, however

his or her interactions are usually odd and one-sided. Children with AS often have

difficulty following the unspoken social rules of society, such as keeping a certain

distance from others, making eye contact, taking turns during a conversation, and taking

an interest in what someone else is saying. Additional symptoms include being clumsy

and poorly coordinated resulting in impaired gross and fine motor skills, and exhibiting

abnormal responses to sensory experiences (American Psychiatric Association, 1994;

Baranek, Foster, & Berkson, 1997; Case-Smith & Miller, 1999; Church, Alisanski, &

Amanullah, 2000; Dunn, Smith Myles, & Orr, 2002; Frith, 1991; Ghaziuddin, Butler,

Tsai, & Ghaziuddin, 1994; Gillberg, 2002; Miller-Kuhaneck, 2004; Miyahara et al.,

1997; Weimer, Schatz, Lincoln, Ballantyne, & Trauner, 2001).

A diagnosis of PDD-NOS is given to individuals who have symptoms similar to

those of other specific PDDs (ie. Autism, AS) but do not meet all of the diagnostic

criteria specifically. The Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition –Text Revision [DSM-IV-TR] (American Psychological Association, 2000) offers

no specific criteria for diagnosing PDD-NOS, except to say that this diagnosis should be




used when impaired social interaction is identified, but the individual is excluded from all

other PDD diagnoses (American Psychiatric Association, 1994). Khouzam and

colleagues (2004) point out that the diagnostic criteria for AS varies as to the nature and

severity of associated symptoms. This variability can make it difficult to distinguish

between AS and PDD-NOS (Klin & Volkmar, 1997; D. Walker et al., 2004). Since

PDD-NOS is a diagnosis of exclusion, reserved for those individuals who do not

precisely meet the diagnostic criteria for a specific disorder, and the most appropriate

criteria for a diagnosis of AS continue to be debated (Klin & Volkmar, 2003b), it is

reasonable to hypothesize that at least some individuals who meet most of the AS criteria,

but fall short in one area or another, are given a more generic diagnosis of PDD-NOS. In

fact, difficulty differentiating between AS and PDD-NOS has caused some clinicians to

use the two interchangeably (Klin, 2003; Klin & Volkmar, 2003a; F. Volkmar & Lord,

2007; D. Walker et al., 2004).

The sensory and motor skill difficulties identified in AS have also been identified

in other autism spectrum disorders (ASDs) (I. M. Smith, 2000; Watling, Dietz, & White,

2001). Evidence suggests that these additional symptoms may be related, however

published research regarding the sensory and motor impairments remains relatively

limited, and research on the treatment of these impairments in children with ASDs is

scarce (Kaplan, Polatajko, Wilson, & Faris, 1993). Sensory Integration (SI) therapy is

one treatment technique used by physical therapists and occupational therapists to

address sensory and motor deficits. Despite anecdotal evidence and many small-scale

studies reporting its effectiveness, few rigorous and well conducted studies have been

performed to support its use (Kaplan et al., 1993; Law, Polatajko, Schaffer, Miller, &




Macnab, 1991; Polatajko, Law, Miller, Schaffer, & Macnab, 1991; Wilson & Kaplan,

1994). Therefore, there is a need to study the effectiveness of SI on various populations

of children with disabilities. This study will evaluate the sensory and motor impairments

observed in children with AS and PDD-NOS, and will assess the effectiveness of SI

therapy on improving the sensory and motor skills of a sample of children who have

these disorders.

The primary objective of this study was to evaluate the assessment and

intervention procedures utilized for the evaluation and treatment of children with ASDs,

specifically AS and PDD-NOS. The specific purposes of this study were: (a) to quantify

the sensory and motor impairments observed in children with AS and PDD-NOS (b) to

determine if children with AS and PDD-NOS demonstrate changes in sensory processing

following SI intervention, and (c) to determine if children with AS and PDD-NOS

demonstrate changes in motor function following SI intervention.

Hypotheses

The hypotheses for this study are that (a) children with AS and PDD-NOS will

demonstrate sensory and motor impairments when compared to normative samples, as

identified on the Sensory Profile, the Sensory Integration and Praxis Tests and the

Bruininks-Oseretsky Test of Motor Proficiency; (b) parents will report an improvement

in the children’s sensory modulation and integration, and the children will exhibit

improved sensory processing following SI therapy as demonstrated by scores on the

Sensory Profile and the Sensory Integration and Praxis Tests, and (c) children will

demonstrate improved motor performance following SI therapy as demonstrated by

higher scores on the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition.




Conceptual Framework

This study is based on the belief that the sensory and motor symptoms

experienced by children with AS and PDD-NOS are the result of abnormalities within the

nervous system. It is also based on the theory of Sensory Integration which provides a

framework for understanding sensory processing dysfunction and for the SI treatment

approach which is described as preparing the body for purposeful interaction with the

environment.

Neuropathophysiology of Asperger’s Syndrome and Pervasive Developmental

Disorder – Not Otherwise Specified. Literature on the neuropathology of AS and other

related ASDs has identified several structures within the nervous system which seem to

play a role in the physical manifestations of these syndromes. Many researchers have

studied ASDs as a group, therefore, their findings can be considered relevant to a

discussion about the neuropathology of AS or PDD-NOS, as some of the features are

similar. No studies have been identified which examined the nervous systems of persons

with PDD-NOS specifically, and few studies have examined the specific characteristics

associated with PDD-NOS, therefore, because of the similarities in the diagnoses, and the

belief that both AS and PDD-NOS are part of a broader autism spectrum, generalizations

are made that include PDD-NOS in a discussion of the neuropathophysiology. It should

also be noted, that at this time the neurological findings seem to be inconsistent, so

definitive answers regarding the exact location of involvement of structures of the central

nervous system (CNS) in children with ASDs are tentative.

Several studies have implicated the brainstem as playing a role in the symptoms

of ASDs, including AS and PDD-NOS. Since the brainstem has connections to all parts




of the brain, abnormalities here may account for the attention and sensory processing

deficits seen in children with ASDs (Huebner, 1992). In addition, the stereotypic

behaviors often seen in children with PDDs, and soft neurological signs, such as

difficulties with balance, finger-thumb opposition, and tactile discrimination, as well as

incoordination and inadequate sound production, implicate brainstem involvement

(Huebner, 1992; Jones & Prior, 1985). Developmental abnormalities and an altered

inferior olive in the brainstem have been identified in children with autism (Bailey et al.,

1998; Palmen, van Engeland, Hof, & Schmitz, 2004). Auditory brainstem response

abnormalities, including prolonged intervals and abnormal individual waves, have also

been noted, which may result in characteristics associated with autism and AS

(Cederlund, 2004; Huebner, 1992). Since the brainstem is involved in the planning and

production of movement, and in integrating visual and vestibular information with

somatosensory inputs, (Kandel, Schwartz, & Jessell, 1991) it is possible that

abnormalities identified within the brainstem of persons with PDDs could account for the

motor delays identified in AS and PDDs. A prolonged postrotary nystagmus, which is

one indicator of how an individual processes vestibular input and which has been

identified in children with autism, may be related to deficient sensory habituation at the

level of the brainstem (Huebner, 1992).

The basal ganglia appears to play a major role in the sensory and motor symptoms

associated with AS and ASDs in general. It processes information for the planning of

movement, prepares the motor systems to act, forms movement commands and corrects

movement errors. It is therefore involved in praxis, which has been considered an area of

weakness in some children with AS and in PDDs in general. The basal ganglia receives




sensory input from the receptors throughout the nervous system, and influences all

sensorimotor activities. Damage in the basal ganglia may therefore be responsible for the

clumsy movement and sensory dysfunction of children with AS. Decreased movement

control, slow voluntary movements, increased involuntary movements, abnormal

postures and abnormal (increased) muscle tone have all been linked to lesions in the basal

ganglia (Kandel et al., 1991; Leonard, 1998; Zigmond, Bloom, Landis, Roberts, &

Squire, 1999). In addition, increased caudate volumes identified in individuals with

autism have been significantly correlated with overall, ritualistic, repetitive behaviors

when measured by the Autism Diagnostic Interview (Sears et al., 1999). A study done by

Minshew (2004) compared dynamic posturography results from child and adult subjects

with autism who did not have mental retardation to a control group. The subjects with

autism were noted to have delayed postural stability development and an underdeveloped

postural control system. This suggested to the researcher that there was basal ganglia

involvement consistent with an increased caudate volume (Minshew, Sung, Jones, &

Furman, 2004). Dysfunction of the basal ganglia has been linked to some of the clinical

symptoms of autism such as dystonia, motor disturbances, bradykinesia, hyperkinesias

and decreased social communication (Damasio & Maurer, 1978). Soft neurological

signs, such as choreiform movements, and difficulties with balance, finger-thumb

opposition and tactile discrimination (Jones & Prior, 1985), incoordination, and

inadequate speech production (Huebner, 1992) have also been linked to this structure.

Additionally, difficulty controlling the force of movement has been identified in children

who are identified as being clumsy, and who demonstrate these signs of basal ganglia

involvement (Lundy-Ekman, Ivry, Keele, & Woollacott, 1991).




The bulk of the neurological studies completed on subjects with AS has been on

the cerebellum. With extensive connections throughout the nervous system, the

cerebellum is involved in movement and has an effect on postural responses and

proximal stability. Difficulties processing information for planned movement, preparing

motor systems to act, forming commands for movement, and correcting errors can be

linked to a lesion in the cerebellum. Clinically, this may present as difficulty timing

coordinated joint movements, poor precision and control of limb movements, and

decreased coordination. Cerebellar abnormalities may also lead to decreased equilibrium,

an ataxic gait, a wide base of support, abnormal nystagmus, abnormal muscle tone, and

decreased use of vestibular information in an upright position (Kandel et al., 1991;

Leonard, 1998; McAlonan et al., 2002; Zigmond et al., 1999). Impairments such as

dysmetria and dysdiadokinesis have been related to cerebellar dysfunction in children

who are considered clumsy (Lundy-Ekman et al., 1991).

The cerebellum also plays a role in sensory modulation and feedback mechanisms

and has connections with the sensory systems, thus influencing head and eye movements,

body equilibrium, muscle use, visual tracking and the smooth progression between visual

movements. Studies have identified decreased purkinje cell numbers throughout the

cerebellar hemispheres of subjects with autism (Bailey et al., 1998; Huebner, 1992;

Palmen et al., 2004). Volume reductions in the grey matter of individuals with AS have

also been reported (Bailey et al., 1998; McAlonan et al., 2002). Huebner’s (1992) review

of autism literature reported smaller lobules within the cerebellum, decreased cerebellar

and neuronal size, increased cell density, agenesis of the cerebellar vermis and impaired

startle reflexes. A literature review by Blacher (2003) reported differences in cerebellar




regions between individuals with AS and high functioning autism (HFA), suggesting a

cerebellar link to the disorders.

Abnormalities in the limbic system have also been identified in subjects with

ASDs, particularly in the amygdala. The amygdala plays a role in autonomic responses,

emotional behaviors, and learning requiring coordination of different sensory modalities.

The limbic system also “plays an important role in sensorimotor gating… [and is used] to

suppress motor responses to irrelevant stimuli” (McAlonan et al., 2002, p. 1595). These

processes are deeply involved in the initial stages of the SI process, in which stimuli from

the self and the environment must first be recognized. The system must then determine

what to attend to and how to respond. Increased cell packing in the hippocampus and the

amygdala and a very simple dendrite pattern have been identified in children with autism

(Palmen et al., 2004). In 1999, a functional Magnetic Resonance Imaging (MRI) study

for persons with HFA or AS, found no amygdala activation in subjects with AS during

decoding of the emotional expressions of others (Baron-Cohen et al., 1999). In addition,

Haznedar and colleagues (2000) noted that the left amygdala was larger in the subjects

with AS compared to those with autism, and the increased size was associated with lower

non-verbal communication scores on the Autism Diagnostic Interview. In all of the

subjects with ASD, increased amygdala volume was correlated with a decreased number

of words remembered (Haznedar et al., 2000). In addition, small neurons and increased

cell density in various structures of the limbic system including the amygdala have also

been identified (Huebner, 1992).

The anterior cingulate, with connections to much of the cerebral cortex, has been

determined to be involved in initiating voluntary behavior and movement, and in the




execution of action (Zigmond et al., 1999). Lesions of the anterior cingulate may result

in apathy and inability to express affect, which is a known problem for children with

ASDs (Kandel et al., 1991; Rinehart, Bradshaw, Brereton, & Tonge, 2001). Palmen’s

(2004) review of the neuropathological findings in autism noted findings of coarse and

poorly laminated anterior cingulate cortices. Haznedar’s (2000) study of MRI and PET

scans for ASDs, including AS, identified the right anterior cingulate, Brodmann’s area,

and the entire cingulate cortex to be smaller. In addition, Haznedar (2000) noted

decreased glucose metabolism in the cingulate gyri in ASDs, with both sides affected in

AS and only the right side affected in autism. The results of Minshew’s (2004) dynamic

posturography study noted decreased anterior cingulate volume and suggest involvement

of the anterior cingulate region, which is consistent with findings of parkinsonian faces

and decreased initiation of movement. Grey matter deficits in this area were noted by

McAlonan (2002) during a comparison study of MRI and sensorimotor gating in AS.

Finally, Rinehart (2001) assessed movement preparation and movement execution in AS

and autism and determined that both groups had a deficits in movement preparation.

Rinehart concluded that poorly planned movement may explain the clumsiness noted in

AS, implicating the anterior cingulate.

The cerebrum is the highest functioning portion of the brain, with various parts of

it involved in motor planning, task preparation and execution, bilateral motor

coordination, muscle control, posture and voluntary movement (Kandel et al., 1991;

Leonard, 1998; Zigmond et al., 1999). Abnormalities in the cerebrum of individuals with

ASDs have been detected by several researchers (Bailey et al., 1998; Berthier, Starkstein,

& Leiguarda, 1990; Lotspeich et al., 2004; Palmen et al., 2004). Among the findings in




individuals with autism are cortical dysgenesis, a thick cortex and migration

abnormalities (Palmen et al., 2004) and developmental cortical abnormalities (Bailey et

al., 1998). Abnormal cortical gyration bilaterally, and cortical dysplasia, which may

mark abnormal cortical organization and connectivity, have been identified in persons

with AS (Berthier et al., 1990). Lotspiech (2004) performed a case control MRI study on

children and adolescents with and without ASDs, and identified the mean cerebral grey

matter volume among subjects with AS to fall between subjects with autism and controls,

suggesting a true spectrum of disorders. In addition, Lotspiech (2004) noted increased

performance IQ scores associated with increased grey matter volumes in the group with

AS as well as a correlation between performance IQ scores and cerebral white tissue

volume. Rinehart (2001) assessed movement preparation and execution in AS and

autism on a motor reprogramming task and determined both groups deficits in movement

preparation, rather than performance, suggesting supplementary motor cortex

involvement, due to difficulty internally initiating or generating a motor program.

Murphy’s (2002) in vivo magnetic resonance spectroscopy study noted

significantly increased prefrontal lobe concentrations of N-acetylaspartate, creatine and

phosphocreatine and choline ( p=0.002, 0.03, 0.003, respectively). This correlated

significantly ( p=0.005) with the severity of obsessive or ritualistic behaviors in a group

with AS, as well as significant correlations ( p=0.02) between social impairments on the

Autism Diagnostic Interview - revised and the concentration of choline in the frontal lobe.

These findings suggest a metabolic difference in the prefrontal lobe of children within the

autistic spectrum (Murphy et al., 2002). A review of AS and HFA literature (Blacher,

Kraemer, & Schalow, 2003) identified increased prefrontal lobe metabolic concentrations




and decreased activation of the medial prefrontal cortex, as well as abnormal oculomotor

functions which suggest evidence of prefrontal cortex involvement. Cederlund (2004)

determined that 6 out of 15 male subjects with AS had hypoperfusion of the frontal lobe.

Among other findings, McAlonan’s (2002) study of adult subjects with AS, found

decreased grey matter volume in the frontal lobe, and left sided white matter frontal lobe

deficits. He concluded that frontostriatal alterations resulted in a startle response that was

not correctly modulated by the preceding stimulus, and suggested that medial frontal lobe

dysfunction results in the clinical symptoms of autism including motor disturbances,

dystonia, brady and hyperkinesias and decreased social communication. In her review of

neuropathological literature of ASDs, Huebner (1992) suggested that frontal lobe

dysfunction may result in stereotyped behaviors, and decreased selective attention. Using

Positron Emission Tomography (PET) in nonhuman primates, Schneider and colleagues

(2007) determined that increased tactile sensitivities, and an exaggerated withdrawal

response were associated with increased neurotransmitter binding in the striatum and

frontal cortex (Schneider et al., 2007).

The parietal lobe may also be involved in individuals with autism spectrum

disorders such as AS and PDD-NOS. This lobe is involved in spatial function, visual

discrimination, and recognizing both sides of the body (Zigmond et al., 1999) and

integrates sensory and motor components of directed attention (Huebner, 1992).

Huebner’s (1992) literature review of the neuropsychology of autistic disorder has noted

differences in the parietal lobe, which affects selective attention, and may affect bilateral

coordination, vision and spatial awareness.




Blacher (2003) reviewed AS and HFA literature and associated AS more with

right hemisphere dysfunction. This was due to abnormal minicolumnar organization

being detected in some parts of the right hemisphere. These findings support the findings

of Klin, Volkmar, Sparrow, Cicchetti, and Rourke (1995), who found a high degree of

concordance between AS and nonverbal learning disorders, which has already been

associated with right hemisphere dysfunction. Cederlund’s (2004) examination of test

results from 100 males with AS revealed that more than 50% had verbal IQ scores that

were above performance IQ scores which is indicative of a non-verbal learning disorder

and right hemisphere dysfunction. Right hemisphere abnormalities have also been

identified on single photon emission computed tomographic imaging studies of

adolescents with AS (McKelvey, et al., 1995). Weimer, et al. (2001) suggest that right

hemisphere dysfunction often results in clumsy behavior, social dysfunction and attention

deficits, which are characteristics commonly seen in individuals with ASDs. Others have

documented left sided neurological signs such as hypertrophy and motor incoordination

(Berthier et al., 1990) in addition to left hemisphere white and grey matter deficits

(McAlonan et al., 2002).

There appears, therefore, to be abnormalities or differences in the neurological

structures of individuals along the autistic spectrum, including AS and PDD-NOS. At

present, no definitive conclusions can be made due to the small sample sizes of the

individuals studied, and variations among the research that has been conducted. It may

be that each individual presents with slightly different neurological abnormalities which

could explain the extreme variability among subjects who have diagnoses that fall along

the autism spectrum. In her review of the neurological literature surrounding autism,




Coleman (2005) confirms this variability, suggesting that many different neurological

areas and abnormalities exist within the nervous systems of persons with autism spectrum

disorders (Coleman & Betancur, 2005). The sensory and motor symptoms of children

with ASDs seem to have the strongest connections to deficits in the basal ganglia,

cerebellum and the brainstem. As Sears (1999) suggests, perhaps it is more a deficit in

the neuronal connections, rather than an abnormality of a specific area of the nervous

system. A study performed by Just, Cherkassky, Kelly and Minshew (2004) supports this

proposal. Results from functional magnetic resonance imaging on persons with high

functioning autism versus controls point to decreased connectivity, and therefore,

decreased integration of the cortical areas of the brain (Just, Cherkassky, Keller, &

Minshew, 2004). Thus it appears that AS and PDD-NOS are abnormalities not only of

certain regions of the central nervous system, but also of the integration of different areas

of the brain.

Since SI theory considers integration at all levels of the nervous system, it may

explain the wide range of symptoms associated with AS, PDD-NOS and other autistic

spectrum disorders. It seems reasonable, therefore to hypothesize that treatments which

work to improve the integration of sensory information in children with AS and PDD-

NOS would also improve both the sensory processing and the motor functioning of these

children. As a result, children’s clinical performance and both the parent and the child’s

perceptions of functioning would be expected to improve.

Sensory Integration. The theories and treatment techniques of SI, which were

developed by A. Jean Ayres in the 1970s and 80s to help explain and treat the various

deficits observed in children with learning disabilities and clumsiness are also being used




as a basis for this study of children with AS and PDD-NOS (Fisher, Murray, & Bundy,

1991). The concepts and applications of SI incorporate three components: the theory, the

evaluation methods for identifying children with SI dysfunction, and SI as a specialized

treatment technique.

The theory of SI is rooted in the belief that all aspects of the nervous system work

together in order for the individual to receive, process and modulate sensory input to

produce a functional response within the environment (Ayres, 1989). Sherrington (as

cited in Bledsoe, 2004), suggests that this process of CNS organization results in the

production of an internal understanding of the surrounding world. This theory also

suggests that appropriate motor and behavioral responses to the environment are possible

only if the child is able to register and process sensory information correctly (Linderman

& Stewart, 1999).

Experts in the field of neurology have proposed more recent theories of motor

control which support the ideas of Ayres. Bernstein (as cited in Thelen, 1995) suggested

that movement is not only a product of the CNS, but rather, is a product of many

components: the environment, body properties, and task demands, which work together

in a heterarchical structure. The nervous system receives sensory information from

various locations within the CNS and is designed to integrate this information. When all

aspects are working at a critical level of function, a child is able to process the properties

of a particular action within the associated environment accurately, and then develop new

adaptive patterns which can be used for higher-level functioning.

A Theory of Neuronal Group Selection (TNGS) has also been proposed, which

states that sensory information is important in adapting movement to the environment.




According to this theory, each action allows the nervous system to organize and become

more efficient, allowing for more goal directed and efficient movements to occur

(Hadders-Algra, 2000; Thelen, 1995). The dynamic systems approach, focuses on the

system as a whole, and holds that any complex system, under certain conditions, will

self-organize to achieve stability. According to the dynamic systems theory, neural

network overproduction occurs first, and is then followed by an elimination of the less

useful connections in performing a particular activity (vonHofsten, 1989)

The full process of SI is segmental. It includes registration that a stimulus

occurred, orientation and attention to it, interpretation of the stimulus, organization of a

response and finally, execution of the response (Williamson, Anzalone, & Hanft, 2000).

Children need to register sensory input (recognize a stimulus), activate their system

(determine what to do with it), and modulate (regulate or adjust to the stimulus) in order

to maintain homeostasis. The ability to complete the full process of SI may vary

depending on the type of sensory input. Success with the entire process is what allows

the child to maintain a state of arousal (Bledsoe, 2004a).

A major premise of SI theory is that there are three major systems involved in

sensory and motor development. These are the tactile, vestibular and proprioceptive

systems, which are considered to be proximal senses. They are the primary and primitive

senses that develop and dominate early in life. Distal senses such as vision and hearing

develop later, as the child matures (Parham & Mailloux, 2001). The tactile system is

essential for the development of motor skills, learning about the environment, knowing

about the body and its boundaries and for emotional well being. It is the primary system

for making contact with the surrounding environment, and is required in order to develop




subsequent skills (Bledsoe, 2004a). Tactile exploration combines with visual

exploration, and together with proprioception, is involved in the development of a body

scheme. Praxis follows in its development, as body scheme and somatosensory inputs

continue to be refined (Brasic-Royeen & Lane, 1991).

The vestibular system develops in utero. It tells us about movement and plays a

key role in balance. The input from this system should result in a feeling of security with

movement. Vestibular input also affects muscle tone, and has a close connection with the

visual system. It is needed to develop perception of space, and plays a role in arousal,

attention and emotion. The vestibular system is involved in the development of the child

by controlling equilibrium and posture (via the visual, tactile, proprioceptive and

vestibular systems), directing eye gaze and compensatory eye movements in response to

head movement, maintaining a constant plane of vision, and regulating arousal and affect

(Bledsoe, 2004a).

Proprioception is the body’s ability to know where it is positioned in space, and

when, where and how quickly to move. It also provides information about how much

force to apply (Fisher et al., 1991). Proprioception allows for the grading of movements

and provides information on the coordination of motor skills (Kranowitz, 1998).

Together with the vestibular system, proprioception provides the basis for the

development of a body scheme and body image by providing a frame of reference for

other forms of sensory input to be interpreted (Fisher et al., 1991). Body scheme is the

body’s internal ability to understand its many components, and how they work together

during motor activities. It allows for motor planning and performance of skilled and

purposeful tasks. The development of a body scheme depends on the body’s ability to




synthesize sensory information from a variety of systems (tactile, proprioception, vision).

According to Ayres (1961), early motor learning is closely associated with the

development of a body scheme. Much of our knowledge of the world begins with

knowledge of our bodies. Without this knowledge, it can be more difficult to develop

number concepts, visual-spatial perception skills and skilled motor tasks (Ayres, 1961).

Proprioception also affects the ability to develop planned sequences or strategies.

Therefore, a deficit in proprioception may make it more difficult to learn a new task

(Anzalone, 1993). Together, it is suggested that the vestibular and proprioceptive

systems work to provide a stable frame of reference, against which other sensory inputs

are interpreted (Fisher et al., 1991).

As a result of the integration of the senses, the child begins to develop some

specific skills. Through the process of tactile, vestibular and proprioceptive system

development, body scheme and praxis, or motor planning, emerge and continue to

develop as the child matures (Brasic-Royeen & Lane, 1991). As the child interacts with

his or her environment, sensory input is processed and integrated, resulting in the

establishment of a body concept (Smith-Roley, Imperatore-Blanche, & Schaff, 2001).

Praxis follows, which is a cognitive process that results in the performance of a

purposeful motor action (Williamson et al., 2000). Praxis includes the stages of ideation

(what to do), planning (how to do it which requires a developed body scheme), and

execution (performing the act) (Bledsoe, 2004a). It allows a child to learn new motor

skills and to adjust skills that have been previously learned in order to achieve success in

a constantly changing environment (Smith-Roley et al., 2001).




It is hypothesized by proponents of SI theory, that human development is related

to SI which is an inherent function of the nervous system. In this process, the sensory

receptors recognize input from pain, touch, vision, gravity, audition, movement,

temperature, smell, and taste. These receptors generate automatic functions such as

posture and balance, bilateral use of the body, homeostasis, reflex maturation,

gravitational security, motor planning and somatosensory awareness, which enhance the

child’s spontaneous play. This play results in the development of motor skills, emotional

maturation, and perceptual skills which provide the basis for higher level motor and

cognitive skills (Bledsoe, 2004a).

A child’s interest and drive to move results from the need to develop the capacity

to perform skilled motor acts. Movement associated with sensory input is important in

maturing from diffuse to more specific sensory perception and integration. As muscle

strength develops, antigravity movement is achieved, muscle control is developed and

cocontraction and equilibrium follow. Development of anti-gravity movement and

stability allows the child to develop more mature motor patterns which provide

opportunities for a variety of movements. The increased sensory feedback from these

movements results in the development of motor planning (Parham & Mailloux, 2001).

As the child learns to motor plan, movement assumes meaning (Bledsoe, 2004a).

Neuroplasticity literature has suggested that children repeat skills until they are mastered

and then they vary or challenge the skill (Schaff, 1994). From a neurological perspective,

this follows the ideas of Ayres and the Theory of Neuronal Group Selection, in that the

child’s actions result in enhanced or modified neuronal pathways which then allow for

more skilled use.




The child’s ability to integrate sensory input can be recognized by observing his

or her behavior. In particular, evaluating the child’s arousal level (alertness and the

ability to transition between states), attention (focus on a desired stimulus/task), affect

(the emotional component of behavior) and action (engagement in adaptive, goal directed

behavior) can provide a basic understanding of the child’s ability to integrate sensory

stimuli (Williamson et al., 2000). Additionally, observing a person’s ability to produce a

graded response that is considered appropriate given the presenting stimulus, provides

information about the individual’s ability to modulate, or regulate, the sensory input

entering the system (McIntosh, Miller, Shyu, & Hagerman, 1999)

Sensory Dysfunction. Sensory dysfunction occurs when a child does not receive

reliable feedback from his or her body to know what he or she is doing, where he or she

is, and where he or she is going. This makes even the most simple tasks challenging. As

a result, exploration and interaction with the environment, which lays the groundwork

and foundation for future skills, decreases. An inability to effectively interact with the

environment can also result in a state of emotional dysregulation, which, when coupled

with the poor socialization skills of a child with AS or PDD-NOS, can result in an

inability to experience positive interactions with the environment and with others

(Laurent & Rubin, 2004).

Dunn (1999) has identified four categories of sensory processing which are

described as a spectrum of sensory thresholds. A low threshold to a sensory input

indicates that even a small amount of input can be overly stimulating for the person,

whereas a person with a high threshold requires more stimulation than normal for his or

her system to recognize that it has received this input. At the same time, an individual




can respond to his or her threshold in either a passive or an active manner. This results in

four possible situations. The first is low registration, in which the individual has a high

neurological threshold and responds in a passive way. Individuals in this category may

appear highly fatigued, bored or may not notice what is going on around them. The

opposite response to a high neurological threshold is sensation seeking. A person who is

sensation seeking also has a high threshold, but responds in an active manner and tries to

provide him or herself with additional sensory input. This results in the person appearing

hyperactive. The third category is sensory sensitivity, which means that a person has a

low threshold to sensory input and responds by becoming easily distracted by all the

sensations he or she is experiencing. Finally, a person who is sensation avoiding also has

a low threshold, but responds actively, by limiting their participation or creating rituals to

prevent or reduce the amount of stimulation within an environment. As the environment

and the type of stimulation change, an individual’s response may also change, such that a

child may be sensory seeking in one situation, while presenting as sensation avoiding in

another situation (Dunn, Saiter, & Rinner, 2002). Successful sensory processing and

integration allows the individual to modulate his or her levels of arousal and attention in

response to sensory input, which in turn, prepares the individual for further sensory

encounters (Anzalone, 1993). Poor sensory processing and integration may result in

abnormal interactions with the environment, including difficulty regulating oneself,

maintaining attention to relevant stimuli, solving problems and communicating. This is

common in AS, and in ASDs in general, where the child is unable to “remain actively

engaged, adapt to novel stimuli, and inhibit impulsive reactions” while behaving in a

socially appropriate manner, (Laurent & Rubin, 2004, p. 286).




Current best practice relies on research to validate the theories and concepts

surrounding the management of a specific diagnosis. In an effort to validate the theories

associated with sensory processing disorder (SPD), research has emerged which confirms

the presence of physiological differences between individuals who have difficulty

processing sensory information, and those who do not. Davies and Gavin (2007)

conducted a study on 28 children with sensory processing disorders and 25 typically

developing children. Brain processing of auditory stimuli was examined using

electroencephalography (EEG) and event-related potentials (ERPs), to assess the brain’s

ability to suppress less important or repeated information, as well as to identify how

consistent the brain’s responses are with respect to organizing the sensory information.

The results of their study confirm that children with sensory processing disorder have

difficulty ignoring irrelevant sensory information, and are less able to organize incoming

sensory information. In addition, the researchers were able to use EEG and ERP results

to distinguish children with sensory processing disorders from typically developing

children with 86% accuracy (Davies & Gavin, 2007).

In a study by McIntosh et al. (1999), children’s skin conductance electrodermal

responses were measured in response to a variety of sensory system inputs. The children

who were referred for occupational therapy due to sensory modulation disorders

responded with either no electrodermal response (underresponsive), or with more

frequent responses and a larger magnitude (overreactive), compared to healthy, control

subjects. In addition, the authors reported a slower habituation rate to sensory stimuli in

children with sensory modulation disruptions compared to controls. These physiological

findings corresponded to parental reports. Those children who experienced abnormal




responses to the stimulation conditions had higher levels of parent-reported behavioral

abnormalities as identified by the Short Sensory Profile (McIntosh et al., 1999).

