pseudoscience and sensory integration theory

Pseudoscience is defined by characteristics including the use of vague, exaggerated or untestable claims, over-reliance on confirmation rather than refutation, lack of openness to testing by other experts, lack of progress, and personalization of issues (see Wikipedia article which is a nice summary). As the article notes, however, it is important to distinguish protoscience with pseudoscience.

At this point in time, 35 years after Jean Ayres wrote Sensory Integration and Learning Disorders, I am willing to consider that this concept of sensory integration theory is no longer 'nascent' and that we have not made appropriate progress toward researching and validating the theory as it is now constituted. For perspective, in 1972 when that book was published, the first hand-held calculator was marketed. Has science not moved forward since that time?

This is not to say that children don't have learning problems, or that they don't have problems in processing sensory information that leads to functional and behavioral problems. What it means is that we need to toss out the proverbial bath water without throwing out the baby when it comes to sensory integration theory.

Why do we need to revisit this? Sensory integration theory does not EXPLAIN why children behave the way they do. Sensory integration theory does not help us PLAN intervention. Sensory integration theory does not PREDICT how behavior will change as a result of intervention.

The most recent textbooks still state that "sensory integration cannot be observed. (Bundy & Murray, 2002, p.3). When I went to school as an undergraduate in the early 1980s I was told that there may be a neurochemical basis to sensory integration difficulties. It was an exciting concept that I was interested to see develop. Twenty five years later after completing my doctorate there is still no definitive cause for the disorder that can be identified.

This matters because there is a credibility gap when an occupational therapist states that a child has SI problems. Therapists have mistakenly believed that if we change the names to SID, or DSI, or SPD that this will somehow change people's minds about the theory. In reality we can call it chicken soup or anything we want - if the theory can't be validated then the name is irrelevant.

Occupational therapists are continuing to dialogue about classification and naming in sensory integration theory. Now we are making distinctions between sensory-seeking vs. sensory avoiding typologies. Or distinctions between active vs. passive coping styles. Ad nauseum. Less attention is paid to neurophysiological underpinnings and basic science research that would actually DO something to elucidate the nature of the disorders.

There is NO LACK of basic science that applies. Why aren't we studying neuronal migration (see Chang, et.al. 2005) or undetected brain damage (see Looney, et.al., 2007)?? Instead we focus on endless classification and naming of some 'unseen process' that we can't define. Then we state that by engaging the child in a series of experiences that they will somehow improve - but here we begin to disagree, with some people advocating passive and prescriptive sensory input and others advocating child-directed approaches. So as a consumer (parent, insurance company, etc) imagine their confusion and hesitancy when they go to some OTs who tell them that their child has some alphabet soup disorder (DSI, SID, SPD, whatever) that can be treated by either active or passive strategies - depending on who you talk to - and that we can't define what is REALLY wrong but we just know that these active or passive strategies will help the brain to function normally.

I wouldn't buy it either.

What I would buy is going to a therapist who tells me that learning disorders often have a physiologic or genetic component and that these causative factors can vary between children. Some of our research points to brain damage, some to neuromigration deficits, and some we just don't understand yet. Either way, the distinct problems that the child has as a result of the organic neurologic problem can be quantified by performance on standardized testing that looks at motor, perceptual, and other cognitive factors that impact occupation. When children have known deficits that we can quantify or measure, we can gather baseline data so that we can measure the effect of our intervention and training attempts. Intervention can involve participation in sensory-based and other activities, but we still need to quantify our progress with a behavioral measure.

After we proceed this way we are left holding data that quantifies the nature of the problem. We have basic science that could be analyzed to determine if there is a 'fit' between the identified organic problem and the clinical signs that are seen. We also have intervention strategies that can be evaluated in terms of progress on standardized measures.

Contrast this to our current state of affairs where all we have is a loosely defined set of behavioral observations, no real science to back it up or validate our intervention strategies, and a pile of people (OTs and non-OTs alike) with products rushing to market music CDs, weighted vests, brushes, and yet another sensory integration book that parents will buy because they are desperate to find answers for the problems that their children are having.

We can do much better.

This is why I now purposefully label sensory integration theory as pseudoscience.



References:

Ayres, A.J. (1972) Sensory integration and learning disorders, Los Angeles: Western Psychological Services.

Bundy, A.C., & Murray, E.A. (2002). Sensory integration: A. Jean Ayres' Theory Revisited in A.C. Bundy, S.J. Lane, & E.A. Murray (2002) Sensory integration: Theory and practice, 2nd ed., Philadelphia: F.A.Davis.

