J Autism Dev Disord (2011) 41:805814 DOI 10.

1007/s10803-010-1104-x

ORIGINAL PAPER

Weighted Vests, Stereotyped Behaviors and Arousal in Children with Autism

Sandra Hodgetts Joyce Magill-Evans John E. Misiaszek

Published online: 14 September 2010 Springer Science+Business Media, LLC 2010

Abstract The homeostatic theory of stereotyped behaviors assumes that these behaviors modulate arousal. Weighted vests are used to decrease stereotyped behaviors in persons with autism because the input they provide is thought to serve the same homeostatic function. This smalln, randomized and blinded study measured the effects of wearing a weighted vest on stereotyped behaviors and heart rate for six children with autism in the classroom. Weighted vests did not decrease motoric stereotyped behaviors in any participant. Verbal stereotyped behaviors decreased in one participant. Weighted vests did not decrease heart rate. Heart rate increased in one participant. Based on this protocol, the use of weighted vests to decrease stereotyped behaviors or arousal in children with autism in the classroom was not supported. Keywords Autism Stereotyped behaviors Weighted vests Arousal Sensory modulation

Introduction Stereotyped behaviors are one of the core features in autism (APA 2000). These behaviors are very heterogeneous, and can be verbal or nonverbal, ne or gross motor in form, or involve complex routines and rituals (Cunningham and Schreibman 2008). Common examples of stereotyped behaviors include, but are not limited to, nger icking, body rocking, hand apping, snifng and scratching objects, spinning objects, running objects or ones ngers across their eld of view, and immediate and delayed echolalia (APA 2000; Schreibman et al. 1999). The most widely accepted theories on stereotyped behaviors are that they serve homeostatic and operant functions (Cunningham and Schreibman 2008; Willemsen-Swinkels et al. 1998). The homeostatic theory assumes that stereotyped behaviors increase or decrease a childs arousal levels depending on whether the child is over- or under-responsive to sensory stimuli. Persons with autism, and especially more severe autism, often have difculty responding to sensory input with behavior that is appropriate to the type and intensity of the sensory input (Ben-Sasson et al. 2009). This is termed sensory modulation dysfunction (Miller et al. 2007). Abnormal responses to sensory input may reect poor modulation of inhibitory and excitatory functions of the nervous system (Baranek 2002). Supporting the homeostatic theory, Soussignan and Koch (1985) found that rhythmical stereotyped movements (leg-swinging) reduced physiological arousal, as measured by decreased heart rate, in typically developing children. Willemsen-Swinkels and colleagues (1998) also used heart rate to investigate stereotyped behaviors in 14 persons with autism. Behaviors associated with distress and composure tended to be repetitive and low-intensity (e.g., making sounds, intense visual examination of object, rocking).

S. Hodgetts (&) J. Magill-Evans J. E. Misiaszek Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-64 Corbett Hall, Edmonton, AB T6G 2G4, Canada e-mail: sandra.hodgetts@ualberta.ca Present Address: S. Hodgetts Department of Pediatrics, Faculty of Medicine, University of Alberta, Edmonton, Canada S. Hodgetts Faculty of Social Work, University of Calgary, Edmonton, Canada

