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

Amy S. Weitlauf, PhD,​a Nila Sathe, MA, MLIS,​b Melissa L. McPheeters, PhD, MPH,​b Zachary E. Warren, PhDa,​c

CONTEXT: Sensory challenges are common among children with autism spectrum disorder(ASD).

abstract

OBJECTIVE: To evaluate the effectiveness and safety of interventions targeting sensory

challenges in ASD.

DATA SOURCES: Databases, including Medline and PsycINFO.

STUDY SELECTION: Two investigators independently screened studies against predetermined

criteria.

DATA EXTRACTION: One investigator extracted data with review by a second. Investigators

independently assessed risk of bias and strength of evidence (SOE), or confidence in theestimate of effects.

RESULTS: Twenty-four studies, including 20 randomized controlled trials (RCTs), were

included. Only 3 studies had low risk of bias. Populations, interventions, and outcomesvaried. 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(insufficient SOE).

LIMITATIONS: Studies were small and short-term, and few fully categorized populations.

CONCLUSIONS: Some interventions may yield modest short-term (<6 months) improvements insensory- 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

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REVIEW ARTICLEAs defined by the Diagnostic
and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5),
features of autism spectrum disorder(ASD) include deficits in social skills
and communication; restricted
and repetitive behaviors; excessive
adherence to routine; intense interest
patterns, and atypical sensory
interests or responses.‍1 Althoughchallenging to operationalize andmeasure clinically, estimates indicatethat 42% to 88% of people with ASD
have impairments related to sensory
processing that include both hyperand hyporesponsiveness.‍2–‍ 4‍ Sensory
symptoms can involve both strong
interests and aversions.
Sensory-focused interventions
commonly target aversions/challenges, meeting needs forsensory input within adaptive
frameworks, or may target perceived
processing deficits, with the goalof improving people’s abilities tointeract with their environments. For
example, a child with ASD may havedifficulty tolerating bright lights,
clothing or food textures, specificnoises, daily living tasks, touch, ormore idiosyncratic stimuli, such as
certain colors. Alternatively, somechildren with may ASD may show afascination with visually examining
objects, seeking out certain textures
to rub/touch (eg, clothing or hair),or experiencing the sound of certain
objects/actions. These sensitivities
and interests can interfere
significantly with children’s abilities
to care for themselves, leave thehome, participate in school, and be
involved in social situations.
Although sensory challenges arecommon and impairing features of
ASD for many, research examining
the nature of sensory impairments
across the life span has been lacking.
Specifically, the field has historicallylacked accepted frameworks fordiagnosing sensory challenges (eg,sensory symptoms were not partof DSM diagnostic criteria until
DSM-5) and developing responsive
2

TABLE 1 Inclusion Criteria
Category
Study population
Publication languages
Admissible evidence(study design andother criteria)

Criteria
Children ages 2–12 y with ASD (mean age + SD is ≤12 y and 11 mo)English only
Admissible designs
RCTs, prospective and retrospective cohort studies with comparison groups,
and non-RCTs
Other criteria
Original research studies published from 2010 to present and not addressedin previous reviews
Studies must have relevant population and ≥20 participants with ASD (nonRCTs) or at least 10 total participants (RCTs)
Studies must address ≥1 of the following for ASD  Outcomes of interest  Treatment modality of interest  Predictors or drivers of treatment outcomes (eg, biomarkers, clinicalchanges)  Maintenance of outcomes across environments or contexts  Sufficiently detailed methods and results to enable data extraction  Reporting of outcome data by target population or intervention

interventions.‍2,​3,​‍ 5,​‍ 6‍ Although anincreasing number of interventions
exist, their mechanisms and targets
for change are not consistently
defined. Broadly, interventions
targeting sensory challenges
involve the incorporation of
sensory experiences (eg, sounds,
texture, pressure, and so on)
to affect a variety of outcomes.
Consensus is also lacking regardingwhether interventions work by
acting on the underlying sensory
processing differences commonly
associated with ASD, how specificversus general these effects may
be, and how generalizable any
improvements may be over time toother situations that may tax sensory
processing systems.
In the present review, a componentof an Agency for Healthcare Research
and Quality-commissioned updateof a comparative effectiveness
review of therapies for children with
ASD conducted by the Vanderbilt
Evidence-based Practice Center,​‍7 we
examine the evidence specificallyfor interventions targeting sensory
challenges in children with ASD.
The full comparative effectiveness
review update‍8 and review protocol(PROSPERO registry number
CRD42016033941) are available atwww.​effectivehealthca​re.​ahrq.​gov.

Methods
Search Strategy and Study Selection
We searched the Medline database
via PubMed, Embase, and the
Cochrane Library from January2010 to September 2016 using a
combination of controlled vocabulary
and key terms related to ASD andsensory challenges (eg, autism, ASD,
and sensory integration). We notethat the original review,​‍9 which thecurrent report updates, included
studies from January 2000 to 2011.
We also hand-searched the reference
lists of included articles and recent
reviews addressing ASD therapies to
identify potentially relevant articles.
We developed inclusion criteria in
consultation with an expert panelof clinicians and researchers (‍Table1). We included comparative study
designs (eg, randomized controlled
trials [RCTs] and prospective or
retrospective cohort studies) andstudies published in English. We
required that eligible RCTs have a
total minimum sample size of 10. We
required a higher minimum sample
size (n = 20) for other comparative
studies because they typically havefewer controls for bias than RCTs.

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Weitlauf et alchildren with ASD,​‍7 and 7‍13–19‍‍‍‍
were included in the previous
review. The studies included 20
RCTs,​‍13–32‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍ 1 nonrandomized trial,​‍33
and 3 retrospective cohort
studies.‍34–‍ 36‍ Three studies had low
risk of bias,​21,​23,​‍ 30‍ 10 had moderate
14,​
risk of bias,​‍ 15,​
‍ 19,​20,​‍ 22,​‍ 24,​‍ 25,​‍ 27,​29,​‍ 31,​‍ 32‍
and 11 (including 1 publication‍26
reporting 2 unique RCTs) had highrisk of bias.13,​16‍ –‍ 18,​‍ 26,​‍ 28,​33‍ –‍‍ 36
‍ Table 2outlines the study characteristics andrisk of bias assessments.

FIGURE 1

Disposition of studies identified for this review. * Numbers do not tally because studies could be
excluded for multiple reasons. † One paper reports 2 separate trials. We also include analysis of
7 comparative studies reported in our 2011 review of therapies for children with ASD; thus, we
describe a total of 24 studies.

Data Extraction and Analysis
One investigator extracted data
regarding study design; descriptionsof study populations, intervention,and comparison groups; andbaseline and outcome data. A second
investigator independently verified
the accuracy of the extraction andmade revisions as needed. Significant
heterogeneity in interventions andoutcomes reported precluded metaanalysis; thus, we synthesized studies
qualitatively and report descriptive
statistics in tables (‍Tables 2 and‍ 3).

Assessment of Study Risk of Bias
and Strength of Evidence

Two investigators independently
evaluated the overall methodologic
risk of bias of individual studies
using the ASD-specific assessment
approach developed and used inprevious reviews of interventions
for ASD.‍7,​10,​‍ 11‍ Senior reviewers
resolved discrepancies in riskof-bias assessment, and we used
an approach described in the full
review‍8 to determine low, moderate,or high risk-of-bias ratings.

Assessment of the strength ofthe evidence (SOE) reflects theconfidence that we have in thestability of treatment effects in theface of future research. The degreeof confidence that the observed
effect of an intervention is unlikely
to change in additional research,
the SOE, is presented as insufficient,
low, moderate, or high. Assessments
are based on consideration of study
limitations, consistency in the
direction of the effect, directness inmeasuring intended outcomes, theprecision of the effect, and reporting
bias.‍12 We determined the SOE
separately for major interventionoutcome pairs using a prespecified
approach, which is described in detailin the full review.‍8

Results
Our searches (conducted for thebroader systematic review update‍8)
identified 6573 citations, of which 24(reported in multiple publications)
met the inclusion criteria (‍Fig 1).
Seventeen of these studies were
published after the completion of
our initial review of therapies for

We categorized interventions
addressed in the included studies
based on the core strategies usedin each intervention. In some cases,
this approach grouped together
interventions that may have used
specific, manualized techniques withothers that used only a subset of
those techniques (eg, “Ayres-based”
sensory integration and sensory
integration models that may haveused some Ayres strategies). We notethat no alternative approaches would
have substantially changed ouroverall findings in terms of SOE.
Based on the literature meeting
criteria for this review, wecategorized interventions as:•• sensory integration-based(interventions using combinationsof sensory and kinetic components,
such as materials with different
textures, touch/massage, swinging
and trampoline exercises, andbalance and muscle resistance
exercises to ameliorate sensory
challenges);•• environmental enrichment-based(interventions incorporatingtargeted exposure to sensory
stimuli to promote tolerance ofstimuli in other contexts);•• auditory integration-based(interventions incorporating
auditory components, such asfiltered sound to ameliorate
sensory processing challenges
via theorized retraining of auralpathways);