Together, these findings show support for one of the basic assumptions in SI theory: that

physiological differences exist between children with sensory processing dysfunction as

compared to those who are typically developing.

Recently, new diagnostic terminology has been proposed, using the term “Sensory

Processing Disorder” rather than “Sensory Integration disorder”. It is believed that this

will help to clarify the differences between the term as a theory, and an intervention, and

to distinguish the therapy-based use of the term from the neurophysiologic use of the

term which explains the process of integrating the sensory signals within the nervous

system at a more cellular level. The associated subcategories of sensory processing

disorder now include Sensory Modulation Disorder, involving diagnoses of Sensory

Overresponsivity, Sensory Underresponsivity and Sensory Seeking Behaviors; Sensory

Discrimination Disorder, which can be identified for any of the body’s senses; and

Sensory-Based Motor Disorder, which includes Dyspraxia and Postural Disorders (L. J.

Miller, Anzalone, Lane, Cermak, & Osten, 2007). It is recommended that this new

terminology be applied to both research and clinical practice (L. J. Miller, Anzalone et

al., 2007), and as such, subsequent aspects of this document will utilize the new

terminology whenever appropriate.

Sensory Integration Therapy. Sensory integration from a therapy perspective is

rooted in beliefs that the environment impacts the growth and maturation of the nervous

system, which is a changeable structure. This is done through the adaptive responses the

child makes. The main purpose of SI therapy is to improve interaction with the external




environment by encouraging adaptive responses. Adaptive responses are purposeful,

goal directed behaviors that give functional meaning to movement. These responses

follow a developmental sequence, and indicate the degree of integration of the system

(Bledsoe, 2004a) . Adaptive responses also allow for feedback into the nervous system.

As a result, the nervous system matures and organizes itself, which allows for increased

interaction with the environment (Schaff, 1994).

The provision of SI therapy relies on several assumptions. These include: (a) the

ability for the CNS to change with intervention, (b) that sensory processing follows a

developmental sequence, (c) although the brain is made up of a hierarchy of systems, it

functions as a single unit, and any sensory system can affect other systems as well as the

overall state of the individual, (d) that SI can lead to and result from adaptive behaviors,

and (e) people seek sensory integration independently, through an inner drive to perform

purposeful, goal directed activities. It is believed that these assumptions are the reasons

why SI therapy can be effective (Bundy, Lane, & Murray, 2002; Fisher et al., 1991).

In accordance with SI theory, classic SI therapy is based on individual needs as

determined throughout the intervention process. Its goal is to improve the ability of the

nervous system to interpret and organize sensory information. The therapy is child

directed, but requires the therapist to incorporate structure while creating an environment

for self-directed exploration. By providing a sensory rich environment and encouraging

active participation at a level which is neither too easy, nor too difficult, SI therapy

allows the child to create new and more appropriate responses to the external world. A

typical schedule includes 45 to 60 minute intervention sessions two times per week.

Expected outcomes to therapy using an SI approach include an increased frequency or




duration of appropriate responses, improved self confidence and self esteem, and

increased social and occupational participation (Parham & Mailloux, 2001). Parham et

al., (as cited in Watling, 2004) developed an instrument called the Essential

Characteristics of Occupational Therapy Using Sensory Integration Intervention

(ECOTUSII), which assesses whether or not the key aspects of SI intervention are being

followed during a treatment session. According to this tool, ten principles must be met:

(a) the room should be organized to encourage the child to become engaged, (b) the

therapist should ensure safety through equipment placement and by staying in close

proximity to the child, (c) sensory opportunities should be presented, (d) a level of

optimal arousal should be obtained and sustained, (e) adaptive responses by the child and

a challenge which is neither too difficult, nor too hard should be promoted, (f) the

therapist should take care that the child is successful with chosen activities, (g) the

therapist should work to guide self-regulated behaviors by allowing the child to make

choices and plan activities as much as possible, (h) the session should follow a context of

play, (i) the child should have the opportunity to collaborate on choosing activities, and

(j) the therapist should work to create a sense of trust, satisfaction and comfort by the

child. The authors of this tool have developed a scoring system to determine how closely

the principles of sensory integration are being followed (Watling, 2004).

Summary. Two concepts provide the basis for this study. First, neural connection

abnormalities within the CNS of children with AS and PDDs in general have been

identified, and correspond to the sensory and motor symptoms of these children. This

provides objective evidence that children with AS and PDD-NOS do have neurological

differences that may impact their sensory processing and motor function. It also supports




research which will test the effectiveness of treatments aimed at improving sensory and

motor symptoms. Also, SI theory, accompanied by research supporting the use of SI

therapy for children with PDDs and AS, provides the basis for the testing and

intervention techniques which will be utilized in this study. Based on this conceptual

framework, a research study was designed to determine whether or not the sensory and

motor skills of a sample of children with AS and PDD-NOS will be affected by SI

therapy.




Literature Review

Characteristics of Children with Asperger’s Syndrome and Pervasive Developmental

Disorder – Not Otherwise Specified

As an autism spectrum disorder, the primary symptom of AS is impaired social

skills. Although the diagnostic criteria are still fairly recent, and there remains a lack of

consensus as to what the criteria should include (Green et al., 2002; Mattila et al., 2007),

a review of current diagnostic criteria provides a basis for the most common impairments

in this population. The Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition –Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000)

indicates that in order to receive a diagnosis of AS, an individual must display the

following criteria: (a) impairments of social interaction, including impairments in

nonverbal behaviors such as eye-to-eye gaze and body postures; difficulty developing

age-appropriate peer relationships; an inability to participate in the interests of others; and

a lack of social or emotional reciprocity, (b) restricted repetitive and stereotyped patterns,

which include excessive preoccupation with certain topics of interest or parts of an

object, rigid adherence to routine or ritual, and stereotyped and repetitive movements,

and (c) functional impairments resulting from the disorder. In addition, individuals

diagnosed with AS should not have a history of language delays, and should not

demonstrate significant cognitive delays or diminished self-help skills. The literature

also reports motor impairments and abnormal responses to sensory input (Church et al.,

2000; Dunn, Smith Myles et al., 2002; Frith, 1991; Ghaziuddin et al., 1994; Klin &

Volkmar, 1995, 2003c; Miller-Kuhaneck, 2004; Wing, 1981). Finally, the clinician who

determines this diagnosis should have ruled out all other specific pervasive




developmental disorders, as well as schizophrenia (American Psychiatric Association,

2000). It is important to note, however, that there is much variability in the symptoms

associated with AS. While the core characteristics are always present to some degree,

each individual case of AS is slightly different, such that other symptoms may, or may

not be noted. Furthermore, many of the features identified as being present in AS are

“found in varying degrees in the normal population” (Wing, 1981, p. 120). Possibly due

to the variability in diagnostic criteria for AS, a diagnosis of PDD-NOS, is sometimes

given to a child who meets most of the criteria for AS, but does not meet all of it

(Cummings, 2008; Rourke & Tsatsanis, 2000). An example is a child who has social

impairments and an early language delay, but who fails to meet all other necessary

criteria for AS or autism at the time of evaluation.

Similar to AS, a diagnosis of PDD-NOS is given to a person who experiences

severe difficulty with reciprocal social interaction and communication skills, or who have

stereotyped behaviors, however a person who receives a diagnosis of PDD-NOS does not

meet the specific criteria for another PDD (American Psychiatric Association, 2000).

Since PDD-NOS is a diagnosis of exclusion, without specific diagnostic criteria,

researchers disagree as to how PDD-NOS actually differs from AS and autism, and a

PDD-NOS diagnosis may be overused (Fombonne, 2003; D. Walker et al., 2004). Klin

and Volkmar (2003) report that evidence suggests clinicians are using the terms AS,

PDD-NOS and HFA synonymously, creating even greater confusion. Walker and

colleagues (2004) compared groups of children with autism, AS and PDD-NOS (mean

ages: 8.25 years, 9.77 years and 7.19 years, respectively) on functioning and symptoms of

autism. They determined that the AS and PDD-NOS groups did not differ on measures




of functioning, including communication, daily living and social skills and IQ. With

respect to autistic symptoms, such as repetitive and stereotyped behaviors, children with

PDD-NOS tended to have fewer symptoms than both the AS and the autism groups. The

author concluded that PDD-NOS falls on the autism spectrum, somewhere between the

more severe autism diagnosis, and the more mild AS diagnosis, (D. Walker et al., 2004).

The variability displayed in these individuals makes it difficult to determine the

true prevalence of AS or PDD-NOS. The relatively recent classification of AS as a

diagnosis, coupled with discrepancies in the most appropriate diagnostic criteria, have

resulted in large ranges in prevalence estimates. Current estimates range from 0.1 to 7.1

cases of AS per 1000 individuals, (Khouzam, El-Gabalawi, Pirwani, & Priest, 2004). In a

review of epidemiological studies on AS, Fombonne (2003) determined that based on

ratios of AS to autism diagnoses, a conservative estimate for the prevalence of AS is 2.5

in 10,000 individuals, and an estimate for the prevalence of PDD-NOS is 15/10,000

(Fombonne, 2003). It is not uncommon for children to wait longer before obtaining a

diagnosis of AS. Compared to an average age of diagnosis for autism of 5.5 years, the

average age to obtain a diagnosis of AS was 11 years (Howlin & Asgharian, 1999). Due

to the variability in the nature and severity of symptoms, and the potential delay in

obtaining a diagnosis of AS, there is likely a substantial number of persons with AS who

have not been diagnosed or identified (Khouzam et al., 2004). This hypothesis was

supported by Mattila (2007), who determined that 9/19 participants entered the study

with no AS diagnosis, even though they presented with traits common in persons with

AS, and received an AS diagnosis through testing by experienced clinicians. The number

of children receiving a diagnosis of AS, however, has clearly shown an increase (Klin,




Volkmar, Sparrow, Cicchetti, & Rourke, 1995). Since 1994, the United States Centers

for Disease Control and Prevention [CDC] has reported a nine-fold increase in the

number of children being serviced that have an autism spectrum disorder (ASD) (Centers

for Disease Control and Prevention, 2008). The CDC has predicted that approximately

24,000 children will be diagnosed with ASD each year (Centers for Disease Control and

Prevention, 2006). A recent study on the prevalence of ASD’s identifies that their

frequency rate (6.2 per 1000 eight year olds living in South Carolina), is second only to

mental retardation (Nicholas et al., 2008). It has been reported that the rate of individuals

with AS living in the United States is between 700,000 and two million (Safran, Safran,

& Ellis, 2003). The increased incidence of AS since its introduction into the DSM-IV

has been related to an increased awareness brought about by the literature, media and

supporting groups and agencies (Klin & Volkmar, 2003c). A controversy remains,

however, regarding whether more children are being affected by AS, or whether more

children are being diagnosed with the disorder (Miller-Kuhaneck, 2004). With the

increase in the number of children with a diagnosis of AS, it is important that

impairments associated with this disorder are properly understood, and that appropriate

intervention techniques are identified. Compared to other PDDs, PDD-NOS is not often

researched as heavily (Cummings, 2008), in part, due to its vague diagnostic criteria. As

a result, aside from Fombonne’s estimate of 15/10,000, prevalence and incidence

estimates for PDD-NOS in the United States are unavailable. These findings are lower

than studies conducted in England and Sweden, which estimate the prevalence of PDD-

NOS to be 36.1 per 10,000 cases and 23.5 per 10,000 cases, respectively (Chakrabarti &

Fombonne, 2001; Gillberg, Cederlund, Lamberg, & Zeijlon, 2006)




Motor Skills of Children with Asperger’s Syndrome and Pervasive Developmental


It is well reported within the literature that motor delays are often present in

persons with PDDs (Freitag, Kleser, Schneider, & Von Gontard, 2007; Molloy, Dietrich,

& Bhattacharya, 2003). As part of an ongoing study for the US Centers for Disease

Control and Prevention, Nicholas and colleagues (2008) reported that 62% of the cases of

ASDs, including children with AS, PDD-NOS and autism, in the study state of South

Carolina have impaired motor skills. Within the diagnostic criteria of the DSM-IV,

motor delays and clumsiness are listed as associated features that are often present in

children with AS, but are not required for diagnosis (American Psychiatric Association,

1994). The same is true for the International Classification of Diseases: Tenth Edition

(ICD-10), which states that while clumsiness is a common characteristic of children with

AS, it is not required for the diagnosis (Ghaziuddin et al., 1994). From the very first case

reports, children with this syndrome have been identified as being motorically awkward,

having poor coordination, and having difficulty with motor skills (Frith, 1991). Children

with AS have also been noted to have delayed motor milestones, poor posture, low

muscle tone, decreased awareness and control of the body, decreased arm swing, stiff

gait, poor rhythm and timing, stiff and clumsy movement patterns, a tendency to break

things, difficulty catching and throwing, and poor handwriting (Frith, 1991; Klin &

Volkmar, 1995, 2003c; Miller-Kuhaneck, 2004; Wing, 1981). Khouzam, El-Gabalawi,

Pirwani and Priest (2004) suggest that motor delays may be one of the first features

recognized in young children, with the more typical AS symptoms presenting later.




In discussing one of his subjects, Asperger stated that “the clumsiness was

particularly well demonstrated during physical education lessons. Even when he was

following the group leader’s instructions…his movements would be ugly and

angular…[his] movements never unfolded naturally and spontaneously…from the proper

coordination of the motor system as a whole. Instead, it seemed as if he could only

manage to move those muscular parts to which he directed a conscious effort of will” (as

cited in Frith, 1991, p. 75). Similar signs of motor clumsiness were identified in nearly

75% of Asperger’s cases, with another one third reported as having awkward body

language and gait (Hippler & Klicpera, 2003). Of 23 children with AS studied by

Gillberg (1989), 83% demonstrated “motor clumsiness” based on the Griffiths

Developmental Scales and clinical observation (Gillberg, 1989). In a review of

neuropsychological profiles of children with AS and HFA, Klin, Volkmar, Sparrow,

Cicchetti and Rourke (1995) identified 19 out of 21 subjects with AS as having fine

motor impairments, and all 21 subjects with AS as having deficits in gross motor skills

(Klin et al., 1995). A retrospective chart review performed by Church, Alisanski and

Amanullah (2000), identified 73% of the 40 study participants with AS as being clumsy.

Of these children, greater than 50% had a history of being “klutzy, clumsy or awkward”

(p. 15) by the age of 11 years, which had been associated with delayed motor skills

during the preschool years. Fifty-eight percent of school age children studied with AS

received occupational therapy services for fine motor deficits, while 33% received

physical therapy services for gross motor delays (Church et al., 2000). A study by

Ghaziuddin and colleagues (1998) compared the motor skills of thirty-six 10 and 11 year

old children: 12 with AS, 12 with PDD-NOS, and 12 with autism. Using the Bruininks




Oseretsky test to measure gross and fine motor performance, the authors identified motor

impairments across all groups, with the group of children with autism performing

significantly worse than the other two groups. Although the group with PDD-NOS was

more impaired in gross motor, fine motor and battery test scores than the group with AS,

the group differences were not statistically significant (Ghaziuddin & Butler, 1998).

As researchers and clinicians become more aware of AS and PDDs, studies that

focus on the motor impairments of these children appear to be increasing in number. The

primary focus of the literature however, has often been to differentiate the motor

problems of ASDs from other disabilities, rather than quantifying the impairments.

Manjiviona and Prior (1995) compared children with AS to children with HFA using the

Test of Motor Impairment – Henderson Revision (Stott, Moyes, & Henderson, 1984),

which assesses manual dexterity, balance and ball skills in children. The results of their

study indicated that 50% of the subjects with AS demonstrated motor impairments.

These impairments were typically noted in both gross and fine motor skills. They also

noted that subjects with AS had difficulty with ball skills, had a hard time controlling the

force and direction of the ball, demonstrated laterality confusion, and tended to act either

overly impulsive, or excessively cautious (Manjiviona & Prior, 1995). Miyahara et. al

(1997) noted similar results in a comparison study of the motor coordination of Japanese

children with AS and those with learning disabilities. Using the standardized Movement

Assessment Battery for Children [Movement ABC] (Henderson & Sugden, 1992), this

group identified motor delays in both groups of children, and ball skills that were more

deficient in the subjects with AS. Additionally, Miyahara et al. (1997) noted that the rate

of children with AS who were diagnosed with Specific Developmental Disorder of Motor




Function (SDD-MF) was 42 times above the prevalence of the normative group

(Miyahara et al., 1997). Green et al. (2002) also used the Movement ABC to compare

children with AS to children with SDD-MF, in an effort to quantify the extent and

severity of motor impairment in AS. All of the participants with AS were found to have

motor impairments. In addition, participants from this group accounted for 83% of those

labeled as being most severely impaired.

Ghaziuddin, Butler, Tsai, and Ghaziuddin (1994) utilized the Bruininks-Oseretsky

Test of Motor Proficiency, to determine if AS could be distinguished from high

functioning autism. While the researchers were unable to identify any significant

differences between the groups, they did note that both groups scored below normative

expectations on all four subtests, which include gross motor, fine motor, upper limb

coordination and the battery composite (Ghaziuddin et al., 1994). Similarly, Miller and

Ozonoff (2000) used the Movement ABC to test children with AS and HFA, and

determined that children with AS fell 1.66 standard deviations below the mean for the

normative sample on overall percentile scores which supported subjective findings of

motor impairment made by other researchers. In addition, after controlling for IQ,

children with AS were identified as obtaining lower scores on the Fine Motor component

of the Movement ABC than the HFA group (J. Miller & Ozonoff, 2000).

Although many experts have identified some form of motor deficit in children

with AS, research is limited with respect to understanding the quality of movement and

the specific causes for the awkward and clumsy appearance in this population. Miyahara,

Tsujii, Hori, Nakanishi, Kageyama and Sugiyama (1997) discussed this gap in the

research, stating that at present, we can only provide subjective descriptions of their




movement patterns and a gross estimate of the level of motor skills of children with AS

compared to children who are typically developing. (Miyahara et al., 1997). One

quantitative study (Freitag et al., 2007) utilized the Zurich Neuromotor Assessment to test

the timed performance and adaptive movements of adolescents with AS and HFA, and

IQ-matched controls, while completing alternating movements, static and dynamic

balance activities and stress gaits, which include walking on toes, heels and the inner and

outer borders of the feet. Results identified diadochokinesis and dynamic balance skills

to be most impaired in the AS/HFA group, and identified an association between the

severity of motor impairment and the degree of social withdrawal in all study participants

(Freitag et al., 2007). Smith (2000) suggests that future research should begin to account

for the causes of poor motor coordination in children with AS, rather than simply

identifying differences (I. M. Smith, 2000). Recently, research has begun to shift towards

identifying these causes. For example, one study compared upper extremity movement

kinematics in children with AS and HFA during a writing task on a digitizing tablet. The

researchers determined that both groups had difficulty with the motor planning required

to perform the task, rather than with the actual execution of the task (Rinehart et al.,

2006). Molloy et al. (2003) examined afferent sensory systems of children with ASDs

and children with typical neurodevelopment, and concluded that poor integration of

sensory input results in motor skill impairments in children with ASDs (Molloy et al.,

2003). Even with emerging studies confirming the presence of motor impairments in

children with ASDs and with AS specifically, to date no studies have been published

regarding the issue of how to address the motor impairments that appear in this

population (Green et al., 2002).




Sensory Processing in Children with Asperger Syndrome and Pervasive Developmental


Successful sensory processing allows the individual to modulate his or her levels

of arousal and attention in response to sensory input, which in turn, prepares the

individual for further sensory encounters (Anzalone, 1993). Impairments in sensory

processing and integration have also been identified in children with AS and PDDs. An

impairment in SI can result in difficulty receiving input from the body and the

surrounding environment, processing sensory input and responding appropriately to the

stimulus. Poor SI can also result in abnormal interactions with the environment,

including difficulty regulating oneself, maintaining attention to relevant stimuli, solving

problems and communicating. These problems appear to be common in AS, where the

child is unable to “remain actively engaged, adapt to novel stimuli, and inhibit impulsive

reactions” while behaving in a socially appropriate manner, (Laurent & Rubin, 2004, p.

286). Case studies and parent reports have suggested definite differences in these skills

when compared to children without AS. It has been indicated that children with AS often

display signs of hypo- or hypersensitivities to light, sound, textures, taste and movement.

Oftentimes there can be a mixed response in a child, such that he or she may be

hyposensitive to one sensory stimulus and hypersensitive to another, or to the same

stimulus at another time (Case-Smith & Miller, 1999; Dunn, Smith Myles et al., 2002;

Frith, 1991; Weimer et al., 2001). Some of the cases described by Asperger (as translated

in Frith, 1991) were identified as having strong likes or dislikes for various fabrics and

sounds, being intolerant to personal grooming and having a fear of movement, which are

signs of hypersensitivity. Others, conversely, demonstrated signs of hyposensitivity,




including a poor sense of personal space, a lack of awareness of objects in the

environment, and preferences for very strong flavors (Frith, 1991). Gillberg (2002),

recognized the relationship between sensory processing difficulties and problems with the

performance of activities of daily living in children and adolescents with AS, such as

bathing, dressing and dental care. He noted that many of these children complained of

pain or discomfort with the water from a shower, hair and nail cutting, and with certain

textures, sounds or scents (Gillberg, 2002).

From as early as the preschool years, children with AS have been identified as

having abnormal responses to sensory stimuli. In a retrospective descriptive study of 40

children with AS, Church, Alisanski and Amanullah (1999) reported that several parents

offered specific comments regarding their child’s sensory impairments which resulted in

their child either “shut(ting) down completely” or “becom(ing) very hyper” (p. 14).

Similar findings have been reported for children with autism and ASDs in

general. The Center for Autism and Related Disabilities (2005) reports abnormal

responses to various sensory experiences, including visual, auditory, olfactory, oral and

tactile inputs for persons with PDD-NOS. Using the Diagnostic Interview for Social and

Communication Disorders (DISCO) to document sensory abnormalities in children based

on specific sensory domains, Leekam and colleagues (2007) confirmed the presence of

sensory abnormalities in persons of all ages with autism. In this two part study, the

authors noted that children with autism more often experienced abnormalities in several

sensory domains (rather than just one area) than children with language impairment or

developmental disability. Significant differences between groups were identified for

touch and smell/taste domains, and these differences did not change with age or IQ




(Leekam, Nieto, Libby, Wing, & Gould, 2007). In a similar study (Tomchek & Dunn,

2007), which used a parent-rated questionnaire, the Short Sensory Profile, to compare

281 children with ASDs, including 21 children with PDD-NOS and four children with

AS, to age-matched children who were typically developing, 95% of the children with

ASDs were found to have sensory processing dysfunction. The authors also explained

that sensory seeking/underresponsiveness, auditory filtering and tactile sensitivity

sections of the test showed the largest differences between the ASD and control groups

(Tomchek & Dunn, 2007).

Stereotypical and repetitive behaviors are another feature commonly associated

with PDDs and AS. Behaviors might include, but are not limited to: outstretched hands,

hand flapping and shaking of fists (Gillberg, 2002), rocking or pacing (Church et al.,

2000) and jumping, or hitting (Frith, 1991). Some researchers believe that the

stereotyped behaviors observed in children with AS and in ASDs in general, are directly

related to the sensory impairments these children face (Rogers & Ozonoff, 2005).

Baranek, Foster, and Berkson (1997), noted that these behaviors are often present along

with signs of tactile defensiveness, and can present as symptoms of inflexibility to

change. In their study that looked at this relationship, the authors compared teachers’

subjective ratings of the presence or absence of abnormal or stereotypical behaviors (as

determined by a yes and no questionnaire), to the student’s performance on the light

touch subtest of the Tactile Defensiveness and Discrimination Test, the Habituation to

Tactile Stimuli Applied to the Face, and the Touch Inventory for Preschoolers. They

found that children with autism and related developmental disabilities demonstrated more

signs of rigidity and sameness, auditory and repetitive verbalization and abnormally




focused attentions, when they were rated by their teachers as being tactually defensive

(Baranek et al., 1997). Walker and colleagues (2004), using the Autism Behavior

Checklist and the Autism Diagnostic Interview – Revised, noted the presence of

repetitive and stereotypical behaviors in all three groups of study participants: children

with AS, children with PDD-NOS, and children with autism.

Due to an apparent inability to successfully integrate and use multimodal

information in a socially acceptable manner, new social situations can also be difficult for

children with ASDs. To cope, they may require unrealistic levels of sameness, engage in

ritualistic or repetitive behaviors, perseverate on topics of interest, overreact to seemingly

minor events, or avoid social interaction altogether (Laurent & Rubin, 2004). Improving

the ability of a child with an ASD to process sensory information effectively will likely

reduce his or her reliance on stereotypical behaviors, rigid environments, and the odd and

awkward behaviors associated with these syndromes (Dawson & Watling, 2000). Smith,

Press, Koenig and Kinnealey (2005) conducted a study that tested this hypothesis and

found that SI intervention reduced the frequency of stereotypical and self-injurious

behaviors in seven children with PDDs or mental retardation, supporting the assumption

that stereotypical behaviors can be related to sensory impairments (S. A. Smith, Press,

Koenig, & Kinnealey, 2005). Only recently, however, has this phenomenon been

recognized and research initiated for children with AS (Dunn, Saiter et al., 2002). In

2002, Dunn, Smith-Myles and Orr conducted a study in which the Sensory Profile, a

parent-reported questionnaire, was administered to parents who had a child with AS.

Their study determined that children with AS had significant impairments in almost all

areas of SI including sensory registration, sensory processing and sensory modulation.




Only Modulation of Visual Input Affecting Emotional Responses and Activity Level was

identified as being within normal limits compared to children without disabilities. In

addition, deficits in integration and modulation were identified for all sensory systems

(Dunn, Smith Myles et al., 2002).

In a pilot study (Klyczek, Shriber, Timler, & Ohtake, 2005) in which children

with AS were evaluated using clinical observations and the Sensory Profile, many similar

findings were noted. All parents reported poor sensory registration, and 75% identified

concerns with emotion, low endurance or tone, and distractibility. Clinical observations

confirmed findings of low tone and distractibility, and also identified difficulty with

visual tracking, and maintaining prone extension and supine flexion positions. While

most children were not identified as being tactually defensive using Clinical

Observations, 60% or more had difficulty with motor planning or execution, and with

equilibrium or righting reactions (Klyczek et al., 2005). These findings suggest the

possibility of poor sensory modulation in children with AS.

Research has suggested a connection between the sensory and motor impairments

seen in children with ASDs. Poor coordination and a general appearance of clumsiness

can occur when the sensory systems are not functioning properly and may become

apparent when observing motor skills and activities of daily living (Murray-Slutsky,

2004). Prudhomme White and colleagues (2007) examined this connection in a group of

68 children with a sensory processing disorder (SPD), and of 68 children with typical

development. They found that children with atypical sensory processing scored

significantly lower on the Assessment of Motor and Process Skills (AMPS) in both

Activity of Daily Living and Process Measures, and also identified a connection between




low Sensory Profile scores and difficulty performing functional tasks, as reflected by the

AMPS scores (Prudhomme White, Mulligan, Merrill, & Wright, 2007).

It seems important to understand that one way the sensory and motor systems are

related, is through proprioception. Proprioception, which involves understanding where

the body and the joints are in space (Parham & Mailloux, 2001), is recognized as being

important for motor function. There is some evidence that suggests that the motor

clumsiness associated with AS may be related to deficits in the processing of

proprioceptive and kinesthetic information (Weimer et al., 2001; Molloy, Dietrich, &

Bhattacharya, 2003). A child who appears to be clumsy and awkward with simple

activities of daily living may not be adequately receiving or processing information about

the position of his or her body (Parham & Mailloux, 2001). Gepner and Mestre (2002)

compared children with AS to a group of children with autism, and to a control group of

normal children using the motor subtest of the Psychoeducational Profile. Their results

indicated that children with AS were often overly sensitive to visual motion and had

increased postural instability, indicating that they had difficulty using proprioceptive

information for balance (Gepner & Mestre, 2002). In 1996, Smyth compared the reaction

times of a group of children identified as being clumsy to a control group using Gubbay’s

Test of Motor Proficiency. Smyth determined that the group identified as being clumsy

demonstrated longer reaction times, suggesting that kinesthetic information was being

processed too slowly in this population (Smyth, 1996). Weimer et al. (2001) conducted a

study on children with AS, in which children were asked to complete a battery of gross

and fine motor tasks, including finger tapping, grooved pegboard, and tests of apraxia,

ataxia and visuomotor integration. They found that children had the greatest difficulty in




tests of apraxia, one leg standing balance with eyes closed, tandem walking and finger

opposition compared to children with normal development. It was noted that each of

these tests required intact proprioception in order to succeed. This suggests that motor

dysfunction in children with Asperger’s may really be a disorder of the sensory pathways

(Weimer et al., 2001). Parham and Mailloux (2001) suggest that the child with decreased

proprioception can also be rejected or avoided by others and labeled as clumsy or

accident-prone. In addition, he or she may also seek additional sensory input in socially

inappropriate ways, such as leaning on another person in an effort to obtain the needed

proprioceptive input (Parham & Mailloux, 2001).

Another possible cause for the clumsiness observed in children with AS may be

poor sensorimotor planning or somatodyspraxia. Dyspraxia that is related to sensory

processing can present as a difficulty with bilateral sequencing, poor sensorimotor

processing, or visuodyspraxia. It occurs when the child is unable to correctly process and

integrate the sensory information presented (Fisher et al., 1991). As with decreased

proprioception, somatodyspraxia may cause the child to appear clumsy or poorly

coordinated, and therefore have difficulty completing gross motor activities (Parham &

Mailloux, 2001).

Molloy, Dietrich and Bhattacharya (2003) performed a case control study on eight

children with ASDs, including AS and PDD-NOS, as well as eight children who were

typical and matched for age, gender and race. A force platform was used to measure

postural stability and compared the responses of different sensory systems. The authors

found that compared to control participants, children with ASDs relied more heavily on

vision to maintain their balance, which suggests difficulty using proprioceptive




information. Additionally, they identified a pattern of sway response that suggested

difficulty with integrating sensory input, rather than a deficit of any one sensory system

(Molloy et al., 2003).

Although it appears that based on the literature, there is some evidence for

sensory impairments in AS and ASDs, they are not included within any set of the

diagnostic criteria. In addition, the sensory issues that have been suggested in AS and

PDD-NOS have not been well studied (Frith, 1991; Smith Myles, Tapscott Cook, Miller,

Rinner, & Robbins, 2000). There also remains a gap in the literature with respect to

objective measurements of the sensory deficits in this group of children. As a result,

similar to motor skills, the sensory modulation and integration skills of children with AS

and PDD-NOS have not been clearly defined, making comparison and generalization

between individuals and studies difficult. It also appears that a “best practice” treatment

approach for persons with AS or HFA has not been identified (Toth & King, 2008), and

no studies to date have examined the effects of SI treatment techniques at improving the

sensory processing or motor skills of children with AS or PDD-NOS.

