Research

Allied health professionals

perceptions of the role of
sensory integration therapy in
managing challenging behaviours
Kala Samayan, Kunju Dhanavendan, Raut Nachiketa
Aim: This study investigated allied health professionals awareness and knowledge of the role of
sensoryintegration therapy in managing challenging behaviours in children with various disabilities.
Methods: Thirty allied health professionals (physiotherapist=4; occupational therapist=4; speech
pathologist=2; paediatrician=1; physical medicine and rehabilitation specialist=1; psychologist=3;
special needs educator=11; social worker=3; vocational instructor=1) with a minimum of three years
experience working with children with developmental and behavioural disorders participated in this study.
Participants were invited to attend a face-fo-face interview, which included eight questions on behaviours
exhibited due to sensory processing issues and two questions related to non-sensory processing issues.
Results: Although the majority (81%) of participants had come across most of the behaviours and
considered most of the identified behaviours as challenging behaviours, less than a quarter (21%) of
participants could identify the causative role of sensory processing disorders and hence, did not identify
the use of sensory integration therapy in managing these behaviours. However, the majority (67%) of
participants indicated feeling very competent at handling challenging behaviours.
Conclusions: There is a need to develop training programmes that focus on sensory integration and
applied behavioural analysis to facilitate multidisciplinary working and improve professional understanding.
Key words: n Hypersensitivity n Hyposensitivity n Sensory processing disorder n Sensory integration therapy
Submitted 11 November 2014; sent back for revisions 21 November 2014; accepted for publication following double-blind
peer review 8 January 2015

2015 MA Healthcare Ltd

hallenging behaviour has been

defined as culturally abnormal
behaviours of intensity, frequency
and duration that are likely to place
the physical safety of the individual or others
in serious jeopardy or deny access to the use
of ordinary community facilities (Emerson,
1995). The main forms of challenging
behaviour identified are aggressive/destructive
behaviour, self-injurious behaviour, stereotypy,
and other socially or sexually unacceptable
behaviours (Qureshi and Alborz, 1992; Hastings
and Remington, 1994). Peshawaria and
Venkatesan (1992) further classified challenging
behaviour under ten headings: i) violent and
destructive; ii) temper tantrum; iii) misbehaves
with others; iv) self-injurious behaviours;
v) repetitive behaviours; vi) odd behaviours;
vii) hyperactivity; viii) rebellious behaviours;
ix) antisocial behaviour; x) fears. Challenging
behaviours are likely to have their onset in
childhood and may be highly persistent over
time (Emerson, 1995); this may then have a
pervasive effect on the childs life.

Some of the perceived social and educational

consequences of challenging behaviours include
(Harris et al, 1996; Porter and Lacey, 1999):
Isolation from peers
n Reduced access to the curriculum
n Reduced opportunities for participation in
extracurricular activities
n Risk of injury to self or others.
Since Ayres described sensory integration
dysfunction in the 1970s (Ayres, 1972; 1979),
sensory-based therapies have been used
increasingly, mainly by occupational therapists,
in the treatment of children with developmental
and behavioural disorders (American Academy
of Pediatrics, 2012). However, although there
is a body of research relating to the perceptions
and behaviour of care staff in relation to clients
demonstrating challenging behaviour (Kiernan and
Kiernan, 1994; Hastings and Remington, 1995;
Harris et al, 1996; Hastings, 1996), relatively little
is known about the perceptions of allied health
professionals on using sensory integration therapy
in the management of challenging behaviour in
children with various disabilities.

International Journal of Therapy and Rehabilitation, April 2015, Vol 22, No 4

Kala Samayan,
Audiologist and
speech pathologist,
National Institute
for Empowerment of
Persons with Multiple
Disabilities, Chennai,
Tamil Nadu, India;
Kunju Dhanavendan,
Special needs educator,
National Institute
for Empowerment of
Persons with Multiple
Disabilities, Chennai,
Tamil Nadu, India;
Raut Nachiketa,
Associate professor of
speech and hearing,
National Institute
for Empowerment of
Persons with Multiple
Disabilities, Chennai,
Tamil Nadu, India.
Correspondence to:
Kala Samayan
E-mail:
kalasamayan21@hotmail.com