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Heart rate decreased during and following stereotyped behaviors associated with distress. Behaviors associated with composure did not affect heart rate, and were assumed to counterbalance under-stimulation, although they also may be used to gain attention from others. Stereotyped behaviors associated with elation were of short duration and involved limb movement (e.g., hand apping, hand and nger mannerisms). They did not affect heart rate, perhaps serving as an outlet for excitement. The second prominent theory is that stereotyped behaviors are operant behaviors, maintained by the direct reinforcement they provide (Cunningham and Schreibman 2008). This reinforcement involves direct sensory input (e.g., visual stimuli from nger mannerisms, auditory stimuli from humming, proprioceptive stimuli from tapping), but can also involve social reinforcement such as attention from others or escape and avoidance of aversive stimuli (Willemsen-Swinkels et al. 1998). Such behaviors are often referred to as self-stimulatory behaviors. This function of stereotyped behaviors is strongly supported, although the underlying mechanisms are not yet understood (Cunningham and Schreibman 2008). Regardless of their cause, intervention addressing stereotyped behaviors can directly interfere with learning and participation in even simple daily functions (Baranek et al. 1997). Suppression of stereotyped behaviors is associated with increased responding and participation in activities (Morrison and Rosales-Ruiz 1997). One commonly used intervention strategy within the classroom is the passive application of somatosensory stimulation through weighted vests (Olson and Moulton 2004a, b). Weighted vest use is typically based on sensory integration theory, which purports that graded sensory inputs, especially tactile and proprioceptive inputs, enhance neurological function and decrease problems caused by difculty modulating sensory input (Baranek et al. 2008; Huebner and Dunn 2001). For example, weighted vests have decreased off-task behavior in some children with autism (Fertel-Daly et al. 2001; Hodgetts et al. in press), although most children have not shown improvements in this area (Hodgetts et al. in press; Stephenson and Carter 2009). Weighted vests have been linked with decreased stereotyped behaviors in persons with autism (Fertel-Daly et al. 2001; Myles et al. 2004; Reichow et al. 2010), although methodological weaknesses in the studies by Fertel-Daly et al. (2001) and Myles et al. (2004) were noted. Other research has found no effect (Deris et al. 2006) or a negative effect (Kane et al. 20042005) of weighted vests on stereotyped behaviors in persons with autism. No published research was located investigating the effects of weighted vests on underlying mechanisms. The purposes of this study were to (1) systematically investigate the effects of weighted vests on stereotyped behaviors in preschool- and elementary-school aged

children with autism in the classroom, and (2) test the effects of weighted vests on heart rate, a robust measure of physiological arousal (Soussignan and Koch 1985), addressing the theoretical basis of their use.

Methods This study represents a subset of a larger sample investigating the effects of weighted vests on a variety of behaviors (Hodgetts et al. in press). Participants and Setting Descriptive information is provided in Table 1. All names are pseudonyms. Participants were 5 boys and 1 girl between the ages of 410 years. Inclusion criteria was a conrmed diagnosis of autism, stereotyped behaviors that interfered with classroom participation based on teacher report, and sensory modulation dysfunction as identied by a total score more than 2 standard deviations below the mean on the parent report Short Sensory Prole (McIntosh et al. 1999). Five children were non-verbal and one had delayed echolalia, but limited or no functional language. Two children had veried severe cognitive delays, and psycho-educational assessment for the other four children could not be completed suggesting severe cognitive delays. All of the children received a diagnosis of autism as part of a multidisciplinary assessment, with four including the ADOSModule 1. Assessment information other than the Short Sensory Prole was from the childs school le. Assessments were completed within the past 2 years. There were no changes in school or home-based services or medications for any participant during the study. Each childs mother provided informed consent for her child to participate. The experimental setting was each childs self-contained classroom specic to children with autism. Each participant was observed at the same time of day during a typical classroom ne-motor table-top activity such as matching, sorting, coloring, and labeling by pointing. Each participants physical classroom environment, classroom teacher and aides, individual aide, and peers remained constant during the study. Aides sat directly beside or across the desk from each participant during activities. Materials and Equipment The commercially purchased weighted vests had two pockets for weights in front and two in the back. Weights were made of steel shot contained in leather pouches. For the baseline and withdrawal conditions, identical pouches

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Table 1 Summary of participant characteristics Weightlbs (wt. in vest) 49 (2 ) 141 Language: PLS-3 63 (3 ) 118 Moderate/low adaptive functioning (VABS) 120 (6) 43 (2 ) 127 Language: FCP, CSBS 50 (2 ; 5) 129 Language: PLS-4 Extremely low adaptive functioning (ABAS) 68 (3 ; 6) 127 Language: MacArthur, FCP Extremely low adaptive functioning (ABAS) Cognitive could not be completed Non-verbal Clonidine (attention/ hyperactivity) Rocking; hand apping Not measured Cognitive could not be completed Non-verbal None Cognitive could not be completed Non-verbal 140 Cognitive: WISC Delayed echolalia None Melatonin (insomnia) Prozac (hyperactivity) Hand and nger mannerisms; icking objects Measured Risperidone (aggression) Delayed echolalia Hand and nger mannerisms; spinning objects Not measured Measured Cognitive not available Non-verbal Clonidine (insomnia, hyperactivity) Clonidine (insomnia) Hand and nger mannerisms; icking objects Measured Cognitive: BSID Non-verbal Nalcrom (allergies) Flicking objects SSP total Standardized assessments Language Medications (parent/chart rationale) Stereotyped behavior Heart rate Measured

