Objective.

The purpose of this study was to find whether

A Meta-Analysis of existing studies of treatment using sensory integration
approaches support the efficacy of these approaches.
Research on Sensory Method. With meta-analysis, the results of sensory
integration efficacy researchstudies published from 1972 to
Integration Treatment the present were synthesized and analyzed. Sixteen studies
were used to compare sensory integration effect with no
treatment (SI/NT), and 16 were used to compare sensory
integration effect with alternative treatments (SI/ALT).
Sadako Vargas, Gregory Camilli Overall average effect sizes, comparisons of the effect sizes
for different dependent variables, and secondaryfactors
Key Words: outcome studies quantitative 9
associated with effect size variation were examined.
Results. The weighted average effect size of SI/NT
method studies was .29. However, there was a significant difference
between the average effect sizes of the earlier studies (. 60)
and the more recent studies (. 03). O f the outcome measures,
larger effect sizes werefound in the psychoeducational cate-
gory (.39) and motor category (.40). Of SI/ALT studies, the
average effect size was. 09, not significantly different from
zero.
Conclusion. Three central conclusions can be made.
First, in the SI/NT comparison, a significant effect was
replicatedfor sensory integration treatment effects in earlier
studies, but more recent studies did not show overallposi-
tive effects. Second, larger effect sizes werefound in psycho-
educational and motor categories. Third, sensory integra-
tion treatment methods werefound to be as effective as
various alternative treatment methods.

Vargas, S., & Camilli, G. (1999). A meta-analysis of research on

sensory integration treatment. AmericanJournal of Occupational
Therapy, 53, 189-198.

reatment using sensory integration approaches has

T gained popularity among parents as an effective

approach to remediation, especially in pediatrics.
However, the concept of sensory integration has been the
subject of criticism and controversy in the fields of
neuropsychology, education, and medicine (Committee on
Children With Disabilities, 1985; Hoehn & Baumeister,
1994; Lerer, 1981). Some professionals support and appre-
ciate the value of sensory integration approaches, whereas
others consider them to be "demonstratively ineffective"
methods of intervention (Hoehn & Baumeister, 1994).
Treatment sessions are costly and often last more than
1 year. Thus, an evaluation of the efficacy of sensory inte-
Sadako Vargas, EdD,OTR,BCP,is Assistant Professor, gration treatment approaches is important from ethical,
Occupational Therapy Department, Kean University of New financial, and rehabilitative points of view. The major topics
Jersey, 311 Willis, Union, New Jersey 07083.
that need to be examined are the efficacy of sensory inte-
Gregory Camilli, PhD, is Associate Professor and Chair, gration treatment approaches (a) compared with other
Educational PsychologyDepartment, Graduate School of intervention strategies, (b) in different behavioral domains,
Education, Rutgers, The State University of New Jersey, New and (c) for different diagnostic and age groups. This article
Brunswick, New Jersey. reviews literature on efficacy studies of sensory integration
treatment approaches and provides a meta-analysis ofstudies
This article was acceptedfor publication August 18, 1998.
from 1972 to 1994.