Chang, B.S., Ly, J., Appignani, B., Bodell, A., Apse, K.A., Ravenscroft, R.S., Sheen, V.L., Doherty, M.J., Hackney, D.B., O'Connor, M. et al. (2005) Reading impairment in the neuronal migration disorder of periventricular nodular heterotopia. Neurology, 64, 799–803.

Looney, C.B. et al. (2007). Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology, 242, 535-41.

Comments

Anonymous said…
It is 2am and I'm here struggling with this notion of yet another label to children. My 4-year old school is trying to make us believe he has this "thing". An engineer myself, I can't figure out what is to be "out-of-sync" without a baseline.
There are very few articles (indexed, at least) in Google on this. Your input is one of the few that dare showing that there is such a thing as "pseudoscience". Please keep posting more about this so those of us in the sea of acronyms to label our children can keep our heads above the trends...
Anonymous said…
Well said.

I am in Canada, where SI is gaining momentum among OTs, especially with the increasing number of children with autism. However, SI therapy in the traditional sense is not nearly as common as in the U.S. However, SI theory still predominates. Aren't you embarassed by your professional colleagues who prophetize SI theory, and really don't understand what they are talking about? I am.
Rachel said…
I know this is a really old entry, but thank you. This morning I was told that my 23 month old with slight torticollis has "sensory issues" that require therapy twice per week. This is a child that is developing normally in every way, other than the slight torticollis. I was skeptical when the therapists couldn't give me a coherent definition of "sensory issues." I didn't want to withhold treatment that he needed, but also didn't want to spend $40 per week on "therapy" that was useless. This confirmed my hesitant feelings. Thank you again - you've saved my family time, money, and who knows how much stress.
Chris said…
@ Rachel...

Sometimes children, even if their torticollis is slight, benefit from short term consultative therapy. The goals of the intervention are to give the family suggestions on positioning or gentle ROM activities to promote proper head alignment. This generally has nothing at all to do with 'sensory integration.'

I have treated many children who have torticollis and it is true that very few of them are happy about being stretched. Even when the range of motion is very gentle it might be a little uncomfortable for a baby. I have seen therapists mis-label this as 'tactile defensiveness.' Rather, I think that what happens is that the child associates touch with a negative stretching experience. This is why I encourage families to do a lot of non-therapy/non-stretching touch around the head and face and neck so the child doesn't perceive all touch in that area as negative. Talk to your therapist about this though and they can give you some specific suggestions for your situation.

Persistent torticollis can have an impact on visual perceptual and motor skills development so just continue to monitor the situation closely.

Good luck to you and your family!
Anonymous said…
THANK YOU! THANK YOU! THANK YOU!
I'm an OT and have thought this same thing since day one. When I was in school, they taught us to critically look at articles before we bought into them; the first thing I noticed was that 99.9% of SI articles are done by OTs! (Similar to the cigarette companies telling you that tobacco doesn’t cause cancer).
And why does everyone (OTs, and every other bandwagon jumper) say “he has sensory issues”? What sensory system? The OTs who hand in these reports do not even elaborate what system is being affected.
The sensory system affects EVERYTHING. You cannot be alive without at least one of your sensory systems being affected by the environment, so isn’t that convenient explanation for any behavior? It’s a catch all diagnosis and it’s sad that my profession promotes this snake oil to desperate families.
Sorry for the rant and thank you for telling the truth.
Sarah, OTS said…
Research is being done in order to determine specific neurological changes of children with SPD and finding that sensory integration is a helpful intervention!
Here are some current articles:
J.P. Owen, E.J. Marco, et al., (2013). Abnormal white matter microstructure in children with sensory processing disorders. NeuroImage: Clinical 2. 844-53.
May-Benson, T. A., Roley, S. S., Mailloux, Z., Parham, L. D., Koomar, J., Schaaf, R. C., Van Jaarsveld, A., & Cohn, E. (2014). Inter rater reliability and discriminative validity of the structural elements of the Ayres Sensory Integration Fidelity Measure . American Journal of Occupational Therapy, 68, 506–513. http://dx.doi.org/10.5014/ajot.2014.010652
Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180030. http://dx.doi.org/10.5014/ajot.2015.018051
May-Benson, T. A., & Koomar, J. A. (2010). Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. American Journal of Occupational Therapy, 64, 403–414. http://dx.doi.org/10.5014/ajot.2010.09071
Mitchell, A. W., Moore, E. M., Roberts, E. J., Hachtel, K. W., & Brown, M. S. (2015). Sensory processing disorder in children ages birth–3 years born prematurely: A systematic review. American Journal of Occupational Therapy, 69, 6901220030. http://dx.doi.org/10.5014/ajot.2015.013755

Also, Lucy Jane Miller’s book, “Sensational Kids: Hope and Help for Children with Sensory Processing Disorder-Revised Edition” (2014) provides detailed and evidence-based information about SPD, OT Sensory Integration (SI) assessments, and SI-OT interventions
Hi Sarah,

The Owen et al article has nothing to do with efficacy of SI treatment. Similarly, the May-Benson et al article has nothing to do with efficacy of SI treatment.

