A Review of Sensory Integration Auditory Integration Therapies

1. �A Review of Sensory Integration & Auditory Integration Therapies� Brittani Argott Caldwell College

2. Overview

3. Sources PsycINFO �sensory integration� and autis* �auditory integration� and autis* Checked box for peer review Results: Sensory Integration: 117 results Controlled studies - 6 Auditory integration � 9 Correlational � 11 Checklists/surveys � 9 Literature review/ commentary � 21 Audiovisual � 9 Parent reports � 3 Not related � 37 Neurological � 7 Occupational Therapy � 2 Used sensory assessment/ review of sensory integration � 2

4. Sources (Continued) Results (continued): Auditory Integration � 20 results Visual-auditory � 1 Commentary/ replies � 5 Checklist � 1 Review � 8 Case studies � 2 Controlled studies - 2 Jacobson Textbook National Standards Project NY State Appendix C American Academy of Pediatrics Sensory Integration Website Auditory Integration Website

5. What is Sensory Integration? �An intervention in which the participant receives sensory stimulation with the goal of improving attention and cognitive functioning, while decreasing disruptive or repetitive behaviors. Examples include brushing the body, compressing the elbows and knees, swinging from a hammock suspended from a ceiling, and spinning around and around on a scooter board. Examples of sensory diet interventions include wearing a weighted vest or wristbands, putting a body sock on the participant, or massaging the child's mouth or other body parts. Sensory Integrative Therapy is often supervised by an occupational therapist.�

6. What is Sensory Integration? � the neurological process that organizes sensation from one�s own body and from the environment and makes it possible to use the body effectively within the environment�(p.11) � Dr. Ayres �These treatments involve establishing an environment that stimulates or challenges the individual to effectively use all of their senses as a means of addressing overstimulation or under stimulation from the environment.� � National Standards Project The stated goal of sensory integration therapy is to "facilitate the development of the nervous system's ability to process sensory input in a more normal way.� � State of NY

7. Video http://www.youtube.com/watch?v=qtszqdr4GW4&feature=related (overview) http://www.youtube.com/watch?v=Zhkty0YBTC8&feature=related (big hug) http://www.youtube.com/watch?v=OvFQvMR59mM&feature=related (weighted belt) http://www.youtube.com/watch?v=i47mm9jW0LM&feature=related (brushing & compression)

8. History Dr. A. Jean Ayres, PhD, OTR, FAOTA (1920 � 1988) developed SIT. She states that the vestibular, proprioceptive, and tactile systems are ancestors of our other senses and thus these must develop before advanced cognitive tasks can be performed. � A. Jean Ayres is best known for her discovery of, and subsequent lectures and publications related to a type of developmental disorder known as sensory integrative dysfunction. She is the author of over thirty refereed journal articles, several books and book chapters, and three major standardized test instruments: the Southern California Sensory Integration Tests (1972), the Southern California Postrotary Nystagmus Test (1975), and the Sensory Integration and Praxis Tests (1989), all published by Western Psychological Services.� http://www.helpinghandstherapy.net/SIPT.html (Sensory Integration and Praxis Tests) � What do you think? There is now a Global Network (SIGN) dedicated to disseminating Dr. Ayres work in the field of sensory integration.

9. History �A. Jean Ayres first proposed a model of human development in the 1960s that she termed �sensory integration� (SI). According to Ayres� theory, SI occurs under the dynamic influence of sensory inputs: gravitational, tactile, proprioceptive, vestibular, visual, and auditory sensations. This process, which begins in the womb, allows for the development of adaptive responses that, in turn, lay the foundation for more complex skills such as language, emotional regulation, and computation. Inefficiencies at more basic levels lead to difficulties in higher areas. According to proponents, sensory integration dysfunction (SID) can manifest as a broad range of developmental and behavioral difficulties. Some estimate that 5% to 10% of the general pediatric population and 40% to 88% of children who have disabilities suffer from SID.�

10. What does SIT claim to do? Enhanced ability to focus on relevant materials in educational, therapeutic, and social environments. Reduction in the rate of aberrant behaviors such as self injury. Generalized improvements in nervous system functioning, reflected in high-level cognitive activity such as language and reading. Improve listening, comprehension, balance, coordination and impulsivity control.