Child

Age

Diagnostic tool (age)

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Adam

80

ADOS (23)

Bobby

66

ADOS (27)

Connor

101

DSM-IV (40)

Hailey

311

ADOS (110)

Ian

56

DSM-IV (210)

Jack

64

ADOS (29)

Note: ABAS = Adaptive behavior assessment system (2nd edition); BSID = Bayley scales of infant development, 2nd edition; CSBS = Communication and symbolic behavior scales Developmental prole; FCP = Functional communication prole; MacArthur = MacArthur communicative development inventories; PLS = Preschool language scales (3 = 3rd edition; 4 = 4th edition); SSP = Short sensory prole; VABS = Vineland adaptive behavior scales (2nd edition); WISC = Wechsler intelligence scale for children (3rd edition)

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containing small Styrofoam balls were used. Raters could not tell if a vest was weighted based on appearance. Each child had their own vest, t so the researchers index and middle ngers t perpendicular under the straps on top of the shoulders and under the side Velcro strips. Heart rate data was collected using a Polar Vantage XL heart rate monitor (Polar Electro, Inc. 2006). Heart rate has been used frequently to measure responses to sensory stimuli in children with autism (Goodwin et al. 2006; Groden et al. 2005), and has been shown to be a particularly sensitive measure of arousal in children (Soussignan and Koch 1985). Although individuals with autism demonstrate signicant between-subject variability in heart rate, withinsubject variability of heart rate is small at baseline and within tasks, and increases as expected with physical exertion (Goodwin et al. 2006; Groden et al. 2005). The Polar Vantage XL is a portable, wireless monitor with a rubber electrode transmitter that fastens to gel pads adhered on a childs chest, and a watch-like receiver. Polar heart rate monitors demonstrate good reliability and validity based on simultaneous comparisons with electrocardiogram data, which is the gold-standard for non-invasive methods of heart rate monitoring (Groden et al. 2005; Kadish et al. 2001). We did not measure heart rate for Connor and Jack because they demonstrated physical resistance to the heart rate monitor when it was introduced. Targeted Behaviors Stereotyped behaviors were dened as repetitive movements or behaviors that did not appear to serve an adaptive function (Baumeister and Forehand 1973; as cited in Kennedy et al. 2000). Consensus was reached amongst the teacher, aide and researcher for the specic targeted behaviors, identied in Table 1. Experimental Design

equipment alone impacted behavior. The B and C phases were randomly assigned to control for observer bias. Heart rate monitors were worn while the child wore the vest on data collection days during B and C phases. Procedures Desensitization to Equipment To decrease potential behavioral and physiological stress responses due to the equipment alone during experimental (B and C) phases each participant wore his or her unweighted vest and heart rate monitor at various times during phase A, but not during Phase A data collection. Based on aide report, the equipment alone did not appear to impact behavior. Weighted Vest Protocol Each participant wore the vest for approximately 20 min each day at school for phases B and C, at approximately the same time each day. Aides used a simple script when putting on and removing the vest, and were coached not to change the script or tone of voice. Researchers did not collect video daily, but the vest was worn daily. Weights were calibrated at 5% of the childs body weight based on a review of the literature and common clinical practice as reported in an informal survey done by the primary author in the city in which the research took place. However, 10% of body weight was used during the second weighted phases for Ian and Jack, at the request of their mothers who did not think that 5% body weight would be enough. The vest was donned independently by Connor, and by the aides for the other ve participants. Aides were the only people, other than the participants, to have contact with the vests. Data Collection

