Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration intervention.

OBJECTIVE: We developed a reliable and valid fidelity measure for use in research on Ayres Sensory Integration (ASI) intervention. METHOD: We designed a fidelity instrument to measure structural and process aspects of ASI intervention. Because scoring of process involves subjectivity, we conducted a series of reliability and validity studies on the process section. Raters were trained to score therapist strategies observed in video recordings of adult-child dyads. We examined content validity through expert ratings. RESULTS: Reliability of the process section was strong for total fidelity score (ICC = .99, Cronbach's alpha = .99) and acceptable for most items. Total score significantly differentiated ASI from four alternative interventions. Expert ratings indicated strong agreement that items in the structural and process sections represent ASI intervention. CONCLUSION. The Ayres Sensory Integration Fidelity Measure has strong content validity. The process section is reliable and valid when scored by trained raters with expertise in ASI.

Goal attainment scaling as a measure of meaningful outcomes for children with sensory integration disorders.

Goal attainment scaling (GAS) is a methodology that shows promise for application to intervention effectiveness research and program evaluation in occupational therapy (Dreiling & Bundy, 2003; King et al., 1999; Lannin, 2003; Mitchell & Cusick, 1998). This article identifies the recent and current applications of GAS to occupational therapy for children with sensory integration dysfunction, as well as the process, usefulness, and problems of application of the GAS methodology to this population. The advantages and disadvantages of using GAS in single-site and multisite research with this population is explored, as well as the potential solutions and future programs that will strengthen the use of GAS as a measure of treatment effectiveness, both in current clinical practice and in much-needed larger, multisite research studies.

Fidelity in sensory integration intervention research.

OBJECTIVE: We sought to assess validity of sensory integration outcomes research in relation to fidelity (faithfulness of intervention to underlying therapeutic principles). METHOD: We identified core sensory integration intervention elements through expert review and nominal group process. Elements were classified into structural (e.g., equipment used, therapist training) and therapeutic process categories. We analyzed 34 sensory integration intervention studies for consistency of intervention descriptions with these elements. RESULTS: Most studies described structural elements related to therapeutic equipment and interveners' profession. Of the 10 process elements, only 1 (presentation of sensory opportunities) was addressed in all studies. Most studies described fewer than half of the process elements. Intervention descriptions in 35% of the studies were inconsistent with one process element, therapist-child collaboration. CONCLUSION: Validity of sensory integration outcomes studies is threatened by weak fidelity in regard to therapeutic process. Inferences regarding sensory integration effectiveness cannot be drawn with confidence until fidelity is adequately addressed in outcomes research.

A multisensory zone in rat parietotemporal cortex: intra- and extracellular physiology and thalamocortical connections.

Multisensory integration is essential for the expression of complex behaviors in humans and animals. However, few studies have investigated the neural sites where multisensory integration may occur. Therefore, we used electrophysiology and retrograde labeling to study a region of the rat parietotemporal cortex that responds uniquely to auditory and somatosensory multisensory stimulation. This multisensory responsiveness suggests a functional organization resembling multisensory association cortex in cats and primates. Extracellular multielectrode surface mapping defined a region between auditory and somatosensory cortex where responses to combined auditory/somatosensory stimulation were larger in amplitude and earlier in latency than responses to either stimulus alone. Moreover, multisensory responses were nonlinear and differed from the summed unimodal responses. Intracellular recording found almost exclusively multisensory cells that responded to both unisensory and multisensory stimulation with excitatory postsynaptic potentials (EPSPs) and/or action potentials, conclusively defining a multisensory zone (MZ). In addition, intracellular responses were similar to extracellular recordings, with larger and earlier EPSPs evoked by multisensory stimulation, and interactions suggesting nonlinear postsynaptic summation to combined stimuli. Thalamic input to MZ from unimodal auditory and somatosensory thalamic relay nuclei and from multisensory thalamic regions support the idea that parallel thalamocortical projections may drive multisensory functions as strongly as corticocortical projections. Whereas the MZ integrates uni- and multisensory thalamocortical afferent streams, it may ultimately influence brainstem multisensory structures such as the superior colliculus.

An exploratory event-related potential study of multisensory integration in sensory over-responsive children.