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3

TABLE 2 Overview of Studies Addressing Interventions Targeting Sensory Challenges
Characteristic

RCTs (n = 20)

Nonrandomized Trials (n = 1)

Retrospective Cohort Studies(n = 3)

Total Literature

3
2

0
0

1
0

4
2

4
4
5
2

0
1
0
0

0
0
2
0

4
5
7
2

5
2
4
6
3

1
0
0
0
0

0
0
0
2
1

6
2
4
8
4

3
1
2
13
1

1
0
0
0
0

2
0
0
1
0

6
1
2
14
1

3
10
7
790

0
0
1
27

0
0
3
193

3
10
11
1010

Intervention category
Sensory integration-based approaches
Environmental enrichment-based
approaches
Auditory integration-based approaches
Music therapy-based approaches
Massage-based approaches
Additional approaches
Treatment duration (wk)
<1–4
5–8
9–12
13–20
≥21
Region of study conduct
Asia
Australia
EuropeNorth America
South America
Risk of bias
Low
Moderate
High
Total participants, N•• music therapy-based(interventions incorporatingplaying or singing music, or
movement to music, to improvechallenging behaviors and sensory
difficulties);•• massage-based (interventions
incorporating touch-based
approaches by a therapist or
caregiver); and•• other/additional (included

interventions [tactile-based tasks,
weighted blankets] not cleanly
fitting into one of the broader
categories).

Studies of Sensory Integrationbased Approaches

In 3 out of 4 small, short-term
studies (1 low,​‍21 1 moderate,​‍20 and
2 high‍13,​34‍ risk of bias), sensoryrelated measures and motor skills
measures improved for children
receiving a sensory integrationbased intervention compared withanother intervention, but effects onother outcomes were typically notstatistically significantly different
4

between groups (Table 3). Several
outcomes were also parent-reported,and parents were often aware ofintervention status.

In 1 RCT, children with ASD anda diagnosed sensory processing
disorder received treatment focusedon sensory integration or treatment
focused on building fine motor
skills.‍21 Both groups improved
significantly on blinded parent andteacher ratings of goal attainment
related to sensory processing,motor skills, and social functioning,with children receiving sensory
integration improving significantly
more than those receiving motor
skills intervention (P ≤ .05). Children
in the sensory integration group
had significantly fewer parent-rated
autistic mannerisms posttreatment
than the fine motor group (P ≤.05), but other measures of sensory
processing, ASD symptoms, orneurologic functioning did not
differ between groups. Another RCT
compared manualized occupational
therapy with sensory integration
to care as usual.‍20 After treatment,children receiving sensory
integration-based treatment showedsignificantly more goals attained andsignificantly greater improvements
in social skills and self-care measurescompared with children receiving
usual care (P = .003). Measures ofadaptive behavior or other measuresrelated to functional skills (eg, selfcare and mobility) did not differ
between groups.
In a retrospective study comparing
sensory integration-based therapy
in children with high functioning
ASD (IQs >70), both groups received
active treatment that included either
sensory integration-based therapy oreclectic group therapy.‍34 Participantsin the sensory integration group
improved significantly more thanthose in the control group inmeasures of motor abilities, memory
and visualization, and combined
sensory motor and cognitive
skills assessed by an unblinded
investigator (P values < .05). They
did not show relative improvements
in measures of spatial positioning,sense of touch, or verbal ability.

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TABLE 3 Key Findings in Studies of Interventions Targeting Sensory Challenges
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB

Outcome Measure/Baseline Scores,
Mean ± SD

Iwanaga et al‍34
Retrospective cohort
G1: sensory integration therapy, 8/8
G2: group therapy, 12/12
Age (mo)  G1: 56.8 ± 9.0  G2: 56.3 ± 6.8
8–10 mo/EOTHigh ROB

Japanese Miller assessment for preschoolers
Total score  G1: ND  G2: ND
Index score  G1: ND  G2: ND
Coordination index score  G1: ND  G2: ND
Nonverbal index score  G1: ND  G2: ND
Complex index score  G1: ND  G2: ND
Verbal index score  G1: ND  G2: ND

Schaaf et al‍20
RCT
G1: sensory integration, 17/17
G2: usual care, 15/14
Age (mo)  G1: 71.35 ± 14.90  G2: 72.33 ± 10.81
10 wk/EOT
Moderate ROB

GAS
G1: ND
G2: ND
PEDI
Functional skills – self-care  G1: ND  G2: ND
Functional skills – mobility  G1: ND  G2: ND
Functional skills – social  G1: ND  G2: ND
Caregiver assistance – self-care  G1: ND  G2: ND
Caregiver assistance – mobility  G1: ND  G2: ND
Caregiver assistance – social  G1: ND  G2: ND
PDDBI
G1: ND
G2: ND

Outcome Measure/Posttreatment Scores,
Mean ± SD

Mean change score from baseline
Total score  G1: 34.38 ± 21.98  G2: 8.25 ± 11.69  G1 vs G2: P = .005
Foundation index score  G1: 34.13 ± 34.21  G2: 11.33 ± 25.54  G1 vs G2: P = ns
Coordination index score  G1: 46.75 ± 36.26  G2: 8.92 ± 17.87  G1 vs G2: P = .008
Nonverbal index score  G1: 45 ± 24.26  G2: 8.25 ± 36.6  G1 vs G2: P = .016
Complex index score  G1: 30.75 ± 20.73  G2: 3.83 ± 31.2  G1 vs G2: P = .034
Verbal index score  G1: 13 ± 44.26  G2: 14.67 ± 31.2  G1 vs G2: P = ns
Mean change score from baseline
GAS
G1: 56.53 ± 12.38
G2: 42.71 ± 11.21
G1 vs G2: P = .003
PEDI
Functional skills – self-care  G1: 10.2 ± 22.6  G2: 1.12 ± 5.6  G1 vs G2: P = ns
Functional skills – mobility  G1: 6.57 ± 23.8  G2: 6.38 ± 15.1  G1 vs G2: P = ns
Functional skills – social  G1: 9.3 ± 17.4  G2: 4.4 ± 13.8  G1 vs G2: P = ns
Caregiver assistance – self-care  G1: 16.6 ± 23  G2: –0.43 ± 8.6  G1 vs G2: P = .008
Caregiver assistance – mobility  G1: 4.8 ± 24.1  G2: 0.22 ± 11.8  G1 vs G2: P = ns
Caregiver assistance – social  G1: 14.4 ± 23.4  G2: –1.8 ± 19  G1 vs G2: P = .039
PDDBI
Sensory/Perceptual approach  G1: –5.9 ± 10.8  G2: –0.67 ± 5.9  G1 vs G2: P = ns

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB

Outcome Measure/Baseline Scores,
Mean ± SD

VABS
G1: ND
G2: ND

Pfeiffer et al‍21
RCT
G1: sensory integration treatment,
20/20
G2: fine motor, 17/17
Age (mo)  G1: 100.00 ± 24.78  G2: 110.47 ± 24.78
6 wk/EOT
Low ROB

Fazlioğlu et al‍13
RCT
G1: sensory integration, 15/15
G2: control (special education), 15/15
Age (y)  G1 + G2: 7–11
12 wk/EOTHigh ROB
Woo and Leon‍22
RCT
G1: sensorimotor enrichment group+ standard care, 13/13
G2: standard care, 15/15

6

Outcome Measure/Posttreatment Scores,
Mean ± SD
Ritualisms/Resistance to change  G1: –6.5 ± 13.7  G2: –1.77 ± 6.3  G1 vs G2: P = ns
Arouse  G1: −7.1 ± 11.6  G2: −3.3 ± 6.0  G1 vs G2: P = ns
VABS-II
Communication  G1: 5.06 ± 10.9  G2: −3.38 ± 18.6  G1 vs G2: P = ns
Daily living skills  G1: 4.2 ± 11.6  G2: −3.0 ± 18.5  G1 vs G2: P = ns
Socialization  G1: 3.8 ± 11.8  G2: −6.7 ± 21.8  G1 vs G2: P = ns
Composite  G1: 15.1 ± 44.7  G2: 0.0 ± 8.1  G1 vs G2: P = ns

VABSCommunication

VABS
  NR

  G1: 62.90 ± 13.39  G2: 64.24 ± 9.62
Socialization  G1: 63.90 ± 17.71  G2: 64.24 ± 9.33
Motor  G1: 60.70 ± 13.20  G2: 61.00 ± 11.24
Composite  G1: 66.80 ± 16.66  G2: 70.18 ± 14.07
Sensory processing measure – total  G1: 68.50 ± 5.62  G2: 67.88 ± 7.28
Social responsiveness scale – total  G1: 82.95 ± 6.37  G2: 82.71 ± 9.10
Sensory evaluation form for children with autism
G1: 98.2 ± 19.3
G2: 95.8 ± 17