167

Research

Methods
Participants and setting
A convenience sample was used in this study,
comprising 30 allied health professionals
(physiotherapist=4; occupational therapist=4;
speech pathologist=2; paediatrician=1; physical
medicine and rehabilitation specialist=1;
psychologist=3; special needs educator=11;
social worker=3; vocational instructor=1) with
a minimum of three years experience working
with children with developmental and behavioural
disorders within a multidisciplinary team.
168

Participants had 8.35.5 years of working

experience and at least three years of experience
working with children with autism spectrum
disorder, intellectual disability, visual impairment
or blindness, hearing impairment and attention
deficit hyperactive disorder (ADHD). Informed
consent was obtained from all participants.

Procedure
A face-to-face interview in a one-to-one
setting was conducted in a quiet room using a
semi-structured interview questionnaire on
challenging behaviour. The questionnaire
was developed specifically for this study and
based on examples of challenging behaviours
in children with sensory processing disorders,
as identified by Sher (2009) (Appendix 1). The
included examples examined four main sensory
processing systemsvestibular, proprioceptive,
tactile and auditoryand were further classified
as either hypersensitivity (over-responsiveness)
or hyposensitivity (under-responsiveness) to
sensory stimuli. The questionnaire was validated
by six allied health professionals, including two
occupational therapists, two speech pathologists,
a psychologist and a special educator. A total
of ten questions were included in the final
version of the questionnaire: eight questions
related to behaviours exhibited owing to
sensory processing disorders and two questions
on behaviours exhibited not due to sensory
processing disorders (Figure 1).
Before beginning the interview, participants
were briefed about the purpose of the study.
Interviews were conducted by two of the authors;
one author conducted the interview while the
other noted down the participants responses.
Participants received the following instructions:
We are trying to elicit how different
allied health professionals perceive
the roles of different members of the
multidisciplinary team in managing
challenging behaviours. I will now read
out ten behaviours, which may or may not
be challenging behaviours in children.
Iwill now give you a list of the ten
behaviours. As I read out each behaviour,
please answer the four accompanying
questions that are listed, keeping in
mind that the behaviour mentioned is
observed in children aged between five
and eightyears. No additional information
about the child will be provided. You
are free to say I do not know, The
information provided is inadequate,
Iam not sure, or pass the question.

International Journal of Therapy and Rehabilitation, April 2015, Vol 22, No 4

2015 MA Healthcare Ltd

An awareness of the role of sensory

integration therapy in managing challenging
behaviours within the multidisciplinary team is
important for the following reasons:
n To provide opportunities for health professionals to identify challenging behaviours so
as to document their prevalence, course and
co-morbidity, quantify the associated level of
burden and produce a coordinated model of
care for the management of such behaviours
n To create an evidence base for the coordination and provision of services for children with
challenging behaviour, e.g. coordinated case
management between schools and outside
support
n To address and help alleviate the stress of
family members and carers through increased
support and service options.
Significantly, children with developmental
and behavioural disorders who present with
challenging behaviours may hinder the ability
of the therapist to commence specific therapies,
and cross referral within the multidisciplinary
team means it is vital for each health professional
to have an understanding of the aetiology and
management of challenging behaviours. Effective
health care team working is widely encouraged
by health services and it has been reported that
for a health care team to be successful, team
members need to agree on the best management
approach, in addition to a consideration of their
own role in relation to that of other specialist
roles within the team (McCallin, 2001; Smith
and Roberts, 2005). Therefore, the aim of this
study was to investigate the awareness and
knowledge of allied health professionals in the
multidisciplinary team of the role of sensory
integration therapy in commonly encountered
behaviours demonstrated by children in order
to highlight the need for standard operating
procedures for the management of challenging
behaviour in the rehabilitation process.

All the examples included in the questionnaire

demonstrated challenging behaviours (Table 1).
The four accompanying questions were:
n Is this is an example of challenging behaviour?
n Have you come across such behaviour in your
clinical practice?
n What do you think are the probable causes of
this behaviour?
n How can this behaviour be managed, and is it
necessary to refer the child to another member
of the multidisciplinary team?
The first two questions were yes/no questions
and were coded as 0 for no and 1 for yes.
The third and fourth questions were open-ended
questions and were coded using a four-point
rating scale (Table 2). The final section of the
questionnaire asked participants to rate how
confident they were in dealing with challenging
behaviours on a five-point Likert scale, with
0 being not at all comfortable and 4 being very
comfortable and confident.
The average interview length was 30 minutes,
and participant responses were tabulated
and coded for analysis immediately after
each interview. The data were analysed using
descriptive statistics.