The systematic reviews that you reference all conflate sensory based with sensory integration studies. The review research that you cite has been seriously flawed and has been heavily criticized by people within and outside of the OT field. The whole purpose of the fidelity elements discussed by May-Benson et al are to avoid the kinds of problems that are present in the reviews you mention. Even though I give credit for the obvious attempts to improve fidelity, it is apparent that those efforts are inadequate because people still can't correctly articulate the assumptions and concepts of this model.

That is understandable for a student, but it is not understandable for practicing clinicians who are still clinging to this model (or clinging to their flawed interpretation of it).

Within this blog you will find numerous posts discussing the fidelity problem. The end-user of this theory is supposed to be clinicians, and those clinicians are supposed to be treating children. We don't need a continuation of the low quality work that has already been produced. I have been in this field for nearly 30 years, and it is no longer acceptable to hear that "research is being done." We have been told that line for too long. Nearly every other sensory-motor approach from that reductionistic era has been modified into a more functional, ecological, and contextual modern model. It is foolish to pour resources into this failed model and it is long overdue for an overhaul.
Rachel said…
I know this is years after the original blog was posted, and new information is now available regarding the biological basis of Sensory Integration Disorder. Sadly, there is still not a lot of consistent data on actual evidence-based therapy treatment plans. There are programs like Interactive Metronome (IM)and Integrated Listening Systems (iLS) that are showing some promising signs with SPD and Autism, but there still isn't enough research on the topic.

I am an adult who has SPD, and I have dealt with it my entire life. I never received any form of treatment for this condition since I wasn't officially diagnosed until about 10 years ago.

For the record, I am not autistic. I am just very hypersensitive to certain sounds, touch and certain lights. I am an educated and fully functioning individual with a job in Academia. The only "accommodations" I allowed myself to receive during college was a quiet room to take my exams. As an adult, I have learned to cope with my triggers and handle them more successfully than I did as a child. I do not consider myself disabled/impaired, nor do I want to be, but I still wouldn't wish this condition on anyone. It is an extremely overwhelming, and at times a miserable world to live in. Thankfully this disorder has finally been validated by researchers as UC San Francisco. I recommend reading up on the topic.

Here are 2 articles that may be of interest to some people.

1- Breakthrough Study Reveals Biological Basis for Sensory Processing Disorders in Kids - https://www.ucsf.edu/news/2013/07/107316/breakthrough-study-reveals-biological-basis-sensory-processing-disorders-kidsi

2 - Brain’s Wiring Connected To Sensory Processing Disorder - UCSF Study Shows Measurable Neurological Differences In Affected Children
https://www.ucsf.edu/news/2016/01/401461/brains-wiring-connected-sensory-processing-disorder

Hi Rachel,

As an academic I am sure you understand the importance of precision when it comes to evidence.

The articles that you cite recruited subjects from an autism program. That the particular subjects in the study didn't meet criteria for ASD diagnosis is more a function of the whims associated with changing diagnostics as opposed to any real objective clinical measure. Perhaps in another clinic someone would provide them a diagnosis. Perhaps under a different DSM someone would provide them with a different diagnosis. The point here is that ASD, whatever it is, is a spectrum disorder and it is not consistently diagnosed. The study did not exclude children with ADHD or other learning disorders. Therefore the results of the imaging studies simply indicate that children who went to an autism program and may have had a number of comorbid conditions were determined to have atypical brain imaging.

That is not confirmation of any sensory processing construct in particular.

How about the researchers control for these comorbidities, or alternately see if children who they believe have a distinct sensory processing 'disorder' can be distinguished from children who have ASD, LD, ADHD, etc.

Although there are still some roads to travel with this line of research I agree that it is interesting. However, I don't agree that it is validating anything at this point, except that some children with obvious developmental conditions have atypical imaging studies. That does not really surprise me. Whether or not that can eventually reach a level of sophistication that we can tease out comorbid conditions I am less optimistic at this point in time.

The value that we require as clinicians includes methods that are evidence based that help people. That should be the real objective behind these efforts.

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