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Comparative Systematic Review of Korea Domestic and International Studies on Sensory Integration Therapy in Patients with Autism Spectrum Disorder

  • Cha, Sumin (Department of Rehabilitation Science, Graduate School, Inje University) ;
  • Park, Sookyoung (Department of Physical Therapy, College of Healthcare Medical Science & Engineering Inje University) ;
  • Choi, Jeonghyun (Department of Rehabilitation Science, Graduate School, Inje University) ;
  • Park, Juhyung (Department of Rehabilitation Science, Graduate School, Inje University) ;
  • Jin, Yunho (Department of Rehabilitation Science, Graduate School, Inje University) ;
  • Hong, Yonggeun (Department of Rehabilitation Science, Graduate School, Inje University)
  • Received : 2019.03.20
  • Accepted : 2019.06.05
  • Published : 2019.09.28
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Abstract

This systematic review compared Korean and international researches on sensory integration therapy in patients with autism spectrum disorder (ASD). We targeted studies on sensory integration therapy for patients with ASD published from January 2000 through July 2016. Specifically, we analyzed the papers that used the phrase 'sensory integration, autism' as keywords. There were fewer Korean studies of sensory integration therapy, and the diversity of research topics were limited, focusing mainly on case studies. There was no difference between the internal/external validity of Korean and those of international studies targeting the clinical environment and patients. Further study of a variety of aspects of sensory integration therapy is needed to gain high internal/external validity.

Keywords

1. INTRODUCTION

Autism spectrum disorder (ASD) is a lifelong developmental disability defined by diagnostic criteria that include deficits in social communication and social interactionand restricted, repetitive patterns of behavior, interests, or activities [1]. The estimated incidence of ASD is about 2.64% in Korea [2], and 1.69% in US [3]. Although many studies have explored the causes and treatment of autism in infancy and childhood since autism was first described by Kanner [4], it still induces a severe disability. ASD constitutes a neurological process that makes it difficult for affected individuals to use their bodies effectively [5], [6]. In children, problems in motor performance, behavior, self-control, and social development may influence activities of daily living (ADLs), and the ability to learn [7]. 

Most commonly, individuals with ASD are characterized as sensory modulation disorders and/or sensory processing disorders such as decreased tactile sensitivity which are linked to stereotypical behaviors, disturbed emotional and social responses [8], [9], [10]. The diminished sensory integration occurs when CNS dysregulates the neural messages about sensory stimuli from body, as well as environment.

Sensory integration therapy is a one of intervention that involves child-centered activities and play and that manages the child’s sensory experiences in a therapeutic environment [11]. Moreover, this intervention facilitates sensory processing and stimulates abilities that are fundamental to ADLs in children: playing, learning, life skills, and social participation [6], [12]. Several international studies have reported that autism involves difficulty with tactile, auditory, or visual processing [13, 14, 15, 16, 17, 18, 19]. The studies of the sense sensory experiences of children with autism showed deficits in sensory processing including tactile, oral, auditory, visual, kinesthetic (speed), and other major modalities in 95% of subjects [20], [21]. The results of these studies suggest that developmental disorders in children with autism reflect difficulty with sensory processing in multiple modalities.

Sensory integration therapy is a one of the neurophysiological approaches being applied to children with autism [22]. It provides controlled sensory stimulation in domains such as proprioception, vestibular sensation, and tactile sensation in an environment that fosters appropriate adaptive responses, ultimately improving the ability to processsensory information [23]. Sensory integration therapy facilitates interaction with the environment, focusing on neurological processes to organize the sensory stimuli effectively [11], [24], [25] and induces responses appropriate to the given environment [26], [27]. Furthermore, the process of handling sensation effectively improves children’s sensory capacity and their ability to organize their behaviors [28]. The technique of sensory integration for children with autism is based on the framework of sensory integration theory [29], [30].

Sensory integration therapy is considered as an effective therapeutic strategy for patient with ASD. However, Korean research on autism and sensory integration therapy has mainly analyzed stereotyped behavior, motor skills, development, sociability, and sensory responses, whereas international research has focused more broadly on the domains of play, social interaction, communication, and adaptive behavior. Since children with autism differ in their characteristics, case studies are also important [31], not only for determining the values and priorities of clients but also to attain therapeutic goals and improve task performance, which helps the therapist to make clinical decisions [32]. Additionally, applying sensory integration therapy based on practical clinical evidence can produce objective results and lead to qualitative improvement in sensory integration therapy [33]. Many recent Korean and international studies have systematically studied sensory integration therapy [33], [34], [35].