11. Discussion? What do you think of the claims? How can they be measured?

12. What are the interventions? 30 � 60 minute sessions one to three times per week usually provided by occupational therapists, who train parents and paraprofessionals to carry out interventions at other times. Smooshing between gymnasium pads or pillow to provide deep pressure Brushing a clients body Joint compression Playing with textured toys Swinging Rolling Jumping on trampoline Riding on scooter boards Weighted vests

13. Modifications of Environment Fabric/ texture of clothing is changed Tags are taken out of clothes Small class sizes Quiet area to reduce stimulation

14. Qualifications Needs to be an occupational therapist, physical therapist, or speech and language pathologist who is trained in SIT. 4 month clinical training and then receive a certificate to perform SIT services. Services can be provided by paraprofessionals only if under a certified individual. To maintain competent experience applying sensory integration methods especially in the format of clinic based services is strongly recommended for a minimum of two years mentorship, through supervision, consultation, and professional guidance by a therapist certified in sensory integration ongoing study and review of the literature that supports sensory integrative theory and its application as the therapist refines their expertise in sensory integration, ongoing feedback from professional peers who are also involved in using sensory integration as a frame of reference, as a check and balance for best practice. If not adhered to does on loose their certification??

15. What Research Support does SIT claim to have? http://www.siglobalnetwork.org/index_en/index.html (Effectiveness of Ayres SI � 8 studies) Short term effects Effects don�t generalize Weak fidelity (weak/lack of experimental control and/or social validity) Most are published by Journal of Occupational Therapists

16. Evidence Based on a review of the studies by Stephenson & Carter (2009) there are 7 studies that examined the use of weighted vests for children with Autism/PDD. Since then 2 additional studies were conducted that examined the use of weighted vests for children with Autism. Reichow, B., Barton, E.E., Sewell, J.N., Good L., & Wolery, M. (2010). Effects of Weighted Vests on the Engagement of Children with Developmental Delays and Autism. Focus on Autism and Other Developmental Disabilities 25(1) 3-11. Quigley, S.P., Peterson, L., Frieder, J.E., & Peterson, S.(2011). Effects of a weighted vest on problem behaviors during functional analyses in children with Pervasive Developmental Disorders. Research in Autism Spectrum Disorders 1(5), 529-538.

17. Evidence (continued)

18. Evidence (continued)

19. Evidence (Continued) Method Participants Tommy � 5 years old � Autism � attended center for 4 years Bert � 4 years old � developmental delays (neurological abnormality) � attended center for 2.5 years Sam � 5 years old � Autism & neurodevelopmental abnormalities � attended center for 2 years Setting � early childhood center integrated class during group activities Materials � vests with weights and apparent weights used out of foam. Experimental Design � alternating treatments design Procedure- weighted vests were 5% of the student�s weight No vest condition, weighted vest condition, & vest without weight condition Dependent Measures � engagement, non-engagement, stereotypic behavior, problem behavior, & unable to see child. Data Collection � videotaped, 10s momentary time sampling IOA was taken using the videotape for 78.6% of sessions for Tommy, 100% of sessions for Bert, and 26.9% of sessions for Sam. IOA was greater than 90%.

20. Evidence (Continued)

21. Evidence (continued)

22. Evidence (Continued) Method Participants Stuart � 6 years old � Asperger�s & ADHD � ABA program with some previous SIT for a short time Morty � 12 years old � Autism � ABA program with some previous SIT at 4 years old Ishmael � 4 years old � Autism � ABA and related services � had a weighted vest the previous year Setting � classroom at a university w/ a two way mirror Materials � weighted vests, break & work cards, and instructional materials Experimental Design � multi-element design embedded within each phase and overall reversal design. Procedure- preliminary information gathering, FA 0% vest, FA No vest (Morty only), FA 5% & 10% vest, Functional Communication training (FCT), FA reversal, & FCT + stimulus fading. Dependent Measures � Stuart: Leaving the work area, Destruction of property, screaming, hitting & kicking Ishmael : Leaving the work area, screaming, and biting Morty � Hitting & kicking, Screaming, and hand biting. Data Collection � 10s partial interval for all behavior & occurrences of work and break choices during intervention. IOA � 40% of sessions with a mean for all participants of 89%.

