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Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: a Systematic Review

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Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: a Systematic Review Interventions Targeting Sensory ChallengesAmy S. Weitlauf, PhD,a Nila Sathe, MA,in MLIS, Autism b Melissa L. McPheeters, Spectrum PhD, MPH, b Zachary E. Warren, PhDa, c CONTEXT: Disorder: A Systematic Reviewabstract Sensory challenges are common among children with autism spectrum disorder OBJECTIVE: (ASD). To evaluate the effectiveness and safety of interventions targeting sensory DATA SOURCES: challenges in ASD. STUDY SELECTION: Databases, including Medline and PsycINFO. Two investigators independently screened studies against predetermined DATA EXTRACTION: criteria. One investigator extracted data with review by a second. Investigators independently assessed risk of bias and strength of evidence (SOE), or confidence in the RESULTS: estimate of effects. Twenty-four studies, including 20 randomized controlled trials (RCTs), were included. Only 3 studies had low risk of bias. Populations, interventions, and outcomes varied. Limited, short-term studies reported potential positive effects of several approaches in discrete skill domains. Specifically, sensory integration-based approaches improved sensory and motor skills-related measures (low SOE). Environmental enrichment improved nonverbal cognitive skills (low SOE). Studies of auditory integration-based approaches did not improve language (low SOE). Massage improved symptom severity and sensory challenges in studies with likely overlapping participants (low SOE). Music therapy studies evaluated different protocols and outcomes, precluding synthesis (insufficient SOE). Some positive effects were reported for other approaches, but findings were inconsistent LIMITATIONS: (insufficient SOE). CONCLUSIONS: Studies were small and short-term, and few fully categorized populations. Some interventions may yield modest short-term (<6 months) improvements in sensory- and ASD symptom severity-related outcomes; the evidence base is small, and the durability of the effects is unclear. Although some therapies may hold promise, substantial needs exist for continuing improvements in methodologic rigor. Departments of aPediatrics, and cPsychiatry, Vanderbilt Kennedy Center, and bDepartment of Health Policy, Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee Dr Weitlauf helped to conceptualize and design the review, helped to acquire, analyze, and interpret data, and helped to draft and revise the initial manuscript; Ms Sathe helped to conceptualize and design the review, helped to acquire, analyze, and interpret data, and drafted and helped to revise the initial manuscript; Dr McPheeters helped to conceptualize and design the review, helped to acquire, analyze, and interpret data, and helped to draft the initial manuscript; Dr Warren To cite: Weitlauf AS, Sathe N, McPheeters ML, et al. Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A Systematic Review. Pediatrics. 2017;139(6):e20170347 Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 139, number 6, June 2017:e20170347 REVIEW ARTICLE Diagnostic TABLE 1 Inclusion Criteria and Statistical Manual of Mental Category Criteria DisordersAs definedFifth by the Edition Study population Children ages 2–12 y with ASD (mean age + SD is ≤12 y and 11 mo) Publication languages English only , (DSM-5), Admissible evidence Admissible designs features of autism spectrum disorder (study design and RCTs, prospective and retrospective cohort studies with comparison groups, (ASD) include deficits in social skills other criteria) and non-RCTs and communication; restricted Other criteria and repetitive behaviors; excessive Original research studies published from 2010 to present and not addressed in previous reviews adherence to routine; intense interest Studies must have relevant population and ≥20 participants with ASD (non- patterns, and atypical sensory1 RCTs) or at least 10 total participants (RCTs) interests or responses. Although Studies must address ≥1 of the following for ASD challenging to operationalize and Outcomes of interest measure clinically, estimates indicate Treatment modality of interest Predictors or drivers of treatment outcomes (eg, biomarkers, clinical that 42% to 88% of people with ASD changes) have impairments related –to sensory Maintenance of outcomes across environments or contexts Sufficiently detailed methods and results to enable data extraction processing that include both2 4 hyper- and hyporesponsiveness. Sensory Reporting of outcome data by target population or intervention symptoms can involve both strong interests and aversions. METHODS Sensory-focused interventions 2, 3, 5, 6 interventions. Although an commonly target