Sensory processing measure – total  G1 vs G2: P = ns
Social responsiveness scale – total  G1 vs G2: P = ns
GAS-parent rated  G1 > G2  G1 vs G2: P < .05; ES = 0.125
GAS-teacher rated  G1 > G2  G1 vs G2: P < .01; ES = 0.360

CARS – autism severity, mean ± SE
G1: 34.38 ± 0.72
G2: 38.07 ± 1.71

Sensory evaluation form for children with autism
G1: 66.5 ± 11.4
G2: 97.3 ± 17.8
G1 vs G2: P < .05

CARS – autism severity  G1: 31.12 ± 1.46  G2: 37.61 ± 1.67

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB
Age (y)  G1 + G2: 6.6 ± 2.5
6 mo/EOT
Moderate ROB

Outcome Measure/Baseline Scores,
Mean ± SD

Leiter-R – nonverbal test scale
G1: 48.46 ± 5.52
G2: 46.2 ± 6.36
EOWPV – expressive language scale
G1: ND
G2: ND

Woo et al‍23
RCT
G1: standard care + sensorimotor
enrichment, 64/28
G2: standard care, 27/22
Age (y)G1: 4.76 ± 1.14
G2: 4.54 ± 1.10
6 mo/EOT
Low ROBADOS – severity
G1: ND
G2: ND
RDLS
Receptive language  G1: 36.19 ± 4.64  G2: 33.37 ± 4.79
Expressive language  G1: 31.46 ± 4.14  G2: 31.47 ± 4.82
Leiter-R
Nonverbal test score  G1: 35.85 ± 4.76  G2: 32.63 ± 6.07
IQ score
G1: 82.96 ± 5.17
G2: 76.63 ± 4.96
SSP – atypical sensory responses
G1: 113.75 ± 4.76
G2: 129.3 ± 4.29

Mudford et al‍15
RCT
G1: auditory integration, 21/21
G2: control treatment, 21/21
Age  G1 + G2: 9.42 y ± 29 mo
10 d (2 sessions/d)/EOT
Moderate ROB
Corbett et al‍14
RCT
G1: Tomatis sound therapy/placebo,
11/11
G2: Placebo/Tomatis sound therapy,
11/11
Age (y)  G1 + G2: 3–7
25 d (2 blocks)/EOT
Moderate ROB
Porges et al‍26
RCT
G1: filtered music, 28/28

ABC – hyperactivity
23.7 ± 9.4
NCBRF – hyperactivity
13.9 ± 5.5

Outcome Measure/Posttreatment Scores,
Mean ± SD  G1 vs G2: P = .03
Leiter-R – nonverbal test scale  G1: 57.23 ± 5.5  G2: 43.7 ± 6.89  G1 vs G2: P = .008
Mean change from baseline,​  EOWPV – expressive language scale   G1: +4.7   G2: +4.67   G1 vs G2: P = ns
Number changing diagnostic classification on ADOS
G1: 6 (21)G2: 0 (0)G1 vs G2: P = .01
RDLS
Receptive language  G1: 43.62 ± 4.14  G2: 37 ± 4.95  G1 vs G2: P = .048
Expressive language  G1: 38.65 ± 4.16  G2: 37.16 ± 4.94  G1 vs G2: P = ns
Leiter-R
Nonverbal test score  G1: 49.19 ± 5.48  G2: 40.05 ± 6.25  G1 vs G2: P = .024
IQ score
G1: 91.38 ± 5.58
G2: 78.16 ± 4.49
G1 vs G2: P = .037
SSP – atypical sensory responses
G1: 125.11 ± 5.42
G2: 132.15 ± 4.09
G1 vs G2: P = .037
Mean change from baseline
ABC – hyperactivity
G1: 0.3 ± 3.6
G2: −4.1 ± 3.9
NCBRF – hyperactivity
G1: −0.3 ± 2
G2: −2 ± 2.2

PPVT
G1: 20.83 ± 28.52

PPVT
G1: 22.83 ± 29.36

G2: 32.20 ± 25.21

G2: 47.20 ± 24.45

EOWVT
G1: 16.50 ± 21.11
G2: 25.20 ± 19.82

EOWVT
G1: 21.50 ± 23.30
G2: 34.40 ± 25

Parent questionnaire
Hearing sensitivity

Parent questionnaire
Hearing sensitivity

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB
G2: headphones only, 36/36
Age  NR
1 wk/EOTHigh ROB

Outcome Measure/Baseline Scores,
Mean ± SD  G1: 18 (50)  G2: 12 (43)Affect  G1: 16 (44)  G2: 17 (61)
Eye contact  G1: 27 (75)  G2: 17 (61)Behavioral organization  G1: 19 (53)  G2: 16 (57)
Emotional control  G1: 18 (50)  G2: 12 (43)Spontaneous speech  G1: 27 (75)  G2: 23 (82)
Receptive speech  G1: 26 (72)  G2: 23 (82)
Listening  G1: 29 (81)  G2: 24 (86)

Porges et al‍26
RCT
G1: filtered music, 50/50
G2: unfiltered music, 32/32
Age (mo)  G1: 53.33 ± 15.95  G2: 56.74 ± 9.25
1 wk/EOTHigh ROB

Spontaneity  G1: 25 (69)  G2: 20 (71)
Relatedness  G1: 30 (83)  G2: 23 (82)
Parent questionnaire
Hearing sensitivity  G1: 23 (46)  G2: 16 (50)Affect  G1: 32 (64)  G2: 19 (59)
Eye contact  G1: 30 (60)  G2: 20 (63)Behavioral organization  G1: 28 (56)  G2: 17 (53)Emotional control  G1: 33 (66)  G2: 19 (59)Spontaneous speech  G1: 41 (82)  G2: 25 (78)
Receptive speech  G1: 45 (90)  G2: 26 (81)
Listening8

Outcome Measure/Posttreatment Scores,
Mean ± SD  G1: 9 (50)  G2: 1 (8)  G1 vs G2: P = .017
Affect  G1: 3 (19)  G2: 1 (18)
Eye contact  G1: 11 (41)  G2: 4 (24)Behavioral organization  G1: 5 (26)  G2: 0 (0)  G1 vs G2: P = .027
Emotional control  G1: 3 (17)  G2: 0 (0)Spontaneous speech  G1: 13 (48)  G2: 4 (17)  G1 vs G2: P = .022
Receptive speech  G1: 8 (31)  G2: 2 (9)Listening  G1: 12 (41)  G2: 2 (8)  G1 vs G2: P = .006
Spontaneity  G1: 12 (48)  G2: 4 (20)
Relatedness  G1: 9 (30)  G2: 3 (13)Parent questionnaire
Hearing sensitivity  G1: 10 (43)  G2: 2 (13)  G1 vs G2: P = .040
Affect  G1: 8 (25)  G2: 4 (21)
Eye contact  G1: 10 (33)  G2: 8 (40)
Behavioral organization  G1: 8 (29)  G2: 3 (18)
Emotional control  G1: 8 (24)  G2: 0 (0)  G1 vs G2: P = .019
Spontaneous speech  G1: 21 (51)  G2: 11 (44)
Receptive speech  G1: 4 (9)  G2: 4 (15)Listening

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB

Srinivasan et al‍31,​‍32
RCT

Outcome Measure/Baseline Scores,
Mean ± SD  G1: 37 (74)  G2: 21 (66)
Spontaneity  G1: 22 (44)  G2: 14 (44)
Relatedness  G1: 32 (64)  G2: 21 (66)

G1: rhythm group, 12/11
G2: robot group, 12/11
G3: standard care, 12/11
Age (y)  G1 + G2: 5–12
8 wk/EOT
Moderate ROB

Training-specific measure – response to social bids (total
word count) early training session (session 2 of 32)
NR
Training-specific measure – response to social bids (total
word count) mid training session (session 7 of 32)
NR
Training-specific measure – response to social bids (total
word count) late training session (session 15 of 32)
NR
Training-specific measure – verbalization to social
partners (percent duration) early – trainerNR
Training-specific measure – verbalization to social
partners (percent duration) early – adult modelNR
Training-specific measure – verbalization to social
partners (percent duration) mid – trainerNR
Training-specific measure – verbalization to social
partners (percent duration) mid – adult modelNR
Training-specific measure – verbalization to social
partners (percent duration) late – trainerNR
Training-specific measure –– verbalization to social
partners (percent duration) late – adult modelNR