A withdrawal design was used, which allowed replication of effects within and across participants. This design is suitable for behaviors that are reversible and where a return to baseline will not cause harm (Bailey and Burch 2002). Because we did not know if the vest and/or heart rate monitor alone would affect a childs behaviors, a 1-week phase without this equipment began the study (Phase A). This phase was only used to evaluate potential effects of the equipment alone when interpreting and discussing the data. Phase A was immediately followed by 2-week phases, B (vest with no weight) and C (vest with 510% body weight). Therefore, Phase A data were considered in relation to Phase B data once raters were unblinded to treatment condition to see if there was a marked difference between the phases, which could indicate that the

Each child was videoed individually, with the video recorder located unobstrusively while still providing a clear view of the child participating in the table-top activity. The aim was to have each child video recorded three times during phase A and ve times during each B and C phases. However, only two phase A videos were obtained for Hailey and Ian. Video recording was started once the vest was worn for approximately 5 min, based on therapists perceptions that the behavioral effects occur immediately (Olson and Moulton 2004a, b). The rst 5 min of video recording were coded. This resulted in a total of ten, 5-min videos for each treatment condition (weight or no weight) per child. Heart rate data, recorded in 5-s intervals, were collected at the same time as behavioral data.

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The primary rater, blinded to treatment condition, collected behavioral data using continuous observation. Each 5-min video was divided into 15-s intervals, and the percentage of intervals during which the child demonstrated stereotyped behavior was recorded. If a child had a stereotyped behavior at any point within an interval (once or multiple times), that interval received one checkmark. For example, if 10 of 20 intervals received a checkmark that child was considered engaged in stereotyped behavior for 50% of the intervals. Inter-rater Reliability A second trained observer independently scored 40% of the videos. Kappa co-efcients were calculated, with .60 as the acceptable minimum, representing good to excellent agreement (Watkins and Pacheco 2001). Reliability training involved in-person meetings with the primary rater to discuss coding procedures, review data collection sheets, review video footage of exemplars and non-exemplars of stereotyped behaviors for each participant, and rene operational denitions of these behaviors if required. Practice sessions using footage from phase A videos occurred until the minimum agreement was reached on three consecutive trials and both raters felt condent in all procedures. Subsequent to reliability training, when the raters did not agree, the primary rater reviewed the video a second time considering the areas of disagreement. Most discrepancies were due to brief behaviors that were easily missed; therefore, the primary rater felt condent that the additional review resulted in more accurate data and only the primary raters scoring was entered as data. Kappa co-efcients averaged 0.74, ranging from 0.61 to 0.85.

Treatment Fidelity Aides completed a daily treatment delity checklist. Aides put a checkmark when the protocol was followed as intended, and provided written comments for days when the treatment protocol was not followed in whole or in part. Treatment delity averaged 90%, ranging from 78 to 96%. Child or aide absence was the most common reason for lack of delity. Data Analysis Visual analysis included interpretation of the level, trend and variability of performance within and between phases, and the immediacy of effects following the introduction or withdrawal of the weighted vest (Horner et al. 2005). Percent non-overlapping data (PND) statistics were used to support visual analysis and provide an objective interpretation of data by providing cut-scores for treatment effectiveness (provided in Table 2), using the formula and cut-scores recommended by Scruggs and Mastropieri (1998). Only B and C phases were used to calculate PND statistics. The lowest point in each B phase was used to calculate PND because a decrease in stereotyped behavior was desired with the treatment. In addition to visual analysis and PND statistics of mean heart rate per day, standard deviation of heart rate was calculated for each child for each day the heart rate monitor was worn to determine if there was a difference in the variability of heart rate between baseline and treatment phases, indicating better modulation. Mean and standard deviation were used as measures of variability because heart rate data were normally distributed.