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 Literature Review published between 1972 and 1976 that Ottenbacher
Of the five literature reviews of efficacy of sensory integra- (1982) included in his meta-analysis and identified a num-
tion treatment approaches that have previously appeared, ber of threats to internal validity. Schaffer listed the
only Ottenbacher's (1982) was a meta-analysis. In the methodological flaws as (a) inadequate sampling and
remaining four studies--Arendt, MacLean, and matching procedures, (b) lack of definitions of the subject
Baumeister(1988), Hoehn and Baumeister (1994), Polatajko, population, (c) potential Hawthorn effects, (d) erroneous
Kaplan, and Wilson (1992), and Schaffer (1984)--the use of gain scores, (e) potential tester bias, and (f) absence
reviewers conducted traditional literature reviews, deriving of information regarding reliability and validity of mea-
their conclusions from logical and critical analyses of pub- sures. A similar claim was made by Arendt et al. (1988),
lished efficacy studies. Ottenbacher's review examined eight who reviewed eight studies published between 1977 and
experimental studies published between 1972 and 1981 1983 on the efficacy of sensory integration treatment
with respect to sensory integration efficacy. Each study was approaches with subjects with mental retardation. Though
coded in terms of(a) subject type; (b) design characteristics, all but one of these studies reported positive gains, the
including subject selection and assignment, total hours of authors found that the studies (a) did not use blinding pro-
treatment, and dependent variables; (c) statistical out- proceduresfor observers, (b) lacked information on interobserver
comes; and (d) publication location, year, and source. The server agreement, and (c) did not control for subjects' het-
eight studies reported 47 outcome measures, each with an erogeneity.
associated statistical test. The mean effect size was .79 across Polatajko et al. (1992) reviewed seven studies pub-
all outcome measures, p < .001. These outcomes were then lished after 1979 pertaining to academic performance of
broken down separately for dependent variable types children with learning disabilities. They examined effect
(motor or reflex performance, academic performance, lan- sizes of the variables that were most likely to have reason-
guage function) and subject type (mental retardation, able effects, with p values between .05 and .20, and found
learning disability, aphasia, at risk). the sensory integration effect sizes to be small. The post hoc
For the dependent variable classes, the mean effect size power analysis with effect sizes of this magnitude suggested
was 1.03 for the motor-reflex variables, .75 for the acade- that larger samples than those used by these studies would
mic performance variables, and .43 for the language vari- have been required to attain significance. Polatajko et al.
ables. Comparing the sensory integration effect among the also found that although multiple hypothesis tests were
diagnostic groups, the mean effect sizes were .52 for the performed in these studies, the impact of sensory integra-
subjects with mental retardation, .68 for the subjects with tion treatment approaches achieved significance in only a
learning disabilities, and 1.20 for subjects with aphasia or few instances. Of nine hypothesis tests having a reading-
who were at risk. On the basis of these findings, related outcome, only one positive result was obtained that
Ottenbacher(1982) concluded that sensory integration treat- favored the sensory integration treatment group. For math-
ment approaches had a positive impact when applied to the mathematicalability, only one of six hypothesis tests achieved
populations investigated. However, Hoehn and Baumeister significance at the .05 level, favoring the sensory integra-
(1994) criticized Ottenbacher's meta-analysis for both tion treatment group. These authors also questioned the
the inadequacies of the original (primary) studies and for validity and sensitivity of the measures used to assess treat-
the method of analysis. The latter criticism focused on the ment effects.
problem of data nonindependence due to the use of out- Hoehn and Baumeister (1994) examined seven studies
come as the unit of analysis and the exclusion of studies published after 1981of treatment using sensory integration
with alternative treatment control groups. To date, no study approaches with children with learning disabilities. They
has attempted to replicate Ottenbacher's meta-analysis. examined experimental effect in four categories: (a) post-
Of the four traditional literature reviews, three exam- rotary nystagmus; (b) sensorimotor, perceptual, and motor
ined efficacy studies of sensory integration treatment measures; (c) cognitive, language, and academic measures;
approaches with subjects with learning disabilities (Hoehn and (d) self-esteem or self-concept, attention, and behav-
& Baumeister, 1994; Polatajko et al., 1992; Schaffer, ioral measures but found only a few instances of notable
1984), and one examined efficacy with subjects with men- effects for sensory integration therapy.
mentalretardation (Arendt et al., 1988). All concluded that This persistent criticism of sensory integration treat-
there was insufficient evidence to support the efficacy of ment approaches warrants a quantitative analysis of all the
sensory integration treatment approaches but differed in sensory integration efficacy studies published up to the
their analytic approaches and rationales for the conclu- present (i.e., 1995) to help resolve questions of efficacy.
sions. Supportive evidence for sensory integration treat-
Meta-Analysis Review Procedure
ment approaches was substantially weakened by inadequate
experimental design. Literature Search
Schaffer (1984) reviewed five early studies by Ayres A literature search was conducted for studies published