However, no systematic review of these studies and no comparative study of international and Korean sensory integration therapy has been conducted. Therefore, the present study examined the research trends through a systematic review of Korean and international studies of sensory integration therapy with autism patients. The review focused on those two questions. First, is there a difference of trends between Korean and international research trends in the application of sensoryintegration therapy in autism patients? Second, is there a difference between intervention methods, intervention effects, and the qualitative level of sensory integration therapy for patients with autism in Korean compared with international research?

 

2. METHODS

2.1 Study design

This study was a descriptive systematic review of Korean and international research on the application of sensory integration therapy in patients with ASD.

 

2.2 Hypotheses 

We hypothesized that there is a difference in research trends between Korean and international studies of sensory integration therapy in ASD patients. Furthermore, the methods, effects, and level of qualitative evidence reflected in studies of sensory integration therapy for ASD patients differ between Korean and international studies.

 

2.3 Subjects 

Korean and international studies of sensory integration therapy in ASD published from January 2000 to July 2016 were analyzed. Inclusion/exclusion criteria were set up in accordance with the purpose of the study. The specific criteria for including and excluding studies were as follows:

 

2.3.1 Inclusion criteria: 

1) Research applying sensory integration intervention in pediatric ASD patients; 
2) Availability of the full text of the study; 
3) Research targeting patients with ASD; and 
4) Research applied in clinical occupational therapy.

 

2.3.2 Exclusion criteria: 

1) Conference papers or presentations; 
2) Theses; and 
3) Systematic reviews. 

 

2.4 Study methods 

2.4.1 Data collection:

To collect data, we have searched for papers using the keyword phrase and study period; Term=(sensory integration) AND ASD AND ((“2000/01/01” [PDat] : “2016/07/31” [PDat])). The MEDLINE/PubMed and Korea National Scholar search engines were used as sources of information. We found 48 international and 21 Korean studies. The citations for reviews and the abstract or full text of these papers were obtained using the Inje University Library Google search engines. Ultimately, five Korean studies and 15 international studies were selected with inclusion/exclusion criteria for this review.

 

2.4.2 Qualitative evaluation of methods:

Two researchers independently evaluated the selected studies in terms of the qualitative level of research based on the level of evidence as defined by the American Occupational Therapy Association (AOTA). The AOTA level of evidence is shown in a Table 1 that provides objective criteria for each study based on the study design, sample size, and internal and external validity [36]. The two researchers reviewed the level of evidence individually, and cases of disagreement were resolved by discussion.

 

Table 1. Level of evidence for AOTA evidence-based practice project 

E1CTBR_2019_v15n3_13_t0001.png 이미지

 

E1CTBR_2019_v15n3_13_f0001.png 이미지

Fig. 1. Study flow diagram

 

3. RESULTS 


Based on the inclusion and exclusion criteria, we have investigated five Korean and 15 international studies (see Tables 2 and 3). Few Korean studies were appropriated and matched to inclusion criteria (see Table 2). Two of Korean papers were consisted to single-subject design using therapeutic intervention and were therefore not rated as having a high level of evidence [33], [37]. And two of Korean studies were comprised of non-subject design studies, and showed level III of evidence [38], [39]. Rest of one Korean study was non-randomized trial, and showed level II [40]. In addition, almost of Korean studies had small sample size (n ≤ 20), except one study [40], which included 30 participants. Both internal and external validity of all Korean studies were evaluated three times. The internal and external validity had many shortcomings, such as poor representation, non-blind evaluation, the lack of items for simultaneous recovery, short duration of treatment, and a small number of subjects. Because the short-term therapeutic effect was insufficient, the internal and external validity of the assessment in all five studies are
questionable. Although there were some limitations in Korean studies, we found that sensory integration therapy reduced stereotyped behaviors and persistent preoccupied behavior and improved attention in ASD children through those of studies.