23. Evidence (continued)

24. Evidence (continued)

25. Evidence (continued)

26. Evidence (continued) Two more studies examined the use of sensory integration with children with autism. Devlin, S., Leader, G., & Healy, O. (2009). Comparison of behavioral intervention and sensory-integration therapy in the treatment of self-injurious behavior. Research in Autism Spectrum Disorders, 5(1), 223-231. Bagatell, N., Mirigliani, G., Patterson, C., Reyes, Y., & Test, L. (2010). Effectiveness of therapy ball chairs on classroom participation in children with autism spectrum disorders. American Journal of Occupational Therapy, 64, 895-903.

27. Evidence (continued) Method Participants � 10 year old boy � Autism � ABA school � gluten & casein free diet � SIB (hand-mouthing & hand-biting) Setting � student�s regular classroom Materials � net swing, therapy ball, bean bag, blanket, T shaped chew tube, and trampoline. Experimental Design � alternating treatments design Procedure � FA (results Escape), sensory integration therapy & behavioral intervention (interspersed requests, FR2 schedule of reinforcement, and extinction) Dependent Measures � hand-biting & hand-mouthing Data Collection � 10s partial interval for functional analyses & event recording for frequency of target behaviors across each daily session. IOA � 34% of FA sessions, 38% treatment sessions, mean agreement was 97%.

28. Evidence (continued)

29. Evidence (continued)

30. Evidence (continued) Method Participants � 6 boys (kindergarten -1st grade) � Autism � speech � PT � OT. Setting � students classroom Materials � therapy ball Experimental Design � single subject design (A-B-C design) Procedure � Baseline, Intervention (9days � during circle time), Choice (of therapy ball or chair � 5days) Dependent Measures � in-seat behavior and engagement Data Collection � momentary time sampling IOA � 18% of the videos total, 96% - 100% for in-seat behavior and 88% - 100% for engagement

31. Evidence (continued)

32. Conclusions There is no scientific evidence to support the use of sensory integration with children with autism. National Standards Projects states that Sensory Integrative Package is Unestablished. �Unestablished Treatments either have no research support or the research that has been conducted does not allow us to draw firm conclusions about treatment effectiveness for individuals with ASD. When this is the case, decision-makers simply do not know if this treatment is effective, ineffective, or harmful because researchers have not conducted any or enough high quality research.� � National Standards Project �There is currently no adequate scientific evidence (based on controlled studies using generally accepted scientific methodology) that demonstrates the effectiveness of sensory integration for young children with autism. Therefore, the use of this method cannot be recommended as a primary intervention method for young children with autism.� � State of NY

33. What is Auditory Integration? �Auditory integration training involves listening to electronically modulated music through earphones. The modifications in the music are based on an individual's response to an audiogram. � NY State �This intervention involves the presentation of modulated sounds through headphones in an attempt to retrain an individual�s auditory system with the goal of improving distortions in hearing or sensitivities to sound.� � National Standards Project �AIT is an intervention in which the service provider identifies sounds to which the participant is believed to be over- or under-sensitive. Then music with selected high and low frequencies is presented via headphones to the participant. Certain frequencies, such as those to which the participant is over- or under-sensitive, may be completely or partially filtered from the music. In Auditory Processing Training, speech sounds are dilated or expanded (i.e., presented more slowly than in typical speech), and then compressed as the student progresses.� � ASAT

34. Video http://www.aitinstitute.org/Video_Player/videos.htm (Evan story)

35. History The concept of Auditory Integration Training (AIT) began in the medical practice of Ear, Nose, and Throat (ENT) physician, Dr. Guy Berard in France in the 1960s. It was first developed for hearing loss. After this, it became known in Europe for overcoming dyslexia. It was the story of an American girl, Georgiana Stehli, labeled as �autistic�, �psychotic�, �dysexic� and �retarded� that brought AIT to the U.S. She also had hyperactive hearing. She received AIT by Dr. Guy Berard at age 11 and she started slow steady recovery from both autism and dyslexia. After AIT her formal diagnosis of �retardation� was no longer an appropriate term and her giftedness in numerous areas began to show. She is now married and a mother who works and travels as a speaker.