Table 2 Data summary Change in stereotyped behaviors Adam Bobby Connor Hailey Ian Jack No effect (PND = 40%) No effect (PND = 0%) ; 18% (PND = 60%) No effect (PND = 0%) No effect (PND = 0%) No effect (PND = 20%) Average % intervals stereotyped behaviors No weight: 27% Weight: 20% No weight: 34% Weight: 32% No weight: 35% Weight: 17% No weight: 11% Weight: 19% No weight: 26% Weight: 21% No weight: 43% Weight: 38% No effect (PND = 20%) No effect (PND = 10%) n/a No weight: 108 (11.10) Weight: 111 (16.37) No weight: 117 (7.98) Weight: 119 (10.04) Change in heart rate between weighted/unweighted phases Increase 7 bmp (PND = 70%) No effect (PND = 10%) n/a Average heart rate per phase (bmp); SD No weight: 104 (5.45) Weight: 111 (3.68) No weight: 111 (8.83) Weight: 111 (7.86)

PND 90%? = very effective; 7990% = effective; 5070% = questionable effect; \50% = ineffective (Scruggs and Mastropieri 1998)

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Results The graphed data (Figs. 1, 2, 3, 4, 5, and 6) and PND statistics suggest that the weighted vest did not functionally decrease motoric stereotyped behaviours but may have possibly decreased Connors verbal stereotyped behaviour. There was considerable variability in behaviour, within and between phases, within and between participants. The weighted vest appeared to decrease variability only for Connor. Visual analysis and PND statistics indicate that the weighted vest was associated with increasing heart rate in
Fig. 1 Stereotyped behavior for Adam

Adam, but based on visual analysis this effect was small. Heart rate did not change in the other three participants. There was considerable variability in mean heart rate within and between phases. Weighted vests did not decrease heart rate variability. A summary of data is presented in Table 2.

Discussion Weighted vests are thought to provide sensory input to help modulate arousal. Typically, vests are implemented to

Fig. 2 Stereotyped behavior for Bobby

Fig. 3 Stereotyped behavior for Connor

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J Autism Dev Disord (2011) 41:805814 Fig. 4 Stereotyped behavior for Hailey

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Fig. 5 Stereotyped behavior for Ian

Fig. 6 Stereotyped behavior for Jack

reduce stereotyped behaviors, which are viewed as a childs attempt to calm and modulate arousal during stressful activities or in stressful environments (Rogers and Ozonoff 2005). Theoretically vests could replace this function of a stereotyped behavior. However, we did not see a decrease in motoric stereotyped behaviors in any participant when wearing a weighted vest; a result replicating previous research with children with autism (Deris et al. 2006; Kane et al. 20042005), although Connor did show changes in verbal stereotyped behavior.

There are at least two possible explanations for the lack of effects of the vests. First, the participants motoric stereotyped behaviors may not be serving an arousal modulation function. Many users of weighted vests identify a calming and modulating function for the vests (Olson and Moulton 2004a; Stephenson and Carter 2009). However, if this is not the purpose of the participants stereotyped behaviors then changes in behaviors would not be expected. Participants behaviors primarily t into WillemsenSwinkels and colleagues (1998) elation category. Such

