Sensory Therapies

Sensory therapies with people with severe and profound intellectual disabilities in popularity have increased since the mid-1990s. There are two main reasons for the increase. First, these individuals have relatively little language and sensory therapies do not require speech. Second, advocates of sensory therapy have noted that people with developmental disabilities are at greater risk for sensory and proprioceptive disorders and handicaps than the general population. There are a variety of sensory therapies that have been developed. They include sensory integration therapy (SIT), auditory integration therapy (AIT) and Snoezelen.

Sensory Integration Therapy

Sensory integration therapy is based on the hypothesis that some people with intellectual disabilities have a sensory deprivation and that maladaptive behaviours provide that missing stimulation. For example, self-injury might provide self-stimulation to the skin, muscles and joints. Sensory integration therapy is needed to provide this missing stimulation through massage, stimulation of the skin with brushing exercises and stimulation of the joints through deep massage and manipulation.

This approach has been extensively evaluated. Indeed, Vargas & Camilla (1999) conducted a meta-analysis of 16 SIT outcome studies. The overall effect size (ES) was small (ES = 0.290). Earlier, less well controlled studies reported larger ESs of 0.6. However, more recent, better controlled studies had effect sizes of essentially zero (0.09). Vargas and Camilla's meta-analysis appears to be a replication of the old phenomenon that novel poorly evaluated treatments appear to be promising, but often these promising effects disappear upon careful evaluation and appropriate control conditions.

Mason & Iwata (1990) evaluated the effects of SIT on three persons who displayed self-injurious behaviour (SIB). Analogue baselines indicated that in one subject SIB was maintained by attention. The rate of SIB depended upon the attention being either withheld or provided non-contingently during SIT. The second subject, whose SIB was maintained by automatic reinforcement, showed a systematic increase in the SIB during SIT. The third subject's SIB function to escape task demands. There was no difference in SIB during baselines with no demands and SIT sessions when there was also no demands. Mason & Iwata (1990) went on to compare SIT with differential reinforcement, which presumably did not provide additional sensory stimulation. For all three participants SIB was effectively reduced by reinforcement methods.

Lindsay et al. (1997, 2001) conducted a comparison of hand massage, physical therapy, Snoezelen and relaxation therapy with eight subjects using a counter balanced, crossover design. They found that hand massage and active therapy either produced no improvements in a range of measures or were mildly aversive.

These studies demonstrate that there is no evidence that SIT is an effective treatment. The last author has commonly observed the practice of providing SIT activities contingent upon maladaptive behaviours, rather than on a time-based schedule as SIT. Hence, it is possible that inappropriate application of SIT might inadvertently promote maladaptive behaviours in some persons with intellectual disabilities. At this time there are no data on this phenomenon, and hence it is unclear how commonly this occurs.

Auditory Integration Training

Auditory integration therapy (AIT) was based on the theory that behaviour problems in some people were due to supersensitivity to certain tones. Behaviour problems can be alleviated by dampening down these supersensitivities. In AIT, participants listen to 10 hours of modified music via headphones. Specific frequencies that the person is sensitive to are filtered out in order to reduce these hypothesised super-sensitivities.

Mudford et al. (2000) reported a double blind, crossover trial of AIT in 16 children with autism. Measures included parent and teacher ratings of behaviour, direct observational recordings, IQ, language and social/adaptive tests. The control condition was superior to AIT on parent behavioural measures. No significant differences were found on teacher measures. Parents could not detect when their children started on the AIT. There is no evidence that AIT reduces challenging behaviour and there are no reports of AIT causing harm to participants. However, the first author recalls that, during his training in the early 1970s, an outside expert attended a ward to review a multiply handicapped blind deaf young woman. During the course of the review he played excessively loud music through headphones in order to ascertain her sensitivity to sound and vibration. The woman became extremely excited by this procedure, which pleased the assessor because he had found some responsiveness and sensitivity in the woman. That evening, she bit through her bottom lip, permanently disfiguring her face. It seemed to the author at the time that it may have been a result of the stimulation that afternoon.