36. What does AIT claim to do? Auditory Integration Training retrains a disorganized auditory system.� The end result is that there is a more efficient processing of auditory information as a result of the 10 day Berard AIT program. The way our bodies respond to and process sound and vibrational energy affects us deeply. � Sound and frequency impacts our overall health, mood, energy level, alertness, attention span, focus, concentration, information processing and how we express ourselves, both verbally and in writing.

37. Discussion? What do you think of the claims? How can they be measured?

38. How is it implemented? The first step in AIT is to obtain a detailed audiogram, which determines auditory thresholds to a larger series of frequencies (octave and interactive frequencies) than are typically used for measuring hearing ability. An auditory training practitioner then examines the audiogram looking for evidence of hyperacusis, which then is examined in relation to the clinical history of sound sensitivities and behavioral profile. If an individual is determined to be an appropriate candidate for AIT, the treatment program consists of 20 half-hour sessions during a 10- to 12-day period, with two sessions conducted daily. Treatment sessions consist of listening to music that has been computer-modified to remove frequencies to which the individual demonstrates hypersensitivities, and to reduce the predictability of the auditory patterns. � American Academy of Pediatrics Concerns have been made of how the sound effects the eardrums of the participant.

39. Time & Cost 10 hour auditory intervention. There are 20 supervised listening sessions of 30 minutes each, completed over 10 or 12 consecutive days. $1,200 - $2,000 for all AIT sessions.

40. Qualifications To Be Eligible for Berard AIT Practitioner Certification, All Practitioner Candidates Must Meet One of the Following Established Criteria: Hold a DOCTORAL DEGREE in Medicine, speech/language pathology, audiology or a related field; OR Hold a MASTER'S DEGREE in speech/language pathology, audiology, special education, or a related field; OR Hold a BACHELOR'S DEGREE in a related field to the above (audiology,� medicine, special education, speech/language, pathology, psychology, occupational therapy, or a related field) with actual documented "on-the-job" paid professional career experience working with special needs populations for five years or more; OR Hold a CURRENT LICENSE as a Registered Occupational Therapist, Physical Therapist, or Psychologist.

41. Qualifications Seminars are intensive training in the specific Berard AIT Protocol. Seminars take approximately 4 to 5 days for completion and include a written final examination. Because of the many years of clinical research in the field of Auditory Integration Training, professionals today may now be trained efficiently in 4 to 5 days in the Berard AIT Protocol. Berard AIT Professional Seminars are done in private, semi-private and/or small group settings. Professional Seminars include lectures, discussion and hands-on work with Berard approved AIT equipment.

42. Qualifications UPON AIT SEMINAR COMPLETION: A provisional certificate is awarded at the end of the successful completion of a Professional Seminar. Once a Professional Seminar is completed, the new AIT Practitioner Candidate is provided with the supervision and guidance from the Berard AIT Professional Trainer for the first 15 clients who are able to perform the audio tests and who received Berard AIT. In addition, the Berard AIT Professional Trainer will require new AIT Practitioner Candidate to complete a client questionnaire for each one of these first 15 clients. The client questionnaire will ask the new AIT Practitioner Candidate to describe how well the client responded to the listening sessions and how well the client. The confidentiality of each client is always maintained while the new Berard AIT Practitioner is being supervised for final certification. The Berard AIT Certificate of Completion is then awarded within eighteen months upon providing fifteen case studies. COST FOR BERARD AIT PROFESSIONAL SEMINARS: The cost for a Professional Seminar is approximately $2,000 (USD or equivalent) per qualified candidate, payable upon registration directly to the Berard AIT Professional Trainer. .

43. Discussion.. What do you think of the qualification? Discuss how they compare to the BCBA.

44. What research support does AIT claim to have? http://www.aitinstitute.org/ait_clinical_studies.htm (clinical studies - see Autism Research Institute comments) Most studies have no control group or placebo group Many utilized surveys No difference between control and AIT groups

45. AIT devices The Digital Auditory Aerobics Device (DAA) exactly replicates the auditory output of the French-made AudioKinetron, the original AIT device. Research using the Audiokinetron applies to results achieved with the DAA device.� DAA Digital Auditory Aerobics was released for sale in the USA after the FDA informed he manufacturer in writing, in September, 1998, that "the product is not subject to FDA regulation.� The Earducator device was originally developed by Rosalie Seymour, SLP/A was released in 1998 and is endorsed by Dr. Guy Berard.