2015 MA Healthcare Ltd

Results
Participant responses are presented in Table 3.
On average, less than a quarter of participants
could identify the cause (17%) and management
(19%) of behaviours due to sensory processing
issues, while a slightly larger proportion of
participants were able to identify the aetiology
(38%) and management (34%) of behaviours due
to non-sensory processing issues. With regard to
challenging behaviours due to sensory processing
disorders, the aetiology and management of
proprioceptive hyper- (B5) and hyposensitivity
(B6) and auditory hyposensitivity (B8) were least
understood by participants, while the aetiology
and management of antisocial behaviours (B9
and B10) were the most understood.
In the final section of the questionnaire,
over 67% of participants rated themselves
as confident and competent in handling
challenging behaviours. Although the majority
(81%) of participants had come across most of
the behaviours and considered most of these
as challenging behaviours, less than a quarter
(21%) of participants could identify the causative
role of sensory processing disorders and hence
did not identify the use of sensory integration
therapy in managing these behaviours.
Additionally, although participants demonstrated

Behaviours
(n=10)

Sensory
processing issue
(n=8)

Vestibular
(n=2)

Non-sensory
processing issue
(n=2)

Proprioceptive
(n=2)

Tactile
(n=2)

Auditory
(n=2)

Figure 1. Classification of behaviours

Table 1. Challenging behaviours examined
Code

Description

Sensory processing issue?

B1

Vestibular hypersensitivity

Yes

B2

Vestibular hyposensitivity

Yes

B3

Tactile hypersensitivity

Yes

B4

Tactile hyposensitivity

Yes

B5

Proprioceptive hypersensitivity

Yes

B6

Proprioceptive hyposensitivity

Yes

B7

Auditory hypersensitivity

Yes

B8

Auditory hyposensitivity

Yes

B9

Antisocial behaviour

No

B10

Antisocial behaviour

No

Table 2. Coding system for open-ended questions

Code

Rating

Expected answer

Mostly incorrect

The participant answered most of the questions incorrectly

Partly correct

The participant is able to determine whether the

behaviour is a sensory processing issue, knows which
health professional the patient should be referred to,
and vaguely refers to or mentions a related activity that
can be used to manage the behaviour

Correct

The participant is able to identify the affected

sensory modality (auditory, tactile, visual, vestibular,
proprioceptive and/or interoceptive) and whether it is
hyposensitive or hypersensitive
The participant is able to identify activities that can be
used to manage the behaviour

Did not know

The participant did not know the answer

a better understanding of antisocial behaviours

compared with other challenging behaviours
identified in the questionnaire, less than half of
the participants were able to correctly identify
the affected sensory modality and/or activities
that could be used to manage these behaviours.
These findings indicate a lack of awareness
among health professionals about when to use
sensory integration therapy and the application
of behavioural principles. However, the majority
(67%) of participants indicated feeling very
competent at handling challenging behaviours.

International Journal of Therapy and Rehabilitation, April 2015, Vol 22, No 4

169

Research

Type

Question

B1

B2

B3

B4

B5

B6

B7

B8

B9

B10

Yes/no questions
Percentage of
yes responses

Is this is an example of challenging behaviour?

76.6

86.6

90.0

63.3

80.0

90.0

66.6

83.3

90.0

86.6

Have you come across such behaviour in your

clinical practice?

90.0

100.0

96.6

73.3

90.0

93.3

70.0

56.6

83.3

83.3

Open-ended
questions
Percentage of
correct answers

What do you think are the probable causes

of this behaviour?

24.4

26.7

36.7

20.0

3.4

0.0

23.4

3.4

50.0

26.7

How can this behaviour be managed, and is it

necessary to refer the child to another member
of the multidisciplinary team?