The Effectiveness of Sensory Integration Therapy

Occupational therapy using sensory integration is a commonly reported treatment

approach for children with ASDs (Stahmer, Collings, & Palinkas, 2005). Despite the

relatively large number of studies performed assessing the effectiveness of SI, this

treatment technique is still under examination, since many of the studies that are available

are dated and many have not used the most appropriate research protocols. A review of

the SI literature reveals that some of the most common problems with these studies are

that they utilized small samples with no control groups, did not adequately describe the




treatment protocols, and studied too many variables to notice a difference in function post

treatment (Vargas & Camilli, 1999). In addition, studies of this type have been subject to

participant variability and ethical dilemmas regarding a no-treatment control group

(Kaplan et al., 1993).

In some studies involving children with PDDs, who have some similarities to

children with AS, SI therapy has been shown to be effective, and has resulted in

improvements in motor coordination, behavior and play. Ayres and Tickle (1980)

performed a study on ten children with autism who received SI treatment two times each

week for more than 11 months. They reported that all but one child showed some

improvement in the areas observed. These included reduced self-stimulatory behaviors,

increased interactions with the environment, and improved test scores (Ayres & Tickle,

1980). Another study provided SI therapy to four children with AS (Watling & Dietz,

2007). While immediate play skills and behaviors were not significantly impacted as a

result of SI therapy, subjective reports suggested that areas of engagement, such as

transitions, eye contact, socialization and behavior, may have shown improvement

(Watling & Dietz, 2007).

Wilson and Kaplan (1994), followed a group of children with autism for two

years after SI treatment, and determined that their gross motor performance continued to

be better than that of the control group who had only received tutoring. In a multiple

baseline study on five, four and five year old boys with autism, Case-Smith and Bryan

(1999) provided ten weeks of therapy based on an SI approach. Their study revealed that

preschool children with autism demonstrated more appropriate goal-directed play,

improved motor planning and fewer unnecessary stereotypical behaviors following




treatment. Linderman and Stewart (1998) provided classical SI therapy to two preschool

boys with autism. After one-hour sessions once a week for seven and eleven weeks, the

boys demonstrated improvements in attention, initiating and leading social interactions,

tolerating new activities, participating in parent-child hugging, and social awareness.

Finally, in a study by Case-Smith and Miller (1999) who surveyed occupational

therapists who had an interest in SI and autism, it was determined that those who used SI

approaches with their children believed that their clients made the greatest improvements

in their ability to process sensory information.

Other studies have examined the effectiveness of SI on children with other

developmental disorders. Although classical SI therapy was not used in their study, Paul

and colleagues (2003) utilized a sensory motor activities program based on SI theory for

31 preschool children. After 12 weeks of therapy, five days a week, the experimental

group, which included 15 children with impairments in typical preschool skills showed

greater improvement than the comparison group using the DeGangi-Berk Test of Sensory

Integration and significantly greater improvement on the Miller Assessment for

Preschoolers (Paul et al., 2003). In a retrospective study of 37 children with

developmental coordination disorder, the effectiveness of a 10-week combined SI and

perceptual motor training program was assessed (Davidson & Williams, 2000). After a

12-month follow-up period, they determined that there was a statistically significant

improvement in fine- and visual motor skills ( p=0.034 and 0.002, respectively) for the

children who participated. In a study of the long term effects of SI therapy and tutoring

(three years after intervention), a more sustained improvement in the gross motor skills of

the SI group was observed when compared to the children who had received tutoring




(Wilson & Kaplan, 1994). Another study by Law, Polatajko, Schaffer, Miller and

Macnab (1991) that used a randomized controlled trial for six to nine year old children,

compared the effects of six and nine months of SI therapy (n=34), or perceptual motor

training (n=33) to no treatment (n=13). The results of their study did not find significant

motor improvements among groups of children with learning disabilities and SI

dysfunction. The authors, however, noted that some children improved a great deal,

while others did not. It was suggested, therefore, that SI intervention may be effective for

certain subgroups of children.

In an effort to improve the scientific rigor of SI effectiveness studies, Miller and

colleagues (2007) have utilized a randomized controlled pilot study to examine the

effectiveness of sensory integration for 3 to 11.6 year old children with sensory

modulation disorders. Twenty four children with sensory modulation disorder were

randomly assigned to one of three groups: a SI group, which provided children with

classical SI therapy two times a week, for 10 weeks; an Alternate Placebo treatment

group, which provided adult attention and table-top play activities; and a No-Treatment

control group, which utilized a 10-week wait list plan. The results from this study

suggested that SI was more significantly more beneficial than the other treatments with

respect to attention ( p = 0.03 compared to no treatment and p = 0.07 compared to an

alternate treatment), cognition ( p = 0.02 compared to the alternate treatment), and in

meeting personalized goals (p < 0.001 compared to both groups). In addition, positive

trends in favor of the SI treatment were noted on parental reports of sensory processing

and sympathetic nervous system responses to sensory challenges (L. J. Miller, Coll, &

Schoen, 2007).




One of the beliefs regarding SI therapy is that it will enhance the child’s ability to

regulate the sensory input received by the body, and in so doing, will improve the child’s

ability to interact with the environment in a socially appropriate manner. Roberts and

colleagues (2007) examined behavior regulation in one, three-year-old child with sensory

modulation disorder, following occupational therapy which employed a SI frame of

reference. The therapy was provided individually, for one hour sessions, three times per

week, using an A-B-A-B protocol. Significant decreases in aggression, oral self-

stimulation, and teacher input, as well as improved engagement skills were noted during

the weeks that the child received therapy (Roberts, King-Thomas, & Boccia, 2007).

Similarly, a case report of a four-year-old child with poor sensory processing who

received SI therapy revealed improvements towards goals in motor planning and

participation, motor skills, decreasing fear of movement, reducing oral sensitivity, and

improving social development (Schaff & Nightlinger McKeon, 2007). In addition, parent

reports on the Sensory Profile and the Goal Attainment Scale indicated that the child’s

occupational performance and participation improved following the SI intervention

(Schaff & Nightlinger McKeon, 2007).

A review of the meta-analyses that have been done on SI (Mulligan, 2003;

Ottenbacher, 1982; Vargas & Camilli, 1999) suggests mixed results in regards to its

effectiveness and a confirmation of the lack of consensus with respect to the effectiveness

of the therapy. The first meta-analysis, performed by Ottenbacher (1982), concluded that

although only a small number of studies were reviewed, SI was an effective treatment

technique with a moderate effect size (mean d -index = .79) (Ottenbacher, 1982). Vargas

and Camilli (1999) performed an extensive meta-analysis of all SI efficacy studies




performed between 1972 and 1994 and among other findings, determined that earlier

studies were more likely to show significant improvement after SI intervention than

studies that were conducted after 1984. They also determined that significant

improvement was more likely in studies which compared SI to no treatment, as opposed

to those which compared SI to an alternative treatment. Both Ottenbacher (1982) and

Vargas and Camilli (1999) noted that SI interventions have had the greatest effects on

motor and psychoeducational variables, as opposed to language, academic performance,

or behavior. In addition, Mulligan (2003) reviewed studies that had been performed from

1980 until 2003 which used treatments based on the general principles of SI theory. She

concluded that as a result of poor scientific rigor, the effectiveness of SI therapy remains

unclear (Mulligan, 2003). It is important to consider however, that there is most likely no

intervention that would be ideal for all individuals with a particular diagnosis, and that

interventions need to be individually based (Baranek, 2002). Although there has been

several years of research in the area of SI effectiveness, some suggest that it is still in the

early phases of determining its true effectiveness (Cool, 1995). While studies on SI

therapy may not have provided consistent evidence of statistically significant

improvements following intervention, positive changes have been noted, resulting in

increased comfort with sensory and motor experiences, and more freedom to engage in

social interactions (Siegel, 1996).

Summary

In addition to problems in communication and social skills, many children with

AS and PDD-NOS can have difficulties with sensory and motor skills which often go

undetected or untreated. While some studies and anecdotal evidence support the




presence of these deficits, there is still a great need for research in this area. Decisions

need to be made regarding the most appropriate diagnostic criteria for identifying these

children, and research is needed to clarify the symptoms of this disorder. It is important

however to address the needs of these individuals now, rather than waiting for these

clarifications to be made (Klin & Volkmar, 2003c, p. xiv). Clearly, it must be determined

which treatment techniques will be most effective for children with ASDs who have

sensory or motor deficits. Even though it is documented that children with these

diagnoses frequently display signs of poor sensory processing and modulation which can

possibly effect their motor skills, can negatively impact their relationship with their

family, and can interfere with their ability to succeed in social and educational activities,

no research has been published on the effectiveness of SI therapy in children with AS or

PDD-NOS. One can hypothesize that if SI has been effective in populations displaying

similar characteristics, such as children with autism or difficulty with sensory

modulation, it might also be a useful intervention with this group of children. Therefore,

in order to contribute to an understanding about the sensory processing and motor skills

of children with AS and related PDDs, and to assess the effectiveness of SI treatment, an

intervention program based on the theories of SI was implemented for children with AS

and PDD-NOS. The purposes of this study were: (a) to objectively quantify the sensory

and motor impairments observed in children with AS and PDD-NOS, (b) to determine if

children with AS or PDD-NOS demonstrate changes in sensory function following SI

intervention as quantified by the Sensory Profile, the Sensory Integration and Praxis

Tests (SIPT) and Clinical Observations, and (c) to determine if children with AS or PDD-




NOS demonstrate changes in motor function following SI intervention as quantified by

the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition.




Methods

This research study was a preliminary study which was intended to examine the

efficacy of SI therapy on the sensory and motor skills of children with AS and PDD-

NOS. Utilizing a one-group pre-test post-test design with a delayed treatment approach,

it sought to provide evidence regarding the level of sensory and motor skills observed in

children with this syndrome. An additional purpose was to determine if SI therapy had

an effect on improving any specific deficits that were identified in this group.

Setting

The evaluation and intervention of the participants recruited for this study took

place in an occupational therapy laboratory within a University setting which contained

equipment necessary to provide SI therapy. An additional, adjacent classroom, which

contained tables and chairs, was also used to conduct testing, when room conflicts or

child distractibility were identified. The occupational therapy laboratory is a 50x35 foot

room which includes equipment such as suspended swings, mats, ramps, scooters and

textured equipment. The room contains two doors for entry and exit, two sinks and a set

of cupboards on one wall and several long tables for completing seated activities, which

can be moved out of the way as needed. The room is equipped with fluorescent light

fixtures and the floors are constructed of vinyl asbestos tiles which are free from damage.

Windows and additional cabinetry line one wall of the room, however since the room is

located in the basement of the building, windows only provide views of a grassy hill, and

shades can be drawn to eliminate distractions or light interference. The ceilings are nine

feet high. Small toys are stored in the drawers, cabinets and portable shelving units




within the room. Mats and other large equipment are stored off the floor, or off to the

sides of the room, leaving a 35 x 24 foot space for treatment to occur.

Due to room conflicts which could not be resolved, a second therapy room with a

large, open area was used for the treatments of one participant for two weeks during the

intervention phase of the study. No suspended equipment was available in the alternate

room, however other equipment in the room was similar to that of the actual treatment

room. Additionally, mobile pieces of equipment were relocated from the original room

to maintain consistency. With the exception of the suspended activities, all other

treatment activities were consistent with the activities listed in the treatment manual.

Participants

Prior to recruiting participants, approval from the University’s Children and

Youth Institutional Review Board was obtained (see Appendix A). At the time of the

study, participants were required to be five to nine years old, with a diagnosis of AS, and

could not be receiving other therapy that utilized an SI approach. After several weeks of

recruitment, permission to accept a diagnosis of PDD-NOS was requested and approved

by the review board, due to difficulty obtaining participants with a definitive AS

diagnosis. Since SI treatment relies on the presence of SI deficits, an additional inclusion

criterion was that participants had SI deficits as determined by initial testing done by the

researcher. Therefore, only children with SI deficits based on initial testing for the study

were eligible to participate in the intervention phase of the research. In order to meet the

standards for the selected battery of tests, subjects were required to be English speaking,

see clearly with or without corrective lenses, and be free of other neurological diagnoses.

An English speaking parent or guardian who was literate and able to provide




transportation to and from the testing and treatment sessions was also required. In order

to account for vacations and illness, subjects were expected to attend at least 17 of the 20

treatment sessions (85%) that were scheduled.

The article entitled The Effects of Occupational Therapy with Sensory Integration

Emphasis on Preschool-Age Children with Autism (Case-Smith & Bryan, 1999) was used

to determine the appropriate sample size for this study. This article evaluated the

effectiveness of a SI treatment protocol on some of the typical behaviors associated with

autism and SI, including mastery play and interaction. Based on an alpha level of .05,

and applying the data from the study, a very large effect size (2.05) was calculated using

the common standard deviation and the mean difference from a paired t-test. A power

table for 80% power indicated that eight subjects were necessary. At the time of study

development, there were approximately 186 children with ASDs between the ages of four

and eleven years, who were being serviced in the county in which the study was

conducted (New York State Office of Vocational and Educational Services for

Individuals with Disabilities (VESID), 2004). Based on an autism to AS ratio of 5:1

(Fombonne & Tidmarsh, 2003), it was conservatively estimated that approximately 37

children with a diagnosis of AS, who were between the ages of 4 and 11 years were being

serviced in the county’s school districts. Since not all children with AS or PDD-NOS

receive services, and diagnosis may be delayed beyond age 11, it was recognized that this

was likely a low estimate of the number of children with AS. As a result of the relatively

small number of potential subjects locally, all potential participants who met the

inclusion criteria, and who agreed to participate by completing consent and assent forms,

were enrolled in the study. During the recruitment period, it was decided to include




children with PDD-NOS, since obtaining study participants who met all study criteria for

AS was becoming difficult. A goal of at least ten subjects was set, based on the power

table described previously and taking into account the possibility of attrition.

Human Subject Protection

Participants were recruited from a University-based clinic that provides speech

and communication services to children with PDDs, and from local psychiatrists, schools

and health care workers who provide services to children with AS or PDD-NOS.

Recruitment of participants also occurred via written advertisements posted at the

University and in offices and schools. Additionally, written fliers were distributed to

parent members of groups and organizations that are affiliated with AS or PDDs. Prior to

the study, a written request for support in recruitment procedures was sent to facilities

and individuals to identify a willingness to assist with the recruitment of participants (see

Appendix B). Letters of support from local service providers can be found in Appendix

C. Appendix D contains radio and written advertisements which were also used to

obtain additional study participants.

The service providers and referral sources who agreed to assist in recruitment

were requested to provide parents of children with AS or PDD-NOS who were between

the ages of five and nine years with an information letter and invitation to participate (see

Appendix E). Written advertisements (see Appendix D) were used to inform the public

of the study. The initial information letter and advertisements explained that this was an

intervention study assessing the effectiveness of SI therapy for children with AS. This

was later revised to include children with PDD-NOS, due to the difficulty in recruiting

children within the age range who had a specific AS diagnosis. Parents were informed




that they could respond, if they were interested in having their child participate, by

calling or contacting the researcher via email to discuss the study details and to schedule

initial testing. At that time, parents who did not already have a copy of the information

letter and invitation were provided with one, and contact information was obtained so that

further parent contact could take place via telephone or mail as necessary. Prior to

testing, parents signed an informed consent form (see Appendix F), accepting the terms

of the study and agreeing to have their child participate. The consent form also indicated

their right to withdraw their child from the study if they wished to do so at any time. The

participants with AS or PDD-NOS were asked to sign an assent form (see Appendix G)

prior to participating, which informed them about what they were expected to do, and

about their right to withdraw from the study.

Information collected for study purposes including the child’s test scores and

other private information, was recorded on the score forms in such a way that both the

parents’ and their child’s identities remained confidential. Since the researcher needed to

formulate a treatment plan for each child based on his or her test results, the researcher

needed to know the child’s name. Since both the researcher and another therapist

conducted the testing during various phases of the research, the child’s first name only

was used during test sessions. The other therapist who administered some of the test

procedures was asked to leave identifying information forms blank, so that code numbers

could be entered by the researcher in order to maintain confidentiality. Once test forms

were returned to the researcher, a code number was assigned to that child. The code

number, rather than the child’s name was used on all testing and treatment paperwork. In

the case that a parent or the tester put the child’s name on the testing forms, the




researcher removed the name with white out, and that child’s code number was put in its

place, in order to identify each participant. With respect to dispersion of study

information, any information regarding this study is and will be reported so that there is

no way that the child can be identified. All forms have and will continue to be stored in a

locked file cabinet in the office of the researcher for seven years, after which time they

will be destroyed.

Study Design

This research study utilized a one-group pre-test post-test design with a delayed

treatment approach. At the initiation of the study, pretesting was conducted using the

pre-study questionnaire, the ASDS, the Sensory Profile, the PEGS, Clinical Observations,

the BOT-2 and the SIPT. To allow subjects to act as their own control, a 5-week

baseline phase, in which no intervention was provided, took place prior to the start of SI

therapy. Midtesting was conducted using the ASDS, the Sensory Profile, the PEGS,

Clinical Observations, the BOT-2 and the SIPT. Sensory integration therapy was

provided for 10 weeks. Therapy sessions took place two days per week, for 45-60 minute

sessions. Post-testing occurred following the 10-week intervention period, and all of the

testing procedures that were followed in the mid-testing phase were repeated.

Instrumentation

Several instruments were used for the collection of data for this study.

Pre-study Questionnaire. Prior to formal testing, a Pre-study Questionnaire (see

Appendix H) was given to the parents during the initial phase of testing. This

questionnaire included demographic data such as the child’s age, gender, AS

characteristics, perceived sensory processing impairments, school setting, and other




services the child was receiving. It was also used to establish that the participant was

English speaking, was able to see clearly with or without corrective lenses, and that he or

she was free of other neurological diagnoses.

The Asperger Syndrome Diagnostic Scale. The Asperger Syndrome Diagnostic

Scale (ASDS) (Myles, Bock, & Simpson, 2001) was completed by parents at all three

testing phases to provide more in-depth information on their child’s AS symptoms, with

respect to language, social and adaptive behaviors, cognition and sensorimotor skills (see

Appendix I). This standardized, norm-referenced test is based on diagnostic criteria from

the DSM-IV, the ICD-10 and an extensive literature review. It has been designed for

children ages 5-18 years. The normative sample used in developing this test included

115 children from throughout the U.S., who were 5-18 years of age, and diagnosed with

AS. The ASDS contains five separate subscales. The first subscale is the Language

Subscale, which addresses receptive and expressive language function. The second

subscale is the Social Subscale, which addresses the child’s eye contact, gestures,

friendships and interactions with others. Next, is the Maladaptive Subscale which

identifies psychological concerns, repetitive behaviors, general behavior and responses to

changes in routine. The Cognitive Subscale addresses memory, intelligence and interests,

and the Sensorimotor Subscale examines the child’s gross and fine motor coordination, as

well as sensory integrative abilities. A test form and a pencil are the only items necessary

to complete the test (Myles et al., 2001).

This assessment was developed to assist in identifying individuals with AS and to

identify changes in AS characteristics over time. In administering this test, parents are

asked to identify observed behaviors which are listed. Subscale scores are added to yield




an AS quotient. This quotient provides the likelihood of a child having AS with 85%

accuracy and has an internal consistency of .83. Higher ASQ scores correspond with

more symptoms of AS, and therefore, a greater likelihood of having a diagnosis of AS.

Cronbach’s alpha of .83 was determined for the ASDS, indicating a very high correlation

between test items and the AS quotient. Subscale consistencies are as follows: Language:

.72, Social: .83, Maladaptive: .80, Cognitive: .64, and Sensorimotor: .67. The interrater

reliability was reported to be high with a correlation coefficient of .93. Content validity

was established, with discrimination coefficients ranging from .47-.67, indicating that

individual items correlate with the total domain measured by the scale. Item construct

validity has also been established by comparing the ASDS to the Gilliam Autism Rating

Scale, identifying a .46 correlation between the two scales (Myles et al., 2001). This

supports the construct validity of the ASDS demonstrating that although the diagnoses

are similar, the ASDS is not screening for autism.

The Sensory Profile. The Sensory Profile (Dunn, 1999) is a parent completed

questionnaire, which assesses the child’s sensory processing and sensory modulation. It

helps to determine areas of sensory processing deficits that may contribute to problems in

completing daily life activities. It was given to the parents to complete at the start of the

study, five weeks into the study, and at the end of treatment (See Appendix J). The

instrument was norm referenced on a group of more than 1,000 children between the ages

of 3 and 10, with and without disabilities. To complete this questionnaire, caregivers

need a score sheet and a pencil.

The Sensory Profile is comprised of 125 questions arranged in a Likert scale.

Low scores on the scale indicate frequent or undesirable behavior that is sensory based.




High scores indicate behavior similar to that of a typically developing child. The test is

made up of three sections. The first section assesses the child’s ability to process sensory

information and is broken down by sensory systems which include: auditory, visual,

vestibular, touch, multisensory and oral. The second section is used to assess the child’s

ability to modulate more than one type of sensory input at a time. This section includes

modulation related to endurance and tone, body position and movement, movement

affecting activity level, input affecting emotional responses, and visual input affecting

emotional responses and activity level. The final section assesses behavioral and

emotional responses, and includes emotional/social responses, behavioral outcomes of

sensory processing and thresholds of response categories. Scores are added for each

section and then used to determine summary scores. Results from the questionnaire also

yield factor summaries that provided information on the child’s sensory seeking

behaviors, emotional reactivity, low endurance or tone, oral sensory sensitivity and

inattention or distractibility, as well as the presence of poor registration, sensory

sensitivity, sedentary behaviors and fine motor and perceptual abilities.

Internal consistency measures for the Sensory Profile ranged from .47-.91, and

standard errors of measurement have been reported to be between 1.0 and 2.8, suggesting

parental scores that are similar to true scores. Content validity was established during

test development. Items were reviewed by a panel of eight experts in SI theory and

practice, and placement of items into categories was agreed upon by 80% of a panel of

155 occupational therapists who were members of the special interest section on SI

through the American Occupational Therapy Association. Thirty-seven items were

identified as being categorized incorrectly, and in those cases, new categories were




developed. By comparing the Sensory Profile to the School Function Assessment (SFA)

(Coster, Deeney, Haltiwanger, & Haley, 1998), moderate to large correlations (.54 to .80)

were identified between the Sensory Profile and the SFA on behavioral regulation and

sensory perception, suggesting convergent validity. Discriminant validity was also

established, with low correlations on specific performance items of the SFA and the

Sensory Profile, suggesting that the Sensory Profile examines sensory processing as a

whole, rather than measuring specific tasks, as the SFA does (Dunn, 1999).

Perceived Efficacy and Goal Setting System. The Perceived Efficacy and Goal

Setting System (PEGS) (Missiuna, Pollock, & Law, 2004) is a picture-based tool which

measures a child’s perceived abilities with respect to functional, daily activities, and

allows a child to assist in creating intervention goals (See Appendix K). The test was

designed for children ages six to nine years, but has been used with five year olds

according to correspondence with the test’s first author. In order to include the children’s

point of view, and to establish a rapport with each child, the PEGS was administered as

the first child-based test at all three phases of testing.

Based on the All About Me (Missiuna, 1998), which measures children’s

perceived abilities on motor tasks, and utilizing cards depicting pictures of children

performing age-appropriate tasks, the PEGS assesses perceptions of performance

primarily on gross and fine motor skills by asking the child to identify which picture most

closely resembles his or her performance on a particular task, and how similar his or her

performance is to the selected card. For example, a child is shown two pictures: one with

a child kicking a ball, and one with a child missing the ball. The pictures are described,

and the child is asked which picture looks like him/her and then, whether or not the




picture is a lot like him/her or a little like him/her. The child’s response corresponds to a

four point rating scale, with one indicating that the child rates him/herself as being very

bad at a particular skill, and four indicating that the child believes he or she is very good

at the skill. Parent and teacher forms are also available, but were not used for the study.

Reliability and validity were established for the PEGS based on an earlier version,

the All About Me, and on a standardization study of 117 six to nine year old children.

Internal consistency of the All About Me identified a Cronbach’s alpha coefficient of

0.85 for both the gross and fine motor scales, and 0.91 for the total measure. Test-retest

reliability of the All About Me was found to have Pearson coefficients of 0.79, 0.76 and

0.77 for the fine motor items, gross motor items and total score, respectively. A

moderate correlation (r=.73) was established between the All About Me and the

Bruininks-Oseretsky Test of Motor Proficiency, (Missiuna et al., 2004).

Clinical Observations. It is generally recommended that clinical observations of

neuromotor performance be used to supplement formal testing in an effort to obtain

additional qualitative information about the child’s functioning (Ayres, 1989; Fisher et

al., 1991). Clinical Observations (see Appendix L), were used in conjunction with the

Sensory Profile and the SIPT at all three phases of the study, to provide this additional

subjective information based on clinical judgment. The Clinical Observations that were

used in this study were adapted from Fisher, Murray and Bundy (1991) and from Ayres

Clinical Observations (as cited in Shriber, 2004). The test battery includes items that are

commonly used to provide information on a child’s sensory modulation, primitive

reflexes, muscle tone, posture, body awareness, bilateral sequencing, motor planning,

coordination and vision (Fisher et al., 1991). In order to guide the examiner through




these items, and to maintain testing consistency between examiners, a Clinical

Observations Worksheet (Appendix M) containing the specific clinical observations,

brief instructions, and possible findings was also used, and the information was then

applied to the Clinical Observations Form for scoring. Although scores on these

observations have not been tested against a normative sample, scoring guidelines are

available that correspond with how the child responds.

The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition. The

Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) (Bruininks &

Bruininks, 2005), was also used to obtain information on the participants (see Appendix

N). This test, which was administered to the children at the beginning of the study, five

weeks into the study, and at the end of the intervention phase of the study, measures the

gross and fine motor performance of individuals, ages 4 to 21 years. The test is broken

down into four composites, each with two subtests. The Fine Manual Control composite

examines fine motor precision and integration. The Manual Coordination composite

assesses manual dexterity and upper-limb coordination. A third composite: Body

coordination, assesses bilateral coordination and balance. Finally, running speed and

agility and strength are assessed in the Strength and Agility composite. The scores from

these subtests are added up to determine a Total Motor Composite Score which can be

used to determine percentile ranks. All composites can also be used to determine age

equivalents, which are broken down by gender, based on data from a normative sample of

1,520 children, ages 4 to 21, representative of the 2001 United States Census and the

Twenty-sixth Annual Report to Congress, in 2004.




Internal consistency reliability has been obtained using Pearson correlations for

subtests and a stratified alpha method for composite scores, and has been reported to

range from moderate to excellent with subtest and composite correlation coefficients

ranging from .60-.97. Test-retest reliability has been established based on a time frame

of 7 to 42 days, with Pearson correlation coefficients averaging .78 (subtest) and .83

(composite) for children ages four to seven years, .76 (subtest) and .83 (composite) for

children ages 8-12, and .69 (subtest) and .77 (composite) for children 13-21 years of age.

Interrater reliability Pearson correlation coefficients range from .86 to .99 for all of the

BOT-2 subtests and composites. In addition, content and construct validity have been

established from a national tryout study conducted by test developers, which

demonstrated validity between subtest score and chronological age. A BOT-2 test kit is

required to administer the test in the standardized manner, and test completion takes

approximately one hour (Bruininks & Bruininks, 2005).

Sensory Integration and Praxis Tests. The children who participated in the study

completed the Sensory Integration and Praxis Tests (SIPT) (Ayres, 1989), at the

beginning of the study, five weeks into the study, and at the end of the intervention phase

(see Appendix O). This series of 17 tests designed for children ages 4 to 8 years, 11

months, extensively assesses their ability to plan and carry out motor actions as well as

various sensory processing abilities. The SIPT is a norm-referenced test based on a

normative sample of 1,750 children from a variety of ethnic backgrounds. There are four

categories of tests, each designed to assess a specific aspect of sensory integration and

praxis. The first category assesses form and space perception. These tests include Space

Visualization, Figure-Ground Perception, Manual Form Perception, and Motor Accuracy




subtests. The second category of tests assess somatic and vestibular sensory processing,

and includes the Kinesthesia, tactile tests (including: Finger Identification, Graphesthesia,

and Localization of Tactile Stimuli), Postrotary Nystagmus, and Standing and Walking

Balance subtests. The third category assesses praxis via the Design Copying, Postural

Praxis, Praxis on Verbal Command, Constructional Praxis, Sequencing Praxis and Oral

Praxis subtests. The final category assesses the child’s ability to perform bilateral

integration tasks and to sequence various tasks. The Bilateral Motor Coordination

subtest, as well as the previously mentioned Oral Praxis, Sequencing Praxis,

Graphesthesia, and Standing and Walking Balance subtests are used to assess this

component of sensory processing. This test is said to be able to be administered in as

little as 1 ½ hours, however experience indicates that approximately three hours are

necessary to complete the entire test battery. If necessary, the test can be given in two

parts in an effort to maintain the child’s attention and endurance for test taking. A SIPT

test kit is required to administer this test, and extensive training and testing is required to

become certified in test administration. The SIPT Manual provides a general description

of the test which was provided to parents by the researcher (See Appendix P).

Validity of the test’s construct has been demonstrated with factor and cluster

analyses in 293 children with and without sensory dysfunction. A subsequent cluster

analysis by Mulligan (2000) was performed on 1,961 children, and resulted in five cluster

profiles being identified. These included: Generalized Sensory Dysfunction and

Dyspraxia, Severe Dyspraxia, Generalized Sensory Integration Dysfunction and

Dyspraxia-Moderate, Low Average Bilateral Integration and Sequencing, and Average

Sensory Integration and Praxis. Tests of concurrent validity have yielded correct




classification of 83-88% of children to whom the test was administered with learning

disabilities or SI dysfunction, based on multiple discriminant analysis. Each of the tests

demonstrated significant ability to discriminate between normal and abnormal sensory

function ( p<.01). Test-retest reliability coefficients have been determined for each

component of the 17 subtests. For this testing, subjects repeated testing 1-2 weeks after

the initial test. The test-retest reliability coefficients that were obtained are as follows:

Space Visualization: .62, Figure-Ground Perception: .54, Manual Form Perception: .69,

Kinesthesia: .33, Finger Identification: .75, Graphesthesia: .72, Localization to Tactile

Stimuli: .54, Praxis on Verbal Command: .88, Design Copying: .94, Constructional

Praxis: .67, Postural Praxis: .88, Oral Praxis: .89, Sequencing Praxis: .84, Bilateral Motor

Coordination: .77, Standing and Walking Balance: .80, Motor Accuracy: .84, Postrotary

Nystagmus: .47. The average reliability coefficient for the SIPT was .74, indicating a

moderate test-retest reliability (Ayres, 1989). The Postrotary Nystagmus subtest is one

subtest that has demonstrated poor test-retest reliability during psychometric testing,

however this same test has yielded more favorable results (.79 to .83) on earlier versions

of the SIPT which utilized identical protocols (Ayres, 1989). As a result of the intensive

training and certification process required to administer the SIPT, interrater reliability has

previously been demonstrated with total accuracy ranging from .94 to .99 for all tests

(Ayres, 1989). Overall the SIPT is the most comprehensive and standardized

performance test available for assessing SI and praxis.

A previous version of the SIPT, the Southern California Sensory Integration Tests

(Ayres, 1972) was not found to be appropriate for test-retest purposes in efficacy studies.