Music Therapy

Auditory integration therapy should not be confused with music therapy, for which there are some indications of modest individual benefits. Hooper & Lindsay (1990) and Hooper, Lindsay & Richardson (1991), using experimental designs borrowed from applied behaviour analysis, have shown improvements in interactional skills and reduction in behaviour problems during and after individual and group music therapy sessions. These changes were modest, but were not evident in a non-directive control condition, drinking tea with the therapist. However the experimental designs were not sufficiently robust and one cannot conclude that music therapy had any specific impact on behaviour.


By far the most multi-sensory intervention is Snoezelen. The rationale is that it provides pleasant sensory experiences to promote relaxing leisure activities for individuals. It has been suggested that maladaptive behaviours, motivated by sensory consequences might decrease by the provision of sensory stimulation provided by Snoezelen. The multi-sensory environment (MSE) is designed with apparently pleasant sounds, lights and smells provided by special equipment such as fibre optic curtains, bubble tubes, the sound of water and birds and so on. The enabler (staff person) interacts with each participant in turn so that each participant receives equal time interacting with the enabler. The enabler assists the clients to have pleasant, enjoyable experiences with the MSE by interacting with the clients frequently. It has been hypothesised that Snoezelen might reduce maladaptive behaviours such as aggression and stereotypies and might improve mood and attention (Hulsegge & Verheul, 1987).

Several uncontrolled studies have suggested that persons with mental retardation might benefit from Snoezelen in some of the ways described above (Ashby et al., 1995; DeBunsen,

1994; Hagger & Hutchinson, 1991). However, all of these studies lacked control conditions, and used non-blind measurement or retrospective data collection. Lindsay etal. (1997,2001) in the study already described above found that although there were improvements in rated enjoyment and relaxation in the Snoezelen condition, they were no greater than those in the relaxation condition which was considerably less expensive to implement. Meijs-Roos (1990) in a study of six individuals found no effects from Snoezelen exposure on affective behaviour, stereotypies and other challenging behaviours. The best controlled study is that of Martin, Gaffan & Williams (1998) in which 27 adults with severe or profound intellectual disability participated. The two conditions evaluated were Snoezelen and a control condition. The control condition consisted of a similar shaped and sized room without the equipment, but with the enabler present interacting with the client non-contingently for an equal time. Observational data were collected on challenging behaviours outside the MSE and control conditions. No effects of MSE over the control condition was found on any measure. There was no evidence that challenging behaviours motivated by access to sensory stimulation reduced more than any other kinds of challenging behaviour.

Hogg et al. (2001) reviewed 16 publications on Snoezelen (there were 18 papers but two reported on data already published in other reports). Only seven studies adhered to recognisable research designs presenting their data in a clear fashion. They concluded that reports of positive effects of Snoezelen settings tended to occur in less formal studies and in more carefully designed studies the effects of Snoezelen were no greater than other sensory experiences. There was no substantive demonstration that the effects either generalised across situations or maintained over time. Hogg et al. (2001) are understanding in the difficulties experienced by those who wished to evaluate the effects of Snoezelen but still conclude that 'on the present balance of evidence, the use of Snoezelen as a first choice for dealing with challenging behaviours must be viewed as highly questionable' (Hogg et al., 2001, p. 370). In the light of evidence reviewed previously for the robust effects of other psychological therapies, this conclusion can only be judged as benign.


The evidence demonstrates that sensory interventions are ineffective and sometimes causes increases in behavioural problems. It is possible that, depending on the function of SIB, the extra sensory input might inadvertently increase SIB or other challenging behaviours for some participants. Providing additional stimulation for persons who are already over aroused may be aversive and set the occasion for escape from that stimulation. Sensory interventions may also set the occasion for high rates of interaction or demands, or be an occasion when there are high rates of interaction. All of these mechanisms might increase escape motivation or attention maintained behaviour. We therefore urge caution because sensory input might sometimes cause harm to some participants. It may be that there are indeed groups of participants who benefit from extra sensory input but at this time we have no reliable method for evaluating who these participants might be.

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