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from 1972 (when the sensory integration theory was intro- studies, and laboratory-type stimulation studies were not
duced) through 1994 with computer search systems included in the analysis. The variations of implementation
(ERIC, PsychoLit, MEDLINE, Dissertation Abstracts), and quality of the treatment using sensory integration
manual searches through article bibliographies, personal approaches were coded, and their effects were investigated.
contact with authors, and consultation With the Sensory Twenty-two articles by 19 authors met the selection criteria.
Integration International Association. The key terms used
for the search were sensory integration, sensory integration Definition of a Study
therapy, sensory stimulation, vestibular stimulation, praxis, The unit of analysis was the primary study, which was
motor planning, learning disability, mental retardation, devel- defined as an experiment with one treatment and one com-
opmental delay, aphasia, speech and language disorder, and parison group. However, several other conventions were
mental disorder. A total of 76 published articles and 5 mas- used. First, an experiment was counted as two studies when
ters' theses were found that reported results of sensory inte- the performance of one experimental group was compared
gration efficacy. with two different comparison groups (e.g., sensory in-
The collected studies were subjected to the following tegration and alternative treatment); however, sensory inte-
inclusion criteria: that they (a) investigated the effect of gration effect with no treatment (SI/NT) and sensory
treatment using sensory integration approaches; (b) report- integration effect with alternative treatments (SI/ALT)
ed a comparison of at least two conditions; (c) reported studies were analyzed separately. Second, when two differ-
findings and results in a manner that allowed quantitative ent articles presented different outcome measures of the
analysis; and (d) reported the outcome measures in the same experiment, the results were combined into one study
broad categories of academic skills, motor function, behav- (e.g., Humphries, Snider, & McDougall, 1993; Hum-
ior, language function, and sensorimotor function. Sensory Humphries,Wright, Snider, & McDougall, 1992).
integration treatment was operationally defined as a treat- The literature selection resulted in 14 articles con-
ment that aimed to enhance development of basic sensory tributing 16 SI/NT comparison studies and 11 articles
integration processes with activities that provide vestibular, contributing 16 SI/ALT comparison studies (see Table 1).
proprioceptive, tactile, or other somatosensory inputs as The sample sizes for each group ranged from 6 to 78 in the
modalities to elicit adaptive body responses. The activities SI/NT studies and 5 to 35 in the SI/ALT studies. For the
were typically client directed, with active participation of SI/NT studies, the total numbers of participants were 341
the person being treated. Case studies, single-group design in the experimental groups and 237 in the control groups,

Table 1
Studies Used for the Meta-Analysis
Reference Diagnosis Comparison Dependent Variable Category N
Ayres (1972)1 Learning disability SI/NT P 4
Ayres (1972) 2 Learning disability SI/NT P 4
Ayres (1977) Learning disability SI/NT S 2
Ayres (I 978) Learning disability SI/NT P 1
Bailey (1978) Psychiatric (adult) SI/NT L 3
Brody, Thomas, and Brody (1977) Mental retardation (adult) SI/ALT/ALT L 4
Bullock and Watter (1978) Minor brain dysfunction SI/NT M 1
Carte, Morrison, Sublett, Uemura, and Setrakian (1984), Learning disability SI/NT P, S 12
Carte et al. (1984)2 Learning disability SI/NT P, S 12
Close, Carpenter, and Cibiri (1986) Mental retardation (adult) SI/NT B, L, M, S 10
Densem, Nuthall, Bushnell, and Horn (1989) Learning disability SI/NT/ALT L, M, P, S 20
DePauw (1978) Aphasia SI/NT/ALT M, S 12
Grimwood and Rutherford (1980) At risk SI/NT P 1
Huff and Harris (1987) Mental retardation (adult) SI/NT M 1
Humphries, Wright, McDougall, and Vertes (1990) Learning disability SI/NT/ALT L, M, P, S 18
Humphries, Wright, Snider, and McDougall (1992) and Learning disability SI/NT/ALT B, L, M, P, S 58
Humphries, Snider, and McDougall (1993)
Jenkins, FeweIl, and Harris (1983)1 Motor delay SI/ALT M 2
Jenkins et al. (1983)2 Motor delay SI/ALT M 2
Montgomery and Richer (1977) Mental retardation (child) SI/ALT/ALT M 6
Morrison and Pothier (1972) Mental retardation (child) SI/ALT/ALT B, L, M 8
Polatajko, Law, Miller, Schaffer, and Macnab (1991) Learning disability SI/ALT B, M, P 7
Schroeder (1982) Learning disability SI/ALT/ALT L, S 6
Werry, Scaletti, and Mills (1990) Learning disability SI/NT B, L, M, P, S 15
White (1979) Learning disability SI/NT P 2
Wilson, Kaplan, Fellowes, Gruchy, and Faris (1992) Learning disability SI/ALT B, M, P, S 19
Ziviani, Poulsen, and O'Brien (1982) Learning disability SI/NT M, P 4
Note. N= 234. Subscripts (1, 2) after the reference indicate that two studies were reported in one article. SI = sensory integration; NT = no treatment; ALT =
alternative treatment; B = behavior; L = language; M = motor; P = psychoeducational; S = sensory-perceptual.