As a result, it had been the position of Sensory Integration International, which until




recently, was the organization that certified individuals in the administration and

interpretation of the test, to discourage using the SIPT to measure change (Bledsoe,

2004b, 2004). Preliminary evidence suggests, however, that the SIPT may be more

sensitive to change than its earlier version, and may therefore be a useful tool in studies

aimed at assessing the effectiveness of SI therapy (Giencke-Kimball, 1990). Since test-

retest reliability has been established, and since this is currently the best tool available to

assess all aspects of SI, the SIPT was utilized to assess change as a result of the

intervention provided to the children. Because of the discrepancy in information

regarding the use of the SIPT for test-retest purposes, it is acknowledged that the results

may need to be interpreted with some caution.

Procedures

Following approval from the Children and Youth Institutional Review Board (see

Appendix A), recruitment for participants took place using three separate methods. First,

clinicians and agencies that had agreed to assist in recruiting participants were asked to

contact the parents or guardians (hereafter referred to as parents) of children who may fit

the study criteria and provide them with a parent information letter and invitation to

participate. This letter provided a general description of the study and inquired about

their interest in having their child participate (see Appendix E). Radio and written

advertisements were also used to recruit potential participants, and were offered to

interested parties of parent support groups (see Appendix D). Parents who contacted the

researcher as a result of the advertisements were given the same parent information letter

and invitation that was provided by the clinicians and agencies. Parents who responded

to the invitation and whose children met the study criteria were provided with an




Informed Consent Form (see Appendix F) that provided further details about the study.

After a signature on the consent form was obtained, the parents completed pre-study

testing regarding their child to determine his or her eligibility and to confirm the presence

of AS symptoms and SI symptoms. Pre-study testing included information obtained from

the parents who were asked to complete a brief pre-study questionnaire (see Appendix

H), the ASDS (See Appendix I), and the Sensory Profile (see Appendix J) to determine if

all inclusion criteria was met. These questionnaires were administered by the researcher

during pre- and mid-study testing. Post-testing was administered by another experienced

occupational therapist certified in administering the SIPT, who had agreed to participate

in this process by responding to a written request to assist in the test administration

process (see Appendix Q). Each parent was instructed by the researcher on how to

complete the Sensory Profile and the ASDS based on the directions from the test

manuals. Parents were also asked to complete the questionnaires based on their child’s

function at that particular point in time. Once all of the parents’ questions were

addressed, they were asked to complete the pre-study questionnaire, the ASDS and the

Sensory Profile. Children who were reported by their parents as meeting basic study

criteria, who scored an AS quotient of at least an 80 on the ASDS, and who were

determined to have at least one factor or section that indicated a “Probable Difference” on

the Sensory Profile were identified as being appropriate for the study. Recruitment of

participants was discontinued when all recruitment resources had been exhausted.

Children with AS or PDD-NOS whose parents provided consent were provided

with an assent form (see Appendix G) that provided information about the study in a

manner that could be easily understood by the children. Following receipt of the child’s




assent, pre-testing of the child occurred. Each child was assessed using the PEGS (see

Appendix K), Clinical Observations (see Appendices L and M), the BOT-2 (see

Appendix N) and the SIPT (see Appendix O). Pre-testing took place over two to three

sessions. Since the researcher needed to know all test results in order to develop a

treatment plan for each individual child, and there were a limited number of clinicians

who are certified to administer the SIPT, it was deemed appropriate by her advisors for

the researcher to conduct pre- and mid-study testing. Therefore, all pre- and mid-study

testing was performed by the researcher, and all post-testing was completed by an

occupational therapist who had previously been trained and certified to administer the

tests. The order of the test administration to the children was as follows: First, the PEGS,

and then Clinical Observations were administered in order to establish a working

relationship with the child and to obtain initial information. Next, the BOT-2 was given.

It was expected that most children would be able to complete this test in one session,

however completion in the second session was allowed for those children who displayed

difficulty in completing the test in session one. In the second testing session, the SIPT

was administered. Due to the length and level of concentration necessary for this test, a

third session was available for subjects who were unable to complete the SIPT in one

day. Rest periods were provided throughout the testing sessions as needed by each child.

For some children, all testing was completed in one day, with an extended lunch break

used to separate testing sessions. Each phase of testing took place over the course of no

more than a seven day period.

Interrater reliability between the researcher and the second examiner was

established for Clinical Observations, the BOT-2 and the SIPT. Within the time frame of




the study, the examiner tested one study participant whose parents had provided consent,

and who had signed an assent form. Clinical Observations, the BOT-2 and the SIPT were

administered to the child. Both examiners were present during this testing process and

simultaneously scored the child.

Upon completion of the first round of testing, participants entered a 5-week

baseline period during which no study-related interventions took place and the families

were instructed to carry on with their typical routines. Approximately two and one half

weeks into the baseline phase, the family was contacted via telephone to ensure that there

were no significant changes in routine, to answer any questions, and to schedule the

second round of testing. Following the baseline period, the ASDS, the Sensory Profile,

the PEGS, Clinical Observations, the BOT-2 and the SIPT were administered for a

second time, using the same protocol as the one used for pre-study testing. The

researcher administered the mid-study tests to the parents and the children five weeks

after the initial testing took place. Midtesting began within one week of the conclusion of

the baseline phase.

Once testing had been completed for the second time, and within one week of the

completion of midtesting, the 10-week intervention phase began. This consisted of one-

on-one sessions, two days per week, for approximately 45-60 minutes in duration, as

recommended by Fisher, Murray and Bundy, (1991). Upon arrival to each session, the

parent of the child was asked to provide any information that might be useful in

providing optimum therapy that day, such as whether or not the child was feeling well, or

if any abnormal activity or circumstance took place since the last session. After this

information was obtained, the session began.




The researcher, who has been trained and certified in SI evaluation and

intervention, conducted all treatment sessions. Sessions followed a SI frame of reference,

which provides the child with specific sensory input in a child-directed activity in order

to improve the child’s ability to process and integrate the input and produce a more

appropriate adapted behavior, (Fisher et al., 1991). Using the results from pre and mid-

study testing, treatment plans were developed based on activities listed in the treatment

manual (see Appendix R). The activities offered during each session were based on

specific areas of weakness identified for each child prior to and during the intervention.

The treatment area was arranged in a way that would entice the child into selecting

appropriate activities. Whenever possible, the child was given the opportunity to select

which activity would be performed, and to provide the guidelines for the activity. For

example, a child might decide to use the net swing for the next activity, and would guide

the therapist as to what “game” would be played (bean bags, rings, rope pull, knocking

into objects). At that point, a theme was agreed upon by the child and the examiner.

Examples include flying on a hot air balloon, building a predetermined structure, such as

a house, and having a treasure hunt.

Every attempt was made to maintain treatment fidelity throughout the study.

Sensory integration theory requires intervention to be highly individualized based on

previous testing and observations made during the session. Therefore, prior to initiation

of the study, a Treatment Manual (see Appendix R) was created by the researcher based

on documented treatment recommendations provided by experts in the field of SI and

was utilized by the researcher throughout the study. The manual incorporates the

theoretical basis for treatment, guidelines for treating, and acceptable activities. A list of




sample treatment activities was provided for each area of concern so that treatment

protocols between children and from session to session remained similar. A list of

acceptable activities was developed for each possible area of need in order to standardize

the treatment and allow for replication of the study. Examples include activities

involving suspended equipment, weights and deep pressure, pushing and pulling,

climbing, jumping and hitting, heavy and resistive activities, and resistive manipulative

activities using materials such as therapy putty (Bundy et al., 2002; Fisher et al., 1991;

Huebner, 2001; Watling, 2004). A checklist and progress note was completed by the

therapist-researcher at the end of every session indicating how the treatment was

conducted (see Appendix S). The progress note included documentation of the specific

order of activities, and was completed at each activity transition during the sessions. The

checklist, which was based on the ECOTUSII, developed by Parham, Cohn, Koomar and

Miller (Watling, 2004), provided a means for evaluating whether or not the key principles

of SI were followed during each session. The researcher’s advisor served as an outside

examiner and observed five random interventions. She also completed the progress

checklist to assess for treatment adherence and therapist competence.

Following completion of the 10-week intervention period, posttesting took place.

This phase of testing began within one week of the final intervention session. Parents

completed the ASDS, and the Sensory Profile, and children completed the PEGS,

Clinical Observations, the BOT-2, and the SIPT. In order to minimize researcher bias,

post-testing was conducted by a licensed occupational therapist trained and certified in

test administration, and who was blind to initial test scores and treatment activities. The




study was considered complete once all posttesting had been completed. Data analysis

followed.

Neither participants, nor their parents were financially compensated for their

participation in this study. As a way of expressing thanks and wishing the child well,

each child received a small trinket of less than ten dollars in value at the end of the study.

Examples include a gift card to a restaurant, or a favorite toy used during the study.

Other than travel expenses to and from the testing and treatment site, no additional costs

were incurred by the participants. Assessment and treatment services were provided free

of charge. Child-specific results from final testing were offered to the parents of the

participants in the form of a summary report following post-testing. Overall results of the

study will be made available to the parents following data analysis and interpretation of

the study results.

Data Analysis

All data was recorded and analyzed in SPSS version 15. Descriptive statistics

were used to report demographic data such as such as age, gender, diagnosis and other

services the child was receiving. To test hypothesis one to determine if children with AS

and PDD-NOS have sensory and motor impairments, the scores achieved by the subjects

on the ASDS, the Sensory Profile, the BOT-2 and the SIPT were compared to established

norms. Based on the information provided in the procedural manuals for each of the

instruments, specific criteria was selected for each test to determine if the participants had

greater impairments than typically developing children. Frequencies of findings were

determined for the ASDS, the Sensory Profile, the BOT-2 and the SIPT, as well as for




Clinical Observations in order to identify the impairments most commonly reported and

identified for the children in the study.

To test the second and third hypotheses, which tested if children with AS and

PDD-NOS demonstrate improvements in sensory processing or motor skills following SI

intervention, scores for the ASDS, Sensory Profile, BOT-2 and the SIPT were analyzed

using repeated measures analysis of variance (ANOVA) in order to compare changes

within individual participant scores across test sessions. Additionally, individual Clinical

Observations item scores were added together in meaningful groups to form subcategory

total scores which were then compared using repeated measures ANOVA. A p value of

less than .05 was considered to be significant. Post hoc testing using pairwise

comparisons was performed to determine whether improvements were related to

intervention. If significant differences were evident from pretest to posttest, or from

midtest to posttest that were not present from pretest to midtest, the hypotheses that

sensory processing or motor skills will improve following SI therapy would be accepted.

The researcher conducted all of the testing during the pretest and midtest phases

of the study. In order to prevent researcher bias, a second examiner conducted the

posttesting for each child who completed the intervention phase. This second examiner

was trained and certified to administer the tests, and was blind to the purposes of the

study, the children’s test scores and the goals and activities performed during

intervention.

Interrater reliability testing was completed for one child during the post-testing

phase. The child was selected based on convenience with scheduling, and the posttesting

phase was selected for reliability testing in order to prevent bias by the second examiner.




The child completed the typical testing protocol for Clinical Observations, the BOT-2

and the SIPT. Both of the examiners observed and scored the tests simultaneously. Their

scores were then compared using the intraclass correlation coefficient (ICC) model three

for a single measurement (Portney & Watkins, 2000). An ICC of at least .75 is

considered good interrater reliability. Since the ASDS and the Sensory Profile are

parent-rated, and the PEGS is child-rated, it was not necessary to determine the rate of

agreement between the two examiners for these instruments.

Use of Data Collected

Data from this study provides preliminary, quantifiable information regarding the

sensory and motor impairments observed in children with AS and PDD-NOS. Analysis

provides initial information on the efficacy of SI therapy in a group of children with AS

and PDD-NOS as determined by results on the Sensory Profile, Clinical Observations,

the SIPT, and the BOT-2. The results from this study can be used to support a larger

clinical trial of the efficacy of SI treatment on the sensory and motor skills of children

with AS and PDD-NOS.




Results

Introduction

This chapter will present the results obtained from this study. The study had three

primary purposes. It was designed to quantitatively assess the presence of sensory

impairments and the presence of motor impairments in children with AS and PDD-NOS,

and to determine if the sensory and motor skills of these children improved following a

10-week intervention utilizing SI therapy. First, background information, information

regarding recruitment of the participants and demographic data and will be reported. The

second section will report the results obtained prior to intervention. This information will

include pretest data, which was obtained upon initial enrollment of the children in the

study, as well as midtest data, which was obtained five weeks later, just prior to the onset

of intervention. The next section in this chapter will describe the data obtained during

post-testing, which was conducted after the 10-week intervention phase. Finally, a

description of the interrater reliability between the researcher and the post-test examiner

will be provided.

Recruitment

Initial contact was made with the parents of 25 children. From this group, seven

families declined participation. Two primary reasons were given. Either families were

unable to commit to the time requirements, or they were looking for specific programs

such as day programs or social groups. Of the remaining 18, two children had no

diagnosis, and three children had diagnoses of autism, cerebral palsy or attention deficit

hyperactivity disorder that excluded them from the study. Three additional children were

already receiving therapy that provided sensory-based treatment, and one child was a




participant in a different study involving children with Asperger’s Syndrome, making

these four children ineligible to participate in this research. The remaining nine children

were enrolled in the study. Six children completed all three testing phases of the study.

An initial criteria for inclusion in the study was for each child to have a known or

suspected diagnosis of AS. After several months of recruitment, it became apparent that

many children between five and nine years of age were either not given a specific

diagnosis, or were given a diagnosis of PDD-NOS. Several parents contacted the

researcher expressing interest in the study, but indicated that their child had a diagnosis

of PDD-NOS with characteristics of AS. Therefore, after approval from the Children and

Youth Institutional Review Board, the inclusion criteria for the study was broadened to

include both a diagnosis of AS and a diagnosis of PDD-NOS with symptoms of AS. In

either case, children who were accepted into the study were required to meet established

scoring criteria on the Sensory Profile and the Asperger Syndrome Diagnostic Scale, in

order to confirm the presence of sensory symptoms and symptoms of AS. All nine of the

initial participants met these requirements.

Demographics

Eight out of the nine participants originally recruited were male, and their ages

ranged from 58 to 111 months, with an average age of 81.9 months (6.8 years).

Participant diagnoses varied. Thirty-three percent of the children (3/9) had a diagnosis of

AS, while 55% (5/9) had a diagnosis of PDD-NOS with characteristics of AS. One child

was reported by a psychologist to have “characteristics of AS”, but had not received an

official diagnosis at the time of the study.




Services

Sixty-seven percent of the participants (6/9) were receiving occupational therapy

that did not utilize sensory based techniques. In most cases, children were receiving

occupational therapy for handwriting activities or muscle tone issues. With parental

permission, contact was made with the occupational therapist either directly or indirectly

through the parent, to confirm that the therapist was not using a sensory-based treatment

approach. One child’s therapist reported use of suspended equipment and tactile

activities at the end of some sessions, as a reward to the child for good behavior and

agreed to avoid use of these activities during the study. Another child had not received

any therapy over the summer months just prior to the start of his enrollment in this study.

His mother requested a change in his Individualized Education Plan for the first part of

the school year, until his involvement in the study ended. One child was receiving

physical therapy at the time of the study, and seven out of nine of the children (77.8%)

were receiving speech therapy services.

Attrition

Over the course of the study, three participants withdrew from the study, resulting

in a total of six children who completed the study. One child withdrew prior to mid-

testing, due to the time commitment necessary. Another child’s mother withdrew him

during mid-testing, as he was having an especially difficult time with the rigorous testing

protocol. A third child withdrew five weeks into the intervention phase because of

unresolved medical issues that were not related to the study, and because of time

commitment concerns. All six of the children who completed all three phases of the

study were male and they ranged in age from 58 to 101 months with a mean age of 79.7




months (6.6 years). Three of the children had a diagnosis of AS, two had a diagnosis of

PDD-NOS and one child had “characteristics of AS”. Five of the six children were

receiving occupational therapy, one child was receiving physical therapy and four

children were receiving speech therapy.

Pre-intervention findings

Pre-intervention data was collected in order to address the first study hypothesis

which was to determine if children with AS and PDD-NOS have sensory or motor

impairments. The following section describes the data obtained on the participants

before any intervention was provided. Information about the baseline sensory and motor

impairments that exist in children with AS and PDD-NOS is described.

All of the participants who were enrolled in the study underwent two phases of

testing prior to the intervention phase. Upon enrollment, pretesting was conducted to

obtain initial data. All nine participants completed this phase. Children then underwent a

five-week baseline phase, in which the child and his or her family were asked to maintain

all typical, daily activities and routines. After five weeks, participants returned for a

second phase of testing which is referred to as the midtest phase. This phase of testing

took place just prior to the onset of the intervention phase. One child withdrew during

this phase, and therefore the data from eight participants was included in the midtesting

data analyses.

The Asperger Syndrome Diagnostic Scale (ASDS). The ASDS was completed by

the parent of each child at pretesting and again at midtesting, which took place just prior

to intervention. The ASDS is used as a screening tool to determine the likelihood of

having a diagnosis of AS. It addresses several areas that are typically impaired in persons




with a diagnosis of AS. A higher score in an ASDS subtest is indicative of greater

impairment in that subcategory. The scores from each of the subtests are added together

and used to determine the Asperger Syndrome Quotient (ASQ). To be eligible for

enrollment in the study, the participants were required to obtain an ASQ value of at least

80, which indicates that the child has a possible diagnosis of AS. Quotient scores above

90 suggest a likely diagnosis of AS and correspond to a percentile rank of 21%. Scores

above 110 correspond to a percentile rank of greater than 77% and indicate that it is very

likely that the child has a diagnosis of AS. Therefore, a high percentile ranking suggests

more symptoms that are indicative of AS. Children whose scores were above the 50

th

percentile were considered to have impairments that were greater than children who are

typically developing. At least half of the participants scored above the 50th

percentile on

the Language, Social, Maladaptive Behavior and Cognitive subscales, and more than half

of the participants scored below the 50th

percentile on the ASQ (See Figure 1). Even

though parents were unaware of the specific scoring criteria for inclusion, all participants

received ASQ scores above 80. Pretest and midtest ASQ scores for all children ranged

from 88 to 122, with a mean ASQ score for the two test phases of 106.3 (see Table 1).




0%

20%

40%

60%

80%

100%

120%

L a n g u a g e

S o c i a l

M a l a d a p t i v e

C o g n i t i v

e

S e n s o r i m o t o r

A S Q

Subtest

P e r c e n

t a g e ( % )

Pretest

Midtest

Figure 1. Percentage of Participants Whose ASDS Scores Were Above the 50th

Percentile.




Table 1

Mean Scores and Percentage of Recruited Participants Scoring Above the Fiftieth

Percentile on the Asperger Syndrome Diagnostic Scale Indicating Impairments in the

Given Subcategory

Subtest Mean

(N=17)

Pretest

(N=9)

Midtest

(N=8)

Language (Expressive Language and

Pragmatics) 6.8 6 = 67% 4 = 50%

Social (Interactions with others) 9.1 5 = 56% 5 = 63%

Maladaptive (Abnormal or immature

behaviors) 8.2 8 = 89% 8 = 100%

Cognitive (Memory and thinking) 8.2 6 = 67% 6 = 75%

Sensorimotor (Sensory and motor skills) 3.6 6 = 67% 3 = 38%

Asperger Syndrome Quotient (ASQ) 106.3 7 = 78% 7 = 88%

Note. Mean is calculated using pretest and midtest scores.

Sensory Profile. The Sensory Profile was given to the parents to identify areas of

sensory processing that they perceived to be affected in their child. This questionnaire

was completed by parents at the pretesting phase, and again at midtesting which occurred

five weeks after the pretest but prior to any intervention. Subtest scores are used to

identify if the child is typical, probably different from, or definitely different from other

children who are typically developing. Children who scored in the probable difference or

definite difference ranges were considered to have sensory processing impairments that




were greater than those of children who are typically developing. Parental responses on

the Sensory Profile suggested that every child in the study was perceived to have

impairments in multiple areas of sensory processing. Out of the 23 areas investigated by

the Sensory Profile, more than 50% of the parents perceived sensory processing

impairments in 21 of those areas including seven of the nine Sensory Profile Factors (see

Table 2) and all 14 of the Sensory Profile Sections (see Table 3). All of the parents rated

their children as being emotionally reactive and easily distracted. All of the parents also

reported their children as having atypical emotional responses, and rated their children as

being unable to modulate sensory input, which in turn, affected their emotional

responsivity levels. Additionally, all of the parents reported abnormal behavioral

outcomes associated with sensory processing. The Sensory Profile further categorizes a

child’s performance as being definitely different from the normative data or probably

different from the normative data. Figures 1 and 2 identify the percentages of children

reported as being definitely different from typically developing children (see Figures 2

and 3).




Table 2

Percentage of Participants Scoring in the Probably Different or Definitely Different

Categories on Sensory Profile Factors Indicating Impaired Sensory Processing

Subtest Pretest

(N=9)

Midtest

(N=8)

Sensory Seeking (actively seeks additional sensory input) 8 = 89% 8 = 100%

Emotionally Reactive (excessive emotional reaction to

sensory input) 9 = 100% 8 = 100%

Low Endurance/Tone (tires easily or shows signs of low tone) 6 = 75%a 5 = 63%

Oral Sensory Sensitivity (overly sensitive in and around the

mouth) 6 = 67% 5 = 63%

Inattention/Distractibility (easily distracted or inattentive) 9 = 100% 8 = 100%

Poor Registration (difficulty receiving and processing sensory

input) 8 = 89% 8 = 100%

Sensory Sensitivity (overly sensitive to sensory input) 3 = 33% 3 = 38%

Sedentary (often inactive) 4 = 44% 3 = 38%

Fine Motor/Perceptual (detailed motor skills such as

handwriting) 6 = 67% 5 = 71% b

a Complete data available for eight participants due to a missing response.

bComplete

data available for seven participants due to a missing response.




Table 3

Percentage of Participants Scoring in the Probably Different or Definitely Different

Categories Indicating Impaired Sensory Processing

Subtest Pretest

(N=9)

Midtest

(N=8)

Auditory Processing (sound) 9 = 100% 7 = 88%

Visual Processing (vision) 7 = 78% 7 = 88%

Vestibular Processing (movement) 9 = 100% 7 = 88%

Touch Processing 9 = 100% 6 = 75%

Multisensory Processing (multiple, simultaneous sensory

experiences) 8 = 89% 7 = 88%

Oral Sensory Processing (mouth) 6 = 67% 6 = 75%

Sensory Processing Related to Endurance/Tone 6 = 75%a 5 = 63%

Modulation Related to Body Position and Movement (levels

of fear with respect to movement of the body) 6 = 67% 6 = 75%

Modulation of Movement Affecting Activity Level

(frequency of movement) 9 = 100% 6 = 75%

Modulation of Sensory Input Affecting Emotional Responses

(personal hygiene and interactions with others) 9 = 100% 8 = 100%

Modulation of Visual Input Affecting Emotional Responses

and Activity Level (use of vision in personal interactions) 9 = 100% 7 = 88%

Emotional/Social Responses (inappropriate behaviors) 9 = 100% 8 = 100%




Table 3 (continued). Percentage of Participants Scoring in the Probably Different or

Definitely Different Categories Indicating Impaired Sensory Processing

Subtest Pretest

(N=9)

Midtest

(N=8)

Behavioral Outcomes of Sensory Processing (efficiency in

tasks such as writing and tolerance to change) 9 = 100% 7 = 100% b

Items Indicating Thresholds for Response (reactions to

smell, participation in play) 9 = 100% 8 = 100%

aComplete data available for eight participants due to a missing response.

bComplete data

available for seven participants due to a missing response.




020

40

60

80

100

120

S e n s. S e e k

E m o t. R e a c t.

L o w E n d / T o n e

O r a l S e n s.

I n a t t n / D i s t r.

P o o r R e g .

S e n s. S e n s i t i v.

S e d e n t a r y

F i n e M

o t o r / P e r c e p

Factor Category

P e r c e n t a g e ( % )

Pretest Midtest

Figure 2. Percentage of Participants Rated as Having Definite Differences from the

Normative Sample on Sensory Profile Factors.

0

20

40

60

80

100

A u d. P r o c.

V i s. P r o c.

V e s t i b. P r o c.

T o u c h P r o c.

M u l t i. P

r o c.

O r a l P r o c.

P r o c. R e l. t o E n d /...

M o d. R e l. t o B o d y

M o d. O f M v m t. A f..

M o d. O f I n p u t A f..

M o d. O f V i s.

I n p u t

E m o t. / S o c. R e s p.

B e h a v. O u t c o m e s

T h r e s h o l d s

f o r R e s p.

Section Category


Pretest Midtest

Figure 3. Percentage of Participants Rated as Having Definite Differences from the

Normative Sample on Sensory Profile Sections.




Perceived Efficacy and Goal Setting System (PEGS). Each child completed the

PEGS in order to obtain his or her personal perspective regarding his or her ability to

perform a variety of motor skills. The PEGS was administered to each child at pretest,

and again five weeks later at midtest, just prior to the start of intervention. Individual

item scores range from one which indicates very poor performance on a given item, to

four which suggests very good performance on an item. These individual scores are

summed to yield a total score. The highest possible total score on the PEGS is a 96,

which would indicate that the child rated himself or herself as “very good”

(corresponding with a score of four) on every item. Out of a possible 96 points, pretest

scores ranged from 59 to 95 and midtest scores ranged from 50 to 96. In order to obtain

these high total scores, children would have had to rate themselves as being good or very

good on most items. Generally speaking, the children’s individual total scores were not

similar between the two test phases.

Clinical Observations. Clinical observations, which were adapted from Fisher,

Murray and Bundy (1991) and from Ayres Clinical Observations (as cited in Shriber,

2004), were done on each child at pretest, and also at midtest just prior to the start of

intervention, in order to obtain additional information regarding the development and

maturity of his or her nervous system. These Clinical Observations were grouped

according to the type of skills that were assessed. Sensory modulation items assessed

very basic responses to sensory input, such as the ability to react appropriately to changes

in body position and sensory experiences, as well as moving on the floor. One hundred

percent of the participants were able to react appropriately to items involving changes in

body position and various sensory experiences, and most children (89% and 88% at




pretest and midtest, respectively) tolerated movement on the floor without difficulty. Just

over half of the participants (56% at pretest and 63% at midtest) reacted appropriately to

tactile input. Clinical Observations indicated that approximately 60% of the participants

had inappropriate levels of activity for the situation at both pretesting and midtesting.

Only 22% were able to maintain prone extension during pretesting and 13% of

participants were able to maintain prone extension during midtesting. Approximately

half of the participants were able to appropriately stabilize their bodies in a quadruped

position. The participants’ ability to maintain appropriate muscle tone in extended

positions ranged from 44% at pretest to 63% at midtest. Bilateral integration was

assessed using a variety of movement sequences and patterns. Most children showed a

hand preference and were able to cross the midline of their body. Approximately half of

the participants demonstrated signs of right-left confusion, and almost all (78% and 100%

at pretest and midtest, respectively) of the participants had difficulty with motor praxis

skills such as catching a bounced ball or hopping. With the exception of in-hand

manipulation, for which approximately 65% of the participants were successful, praxis

(motor planning) was an area of difficulty for the majority of participants. Finger to

thumb touching and supine flexion were especially difficult for these participants. The

percentage of children who were able to correctly touch each finger to his or her thumb

was 11% at pretest and 13% at midtest. In the pretesting phase, 44% of the children were

able to maintain supine flexion, however only 25% maintained this position during

midtesting. The percentage of children who demonstrated associated movements was

78% at pretest and 87% at midtest. At pretesting, 33% of the children were able to

accurately touch their finger to their nose and 38% of the participants were able to




perform this movement at midtesting. Approximately 33% of the participants were able

to perform slow ramp movements at pretesting, 63% of the participants successfully

performed slow ramp movements at midtesting. At pretesting, 44% of the participants

were successfully able to automatically protect themselves from falling forward,

backwards and sideways in long sitting, tall kneeling and standing. Seventy-five percent

of the participants demonstrated protective extension in these positions at midtesting.

While 67% and 63% of the participants were able to visual track objects at pre and

midtesting, respectively, only 44% of the children were able to converge and diverge

their eyes to follow an object at pretest. The ability to converge and diverge was reduced

to 38% at midtest. Just under 56% of the children were able to perform quick

localization movements with their eyes at pretest, and 63% were able to perform quick

localization movements at midtest. (see Figure 4).

0%

20%

40%

60%

80%

100%

120%

A c t i v i t y L e v e l

P r o n e E

x t e n s i o n

M o t o r S k i l l s

F i n g e r / T h u m b

A s s o c. M v m t.

F i n g e r / N o s e

Clinical Observation Items


Pretest

Midtest

Figure 4. Percentage of Participants Impaired On Selected Clinical Observations




Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). The

BOT-2 was administered to obtain quantitative information about the participants’

abilities to perform gross and fine motor skills. This test was given to the participants at

pretesting, and also at midtesting, which occurred just prior to the start of intervention.

Composite scores are obtained by summing the scores of different subtests within the

BOT-2, providing a broader picture of motor skill performance. On all of the composite

scores of the BOT-2 during pretest and midtest, the children demonstrated difficulties in

motor skill performance. Subtest and composite scores can be used to obtain percentile

ranks based on age and gender referenced norms. Scores that are equal to or below the

18th

percentile are equivalent to one standard deviation below the mean. Therefore, a

percentile score of 18 was used to identify children whose impairments were greater than

typically developing children. More than half of the children in the study scored below

the normative values on the Fine Manual Control, Manual Coordination and Body

Coordination Composites (see Table 4).




Table 4

Percentage of Participants Whose Bruininks Oseretsky Test of Motor Proficiency

(BOT-2) Composite Scores Fell At or Below the Eighteenth Percentile Compared to

Normative Data Indicating Impaired Motor Skills

BOT-2 Composite Scores Pretest

(N=9)

Midtest

(N=8)

Fine Manual Control (Fine Motor Precision and Fine

Motor Integration ) 5 = 56% 5 = 63%

Manual Coordination (Manual Dexterity and Upper-Limb

Coordination) 6 = 67% 4 = 50%

Body Coordination (Bilateral Coordination and Balance) 8 = 89% 7 = 88%

Strength and Agility (Running Speed and Agility and

Strength) 4 = 44% 3 = 38%

Sensory Integration and Praxis Tests (SIPT). The SIPT was completed by each

participant in order to obtain quantitative data regarding his or her sensory skills. This

test utilizes a computer-based scoring system which provides subtest scores up to three

standard deviations above or below the mean. A score of one standard deviation below

the mean was used to identify an impairment that was greater than that of a typically

developing child. At both the pretest and the midtest phases of the study which were

completed prior to initiation of intervention, participants demonstrated scores below one

standard deviation from the mean on all 17 subtests of the SIPT. There was a wide

variability in the frequencies of children performing below one standard deviation on




each subtest. All of the children scored below one standard deviation from the mean on

the standing and walking balance subtest, at both the pretest and the mid-test phases of

the study. More than 50% of the children scored below one standard deviation from the

mean on either the pretest or the midtest for the following subtests: Location of Tactile

Stimulation, Praxis on Verbal Command, Design Copying, Postural Praxis, Oral Praxis,

and Graphesthesia (see Table 5).




