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 malfunctioning of this process. The diagnosis of sensory integration disorder (SID)—also called sensory processing disorder (SPD)—is made mainly by occupational therapists and has little recognition by mainstream medicine. The term refers to to children who exhibit unusual or exaggerated sensitivity to various sensory stimuli. They may, for example, dislike "scratchy" clothing, shirt tags, or "squishy" substances on their skin. They may be overly sensitive to loud noises or very picky about what they eat. They may be distractible or have difficulty concentrating. They may also have behavioral problems (anxiety, hyperactivity, oppositional behavior) or mild delays in motor skills. Children with such problems clearly exist, but the key question is whether SID should be considered a distinct syndrome worthy of a medical definition. This article also questions whether the treatment offered by advocates of this diagnosis has any effect on a child's functioning over time.
The term "sensory integration disorder" was coined in 1968 by A. Jean Ayres, PhD, OTR (1920-1988), an occupational therapist and licensed clinical psychologist. She defined sensory integration as "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." Ayres operated a private clinic and taught graduate students at the University of Southern California.
In 1984, Ayres sold her clinic to Sensory Integration International (SII), but continued to work as a consultant. SII was a non-profit organization that promoted education, research, and treatment related to Ayres's concepts . During much of its existence, however, it was plagued with controversy [2-4]. Records on file in the Los Angeles Superior Court indicate that between 1998 and 2006, SII was sued at least 15 times by individuals. In 2006, the California Attorney General accused SII and its operators with failing to refund fees for canceled seminars, failing to pay overdue taxes, and trying to evade creditors by setting up another corporation to which it transferred money . In 2007, in response to this complaint, a Superior Court Judge issued an injunction that shut down all company operations [6,7]. In 2008, under a settlement, the Court set up a fund through which people whose courses were canceled could recover money. .
Proponents of sensory integration theory believe that inappropriate or deficient sensory processing is a developmental disorder amenable to therapy and that treatment can improve developmental outcomes. However, the prevailing medical opinion is that SID does not meet the usual standards required to qualify as a diagnosis. The most widely recognized psychiatric diagnostic system is the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which the American Psychiatric Association published in 2012. Despite campaigning by occupational therapists, the DSM-V's editors did not include SID as a diagnostic entity because the symptoms are non-specific.
Many children with autism have “sensory issues” such as oversensitivity to touch. Similar symptoms occur with other neurodevelopmental and behavioral problems (including attention-deficit/hyperactivity disorder) and anxiety disorders. However, the prevailing medical view is that “sensory symptoms” are a nonspecific indicator of neurodevelopmental immaturity rather than a distinct disorder. Such symptoms can also occur in children considered normal. For these reasons, few pediatric neurologists believe that SID should be considered a separate and distinct diagnostic entity.
Moreover, except in cases of autism, these sensory symptoms are virtually always outgrown. Do you know of any non-autistic adults with the type of "sensory problems" said to occur in SID? I work in the largest neurology group in my state. Although we see every conceivable neurological complaint, I have yet to hear from my colleagues of even one case of "SID" in an adult. In my experience, children who had been diagnosed with "SID" were overly anxious and come from a family that includes others who suffer from an anxiety disorder.
Sensory integration therapy (SIT)—also called sensory processing therapy (SPT)—has been described as "an occupational therapy intervention that uses individually tailored, sensory-rich activities in a child-directed, playful and interactive manner to facilitate adaptive responses and functional behaviors." . Its goal is not to teach specific behaviors or skills but to remediate perceived sensory difficulties so the child's overall functioning will improve . The methods used 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 activities may utilize equipment such as weighted clothing, special shoes, textured mitts, carpet squares, scooter boards, ramps, swings, and bounce pads. The therapy sessions 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 specific problem that requires treatment.
Ayres and her followers have portrayed sensory integration concepts as rooted in well established scientific models of neurological structure and function. However, its basic concepts are unsubstantiated and some have been refuted by research. In 2005, experts at the University of Rochester Medical Center concluded that there had been no adequate controlled studies either supporting the existence of SID as a distinct and definable entity or clearly demonstrating that SIT is more effective than no treatment at all . In 2012, the American Academy of Pediatrics issued a policy statement that concluded:
Sensory-based therapies involve activities that are believed to organize the sensory system by providing vestibular, proprioceptive, auditory, and tactile inputs. . . . However, it is unclear whether children who present with sensory-based problems have an actual "disorder" of the sensory pathways of the brain or whether these deficits are characteristics associated with other developmental and behavioral disorders. Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. Other developmental and behavioral disorders must always be considered, and a thorough evaluation should be completed. Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders. Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive .
The AAP policy statement advises pediatricians with patients who are receiving sensory-based therapy to help families determine whether it seems to be helpful. This would involve (a) creating explicit treatment goals, designed at the onset of therapy, (b) keeping a behavioral diary, (c) assessing the child's ability to do such things as focus, tolerate foods, and be in a room with loud noises, and (d) scheduling discussions about whether the therapy is working to achieve the stated goals.
A review of sensory processing interventions published in 2015 concluded that "although small randomized controlled trials resulted in positive effects for sensory integration therapies, additional rigorous trials using manualized protocols for sensory integration therapy are needed to evaluate effects for children with autism spectrum disorders and sensory processing problems." 
Aetna maintains a handy summary of the scientific literature on SID that is updated twice a year. Based on its literature review, Aetna considers SIT experimental and does not pay for it . However, a few insurance companies do cover it, and some school districts provide it.
The Bottom Line
Most children develop and improve their behavior spontaneously. Since few (if any) adult patients have SID, it is reasonable to question whether costly interventions are really necessary for what are most likely self-limiting problems of neurodevelopmental immaturity and anxiety. Well-designed scientific studies are needed to determine whether or not SID is a definable 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. Working with a friendly and relaxed therapist can be calming to children. I believe that families with children with behavioral or anxiety disorders would be better off getting standard treatment than investing time and money in unproven approaches.
- The Ayres Clinic. Sensory Integration International Web site, archived July 3, 2007.
- Brown EJ. The fight for Jean Ayres' legacy. Advance Healthcare Network for Occupational Therapy Practitioners Web site, posted Oct 18, 2004.
- Brown EJ. SI after Ayres. Advance Healthcare Network for Occupational Therapy Practitioners Web site, posted Nov 1, 2004.
- Brown EJ. What's in a name? Advance Healthcare Network for Occupational Therapy Practitioners Web site, posted Nov 15, 2004.
- Second amended complaint. The People of the State of California v. Sensory Intergration International et. al. Los Angeles Superior Court, Jan 22, 2007. (Sensory Intergration International was SII's parent company.)
- Amended order re: preliminary injunction. The People of the State of California v. Sensory Intergration International, et. al. Los Angeles Superior Court, Jun 22, 2007.
- Glomstad J. Court halts SI from doing business. Advance Healthcare Network for Occupational Therapy Practitioners Web site, posted July 9, 2007.
- Sensory Integration International notice of possible refund. Advance Healthcare Network for Occupational Therapy Practitioners Web site, posted March 31, 2008.
- Schaaf R, Case-Smith J. Sensory interventions for children with autism. Journal of Comparative Effectiveness Research 3:225-227, 2014.
- A parent's guide to understanding sensory integration. Sensory Integration International, 1991. Available on the Exceptional Family Resource Center Web site.
- Smith T, Mruzek D, Mozingo D. Sensory integrative therapy. In Jacobson JW, Foxx RM, Mulick JA (editors), Controversial Therapies for Developmental Disabilities. Mahwah, NJ: Laurence Erlbaum Associates, 2005, pp 331-350.
- AAP policy statement: Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 129:1186-1189, 2012.
- Case-Smith J and others. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism 19:133-148, 2015.
- Sensory and auditory integration therapy. Aetna Clinical Policy Bulletin Number 0256, October 23, 2015.
Dr. Heilbroner is a board-certified pediatric neurologist who practices in Ridgewood, New Jersey. He specializes in diagnosing and treating neurobehavioral disorders and sees a wide range of other pediatric and adult neurological problems. He has done research on ADHD, learning disabilities, and epilepsy and lectured to medical professionals, teachers, and parent groups on topics such as ADHD, learning disabilities, autism, tics, headaches, seizures, and concussions. He is coauthor of Pediatric Neurology: Essentials for Clinical Practice (Lippincott, 2007) and is currently working on a book for parents and teachers.
This article was revised on November 9, 2015.