Outcome Measure/Posttreatment Scores,
Mean ± SD  G1: 11 (30)  G2: 6 (29)
Spontaneity  G1: 8 (36)  G2: 5 (36)
Relatedness  G1: 11 (34)  G2: 6 (29)
Joint attention test – total score
G1 vs G2 vs G3, P = NS; SMD = 0.55; 95% CI, (SMD) =−0.13 to 1.24
G1 vs G2 vs G3, P = NS; SMD = 0.25; 95% CI (SMD) =−0.38 to 0.89
G1 vs G2 vs G3, P = NS; SMD = 0.71; 95% CI (SMD) =−0.01 to 1.43
Training-specific measure – response to social bids (total
word count) early training session
G1: 4.4 ± 4.19
G2: 5.92 ± 7.04
G3: 4.5 ± 3.9
Training-specific measure – response to social bids (total
word count) mid training session
G1: 3.8 ± 3.29
G2: 7.25 ± 6.74
G3: 7.33 ± 8.81
Training-specific measure – response to social bids (total
word count) late training session
G1: 9.8 ± 8.53
G2: 7.67 ± 7.6
G3: 5.67 ± 4.16
Training-specific measure – verbalization to social
partners (percent duration) early – trainer
G1: 6.1 ± 5.7
G2: 3.9 ± 4.2
G3: 12.1 ± 8.6
Training-specific measure – verbalization to social
partners (percent duration) early – adult model
G1: 2.1 ± 2.3
G2: 1.9 ± 1.1
G3: 2 ± 1.6
Training-specific measure – verbalization to social
partners (percent duration) mid – trainer
G1: 12.8 ± 14.5
G2: 5.1 ± 5.3
G3: 14.5 ± 11.3
Training-specific measure – verbalization to social
partners (percent duration) mid – adult model
G1: 1.8 ± 1.9
G2: 3.4 ± 1.7
G3: 2.2 ± 1.9
Training-specific measure – verbalization to social
partners (percent duration) late – trainer
G1: 14.8 ± 15
G2: 6.3 ± 6.1
G3: 14.4 ± 8.6
Training-specific measure – verbalization to social
partners (percent duration) late – adult model
G1: 2.2 ± 2.3
G2: 5.4 ± 4.2

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB

Outcome Measure/Baseline Scores,
Mean ± SD

Training specific measure – vocalization patterns
NR
Training specific measure – verbalization patterns
NR
Ghasemtabar et al‍33
Non-RCT
G1: music therapy, 13/13
G2: control, 14/14
Age (y)  G1: 8.96 ± 1.36  G2: 9.23 ± 1.54
45 d/2 months
High ROB
Thompson et al‍25
RCT
G1: family-centered music therapy(FCMT), 12/11
G2: early intervention program, 11/10
Age (mo)  G1: 43.92 ± 6.46  G2: 47.00 ± 7.18
16 wk/EOT
Moderate ROB

Social skills rating system
G1: 27.69 ± 4.76
G2: 26.92 ± 4.49

G3: 2.6 ± 2.4
Training-specific measure – vocalization patterns
G2 vs G1, G3, P < .002; SMD = 0.75–0.76
Training-specific measure – verbalization patterns
G1 vs G3, P = NS
G3 vs G1, G2, P = .001; SMD = 0.78
Social skills rating system  
2-mo follow-up  G1: 30.61 ± 4.25  G2: 26.85 ± 3.82

VSEEC – social interaction
G1: 49.1 ± 12.4
G2: 45.09 ± 8.13
SRS
G1: 105.4 ± 27.1
G2: 106.2 ± 26.1
MBCDI
Speech and language  G1: 180 ± 108  G2: 170 ± 109
PCRI
G1: 194.3 ± 23.1
G2: 191.6 ± 19.4

Gattino et al‍30
RCT
G1: relational music therapy +clinical routine activities, 12/12
G2: clinical routine activities, 12/12
Age (y)  G1 + G2: 9.75 ± 1.39
7 mo/EOT
Low ROBCARS – verbal communication
G1: 2.67 ± 0.49
G2: 2.54 ± 0.33

Kim et al‍16
RCT
G1: music therapy, 15/10
G2: toy play, 15/10
Age (mo)  G1 + G2: 51.20 ± 12.08
12 weekly, 30 min sessions/EOTHigh ROB
Silva et al‍29
RCT  G1: qigong massage, 55/42  G2: control, 48/42

PDDBI
Level of agreement at pre-treatment: 0.19

10Outcome Measure/Posttreatment Scores,
Mean ± SD

CARS – nonverbal communication
G1: 2.42 ± 0.42
G2: 2.08 ± 0.47
CARS – social communications
G1: 12.29 ± 1.78
G2: 11.38 ± 1.65

Aberrant behavior checklist
G1: 82.4 ± 25.9
G2: 83.1 ± 25.9

Change scores from baseline
VSEEC – social interaction  G1: 22.4 ± 10.1  G2: 0.9 ± 11.9  G1 vs G2: P < .001
SRS  G1: −7.7 ± 17.3  G2: −1.4 ± 11.5  G1 vs G2: P = ns
MBCDI  Speech and language   G1: 78.9 ± 73.4   G2: 58.7 ± 79.8   G1 vs G2: P = ns
PCRI
G1: 8.0 ± 9.19
G2: 0.2 ± 10.3
G1 vs G2: P = ns
CARS – verbal communication
G1: 2.54 ± 0.45
G2: 2.58 ± 0.44
G1 vs G2, P = .50; SMD = 0.39 (95% CI, 0.21–0.57)
CARS – nonverbal communication
G1: 2.5 ± 0.37
G2: 2.33 ± 0.54
G1 vs G2, P = .35; SMD = 0.39 (95% CI, 0.08–0.86)
CARS – social communications
G1: 12.25 ± 1.54
G2:​11.​92 ± 1.24
G1 vs G2, P = .34; SMD = 0.39 (95% CI, 70.08–0.86)
PDDBI
Level of agreement at post-treatment: 0.67
G1 vs G2: P = ns

Aberrant behavior checklist
G1: 62.4 ± 26.6
G2: 75.7 ± 28.6
G1 vs G2: P = .006

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB
Age (y)G1 + G2: 2–5
5 mo/EOT
Moderate ROB

Outcome Measure/Baseline Scores,
Mean ± SD
VABS – daily living skills
G1: 34.3 ± 17.7
G2: 37.5 ± 20
VABS – socialization
G1: 36 ± 14.4
G2: 40.7 ± 17.4
Self-regulatory difficulties
G1: 57.6 ± 11.2
G2: 57.4 ± 13.4
Abnormal sensory response
G1: 39.7 ± 9.1
G2: 41.3 ± 10.3
CARS – total score
G1: 39.7 ± 6.6
G2: 38 ± 7.8

Silva et al‍35
RCT
G1: qigong massage + qigong
sensory training, 97/97
G2: control, 32/32
Age (y)  G1: 3.87 ± 1.11  G2: 4.16 ± 0.95
5 mo/EOTHigh ROB
Silva et al‍24
RCT
G1: qigong massage, 28/24
G2: wait-list control, 19/18
Age, mean mo  G1 + G2: 58
4 mo/EOT
Moderate ROB

Abnormal tactile response – total score
G1: 20.91 ± 7.13
G2: 22.31 ± 8.52
Self-regulatory difficulties
G1: 45.43 ± 11.21
G2: 50.94 ± 15.69

Teacher ABC
Autism severity score  G1: 76.3 ± 19.6  G2: 76.7 ± 30.1
PDDBI
Sensory  G1: 56.4 ± 10.6  G2: 56.5 ± 11.5
Maladaptive behavior  G1: 60.9 ± 13.0  G2: 61.8 ± 15.8
Social/language/communication abilities  G1: 49.9 ± 11.4  G2: 51.6 ± 12.1
SSC
Sense
  G1: 38.1 ± 12.1  G2: 40.6 ± 14.6
Self-regulation  G1: 49.1 ± 11.7  G2: 48.9 ± 12.7
Autism composite score

Outcome Measure/Posttreatment Scores,
Mean ± SD
VABS – daily living skills
G1: 42.7 ± 19.1
G2: 45.9 ± 22.7
G1 vs G2: P = NR
VABS – socialization
G1: 45.7 ± 16.3
G2: 48.6 ± 21
G1 vs G2: P = NR
Self-regulatory difficulties
G1: 45.1 ± 11.5
G2: 54 ± 14.5
G1 vs G2: P = .00006
Abnormal sensory response
G1: 30.4 ± 9.8
G2: 38.6 ± 11.6
G1 vs G2: P = .00002
CARS – total score
G1: 38.2 ± 6.6
G2: 37.7 ± 7.8
G1 vs G2: P = ns
Abnormal tactile response – total score
G1: 15.57 ± 6.86
G2: 21.34 ± 8.41
G1 vs G2: P < .001
Self-regulatory difficulties
G1: 34.3 ± 10.88
G2: 49.03 ± 15.45
G1 vs G2: P < .001

ABC  Autism severity score   G1: 56.1 ± 26.4   G2: 75.3 ± 38.9   G1 vs G2: P = ns
PDDBI  Sensory   G1: 50.1 ± 11.8   G2: 55.6 ± 10.0   G1 vs G2: P = .032  Maladaptive behavior   G1: 52.3 ± 14.9   G2: 61.3 ± 15.2   G1 vs G2: P = .003  Social/language/communication abilities   G1: 53.0 ± 10.7   G2: 53.1 ± 12.2   G1 vs G2: P = ns
SSC  Sense   G1: 28.5 ± 12.2   G2: 39.4 ± 12.6   G1 vs G2: P = .001  Self-regulation   G1: 39.2 ± 14.7   G2: 49.2 ± 11.6   G1 vs G2: P = .00002  Autism composite score