Table 5

Percentage of Participants Scoring Below One Standard Deviation From the Mean on

the SIPT Subtests Based on a Normative Sample of Children

SIPT Subtest Pretest

(N=9)

Midtest

(N=8)

Space Visualization 1 = 11% 2 = 29%

Figure Ground 1 = 11% 2 = 29%

Manual Form Perception 4 = 44% 1 = 14%

Kinesthesia 2 = 22% 5 = 71%

Finger Identification 4 = 44% 2 = 29%

Graphesthesia 4 = 44% 4 = 57%

Location of Tactile Stimuli 5 = 56% 3 = 43%

Praxis on Verbal Command 5 = 56% 3 = 43%

Design Copying 5 = 56% 2 = 29%

Constructional Praxis 3 = 33% 2 = 29%

Postural Praxis 6 = 67% 4 = 57%

Oral Praxis 7 = 78% 6 = 86%

Sequencing Praxis 4 = 44% 2 = 29%

Bilateral Motor Control 2 = 22% 1 = 17%

Standing Walking Balance 9 = 100% 7 = 100%

Motor Accuracy 4 = 44% 2 = 29%

Postrotary Nystagmus 3 = 33% 2 = 29%




Post-intervention findings:

This section will report the data obtained after ten weeks of SI therapy, during the

posttesting phase of the study. Since data analysis in this section compared posttesting

scores to those scores obtained during the pretesting and midtesting phases of the study,

these results provide information regarding the effectiveness of the intervention. Due to

the withdrawal from the study of three of the original participants, post intervention

testing was completed on six children.

Interrater Reliability.

The testing in this study was completed by two different examiners. The primary

researcher conducted the tests during the pretest phase and the midtest phase. The tests

during the posttest phase were administered by a second examiner who was blind to the

purposes of the study, the children’s test scores and the goals and activities performed

during intervention. An Intraclass Correlation Coefficient (3,1) was used to provide

information about the level of agreement between the two examiners on the performance

based tests, which included Clinical Observations, the BOT-2 and the SIPT.

On Clinical Observations, the examiners agreed on 22 out of 24 possible items,

demonstrating consistency with scoring. The interrater reliability for the raters was

ICC=.46 ( p<.05), 95% CI (.07, .72). Since the data in Clinical Observations are

dichotomous, a Cohen’s Kappa was also obtained. The results from a kappa analysis

were Kappa = .45 ( p<.05). The raters’ standard scores for the BOT-2 were also

compared. The raters scored exactly the same on one out of four possible standard

scores, and scored nearly the same on the remaining three. The interrater reliability for

the raters was ICC=.88 ( p<.05), 95% CI (.01, .99). An ICC was also obtained for the




SIPT scores. The examiners agreed on 10 out of 17 possible scores. The interrater

reliability for the SIPT was ICC=.55 (p<.05), 95% CI (.11, .81).

The Asperger Syndrome Diagnostic Scale (ASDS). The ASDS provides

information regarding the presence of symptoms that are often present in a person who

has AS. A lower post-test score on the ASDS indicates that the child demonstrated fewer

AS characteristics following intervention. The mean ASQ score at posttest was 99.2.

This is a decrease, and therefore an improvement, from the mean pretest and midtest

score of 106.0 and 106.3, respectively. Analysis using Repeated Measures of ANOVA

indicated that scores showed a tendency to improve after intervention, particularly in the

area of Maladaptive behaviors. These changes however, were not significant (see Table

6).




Sensory Processing. Analysis using Repeated Measures of ANOVA was used to

compare Sensory Profile scores at each phase of the study. Sensory Profile results

indicated several improvements in the children’s ability to process sensory information

following SI therapy. Significant improvements ( p<.05) were noted from midtest to

posttest in Sensory Seeking behaviors which decreased. Significant improvements were

also noted from midtest to posttest in Auditory Processing, Modulation of Movement

Affecting Activity Level and Modulation of Visual Input Affecting Emotional Responses

and Activity Level ( p<.05). Several other areas approached significance. Areas

approaching significance in their improvement included Fine Motor and Perceptual skills

( p=.08), Multisensory Processing ( p=.08), and Modulation Related to Body Position and

Movement ( p=.08) (see Tables 7 and 8). Additionally, Touch Processing improved

significantly, however the improvement was noted across all phases of the study.




Sensory Integration and Praxis Test. Objective findings of a child’s ability to process

sensory information were obtained using the SIPT. Analysis using Repeated Measures of

ANOVA was performed in order to identify any significant SIPT score differences after

intervention. Significant improvements were noted on four subtests which included:

Constructional Praxis, Postural Praxis, Oral Praxis and Standing and Walking Balance

(See Figure 5). Children’s performance significantly decreased following intervention on

the Bilateral Motor Control subtest (see Table 9).

-3

-2

-1

0

1

SIPT Subtests

Pretest

Midtest

Posttest

Figure 5. Mean Scores on Selected SIPT Items at Pretest, Midtest and Posttest

Constr.Praxis

PosturalPraxis

OralPraxis

Stand/WalkBalance

Kinesthesia Graphesthesia

S t a n d a r d D e v i a t i o n s F r o m t h e M e a n




Motor Skill Performance

Bruininks Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). The

BOT-2 was conducted to assess the motor skills of the study participants. Repeated

Measures of ANOVA was used to analyze data from the BOT-2, in order to identify any

significant score differences following intervention. Several children showed

improvements on their BOT-2 scores after ten weeks of SI therapy. Significant

improvements were noted for the Balance subtest from pretest to posttest, and results for

the Running Speed and Agility subtest approached significance (see Table 10).




Clinical Observations. Each child performed a series of short tests known as

Clinical Observations, which are meant to provide the examiner with information

regarding the maturity and development of the child’s nervous system. In an effort to

manage the number of items in Clinical Observations, related items were grouped

together into subcategories which were then analyzed using repeated measures ANOVA.

Praxia, which assesses a child’s ability to motor plan through skills such as touching each

finger to the thumb, and alternating supination and pronation of the wrists, approached

significance ( p=.05). Bilateral Integration also approached significance ( p=.06), which

suggests that when using Clinical Observations as a measure, children also improved in

their ability to correctly use both sides of their body in the performance of a motor skill

(see Table 11).




Treatment Fidelity

On four random occasions, an outside examiner observed the treatment sessions

and also completed the Progress Note and Checklist. Results were compared. The

results from each of the four visits identified that the therapist and the outside examiner

agreed on all aspects of the checklist except for one item. The therapist and the outside

examiner did not agree on the length of time that the intervention was child directed.

Summary of Results

The participants in this study demonstrated impairments in sensory processing

and motor skills. In addition, behaviors such as inattention and abnormal emotional

responses to sensory experiences were identified. A ten-week intervention phase was

effective in improving some areas of sensory processing, some motor skills and some

behaviors (see Table 12). The results from this study provide preliminary evidence to

support the use of SI therapy in children with AS and PDD-NOS.




Table 12. Summary Table of Impairments and Areas of Improvement

Behaviors or Functions

Impairments

Prior to

Intervention

Improvements

Following

Intervention Instrumentation Used

Inattention/Distractibility X ASDS, Sensory Profile

Emotional/Social

Responses X ASDS, Sensory Profile

Behaviors X X

ASDS, Sensory Profile,

Clinical Observations

Sensory Seeking X Sensory Profile

Sensory Processing X X SIPT, Sensory Profile

Modulation of Sensory

Input X X Sensory Profile

Balance X X SIPT, BOT-2

Praxis X X

SIPT, BOT-2, Clinical

Observations

Coordination X

SIPT, BOT-2, Clinical

Observations

Strength and Agility X BOT-2




Discussion

Introduction

This was an initial efficacy study which had three primary purposes. First, it was

intended to provide evidence regarding how children with AS and PDD-NOS process

sensory information. Its second purpose was to provide evidence regarding the level of

motor skill performance observed in this group. A third purpose was to determine if SI

therapy had an effect on improving any specific sensory and/or motor deficits that were

identified in this group of children. A one-group pre-test post-test design with a delayed

treatment approach was utilized to test the research hypotheses.

In this chapter, the results of the study will be discussed. It will begin with a

discussion of the relationships between the study results and the proposed hypotheses.

This will provide evidence as to the nature and severity of sensory and motor

impairments in children with AS and PDD-NOS. It will also provide evidence as to the

effectiveness of SI therapy on the sensory and motor skills of the study participants. The

second section will discuss the relationship of the results to the conceptual framework

which provided the basis for the study. Next, relationships between the findings of this

research study and the findings from previous, related research studies will be identified

and discussed. The fourth section will discuss additional findings which were not

included in the study hypotheses, but provide useful information regarding children with

ASDs and SI therapy. The strengths and limitations of the study design and data

collection methods will follow. Finally, implications for practice will be discussed, along

with recommendations for future research as it applies to children with AS and PDD-

NOS.




Relationship of the Results to the Stated Hypotheses

This study had three primary hypotheses. The hypotheses were (a) children with

AS and PDD-NOS will demonstrate sensory and motor impairments when compared to

normative samples, as identified by the Sensory Profile, the Sensory Integration and

Praxis Tests (SIPT) and the Bruininks-Oseretsky Test of Motor Proficiency, Second

Edition (BOT-2); (b) parents will report an improvement in the children’s sensory

modulation and integration, and the children will exhibit improved sensory processing

following SI therapy as demonstrated by scores on the Sensory Profile and the SIPT, and

(c) children will demonstrate improved motor performance following SI therapy as

demonstrated by higher scores on the BOT-2.

First, it was hypothesized that children with AS and PDD-NOS would

demonstrate sensory and motor impairments when compared to normative samples, as

identified on the Sensory Profile, SIPT and the BOT-2. To address this first hypothesis,

pretest and midtest scores on the Sensory Profile, the SIPT and the BOT-2, were

compared to established age and gender referenced norms.

In order to assess the sensory processing abilities of children with AS and PDD-

NOS, the parents of the participants were asked to complete the Sensory Profile at the

pretesting and the midtesting phases of the study. The Sensory Profile is a parent-rated

questionnaire which provides a parent’s perspective as to the nature and severity of his or

her child’s ability to process sensory information and use it in daily activities.

Participants whose scores were classified as probably different or definitely different

were on the Sensory Profile were considered to have greater impairments than children

who are typically developing. The participants in this study were identified as being




typically different or definitely different from the normative sample on all 23 subtests of

the Sensory Profile. More than half of the parents reported impairments that were greater

than typically developing children in 21 of those areas. Subjectively, this supports the

hypothesis that children with AS or PDD-NOS have sensory impairments as compared to

normative samples on the Sensory Profile. On both pretest and midtest, which occurred

prior to the start of the intervention phase, 100% of the participants were rated by their

parents to have difficulty in several areas of sensory processing. Some of the most

common sensory impairments in this cohort included Emotional Reactivity, Inattention or

Distractibility, Modulation of Sensory Input Affecting Emotional Responses, Emotional

or Social Responses and Behavioral Outcomes of Sensory Processing. Emotional

reactivity can be described as having an emotional reaction to sensory input that is more

than would typically be expected. A child who is considered emotionally reactive may

be overly sensitive to criticism, may cry easily or may offer more than typical affection

towards others. A poor score on Inattention and Distractibility would be identified in

children who tend to be easily distracted or inattentive. Emotional and Social responses

describe inappropriate or immature behaviors, such as throwing temper tantrums, having

signs of low self esteem or having excessive fears that interfere with daily routines.

Behavioral Outcomes of Sensory Processing are those daily activities that require the

ability to process sensory information, such as writing, performing tasks efficiently and

tolerating changes in routine. It appears from the results that the sensory processing

impairments identified in the children in this study frequently affect their behavior and

their ability to control their emotions. Less common parental concerns, where fewer than

50% of the children were rated as being probably different or definitely different include




Sensory Sensitivity, which describes a child who, for example, is overly fearful of

movements and heights, and Sedentary behaviors which describe preferences toward

quiet activities or activities that do not require much movement.

In addition to the information that was obtained using the Sensory Profile, The

SIPT was also used at the pretest phase and at midtesting, just prior to intervention, in

order to objectively assess the sensory processing abilities of children with AS and PDD-

NOS. The SIPT is a performance-based test which can provide evidence regarding a

child’s ability to process sensory information and plan motor actions. Scores are

computer generated, and output is in the form of standard deviations. Children whose

scores fell below one standard deviation from the mean were considered to have

impairments greater than children who are typically developing. The participants in this

study fell below one standard deviation from the mean on each of the 17 subtests of the

SIPT. All of the children were considered to have greater than typical impairments on

the Standing and Walking subtest, which assesses a child’s ability to maintain his or her

balance while performing standing and walking tasks with his or her eyes open or closed.

In addition, more than half of the participants scored below one standard deviation on

either the pretest or the midtest on the following subtests: Praxis on Verbal Command,

Postural Praxis, Oral Praxis, Design Copying, Location of Tactile Stimulation and

Graphesthesia. The Praxis on Verbal Command subtest requires a child to position

himself or herself correctly following only verbal directions. Postural Praxis on the other

hand, requires the child to mirror the body positions made by the examiner when no

verbal cues are given. Oral praxis is similar, however the positions and tasks are limited

to the mouth and tongue. Design Copying involves copying line drawings from a printed




image. Location of Tactile Stimulation requires a child to identify which of his or her

fingers were lightly touched when vision was occluded. Finally, on the Graphesthesia

subtest, the examiner draws a simple set of lines on the back of the child’s hand when

vision is occluded, and the child is asked to repeat the drawing with his or her eyes open.

A theme that emerged from these findings was that the children in this study experienced

difficulty with motor planning tasks regardless of the visual or verbal input he or she

received. This was true on more isolated motor tasks such as drawing or oral motor

activities, as well as on whole body tasks such as imitation, standing and walking. In

addition to supporting the parent perceptions on the Sensory Profile, the results from the

SIPT provided quantitative data to support the hypothesis that children with AS and

PDD-NOS have sensory impairments that are greater than typically developing children.

Based on the Sensory Profile and the SIPT, the participants in this study were

impaired in many areas of sensory processing and integration, as compared to normative

data for each of the tests. The hypothesis that the children would demonstrate

impairments is accepted for impairments in Emotional Reactivity, Inattention or

Distractibility, Modulation of Sensory Input Affecting Emotional Responses, Emotional

or Social Responses, Behavioral Outcomes of Sensory Processing, Sensory Sensitivity

and Sedentary behaviors as measured by the Sensory Profile. The hypothesis can also be

accepted for impairments in Standing and Walking Balance, Praxis on Verbal Command,

Postural Praxis, Oral Praxis, Design Copying, Location of Tactile Stimulation and

Graphesthesia as measured by the SIPT. It is important to note that although the

impairments that are listed do not include every area of sensory processing that was




evaluated during the pretesting and midtesting, every area of sensory processing and

integration was impaired in at least one study participant.

Another purpose of the current study was to examine the motor skills of children

with AS and PDD-NOS. In order to identify if motor skill impairments existed in this

group of children, the BOT-2 was administered during the pretest and midtest phases of

the study, prior to the intervention phase. The BOT-2 is a performance-based test which

provides objective information regarding a child’s ability to perform gross and fine motor

skills. The scores achieved by the subjects on the BOT-2 were compared to established

age and gender referenced norms. If subjects fell at or below the 18

th

percentile they

were considered to have greater impairments than children who are typically developing.

Subtest scores are combined to form composite scores in four key areas of motor skill

performance: Fine Manual Control, Manual Coordination, Body Coordination and

Strength and Agility. On all of the composite scores obtained during pretest and midtest,

more than half of the participants were found to score below the 18th

percentile for their

age and gender. As a group, the children had the most difficulty with the Manual

Coordination and Body Coordination composites. The Manual Coordination composite

examines a child’s manual dexterity in tasks such as sorting cards, stringing blocks and

placing pegs in a pegboard. It also assesses upper-limb coordination through a series of

ball skills using a tennis ball. The Body Coordination composite assesses bilateral

coordination including hand tasks, hand and feet tasks, and whole body skills, as well as

standing balance skills on the floor and on a narrow balance beam. These findings

suggest that perhaps the children’s greatest difficulties with respect to their motor skills is

in their inability to coordinate their bodies to perform fine motor and gross motor




movements. The data obtained provides quantifiable evidence to support the hypothesis

that the children with AS and PDD-NOS in this study had motor impairments as

compared to children in the normative sample of the BOT-2 who were typically

developing. Therefore, the hypothesis is accepted for impairments in Manual

Coordination and Body Coordination. The children were also impaired in other areas of

motor skill performance, including Fine Manual Control and Strength and Agility,

although these impairments were less frequent.

In addition to the data obtained from standardized testing using the Sensory

Profile, the SIPT and the BOT-2, Clinical Observations, which are used as a supplement

to standardized testing, were also completed on the participants at pretesting, midtesting

and posttesting. Through a series of short and simple tasks, the examiner is able to gain

additional information regarding the development and maturity of the child’s nervous

system. The Clinical Observations in this study were grouped according to the type of

skills that were assessed. Frequencies of findings were determined for each subtest of the

Clinical Observations in order to identify the impairments most commonly reported for

the children in the study. In the area of sensory modulation, children had the greatest

difficulty maintaining appropriate levels of activity for the testing situation. High levels

of energy were observed in each of these cases. More than half of the children were

found to have difficulty reacting appropriately to tactile stimuli. In other areas of basic

sensory modulation, such as the ability to tolerate changes in body position and

movement, most of the children performed in a typical manner. These findings were

consistent with parent reports on the Sensory Profile, which identified a general ability of




the children to tolerate movement and changes in body position, but difficulties with

attention and distractibility.

Controlling their posture was also relatively difficult for the participants in this

study. A majority of the participants had difficulty maintaining a prone extension posture

at both pretest and midtest, and only about half of the children were able to stabilize their

bodies in a quadruped position. The ability of the children to maintain appropriate

muscle tone varied between pretest and midtest, however it should be noted that at least

40% of the participants showed signs of low muscle tone at both the pretest and midtest

phases. Parents also reported low endurance and tone on the Sensory Profile.

Another area that was assessed through Clinical Observations was Bilateral

Integration. It was assessed using a series of activities that progressed in difficulty. In

general, most children showed a hand preference and were able to cross the midline of

their body. These skills are expected in children who are five to nine years of age.

Typically, children in this age group are able to differentiate between their right and left

sides. Approximately half of the participants in the study showed signs of right-left

confusion. The final observation of bilateral integration involved higher level skills such

as catching a bounced ball, hopping and jumping. In this area, a majority of the

participants demonstrated signs of difficulty. These findings of poor bilateral integration

with higher level skills were confirmed by the results obtained on the subtests of both the

SIPT and the BOT-2 that measured similar skills.

Clinical Observations also provided information about each child’s ability to plan

motor actions. The results from Clinical Observations indicated that praxis was another

area of difficulty for the children in this study. While these results may have been related




in part to the children’s low muscle tone, no more than half of the children were able to

assume and maintain a supine flexion position. Although most children were able to

manipulate a small object in their hands, an overwhelming majority of the participants

could not demonstrate smooth finger to thumb opposition without visual assistance. In

addition, no more than half of the children were able to coordinate their hands to rapidly

alternate moving from supination to pronation at either the pretest or the midtest.

Some of the Clinical Observations are designed to assess the maturity of the

central nervous system. These observations, which are expected to be seen in children

five to nine years of age, include touching the finger to the nose with the eyes closed,

performing slow upper extremity (ramp) movements, and automatically protecting

oneself from falling. At both pretest and midtest, more than half of the children had

difficulty touching their finger to their nose with their eyes closed. On the ramp

movement subtest which assesses bilateral integration, praxis and proprioceptive

awareness, the frequencies of children who were able to perform this task varied greatly

between pretest and midtest. Responses on the protective reactions subtest also varied.

On midtest, more than half of the children were successfully able to perform both of these

skills. Associated reactions also fall into the category of Clinical Observations, but they

are expected to be integrated, and therefore not seen during typical activities performed

by children in this age group. More than half of the participants demonstrated associated

movements or fixing patterns during typical activities. Since the ability to perform

activities correctly, without associated movements relies on a mature central nervous

system to process and integrate information from a variety of sensory and motor sources,

the findings of associated movement reactions suggest the possibility of a lack of




maturity within the central nervous system. Caution should be used when interpreting

this however, since formal neurologic testing would be required for confirmation.

Finally, Clinical Observations provide information about a child’s ability to move

his or her eyes in a smooth and controlled pattern. Most children in this study were able

to track an object and perform quick localization skills with their eyes. An area of

difficulty for the participants however was in eye convergence and divergence. More

than half of the participants were unable to perform this skill. It should also be noted that

in general, children required the use of their eyes to guide them in the performance of

various tasks. When vision was occluded in activities such as finger to thumb touching,

identifying shapes through touch, and balancing skills, several of the children were either

unable to perform the task, or became anxious or frustrated. The children’s reliance on

vision was noted during all three phases of testing, however their tolerance for

performing skills without the use of their vision seemed to improve following

intervention.

Although Clinical Observations are not standardized, they are a useful supplement

to standardized testing. Since each Clinical Observation is performed to assess a separate

item, it is difficult to make specific conclusions from the findings. Clinical Observations

are said to provide additional information to the therapist regarding nervous system

maturity (Fisher et al., 1991). Overall, it appears that children with AS and PDD-NOS

are able to perform basic skills, such as tolerating simple touch and movement, moving

the eyes for basic tracking, and crossing the midline of the body. This suggests nervous

system maturity at a basic level. As the skills become more challenging however, such as




is needed for prone extension, hopping and finger to thumb touching, performance

declined noticeably, perhaps suggesting signs of an immature nervous system.

In addition to assessing the sensory and motor skills of children with AS and

PDD-NOS, this study examined the effectiveness of SI therapy. The second hypothesis

was that parents would report improvements in their children’s sensory modulation and

integration and the children with AS and PDD-NOS would show improvements in

sensory processing skills following ten weeks of SI therapy. To address this hypothesis,

scores for the Sensory Profile and the SIPT were analyzed using repeated measures

analysis of variance (ANOVA) in order to compare changes within individual participant

scores. Post hoc analysis was completed for those subtests that showed significant

changes in order to identify if the significant improvements were evident following

intervention. If significant differences were evident in the post-test scores that were not

evident between the pre- and mid-tests, the hypothesis that sensory processing would

improve following SI therapy would be accepted.

Nine Sensory Profile factors were analyzed to determine if significant differences

were evident following SI therapy. The Sensory Seeking factor, which describes

children’s responses to sensory input, improved significantly ( p<.05) following

intervention. Post hoc analysis identified significant (p<.05) changes between pretest and

posttest, and also between midtest and posttest. This means that parents reported less

frequent attempts by their child to seek out and provide himself or herself with additional

sensory input.

Three sections of the Sensory Profile, which examine how information is

processed by the specific senses, also showed significant improvement following




intervention. These include Auditory Processing, Modulation of Movement Affecting

Activity Level and Modulation of Visual Input Affecting Emotional Responses and

Activity Level ( p<.05). Post hoc analysis revealed significant improvements in Auditory

Processing from pretest to posttest ( p<.05). Modulation of Visual Input Affecting

Emotional Responses and Activity Level assesses a child’s ability to use visual input

appropriately during personal interactions. Examples include the ability to make eye

contact, and the ability to recognize but not visually obsess about the actions of others. In

this subtest, children demonstrated significant improvement from pretest to posttest

(p<.05). Significant differences were also identified for Modulation of Movement

Affecting Activity Level which assesses whether a child is “constantly on the move” or is

more sedentary. For this subtest however, when post hoc analyses were completed, the

results did not indicate significant differences.

Repeated measures ANOVA approached significance on four other subtests of the

Sensory Profile. These tests included Fine Motor and Perceptual Skills ( p=.08),

Multisensory Processing ( p=.08) and Modulation Related to Body Position and

Movement ( p=.08). An improvement in Fine Motor and Perceptual skills reflects

improvements in a child’s ability to perform fine motor skills such as writing and

drawing. An improvement in Multisensory Processing points to improvements in a

child’s ability to process information that is entering the body from more than one

sensory system. Finally, the results on the Modulation Related to Body Position and

Movement subtest suggest that following the 10-week intervention phase, the children

were better able to control the amount of movement in which they engaged.




While the Sensory Profile was useful in obtaining the parents’ perceptions of their

children’s abilities to process sensory information during the various phases of the study,

in order to obtain objective data on the children’s sensory processing abilities, the SIPT

was used. These results indicated that following intervention, significant improvements

were noted on four out of seventeen of the subtests of the SIPT. Participants showed

significant improvements in Constructional Praxis, Postural Praxis, Oral Praxis and

Standing and Walking Balance ( p<.05). These findings suggest improvements in three

areas of motor planning which include planning required to construct complex structures

out of blocks, planning required to imitate body positions, and planning required to

imitate mouth and tongue movements. The ability to maintain balance and coordinate the

body during standing and walking tasks also improved significantly following SI therapy.

It should be noted that the areas of praxis and standing and walking balance were the

same areas found to be most impaired in the children prior to intervention. In each of

these subtests, changes were significant from pretest to posttest and from midtest to

posttest, suggesting that the improvements were related to the intervention. Additionally,

Location of Tactile Stimuli, which assesses a child’s ability to identify which fingers

were touched when vision was occluded, approached significance ( p=.06). This was also

identified as an area of difficulty for more than half of the participants prior to

intervention.

The results of improved praxis and balance are of great interest. In her discussion

of praxis, Ayres (1972) states that “the effectiveness of a child’s action upon the

environment will reflect accuracy of sensory input” (Ayres, 1972, p. 127). Additionally,

Ayres states that higher level sensory processing such as praxis occurs only after more




basic sensory processing occurs (Ayres, 1972). Based on the results from the SIPT, the

children showed the greatest improvements in areas of motor planning even though task-

specific motor planning skills were not addressed in intervention. By providing

opportunities for sensory processing within each of the sensory systems, perhaps the

treatments that were provided during the intervention phase allowed the children

opportunities to receive adequate sensory feedback in order for more refined, and

ultimately higher level sensory processing, such as praxis to occur.

Since parents reported significant improvements following SI therapy, and the

objective findings from the SIPT identified some significant improvements following SI

therapy, the hypothesis that the sensory processing abilities of children with AS or PDD-

NOS will improve following SI therapy is accepted for improvements in Sensory

Seeking, Auditory Processing, Modulation of Movement Affecting Activity Level and

Modulation of Visual Input Affecting Emotional Responses and Activity Level which

were assessed with the Sensory Profile. It is also accepted for improvements in

Constructional Praxis, Postural Praxis, Oral Praxis and Standing and Walking Balance as

measured by the SIPT. Significant improvements were not identified for Emotional

Reactivity, Low Endurance and Tone, Oral Sensory Sensitivity,

Inattention/Distractibility, Poor Registration, Sensory Sensitivity, Sedentary Behaviors,

and Fine Motor/Perception which were measured by the Sensory Profile. Other areas that

did not show significant improvements following SI therapy that were measured by the

Sensory Profile were Visual, Vestibular, Touch, Multisensory and Oral Sensory

Processing, Sensory Processing Related to Endurance/Tone, Modulation Related to Body

Position and Movement, Modulation of Sensory Input Affecting Emotional Responses,




Emotional and Social Responses, Behavioral Outcomes of sensory processing, and Items

Indicating Thresholds for Response. Improvements were identified but were not

significant for several other subtests of the Sensory Profile. The SIPT subtests that did

not demonstrate significant changes following intervention were Space Visualization,

Figure Ground, Manual Form Perception, Kinesthesia, Graphesthesia, Location of Tactile

Stimulation, Praxis on Verbal Command, Design Copying, Sequencing Praxis and

Bilateral Motor Coordination. Therefore, the hypothesis that the participants would show

improvements in sensory processing following SI therapy is rejected for these areas.

The third and final hypothesis was that children would demonstrate improved

motor performance following SI therapy as demonstrated by higher scores on the BOT-2.

In order to address this hypothesis, posttest scores from the BOT-2 were compared to

pretest and midtest scores using repeated measures ANOVA. The results indicated that

the participants demonstrated significant improvements ( p<.05) on the Balance subtest,

with significant changes occurring from pretest to posttest. Additionally, significance

was approached on the Running Speed and Agility subtest ( p=.07), which assessed a

child’s running speed and ability to perform repetitive stepping and hopping skills. This

means that children demonstrated more success in balancing and coordinating their

bodies to perform complex motor skills following the intervention. Composite scores

were not significantly impacted following intervention. Therefore, since significant or

nearly significant improvements were noted for two subtests of the BOT-2 during posttest

that were not present for pretest or midtest, the third hypothesis is accepted for the

specific areas of balance and running speed and agility. Therefore, it appears that certain

areas of motor function can be improved following SI therapy. It should also be noted




that the participants did not demonstrate significant improvements in Fine Motor

Precision, Fine Motor Integration, Manual Dexterity, Upper-Limb Coordination, Bilateral

Coordination or Strength, which may suggest that some types of motor skills, such as

balance, running and agility may respond better to ten weeks of SI therapy than other

types of motor skills.

Relationship of the Study to the Conceptual Framework

This study was based on two primary concepts. First, it was based on the belief

that the sensory and motor symptoms exhibited by children with AS and PDD-NOS are

the result of abnormalities within the nervous system. It was also based on the theory of

Sensory Integration which suggests that the body must accurately receive and process

sensory input from the environment in order for a person to respond with appropriate and

goal-directed behaviors. This section will investigate the results of the study protocol as

they relate to the conceptual frameworks which served as the foundations for this study.

The first concept to guide the development of this study was that there is a

neuropathophysiological cause to the disorders addressed in this study. Previous research

has reported neural connection abnormalities within the central nervous systems of

children with AS and PDDs in general (Huebner, 1992). These neural connection

abnormalities correspond to the sensory and motor impairments which have previously

been identified in persons with AS and PDDs. It is important to note that this study was

not intended to identify the specific neurological abnormalities within the brain. Internal

abnormalities within the central nervous system however, have been linked to physical

impairments that are observed in children with AS and PDD-NOS (Huebner, 1992).

Therefore, it is worthwhile to review the neurological structures that have been




implicated in AS and PDD-NOS and where appropriate, offer support, albeit indirect, to

the current base of knowledge.

It appeared to be evident through testing and observation that the participants in

this study experienced a variety of sensory and motor impairments. To summarize, their

greatest areas of difficulty appeared to be inattention and distractibility, impaired balance

and praxis and poor bilateral coordination. In addition, the children experienced sensory

processing impairments that seemed to affect their ability to react in a socially and

emotionally appropriate manner within their environment. Several structures within the

brain have been identified as having an influence over these sensory and motor processes.

The brainstem for example, is involved in attention, balance, and coordination (Huebner,

1992). The basal ganglia and the cerebellum are both involved in the planning and

production of motor actions. In addition to its involvement in praxis, the cerebellum is

involved in balance and coordination (Kandel et al., 1991; Leonard, 1998; Zigmond et al.,

1999). The highest functioning portion of the brain, the cerebrum, is involved in motor

planning and execution, bilateral motor coordination, muscle control, posture and

voluntary movement, (Kandel et al., 1991; Leonard, 1998; Zigmond et al., 1999) all of

which relate to impairments that were identified in the participants of the current study.

In addition, metabolic differences within the cerebrum (Murphy et al., 2002) have been

linked to the same types of social impairments and obsessive or ritualistic behaviors that

were reported and observed in the participants in this study. The functions of the parietal

lobe, which include selective attention, and possibly, bilateral coordination, vision and

spatial awareness (Huebner, 1992) also relate to the results of the current study, which

suggested that the participants had impaired attention, bilateral coordination and spatial




awareness, as well as a possible overreliance on vision. The amygdala within the limbic

system is involved in emotional behaviors and it is also involved in learning that requires

multisensory processing. It is also important for attending to relevant stimuli (McAlonan

et al., 2002). While it was not possible, nor was it within the realm of this study to

determine if the participants had abnormalities within the structures of their brains, the

fact that they displayed some significant impairments in sensory and motor skills linked

to these neurological structures may offer some support for the possibility of a

neurological basis for the sensory and motor impairments that are seen in children with

AS and PDD-NOS.

