Why "Sensory Integration Disorder" Is a Dubious Diagnosis
Peter L. Heilbroner, MD, PhD
"Sensory integration" refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound, and gravity. It has been postulated that certain behavioral and emotional problems result from the malfunctioning of this process. The term "sensory integration disorder (SID)" is used to characterize children who exhibit exaggerated sensitivity to sensory stimuli. The term was coined during the 1970s by A. Jean Ayres, PhD, OTR, an occupational therapist and licensed clinical psychologist who operated a private clinic and taught graduate students at the University of Southern California . Ayres died in 1989, but the clinic she founded has been maintained .
Parents of children alleged to have SID typically describe an aversion to loud noises, coarse clothing textures, and particular tastes and textures of food. Many of these children are also clumsy and have a history of late attainment of developmental milestones (i.e., were late to learn to walk or talk). Others exhibit coordination and fine motor problems. These children also tend to have behavioral and social problems.
The methods used to treat these children include brushing the skin, using weighted clothing and special shoes, various exercises intended to improve coordination (“vestibular training”), and other techniques claimed to to “desensitize” or fine-tune the patient’s nervous system. The therapies typically are expensive, involve months to years of weekly or more-frequent sessions, and imply to parents and children that there is, in fact, a problem that requires treatment.
Few pediatric neurologists believe that SID is a real diagnostic entity. We note that children with a range of neurodevelopmental and behavioral disorders, including attention-deficit/hyperactivity disorder, autism, and anxiety disorders also have “sensory issues” such as oversensitivity to touch. Many neurologists therefore feel that “sensory symptoms” are a nonspecific indicator of neurodevelopmental immaturity, not a sign of a distinct disorder. Yet thousands of children are sent for these therapies by their parents, at no small expense. Aetna considers sensory integration therapy experimental and does not pay for it . However, a few insurance companies do cover it, and some school districts provide it.
Anecdotal evidence from parents is often used to support the existence of SID and the effectiveness of treatment. A review of the literature on sensory integration disorder reveals mostly poorly designed studies and flawed methodology. Studies with tiny sample sizes (as small as one patient!) are common [3-7]. Other studies investigate sensory symptoms in children with a serious underlying disorder such as autism [8-12], or mental retardation [13-16], and are therefore unlikely to be especially relevant to more normal children. Still other research assesses sensory therapies in the treatment of tangentially related conditions, like learning disability [17-23] or neuromotor delays [24-27]. In some cases where treatment appears to benefit, the therapies may simply be a calming influence on a nervous child. However, there are no adequate controlled studies either supporting the existence of SID as a distinct and definable entity, or clearly demonstrating the effectiveness of the therapies used for SID compared to no treatment at all [28-30]. In my experience, children diagnosed with "SID" are simply very anxious and come from a family that includes others who suffer from an anxiety disorder.
It should be remembered that most children develop and improve their behavior spontaneously. Given the fact that few (if any) adult patients have sensory integration disorder, it is reasonable to question whether costly interventions are really necessary for what is a most likely a self-limiting problem of neurodevelopmental immaturity and anxiety. I also believe that children or families whose behavioral or anxiety disorders could benefit treatment would be better off seeking standard treatment than wasting time and money on unproven or irrational approaches.
Well-designed scientific studies are needed to determine whether or not SID is indeed a disorder, and even if so, whether the treatments currently prescribed are effective or necessary. Until studies along these lines are conducted, the diagnosis of SID should prompt a healthy degree of skepticism.
- About the Ayres Clinic. Sensory Integration International Web site, accessed May 1, 2005.
- Sensory and auditory integration therapy. Aetna Clinical Policy Bulletin Number 0256, May 11, 2004.
- Magrun M and others. Effects of vestibular stimulation on spontaneous use of verbal language in developmentally delayed children. American Journal of Occupational Therapy 35:101-104, 1981.
- Sandler A, Coren A. Relative effectiveness of sensory integrative therapy and overcorrection in the treatment of stereotyped behavior: An exploratory study. Training Quarterly on Developmental Disabilities 1:17-24, 1980.
- Wells ME, Smith DW. Reduction of self-injurious behavior of mentally retarded persons using sensory integrative techniques. American Journal of Mental Deficiency 87:664-666, 1983.
- Danner P. Effectiveness of sensory integrative procedures on four Finnish preschoolers with minimal brain dysfunction. Unpublished Master’s thesis, University of Southern California, Los Angeles, 1983.
- Ottenbacher K. Patterns of postrotary nystagmus in three learning disabled children. American Journal of Occupational Therapy 36:657-663, 1982.
- Ayres AJ, Tickle LS. Hyper-responsivity to touch and vestibular stimuli as a predictor of positive response to sensory integration procedures by autistic children. American Journal of Occupational Therapy34:375-381, 1980.
- Ayres AJ, Mailloux ZK. Possible pubertal effect on therapeutic gains in an autistic girl. American Journal of Occupational Therapy 37:535-540, 1983.
- Reilly C and others. Sensorimotor versus fine motor activities in eliciting vocalizations in autistic children. Occupational Therapy Journal of Research 3:199-212, 1983.