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB

Outcome Measure/Baseline Scores,
Mean ± SD
G1: 59.8 ± 11.1
G2: 60.2 ± 15.9

Piravej et al‍18
RCT
G1: traditional thai massage +sensory integration therapy, 30/30
G2: sensory integration therapy,
30/30
Age (y)  G1: 4.84 ± 1.86  G2: 4.48 ± 1.8
8 wk/EOTHigh ROBCPRS – conduct problem
G1: 0.69 ± 0.31
G2: 0.59 ± 0.34

CPRS – learning problem
G1: 1.86 ± 0.55
G2: 2.02 ± 0.56
CPRS – psychosomatic
G1: 0.41 ± 0.45
G2: 0.43 ± 0.34

CPRS – anxiety
G1: 0.76 ± 0.53
G2: 0.62 ± 0.49
CPRS – hyperactivity
G1: 1.45 ± 0.51
G2: 1.53 ± 0.48
CTRS – conduct problem
G1: 0.98 ± 0.38
G2: 1.11±0.27
CTRS – hyperactivity
G1: 1.59 ± 0.49
G2: 1.8 ± 0.36
CTRS – inattention-passivity
G1: 1.56 ± 0.41
G2: 1.67 ± 0.27
CTRS – hyperactivity index
G1: 11.5 ± 9.23
G2: 13.9 ± 7.67
Sleep behavior – sleep diaryG1: 11.5 ± 9.23
G2: 13.9 ± 7.67

12   G1: 50.9 ± 14.8   G2: 58.9 ± 12.3   G1 vs G2: P = NR
CPRS – conduct problem
G1: 0.6 ± 0.26
G2: 0.63 ± 0.33
G1 vs G2, P = .03

CPRS – impulsivity-hyperactivity
G1: 1.62 ± 0.6
G2: 1.65 ± 0.65

Silva et al‍17
RCT
G1: qigong sensory training, 25/25
G2: waitlist control, 21/21
Age (mo)
G1: 65.2 ± 20.7
G2: 53.3 ± 18.7
5 mo/EOTHigh ROB

Outcome Measure/Posttreatment Scores,
Mean ± SD

ABC – total score
G1: 48.5 ± 20.8
G2: 64.3 ± 33.8
PDDBI – maladaptive behavior score (parent)
G1: 56.8 ± 11.5
G2: 59.5 ± 10.7
PDDBI – maladaptive behavior score (teacher)
G1: 50.9 ± 10.4

CPRS – learning problem
G1: 1.76 ± 0.48
G2: 1.87 ± 0.53
G1 vs G2, P = ns
CPRS – psychosomatic
G1: 0.41 ± 0.32
G2: 0.39 ± 0.25
G1 vs G2, P = ns
CPRS – impulsivity-hyperactivity
G1: 1.44 ± 0.4
G2: 1.69 ± 0.57
G1 vs G2, P = ns
CPRS – anxiety
G1: 0.62 ± 0.56
G2: 0.73 ± 0.5
G1 vs G2, P = .01
CPRS – hyperactivity
G1: 1.32 ± 0.41
G2: 1.42 ± 0.42
G1 vs G2, P = ns
CTRS – conduct problem
G1: 0.64 ± 0.35
G2: 0.71 ± 0.26
G1 vs G2, P = ns
CTRS – hyperactivity
G1: 1.24 ± 0.5
G2: 1.49 ± 0.37
G1 vs G2, P = ns
CTRS – inattention-passivity
G1: 1.18 ± 0.51
G2: 1.34 ± 0.36
G1 vs G2, P = ns
CTRS – hyperactivity index
G1: 1.1 ± 0.49
G2: 1.28 ± 0.4
G1 vs G2, P = ns
Sleep behavior – sleep diaryG1: 5.33 ± 3.28
G2: 8.2 ± 6.83
G1 vs G2: P = ns
ABC – total score
G1: 33.9 ± 18.6
G2: 59.4 ± 35.4
G1 vs G2: P = .003
PDDBI – maladaptive behavior score (parent)
G1: 45.6 ± 10.8
G2: 57.5 ± 10.4
G1 vs G2: P = .0003
PDDBI – maladaptive behavior score (teacher)
G1: 44 ± 7.6

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB

Outcome Measure/Baseline Scores,
Mean ± SD
G2: 56.5 ± 13.3
PDDBI – social/language/communication score (parent)
G1: 57.5 ± 6.8
G2: 49 ± 13.1
PDDBI – social/language/communication score (teacher)
G1: 53.7 ± 9.7
G2: 47 ± 13
PDDBI – sensory score (parent)
G1: 54.2 ± 9.6
G2: 56 ± 9.6

Lee‍36
Prospective cohort
G1: massage therapy + attachment
promotion program, 23/23
G2: attachment promotion program,
21/21
Age (mo)  G1: 19 ± 4  G2: 9 ± 12
4 mo/EOTHigh ROB
Silva et al‍19
RCT
G1: qigong massage, 8/8
G2: no treatment, 7/7
Age (y)  G1 + G2: 2–6
5 mo/EOT
Moderate ROB

Social maturity scale
G1: 63.13 ± 15.76
G2: 51.24 ± 10.48

G2: 49.7 ± 12.2
G1 vs G2: P = ns
PDDBI – social/language/communication score (parent)
G1: 56.7 ± 9.7
G2: 49.2 ± 12.8
G1 vs G2: P = .007
PDDBI – social/language/communication score (teacher)
G1: 56.7 ± 9.7
G2: 47.6 ± 12.1
G1 vs G2: P = .010
PDDBI – sensory score (parent)
G1: 46.2 ± 9.1
G2: 55.3 ± 10
G1 vs G2: P = .005
Social maturity scale
G1: 70.74 ± 16.39
G2: 52.86 ± 10.18
G1 vs G2, P = .005

CARS – total score
G1: 44.31 ± 0.57
G2: 41.76 ± 5.07

VABS – living skills
G1: 28.8
G2: 24.1
VABS – socialization
G1: 29.8
G2: 24.7
VABS – receptive language
G1: 33.8
G2: 23.6
VABS – expressive language
G1: 31.5
G2: 24.4
VABS – gross motor skills
G1: 37.5
G2: 33.4
VABS – fine motor skills
G1: 36
G2: 29
Short sensory profile – total score
G1: 16.2
G2: 15.7
ABC – total score
G1: 71.3
G2: 87.7

Latham and Stockman‍28

Outcome Measure/Posttreatment Scores,
Mean ± SD

Verbal scoring

CARS – total score
G1: 37.74 ± 7.49
G2: 39.19 ± 5.43
G1 vs G2, P = NS
Mean change score from baseline
VABS – living skills
G1: 9.8
G2: 0.9
G1 vs G2: P = .02
VABS – socialization
G1: 10G2: 4.7
G1 vs G2: P = .04
VABS –receptive language
G1: 8.3
G2: 10.6
G1 vs G2: P = ns
VABS – expressive language
G1: 8.9
G2: 6.7
G1 vs G2: P = ns
VABS – gross motor skills
G1: 6.5
G2: 0.9
G1 vs G2: P = ns
VABS – fine motor skills
G1: 8.8
G2: 7.6
G1 vs G2: P = ns
Short sensory profile – total score
G1: –5.4
G2: 2.7
G1 vs G2: P = .01
ABC – total score
G1: –13.3
G2: –24.3
G1 vs G2: P = ns
Verbal scoring

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TABLE 3 Continued
Source, Study Design, Groups, N
Enrollment/N Final, Mean Age, Months± SD, Treatment Duration/Follow-up
Time Point Posttreatment, ROB
RCT
G1: participation (tactual-kinesthetic
experience), 17/17
G2: observation, 17/17
Age (y)  G1: 8.36 ± 2.6  G2: 8.69 ± 3.0
24–48 h/EOTHigh ROB

Gringras et al‍27
RCT
G1: weighted blanket, 36/27
G2: control blanket, 37/27
Crossover trial 73/54
Age (y)  G1: 8.7 ± 3.3  G2: 9.9 ± 2.8
2 wk/EOT
Moderate ROB