aversions/ increasing number of interventions Search Strategy and Study Selection challenges, meeting needs for exist, their mechanisms and targets sensory input within adaptive for change are not consistently frameworks, or may target perceived ’ defined. Broadly, interventions processing deficits, with the goal targeting sensory challenges We searched the Medline database of improving people s abilities to involve the incorporation of via PubMed, Embase, and the interact with their environments. For sensory experiences (eg, sounds, Cochrane Library from January example, a child with ASD may have texture, pressure, and so on) 2010 to September 2016 using a difficulty tolerating bright lights, to affect a variety of outcomes. combination of controlled vocabulary clothing or food textures, specific Consensus is also lacking regarding and key terms related to ASD and noises, daily living tasks, touch, or whether interventions work by sensory challenges (eg, autism, ASD, more idiosyncratic stimuli, such as acting on the underlying sensory and sensory integration). We note certain colors. Alternatively, some 9 processing differences commonly that the original review, which the children with may ASD may show a associated with ASD, how specific current report updates, included fascination with visually examining versus general these effects may studies from January 2000 to 2011. objects, seeking out certain textures be, and how generalizable any to rub/touch (eg, clothing or hair), We also hand-searched the reference improvements may be over time to or experiencing the sound of certain lists of included articles and recent other situations that may tax sensory objects/actions. These sensitivities reviews addressing ASD therapies to ’ processing systems. and interests can interfere identify potentially relevant articles. significantly with children s abilities In the present review, a component to care for themselves, leave the We developed inclusion criteria in of an Agency for Healthcare Research home, participate in school, and be consultation with an expert panel and Quality-commissioned update involved in social situations. of clinicians and researchers (Table of a comparative effectiveness 1). We included comparative study Although sensory challenges are review of therapies for children with designs (eg, randomized controlled common and impairing features of ASD conducted by the Vanderbilt7 ASD for many, research examining Evidence-based Practice Center, we trials [RCTs] and prospective or the nature of sensory impairments examine the evidence specifically retrospective cohort studies) and across the life span has been lacking. for interventions targeting sensory studies published in English. We Specifically, the field has historically challenges in children with ASD. required that eligible RCTs have a total minimum sample size of 10. We lacked accepted frameworks for The full comparative8 effectiveness n diagnosing sensory challenges (eg, review update and review protocol required a higher minimum sample sensory symptoms were not part (PROSPERO registry number size ( = 20) for other comparative of DSM diagnostic criteria until CRD42016033941) are available at studies because they typically have DSM-5) and developing responsive www. effectivehealthca re. ahrq. gov. fewer controls for bias than RCTs. Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 WEITLAUF et al – 7 13 19 children with ASD, and 7 were included– in the previous review.13 The32 studies included 20 33 RCTs, – 1 nonrandomized trial, and 3 retrospective34 36 cohort studies. 21, Three 23, 30 studies had low risk of bias,14, 15, 19, 20,10 22, had24, 25, moderate 27, 29, 31,32 risk of bias, 26 and 11 (including– 1 publicatio– n reporting 2 13,unique 16 18, 26, RCTs) 28,33 36 had high risk of bias. Table 2 outlines the study characteristics and risk of bias assessments. We categorized interventions addressed in the included studies based on the core strategies used FIGURE 1 in each intervention. In some cases, Disposition of studies identified for this review. * Numbers do not tally because studies could be this approach grouped together excluded for multiple reasons. † One paper reports 2 separate trials. We also include analysis of interventions that may have used 7 comparative studies reported in our 2011 review of therapies for children with ASD; thus, we specific, manualized techniques with describe a total of 24 studies. “ ” others that used only a subset of Data Extraction and Analysis those techniques (eg, Ayres-based sensory integration and sensory Assessment of the strength of integration models that may have the evidence (SOE) reflects the used some Ayres strategies). We note One investigator extracted data confidence that we have in the that no alternative
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