30.0

30.0

26.7

26.7

10.0

10.0

10.0

6.7

34.4

33.4

Discussion
Sensory integration disorders vary between
individuals in their characteristics and
intensity. In some, the disorder is barely
noticeable, while others have trouble with
daily functioning. Children can be born
hypersensitive or hyposensitive to varying
degrees and may have trouble in one sensory
modality, a few, or all of them. Children who
receive the diagnosis of sensory integration
dysfunction should also be observed for signs
of anxiety problems, ADHD, food intolerances,
behavioural disorders and autism. Genetic
problems such as Fragile X syndrome should
be looked into as well (Baranek, 1999).
In this study, four behavioursvestibular
hypersensitivity (B1), tactile hypersensitivity
(B3), proprioceptive hypersensitivity (B5) and
auditory hypersensitivity (B7)were identified
as being caused by sensory hypersensitivity.
Hypersensitivity is caused by an over-reaction
of the normal protective senses, resulting in
social and emotional problems, including hypervigilance, anxiety and aggression (Wilbarger,
1995). Symptoms vary widely and include:
n A dislike of being touched
n Feeling discomfort or pain from clothing
rubbing against skin
n Dislike for foods with mixed textures
n Discomfort when one looks directly into the
eyes of another person
n Exaggerated startle reflex
n Dislike of complex visual stimuli, such as fastmoving objects or colours.
A further four behavioursvestibular
hyposensitivity (B2), tactile hyposensitivity (B4),
proprioceptive hyposensitivity (B6) and auditory
hyposensitivity (B8)were identified as being
caused by sensory hyposensitivity. Hyposensitivity
is characterised by an unusually high tolerance
for environmental stimuli, and a child with
hyposensitivity might appear restless and seek
sensory stimulation (Ben-Avi et al, 2012).
170

Once children with sensory processing

disorders have been accurately diagnosed,
they benefit from a treatment programme
of occupational therapy with a sensory
integration approach (American Academy
of Pediatrics, 2012). When appropriate and
applied by a well-trained clinician, listening
therapy (such as Integrated Listening Systems)
or other complementary therapies may be
combined effectively to enhance patient
outcomes (Berard, 1982; Dunn, 2001).
Occupational therapy with a sensory
integration approach typically takes place in an
environment specifically designed to stimulate
and challenge all of the senses. During the
session, the therapist works closely with the
child to provide a level of sensory stimulation
that the child can cope with, while encouraging
movement within the room. Children with
hyposensitivity may be exposed to strong
sensations, such as stroking with a brush,
vibrations or rubbing. Play may involve a range
of materials to stimulate the senses, such as
play dough or finger painting. Children with
hypersensitivity may be exposed to peaceful
activities, including quiet music and gentle
rocking, in a softly lit room. Table 4 provides
a list of activities that occupational therapists
can recommend to improve sensory processing;
these suggestions are in relation to the
behaviours identified in the questionnaire.
While occupational therapists using a sensory integration frame of reference focus on
increasing a childs ability to tolerate and
integrate sensory input, other members of the
multidisciplinary team may focus on environmental accommodations that parents and school
staff can use to enhance the childs function
at home, school, and in the community (Biel
and Peske, 2005). The Wilbarger (1995) sensory
diet and research by Ross (2011) emphasise
the importance of incorporating other sensory
stimulating activities into the daily routine of
the patient (Table 5). A carefully designed pro-

International Journal of Therapy and Rehabilitation, April 2015, Vol 22, No 4

2015 MA Healthcare Ltd

Table 3. Participant responses

gramme of sensory input throughout the day that

is implemented at home and at school can create profound and lasting changes in the childs
nervous system (Wilbarger, 1995). In order to
treat patients with the Wilbarger Protocol, it is
important for health professionals to receive
regular and updated training (Wilbarger and
Wilbarger 1991; 2002).

Limitations
The results of this study cannot be generalised
to all allied health professionals who work with
children with developmental and behavioural
disorders given the small size of the sample.
Additionally, as only staff from the National
Institute for Empowerment of Persons with
Multiple Disabilities, India, were recruited to
participate in this study, it cannot necessarily be
inferred that all allied health professionals have
the views expressed in this study.