Children who are over-responsive to sensation have defensive and "fight or flight" reactions to ordinary levels of sensory stimulation in the environment. Based on clinical observations, sensory over-responsivity is hypothesized to reflect atypical neural integration of sensory input. To examine a possible underlying neural mechanism of the disorder, integration of simultaneous multisensory auditory and somatosensory stimulation was studied in twenty children with sensory over-responsivity (SOR) using event-related potentials (ERPs). Three types of sensory stimuli were presented and ERPs were recorded from thirty-two scalp electrodes while participants watched a silent cartoon: bilateral auditory clicks, right somatosensory median nerve electrical pulses, or both simultaneously. The paradigm was passive; no behavioral responses were required. To examine integration, responses to simultaneous multisensory auditory-somatosensory stimulation were compared to the sum of unisensory auditory plus unisensory somatosensory responses in four time-windows: (60-80 ms, 80-110 ms, 110-150 ms, and 180-220 ms). Specific midline and lateral electrode sites were examined over scalp regions where auditory-somatosensory integration was expected based on previous studies. Midline electrode sites (Fz, Cz, and Pz) showed significant integration during two time-windows: 60-80 ms and 180-220 ms. Significant integration was also found at contralateral electrode site (C3) for the time-window between 180 and 220 ms. At ipsilateral electrode sites (C4 and CP6), no significant integration was found during any of the time-windows (i.e. the multisensory ERP was not significantly different from the summed unisensory ERP). These results demonstrate that MSI can be reliably measured in children with SOR and provide evidence that multisensory auditory-somatosensory input is integrated during both early and later stages of sensory information processing, mainly over fronto-central scalp regions.

Parasympathetic functions in children with sensory processing disorder.

The overall goal of this study was to determine if parasympathetic nervous system (PsNS) activity is a significant biomarker of sensory processing difficulties in children. Several studies have demonstrated that PsNS activity is an important regulator of reactivity in children, and thus, it is of interest to study whether PsNS activity is related to sensory reactivity in children who have a type of condition associated with sensory processing disorders termed sensory modulation dysfunction (SMD). If so, this will have important implications for understanding the mechanisms underlying sensory processing problems of children and for developing intervention strategies to address them. The primary aims of this project were: (1) to evaluate PsNS activity in children with SMD compared to typically developing (TYP) children, and (2) to determine if PsNS activity is a significant predictor of sensory behaviors and adaptive functions among children with SMD. We examine PsNS activity during the Sensory Challenge Protocol; which includes baseline, the administration of eight sequential stimuli in five sensory domains, recovery, and also evaluate response to a prolonged auditory stimulus. As a secondary aim we examined whether subgroups of children with specific physiological and behavioral sensory reactivity profiles can be identified. Results indicate that as a total group the children with severe SMD demonstrated a trend for low baseline PsNS activity, compared to TYP children, suggesting this may be a biomarker for SMD. In addition, children with SMD as a total group demonstrated significantly poorer adaptive behavior in the communication and daily living subdomains and in the overall Adaptive Behavior Composite of the Vineland than TYP children. Using latent class analysis, the subjects were grouped by severity and the severe SMD group had significantly lower PsNS activity at baseline, tones and prolonged auditory. These results provide preliminary evidence that children who demonstrate severe SMD may have physiological activity that is different from children without SMD, and that these physiological and behavioral manifestations of SMD may affect a child's ability to engage in everyday social, communication, and daily living skills.

Perspectives on sensory processing disorder: a call for translational research.

THIS ARTICLE EXPLORES THE CONVERGENCE OF TWO FIELDS, WHICH HAVE SIMILAR THEORETICAL ORIGINS: a clinical field originally known as sensory integration and a branch of neuroscience that conducts research in an area also called sensory integration. Clinically, the term was used to identify a pattern of dysfunction in children and adults, as well as a related theory, assessment, and treatment method for children who have atypical responses to ordinary sensory stimulation. Currently the term for the disorder is sensory processing disorder (SPD). In neuroscience, the term sensory integration refers to converging information in the brain from one or more sensory domains. A recent subspecialty in neuroscience labeled multisensory integration (MSI) refers to the neural process that occurs when sensory input from two or more different sensory modalities converge. Understanding the specific meanings of the term sensory integration intended by the clinical and neuroscience fields and the term MSI in neuroscience is critical. A translational research approach would improve exploration of crucial research questions in both the basic science and clinical science. Refinement of the conceptual model of the disorder and the related treatment approach would help prioritize which specific hypotheses should be studied in both the clinical and neuroscience fields. The issue is how we can facilitate a translational approach between researchers in the two fields. Multidisciplinary, collaborative studies would increase knowledge of brain function and could make a significant contribution to alleviating the impairments of individuals with SPD and their families.

Physiological and behavioral differences in sensory processing: a comparison of children with autism spectrum disorder and sensory modulation disorder.