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 whereas the corresponding sample sizes in SI/ALT com- negligible differences were found. Second, this
parisons were 250 in the experimental groups and 191 in dichotomization enabled parallel analysis across all inde-
the control groups. The female-male ratio was approxi- pendent variables, especially in regard to obtaining and
mately 1 to 6 for children and about 1 to 1 for adults. interpreting Q statistics.
Differential scores by gender were not reported in the Quality of treatment usingsensoryintegration approaches.
StUdies. The treatment methods were first coded according to the
criteria for using sensory integration approaches in treat-
Measurement Variables ment established by Ayres and her colleagues (Kimball,
A total of 264 outcome measures was reported in the 24 1988), and the list of sensory integration treatment quality
primary studies for which 228 effect sizes were calculated: indicators was constructed by collapsing the multiple crite-
122 effect sizes for the SI/NT analysis and 106 for the ria into one scale. Points were assigned to each treatment
SI/ALT analysis. To minimize the number of the depen- method according to the sensory integration treatment
dent variables, the outcome measures were classified into quality indicators. The points assigned ranged from 3 (low
five categories: psychoeducational, behavior, language, quality) to 11 (high quality). High sensory integration qual-
motor, and sensory-perceptual (see Table 2). To help reduce ity indicated that the treatment adhered closely to the estab-
subjective bias, the classification task was submitted to five lished treatment criteria, and low sensory integration qual-
expert judges who were three occupational therapists, one ity meant that the treatment deviated from the established
learning consultant, and one child psychologist. Judges had criteria. The average sensory integration quality scores were
an initial agreement rate of about 95% before discussion 7.56 for the SI/NT studies and 7.31 for the SI/ALT stud-
and reclassification. Approximately 67% of the effect sizes studies,indicating that the overall sensory integration quality
were classified as either psychoeducational or sensory- was similar. For the moderator effect analysis, the sensory
perceptual in the SI/NT studies. In the SI/ALT studies, integration quality of treatment variable was dichotomized
44% of the total effect sizes were in the psychoeducational into low (3-7 points) and high (8-11 points).
and sensory-perceptual categories. Total treatment hours. Treatment hours were defined as
the total hours of treatment provided to the experimental
Design Variables group, and this variable was calculated by multiplying the
minutes per session by weekly frequency by total weeks of
After the studies were selected, their various features were
treatment. Two of the SI/NT studies did not report the
coded or given quantitative descriptions. With the coded
weekly frequency or the session length, resulting in 14
results, the study characteristics were categorized into 11
studies for this analysis. The treatment hours ranged from
variables to investigate associations with the magnitude of
13 (25-min session twice weekly for 4 months) to 180
sensory integration effects. Treatment-relatedvariables were
(45-min session five times weekly for 12 months). The
quality of treatment using sensory integration approaches,
average hours of SI/NT studies was about 60, and the
total treatment hours, diagnosis and age and children's age.
average hours of SI/ALT studies was about 36. The hour
Design-related variables were design quality, sampling
variable was dichotomized into Level 1 (< 60 treatment
method, number of outcome measures, number of mea-
hours) and Level 2 (> 60 treatment hours).
surement categories, professional affiliation of the
Diagnosis andage. Although six diagnostic groups were
researchers geographic location, and publication year. For
represented in the studies, examination of sensory integra-
two reasons, all independent variables were dichotomized,
tion effect for each was not possible because of the sparse
including age, publication year, sensory integration and
representation of some of the diagnoses. The majority of
design quality, number of outcome measures, and number
the studies were of children with learning disabilities, and
of measurement categories. First, on inspection of correla-
other diagnostic groups were examined in only a few stud-
tions among original and dichotomized independent variables
studies.Additionally, most of the participants in these latter
Table 2
diagnostic groups were adults, leading to the confounding
Definition of the Measurement Variable Category of age and diagnosis. Therefore, the diagnostic and age
Category Definition variables were combined into one, diagnosis and age, with
Psychoeducational Measures of IQ, cognition, and academic performance Level 1 for the adults (> 21 years of age) with chronic con-
Behavior Measures of behavioral function, such as attention, conditions,such as mental retardation and psychiatric disorder,
social and personal interaction, activity level, self- and Level 2 for the children (< 12 years of age) with learn-
esteem, and coping skills
Language Measures of language and speech function ing disabilities and other developmental disorders.
Motor Measures of fine and gross motor function Children's ages.The average ages of the children ranged
Sensory-perceptual Measures of perceptual and the sensory integrative
functions such as visual-perception, visual-motor from 4 to 10 years in SI/NT studies and 3 to 9 years in
integration, praxis, and somatosensory and vestibular SI/ALT studies. The average age was dichotomized as Level
functions
1 (younger group) and Level 2 (older group). The cut-off

