Steven R. Shaw, NCSP
Anyone who works with children with autism, learning
disabilities, or mental retardation has observed
the child who craves being held tightly, the child
with high pain tolerance, the child with tactile
defensiveness, the child who is clumsy, and the
child who cannot tolerate tags on the inside of
her shirt. Sensory integration (SI) dysfunction
appears to be a productive explanation for these
problems (American Occupational Therapy Association,
1997; Case-Smith & Bryon, 1999). Moreover,
SI therapy seems a logical approach to addressing
Background of Sensory Integration Therapy
Sensory integration is a normal developmental
process involving the ability of the central nervous
system (CNS) to organize sensory feedback from
the body and the environment in order to make
successful adaptive responses (Ermer & Dunn,
1998). The basic tenets of SI are: 1) the CNS
is plastic; 2) SI matures along a predictable
developmental sequence; 3) SI therapy attempts
to revisit and restructure the development of
sensory integration in cases where the normal
developmental progression has been disrupted;
4) SI therapy links an adaptive response to sensory
input; and 5) children have an inner drive to
integrate information (Bundy, Lane, Fisher, &
Murray, 2002). Among the therapeutic techniques
are deep brushing; swings for vestibular input;
textures; bounce pads; scooter boards; weighted
vests and other clothing; ramps; and generally
increasing or decreasing sensory diet, depending
on the needs of the child. When Jean Ayres (1979)
first developed SI she proposed that, by revisiting
the developmental process of integrating information
from the senses into an organized whole through
a carefully controlled sensory diet, learning
disabilities and other developmental disabilities
could be cured (Carte, Morrison, Sublett, Uemura,
& Setrakian, 1984; Kranowitz, Szlut, Balzer-Martin,
Haber & Sava, 2001).
Evidence Belies Appeal of SI
There is one small problem. The problem is that
it does not work. There is no evidence that SI
therapy is or has ever been an effective treatment
for children with learning disabilities, autism,
or any other developmental disability. This is
not one of those common cases where there is not
enough information upon which to effectively evaluate
the treatment. In fact, there are plenty of quality
outcome studies (41 as of this writing). There
is no study that uses a quality research design
(e.g., random assignment of subjects, matched
control groups, consideration of the effects of
maturation, evaluators blind to treatment condition)
that finds SI therapy to be effective in reducing
any problem behaviors or increasing any desired
behaviors. There is plenty of evidence from which
a verdict can be drawn. And the verdict is that,
despite the intuitive appeal and glowing testimonials,
SI therapy is not an effective treatment (Gresham,
Beebe-Frankenburger, & MacMillan, 1999; Hoehn
& Baumeister, 1994; Shaw, Powers, Abelkop,
& Mullis, 2002).
Literature in a field can be compiled and integrated
through a method called meta-analysis. All results
are reduced to a metric called an effect size.
Effect sizes are expressed in standard deviation
units. The rule of thumb is that an effect size
greater than .50 is large and an effect size of
.20 to .50 is moderate. Effect sizes of less than
.20 are rarely significant. Another common pattern
is that poorly designed studies result in greater
effect sizes than well-designed studies. That
is the case with SI therapy. Several early studies
that did not assign participants randomly found
positive outcomes. Forty-one studies had random
assignment of subjects, which is considered a
minimum criterion for a quality design. Subjects
include children with the following diagnoses
(N refers to the number of studies considered):
autism (N=8), learning disabilities (N=23), mental
retardation (N=5), motor problems (N=3) and multiple
developmental issues (N=2).
From all of these studies, each with multiple
variables, 218 effect sizes were calculated. Of
note is that there were no significant effect
sizes for language improvement (-.08), behavior
(.02) and sensory motor functions (-.10). There
were small, but significant effects for motor
skills (.24) and psychoeducational performance
(.26). However, if only the studies that considered
maturation factors are included (N=12), then the
effect sizes for motor skills and psychoeducational
performance are reduced to nearly zero (.03 and
-.04, respectively; Shaw et al., 2002).
There simply is no evidence of the efficacy of
SI therapy (Cummins, 1991). Many have tried. It
certainly is possible that the studies lacked
sufficient power to demonstrate effectiveness,
dependent measures are not sufficiently sensitive
to change, or that experimental designs may be
biased against finding positive effects (Vargas
& Camilli, 1999). These are important academic
questions to be answered. However, for a procedure
with no evidence of efficacy to be used on the
public with claims of success, to charge money
for these services, and to train practitioners
in this model borders on unethical behavior. At
least some evidence that SI procedures are "safe
and effective," to use Food and Drug Administration
language, is required before moving a technique
from theory and experimentation to the public.
The Placebo Effect of SI
If this is so, then why do so many therapists
and parents swear by the effectiveness of SI therapy?
In a word: placebo. Placebo is a powerful tool
used in many professions. If someone believes
that a therapy works and invests personal energy
into making a therapy work, then to some degree
it will work. In SI therapy a skilled professional
is spending one-on-one time with a child, coaching
parents on how to interact with their child, supplying
answers to parents, and giving parents hope (Ottenbacher,
1982). These are fabulous and valuable activities.
Parents are empowered. Parents become hopeful
and involved. However, these activities have nothing
to do with SI therapy. A professional could provide
the same positive messages by giving the child
a massage or playing checkers with a child and
there would be the perception of positive outcomes.