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behaviors may serve as an outlet for excitement or provide sensory feedback. The sensory feedback function of stereotyped behaviors appears plausible for our participants, given that their behaviors occurred across activities and environments (e.g., calm days, busy days). Most of their stereotyped behaviors provided more than just tactile and proprioceptive input. For example, hand and nger mannerisms, hand apping and icking also provided visual input. Weighted vests could not provide this variety of sensory input. A second possible explanation is that if the behaviors were modulatory, the input provided through the weighted vest was not sufcient to replace that provided by the behaviors. Weighted vests use is currently based on theory and precedent, and not empirical support (Reichow et al. 2010). Assuming that weighted vests are effective for some children, the optimal amount of weight, wearing time, and response time are not known, and, therefore, may not have been represented in our protocol. Connors decrease in verbal stereotyped behaviors could support the arousal modulation hypothesis. Connor was the only participant with verbal (not motoric) stereotyped behaviors. However, the verbal nature of his behaviors may be less relevant than his overall emotional state. Connor was the most agitated and anxious of all the participants, often yelling, banging his desk or the wall, throwing his chair, and turning over his school desk when upset. Previous research on somatosensory stimulation and personal accounts of the calming effects of deep-pressure input suggest that this type of input may be most effective for individuals who are anxious or agitated (Edelson et al. 1999; Grandin and Scariano 1986), like Connor. Although under-responsivity to sensory input is more common in persons with autism, some people demonstrate over-responsivity to sensory input (Rogers and Ozonoff 2005), and there is evidence for an association between sensory over-responsivity and anxiety in persons with autism (Green and Ben-Sasson in press). Anxiety and agitation are represented by physiological over-arousal, such as increased heart rate (Goodwin et al. 2006). Thus, the arousal modulation theory for weighted vests could be supported if the weighted vest resulted in decreased heart rate for Connor. Unfortunately, we do not have heart rate data for Connor. There was no decrease in heart rate in any participant with motoric stereotyped behavior. Adam had an increase in heart rate with the weighted vest. His behaviors might t into Willemsen-Swinkels and colleagues (1998) composure category where stereotyped behaviors counter-balance under-stimulation. However, even with a physiological effect of the weighted vest, this was not related to functional changes, as Adams stereotyped behaviors did not decrease. The metabolic demands of activities also underlie heart rate. Typically developing children demonstrated an

increase in heart rate of approximately 8 beats per minute while wearing a backpack with 10% bodyweight when standing still (Hong et al. 2000). Therefore, it is possible that Adams heart rate increased due to the increased metabolic demand from carrying the load. Increased metabolic load may have confounded the heart rate data for other participants for whom the weighted vest had a physiological effect, but did not show any change in heart rate with the weighted vests. In other words, an effect of the weighted vest on decreasing heart rate combined with increased heart rate due to carrying increased load could have created a wash out effect of no heart rate response. However, the potential increase in heart rate due to metabolic load in our study should have been less than the 8 beats per minute found by Hong and colleagues because, other than Ian, the vests only contained 5% body weight, the participants were sitting and the weight was evenly distributed around the body, unlike a backpack. Of note, Ian did not show a difference in mean heart rate between 5 and 10% body weight. The theoretical basis for weighted vests assumes that the touch-pressure input provided by weighted vests has a regulatory inuence over other stimuli regardless of the type of sensory input. Thus, weighted vests are recommended to provide an overall calming and modulating inuence to decrease stereotyped behaviors, regardless of their form (Olson and Moulton 2004a, b; Stephenson and Carter 2009). We did not nd that weighted vests had an impact on motoric stereotyped behaviors, but, these behaviors have been successfully eliminated with behavioral intervention (e.g., systematic extinction procedures) when replaced with more socially appropriate means of achieving the same type of sensory stimulation (Cunningham and Schreibman 2008). This suggests that intervention targeting stereotyped behaviors is more likely to be effective if these behaviors are replaced with a more functional behavior of the same type (sensory specic) rather than the use of a weighted vests to decrease the behavior (Cunningham and Schreibman 2008). There are limitations of this study. We did not do a functional analysis of behaviors; therefore, we do not know the purpose of each childs stereotyped behaviors. Additionally, due to time constraints imposed by the school system, we pre-determined phase length to ensure three demonstrations of experimental effect (BCBC phases), as recommended for experimental control in single-case research (Horner et al. 2005). As a result, there were some cases when phases were switched prior to achieving stability during B phases. Thus, internal validity decreased because we could not be condent that changes in behavior were isolated to effects of the weighted vest and not an unknown variable for all participants. Phase A had to be limited to 2 or 3 data points for each participant, which is