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age was approximately 7.6 years for the SI/NT studies and West Coast where Ayres developed the sensory integration
7.0 years for SI/ALT studies. theory and treatment approaches. The foreign countries
Design quality. In previous literature reviews, method- represented were Canada, Australia, and New Zealand,
ological inadequacy was discussed as a factor that weakened with the largest number of the foreign studies from
the study conclusions. Therefore, design quality, defined as Canada. The studies were classified into Level 1 (United
the degree of internal validity, was coded on the basis of States) and Level 2 (foreign).
Cook and Campbell's (1979) formulation. Points were Publication year. The year variable was dichotomized
assigned to individual studies on a scale of 0 to 8, with 0 into Level 1 (1972-1982) and Level 2 (1983-1994), with
indicating the best quality design. The average design qual- eight studies in each level. The earlier studies include those
ity points was 2.50 for the SI/NT studies and 2.13 for by Ayres (1972, 1977). An examination of the sensory inte-
SI/ALT studies. The design quality variable was dichoto- gration effects over the years might give some insight into
mized into Level 1 (0-2) and Level 2 (3-8). trends in efficacy.
Sampling method. The sampling method variable was
dichotomized into Level 1 (broad sampling), consisting of M e t h o d o f Analysis
the studies with participants from more than one facility or Effect Size Calculation
school, and Level 2 (narrow sampling), consisting of the The effect size was used to gauge the difference between the
participants referred to clinics or residing or attending one pretest and posttest change scores of the treatment and
rehabilitation facility. The sampling method defines the comparison groups. Effect sizes were calculated from the
target population to whom the result could be generalized, pretest and posttest means and standard deviations, chi-
representing an aspect of external validity. square statistics, gain scores extracted from graphs, and t or
Number ofoutcome measures.This variable was defined F statistics with the formulas presented by Hedges and
as the number of the effect sizes each study contributed to Olkin (1985) and Cooper (1989). In this study, a positive
the analysis. The number of the outcome measures ranged effect size indicated that sensory integration group per-
from 1 to 29 for both SI/NT and SI/ALT comparisons. performanceexceeded that of the comparison group, and a
One possible implication of the number of the outcome negative effect size indicated that the comparison group
measures is that using multiple measures could result in a members showed more improvement than the sensory
more reliable index of the ability being measured than integration group. An effect size of 1.0 is typically inter-
using a single measure. The average number of the out- interpretedas the average participant in the treatment group
come measures was 7.6 for the SI/NT studies and 6.6 for exceeding 84% of the participants in the control group on
the SI/ALT studies. This variable was dichotomized into the outcome measure. The value of effect size was multi-
Level 1 (1-4 outcomes) and Level 2 (> 4 outcomes). plied by a correction factor for sample size bias to obtain an
measurement
Number of measurement categories.The outcome mea- unbiased estimator (Hedges & Olkin, 1985).
sures were classified into five measurement categories:
psychoeducational, behavior, language, motor, and sensory- Weighing Effect Sizes
perceptual. The average number of measurement categories
was 2.3 for SI/NT studies and 2.4 for SI/ALT studies. This To increase the precision and reliability of the average
variable was dichotomized into Level 1 (1 category) and effect sizes (within a category of an independent variable),
Level 2 (more than 1 category). a single composite weight was constructed by multiplying
Professional affiliation of the researchers. Sensory inte- three individual weights. These individual weights repre-
gration theory and treatment approaches are most popular sent three different aspects of study design. The variance
among occupational therapists. It was of interest, therefore, weight is inversely proportional to the variance of each
to compare the results of the studies conducted by occupa- effect size and was formulated by Hedges and Olkin
tional therapists with those conducted by other profession- (1985); it generally provides larger weights to the studies
als to examine the moderating effect of professional affilia- with larger samples. The measurement weight is 1/k where k
tion. Level 1 studies were those in which at least one is the number of the effect sizes used in one study. The
occupational therapist was included as a main author, and measurement weights for effect sizes within a study sum to
Level 2 studies were conducted by other professionals. The unity, giving each study an equal contribution to analytic
majority of the studies (75%) were conducted by occupa- results (regardless of the number of the effect sizes derived
tional therapists. from the study). The study weight was 1/n where n was the
Geographiclocation.The geographic location of a study number of the comparisons made with the same experi-
could influence the treatment effect because of various rea- mental group. This weighing scheme ensures that studies
sons, such as a difference in the social and educational are weighted equally with regard to their impact on ana-
backgrounds of the participants and the therapists. Within lytic results and gives greater weight to effect sizes that
the United States, more studies were conducted on the have greater precision (i.e., smaller standard errors).