A high incidence of sensory processing difficulties exists in children with Autism Spectrum Disorder (ASD) and children with Sensory Modulation Disorder (SMD). This is the first study to directly compare and contrast these clinical disorders. Sympathetic nervous system markers of arousal and reactivity were utilized in a laboratory paradigm that administered a series of sensory challenges across five sensory domains. The Short Sensory Profile, a standardized parent-report measure, provided a measure of sensory-related behaviors. Physiological arousal and sensory reactivity were lower in children with ASD whereas reactivity after each sensory stimulus was higher in SMD, particularly to the first stimulus in each sensory domain. Both clinical groups had significantly more sensory-related behaviors than typically developing children, with contrasting profiles. The ASD group had more taste/smell sensitivity and sensory under-responsivity while the SMD group had more atypical sensory seeking behavior. This study provides preliminary evidence distinguishing sympathetic nervous system functions and sensory-related behaviors in Autism Spectrum Disorder and Sensory Modulation Disorder. Differentiating the physiology and sensory symptoms in clinical groups is essential to the provision of appropriate interventions.

Multisensory integration in children: a preliminary ERP study.

The spatio-temporal scalp distribution of multisensory auditory-somatosensory integration was investigated in typically developing children ages 6-13. Event-related potentials were recorded from 32 scalp electrodes while participants watched a silent cartoon. Three types of sensory stimulation were presented pseudo-randomly: auditory clicks, somatosensory median nerve electrical pulses, or simultaneous auditory and somatosensory stimuli. No behavioral responses were required of the participant. To examine integration, responses to simultaneous auditory and somatosensory stimulation were compared to the sum of unisensory auditory plus unisensory somatosensory responses for four time-windows: (60-80 ms, 80-110 ms, 110-150 ms and 180-220 ms). Results indicated significant multisensory integration occurred in central/post-central scalp regions between 60-80 ms in the hemisphere contralateral to the side of somatosensory stimulation and between 110-150 ms in the hemisphere ipsilateral to the side of somatosensory stimulation. Between 180-220 ms, significant multisensory integration was evident in central/post-central regions in both hemispheres as well as midline scalp regions. This study suggests that children exhibit differential processing of multisensory compared to unisensory stimuli, as has previously been reported in adults.

Effects of ventrobasal lesion and cortical cooling on fast oscillations (>200 Hz) in rat somatosensory cortex.

High-frequency oscillatory activity (>200 Hz) termed "fast oscillations" (FO) have been recorded in the rodent somatosensory cortex and may reflect very rapid integration of vibrissal information in sensory cortex. Yet, while electrophysiological correlates suggest that FO is generated within intracortical networks, contributions of subcortical structures along the trigeminal pathway remain uncertain. Using surface and laminar electrode arrays, in vivo recordings of vibrissal and electrically evoked FO were made within somatosensory cortex of anesthetized rodents before and after ablation of the ventrobasal thalamus (VB) or during reversible cortical cooling. In VB-lesioned animals, vibrissal stimulation failed to evoke FO, while epicortical stimulation in lesioned animals remained effective in generating FO. In nonlesioned animals, cortical cooling eliminated vibrissal-evoked FO despite the persistence of thalamocortical input. Vibrissal-evoked FO returned with the return to physiological temperatures. Results from this study indicate that somatosensory cortex alone is able to initiate and sustain FO. Moreover, these data suggest that cortical network interactions are solely responsible for the generation of FO, while synchronized thalamocortical input serves as the afferent trigger.

Two distinct regions of secondary somatosensory cortex in the rat: topographical organization and multisensory responses.

In rodents, as in other species, regions of secondary somatosensory cortex (SII) may be distinguished from primary cortex (SI) both anatomically and electrophysiologically. However, the number of rodent SII subregions, their somatotopic organization, and their function are poorly understood. The presence of multisensory responsive neurons in some areas of SII suggests that one of its roles may be in the integration of somatosensory information with information from other sensory modalities. In this study, we used auditory, somatosensory, or combined auditory/somatosensory stimuli, and high-resolution epipial-evoked potential maps of rat SII to identify the number of spatially discrete subregions, estimate their somatotopic organization, and delineate regions with multisensory response properties. Maps revealed two distinct subregions within SII, one rostral and the other caudal, which were situated lateral to the posteromedial barrel subfield. Distinct somatotopies were evident at both SII loci, and analysis of evoked responses within both areas indicated multisensory interactions. These data are consistent with the presence of classically defined rostral SII regions and provide functional evidence for a lesser known, but distinct, caudal SII area. Furthermore, evidence for multisensory interactions within SII suggests that both secondary areas may process features specifically associated with multisensory integration in parallel with unimodal processing in primary areas.