Abstract
Systematic review briefs provide a summary of the findings from systematic reviews evaluated in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings from the systematic review on the effectiveness of sensory-based interventions (excluding Ayres Sensory Integration® [ASI]) for children and youth 0–21 yr of age.
Full Systematic Review Question
What is the effectiveness of specific sensory-based interventions, including sensory techniques, sensory environmental modifications, and caregiver-focused sensory interventions; excluding Ayres Sensory Integration® (ASI), to support functioning and participation for children and youth (0–21 yr of age) with challenges in processing and integrating sensory information that interferes with everyday life participation?
Current Theme Reported
The main theme of the studies presented in this systematic review includes sensory-based interventions for children with sensory integration and processing differences. The following subthemes were identified: Sensory techniques Alternative seating Multiple sensory techniques Sensory tools Deep-pressure tactile input Sensory input provided by caregivers Modifications to the sensory environment.
Clinical Scenario
Sensory processing differences occur in about 5%–25% of children in the United States (Ben-Sasson et al., 2009; Jussila et al., 2020). Many of these children receive occupational therapy services due to concerns with sensory processing differences that impact their ability to perform daily occupations. Occupational therapy practitioners (OTPs) are skilled in using sensory interventions to address sensory integration and processing needs. In fact, 95% of OTPs working in pediatrics report using sensory interventions in their treatment (Mailloux & Smith Roley, 2010, as cited in Schaaf et al., 2018). Sensory interventions include ASI and sensory-based interventions (Case-Smith et al., 2014). ASI has specific equipment, training, and intervention components that must be present within the intervention to be considered ASI (Parham et al., 2011; Schaaf & Mailloux, 2015).
In addition to ASI, other sensory-based interventions (SBIs) are often used as part of sensory and sensory-regulation programs. SBIs only require passive participation of a child and are designed to fit within a child’s routine (Case-Smith et al., 2014). SBIs passively target one or more sensory systems, aiming to temporarily change a child’s physiological arousal level to better match the demands of the environment or task, thereby increasing occupational performance (Case-Smith et al., 2014; Polatajko & Cantin, 2010). SBIs may be done by the child or to the child. Although they may be part of the direct, skilled intervention, they are not designed to be a stand-alone technique but part of the more holistic plan of care. This systematic review examined SBIs; ASI interventions were excluded.
A systematic review examining the use of SBIs, such as wearing a weighted vest, sitting on a therapy ball, utilizing cushions or swings, and physical activity, demonstrated mixed results of effectiveness on attention, behaviors, and task engagement in the school setting (Ouellet et al., 2018). Watling and Hauer’s (2015) systematic review of SBIs demonstrated weak evidence supporting their use for improving participation and functional outcomes for children with sensory processing differences.
Sensory environmental modifications seek to adapt the environment to improve the fit between the person and the demands of the environment, much as described in the Person-Environment-Occupation theory (Law et al., 1996). In the Watling and Hauer (2015) review, only one study examining the sensory environment met the inclusion criteria with positive results. However, this small study did not provide enough evidence to support the effectiveness or ineffectiveness of sensory environmental modifications.
Many children with sensory processing differences may have challenges that impede their ability to engage in family and school activities (Butera et al., 2020; Ismael et al., 2018). By including caregiver training in the intervention process, OTPs can provide family-centered care and interventions that extend beyond the therapy session (D’Arrigo et al., 2019). Models of caregiver training, such as coaching and parent education, are popular in pediatric therapy to empower caregivers to perform interventions even when the therapist is not present (Kessler & Graham, 2015). Both training and caregiver education can help increase understanding of sensory processing and ensure that the sensory home interventions are congruent with the theory of sensory integration (King et al., 2017).
Miller-Kuhaneck and Watling (2018) conducted a systematic review examining the effectiveness of caregiver education and coaching for children and youth with sensory integration and processing challenges. Overall, results showed positive outcomes in areas of participation, such as parental stress, child performance, and implementation of interventions with good fidelity; however, due to the limited number of studies included in the review (four), the evidence for caregiver training was inconclusive. In addition, the studies included in the review only represented autistic children, limiting the generalizability of the studies to other populations. Another scoping review of coaching parents of children with sensory processing differences (Allen et al., 2021) indicated positive changes in the child’s goals, parent stress, and the parent’s sense of competence.
Historically, SBIs have weak levels of evidence of effectiveness. Previous systematic reviews indicated weak evidence as to the effectiveness of interventions designed to address one sensory system (e.g., auditory interventions, weighted vests, ball seats), had insufficient evidence on the effect of modifying the sensory environment, and did not report on caregiver interventions (Watling & Hauer, 2015). However, difficulties with methodology and outcomes have been noted (Watling & Hauer, 2015; Case-Smith, 2014). In consideration of evidence before 2015, the purpose of this systematic review was to examine the evidence since 2015 related to sensory interventions, including sensory techniques, sensory environmental modifications, and caregiver education and training on sensory interventions. This review did not include interventions related to ASI.
Summary of Key Findings
For the purpose of this systematic review, we used the following definitions for sensory interventions: “Sensory technique” is defined as the application of particular sensory stimuli, or the provision of materials and activities that provide particular types of sensory stimuli, by direct application to the child’s body or by the child’s body being placed directly on or in an object or device (e.g., sitting on a therapy ball or wearing a compression device). Interventions without any mention of ASI fidelity were included as sensory techniques. “Sensory environmental modification” is defined as a compensatory intervention in which a change is made in the intensity, complexity, or quality of one or more sensory elements in the ambient physical environment surrounding the child to support child functioning and participation. “Caregiver-focused interventions” is defined as working with a child’s caregiver (e.g., parent, guardian, teacher, coach, babysitter, sibling, etc. who attends to the needs or looks after a child) to provide support for the sensory needs of a child who exhibits challenges in integrating and processing sensory information. Interventions are designed to occur in the natural context and support participation of the child and group of which the child is a member.