Previous research on the nervous systems of persons with ASDs has identified

several areas that may be implicated. One of the findings of this study was that the

children had impairments in balance, coordination and motor planning, as well as rigid

and emotional behaviors and difficulties with attention. Three structures within the brain

have been indicated to control this unique combination of both motor performance and

behaviors and attention. These include the brainstem, the cerebrum and the parietal lobe.

The impairments observed in the study participants seem to have the strongest

connections to two of these structures. As has been suggested in previous literature

(Bailey et al., 1998; Palmen et al., 2004) the brainstem, with its extensive connections to

and from many of the structures within the brain may not function effectively in children

with AS and PDD-NOS. Therefore, if the neurological messages to and from the

brainstem are not being received and sent correctly, impairments such as decreased

attention, poor balance and incoordination can result. The participants in this study

demonstrated impairments in all three of these areas associated with brainstem function.




The children in this study also appeared to have difficulty with skills that involved

higher-level sensory processing and motor planning. Examples of these skills include

imitation skills, balance skills, hopping and nonreciprocal movements. The cerebrum

which controls these higher level functions may also therefore have an impact on the

deficits observed in the participants. Dysfunction at this level of the brain may account

for the poor motor planning, and impaired bilateral motor coordination that was observed

in the participants. In addition the social impairments and rigid behaviors that were

reported and observed in the participants of this study may be the result of abnormalities

within the cerebrum.

Other neurological researchers have suggested that children with PDDs have

impairments in multiple neurological areas, and that the connections between different

areas of the CNS are most likely impaired (Coleman & Betancur, 2005; Just et al., 2004;

Sears et al., 1999). Although every child in this study demonstrated signs of sensory and

motor impairments, and some similarities were identified, the nature and severity of the

sensory and motor impairments differed between the children. This supports the idea that

their impairments may be due to abnormal connections between several neurological

areas, rather than an abnormality in one specific area. Since SI therapy is intended to

improve neural connections, the findings of some improved sensory and motor skills

following SI intervention also help to offer some support for the concept that providing

opportunities for the nervous system to refine its neural connections may result in

improved function.

In addition to associating the neurological structures of the brains of children with

ASDs to how they function, this study was also based on the theory of Sensory




Integration, which provides a framework for understanding sensory processing

dysfunction and the SI treatment approach. According to SI theory, all aspects of the

nervous system must work together to register and process sensory information in order

for the individual to produce appropriate motor and behavioral responses within his or

her environment (Ayres, 1989; Linderman & Stewart, 1999). Based on this theory, the

sensory processing impairments identified in the participants in this study may have

contributed to the children’s difficulties in behaving appropriately and producing age-

appropriate movements.

The process of sensory integration involves several steps. First, the body must

recognize that a stimulus occurred. Next, the body must attend to and interpret the

stimulus. It can then organize and execute a response to the stimulus (Williamson et al.,

2000). When a child is successful in sensory processing, and he or she is able to regulate

the sensory information that is entering the system, an appropriate and graded response

should occur (McIntosh et al., 1999). The process of SI also involves several sensory

systems. It is through the interaction of the three primary sensory systems, which include

the tactile, vestibular and proprioceptive systems, that a child’s body scheme and praxis

develop (Brasic-Royeen & Lane, 1991). This internal map of the body, and the ability to

plan motor actions are a requirement for efficient performance of motor skills.

Individually, the children in this study demonstrated impairments in some or all three of

the primary sensory systems through the scores they obtained on the Sensory Profile,

Clinical Observations, and the SIPT. Based on their scores on the SIPT and the BOT-2,

the children also demonstrated difficulty with performing appropriate and graded

responses to a given stimulus. The findings of poor praxis, and difficulty producing




appropriate and graded movements, are the physical manifestations that suggest that the

nervous system may be struggling to make the appropriate connections at one or more

points along the SI pathways. The impairments that were identified in both the sensory

and motor skills of the study participants lend support to the idea that a child’s ability to

process sensory information can affect his or her ability to perform motor tasks.

Just as impairments in sensory processing can affect the performance of motor

skills, Laurent and Rubin (2004) described the emotional frustration that accompanies

sensory dysfunction, which occurs as a result of the child’s inability to appropriately

interact with his or her environment and with others (Laurent & Rubin, 2004). These

emotional frustrations were noted during the testing sessions, as the tasks involved in the

testing became more difficult. Emotional frustrations were also reported by the parents.

Other theories that have been proposed also provide a conceptual basis for the

current study. For example Bernstein (as cited in Thelen, 1995) states that movement

requires the nervous system to adequately adapt to changes within the environment, to

changes in body properties and to task demands. This may explain why the children in

this study were often able to perform basic skills, but demonstrated signs of increased

frustration and poor performance when the skill level was increased. The Theory of

Neuronal Group Selection (TNGS) suggests that every action is an opportunity for the

nervous system to reorganize and improve its efficiency (Hadders-Algra, 2000; Thelen,

1995). Similarly, the dynamic systems approach supports the idea that the entire system

will self-organize in order to achieve stability (vonHofsten, 1989). Initially, at pretest

and at midtest which occurred just prior to the 10 week intervention, the children were

often inefficient in skills involving motor planning, balance and bilateral coordination.




Using the ideas suggested by Bernstein, the TNGS and the dynamic systems approach as

frameworks, one could suggest that the children’s nervous systems were having difficulty

with the process of neural reorganization and refinement. By allowing the children to

guide their own participation in sensory-based activities within a safe and nonthreatening

environment during the study, an opportunity for their nervous systems to potentially

form more efficient neural pathways, which ultimately resulted in improvements in their

sensory and motor skills seemed to occur. It should be noted that the intervention phase

of this study did not involve the repetitive performance of skills which were examined

during testing. In fact, tasks which were similar to the testing situation were specifically

avoided in the intervention phase, so as not to cause a training effect.

Within the realm of SI, how a child processes various forms of sensory input has

also been described. In the specific area of sensory processing, four categories of

processing have been identified. Together, these categories create a spectrum of sensory

thresholds regarding how a person responds to sensory input from the environment.

These thresholds include low registration, sensory seeking, sensory sensitivity and

sensation avoiding. With low registration, the individual requires more sensory input

than is being provided before he or she can recognize its presence. A child who is

sensation seeking, actively attempts to provide him or herself with additional sensory

experiences in order to recognize and feel the input. A child who has sensory sensitivity

becomes easily distracted or overwhelmed by sensory input, and if the child is sensation

avoiding, he or she will set rigid limits on the amount of sensory input that is received

(Dunn, Saiter et al., 2002). These categories of sensory processing have been supported

by physiologic evidence. For example, in a study by Davies and Gavin (2007) which




compared electroencephalography (EEG) and event-related potentials (ERP) in children

with sensory processing disorders and children who were typically developing, the EEG

and ERP results suggested that participants with sensory processing disorders had

difficulty ignoring irrelevant sensory information. They were also less able to organize

incoming sensory information (Davies & Gavin, 2007). Additionally, McIntosh, Miller

and Hagerman (1999), found that children who had sensory modulation disorders

demonstrated either no skin conductance electrodermal response or more frequent

responses and larger magnitudes compared to subjects who were healthy controls.

According to the authors, this suggests either underresponsive or overreactive responses

to sensory stimuli in children with sensory modulation disorder. Additionally, the

participants with sensory modulation disorder demonstrated slower habituation rates to

sensory stimuli and their parents reported more behavioral abnormalities on the Short

Sensory Profile (McIntosh et al., 1999).

The results of the current study suggest that the children who participated can be

described as falling into many or all of the four categories of sensory processing. This

seemed to depend on the situation and the system that received the input. One of the

focuses of the intervention provided in this study was to improve the children’s abilities

to modulate the sensory input from one or a variety of sources, in order to produce a more

appropriate adaptive response. This was accomplished by providing opportunities for

their nervous systems to be able to recognize appropriate incoming stimuli and ignore

irrelevant sensory input. As treatment progressed, the children in this study appeared to

improve in their ability to tolerate and process sensory input from a variety of sources.

They were also able to tolerate a wider variety of intensities of sensory input while




maintaining an active and alert state and engaging in purposeful, goal-directed play.

These findings support the use of SI therapy for children with AS and PDD-NOS. It

seems that the active and frequent participation in sensory-rich experiences allowed the

children’s nervous systems to recognize that sensory input was entering the system and

that it was able to refine its neural connections through active participation and repetition

so that eventually, a more appropriate adaptive response was elicited. With each

successful interaction with the environment that can occur during SI intervention, the

theory suggests that the child will become more comfortable with the sensory experience

and more willing to participate in future interactions with his or her environment. This

appeared to be the case during the posttesting phase of the study, where some participants

demonstrated a new willingness to try the activities, even if they were not yet capable of

performing them correctly.

As has been indicated, the methodology utilized in this study was based primarily

on the SI theory. In accordance with this theory, the study attempted to provide classic SI

therapy, which was based on individual needs as determined throughout the intervention

process. Using a structured environment which was created by the therapist, the children

in this study participated in child-directed, one-on-one therapy sessions that lasted 45-60

minutes. Two sessions were completed each week for a period of 10 weeks. All six

children who completed the post-testing phase participated in at least 17 out of 20

possible sessions. Every effort was made to allow for the child to direct the therapy

session. In some cases however, particularly in the early treatment sessions, more

direction from the therapist was necessary. The children were offered choices to select

from available activities rather than allowing for “free reign” which may have resulted in




a non-productive session. More specifically, these choices were offered due to the

severity of the children’s sensory processing impairments, their inability to independently

select developmentally appropriate activities, or their desire to engage in activities that

were either too easy or overstimulating for their systems. Equipment was offered in such

a way that over time, each child gained more and more control over what activities he or

she would do. The child was also responsible for selecting the theme for the task, thus

giving additional meaning to the activity. By providing a sensory rich environment and

encouraging active, meaningful participation at a level that was neither too easy, nor too

difficult, the participants in the study had an opportunity to create new and more

appropriate responses to the sensory input provided.

To maintain the use of a sensory integrative approach to the intervention, many

aspects of the treatment that was provided were closely monitored for their fidelity.

Based on observation and discussion with the parents, a Progress Note and Checklist (see

Appendix S) was completed during and after each session by the researcher. The

progress note was used to document subjective and objective information regarding the

child’s responses to, and progress in therapy and in functioning. Treatment sessions were

conducted based on a treatment manual which was created for this study (see Appendix

R). During a therapy session, the researcher kept a detailed list of all treatment activities

that were performed, so as not to accidentally alter the order or nature of the activities. A

checklist, which was based on the Essential Characteristics of Occupational Therapy

Using Sensory Integration Intervention (ECOTUSII) (Watling, 2004) was completed

after every session to monitor the researcher’s fidelity to treatment during the session.

The researcher, in filling out the checklist, provided information that indicated how well




the session met the ten principles of SI therapy. Specifically, the length of the session,

the amount of time in which the session was child directed and the sensory systems that

were addressed were documented. In addition, the researcher indicated if the session was

one-on-one, whether or not the room was organized in a way that encouraged child

participation, and if safety was maintained. Finally, the researcher indicated if an effort

was made to sustain optimal arousal, to support the child’s success, and to grade the

difficulty of the activity. In addition it was noted if the child was allowed to choose and

plan activities, maintain a context of play, had active control and self direction, and if a

sense of trust, appreciation and respect was maintained. In an effort to maintain

treatment fidelity, an outside examiner observed four random sessions of intervention and

completed the Progress Note and Checklist. The therapist and outside examiner agreed

on all aspects of the checklist at each session except on whether or not the session was

child-directed. No discussion was made prior to the study to agree upon how this tool

would be completed, and therefore it is possible that this item may have been interpreted

in two different ways. The treating therapist reported child-directed time as any time in

which the child was directly involved in the planning or selecting process of the task,

even if support was offered by the therapist. The outside examiner on the other hand,

limited her reports of child-directed time to only those times when the child was solely

responsible for selecting and directing the activity. As a result, these values varied

greatly between the examiner and the outside examiner. Regardless of the value

indicated, both the therapist and the outside examiner agreed that every effort was made

to allow the child to direct the session as much as possible.




Summary of Conceptual Framework Relationships. Every aspect of this study

was designed with the conceptual framework in mind. Although it did not intend to

identify specific neurological pathologies involved in AS and PDD-NOS, the physical

findings which included deficits in attention, balance, motor planning, and bilateral

coordination appear to be linked to specific neurological structures which have been

identified as being abnormal in persons with ASDs. In particular, the impairments

identified in the participants of this study seem to have the closest connections to the

functioning of the brainstem and cerebrum.

In addition to the neurological framework which supported this study, the theory

of SI provided the basis for the testing and treatment phases of this study. Every effort

was made to adhere to the guiding principles behind SI theory, SI dysfunction and SI

treatment. The results from the study demonstrated some support for the theory of SI.

Participants showed clear signs of sensory dysfunction which impacted their ability to

engage with their environment in an age-appropriate and typical manner. As the children

gained more opportunities to allow their nervous systems to adapt to a sensory-rich

environment, their behaviors and their ability to perform sensory and motor tasks also

appeared to improve.

Relationship of the Results to the Literature

This study was developed based on an extensive review of previous literature and

research on children with pervasive developmental disorders. This section examines the

results of the current study in comparison with the findings of previous studies. The

similarities and differences between this research and earlier research will help to clarify

what has been gained by conducting the current study. This section begins with a




discussion of participant recruitment and the relationships to what has been reported in

the literature about children with AS and PDD-NOS. It will continue with a discussion

regarding the sensory processing skills of the children in the study as they relate to the

research literature. Next, the findings regarding the motor skill performance of the study

participants will be compared to previous research, followed by the results from this

study as they relate to earlier SI efficacy studies.

Recruitment . Despite the reported and estimated numbers of children living in the

area in which the study was being conducted, one major challenge in this study was the

recruitment of children who met the criteria for age and diagnosis. Parents frequently

reported either the absence of any diagnosis, or the absence of a specific AS diagnosis.

In some cases, parents reported a long waiting list to see a specialist for diagnosis. In

other cases, parents reported that their child had signs or symptoms of AS, but did not

meet all diagnostic criteria based on the DSM-IV, and were either diagnosed with PDD-

NOS or were not given a specific diagnosis. According to Howlin and Asgharian (1999),

the average age of receiving a diagnosis of AS is approximately 11 years, which may

help to explain the shortage of potential participants for this study who had to be between

five and nine years of age. Results from a survey-based study conducted by these

researchers in the United Kingdom, indicated that 77% of the participants did not receive

a diagnosis of AS until they were at least 15 years old (Howlin & Asgharian, 1999).

Additionally, several researchers have pointed to discrepancies within the diagnostic

criteria for AS, which may result in missing or incorrect diagnoses (Klin & Volkmar,

2003a; Mattila et al., 2007). Although no attempts were made in this study to examine

the prevalence or incidence of AS or PDD-NOS, the difficulty in finding participants who




underresponsiveness or mixed thresholds. The authors specifically reported signs of

auditory, oral and tactile sensitivity (Church et al., 2000). Similar concerns were

expressed through anecdotal reports from the parents in the current study who reported

that their children became frustrated or had a “melt-down” in settings that had loud or

excessive noise. Additionally, several parents reported that their children had a very

limited diet due to hypersensitivities to either tastes or textures. Tactile sensitivity in the

form of limited clothing choices and tactile defensiveness were also reported by the

parents. Each of these findings was confirmed during testing and witnessed by the

researcher during the course of this study. Although anecdotal reports cannot

conclusively confirm that a sensory processing problem exists, the reports of these

parents offered support for some of the findings of the Church et. al (2000) study.

Research reported by Leekam and colleagues (2007) also identified findings of

sensory impairments in a group of individuals with autism, using the Diagnostic

Interview for Social and Communicative Disorders (DISCO). Ninety percent of the

participants in their study had sensory impairments, and the majority of those individuals

had sensory processing deficits in more than one sensory system (Leekam et al., 2007).

Even though the Leekam study involved children with a diagnosis of autism, the findings

of multisensory processing deficits were similar in the current study of children with AS

and PDD-NOS. This was indicated by low sensory processing scores on several sections

of the Sensory Profile which were below what would be expected of a child who is

typically developing. This provides support for the evidence that suggests that sensory

processing impairments can occur across the autism spectrum.




To obtain information specifically on the sensory processing of children with AS

and PDD-NOS, the parents in the current study completed the Sensory Profile. This

assessment provides subjective evidence regarding how the parents feel about their

children’s sensory processing. Much like the study done by Dunn and colleagues (2002)

who identified children with AS as being impaired in 22 out of 23 possible areas assessed

by the Sensory Profile (Dunn, Smith Myles et al., 2002), the parents in the present study

reported sensory processing impairments in all 23 areas of sensory processing. More

than 50% of the parents reported impairments in 21 of those areas. Every participant in

the current study was rated by his or her parent on the Sensory Profile as being

emotionally reactive and easily distracted, as having emotional responses that differed

from a typically developing child, and as being unable to modulate sensory input. Every

parent also reported that their child had difficulty with the behavioral outcomes of

sensory processing such as tolerating changes in routine and hand writing. It is important

to understand that the scores on the Sensory Profile correspond to one of three levels of

dysfunction, including “typical performance”, a “probable difference” from typically

developing children and a “definite difference” from children who are typically

developing. More than half of the children in the current study scored in the definitely

different category indicating the most severe form of dysfunction for several of the

subtests. The subtests in which the children were definitely different included Sensory

Seeking, Emotionally Reactive, Low Endurance/Tone, Inattention/Distractibility, Poor

Registration, Auditory Processing, Vestibular Processing, Touch Processing,

Multisensory Processing, Sensory Processing Related to Endurance/Tone, Modulation

Related to Body Position and Movement, Modulation of Sensory Input Affecting




Emotional Responses, Modulation of Visual Input Affecting Emotional Responses and

Activity Level, Emotional/Social Responses and Behavioral Outcomes of Sensory

Processing.

Corresponding with the current study’s findings, a study on a cohort of 400

children, including children with AS and PDD-NOS (Tomchek and Dunn, 2007) found

that nearly 84% of the participants with ASDs met the criteria for “definite differences”

on the total score on an abridged version of the Sensory Profile. More than half of the

participants with ASDs scored in the definitely different category for the Tactile and

Taste/Smell Sensitivity, Underresponsive/Seeks Sensation, and Auditory Filtering

subtests (Tomchek & Dunn, 2007). Although the categories of sensory processing

differed somewhat due to the different versions of the Sensory Profile that were used,

both the current study and the Tomchek and Dunn study indicate that children with ASDs

appear to have a definite difference in several areas of sensory processing from children

included in the normative sample.

The current study is only one of three studies to assess children with AS using the

Sensory Profile, however it supports previous findings obtained using the Sensory

Profile. Dunn and colleagues (2002) and Klyczek and colleagues (2005) both identified

difficulty with modulating sensory input in their samples of children with AS. In a very

different type of study, the purpose of the research of McIntosh, Miller, Shyu and

Hagerman (1999) was to demonstrate this difficulty by testing electrodermal responses in

children who had sensory modulation disorder. Their results indicated that the children

in their study who had difficulty modulating sensory input also had impaired

electrodermal responses. This finding also correlated with greater impairments in




and parental reports, a difference between these studies and the current study is that the

current study utilized the BOT-2 to provide an up-to-date, objective measure of motor

skill performance, This objective and standardized assessment determined that the

participants in the current study have poor coordination and difficulty performing some

motor skills.

Although they did not use the BOT-2, there are a few other studies that have

attempted to objectively quantify the motor impairments in children with AS using more

formal and standardized instruments. Manjiviona and Prior (1995) compared children

with AS to children with HFA using the Test of Motor Impairment – Henderson Revision

(Stott et al., 1984). This instrument assesses the manual dexterity, balance and ball skills

in children. In comparison to the current study which identified motor impairments in all

of the study participants, the results of the Manjiviona and Prior (1995) study indicated

that 50% of the subjects with AS demonstrated motor impairments. With an average age

of 11 years, the participants in the Manjiviona and Prior study were older than the

participants in the current study. One possible reason for the difference in the frequency

of motor impairments between the two studies is that motor skills in persons with ASDs

are not consistent over time (Freitag et al., 2007). More conclusive statements however,

cannot be made at this time.

There have been three studies that have used the Movement Assessment Battery

for Children [Movement ABC] (Henderson & Sugden, 1992) on groups of children with

ASDs, including children with AS. In all three of these studies, the researchers identified

motor delays in the participants who had a diagnosis of AS (Green et al., 2002; J. Miller

& Ozonoff, 2000; Miyahara et al., 1997). The motor delays in those studies included




difficulties with ball skills, imitation activities and fine motor skills. The current study,

which utilized the BOT-2 to identify motor impairments and decreased coordination in all

of the study participants, is consistent with the findings from Green et al. (2002) which

reported motor impairments in 100% of the participants with AS. It appears that many

children with AS and ASDs experience difficulties with performing motor skills in a

coordinated fashion. Perhaps this is because of the impairments that have been identified

in sensory processing, sensory modulation and motor planning. If a child is unable to

adequately process or modulate incoming sensory information in order to produce an

appropriate response, and if he or she has difficulty planning motor actions, he or she will

most likely appear clumsy or poorly coordinated.

Similar to the current study, there have been two other studies that have used the

Bruininks Oseretsky Test of Motor Proficiency to examine the motor skills of children

with ASDs. The present study indicated that the BOT-2 test scores fell below the 50th

percentile for children with AS and PDD-NOS, particularly in the areas of manual and

bilateral coordination. This supports the findings of the Ghaziuddin, Butler, Tsai and

Ghaziuddin (1994) and Ghaziuddin and Butler (1998) studies which also identified motor

impairments in children with ASDs based on Bruininks Oseretsky test scores. In contrast

to the Ghaziuddin studies however, the current study utilized a more recent version of the

Bruininks test, the BOT-2, which is based on a more current normative sample. No other

studies have been reported which have used the BOT-2 with this population of children.

As a result, the findings from the current study, which identified impairments in motor

coordination and motor skill performance in the study participants, provide up to date




evidence that children with AS and PDD-NOS are impaired in their ability to perform

some motor skills in an age-appropriate manner.

Another study performed by Freitag et al. (2007) assessed the motor skills of

adolescents with AS, HFA and IQ-matched controls using the Zurich Neuromotor

Assessment. The greatest impairments that were reported for their participants were in

alternating wrist supination and pronation movements and dynamic balance tasks. These

impairments were also found in the children who participated in the current study. In

addition, the findings from this study share an additional similarity to the findings of the

Freitag study in that the children in both studies demonstrated greater ease with more

simple motor movements such as symmetrical, repetitive movements that involve the legs

or hands and balance on two feet with the eyes open, as compared to more complex

motor skills such as alternating leg and hand movements, sequential finger movements

and balance skills on one foot with the eyes closed.

Although it is clear that the SIPT, which was used in this study, focuses on

assessing a child’s ability to process and integrate sensory input from a variety of

sources, the test of Postural Praxis within the SIPT assesses a child’s ability to motor plan

and imitate postures that are assumed by the examiner. Similar to the praxis tests

administered in the current study, Green and colleagues (2002) used a gesture test to

assess motor planning and postural imitation in a group of children between the ages of 6

years and 11 years who had a diagnosis of AS. Just as in the current study which found

that the participants had difficulty with planning whole body movements as well as oral

movements, Green and colleagues (2002) also identified signs of poor imitation skills in

the study participants. The fact that children in both studies demonstrated impaired




imitation skills, and that the children in the current study were identified as having

additional impairments in Oral Praxis and Praxis on Verbal Command, seems to indicate

that the impaired motor skills evident in these children appears at least in part, due to

their poor motor planning skills. In another study involving children with AS and HFA,

Rinehart et al. (2006) suggested that impaired motor planning was the primary cause for

difficulty with writing tasks, rather than an impairment with the kinematics involved in

performing the movements. The patterns of impairments shown in the children in the

current study also seem to suggest impairments in motor planning skills, as suggested by

poor praxia scores on the SIPT and poor motor skills on the BOT-2. In addition, the

participants in the current study frequently attempted to receive additional proprioceptive

input in the form of deep pressure and resisted activities.

Findings that a motor planning deficit exists in children with AS are also

consistent with a study performed by Weimer and colleagues (2001) which assessed the

motor skills of these children along with a group of typically developing controls. Non-

standardized tests that included balance activities, pegboard skills, finger-to-thumb

opposition and tests of praxis were used. The participants in their study, much like the

participants in the current study, had difficulty with tests of praxis, standing and walking

balance tasks and finger-to-thumb opposition, which again supports the idea that motor

planning and balance tasks may be difficult for these children. Unlike the Rinehart

(2006) study however, Weimer and colleagues (2001) relate impairments in movement to

an underlying deficit in proprioception, rather than impaired praxis. They suggested that

these children exhibit an increased reliance on visual input because of their poor

proprioceptive awareness.




An increased reliance on visual input has been identified by other researchers

(Molloy et al., 2003) as well. To assess the contributions of the sensory systems on

postural stability, Molloy, Dietrich and Bhattacharya (2003) utilized a force platform

with children with ASDs. The results from their study indicated that children with ASDs,

compared to a control group of children relied heavily on their visual sense in order to

maintain their balance and postural stability. This may be consistent with an observation

made in the current study, where some of the children demonstrated either an

unwillingness to close their eyes for testing or frustration when they were required to

close their eyes for testing. In addition, other children in the current study demonstrated

decreased sensory processing such as difficulty identifying where their hand was touched,

or identifying which shape they were feeling in their hand when they were unable to use

their visual system to assist them. Their motor skills were also more difficult for them

when their eyes were closed in activities such as touching their finger to their nose and

walking. Each of these findings on the children in this study support the findings of the

Weimer (2001) and Molloy (2003) studies that suggest that children with ASDs

demonstrate an overreliance on visual input, which may suggest possible impairments in

the ability of the nervous system to integrate input coming from more than one sensory

source.

The Efficacy of Sensory Integration Therapy. Many researchers have utilized a

variety of study designs to evaluate the effectiveness of SI therapy with children who

have disabilities including autism, PDDs and learning disabilities. The results of their

studies have indicated different outcomes. Linderman and Stewart (1998) conducted an

intervention study that provided SI therapy to two three-year-old boys with PDDs.




Therapy was provided for one hour per week for seven weeks and eleven weeks,

respectively. Function was assessed utilizing the Functional Behavior Assessment for

Children with Sensory Integrative Dysfunction. Improvements were identified in social

interaction and responses to touch and movement. Additionally, decreased frequencies of

aggressive or highly active and distracting behaviors were identified following

intervention. Although the current study utilized the Sensory Profile to measure sensory-

based functional behaviors rather than the Functional Behavior Assessment, both studies

identified similar improvements in sensory-based functional behaviors. These

improvements indicated fewer disruptive behaviors, improved attention and improved

responses to sensory input. Findings from both studies therefore appear to offer support

for the use of SI therapy as an intervention for these children. A more recent case study

of a four year old boy with poor sensory processing was reported by Schaaf and McKeon

Nightlinger (2007). The results of ten months of individualized SI therapy, provided

once a week, resulted in improvements in Sensory Profile scores and the achievement of

several established occupational performance goals (Schaff & Nightlinger McKeon,

2007). The authors suggested that the results obtained indicated that an improvement

was made in the child’s sensory processing as a result of the intervention. The current

study is the second known study to utilize Sensory Profile scores in a pretest-posttest

scenario. In both cases, parents reported via the Sensory Profile that improvements were

seen in their children’s ability to receive, process and integrate sensory information in a

manner that allowed for more appropriate and more efficient performance in daily

activities.




Other researchers have used modified versions of traditional SI therapy in an

effort to measure its effectiveness. In an attempt to measure the outcomes of intervention

using a 10-week Sensory Integration and Perceptual-Motor protocol, Davidson and

Williams (2000) studied the impact of treatment for children with Developmental

Coordination Disorders. Unlike the current study which identified significant

improvements in the Balance subtest and nearly significant improvements in the Running

Speed and Agility composite of the BOT-2, the Davidson and Williams study did not find

significant improvements on tests of motor skills using the Movement Assessment

Battery for Children, and the Beery-Buktenica Developmental Test of Visual-Motor

Integration (Davidson & Williams, 2000). This finding might be explained by four major

differences that existed between these two studies. First, the studies differed in the

diagnosis of the participants. In the Davidson and Williams study, the children had a

diagnosis of Developmental Coordination Disorder, whereas in the current study, motor

impairments were identified in the children with AS and PDD-NOS, but were not a

requirement for enrollment. Second, sensory processing impairments were confirmed for

the children in the current study via sensory testing prior to the initiation of SI therapy.

Another difference between the two studies is that the current study attempted to use a

traditional SI treatment approach, whereas the Davidson and Williams study utilized a

combination of SI and perceptual motor therapy. It is possible that the incorporation of

the perceptual motor component into an SI protocol as in the Davidson and Williams

study resulted in the need for the participants to simultaneously respond to sensory input

and process information at a cognitive level, which may have been too difficult for the

participants to do in an effective and efficient manner. Finally, the SI therapy provided




during the current study was focused on improving sensory processing which was

considered a prerequisite to good motor performance, rather than specifically on motor

skill performance. Perhaps this more focused approach of addressing sensory processing

resulted in improvements in these motor skills that would not have otherwise occurred if

the treatment was focused solely on motor performance.

In a different type of study, Kaplan, Polatajko, Wilson and Faris (1993) reported

the results of two interventions which were conducted simultaneously, and which

assessed the effectiveness of SI therapy compared to tutoring or perceptual motor

training. Motor skills and academic performance were assessed as the outcomes. In both

studies, treatment was provided for at least six months and change was measured using

the Bruininks Oseretsky Test of Motor Proficiency, along with other instruments that

assessed academic and visual motor skills. Overall, all three treatment techniques yielded

positive results for the children although they were not statistically significant.

Therefore, the authors concluded that SI treatment was no more beneficial than tutoring

or perceptual motor therapy in improving academic or motor skills. Explanations for

these findings included the use of a heterogeneous sample (Law et al., 1991), and the

effects of the child interacting with an adult, rather than specific treatment effects

(Wilson & Kaplan, 1994). Even though the SI treatment provided in the current study

was not compared to another type of treatment, the SI intervention provided did result in

significant improvements in some areas of sensory processing and motor skill

performance when compared to a five week baseline phase in which no treatment was

provided. Additionally, the current study utilized a more homogeneous sample than

some of the other studies in that it included a group of children with a specific diagnosis,




who were also confirmed to have sensory and motor impairments. This homogeneity

may have allowed for more positive effects to be identified. Two years following the

original study by Kaplan, Polatajko, Wilson and Faris (1993), Wilson and Kaplan (1994)

repeated the testing procedures on a group of children from the original cohort to

determine if there were any long term effects of the intervention. This time, the group

who received SI therapy showed significantly improved gross motor performance ( p<.02)

compared to the group who received tutoring. Their results therefore offered support for

using SI therapy for the improvement of long term motor skill goals. Although long term

effects were not assessed in the current study, the gross motor skill improvements

identified in all three studies suggest the possibility that SI therapy may have some

efficacy in improving motor coordination and motor skills.