ConclusionS
Although the majority of the participants had
come across most of the behaviours identified
in the questionnaire and considered nearly all
of these as challenging behaviours, less than
a quarter of participants could identify the
correct aetiologies or treatment strategies. Thus,
there is an urgent need to develop training
programmes focusing on sensory integration
and basic applied behavioural analysis. This
would facilitate multidisciplinary working and
IJTR
improve professional understanding. 

2015 MA Healthcare Ltd

Conflict of interest: none declared.

American Academy of Pediatrics (2012) Sensory integration
therapies for children with developmental and behavioral
disorders. Policy statement. Pediatrics 129(6): 11869.
doi: 10.1542/peds.2012-0876
Ayres AJ (1972) Sensory Integration and Learning Disorders.
Western Psychological Services, Los Angeles
Ayres AJ (1979) Sensory Integration and the Child. Western
Psychological Services, Los Angeles
Baranek GT (1999) Autism during infancy: A retrospective
video analysis of sensory-motor and social behaviours at
9-12 months of age. J Autism Dev Disord 29(3): 21324
Ben-Avi N, Moshe A, Batya E (2012) Sensory processing difficulties and interpersonal relationship in Adults: An explorative study. Scientific Research, Psychology 3(1): 707
Berard G (1982) Auditory Integration Training. http://www.
drguyberard.com/ (accessed 11 March 2015)
Biel L, Peske N (2005) Raising a Sensory Smart Child: The
Definitive Handbook for Helping Your Child with Sensory
Integration Issues. Penguin, New York
Dunn W (2001) The sensations of everyday life: Empirical,
theoretical, and pragmatic considerations. Am J Occup
Ther 55(6): 60820
Emerson E (1995) Challenging Behaviour: Analysis and
Intervention in People with Learning Disabilities.
Cambridge University Press, Cambridge

Key points
n Challenging behaviours in children with developmental and behavioural
disorders may be observed due to sensory processing disorders
n Sensory-based therapies have been used increasingly by occupational therapists
in the treatment of children with developmental and behavioural disorders
n There is an urgent need to develop training programmes focusing on
sensory integration to facilitate multidisciplinary working.

Table 4. Activities to manage sensory hypersensitivity and hyposensitivity

Equipment

Function

B1

Trampoline

Stimulate vestibular sensitivity

B2

Therapy ball

Stimulate proprioceptive sense and relaxation

B3

Sand bath

Calm down or organise tactile sensitivity

B4

Visual stimulation
through lights

Increase attention span and sitting tolerance

B5

Ball pool

Organise tactile sensitivity

B6

Balancing board

Stimulate vestibular sensitivity and motor coordination

B7

Ladder

Stimulate vestibular sensitivity

B8

Vibrator

Stimulate proprioceptive sense

B9

Tunnel

Stimulate proprioceptive sense

B10

Swing

Stimulate vestibular and proprioceptive sense

Table 5. Alerting and calming activities

Sense

Alerting activity

Calming activity

Touch

Rubbing, patting, the cold

e.g. clapping hands

Hugging, holding, stroking,

e.g. self-massaging

Vestibular

Rotation, rapid forward

movement, e.g. running

Slow, rhythmic movement,

e.g. sitting in a rocking chair

Proprioceptive

Light pressure, e.g. brushing

the skin with a feather

Moderate pressure, e.g. being

wrapped up in a blanket

Visual

Bright colours, bright light,

e.g. flashing images

Pastel colours, low-intensity

settings, e.g. candlelight

Hearing

Irregular, loud and

contrasting sounds,
e.g. banging on a piano

Melodious, rhythmic, slow music,

e.g. strumming a harp, listening to
classical music

Smell

Pungent smells, e.g. vinegar

Sweet, faint smells, e.g. vanilla

Taste

Strong flavors, crunchy food,

e.g. hot peppers, pretzels

Smooth texture, warm,

e.g. hot chocolate

Adapted from: Ross, 2011

Harris J, Cook M, Upton G (1996) Pupils with Severe

Learning Disabilities who Present Challenging Behaviour.
British Institute of Learning Disabilities, Birmingham
Hastings RP (1996) Staff strategies and explanations for
intervening with challenging behaviours. J Intellect
Disabil Res 40(Pt 2): 16675
Hastings RP, Remington B (1994) Rules of engagement:
toward an analysis of staff responses to challenging behaviour. Res Dev Disabil 15(4): 27998
Hastings RP, Remington B (1995) The emotional dimension of working with challenging behaviours. Clinical
Psychology Forum 79: 1116
Kiernan C, Kiernan D (1994) Challenging behaviour in
schools for pupils with severe learning difficulties. Mental
Handicap Research 7(3): 117201