46. AIT devices Filtered Sound Training Device (FST) has been developed by Rosalie Seymour SLP/A to make it more accessible and less expensive.� Filtered Sound Training (FST) uses PC technology and equipment to deliver�the same�quality of sound intervention in home or office or school. Since most people can access a PC, whether in your home or at your child�s school. The program is loaded onto the PC or laptop, and the programming runs the twenty sessions in the same manner. The older Audiokinetron device was invented by Dr. Guy Berard in France.� This device is now being phased out and is no longer manufactured or serviced. The official FDA position is that if the Audiokinetron is used solely as an aid to education, it is not considered a medical device and is not subject to FDA regulation. BGC Device for Auditory Integration Training - Bill Clark, an audio engineer familiar with the Audiokinetron was the developer of the BGC device.� The BGC was made in the USA to duplicate the French Audiokinetron device.�

47. What type of music?

48. Evidence

49. Conclusion National Standards Projects states that Auditory Integration Training is Unestablished. �Unestablished Treatments either have no research support or the research that has been conducted does not allow us to draw firm conclusions about treatment effectiveness for individuals with ASD. When this is the case, decision-makers simply do not know if this treatment is effective, ineffective, or harmful because researchers have not conducted any or enough high quality research.� � National Standards Project AIT is also expensive and can potentially damage hearing.

50. Questions?

51. References Ayres, A.J. (1972). Sensory integration and learning disorders. Los Angeles: Western Psychological Services. Ayres, A.J. (1979). Sensory integration and the child. Los Angeles: Western Psychological Services. Dawson,G. & Watling, R. (2000). Interventions to Facilitate Auditory, Visual, and Motor Integration in Autism: A Review of the Evidence. Journal of Autism and Developmental Disorders, 30(5), 415-421. Jacobson, JW. (2005). Controversial therapies for developmental disabilities. Mahwah, NJ: Lawrence Erlbaum Associates, Publishers. Quigley, S.P., Peterson, L., Frieder, J.E., & Peterson, S.(2011). Effects of a weighted vest on problem behaviors during functional analyses in children with Pervasive Developmental Disorders. Research in Autism Spectrum Disorders 1(5), 529-538. Reichow, B., Barton, E.E., Sewell, J.N., Good L., & Wolery, M. (2010). Effects of Weighted Vests on the Engagement of Children with Developmental Delays and Autism. Focus on Autism and Other Developmental Disabilities 25(1) 3-11. Schechtman, M.A. (2007). Scientifically Unsupported Therapies in the Treatment of Young Children with Autism Spectrum Disorders. Psychiatric Annals 37(9). Stephenson, J., & Carter, M. (2009). The Use of Weighted Vests with Children with Autism Spectrum Disorders and other Disabilities. Autism Dev Disord 39:105-114. Williames, L.D., Erdie-Lalena, C.R. (2009). Complementary, Holistic, and Integrative Medicine: Sensory Integration. Pediatrics in Review, 30(12), 91-93.

52. References (continued) http://www.asatonline.org/intervention/treatments/sensory.htm http://www.siglobalnetwork.org/guidelines.pdf http://www.siglobalnetwork.org/index_en/index.html http://www.autismspeaks.org/whattodo/index.php#sti http://www.siglobalnetwork.org/guidelines.pdf http://www.nationalautismcenter.org/pdf/NAC%20Standards%20Report.pdf http://www.health.state.ny.us/community/infants_children/early_intervention/disorders/autism/app_c.htm#APPENDIX_C http://www.aitinstitute.org/ait_clinical_studies.htm http://www.aitinstitute.org/ait_practitioners.htm http://www.asatonline.org/intervention/treatments/auditory.htm http://www.aitinstitute.org/become_AIT_practitioner.php

53. References (continued) http://www.aitinstitute.org/ait_music.htm http://www.aitinstitute.org/ait_devices.htm http://pediatrics.aappublications.org/content/102/2/431.full#fn-group-1

54. Thank you!!!