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 Homogeneity Analysis and Moderator Effect and number of outcome measures. Only significant effects
Hedges' homogeneity statistic Q was used to investigate are reported.
within and between variances among the levels of each Publication year. There was a significant difference in
independent variable (Hedges & Olkin, 1985). The overall the magnitude of the effect sizes reported b y the early
Q statistic tests the null hypothesis of equal effect sizes. If (1972-1982) studies and recent (1982-1994) studies, p =
the null hypothesis is not rejected, the average effect size is .005. The average effect size of the early studies was .60
considered representative of the whole group. When the (95% confidence interval = .33--.86), whereas the average
hypothesis is rejected (at a particular alpha level), the alter- effect size of the more recent studies was .03 (95% confi-
native hypothesis that the effect sizes differ is supported, dence interval = -.20-.26). Table 5 breaks down effect sizes
and the moderator effects contributing the difference are for measurement categories by early and recent studies.
investigated. The overall Q statistic is labeled T and QT = Number of outcome measures. Studies using four or
QB + QW, where QB represents differences between levels of fewer total outcomes tended to have a higher average
a moderator variable and QW represents differences within effect size than those using more than four (p < .05). The
levels of the moderator variable. The pattern of moderator average effect size of the former type was .53 (95% confi-
variable confounding was examined with hierarchical clus- dence interval = .28-.78), whereas the average effect size
ter analysis. of the latter studies was .03 (95% confidence interval =
-.18-.32).
Results o f the Sensory Integration Versus Number of measurement categories. The studies that
N o - T r e a t m e n t Analysis examined the sensory integration effects in only one depen-
The weighted average effect size for all SI/NT studies was dent variable category yielded significantly greater magni-
.29, significantly different from zero at the .05 level (95% tude of the effect sizes than studies that examined the effects
confidence interval = .12-.48). The total within variance in two to five categories (p = .05). The average effect size of
(overall QR) was 28.10, exceeding the expected variation the measurement category was .53 (95% confidence inter-
due to the sampling error, X2(15, 16) = 28.10, p < .05, indi- val = .26-.80), whereas the average effect sizes of the latter
cating that the effect sizes were not homogeneous and, con- studies was. 10 (95% confidence interval = -. 13-.33).
consequently,that the average effect size was not representative Clusteranalysis.The cluster analysis revealed significant
of all SI/NT studies. Therefore, the moderator effects of confounding of the three variables cited previously. The
the measurement and design variables were examined. early studies used a fewer number of the outcome measures
in one or two categories, and the recent studies used many
Difference Among Measurement Categories outcome measures in more than three categories. Thus, it
The QB among category variations was :not significant, Ch-siq2uared was not possible to identify unique effect of each of the
(4, 16) = 2.88, p > .50, indicating that there were no sig- three variables. For ease of interpretation, results for the
nificant differences among the average effect sizes of the three variables will simply be referred to as "chronological
trend."
five categories. Homogeneity was attained in each category.
Effect sizes for dependent variable categories are shown in Attempts were made to explore and identify the reason
Table 3. for the chronological trend of the decreased sensory inte-
gration effect. The results were as follows:
Differences of Effects Associated With the Design Variables 1. The decrease in the sensory integration effect was
The weighted average effect sizes of each level and sublevel not due to the increased degree of improvement
of the design variables are shown in Table 4. Significant made by the subjects in the no-treatment group in
moderator effects were noted for three design variables-- the recent years because the pretest and posttest
the publication year, number of measurement categories, differences of the no-treatment group remained
statistically equal through the years.
Table 3 2. The scores of the common standardized tests used
Average Effect Sizes and Standard Errors of the
Measurement Categories (SI/NT)
in both periods also decreased in the recent stud-
studies;therefore, the decreases of the sensory integra-
Measurement Variablea Effect Size SE k N
tion effect sizes could not be attributed to the
Psychoeducational .39* .15 40 11
Behavior -.08 .33 12 3 increased number of outcome measures used in the
Language .13 .34 10 5 recent studies.
Motor .40* .17 18 10
Sensory-perceptual .14 .21 42 8
3. Decrease in the effect sizes had no notable rela-
Note. SI/NT = sensory integration with no treatment.
tionship to the testers' awareness of the experimen-
"All categories have a homogeneous set of effect sizes. tal group affiliation of the participants or the expe-
*Significantly different from zero at alpha = .05. rience level of the treatment providers.