Many different assessment tools have been used in SI effectiveness studies. Even

though the SIPT is considered to be one of the best tools to measure a child’s ability to

integrate sensory information and plan movements, there has been only one other

reported study that has utilized the SIPT to measure change following intervention. In a

study by Gienke-Kimball (1990), the SIPT was used to assess a group of 19 children

before and after a six month treatment program involving SI intervention that was

provided two times per week. Although results were analyzed differently between the

two studies, both studies were successful in measuring the change in SIPT scores before

and after intervention. In addition, the findings of significant improvements in several

areas of praxis as well as standing and walking balance were similar between the two

studies, providing objective data to support the hypothesis that children with AS and




PDD appear to improve in their ability to process sensory input following SI therapy for

these particular skills.

Additional Findings

Three primary hypotheses were addressed in this study. In addition to the

findings that relate specifically to these three hypotheses however, the testing and

treatment protocol yielded additional data which may provide useful information to

researchers and clinicians. Therefore, this section will discuss the behavioral changes

that were identified following the 10-week intervention phase. Additionally, the results

from the ASDS, the PEGS and Clinical Observations will also be reviewed.

Behavioral Changes. A child’s behavior can provide good insight regarding his

or her ability to adequately receive and process sensory information (McIntosh et al.,

1999; Williamson et al., 2000). The ASDS and the Sensory Profile provide specific

information regarding the child’s behaviors as they relate to AS and to sensory

processing. Based on the results of administering the ASDS, almost every participant in

the current study was found to demonstrate signs of rigidity, immaturity and obsessive

behaviors on the Maladaptive Behavior subtests at both pretest and midtest phases.

These findings were also supported by the Sensory Profile, where 100% of the parents

reported signs of inattention, distractibility and emotional reactivity in their children. The

importance of sensory processing on emotional regulation is discussed by Laurent and

Rubin (2004). They state that an inability to react in an emotionally appropriate manner,

becoming overly stressed or shutting down, is likely to occur when an individual is

unable to regulate himself or herself internally, and in the context of a social interaction

(Laurent & Rubin, 2004). In addition to the parental reports on the ASDS and the




Sensory Profile, which indicated maladaptive behaviors, emotional reactions to sensory

input and distractibility, some of the children in this study also displayed some of these

behaviors during testing. These behaviors included signs of frustration and either

emotional withdrawal, or emotional meltdowns. The behaviors were seen less frequently

during the intervention sessions, when one of the focuses was on providing opportunities

for self regulation by the children.

Following SI intervention in the current study, there was an improvement in

Maladaptive behavior scores on the ASDS with the analysis revealing results that were

nearly significant ( p=.08). These results seem to offer support for the findings of Case-

Smith and Bryan (1999) which identified improvements in the level of engaged behaviors

and interaction in a group of five children with PDDs following 10 weeks of one-on-one

SI therapy sessions (Case-Smith & Bryan, 1999). Additionally, the results from the

current study are also consistent with findings from a single-subject study by Roberts,

King-Thomas and Boccia (2007) which noted reduced aggression, an improved ability to

engage within the environment and less frequent teacher involvement to manage the

behaviors of a three year old child with a sensory modulation disorder (Roberts et al.,

2007). In addition, a third study assessing the impact of SI therapy on the behavior of

children with ASDs was conducted by Watling and Dietz (2007). The authors measured

the frequency of undesirable behaviors and levels of engagement immediately after

intervention, in four boys who received alternating phases of treatments including SI

intervention and seated activities at a table. Neither the frequency of undesirable

behaviors, nor the frequency of engagement improved significantly during the SI

treatment phases. Subjective reports from the parents however suggested improvements




in both behavior and engagement after the post-intervention data collection period ended,

rather than immediately following treatment. Subjectively, the results of the current

study suggest similar reports being made by the parents regarding their child’s behavior

and engagement. While the children often seemed to leave the therapy sessions

demonstrating no major behavioral changes from the start of therapy, their parents

reported that behavioral changes occurred on the way home or for the remainder of the

day. One parent for example often reported better regulation of activity levels following

the treatment sessions which made the family’s evening routine easier to manage.

Therefore the results from the Case-Smith and Bryan (1999) study, the Roberts, King-

Thomas and Boccia (2007) study, the Watling and Dietz (2007) study and the current

study lend some support to the suggestion that SI therapy may result in improved and

more typical behavioral patterns.

Findings Related to the Asperger Syndrome Diagnostic Scale (ASDS). The

ASDS was administered to the participants at each phase of the study for two primary

reasons. Prior to enrollment, the ASDS was used to determine eligibility for the study.

For the purposes of this study, the pretest, midtest and posttest scores of the ASDS were

compared using repeated measures ANOVA to identify any significant changes in AS

characteristics following 10 weeks of SI therapy. For this test, it is important to

understand that a lower score represents fewer AS characteristics. According to the

scoring criteria for the ASDS, as the ASQ increases, the likelihood of the child having

AS increases. Scores between 80 and 89 suggest a possibility of an AS diagnosis. This

means that a child whose ASQ score is between 90 and 110 is considered “likely” to have

a diagnosis of AS, and a score above 110 indicates that the child is “very likely” to have a




diagnosis of AS. Individual subtest scores were summed together to obtain a percentile

score.

At the time of both pretesting and midtesting, all of the children, including those

with a PDD-NOS diagnosis, received an Asperger Syndrome Quotient (ASQ) between 80

and 122, with a mean score of 106.3. Before intervention, the average participant in the

study was rated by his or her parent as having enough signs and symptoms of AS to be

considered “likely” to have a diagnosis of AS. Based on these percentile scores it was

determined that on every subtest, at both pretest and midtest, at least 50% of the

participants were rated by their parents as having more symptoms of AS than a child who

is developing typically. Upon visual inspection of the data, the scores of the children on

the ASQ was lower following the intervention, suggesting that fewer AS characteristics

were observed by the parents following the treatment. Repeated measures ANOVA

however, indicated no significant changes in the ASQ scores. Following 10 weeks of SI

therapy, the mean score for the children decreased from 106.3 to 99.2, which is indicative

of a reduction of AS signs and symptoms, but not a large enough change to decrease the

reported likelihood of having a diagnosis of AS. Although ASDS subtest scores did not

change significantly following SI therapy, scores on the Maladaptive Behaviors subtest

approached significance ( p=.08), which suggests that children demonstrated fewer rigid

or obsessive behaviors and more signs of flexibility to changes in their daily routine.

Findings Related to The Perceived Efficacy and Goal Setting System (PEGS). In

an attempt to obtain the child’s perspective on his or her ability to perform various

activities of daily living, the PEGS was administered at all phases of the study. The test

examines self perceptions on 24 different motor skills, with each skill acting as its own




subtest. Using pictures of successful and unsuccessful task performance, children are

asked to identify how similar the picture was to his or her abilities. Based on the child’s

answers, a four point scoring system is used. A score of one indicates that the child

perceives himself or herself to be very bad at a particular skill and a score of four

indicates that the child rated himself or herself as being very good at a skill. In an effort

to simplify the findings, the PEGS total score, which is obtained by summing the

individual scores, was used for analysis. Overall, most children rated themselves as

being good or very good on most items at all phases of the study. Out of a possible 96

points, which is achieved by rating yourself as very good at every skill in the test, average

total scores for the pretest, midtest and posttest phases of the study were 72.4, 78.2 and

76, respectively. These findings were very similar to the results from a study on five to

ten year old children with a diagnosis of Developmental Coordination Disorder, which

compared the children’s self perceptions to the perceptions of their parents and teachers,

and to scores on the Movement Assessment Battery for Children (Dunford, Missiuna,

Street, & Sibert, 2005). The PEGS total scores in the Dunford et al. study ranged from

42 to 92, and the mean scores were 71.4 for males and 70.6 for females. This was

different than the range of the participants’ scores in the current study, which was 50 to

96. This suggests that the children in the current study tended to rate themselves as being

slightly more able to perform motor skills than the children in the Dunford et al. study.

The mean total score from the current study was also similar to that of another study

which utilized the PEGS on a large group of children with a variety of diagnoses

including Attention Deficit Hyperactivity Disorder, Developmental Coordination

Disorder and Physical Disabilities (Missiuna et al., 2004). The mean total PEGS score




for the children in that study was 75.9 with little variability based on diagnosis. Parents

in that study who were also asked to complete the PEGS on their child reported lower

total scores when compared to their children’s ratings. Additionally, the Missiuna,

Pollock and Law study found no correlation between the children’s ratings and their

performance on the School Function Assessment which evaluates performance on school-

related tasks as well as the amount and type of support needed. In the current study, the

parents were often able to hear their child’s responses to the PEGS as it was being

administered. Although the parent version of the PEGS was not given to them, they

reported to the researcher that their children were not being accurate in their self-reported

ratings. Missiuna and colleagues (2006) suggest that although children consistently

overrate themselves on the PEGS, its primary purpose is for goal-setting, rather than for

use as a pretest-posttest tool. In the current study, the change following intervention was

not significant, suggesting that the children’s perceptions of their abilities to perform

motor skills were not altered after 10-weeks of SI therapy. Knowing that the children in

this study had motor impairments as identified on tests of motor performance, and as

reported by parents anecdotally, it appears that the participants in this study might not

have accurately perceived their true motor abilities. Perhaps the very literal nature of

children with PDDs makes it difficult for them to accurately identify which of two picture

choices for each item in the PEGS is “most like” himself or herself. A second possible

explanation for the high self-perceived ratings is that children with PDDs often desire to

be good at things in order to fit better in their environments. A third possibility,

suggested by Missiuna and colleagues (2006), is that perhaps these children do not realize

how much external effort is actually being provided to make them successful.




Findings Related to Clinical Observations. Since Clinical Observations can be a

useful supplement to standardized testing, the pretest, midtest and posttest scores of

Clinical Observations were also compared in this study in order to identify any

significant changes following the intervention. In an effort to manage the number of

items in this test, related items were grouped together into subcategories which were then

analyzed using repeated measures ANOVA. Two subtests approached significance for

improvement. These two tests were Praxia ( p=.05), which suggests that the children

improved in their ability to plan coordinated movements, and Bilateral Integration

( p=.06), which suggests that the participants also improved in their ability to recognize

and coordinate the two sides of their bodies in order to perform a motor skill. These two

subtests were indicated earlier as being two of the areas that were most challenging for

children at the pretest and midtest phases of testing. In addition, similar impairments at

pretest and midtest, and similar improvements at posttest were noted in these areas on the

SIPT and the BOT-2, which supports the study findings overall that sensory and motor

impairments are present in children with AS and PDD-NOS, and that SI therapy can

improve the sensory processing and motor skills in this population. As indicated

previously, many of the items included in Clinical Observations assess nervous system

development and maturity at a very basic level. Based on the pretesting and midtesting

findings from Clinical Observations, it appears that many of these basic skills, such as

tolerating simple sensory experiences, were not as impaired as the higher level skills,

such as hopping and reciprocal jumping, which involved bilateral coordination and motor

planning. Since Clinical Observations were only scored as typical or impaired,

improvement is only possible if the child was originally performing below the




expectations for a child his or her age. This may help to explain why the participants

made the greatest improvements in these particular sections of Clinical Observations.

Strengths and Limitations

Several strengths have been identified in this research study. First, this research

utilized standardized, performance based tests of sensory function. Previous research had

focused primarily on more subjective ratings such as observations and parent reports.

This objective and quantitative evidence of sensory impairments provides support to the

subjective reports that have previously identified sensory impairments in children with

AS and PDD-NOS. Additionally, this is the first known study to report SIPT scores for

children with AS and PDD-NOS. As the current “gold standard” for assessing sensory

processing and praxis skills, the SIPT has provided strong evidence to support that

children with ASDs have sensory impairments that may impact their function.

Similar to other studies, this study adds to the limited knowledge regarding the

motor impairments that have been identified in children with AS and PDD-NOS. What

distinguishes this study from others, however, is that it utilized the BOT-2 which is the

most recent version of this test, thus updating the evidence that children with ASDs

exhibit impairments in motor skills. Additionally, since both sensory and motor

impairments were assessed on the same group of children, some connections can be made

regarding the relationship between sensory and motor skills in this population.

An additional strength of this study is that it is the first reported study to assess

the effectiveness of SI as an intervention for children with AS. Evidence regarding the

most effective treatment techniques for children with ASDs has been severely lacking,

especially with respect to treatment that addresses the sensory and motor impairments in




skills following SI therapy, the children in this study also were reported and observed to

demonstrate reductions in inappropriate or immature behaviors that are often identified in

children with ASDs. These findings also offer support for the use of SI intervention as a

treatment technique for children with AS and PDD-NOS for improving sensory

processing and motor skill performance.

This study is also acknowledged to have limitations. A major limitation was the

small sample size. While ten children began participation in the study, six children

completed all phases of the study. Four children who were recruited withdrew prior to,

or during intervention. Randomized controlled testing with large sample sizes is

generally recommended for obtaining greater validity and confidence regarding the

outcomes. Given the heterogeneity of children with sensory processing disorders, the

relatively low number of children with a diagnosis such as AS or PDD-NOS who could

participate, and the amount of time required to conduct such an intervention study

indicates that conducting a large-scale study would be difficult without having prior

evidence to support it. Since research in this area is still in the early stages, effectiveness

with a small sample such as the sample used in this study can be used to provide support

for larger studies in the future.

An additional limitation in the study was the lack of a control group. Limited

recruitment and ethical restrictions regarding withholding treatment from a child were the

two primary reasons for not having participants assigned to be controls. In order to

account for the absence of a control group however, a five week baseline phase was

implemented just after initial testing. In this way, the participants themselves acted as

their own controls. After five weeks of no study-related activities, midtesting was




performed to ensure that changes were not related to maturation. Following midtesting,

the ten-week intervention phase took place, and the results of posttesting following

intervention were compared to pretest and midtest scores to identify any significant

improvements.

During the development of the study, it was recognized that the SIPT is not

generally used in research to identify change before and after intervention, and that this

may be a limitation in the study. Currently however, the SIPT is the best tool available to

objectively measure sensory processing skills, and preliminary research has supported its

use in this manner. The findings from this study are in agreement with the findings from

Kimball (1990) which suggested that the current version of the SIPT may be a useful tool

for assessing change following intervention. In addition, since the SIPT scores during

each phase of testing corresponded to the subjective ratings by the parents, and the

observations made by the examiners during Clinical Observations, the results suggest that

greater confidence in using the SIPT in this manner is something to be considered.

A final study limitation relates to the low values for interrater reliability. It has

been suggested that ICC values that are greater than .75 are indicative of good reliability

and ICC values below .75 are indicative of poor or moderate reliability (Portney &

Watkins, 2009). Although the results from ICC testing for the BOT-2 can be considered

indicative of good reliability (ICC=.88), testing for Clinical Observations and the SIPT

yielded moderate results for interrater reliability (ICC=.46 and ICC=.55, respectively).

The results from the reliability testing should be considered with caution however, for

two reasons. First, because of the small sample size, reliability testing was only

performed on one child, and therefore, data for the analysis was limited. Having a single




recognize that although sensory and motor impairments are not required for a diagnosis

of any ASD, their presence in children with ASDs is very real. One hundred percent of

the children in this study demonstrated impairments in sensory and motor skills which

can impact their ability to participate in the home and school settings. Still, only 67% of

the children were reported by their parents and therapists to be receiving occupational

therapy, and this therapy was not focused on their sensory impairments. In addition, only

one child was receiving physical therapy at the time of the study. Even though it is

recognized that social impairments are one of the key features in these diagnoses, it is

important that the presence of sensory and motor impairments not be overlooked. Those

who assess individuals with PDDs should, at a minimum, screen for the presence of

sensory and motor impairments. For the children in this study, the most frequent and

most severe impairments were in the areas of inattention or distractibility, emotional and

social responses and behaviors, modulation of sensory input from a variety of sensory

systems, praxis and coordination. It is believed that impairments in these areas can affect

an individual’s ability to interact appropriately and efficiently with the surrounding world

at home and at school, and that this may lead to coping mechanisms and social responses

that are viewed as inappropriate or immature. Therefore, any professional who works

with a child who has an ASD should consider the presence of sensory and motor

impairments and should take steps to ensure that the child’s needs in these areas are

addressed.

In regards to the assessment instruments utilized in this study, they did

demonstrate that they were useful in identifying impairments in this group of children.

Provided they have received appropriate training, the results obtained from the study




suggest that clinicians should consider using the tools described when examining children

with ASDs. It is important to recognize, however, that the battery of tests administered

during this research study were quite rigorous and very time consuming. In the clinical

setting, administration of all of these tests would not be practical. Therefore, care should

be taken to select the instruments which best meet the needs of the child, the clinician and

the facility.

Anecdotal evidence is and has historically been useful from a clinical perspective.

Soon after the study, one parent proudly reported observable successes in her child’s

tolerance for sensory input and his ability to maintain balance and coordinate motor

skills. In addition, three of the six parents whose children completed the study contacted

the researcher after the research period to indicate significant improvements in their

children following their participation in the study. One parent reported receiving very

positive reports from the child’s school for the first time in a long time. Another parent

reported significant reductions in tactile and oral sensitivity which began during the

intervention and continued with the implementation of a sensory-based occupational

therapy treatment program with another therapist after the conclusion of the study. A

third parent reported school assessment scores that were in the 13th

to 34th

percentiles

approximately two years before the study and an improvement to the 47th

to 97th

percentiles in the year following intervention. Although the reasons for this improvement

cannot be certain, this parent attributed at least part of the child’s success to the intensive

therapy he received during the study.

Although not measured during the course of the study, two anecdotal observations

were also made by the researcher that may be of interest to clinicians. First, the children




responded exceptionally well to oral input in the form of resistive oral motor activities as

a means for calming and organizing them. In addition, in some children, whole body

tone appeared to improve following these oral activities. As a result, the importance of

the oral area to development and organization should be considered. In this study

resisted oral activities were often used as a way to prepare the entire body for work,

which in some cases was effective. It was also noted that most children required a

combination or a sequence of proprioceptive and vestibular activities in order to maintain

an appropriate state of arousal and organization. Although it is not known how previous

therapy had been provided by other therapists, some of the participants’ therapists have

anecdotally identified that input to either the child’s vestibular system or his or her

proprioceptive system independently resulted in signs of poor sensory modulation, such

as becoming hyperactive or melting down. During the intervention phase of the current

study, it appeared that the children could tolerate a greater variety of sensory experiences

when the activities incorporated either simultaneous proprioceptive and vestibular

experiences, or they provided consecutive proprioceptive and vestibular input. It seemed

that the proprioceptive input provided the children’s bodies with the information needed

to feel more secure for moving through space during the activities that involved the

vestibular system.

It is acknowledged that a great debate remains as to the effectiveness of SI

therapy. The results of this pilot study suggested that it was effective in improving some

areas of sensory processing, motor skills and behaviors of children with AS and PDD-

NOS. It followed the principles of classical SI therapy. It was child-directed and it

provided therapy in a one-on-one environment that was rich in sensory experiences.




Sessions were conducted two times per week for 45 minutes to one hour. Although each

session was based on the individual needs of each child at that particular time, a treatment

manual was utilized to maintain consistency with the activities performed during each

session. The most notable improvements following intervention were seen in the areas of

sensory processing, modulation of sensory input, praxis, standing and walking balance

and running speed and agility and reductions in inattention and distractibility. Further

research is needed to continue the examination of the effectiveness of SI therapy. This

study however provides some initial evidence to support the use of SI for children who

have AS and PDD-NOS with associated sensory and motor impairments.

Implications for Future Research

For years, researchers have reported the presence of sensory impairments in

ASDs. Their claims have largely been based on observation and subjective measurement

tools. This study provided some initial objective evidence to support the existence of

sensory impairments in ASDs. Future research should continue to objectively measure

sensory impairments in this population, and to compare the objective results with the

subjective findings that are more commonly reported. This research should occur for all

diagnoses in the autism spectrum, not necessarily to identify differences between

diagnoses, but rather to confirm their presence so that sensory impairments can be

recognized within the diagnostic criteria for ASDs.

A second recommendation is for continued research on the motor impairments

associated with ASDs. This study supports previous research that confirms the presence

of motor skill impairment in children with AS and PDD-NOS. At this point, more

specific and more refined analyses should be considered. For example, specific task




evidence that SI therapy may be an appropriate treatment technique for children with AS

and PDD-NOS. As more children are being diagnosed with ASDs, it is critical that

researchers and clinicians address all of their needs, including those that involve sensory

processing and motor skill performance. This research study provides preliminary

evidence on the efficacy of SI therapy for children with AS and PDD-NOS.




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Appendix A

Approval from the Institutional Review Board




Appendix B

Sample Request for Support in Recruitment Procedures




University at Buffalo


Kimball Tower, Room 515

3435 Main Street

Buffalo, New York 14214

Date

To Whom It May Concern:

My name is Kristen Klyczek. I am a physical therapist and a graduate student at the University at

Buffalo. I am pursuing a Ph.D. in Rehabilitation Science. As part of my dissertation, I am

planning to conduct a study entitled: “The Effectiveness of Sensory Integration Therapy on theSensory and Motor Skills of Children with Asperger’s Syndrome”. I would like to request your

support by allowing me to recruit participants from your facility for this study.

For my study, children who have Asperger’s Syndrome will receive free Sensory Integration

treatment, and the effect of this intervention will be measured by pre-, mid-, and post-studytesting. As you may know, research to support the use of Sensory Integration Therapy is greatly

needed. The role of you and your facility, would simply be to allow me to post fliers within your

facility. Additionally, if you agree, I would attend a parent group, briefly present my research,

and distribute fliers to persons indicating their interest. You will incur no costs by agreeing to

assist me, and only those persons interested would be given the flier.

I am including a copy of the flier for you to review. I will contact you in approximately two

weeks to see if you can provide assistance in my recruitment of participants. Feel free to contact

me by telephone at 716-639-9201, or via email at [email protected] if you wish to discuss this

matter, or if you have other ideas regarding how you might be able to help. I look forward to

working with you, and sincerely appreciate your consideration.

Sincerely,

Kristen Klyczek, PT

PhD Student


Enclosure




Appendix C

Letters of Support for Recruitment Procedures




Appendix D

Radio and Written Advertisements




Script for Radio Announcement

A study is being conducted at the University at Buffalo for children with Asperger’s

Syndrome, to determine if children with this disorder benefit from Sensory Integration

Therapy. To be eligible for the study, children must be between the ages of 5 and 9 years

at the time the study is being conducted. Participants will receive 10 weeks of free

therapy sessions under the direction of a qualified physical or occupational therapist that

include fun activities which incorporate movement and the senses of the body. Both

participants and their parents will be required to complete pre-, mid- and post-study

testing which involves both sensory and motor questionnaires and tests. The testing and

intervention will take place on UB’s South Campus at 3435 Main Street. For more

information, please contact Kristen Klyczek at (716) 639-9201, or by email at

[email protected].




Written Advertisement

Free Testing and Treatment for

Children with Asperger’sSyndrome

Why? A study is being conducted for children with

Asperger’s Syndrome, to determine if they benefit fromSensory Integration Therapy

Where? University at Buffalo, 3435 Main Street,

South Campus

Who? Children ages of 5 and 9 years who have

Asperger’s Syndrome, and their parents

What does it involve? Participants will receive10 weeks of free therapy sessions that include funactivities which incorporate movement and the sensesof the body. Participants and their parents will alsocomplete pre-, mid- and post-study testing usingsensory and motor tests

How do I sign up? For more information, please

contact Kristen Klyczek at (716) 639-9201 or

email her at [email protected]




Appendix E

Parent Information Letter and Invitation




Date

Dear Parent:

My name is Kristen Klyczek. I am a graduate student at the University at Buffalo, and a licensed

physical therapist in New York State. I am pursuing a Ph.D. in Rehabilitation Science. As part

of my dissertation, I am planning to conduct a study that will determine how effective sensoryintegration therapy is for children with Asperger’s Syndrome. You have been identified by your

child’s service provider or physician as someone who may be interested in having your child

participate in this study.

This study will offer free testing and treatment for children ages 5 to 9 years, who have

Asperger’s Syndrome, and who are not already receiving sensory integration therapy. It involves

10 weeks of therapy sessions which include fun activities in a one-on-one setting, allowing your

child to move and explore his or her senses in a non-threatening and safe environment. As part of

the study, you would be required to complete parent questionnaires, and your child would

participate in a series of clinical assessments including the Sensory Integration and Praxis Tests.

This would occur three times over the course of the study in order to determine the effectiveness

of treatment. While you would be required to travel to and from UB’s Main Street Campus, youwould incur no additional expenses for your child’s participation in this study. Your child’s test

results, and the results from the study will be made available to you at the end of the study.

Please note that confidentiality is a high priority, and any information obtained from this study

will be kept confidential. This means that your child’s name will not appear on any reports

regarding the final results of the study.

An index card is enclosed with this letter. The index card will simply give me, Kristen Klyczek,

permission to contact you in order to determine if your child is eligible to participate. In the

event that your child is selected to participate, a separate consent form would be provided before

beginning the testing and treatment. If you are interested in learning more about this study, or if

you are interested in having your child be considered for the study, please provide your name,

address and phone number on the attached index card and either return it to your service provideror return it to me in the enclosed self addressed, stamped envelope. You can also contact me by

telephone at 716-639-9201 or email me at [email protected].

Your permission for me to contact you does not obligate you to have your child participate in the

study. If your child will be participating, you will receive a separate consent form that will

provide further explanation regarding the study and about your child’s rights as a participant. I

will look forward to hearing from you and sincerely appreciate your consideration of having your

child participate.

Sincerely,

Kristen Klyczek, PT

PhD Student


Enclosure




Appendix F

Parent Informed Consent Form




THE EFFECTIVENESS OF SENSORY INTEGRATION THERAPY ON THE

SENSORY AND MOTOR SKILLS OF CHILDREN WITH ASPERGER’S

SYNDROME

CONSENT FORM

INTRODUCTION

The purpose of this consent is to provide you with enough information to make an

informed decision as to whether you will agree to have your child be a subject in research

that take place during the 2007 calendar year. You and your child have been invited to participate in this study because your child was identified by his or her clinician as

having Asperger’s Syndrome, being between 5 and 9 years of age, and being free of any

other neurological diagnoses.

PURPOSE

Kristen Klyczek, hereafter referred to as the researcher, is conducting this study todetermine if children with Asperger’s Syndrome have any difficulty with sensory

integration, which is the ability to process information from the senses. Another purpose

is to see if sensory integration therapy is an effective treatment for children withAsperger’s Syndrome. To conduct the study, your child will take part in a therapy

program designed around his or her specific needs, in order to improve his or her ability

to take in information from his or her senses, process that information and then use it tocomplete play skills and daily activities. The body has many sensory systems including

touch, vision, movement and an awareness of where the body is in space. Sometimes,when these systems overreact or do not react enough, people have difficulty behaving or

moving in ways that are considered typical. Sensory integration therapy may help these

systems to work together more easily, in order for your child to behave and perform daily

skills without difficulty.

PROCEDURES

This study will be conducted at the University at Buffalo, in a room designed to provide

sensory integration therapy. Since the procedures can be done at a time convenient for

you and your child, there will be no interruption to your child’s school day. With yourconsent, you will be asked to complete a short questionnaire. It will provide information

about your child, such as his or her age, gender and the services he or she is receiving.

You will also be asked to complete the Sensory Profile, and the Asperger’s Syndrome

Diagnostic Scale, caregiver questionnaires which will provide additional information

about your child’s diagnosis and his or her sensory systems. Together, these

questionnaires will determine whether or not your child is eligible for the study. If your

child is identified as being eligible to participate, and if you provide consent, and yourchild agrees, he or she will participate in three tests to measure how he or she uses his or

her sensory and motor skills. These tests include: Clinical Observations, the Perceived




Efficacy and Goal Setting System, the Bruininks-Oseretsky Test of Motor Proficiency, 2nd

Edition, and the Sensory Integration and Praxis Tests.

Next, a five-week period of no testing or intervention will take place. During this time,

your child will not receive any study-related intervention, and you and your child will be

instructed to follow a typical family and school routine. After five weeks, you and yourchild will be asked to return for testing which will include giving your child the Sensory

Profile, the Asperger’s Syndrome Diagnostic Scale, Clinical Observations, the Perceived

Efficacy and Goal Setting System, the Bruininks-Oseretsky Test of Motor Proficiency, 2nd

Edition, and the Sensory Integration and Praxis Tests.

After the second phase of testing has been completed, your child will participate in a 10-week therapy program consisting of two individualized sessions per week, for

approximately 60 minutes per session. During the sessions, your child will be involved

in a series of activities designed to meet his or her specific needs. Sessions will include

activities on the floor and on special therapy equipment designed to provide input to your

child’s sensory systems. Activities may include skills such as running, jumping,climbing and swinging, which will often be incorporated into games, challenges and

obstacle courses. All equipment will be used with mats placed on the floor, assistancewill be provided, and precautions will be taken to ensure your child’s safety.

Following the 10-week intervention phase, you and your child will complete a final roundof testing. You will be asked to complete the Asperger’s Syndrome Diagnostic Scale and

the Sensory Profile, and your child will be tested using Clinical Observations, thePerceived Efficacy and Goal Setting System, the Bruininks-Oseretsky Test of Motor

Proficiency, 2nd

Edition, and the Sensory Integration and Praxis Tests. Once you and

your child have completed this testing, the study will be complete.

TIME COMMITMENT

The study is expected to be implemented and continue through the 2007 calendar year.Your child’s participation will require one 60-minute session two days per week, for 10

weeks. In addition, both you and your child will be required to complete three phases of

testing. These will take place upon initial enrollment into the study, five weeks afterstudy enrollment, and again at the completion of the 10-week intervention phase. Each

phase of testing will take two to three sessions, depending on your child’s ability to

maintain his or her interest and endurance. Each test session will take approximately 2 to3 hours, with breaks given as necessary.

RISKS

There are minimal risks involved in this study. Risks are similar to those present when

your child participates in gym class or playground activities. Although these risks are

present, all procedures will be followed to ensure your child’s safety. These proceduresinclude: a) measuring the equipment to your child’s size so that his or her hands or feet

can touch the floor, b) placing mats beneath and around the equipment and c) having an




adult present at all times. Using these precautions, it is unlikely that your child would fall

onto a mat or sustain a minor injury. If this occurs however, acute medical care will be provided by the researcher or examiner and follow up action will be taken, which will

include contacting you and your child’s physician. The State University of New York at

Buffalo does not provide for medical care or compensation for medical care in the event

of injury as a result of participation in a research project. This is not, however, a waiveror release of your legal rights.

BENEFITS

The information from this study will provide initial evidence as to whether sensory

integration therapy is a beneficial intervention for children with Asperger’s Syndrome.Although the outcome of this study is not known, if the results indicate that sensory

integration therapy is useful in improving the children’s ability to plan and perform play,

school and daily skills, your child may benefit directly.

CONFIDENTIALITY

The information obtained during the study regarding your child’s ability to receive, process and use sensory information will be recorded on the test forms in such a way that

both you and your child’s identity will remain confidential. This means that a code

number, rather than your child’s name will be used. Licensed physical and occupationaltherapists who have the proper certification to administer the tests will complete the

assessments with your child. Upon receipt of the test sheets, the researcher will remove

your child’s name and replace it with the code number assigned to your child. If anyinformation collected is printed in a report or used in a presentation, it will be reported so

that there is no way your child can be identified. All forms will be stored in a locked filecabinet for seven years in the office of Dr. Linda Shriber, primary advisor to the study, at

the State University of New York at Buffalo. The researcher will destroy all written

records after seven years.