Placebo is neither a bad thing nor something to
be ignored. There is an estimate that 30% of physician
treatment effectiveness is due to placebo (Roberts,
Lauriello, Geppert, & Keith, 2001). Certainly
the same is probably true of psychological counseling
(Roberts, et al., 2001). I rarely dismiss SI as
a treatment option because there is likely to
be some good derived from the family working with
these skilled professionals. I will only argue
against SI when the diagnosis of SI dysfunction
and subsequent treatments interfere with a more
appropriate diagnosis with a potential to result
in an effective treatment plan. Perhaps this is
a wrong approach. If parents, Medicaid, or insurance
companies are paying 60 to 80 dollars per hour
of therapy, then they should be ensured that the
child is receiving an effective treatment rather
than a placebo.
An interesting phenomena is noted on the popular
website Amazon.com. A popular part of this website
is that people who have read books submit short
reviews. These reviews are posted along with other
information about the book. Customers then write
in to say how helpful is a given review. Reviews
of the popular book, The Out-of-Sync Child (Kranowitz
& Silver, 1998), that were positive, glowing,
and unquestioning were usually considered to be
helpful (19 of 20 comments). The one review that
questioned the book's major premises was universally
reported to not be helpful at all (0 of 4 comments).
People want firm and intuitively appealing answers,
identification of causes of the problems, and
guaranteed cures. The general public values certainty.
Scientific support is irrelevant. The probabilistic
approach of science is not as satisfying to desperate
parents as unquestioned conviction, certainty
of conclusions and declarations of "fact."
Close to Psuedoscience?
To a scientist-practitioner there are several
extremely disturbing aspects of SI. There are
several aspects of SI that are dangerously close
to the criteria used to define pseudoscience (Gardner,
1982). Among these criteria are: a) Reliance on
subjective validation (i.e., failing to consider
maturity, errors in initial diagnoses and the
effects other valid treatment regimens in cases
where children improve); b) nearly exclusive reliance
on anecdotes, rumor, common sense and eyewitness
testimony to support a treatment validity; c)
an indifference to facts (i.e., despite advances
in developmental cognitive neuroscience and a
large body of research on SI, there have been
no major changes in theory of SI since Jean Ayres's
1979 book, Sensory Integration and the Child);
d) beginning with a spectacular and emotionally
appealing hypothesis and only acknowledging supporting
items while ignoring all contrary evidence; e)
deliberately creating mysteries and mysterious
new constructs (i.e., SI theorists invented the
concept of "near senses" and refers
to mysterious plasticity of the CNS without explanation
of how SI uses neural plasticity toward a restructuring
of brain structure); f) the literature is aimed
at the general public rather than the academic
or clinical community; and g) convinces people
by appeals to hope and faith in cases where the
scientific and clinical community has no scientifically
accepted answers. Moreover, the original SI therapy
was developed for use for children with learning
disabilities. This application of SI therapy is
nearly universally discredited (see DiMatties
and Quirk  for an exception). Now SI therapy
is being applied to children with autism, developmental
dyspraxia, mental retardation, nonverbal learning
disabilities and children with general motor clumsiness
and environmental sensitivities. SI proponents
may eventually find or create a disorder that
SI therapies effectively treat. At this point,
the search continues.
Ties to Psychomotor Patterning
There are many similarities between SI and psychomotor
patterning that are also disturbing. Psychomotor
popularized by Doman and Delacato, is a method
that posits the child has not effectively acquired
neurodevelopmental and evolutionary motor patterns
(i.e., the assumption that ontogeny recapitulates
phylogeny is given great emphasis in this model).
A diet of sensory input, appropriate nutrition,
breathing exercises and series of patterned motor
movements are proposed to cure learning disabilities,
mental retardation, brain injury and autism. The
diet of sensory input and motor movements are
quite similar to those now used in SI. Psychomotor
patterning has been dismissed on two occasions
by the American Academy of Pediatrics (1982; 1999)
as completely ineffective. Psychomotor patterning
is also featured on the website, www.quackwatch.org
While Awaiting Research Evidence.
Despite this harsh criticism, SI theorists and
practitioners may be close to something important.
I strongly encourage continued research in this
area. However, the general public should not be
Guinea pigs. Nor should resources be taken from
effective treatments to go towards an unproved
treatment. I hope that when new and improved SI
models are proven safe and effective, they will
dramatically improve the lives of children and
their families. When there is evidence of SI as
a safe and effective treatment, I promise to publicize
such positive findings as vigorously as I have
pointed out its current shortcomings.
American Academy of Pediatrics. (1982). Policy
statement: The Doman-Delacato treatment of neurologically
handicapped children. Pediatrics, 70, 810-812.
American Academic of Pediatrics. (1999). Policy
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American Occupational Therapy Association (1997).
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in school-based occupational therapy. The American
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Ayres, A. J. (1979). Sensory integration and
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Bundy, A. C., Lane, S. J., Fisher, A. G., &
Murray, E. (2002). Sensory integration: Theory
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Kranowitz, C. S., & Silver, L. B. (1998).
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Kranowitz, C. S., Szlut, S., Balzer-Martin, L.,
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Shaw, S. R., Powers, N. R., Abelkop, S., &
Mullis, J. (2002, February). Sensory integration
therapy: Panacea, placebo, or poison? Paper presented
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The American Journal of Occupational Therapy,
Steven R. Shaw, Ph.D., NCSP, is a Communiqué
Contributing Editor and the lead school psychologist
at The Children's Hospital, Greenville, SC and
Associate Professor of Pediatrics, Medical University
of South Carolina. Parts of this paper
were presented at the 2002 Annual NASP Convention
and appeared in The Tennessee School Psychologist.
He can be
reached for comments and hate mail at firstname.lastname@example.org.