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Table 4
Average Effect Sizes of Design Variable Levels and Sublevels (SI/NT)
Effect Size
Variable Level Sublevel (Sublevel Effect Size) N

Quality of treatment using sensory integration 1 (low) .23 7

1.1 (lowest)" (.00) (4)
1.2 (highest of low) (.60)* (3)
2 (high) a .34* 9
Total number of treatment hours 1 (< 60 hr)a .33* 8
2 (> 60 hr)a .11 6
1 (adult/chronic)" .21 3
Diagnosis and age
2 (child/learning disability) .3O 13
1 (4 up to 8 years) .23 7
Children's age
1.1 (4 years)a (.92)* (2)
1.2 (6 and 7 years)a (.05) (5)
2 (8 to 10 years)* .39" 6

Design quality 1 (high)a .36" 9

2 (low) .18 7
2.1 (highest of low) (-.07) (4)
2.2 (lowest) (.35) (3)
1 (broad samplingS* .33* 8
Sampling method
2 (narrow sampling)" .25 8
Number of outcome measures I (few)a .53* 8
2 (many)a .07 8
Number of measurement categories 1 (few)' .53* 7
2 (many)" .10 9
Geographic location of study 1 (United States)' .25* 8
2 (foreign) 933* 8
2.1 (Australia)a (.93)* (3)
2.2 (New Zealand)a (-.01) (2)
2.3 (Canada) (.19) (3)
Professional affiliation of the researchers 1 (occupational therapy) .37* 13
1.1 (early studies)a (.62)* (7)
1.2 (recent studies) a (.07) (6)
2 (not occupational therapy) a .03 3
Publication year 1 (early studies)a .60* 8
2 (recent studies) a,b .03 8

Note. SI/NT = sensory integration with no treatment. Sublevel effects sizes and number of contributing studies are shown in parentheses.
aLevel and sublevel that attained homogeneity, bLevel and sublevel that showed significant between variations.
*Significantly different from zero at alpha = .05.

Results o f the Sensory Integration Versus categories of SI/ALT studies are presented in Table 5. The
Alternative Treatment Analysis magnitude of the effect sizes varied from -. 19 (95% confi-
dence interval = -.83-.46) in the language category to .28
Differences among SI/ALT studies using Qr were non- (95% confidence interval = -.05-.62) in the motor catego-
significant, X2(1, 16) = 20.7, p > .10, implying that the
ry. This result implies that sensory integration and alterna-
effect sizes in this comparison were homogeneous. The tive treatment approaches showed equal effects.
average effect size was .09 and not significantly different
from zero (95% confidence interval = -.11-.28). Thus, the
Chronological Trendof the SI/ALT Studies
estimated average effect size is representative of the total
group of the studies, and no further inferential analysis was Although not significant, a trend appeared in which recent
performed. The average effect sizes of the measurement cat- studies yielded smaller effect sizes than the earlier studies in

Table 5
Average Effect Sizes for Measurement Categories by Early and Recent Studies
Early (1972-1982) Recent (1983-1993)

Category Effect Size SE k N Effect Size SE k N

Psychoeducational .62* .19 11 4 .07 .23 29 6

Behavior NA NA 0 0 -.08 .33 12 3
Language .25 .54 3 1 .04 .44 7 4
Motor .65* .21 7 4 -.04 .27 11 6
Sensory-perceptual .41 .64 4 1 .11 .22 28 7
Note. NA = no effect size in this category.
*Significantly different from zero at alpha = .05.