 

Table 2. Characteristics of Korean domestic researches

E1CTBR_2019_v15n3_13_t0002.png 이미지

 

Among the 15 international studies, one study enrolled the most subjects, with 93 children in the test group [41] and Foxeet al [42] enrolled 84 children in the test group and 142 children in the control group. Most of the remaining studies had small sample sizes of fewer than 20 participants. Regarding the study designs, there were two randomized trials (level I), seven comparative non-randomized trials with more than two groups (level II), four non-subject design studies (level III), one single subject design studies (level IV), and one case study (level V).

 Regarding the internal and external validity, only short-term treatment effects could be determined due to the small sizes of the study groups, non-blinded nature of the studies, lack of an item for simultaneous recovery, and short duration of treatment. Consequently, the internal validity was between 2 and 3 level, the external validity also showed between b and c level (see Table 3). The Korean studies evaluated only general therapeutic effects of sensory integration therapy, whereas there were numerous studies including therapeutic equipment [43], efficacy of therapy [44], [45], [46], the appropriateness of treatment protocols [47], and treatment factors that might affect outcomes [41], and the link between multisensory temporal integration in ASD [48].

 

Table 3. Characteristics of the international researches

E1CTBR_2019_v15n3_13_t0003.png 이미지

 

4. DISCUSSION 

This study reviewed the results of Korean and international studies of sensory integration therapy in patients with ASD and compared Korean with international trends in sensory integration therapy in ASD patients, examining the status of sensory integration therapy and providing basic data.

It has been known that ASD is marked by impairments in reciprocal social interaction and communications due to limited, repetitive, and stereotyped behaviors [49], [50], [51]. ASD is the main target of sensory integration therapy [52], which can discover the early symptoms of sensory integration disorder in autistic children and can be used to alleviate symptoms and to provide the necessary foundation for treatment [53], [54]. There were far fewer Korean studies (five articles) than international studies (15 articles). Moreover, the international studies had a variety of designs, including two randomized trials, seven non￾randomized trials, four non-subject design studies, one singlesubject design studies, and one of case study. In comparison with five Korean studies, two studies were single-subject design studies and two studies were non-subject design studies and rest of one study was non-randomized trial. The reviewed Korean and international studies had internal validity of 2–3 level and external validity of b–c level (see Tables 2 and 3). The clinical nature of these human studies raises issues concerning the small sample size, short treatment duration, and difficulty excluding the effects of comprehensive rehabilitation therapy. In terms of the diversity of the study results, the international studies showed the effects of traditional sensoryintegration intervention and provided various suggestions, suchas coordination, social skills, stereotyped behavior, task performance, arousal level, activity levels involving home/school/family, participation in family activities, play behavior, and aggression [55, 56, 57, 58, 59, 60]. Particularly, present international studies have investigated the need for validation of new assessment/treatment equipment [43], the importance of examining the adequacy of treatment protocols [47], the requirement that sensory integration treatment factors that might affect outcomes be considered [41], and modified application of sensory integration in ASD [48]. The Korean research also demonstrated reduction of obsessive behaviors [61], improvement in attention [38], decreased stereotyped behavior [37], recovery of sensory control [40], and progress in proprioception-vestibular, auditory-visual, revolution-vestibular, and tactile [39] in ASD after sensory integration therapy. However, few studies exist for ASD and sensory integration therapy in Korea therefore, additional and various studies on sensory integration therapy in ASD are required. Furthermore, the studies are needed to establish basic information on sensory integration therapy by comparing Korean and international research. Eventually, this review may contribute to improving the quality of life of autistic children through therapeutic intervention using sensory integration therapy.

One limitation of this study is that it analyzed the Korean and international studies at the same level, and there were insufficient subjects in the studies. Future Korean and international studies should examine the assessment tools and intervention methods used.

 

5. CONCLUSION

This study examined Korean and international studies of sensory integration therapy in ASD patients published from January 2000 to July 2016 and compared the results. The Korean research on sensory integration treatment was very limited, and its qualitative level of evidence was very low. Furthermore, this research lacked diversity compared with international studies. The Korean and international studies had low internal/external validity due to the focus of the studies on children in their natural environments. Additional studies with appropriate study designs are needed to obtain high internal and external validity. Korean studies of sensory integration therapy should be more diverse.

 

ACKNOWLEDGEMENTS 

We thank members of the HONG’s lab for constructive and critical comments. This work was supported by grants from NRF (2017R1D1A1B03029565 to Y.H., 2014R1A1A3051724 to S.P.), Republic of Korea.

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