- Slavik BA and others. Vestibular stimulation and eye contact in autistic boys. Neuropediatrics 15:33-36, 1984.
- Wolkowicz R and others. Sensory integration with autistic children. Canadian Journal of Occupational Therapy 44 171-175, 1977.
- Montgomery P, Richter E. Effect of sensory integrative therapy on the neuromotor development of retarded children. Physical Therapy 57:799-806, 1977.
- Clark FA and others. A comparison of operant and sensory integrative methods on developmental parameters in profoundly retarded adults. American Journal of Occupational Therapy 32:86-92, 1978.
- Huff DM, Harris SC. Using sensorimotor integrative treatment with mentally retarded adults. The American Journal of Occupational Therapy 41:227-231, 1987.
- Ayres AJ. A study on the effectiveness of sensory integration procedures: Final research report. Pasadena CA: Center for the Study of Sensory Integrative Dysfunction, 1976.
- Ayres AJ. Learning disabilities and the vestibular system. Journal of Learning Disabilities 11:18-29, 1978.
- Carte E and others. Sensory integration therapy: A trial of a specific neurodevelopmental therapy for the remediation of learning disabilities. Journal of Developmental Behavioral Pediatrics, 5:189-194, 1984.
- Kawar M. The effects of sensorimotor therapy dichotic listening in children with learning disabilities. American Journal of Occupational Therapy 27:226-231, 1972.
- McKibbin EH. The effect of additional tactile stimulation in a perceptual-motor treatment program for school children. American Journal of Occupational Therapy 27:191-197, 1973.
- Ottenbacher K and others. Nystagmus duration changes of learning disabled children during sensory integrative therapy. Perceptual Motor Skills 48:1159-1164, 1979.
- White M. A first-grade intervention program for children at risk for reading failure. Journal of Learning Disabilities 12:26-32, 1979.
- Schaffer R. Sensory integration therapy with learning disabled children: A critical review. Canadian Journal of Occupational Therapy 51:73-77, 1984.
- Ayres AJ. Effect of sensory integrative therapy on the coordination of children with choreathetoid movements. American Journal of Occupational Therapy 31:291-293, 1977.
- Jenkins JR and others. Comparison of sensory integrative therapy and motor programming. American Journal of Mental Deficiency 88:221-224, 1983.
- Burns YR. Sensory integration or the role of sensation in movement. American Journal on Mental Retardation 92;412, 1988.
- American Academy of Pediatrics Committee on Children with Disabilities. School-aged children with motor disabilities. Pediatrics 76:648-649, 1985.
- Hoehn TP, Baumeister AA. A critique of the application of sensory integration therapy to children with learning disabilities. Journal of Learning Disabilities 27:338-350, 1994.
- Description of sensory integration. Association for Science in Autism Treatment Web site, accessed April 30, 2005.
- Dawson G, Watling R. Interventions to facilitate auditory, visual, and motor integration in autism: a review of the evidence. Journal of Autism and Developmental Disorders 30:415-421, 2000.
- Arendt RE and others. Critique of sensory integration theory and its application in mental retardation. American Journal of Mental Deficiency, 92:401-429, 1988.
- Clark FA, Pierce D. Synopsis of pediatric occupational therapy effectiveness: Studies on sensory integrative procedures, controlled vestibular stimulation, other sensory stimulation approaches, and perceptual-motor training. Presentation for the Occupational Therapy for Maternal and Child Health Conference. Santa Monica, CA, 1986.
- Denhoff E. Current status of infant stimulation or enrichment programs for children with developmental disabilities. Pediatrics, 67:32-37, 1981.
- Dunst CJ, Rheingrover AM. An analysis of the efficacy of infant intervention programs with handicapped children. Evaluation and Program Planning 4:287-323, 1981.
- Henderson A. Research in occupational therapy and physical therapy with children: In Camp BW (Ed.) Advances in Behavioral Pediatrics. Greenwich, CT: Jai Press, 1981.
- Kimball J. The emphasis is on integration, not sensory. American Journal on Mental Retardation, 92:423- 424, 1988.
- Kinsbourne M, Caplan P. Children’s learning and attention problems. Boston: Little, Brown and Company, 1979.
- Ottenbacher KJ. Sensory integration: myth, method, and imperative. American Journal on Mental Retardation 92:425-426, 1988.
- Ottenbacher K. Sensory integration therapy: Affect or effect. American Journal of Occupational Therapy 36:571-78, 1982.
- Ottenbacher K, Short MA. Sensory integrative dysfunction in children: A review of theory and treatment. Advances in Developmental and Behavioral Pediatrics 6:287-329, 1985.
- Pearson PH. The results of treatment: the horns of our dilemma. Developmental Medicine and Child Neurology 2:417-418, 1982.
- Taft L. Are we handicapping the handicapped? Developmental Medicine and Child Neurology, 14:703-704, 1972.
- Tickle L. Perspectives in the status of sensory integration theory. American Journal of Occupational Therapy 42:427-433, 1988.
Dr. Heilbroner practices pediatric neurology at The Valley Hospital in Ridgewood, New Jersey.
This article was posted on May 1, 2005.