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 the SI/ALT comparison. Pearson product-moment corre- and SI/ALT comparisons. Comparing the studies from
lation between publication year and effect size was signifi- different geographic locations, the studies (all published
cant and negative, r(16) = -.73, p = .001. The related char- before 1982) from Australia yielded the largest effect size
acteristics of the chronological trend were similar to those of .93. However, because of the confounding of the
in the SI/NT comparison. The publication year correlated chronological trend, the reason for the large effect cannot
significantly with the number of outcome measures, r(16) be isolated.
= .69, p = .004, and the number of measurement cate-
gories, r(16) = .56, p = .033. How Are the Results of This Study Related to the
Literature Review?
S u m m a r y o f Findings
Are Sensory Integration Treatment Approaches Effective? The results of the current study shed some light on contra-
dictory findings reported by previous reviews. Ottenbacher
Sensory integration treatment approaches were found to (1982) reported a positive effect size (.68) of sensory inte-
be most effective in the earlier studies that compared the gration treatment approaches as a result of the meta-analy-
performances of sensory integration groups with no-treat- sis of the SI/NT studies published between 1972 and
ment groups, whereas the recent SI/NT studies found no 1981, but the literature review of more recent studies
sensory integration effect. Sensory integration effect was found no overall sensory integration effect (Hoehn &
statistically equal to the effect of other alternative treat- Baumeister, 1994; Polatajko et al., 1992). In regard to the
ments. For both comparisons, there was a chronological sensory integration effect on the outcome categories, the
trend of recent decrease of the sensory integration effect. current findings were similar to those reported by the pre-
vious literature reviews. Ottenbacher noted the largest sen-
What Do Sensory Integration Treatment sensoryintegration effect in motor and psychoeducational cat-
Approaches Improve? egories, similar to the current findings with early SI/NT
In the earlier studies that compared sensory integration comparison. The authors of the four more recent literature
groups with no-treatment groups, the improvement reviews did not find positive effects in any areas.
occurred in the psychoeducational and motor performance
areas. Sensory integration effect was statistically equal to
Study Limitations
the alternative treatment effects in all areas. No improve- Because of the limited number of studies reviewed and
ment was noted in the sensory-perceptual area. A similar sparse representation of pertinent information, it was not
pattern was obtained for the alternative treatment. possible to investigate the difference of sensory integration
effect among different types of disabilities, among pre-
For Whom Are Sensory Integration Treatment school-age and school-age children, among different school
Approaches Effective, and What Moderator Variables grades, and among different types of alternative treatments.
Should Be Considered? The original studies lacked comprehensive information
The sensory integration effect was statistically indistin- about age-specific score distributions, specific types of dis-
guishable for adults with chronic conditions and children ability, relationships among the multiple outcome mea-
with learning disabilities and other developmental disor- sures, provider qualifications, and detailed descriptions of
ders. There was no association between the magnitude of the treatment strategies. When such information was not
sensory integration effect and sensory integration quality of reported, it was coded as missing.
the treatment, meaning that a pure sensory integration Another limitation is the lack of interrater verification
treatment method did not show advantages over adapted of the coding process. Other researchers may use different
methods. Likewise, sensory integration did not show strategies for coding and defining variables. Certain vari-
notable advantage over alternative treatment methods. ables required some degree of judgment, especially sensory
With respect to treatment frequency and duration, there
was no indication that a better result was achieved by Table 6
Average Effect Sizes and Standard Errors of the
increasing the treatment hours. Two earlier studies with the Measurement Categories (SI/ALT)
youngest group of children (about 4 years of age) yielded Measurement
the largest effect size of .92, but this result could not be Variablea Effect Size SE k N
attributed to the age factor because of the confounding Psychoeducational .12 .23 24 5
effect of the chronological trend. Behavior .07 .31 15 5
Language -. 19 .33 11 9
Motor .28 .17 28 12
What Other Factors Influenced the Magnitude of the Effect Sensory-perceptual -. 11 .21 28 9
Sizes of Sensory Integration Treatment Approaches? Note. SI/ALT = sensory integration with alternative treatment.
a All categories have a homogeneous set of effect sizes.
The chronological trend was demonstrated in both SI/NT *Significantly different from zero at alpha = .05.

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integration quality, design quality, and diagnosis and age. Acknowledgments
For sensory integration quality, nine individual judgments This study was completed as part of the requirements for the first
author's Doctorate Degree in Educational Statistics and Measurement,
were obtained and summed into an overall score. Although Rutgers, The State Universityof New Jersey.In the spirit of meta-analy-
interrater reliability was not obtained, coefficient alpha for sis, the coding form and other technical data can be obtained from the
this scale was found to be .80. Likewise, five individual first author to evaluate the procedures of this study.
judgments were required for design quality, and a coeffi-
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