This systematic review included quantitative evidence at Level 1 and Level 2 based on Nursing-Johns Hopkins Evidence-Based Practice Model (Dang et al., 2022), including single-subject designs at Logan Level 4 or higher (Logan et al., 2008) that used SBIs. The strength of the evidence reported in the tables below was determined using the U.S. Preventive Task Force grade definitions (2018). The risk of bias for most studies was low to moderate. Twenty-one articles were reviewed, with 4 articles at Level 1 and 17 at Level 2 (Dang et al., 2022). Seven of the Level 2 studies were single-subject designs (Logan Level 4 or higher). A total of 718 participants, ages 1–18 yr, were represented in the studies. The diagnoses of participants included autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), sensory processing disorder, and developmental delay. Seven studies took place in a school setting, three in the home setting, seven in a clinic setting, and four in a clinic and either home or school.
Evidence Table for SBIs
Note. BRIEF = Behavior Rating Inventory of Executive Function; CB = control blanket; CI-ASD = Intervention adapted for ASD; NC = noise cancelling; PedsQL = Pediatric Quality of Life Inventory; SE = sleep efficiency; SG = sensory garden; SI = indoor sensory intervention; SOL = sleep onset latency; TST = total sleep time; WASO = wake after sleep onset; WB = weighted blanket.
Bottom Line for Occupational Therapy Practice
This systematic review revealed mixed evidence on the effectiveness of sensory-based interventions to improve participation and functional outcomes. Consistent with the last major systematic review of sensory-based interventions (Case-Smith et al., 2014), studies examining alternative seating did not find significant effects on occupational performance or participation outcomes, such as behavior or attention. However, it is important to note that while alternative seating did not demonstrate externally observable impacts on behaviors or attention, no study examined the child’s perspective, the individual using the alternative seating option (e.g., how the child felt in the context of occupation while using the alternative seating). In future studies, gaining the child's perspective may provide useful information regarding the impacts of alternative seating for the person using the modality. Additionally, alternative seating did not appear to have any negative effects. Therefore, this modality may still be a consideration for children with sensory processing differences. Yet, it should not be expected to improve attention and on-task behavior as a stand-alone intervention.
The use of multiple sensory techniques that included activities targeting multiple sensory systems (i.e., sensory diets, sensory activities with vestibular, proprioception, and tactile components) demonstrated effectiveness in improving functional outcomes. However, the previous systematic review by Watling and Hauer (2015) found small to no effects with SBIs targeting a single sensory system for children with autism spectrum disorder, this review supports that addressing one sensory system may positively affect function and participation with specific populations. One study addressed the auditory system by modifying the way the sensory receptors received input by wearing earmuffs. This resulted in positive effects on auditory-related participation goals (Ikuta et al., 2016). Additionally, deep-pressure tactile input provided as a single intervention demonstrated positive results. Deep-pressure tactile stimulation has physiological effects on the nervous system, decreasing sympathetic arousal (Reynolds et al., 2015) and increasing parasympathetic activity (Chen et al., 2013). Therefore, to assist the child in organizing and facilitating participation in occupations (e.g., sleep), deep-pressure tactile input can be an important tool for practitioners, caregivers, and children with sensory processing differences. At the same time, a study looking at the impact of fidget spinners for students with attention-deficit/hyperactivity disorder (Graziano et al., 2018) found no improvements in motor movements and decreased attention to task.
Several studies evaluated the effectiveness of sensory-based interventions when training and involving caregivers, and interventions in the home as part of the therapeutic process. Evidence supported the training of caregivers on sensory processing and sensory techniques in addition to direct skilled therapy. Although there were a variety of outcomes used to measure the effectiveness of caregiver-based training programs, overall, this intervention demonstrated significant positive effects. This indicates that caregiver training on sensory processing and sensory interventions should be a part of the occupational therapy process for children with sensory processing differences. The current research supports time spent with caregivers as a valid and evidence-based occupational therapy intervention and guides practitioner use of the current procedural terminology caregiver training code as long as the criteria established by the Centers for Medicare and Medicaid Services (American Medical Association, 2023) for reimbursement are met.
As with the last systematic review (Watling & Hauer, 2015), there is still minimal evidence of the effectiveness of modifying the sensory environment. This is an important area for future occupational therapy research as many organizations offer “sensory- friendly” opportunities with modifications to the sensory environment, which is not supported by the current evidence to impact participation. In addition, as children with sensory processing differences age, workplace accommodations for sensory environmental modifications may be requested as a reasonable accommodation under the Americans with Disability Act. Current evidence for sensory environmental modifications is limited. Therefore, additional research is needed in this area across environments and the lifespan to provide the best recommendations to support participation.
To summarize, there is some sensory-based intervention evidence showing effectiveness. This may indicate a need to examine other outcomes or to examine how sensory tools are being used within occupational therapy practice. The evidence validated caregiver training programs as part of the occupational therapy process to support participation for children with sensory processing differences as well as caregiver outcomes.
Footnotes
*indicates articles included in the brief systematic review