Outcome Measure/Baseline Scores,
Mean ± SD

Outcome Measure/Posttreatment Scores,
Mean ± SD

Day 1 – verbal 1  G1: 8.12 ± 5.52

Day 2 – verbal 3  G1: 8.35 ± 6.06  G2: 6.00 ± 5.20  G1 vs G2: P = .041
Day 1 – verbal 2  G1: 7.76 ± 5.51  G2: 5.74 ± 5.41  G1 vs G2: P = .065
Nonverbal scoring
Day 1 – score 1  G1: 8.10 ± 1.97  G2: 4.60 ± 3.42  G1 vs G2: P = .001
Day 1 – rating 1  G1: 2.95 ± 1.08  G2: 3.90 ± 1.16  G1 vs G2: P = .010  G2: 5.39 ± 4.76  G1 vs G2: P = .031
Day 2 – verbal 4  G1: 8.25 ± 5.62  G2: 5.66 ± 5.02  G1 vs G2: P = .017
Nonverbal scoring
Day 2 – score 2  G1: 8.35 ± 1.66  G2: 6.13 ± 3.47  G1 vs G2: P = .010
Day 2 – rating 2  G1: 2.88 ± 0.96  G2: 3.57 ± 1.23  G1 vs G2: P = .020

% of time blanket in place, n = 67
G1: 75.6 ± 25.4
G2: 73.7 ± 25.7
TST, n = 67
G1: 528.9 ± 127.1
G2: 513.0 ± 154.1
SOL min, n = 67
G1: 55.6 ± 37.8
G2: 57.2 ± 42.8
Proportion of nights with ≥1 wake, n = 67
G1: 0.2 ± 0.3
G2: 0.2 ± 0.3
Average time awake, n = 67
G1: 15.6 ± 13.4
G2: 14.6 ± 13.3
TST min, n = 65/66
G1: 454.4 ± 62.4
G2: 457.7 ± 64.6
SOL min, n = 59
G1: 74.3 ± 48.7
G2: 69.9 ± 43.8
Sleep efficiency, %, n = 59
G1: 73.4 ± 9.3
G2: 74.2 ± 7.8
No. of night awakenings, n = 65/66
G1: 19.1 ± 6.7
G2: 19.5 ± 6.9
Time awake after sleep onset, n = 65/66
G1: 84.1 ± 43.1
G2: 83.8 ± 41.4

% of time blanket in place  G1 vs G2: P = ns
TST  G1 vs G2: P = ns
SOL min  G1 vs G2: P = ns
Proportion of nights with ≥1 wake  G1 vs G2: P = ns
Average time awake  G1 vs G2: P = ns
TST min  G1: 452.8 ± 65.0  G2: 455.4 ± 65.8 P = ns
SOL min  G1: 71.4 ± 48.2  G2: 70.6 ± 44.3 P = ns
Sleep efficiency (%)  G1: 73.6 ± 9.3  G2: 74.2 ± 8.0 P = ns
No. of night awakenings  G1: 19.5 ± 7.0  G2: 19.5 ± 6.8 P = ns
Time awake after sleep onset  G1: 84.6 ± 42.6  G2: 84.5 ± 41.5 P = ns

ABC, Autism Behavior Checklist; ADOS, Autism Diagnostic Observation Schedule; CARS, Childhood Autism Rating Scale; CI, confidence interval; CPRS, Conners' Parent Rating Scale; CTRS,
Conners' Teacher Rating Scale; EOT, end of treatment; EOWPV, Expressive One-Word Picture Vocabulary Test; EOWVT, Expressive One Word Vocabulary Test; ES, effect size; G1, group 1;
G2, group 2; GAS, Goal Attainment Scaling; Leiter-R, Leiter International Performance Scale-Revised; MAP, Miller Assessment for Preschoolers; MBCDI, MacArthur-Bates Communicative
Development Inventories; NCBRF, Nisonger Child Behavior Rating Form; ND, no data; NR, not reported; ns, not significant; PCRI, Parent–Child Relationship Inventory; PDDBI, Pervasive
Developmental Disorders Behavior Inventory; PEDI, Pediatric Evaluation of Disability Inventory; PPVT, Peabody Picture Vocabulary Test; RDLS, Reynell Developmental Language Scales; ROB,
risk of bias; SMD, standardized mean difference; SSC, Sense and Self-Regulation Checklist; SOL, sleep onset latency; SRS, Social Responsiveness Scale; SSP, Short Sensory Profile; TST, total
sleep time; VABS, Vineland Adaptive Behavior Scale; VSEEC, Vineland Social-Emotional Early Childhood Scales.

14

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Finally, in an RCT evaluating theeffects of a sensory integration-based
protocol on low-functioning children
with ASD, children receiving sensory
integration-based intervention had
significantly fewer parent-rated
sensory problems at follow-up thanchildren in the usual-care control
group.‍13

Studies of Environmental
Enrichment-based Approaches

Two small RCTs (low‍23 andmoderate‍22 risk of bias) ofenvironmental enrichment examined
the same protocol and reported
improvements in ASD symptoms,
receptive language, and nonverbal
cognitive skills after 6 months oftreatment (‍Table 3). Comparedwith usual care, children receiving
environmental enrichment had
a more significant decrease inclinician-rated ASD symptoms (P= .03) at the end of treatment in 1
RCT, with nearly 5 times as many
participants in the treatment group
showing clinically significant drops of≥5 points (42% vs 7%, P = .03).‍22 The
treatment group also had a 9-point
increase in nonverbal cognitive
skills compared with a decrease of∼3 points in the usual care group (P= .008). Both groups improved on
expressive language skills, with nosignificant differences.

A second RCT built on the
preliminary work by examining
use of the same sensorimotor
enrichment regimen over 6 months.‍23
The treatment groups, which
experienced significant attrition,
showed more improvement than
did the control group in receptive
language skills, but both groups
improved comparably for expressive
language. The treatment group had
significantly more improvement onmean nonverbal IQ scores as wellas parent-rated sensory reactivity.
Although more children in thetreatment group compared withthe control group shifted theirdiagnostic classification on theAutism Diagnostic Observation
Schedule-2 from “autism” to “autism
spectrum,​” all children across bothgroups continued to meet the cutoffs for ASD, making it difficult tointerpret the clinical significance ofthe findings.

Studies of Auditory Integrationbased Approaches

Two small, short-term RCTsof auditory integration-based
approaches (moderate risk of bias)
reported no significant differences
between groups in language
outcomes assessed on parent,teacher, and clinician observation
measures.‍14,​15‍ Two high risk ofbias RCTs (reported in a single
publication) reported significant
parent-rated improvements inhearing sensitivity and behavior(‍Table 3).‍26 One crossover RCT
comparing music passed throughan electronic ear for attenuationand modulation to commercially
produced music reported nostatistically significant treatment
effects on language skills.14 Another
RCT of auditory integration therapy
for children with significant language
delays reported no significant
benefits of auditory integration.‍15
Two RCTs examined the use offiltered music and reported someparent-rated improvement in hearing
sensitivity, spontaneous speech,
listening, and behavioral organization
after filtered music compared withchildren in the control condition (P≤ .05).‍26 Across both trials, groups
did not differ in the other behavioral
domains rated.

Studies of Music Therapy-based
Approaches

Five small studies (2 low,​‍30–‍ 32‍ 1
moderate,​‍25 and 2 high16,​33‍ risk ofbias) addressing music therapybased approaches reported somesignificant effects on measuresof behavior (social engagement,
behavioral organization), verbal
and nonverbal communication, andjoint attention (directing and sharing

attention to objects or events) withmusic-based intervention comparedwith control interventions (‍Table3). Studies used different protocols
and addressed different outcomes,
and thus, drawing conclusions acrossstudies is challenging.

One RCT (reported in 2 publications)compared a trainer-led rhythm andmovement-based approach, a robot
group focused on imitation, and acontrol group engaging in tabletop
activities.‍31,​32‍ Both rhythm and robot
treatment groups demonstrated
greater posttest attention to trainers
than to objects than did the control
group (P < .001), with greaterattention in the rhythm group than
the robot group (P < .001). The
rhythm group also demonstrated thegreatest duration of spontaneous
social attention, followed by the
robot group and the control group(P < .001). Children in the robot
group had greater self-directed
vocalization compared with theother groups (P < .002), whereas
children in the rhythm and control
groups had greater spontaneous
social verbalization to trainers than
did children in the robot group (P< .03). In another RCT, children
who received family-centered
music therapy plus early intensive
intervention had more improvement
than those receiving early intensive
intervention alone in parent-ratedsocial engagement (P < .001), but
remained significantly impaired
relative to typically developing
peers.‍25 Groups did not differ onparent-reported autism symptoms,
speech and language, or quality of theparent-child relationship.
In a crossover RCT comparing music
therapy and toy play, investigators
observed more joy, emotional
synchronicity, and initiation ofengagement during music therapy
than in play sessions. In addition,
children had significantly more
compliant behavior and significantly
fewer episodes of lack of responsein the music therapy condition.‍16

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15

Finally, 2 studies evaluating different
forms of music therapy comparedwith treatment as usual or notreatment reported no significant
group differences in outcome
measurements, including ASD
symptom severity and social skills at
follow-up.‍30,​33‍

Studies of Massage

Studies compared either massage
with no massage; massage plus
sensory integration-based treatment
versus sensory integration-based
treatment alone; and massage
plus attachment therapy versus
attachment therapy alone (‍Table
3). Almost all studies were from1 group of investigators, and theparticipant overlap is unclear.
Studies comparing massage tono massage generally reported
improvements related to sensory
processing, autism symptoms, andparent stress in both treatment
and control groups over the courseof 5 months of either parent- or
parent and therapist-delivered
intervention, with treatment groups
improving significantly more thancontrols. The difficulty differentiating
populations in these studies limits
the SOE for their findings, although
results seem promising regarding asensory-focused intervention thatcan be delivered within the homeenvironment with minimal risk ofharms.