International Journal of Therapy and Rehabilitation, April 2015, Vol 22, No 4

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Research
Appendix I. Participant questionnaire
SECTION 1 BACKGROUND INFORMATION
Name:
Age/gender:
Professional qualification:
Years of experience:
Designation:
SECTION 2 PERCEPTIONS ON BEHAVIOURS

For each behaviour, please answer the four accompanying questions listed below. When answering these questions,
keep in mind that the behaviour mentioned is observed in children aged between five and eightyears. No additional
information about the child will be provided. You are free to say I do not know, The information provided is
inadequate, I am not sure, or pass the question.

Is this an example of challenging behaviour? Yes/No

Have you come across such behaviour in your clinical practice? Yes/No
What do you think are the probable causes of this behaviour?
How can this behaviour be managed, and is it necessary to refer the child to another member of the multidisciplinary team?

Behaviour 1
The child does not like getting into the lift or sitting on the seesaw and does not like being carried.
Behaviour 2
The child constantly rocks his body, is constantly moving and loves swinging.
Behaviour 3
The child does not like to be touched or wearing body-fitting clothes. The child avoids doing any activities that involve
touching semi-solid materials such as clay and gum.
Behaviour 4
The child likes to chew toys and will indicate if he gets hurt.
Behaviour 5
The child has difficulty with feeding and dressing. The child often spills her food and cannot manage zips and buttons.
Behaviour 6
The child has the habit of grinding her teeth and hitting her head on the wall whenever she is unoccupied.
Behaviour 7
The child shows feelings of distress when loud music is playing and does not seem to be able to understand oral instructions
well in a noisy environment.
Behaviour 8
The child enjoys listening to music constantly.
Behaviour 9
The child keeps disturbing the child sitting next to him.
Behaviour 10
The child steals things that belong to other children.
SECTION 3 ABILITY TO MANAGE CHALLENGING BEHAVIOURS

McCallin A (2001) Interdisciplinary practice--a matter of

teamwork: an integrated literature review. J Clin Nurs
10(4): 41928
Peshawaria R, Venkatesan S (1992) Behavioural Assessment
Scales for Indian Children with Mental Retardation. http://
bit.ly/1HRIO4k (accessed 11 March 2015)
Porter J, Lacey P (1999) What provision for pupils with challenging behaviour? British Journal of Special Education
26(1): 238. doi: 10.1111/1467-8527.00096
Qureshi H, Alborz A (1992) Epidemiology of challenging
behaviour. Mental Handicap Research 5(2): 13045
Ross M (2011) Five stage group: Older adult interventions to
facilitate social participation. In: Cole MB, Donohue MV.
Social Participation in Occupational Contexts. SLACK
Incorporated, Thorofare, NJ: 285

172

Sher B (2009) Early Intervention Games. Jossey Bass,

SanFrancisco
Smith S, Roberts P (2005) An investigation of occupational
therapy and physiotherapy roles in a community setting.
Int J Ther Rehabil 12(1): 217
Wilbarger P (1995) The sensory diet: Activity programs
based on sensory processing theory. Sensory Integration
Special Interest Section Newsletter 18: 14
Wilbarger P, Wilbarger J (1991) Sensory Defensiveness in
Children Aged 2-12. Avanti Educational Programs,
Toronto, Ontario Canada
Wilbarger J, Wilbarger P (2002) The Wilbarger approaches
to treating sensory defensiveness. In: Bundy AC, Lane SJ,
Murray EA. Sensory Interaction: Theory and Practice.
2ndedn. FA Davis, Philadelphia

International Journal of Therapy and Rehabilitation, April 2015, Vol 22, No 4

2015 MA Healthcare Ltd

On a scale of 04, how comfortable are you working with children with challenging behaviours:
Not at all
Very comfortable and
comfortable
and confident
0
1
2
3
4

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