PAYMENT

There will be no direct compensation to you or your child for participating in the study,however all testing and treatment procedures will be provided to you and your child at no

cost. If you wish to receive a summary of the results of the study upon its completion,

record your full name and address on the index card provided to you and return it to theresearcher. A summary of the results will be mailed to you upon the study’s completion.

VOLUNTEERING FOR THE STUDY

Your permission to have your child participate in this study is completely voluntary. If

you do not want your child to participate, there will be no penalty or loss of benefits to

which you or your child are otherwise entitled. If you choose to have your child participate, but then decide to withdraw him or her, you may do so at any time by

contacting Kristen Klyczek at 639-9201. In addition, if your child demonstrates signs of




discomfort during the testing or treatment sessions, the tester or the researcher may

request withdrawal from the study. If someone other than yourself initiates thewithdrawal, you will be notified by the researcher immediately and services to which you

or your child are entitled will not be effected.

If you should have any questions about your child’s rights as a subject in a researchstudy, you should contact (anonymously, if you wish) the Children and Youth

Institutional Review Board, Women and Children’s Hospital of Buffalo, 219 Bryant

Street, Buffalo, NY 14222, or by phone at (716) 878-7859, to speak with the PatientRepresentative about questions regarding patient rights.

SUBJECT STATEMENT

I have read the explanation provided to me. I have had all my questions answered to my

satisfaction, and voluntarily agree to allow my child to participate in the study.

I HAVE BEEN GIVEN A COPY OF THIS CONSENT FORM.

SIGNATURE OF PARENT/GUARDIAN DATE

I certify that I obtained the consent of the subject whose signature is above. I understandthat I must give a signed copy of the informed consent form to the subject, and keep theoriginal copy in my files for 3 years after the completion of the research project.

SIGNATURE OF INVESTIGATOR DATE

(OR PERSON OBTAINING CONSENT)

SIGNATURE OF WITNESS DATE




Appendix G

Child’s Assent Form




THE EFFECTIVENESS OF SENSORY INTEGRATION THERAPY ON THE

SENSORY AND MOTOR SKILLS OF CHILDREN WITH ASPERGER’S

SYNDROME

CHILD’S ASSENT FORM

WHO AM I?

My name is Kristen Klyczek and I am a Physical Therapist. I go to school at theUniversity at Buffalo.

WHY ARE WE HERE?

I want to tell you about a study for children like you. A study is like a school project, and

I would like to see if you want to be in the study too.

WHY ARE WE DOING THIS STUDY?

Sometimes, children need extra help playing and doing different activities at school andhome. Physical therapists and occupational therapists work with these children to help

them. I am doing a study to see if a kind of therapy, called sensory integration will help

you to play and move better.

WHAT WILL HAPPEN TO YOU IF YOU ARE IN THE STUDY?

If you want to be in this study, you will do many things. Here is a list:

1. First, you will meet with me or someone else, who is also a therapist. We willmeet two or three times and will be together for two or three hours. You will take

four tests that are like games to see how your body works. Some parts are easy

and some are harder. You should try your best, but don’t worry if you cannot do

something. It’s okay.2. Next, you will wait for five weeks before you come back. You will take the tests

again.

3. After that, you will come to work with me two times each week for 10 weeks.You will spend about one hour working with me each time. We will work on

things that you might do in gym class or on the playground. Most times it will

probably feel like we are playing.4. After 10 weeks of working with me, you will do the same tests one more time.

5. Once you are done with the tests, we will be done working together.

WHAT MIGHT HAPPEN IF YOU ARE IN THE STUDY?

Whenever people exercise and play, there is a chance they might fall or get hurt. We will

be very careful to make it safe for you so that you do not get hurt. The things we use will be set up just for you, to make it safer. An adult will always be near you, and there will




be mats set up in case you lose your balance or fall. You might feel like you are playing

when you come to therapy. If this therapy helps you, it might be easier to play and move.

DO YOU HAVE TO BE IN THE STUDY?

You do not have to be in the study. No one will be mad at you if you do not want to dothis. You can change your mind later if you decide you don’t want to be in the study

anymore.

WHO WILL KNOW THAT YOU ARE IN THE STUDY?

No one will know that you are in the study except your mom or dad.

DO YOU HAVE QUESTIONS?

Do you have any questions right now? You can always ask us questions, now or later.You can talk to me, my teacher or someone else anytime. Here are some telephone

numbers for you or your parents to call us:

Kristen Klyczek (716) 639-9201

Dr. Linda Shriber (716) 829-3141 extension 129

If you would like to be in my study, please sign or print your name on the line below:

Signature of Child: ______________________________________ Date: _____________

Signature of Parent/Guardian: _____________________________ Date: _____________

Signature of PI or Designee: ______________________________ Date: _____________

Signature of Witness: ___________________________________ Date: _____________




Appendix H

Pre-Study Questionnaire




THE EFFECTIVENESS OF SENSORY INTEGRATION THERAPY ON THE SENSORY

AND MOTOR SKILLS OF CHILDREN WITH ASPERGER’S SYNDROME

PRE-STUDY QUESTIONNAIRE

Dear Parent,

Thank you for consenting to participate in this study with your child. What follows is a brief

questionnaire that will help to determine your child’s eligibility for the study, and will also

provide general information for proper reporting. Please understand that this information will be

kept strictly confidential, and that your child’s name will be replaced by a code number on all

study-related paperwork.

Please take a few moments to complete this questionnaire to your best ability. It is

important that no questions are left blank or unanswered. Feel free to ask any questions

you may have, and to add any additional information which you feel is pertinent at the end

of the questionnaire.

CONTACT INFORMATION:

Your Child’s Name __________________________________________________________

Your Name _________________________________________________________________

Address _____________________________________________________________________

Telephone ___________ Emergency Contact Name _______________ Number ___________

DEMOGRAPHIC INFORMATION PERTAINING TO THE STUDY PARTICIPANT:

Date of Birth: __________________ Sex: M / F Grade in School: ___________

School Setting: Private / Public

Regular Classroom / Special Education Classroom / Inclusion Classroom

Other

_________________________________________________________

Services My Child is Receiving: PT / OT / Speech Therapy / Special Education / Tutoring

Other

_________________________________________________________

May we contact your child’s therapist? Yes _____ No _____

If Yes: Name _____________________ Telephone Number: ______________

Is your child receiving Sensory Integration Therapy as part of any services he or she is

receiving? Yes / No

Language preference: English / Spanish / Other: ______________________

Child uses: Glasses / Contact Lenses / Neither and CAN / CANNOT see clearly




Other medical diagnoses: _______________________________________________________

My child has a history of: Seizures / Cerebral Palsy / Neurological diagnosis: ____________

Please list why YOU would consider your child to have a diagnosis of Asperger’s

Syndrome: __________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

Circle all that apply to, or are descriptive of your child:

Impaired social interaction

Impaired eye contact with people

Impaired eye contact with activities

Limited facial expressions

Abnormal body postures

Use of abnormal gestures

Difficulty developing peer relationships

Decreased social or emotional exchanges

with others

Repetitive and stereotyped patterns ofbehavior

Excessive preoccupation with topics or

objects

Rigid adherence to routine or ritual

Stereotyped and repetitive motor

movements

Impaired functioning (social,

occupational…)

Language delays

Academic delays

Unable to help him/herself in daily

activities

Accident Prone

Clumsy or poorly coordinated

Extreme like for certain sounds, flavors,

textures, movements

Extreme dislike for certain sounds,

flavors, textures, movements

Please comment on any noteworthy or unusual ways in which your child responds to:

Taste: ________________________________________________________________________

Sound: _______________________________________________________________________

Touch: _______________________________________________________________________

Sight: ________________________________________________________________________

Movement: ___________________________________________________________________




Appendix I

Asperger Syndrome Diagnostic Scale

Sample Items




Asperger Syndrome Diagnostic Scale

Sample Items

Language Subscale: Observed Not Observed

Speaks like an adult in an academic or

“bookish” manner and/or overly uses correct

grammar

Social Subscale:

Has little or no ability to make or keep friends

Maladaptive Subscale:

Exhibits a strong reaction to a change in his or

her routine

Cognitive Subscale:

Lacks organizational skills

Sensorimotor Subscale:

Has a restricted diet consisting of the same

foods cooked and presented in the same way

Appears clumsy or uncoordinated

Selected From: Myles, B. S., Bock, S., & Simpson, R. (2001). Asperger Syndrome

Diagnostic Scale Examiners Manual. Texas: Pro-Ed, Inc.




Sensory Profile Caregiver Questionnaire

Sample Items

Sensory Processing: Always Frequently Occasionally Seldom Never

Responds negatively to

unexpected or loud noises

Covers eyes or squints to

protect eyes from light

Seeks all kinds of movement

and this interferes with dailyroutines (for example, can’t

sit still, fidgets)

Reacts emotionally or

aggressively to touch

Has difficulty paying

attention

Picky eater, especiallyregarding food textures

Modulation:

Poor endurance/tires easily

Seems accident-prone

Takes excessive risks during

play

Is overly affectionate

Behavior and Emotion

Responses:

Is sensitive to criticisms

Has temper tantrums

Poor frustration tolerance

Doesn’t express emotions

Selected From: Dunn, W. (1999). Sensory Profile: User’s Manual San Antonio:

Psychological Corporation.




Perceived Efficacy and Goal Setting System

Sample Items

Item A Lot A Little A Little A Lot

Catching balls – good

Catching balls – not good

Tying shoes – difficult

Tying shoes - easy

Playground – does not like to

try new things

Playground – likes to try newthings

Drawing – not neat

Drawing – neat and clear

Selected From: Missiuna, C., Pollock, N., & Law, M. (2004). The Perceived Efficacy and

Goal Setting System Manual. San Antonio: Psych Corp; Harcourt Assessment.




Appendix L

Clinical Observations Documentation Form




Clinical Observations

Adapted from:

Fisher, A.G., Murray, E., & Bundy, A. (1991). Sensory Integration Theory and Practice.Philadelphia: F.A. Davis Company.

Shriber, L. (2004). "Sensory Integration and Neurodevelopmental Therapy Course."University at Buffalo, Buffalo, NY.

The following is a list of activities to be observed outside of formal testing. This listserves as an example of activities, as some items may not be observed, while otheritems not on this list may be noted during the session:

Sensory Modulation:

Reaction to changes in body positionNormal Reaction

Gravitational Insecurity in the form of excessive fearResponses to movement

Tolerates movement wellDemonstrates signs of discomfort (nausea, vomiting, dizziness)

Reaction to tactile stimuliTolerates many forms of touch and texturesOverreacts of demonstrates discomfort with touch or textures

Reaction to sensory experiences Actively seeks new challenges and activities Avoids new activities or sensory stimuli

Distractibility Able to attend to activity at hand

Difficulty attending to the taskLevel of Activity

Appropriate levels of activity for the situation Abnormally high or low levels of activity for the situation or difficulty withtransitions from one activity to the next

Posture:

Prone Extension Able to hold 10-20 secondsDifficulty assuming a prone extension position

Quadruped

Able to stabilize trunk and extremitiesUnable to maintain with proper stability or locking at joints

Muscle ToneNormal tone in extended positionsIncreased or decreased tone observed in the extremities or at the low back




Bilateral Integration:

Hand PreferenceConsistently uses preferred handInconsistent with hand use

Crossing MidlineEasily brings extremities past midline

Avoids crossing the midline of the bodyRight-Left Confusion

Demonstrates understanding of right and leftConfuses right and left

Motor Skills (Catching bounced ball, hopping, skipping, Symmetrical and reciprocalstride jumping, stepping over a moving object)Demonstrates ability to plan and execute a smooth pattern of movementUnable to execute a smooth movement or demonstrates difficulty with the task

Praxia:

Supine Flexion Able to hold 10-20 secondsDifficulty assuming a supine flexion position

Finger-Thumb touchingDemonstrates smooth finger thumb opposition without visual assistanceUnable to touch thumb to fingers in smooth pattern

In-Hand Manipulation Able to move objects within the handRequires both hands or setting the object down to manipulate an object

Pronation/Supination of the Upper Extremity Able to execute a smooth sequence of palmar to dorsal hand slaps

Unable to alternate hands between palm and dorsal surface

Central Nervous System Maturity:

Associated MovementsNo additional movements or fixing noted with age-appropriate skills

Additional movements or fixing patterns observed with age-appropriate skillsFinger to Nose

Able to touch finger to nose in an smooth, alternating patternUnable to touch finger to nose in an smooth, alternating pattern

Slow (Ramp) MovementsMirrors flexion and extension of elbows in a smooth, symmetrical manner

Unable to flex and extend elbows smoothly and symmetricallyProtective Extension and Equilibrium Reactions (In Quadruped, Sitting, Kneeling and

Standing)Demonstrates ability to extend body on weight bearing side to maintain balanceor catch himself or herself when fallingUnable to maintain balance with reaching out of center of balance, does notextend limb to catch himself or herself, or demonstrates flexion on the weightbearing side




Appendix M

Clinical Observations Worksheet




13. Schilder’s Arm Extension: (90 degrees shldr flexion; eyes closed, pt. counts

to 10)Arm Raising: R / L Elbow Hyperextension: R / L

Coreoathetosis: None Slight Definite

Position Changes of arms: None Slight Definite

(Eyes open; passive rotation of the head)Trunk Rotation: None Slight Definite

Head Resistance: None Slight Definite

Discomfort: None Slight Definite

14. Righting Reactions: (standing)

Eyes Open: Normal AbsentEyes Closed: Normal Absent

15. Prone Extension: ______ seconds _______effort

16. Symmetrical TNR: (quadruped) No change in joint flexion or extension

Slight change in joint positionDefinite change in joint position

17. Asymmetrical ATNR: Quadruped: No flexion with passive head turnSlight flexion with passive head turn

Definite flexion or head resistance

Reflex Inhibiting Posture: (quadruped; hand on hip;contralateral leg extended; snap finger and have pt.

look at you on the side of the hand on hip)Assumes and maintains balance

Assumes with great difficulty

Cannot assume

18. Supine Flexion: _____ seconds ______ effort

19. Postural Background Movements: Normal Slight Irregular Poor




Appendix N

Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Sample Items




Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Sample Items

Fine Manual Control Composite

Motor Precision Subtest

Drawing Lines through Paths without touching the lines

Folding paper along a line

Fine Motor Integration Subtest

Copying a Circle

Copying a Star

Manual Coordination Composite

Manual Dexterity Subtest

Transferring Pennies from the desk to a box

Stringing Blocks

Upper-Limb Coordination Subtest

Catching a Tossed Ball – Both Hands

Dribbling a Ball - Alternating Hands

Body Coordination Composite

Bilateral Coordination Subtest

Jumping Jacks

Tapping Feet and Fingers – Opposite Sides Synchronized

Balance Subtest

Walking Forward on a Line

Standing on One Leg on a Line – Eyes Closed

Standing Heel-to-Toe on a Balance Beam




Strength and Agility Composite

Running Speed and Agility Subtest

Shuttle Run

One-Legged Stationary Hop

Strength Subtest

Standing Long Jump

Sit-Ups

Selected From: Bruininks, R. H., & Bruininks, B. D. (2005). Bruininks-Oseretsky Test of

Motor Proficiency (2nd Edition). Circle Pines, Minnesota: AGS Publishing.




Appendix O

Sensory Integration and Praxis Tests

Descriptions and Examples




Sensory Integration and Praxis Tests

Descriptions and Examples

Subtest Description Example

Space

Visualization

The child is asked to select which

of two shapes fits the given “hole”

Offering an egg shape and a

diamond – which fits the egg-

shaped hole?

Figure-Ground

Perception

The child is asked to identify three

figures within a more complex picture

Standing and

Walking Balance

The child is asked to balance and

walk with eyes open and eyes

closed

Stand heel to toe

Stand, balance left foot, eyes

closed

Design Copying The child is asked to copy abstract

drawings

Postural Praxis The child is asked to imitate a static

position performed by the examiner

One hand on the side of the

head, other hand on the hip,the head and trunk are leaning

Bilateral MotorCoordination

The child is asked to imitate asequence of hand movements

Tap: Right hand, left hand,right hand, left hand

Praxis on Verbal

Command

The child is asked to follow the

instructions for movement

“Put both hands on your head

and bend your knees”

Constructional

Praxis

The child is asked to build a

complex structure that is the same

as the given block structure

Postrotary Nystagmus

The child sits on a spinning boardwith his or her head forward 30

degrees. He or she is spun 10 timesin one direction and 10 times in the

other direction within 20 seconds

each time.

Motor Accuracy The child is asked to trace a line

without leaving the line




SequencingPraxis

The child is asked to imitate a seriesof progressively difficult

movements with hands and feet

Clap, Clap

Clap, Clap, Tap both hands

Clap, Clap, Tap both hands,

Tap both hands…

Oral Praxis The child is asked to imitate oral

movements made by the examiner

Touch tongue to the upper

lip, then the lower lip, twotimes

Manual Form

Perception

The child is asked to identify the

picture or the shape that

corresponds to a shape that was placed in his or her hand with vision

occluded

Circle

Star

Hexagon

Kinesthesia The child’s finger is moved from

one position to another, and he or

she is asked to return to the originallocation with vision occluded

Finger

Identification

The child is asked to identify which

fingers were touched when vision

was occluded

Left ring and left little fingers

are touched simultaneously

Graphesthesia The child is asked to use one finger

to copy a line that was drawn on hisor her hand when vision was

occluded

An “X” is drawn on the back

of the hand

Location of

TactileStimulation

The child is asked to identify the

exact spot he or she was touched onthe hand or lower arm

Selected From: Ayres, A. J. (1989). Sensory Integration and Praxis Tests Manual. Los

Angeles: Western Psychological Services.




Appendix Q

Request For Assistance in Test Administration of Participants




University at Buffalo


Kimball Tower, Room 515

3435 Main Street

Buffalo, New York 14214

Date

To Whom It May Concern:

My name is Kristen Klyczek. I am a graduate student at the University at Buffalo, and I am

pursuing a Ph.D. in Rehabilitation Science. As part of my dissertation, I am planning to conduct

a study titled: “The Effectiveness of Sensory Integration Therapy on the Sensory and Motor Skillsof Children with Asperger’s Syndrome”. I would like to request your assistance in testing study

participants.

For my study, a minimum of eight children who have Asperger’s Syndrome will receive Sensory

Integration treatment, and the effect of this intervention will be measured by pre-, mid-, and post-study testing. Clinical testing will include the Sensory Integration and Praxis Tests, the

Bruininks Oseretsky Test of Motor Proficiency, Second Edition, the Perceived Efficacy and Goal

Setting System, and Clinical Observations. It will also require parents to complete a demographic

survey, the Sensory Profile and the Asperger Syndrome Diagnostic Scale. I plan on conducting

much of the pre- and mid- study testing personally, however for study validity, it is important to

have an outside examiner perform post-study testing. I would greatly appreciate any time you

could offer for this purpose. Unfortunately, I do not have funding to compensate you for your

time, however I will cover the costs for all testing materials, and your generous work will be

recognized in my dissertation and in any subsequent publications or presentations should you

provide consent.

I am sure you can appreciate how critically important it is to support research that involvestreatment of children with disabilities. Completing smaller studies, such as this will hopefully

lead to larger-scale studies regarding the efficacy of treatment of children with Asperger’s

Syndrome. I would appreciate your contacting me by telephone at 716-639-9201, or via email at

[email protected] to discuss this matter further. I will contact you in approximately two

weeks to see if I can provide any additional information and to obtain your decision. I will look

forward to speaking with you, and sincerely appreciate your consideration.

Sincerely,

Kristen Klyczek

PhD Student





Appendix R

Treatment Manual




The Effectiveness of Sensory Integration Therapy on the Sensory and Motor Skills

of Children with Asperger’s Syndrome

Treatment Manual

Goals for Treatment:

The primary goal of SI therapy is to improve the ability of the nervous system to

interpret and organize sensory information. This can be accomplished by providing

child-centered sensory experiences at a “just-right” level of challenge that promote

interpretation and organization of sensory input within the child’s nervous system in

order to improve the child’s ability to interact with his or her environment.

Mode of Delivery:

The activities within this treatment manual are designed for a ten-week treatment

period using direct, one-on-one therapy. Sessions are designed to be provided for 45-60

minutes each. The provider, will be a licensed physical therapist who is trained and

certified in SI evaluation and intervention, and will conduct all treatment sessions. A

sensory integration frame of reference will be followed at all times.

Session activities will be child-directed whenever possible, however the types of

activities offered to the child will be based on the needs of the child, identified during

pretesting, previous sessions and that session itself. A list of treatment options has been

provided.




Equipment Specifications:

The following equipment is available for use during the study:

Suspended equipment: New swing, Platform swing, disc swing

Therapy Balls: Assorted sizes and shapes

Mats and Landing Cushions: Six mats: 9’10”x 6’ x 3”

Mat Tables: Two: 7’x 5’ raised 21” off the floor, and two: 6’x 4’, 18” off the floor

Panel Mats: Three: 4 panels each

Wedges: Assorted sizes and shapes

Bolsters: Assorted sizes and shapes

Scooter boards

Tilt boards

T-stools

Adjustable benches

Ramp: 22” wide, extending 57”

Mirrors: full length

Mini-trampoline

Floor balance beam: 8’ x 4” x 1” high

Elevated balance beam

Tunnels: Rigid, flexible, and resistive tunnels

Weighted equipment: vests, toys, cuff weights

Blankets, elastic fabrics and resistive vests




Large manipulative toys and accessories including: Balls, hula hoops, ropes, theraband

Small toys including: plastic cones, bean bags, textured balls and objects, puzzles

Tactile toys and accessories including: rice buckets, bean buckets, creams (shaving), play

dough/clay, textured objects

Treatment Options:

What follows is a list of basic treatment options, which have been taken from

published lists that have been provided by experts in the field of SI. In addition,

modifications to treatment suggestions and additional ideas have been listed, in order to

properly utilize the available equipment and resources. The options listed provide a

framework for intervention with basic activity descriptions. Each activity will tailored to

match the child’s interests or the intended functional purpose. For example, a prone

activity on a suspended swing, in which the child is throwing beanbag “gold” into a

basket might be altered by having the child ring hula hoop “sprinkles” around “ice cream

cones” (plastic cones) instead. Options are listed based on the primary need the activity

might address, however treatments that are on this list may also be appropriate for other

purposes. An example is a vestibular activity such as jumping on a trampoline, which

may also be used to provide increased proprioceptive awareness to a child. Therefore, as

long as the activity is listed, it may be used during intervention. The therapist will make

every attempt to use only those activities listed in this manual, however if an activity is

performed which is not listed, the therapist will describe both the activity and its purpose

in writing.




Vestibular Input

Purpose Activity

Calming • Slow, rhythmic movements

•

Slow, linear swinging• Eyes in line with the horizon

• Minimal visual stimulation

Alerting • Quick, unpredictable movements

• Swinging in an angular pattern

• Quick changes in direction

• Visually stimulating environment

• Use of suspended equipment

• Activities with the body positionaltered from neutral

Generalized Vestibular Input • Weight shifting quickly

(Useful for promoting eye contact, • Rolling or rocking activities (rollup in

extension, muscular cocontraction, blankets, rolling obstacle course,rock back

improving postural or gravitational security, and forth while sitting and holding

hands)

promoting improved equilibrium) • Using the head in various positions

to move a ball

• Rocking while seated on a bolster

or therapy ball

• Rolling on the floor, or down an

incline

• Swinging in prone, supine flexion,sitting or standing (the therapist orchild initiates

the movement by holding ropes,

hoops, or objects, or by keeping

hands on the floor)

• Walking up and down inclines, on

a balance beam, on rough surfaces,with assistance as needed

• Slides close to the floor with mats

• Scooter Board (supine, prone,

sitting, or kneeling; on the floor, or prone down an incline)

• Being pulled on a piece ofcardboard while trying to maintain




balance (prone, sitting, kneeling,

standing)

• Tilt board (supine, prone, sitting,kneeling, standing)

• Movement activities to music

• Bouncing on the floor, on atrampoline, on a therapy ball or

Hippity-Hop toy

• Turning, rotating, spinning(independently, or using equipment

such as a Sit n’ Spin)

Gravitational Insecurity

Purpose Activity

Reducing gravitational insecurity • Prone activities on the ground

• Rolling on the floor or mat

• Rolling in a barrel

• Proprioceptive activities

• Linear activities such as swingingon suspended equipment, or using a

scooter board (may have child knocksomething over in the backwards

direction if he or she has a fear of

backwards movement)

• Quadruped activities such as anobstacle course

Poor Posture

Purpose Activity

Often low tone, poor postural stability, poor equilibrium reactions, decreased proneextension, poor supine flexion – together, indicate vestibular and proprioceptive

processing deficits

Facilitating extension against gravity • Prone propping activities

(Cocontraction of extensor muscles) • Supported prone activities usingextension of the neck and upper back

(activities that are in prone on

elbows)

• Weight shifting in prone (on

extended elbows)



The Effectiveness of Sensory Integration Therapy 259

Proprioceptive Input

Purpose Activity

Calming•

Slow, steady activities• Resistance activities

• Slowly alternating pushing and

pulling

• Firm, deep pressure: tight wraps,

blankets,mats

Alerting • Quick, jerky movements

• Activities involving stopping andstarting quickly

Generalized Proprioceptive Input • Firm, deep pressure: tight wraps, blankets,

(Useful for producing a calming effect, mats

promote body awareness, enhance motor • Weights (provided via clothing,

toys, cuff planning, improve balance, alter muscle tone) weights, weighted blankets)

• Joint compression or traction

• Scrubbing activities (using brushes,sponges, washcloths)

• Weight bearing and weight shifting

activities (in prone, quadruped,sitting, kneeling, standing)

• Locomotor activities: rolling,

crawling, hopping, skipping,marching, stomping, clapping,

• Therapy ball activities (prone onhands, bouncing on the ball, pushing

or bouncing balls)

• Bumping into and knocking downobjects

• Hitting or punching activities(balls, balloons, pillows)

• Stair climbing

• Heavy work: pushing, pulling,carrying

heavy objects, lifting




• Races pushing or carrying therapy balls, medicine balls, weighted

objects

• Tug of War

• Resistance tunnels

• Climbing activities up incline, or innet

• Jumping (on the floor, on atrampoline, onto a soft surface)

• Wheelbarrow walking (on hands)or crawling

• Push-ups, sit-ups

Tactile Input

Purpose Activity

The following guidelines should be followed when providing tactile experiences to a

child with

poor tactile processing or integration:1. Input should be child administered (choosing activities and the amount of

pressure and time)

2. Deep pressure is usually more tolerable, but some children prefer quick or light

touch, so determine what is appropriate for each child based on response3. Input to the arms and legs (also back) is usually sufficient – no need for whole

body

4. Apply input in the direction of hair growth or go back and forth

5. Provide proprioception first, then more tactile6. Try enclosed spaces for providing new tactile/proprioceptive experiences

Calming • Warm temperatures

• Deep touch pressure

• Rolling balls, bolsters or otherobjects over the child

• Compression of the child withmats, toys, hugging, wraps

• Weight bearing activities

• Smooth textures

Alerting • Rough textures

• Cold temperatures

• Light, inconsistent, unexpected or pressure point touch

• Touch in direction opposite of hairgrowth




• Touch to the face

Generalized Tactile Input • Textured surfaces on equipment(Useful in improving acceptance of touch (carpet, satin, corduroy, sheepskin)

and tactilely defensive situations) • Pulling child on various surfaces

• Brushes• Vibrators

• Dry textured objects and materials(balls, toys, rice, beans fabrics, sand,

powder)

• Ball bath

• Writing with chalk, erasing withhand

• Wet textured objects and materials

(play dough or clay, grass, slimey,sticky or gooey objects, finger paint,

water, bubbles, shaving cream,lotion)

• Obstacle courses that incorporate a

variety of textures

Enhancing sensory modulation • Deep pressure

(decrease defensiveness) • Weighted vests, backpacks, hats

• Large pillows and mats for

burrowing

• Large therapy balls – roll over

child or child pushes against w/therapist

• Activities requiring the child tomove heavy objects – such as pulling

on end of rope, barrels, therapist on

equipment

• Theraband wrapped on skin

• Proprioceptive activities

• Jumping, bouncing

• Vibration to arms and legs

•

Textured coverings on equipment• Textured mitts on skin

• Searching for objects in boxes oftactile experiences (beans, rice)

• Ball pits

• Resistance activities for the mouth,such as sucking through a straw

(sour = organizing)




• Activities involving alternatingflexion and extension of the arms

• Activities that require the child toaim at specific targets (throwing,

touching, kicking, squirting) while

on a stable or moving surface• Whole body activities progressingto movement of specific body parts

• Resistance activities

• Counting or singing a song while performing an activity to keep the

rhythm

• Create new activities with oldskills (jump onto mats one day and

into a hula hoop the next

• Jumping, hopping, jumping jacks,

skipping, stride jumping• Stepping over moving objects

References

Bundy, A. Lane, S. & Murray, E. (2002). Sensory Integration Theory and Practice (2nd

Edition). Philadelphia, PA: F.A. Davis Company.

Fisher, A.G., Murray, E. & Bundy, A. (1991). Sensory Integration Theory and Practice.

Philadelphia, PA: F.A. Davis Company.

Huebner, R.A. (1992). Autistic Disorder: a neuropsychological enigma. The American


Shriber, L. (2004). Sensory Integration and Neurodevelopmental Therapy Course.

University at Buffalo, Buffalo, NY.

Watling, R. (2004). The effect of sensory integration on behavior and engagement in

young children with autistic spectrum disorders. University of Washington.




Appendix S

Therapy Session Progress Note and Checklist




Therapy Progress Note and Checklist

Code Number: ____________________ Date of Session: _______________

Subjective:__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Objective:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________Assessment:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Plan:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

List All Activities Performed During The Session:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Additional Comments:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________




1. Circle which items were targeted during this session:

Gustatory Tactile Olfactory Auditory Vestibular

Proprioceptive Bilateral Coordination Kinesthesia Praxis

2. Was the session one-on-one? Yes / No Length of Session: __________Minutes

3. Approximately how many minutes were child directed? _____ Therapistdirected?_____

4. Did the therapist set up the equipment or arrange the room to entice the child intochoosing and engaging in an activity? Yes / Somewhat / No

Comments:________________________________________________________

5. Did the therapist ensure physical safety of the child either through placement of

equipment or through therapist’s proximity and actions? Yes / Somewhat / NoComments:

_____________________________________________________________

6. Did the therapist work to sustain an optimal level of arousal? Yes / Somewhat / No

Comments: _____________________________________________________________

7. Did the therapist present or support activities in which the child could be successful inresponse to the challenge? Yes / Somewhat / No

Comments: _____________________________________________________________

8. Did the therapist adjust the activity in response to the child, so that the activity was

neither too difficult, nor too easy? Yes / Somewhat / NoComments:

_____________________________________________________________

9. Did the therapist support the child’s Self-organization of behavior by giving the child

chances to make choices and plan activities? Yes / Somewhat / No

Comments: _____________________________________________________________

10. Did the therapist maintain a context of play throughout the session?Yes / Somewhat / No

Comments:

_____________________________________________________________

11. Did the therapist allow for active control and self direction by the child as much as

possible? Yes / Somewhat / No




Comments:

_____________________________________________________________

The Efficacy of Sensory Integration Therapy on Children With Asperger's Syndrome and Pdd-nos

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