Five studies‍17,​19,​‍ 24,​‍ 29,​‍ 35 (3 moderate‍19,​24,​
‍ 29
‍
17,​
3
5
and 2 high‍risk of bias) with
unclear participant overlap
compared children who received
massage to wait-listed controls
or those who received usualcare. Children receiving massage
improved significantly on parent
ratings of autism symptoms aswell as parent ratings of sensory
challenges and self-regulation skills
compared with children not receiving
massage (P ≤ .05).‍17,​19,​‍ 24‍ Gains
were maintained for 19 treatmentgroup participants whose parents
were available to provide data 5
16months posttreatment, but data were
unavailable on other participants.‍17
In a retrospective report, children
receiving either parent-deliveredor parent and therapist-delivered
massage had greater improvements
in tactile defensiveness, selfregulation skills, and parent stressthan did children not receiving
massage (P < .001).35 In 1 reportassessing parent and therapistdelivered massage, post-hoc analyses
revealed specific treatment effects
on parent-rated, but not clinicianrated, measures of autism symptoms,
receptive (but not expressive)
language, sensory processing, andparent stress improved more in thetreatment group compared withthe control group (P < .01). Groupdifferences in social and daily living
skills were not significant.‍29

One RCT (high risk of bias)
comparing sensory integrationbased therapy compared withsensory integration-based therapy
plus traditional Thai massage,
parent-rated measures of anxiety
and conduct improved in themassage group versus the control
group (P ≤ .03).‍18 Children in bothconditions had improved sleep aswell as teacher ratings of conduct,
attention, and activity level (P = NS).
One retrospective cohort study (highrisk of bias) investigating massage
therapy with and without attachment
therapy reported significant
improvements in social maturity inthe massage group compared with
attachment therapy alone (P = .005),
but measures of symptom severity
did not differ significantly between
groups.‍36

Additional Studies

Other interventions with sensoryrelated components reported limited
differences between treatmentgroups (‍Table 3). One RCT (highrisk of bias) examining the impactof a hands-on, tactile-based activity
on the ability to learn a novel task
reported greater perceived ease oflearning for children in the hands-on
participation group compared withchildren in the control, observationonly condition immediately
posttreatment (P values ≤ .05).‍28 In
another RCT (moderate risk of bias),
parents were more likely to rate
their children as calmer and sleeping
better when using a weighted
blanket (P ≤ .04), despite a lack ofphysiologic evidence to support this(no significant group differences inactigraphy measures).‍27 Investigators
reported that 1 child developed arash that may have been due to theblanket (resolved in 2 days).

SOE‍ able 4 outlines SOE ratings.
T
Sensory-related and motor skill
outcomes improved in children
receiving a sensory integrationbased intervention compared withthose receiving usual care or othertreatment (significant improvements
in 3 of 4 studies addressing theoutcome). We have low confidence
in these conclusions given thesmall sample sizes and short study
durations (low SOE). Similarly, we
have low confidence in the conclusionthat environmental enrichment
approaches improved nonverbal
cognitive skills (low SOE). Theseenrichment approaches did not affectexpressive language. We have low
confidence in this conclusion (lowSOE). We have low confidence in the
conclusion that auditory integrationbased approaches do not improve
language outcomes (low SOE).

Massage improved sensory
challenges and ASD symptom
severity compared with no massage.
Our confidence in this conclusion
is low (low SOE). Massage did not
improve maladaptive behavior (lowSOE). We could not make conclusions
about other comparisons, including
for music therapy or the effects ofsensory or auditory integrationbased approaches or massage onother outcomes, given the lack of data
(insufficient SOE).

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17

Study
Limitations

Consistency

High

Consistent

DirectDirectMassage Versus Waitlist Control
ASD symptom severity‍ 1 high‍17
RCT: 2 moderate,​‍24,​29(N = 191)

Consistent

DirectConsistent

DirectHigh

DirectConsistent

DirectAuditory Integration-based Approaches Versus Control
Language
High
Inconsistent‍ 1 high‍26
RCT: 2 moderate,​‍14,​15(N = 91)

Expressive language
RCT: 1 low,​‍23 1 moderate‍22(N = 78)

Motor skills
High
RCT: 1 low,​‍21 1 moderate‍20(N = 69)
Retrospective cohort: 1 high‍34(N = 20)
Environmental Enrichment Versus Usual Care
Nonverbal cognitive skills
High
RCT: 1 low,​‍23 1 moderate‍22(N = 78)

Retrospective cohort: 1 high‍34(N = 20)

Sensory Integration-based Approaches Versus Control Approaches
Sensory challenges
High
Inconsistent
RCT: 1 low,​‍21 1 moderate,​‍20 1high‍13 (N = 99)

Intervention/Outcome, Study
Design, Risk of Bias, and No. ofStudies, (N Total)

TABLE 4 SOE for Interventions Targeting Sensory Challenges
Directness

Imprecise

Imprecise

Imprecise

Imprecise

Imprecise

Imprecise

Precision

Undetected

Undetected

Undetected

Undetected

Undetected

Undetected

Reporting Bias

Low SOE for improvements in ASD symptom
severity with massage versus control inthe short term (<6 mo) Significant groupdifferences in all 3 studies; SOE is low given
unclear overlap in participants and high study
limitations.

Low SOE for lack of effects of auditory integration
approaches on language No group differences inoutcomes in 2 small crossover RCTs with shortterm follow-up; parent-rated improvements inspontaneous speech in treatment group versus
control in a third RCT.

Low SOE for positive effects of enrichment on IQ.
Significant improvements in IQ (Leiter Scale) inchildren receiving enrichment compared withthose receiving usual care in 2 small RCTs withshort-term follow-up and high limitations given
small sample size
Low SOE for lack of effect of enrichment on
expressive language. No group differences in
expressive language in 2 small RCTs with shortterm follow-up and high limitations given small
sample size.

Low SOE for positive effects of sensory integrationbased approaches on sensory challenges.
Significant improvements in sensory-related
behaviors in treatment groups compared with
control in 2 RCTs and 1 cohort study. No groupdifferences in third RCT on parent-reported
measure of sensory behaviors, but significant
improvement in treatment group in sensoryrelated goals; all studies were small andshort-term.
Low SOE for positive effects of sensory integration
on motor skills. Significant improvements intreatment groups versus control in 3 small
studies.

Finding SOE GradeDirect
ConsistentHigh

DirectConsistentHigh

We could not make conclusions about effects of music therapy, a tactile-based task, and weighted blankets given the number of studies addressing each intervention or outcome (insufficient SOE). We also could not make conclusions about otheroutcomes reported in studies of sensory integration-based approaches, auditory integration-based approaches, environmental enrichment, or massage given differences in outcome reporting (insufficient SOE).

Imprecise

Undetected

Low SOE for positive effects on sensory challenges
with massage versus control in the short term(<6 mo). Significant group differences in all
4 studies; SOE is low given unclear overlap inparticipants and high study limitations.
Low SOE for no effect on maladaptive behaviors
with massage versus control in the short term(<6 mo). No significant group differences in
2 studies; SOE is low given unclear overlap inparticipants and high study limitations
Undetected
ImpreciseFinding SOE Grade
Reporting Bias
Precision
Directness
Consistency
Study
Limitations

Intervention/Outcome, Study
Design, Risk of Bias, and No. ofStudies, (N Total)
Sensory challenges
RCT: 2 moderate,​‍24,​29‍ 1 high‍17 (N= 191)
Retrospective cohort: 1 high‍35(N = 129)
Maladaptive behaviors
RCT: 1 moderate,​‍24 1 high‍17 (N= 88)

TABLE 4 Continued
18

Discussion
We identified limited evidence
for positive effects of sensory
integration-based, environmental
enrichment, and massage
modalities. The lack of consistency
in implementation combinedwith generally small sample sizes(median sample size = 34 total) andlimited follow-up make it difficult todraw strong conclusions regarding
treatment efficacy. Populations
across studies were heterogeneousin terms of sensory challenges, ASD
severity, age, and intellectual andadaptive functioning. Interventions,even within our broader categories,
used differing sensory-specificapproaches in differing combinationsof components, settings, andduration, complicating our ability todraw conclusions across the body ofliterature. Longer-term outcomes arelimited as is our ability to determine
the effects of interventions on theunderlying sensory challenges
themselves. Potential harms ofinterventions were addressed in only
1 study, and few studies assessedfactors that may modify effectivenessor drive the effects of interventions.
Studies often used multicomponent
strategies, and teasing apart theeffects of specific components is not
currently possible. These limitationsin the evidence underscore theneed for caregivers and referring
providers to assess the possible
benefits of specific sensory-focusedintervention modalities based on theindividual needs of the child, broader
family goals and capacities, andinterventions of more establishedeffectiveness. In this capacity, some
practice groups have recommended
clear communication regarding thelimits of intervention.‍37,​38‍
Despite these limitations,investigators have made significant
improvements in incorporating
commonly used measures ofsymptom severity, behavior,language, and sensory difficulties
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Weitlauf et alstudies. Parent-reported outcomesare necessary in this populationof children, many of whom may
not be able to complete aspectsof assessments; however, studies
are increasingly incorporating
standardized interactive or
observational measurement
strategies. Moreover, an increasinguse of treatment fidelity measuresand replicable intervention protocols
establishes a promising baseline for
future investigations. Investigatorsin the area are also well aware of thechallenges of conducting researchusing a disparate and variously
defined set of approaches in a highly
heterogeneous population andhave made strides in incorporating
outcome measures that attempt
to balance heterogeneity andcomparative effectiveness andmeasures of intervention fidelity.‍39

Our findings generally alignwith recent previous reviewsof sensory-focused‍ –‍‍‍‍‍‍ 49‍ Previous reviews
interventions.‍6,​40
typically noted low to moderate
support for sensory integrationbased approaches and limited
evidence for other approaches.
Reviews differentiating sensory
integration approaches and moregeneral “sensory-based” approaches
reported better evidence from thosestudies that evaluated specific,
typically manualized, sensory
integration modalities compared‍with sensory-based approaches.‍3,​47
One review of auditory integration
approaches reported no evidence ofeffectiveness.‍41 One review of music
therapy reported promising findings
related to improvements in social
interaction and communication,​50
and 1 review addressing massage
reported that limited evidence
precluded conclusions.‍40 Previous
reviews also consistently noted
considerable heterogeneity, limited
study quality/high risk of bias,
limited follow-up, and lack oftreatment fidelity.

Limitations of the Review
We included studies published in
English only and did not include grayliterature. Based on a scan of nonEnglish publications, we concluded
that excluding non-English studies
would not introduce significant bias
into the review, and previous studies
have noted limited bias from suchexclusion.‍51–‍ 53‍ We also included only
comparative studies of interventions
with a sensory-specific focus andthat included at least 10 children
with ASD, and this undoubtedlymeans that most single-subject
design studies were not includedin this review. Single-subject
designs can be helpful in assessing
response to treatment in short timeframes and under tightly controlled
circumstances, but they typically do
not provide information on longerterm or functional outcomes.

As noted, other approaches tocategorizing sensory-focusedinterventions could also be used,
and widespread consensus on acategorization approach is lacking.
This review was also focused
specifically on children with ASD
and only on interventions targeting
sensory challenges. Sensory
approaches may be used withindividuals with other diagnoses,
and findings may be generalizable
to children with ASD. However,including studies of children withother conditions was beyond ourscope, as was inclusion of any
intervention approach (eg, primarily
behavioral or educational) reportinga sensory-related outcome. Finally,
we used a nonvalidated tool toassess risk of bias, although the toolevaluates similar constructs to those
assessed by tools such as that used by
the Cochrane Collaboration, with theaddition of ASD-specific domains.

Areas for Future Research

Several adjustments to study design
would strengthen our ability to draw
conclusions from future work. Many
sample sizes were small, limiting

their power to detect effects. Durationof treatment and follow-up weregenerally short, and the extent towhich the effects of therapies could be
expected to continue after cessation oftreatment is not clear. Although someapproaches may not hypothesize suchdurability, such data are neverthelessnecessary for guiding pragmatic
implementation and setting realistic
expectations of effects for clinicians
and families. In addition, few studies
adequately accounted for concomitantinterventions that might confoundobserved effectiveness.

Compared with our previous review,
more studies used a common set ofoutcome measures. The extent towhich these measures assess changes
in potential underlying sensoryrelated impairments remains
unclear, and understanding whether
intervention can alter underlying
vulnerabilities rather than shortterm behavioral responses is a
critical need. Translational work
to understand the relationshipbetween sensory symptoms and theirpotential neurobiology would inform
intervention design.
It will be important for future
work to compare sensorybased interventions not only totreatment as usual, but also to otherinterventions that involve engaged
and active time with an adult, as
did some studies in the current
review.‍21,​23,​‍ 36‍ Additional researchis needed that controls forenvironmental or social factorsthat could cloud our ability to draw
conclusions regarding effects. It
will be important to identify whichchildren are likely to benefit fromparticular interventions. To date,studies have provided limited
characterization of treatment
responders as well as the extent ortype of sensory challenges children
experience at baseline. Interventions
targeting sensory challenges by
their nature often employ multiple
components, but our understandingof which components may drive

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19

effectiveness is lacking. Component
analyses in this field would be
productive for refining intervention
approaches and for assessing thegeneralizability of results.

Conclusions
In sum, some interventions targeting
sensory challenges may yield modest
improvements, primarily in sensoryand ASD symptom severity-related
outcomes. However, the evidence basefor any category of intervention issmall, and the durability of the effects
beyond the immediate intervention
period is unclear. Sensory integrationbased approaches improved outcomes
related to sensory challenges andmotor skills, and studies of massage
reported improvements in sensory
responses and ASD symptoms.
Environmental enrichment was also
associated with improvements innonverbal cognitive skills in the shortterm. Auditory integration-based
approaches did not improve language
outcomes. Some positive effects wereassociated with other approaches
studied (music therapy, weighted
blankets), but findings in these small
studies were not consistent. Dataon longer-term results are lacking.
Although some therapies may holdpromise and warrant additional study,
substantial needs exist for continuing
improvements in methodologic rigor
in the field.

Acknowledgments
Dr Shanthi Krishnaswami and Ms
Jessica Kimber contributed to thedata extraction. We thank the fullresearch team and our Agency for
Healthcare Research and Quality taskorder officers and associate editor for
their input.

Abbreviations
ASD: a utism spectrum disorderDSM-5: D iagnostic and Statistical
Manual of Mental
Disorders, Fifth Edition
RCT: r andomized controlled trial
SOE: s trength of the evidence

helped to conceptualize and design the review, helped to acquire, analyze, and interpret data, and helped to draft the initial manuscript; and all authors approved
the final manuscript as submitted and agree to be accountable for all aspects of the work.
This project was funded under contract HHSA209201500003I from the Agency for Healthcare Research and Quality, US Department of Health and Human
Services. The authors of this manuscript are responsible for its content. Statements in the manuscript should not be construed as endorsement by the Agency
for Healthcare Research and Quality or the US Department of Health and Human Services. The Agency for Healthcare Research and Quality retains a license todisplay, reproduce, and distribute the data and the report from which this manuscript was derived under the terms of the agency’s contract with the author.
This manuscript was derived from a systematic review conducted by the Vanderbilt Evidence-based Practice Center, “Interventions Targeting Sensory Challenges
in Children With Autism Spectrum Disorder (ASD)—an Update,​” which will be published in full on the Agency for Healthcare Research and Quality Web site.
DOI: https://​doi.​org/​10.​1542/​peds.​2017-​0347
Accepted for publication Feb 10, 2017
Address correspondence to Amy S. Weitlauf, PhD, Department of Pediatrics, Vanderbilt Medical Center, Vanderbilt Kennedy Center, 230 Appleton Place, PMB 74,
Nashville, TN 37203. E-mail: amy.s.weitlauf@vanderbilt.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: All authors received funding for this project under Contract No. HHSA290201500003I from the Agency for Healthcare Research andQuality, US Department of Health and Human Services. No authors have any other financial or other disclosures relevant to this article.
FUNDING: This work was supported by the Agency for Healthcare Research and Quality (contract HHSA290201500003I).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: Companions to this article can be found online at www.​pediatrics.​org/​cgi/​doi/​10.​1542/​peds.​2017-​0346 and www.​pediatrics.​org/​cgi/​doi/​10.​
1542/​peds.​2017-​0730.

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Weitlauf et alInterventions Targeting Sensory Challenges in Autism Spectrum Disorder: A
Systematic Review
Amy S. Weitlauf, Nila Sathe, Melissa L. McPheeters and Zachary E. Warren
Pediatrics 2017;139;
DOI: 10.1542/peds.2017-0347 originally published online May 26, 2017;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A
Systematic Review
Amy S. Weitlauf, Nila Sathe, Melissa L. McPheeters and Zachary E. Warren
Pediatrics 2017;139;
DOI: 10.1542/peds.2017-0347 originally published online May 26, 2017;

The online version of this article, along with updated information and services, islocated on the World Wide Web at:
http://pediatrics.aappublications.org/content/139/6/e20170347

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by theAmerican Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN:.

Downloaded from http://pediatrics.aappublications.org/ by guest on November 4, 2017