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813 Bailey, J. S., & Burch, M. R. (2002). Research methods in applied behavior analysis. Thousand Oaks, CA: Sage Publications. Baranek, G. T. (2002). Efcacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders, 32, 397422. Baranek, G. T., Foster, L. G., & Berkson, G. (1997). Tactile defensiveness and stereotyped behaviors. American Journal of Occupational Therapy, 51(2), 9195. Baranek, G. T., Wakeford, C. L., & David, F. J. (2008). Understanding, assessing and treating sensory-motor issues in young children with autism. In K. Chawarska, A. Klin, & F. Volkmar (Eds.), Autism spectrum disorders in infancy and early childhood: Diagnosis assessment and treatment (pp. 104140). New York: Guilford Press. Baumeister, A. A., & Forehand, R. (1973). Stereotyped acts. In N. R. Ellis (Ed.), International review of research in mental retardation (Vol. 6). New York: Academic Press. Ben-Sasson, A., Hen, L., Fluss, R., Cermak, S. A., Engel-Yeger, B., & Gal, E. (2009). A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(1), 111. Cunningham, A. B., & Schreibman, L. (2008). Stereotypy in autism: The importance of function. Research in Autism Spectrum Disorders, 2(3), 469479. Deris, A. R., Hagelman, E. M., Schilling, K., & DiCarlo, C. F. (2006). Using a weighted or pressure vest for a child with autistic spectrum disorder. (ERIC Document Reproduction Service No. ED490780). Edelson, S. M., Edelson, M. G., Kerr, D. C. R., & Grandin, T. (1999). Behavioral and physiological effects of deep pressure on children with autism: A pilot study evaluating the efcacy of Grandins hug machine. American Journal of Occupational Therapy, 53, 145152. Fertel-Daly, D., Bedell, G., & Hinojosa, J. (2001). Effects of a weighted vest on attention to task and self-stimulatory behaviors in preschools with pervasive developmental disorders. American Journal of Occupational Therapy, 55, 629640. Goodwin, M. S., Groden, J., Velicer, W. F., Lipsitt, L. P., Baron, M. G., Hofmann, S. G., et al. (2006). Cardiovascular arousal in individuals with autism. Focus on Autism and Other Developmental Disabilities, 21, 100123. Grandin, T., & Scariano, M. M. (1986). Emergence labeled autistic. Novato, CA: Arena Press. Green, S.A., & Ben-Sasson, A. (2010). Anxiety disorders and sensory over-responsivity in children with autism spectrum disorders: Is there a causal relationship? Journal of Autism and Other Developmental Disorders. doi:10.1007/s10803-010-1007. Groden, J., Goodwin, M. S., Grace Baron, M., Groden, G., Velicer, W. F., Lipsitt, L. P., et al. (2005). Assessing cardiovascular responses to stressors in individuals with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 20, 244252. Hodgetts, S., Magill-Evans, J., & Misiaszek, J. (2010). Effects of weighted vests on classroom behavior for children with autism and cognitive impairments. Research in Autism Spectrum Disorders. doi:10.1016/j.rasd.2010.06.015. Hong, Y., Li, J. X., Wong, A. S. K., & Robinson, P. D. (2000). Effects of load carriage on heart rate, blood pressure and energy expenditure in children. Ergonomics, 43(6), 717727. Horner, R. H., Carr, E. G., Halle, J., Mcgee, G., Odom, S., & Wolery, M. (2005). The use of single-subject research to identify evidence-based practice in special education. Exceptional Children, 71, 165179. Huebner, R. A., & Dunn, W. (2001). Introduction and basic concepts. In R. A. Huebner (Ed.), Autism: A sensorimotor approach to management (pp. 340). Austin, TX: Pro-ed.

less than the minimum of 5 data points recommended by Horner and colleagues. Although heart rate has been deemed a robust measure of physiological arousal, it does not provide information about the responsible mechanisms since it is under joint control of sympathetic and parasympathetic inuences (Goodwin et al. 2006). It has been suggested that it is parasympathetic inuences that are specically targeted by weighted vests, although this has not been empirically tested (Lane 2001). A more sophisticated measure of autonomic activity, such as heart rate variability, may have provided more insight into the effects of weighted vests on underlying mechanisms.

Summary and Conclusions More research is needed addressing the function of stereotyped behaviors in persons with autism, including linking behaviors to underlying mechanisms. Similarly, systematic research is needed on the functional effects of weighted vests and other sensory stimulation interventions. No other research has tested the theoretical basis for weighted vests by measuring effects on underlying mechanisms. Even if physiological responses to the somatosensory stimulation provided through weighted vests were found, these effects need to be linked with functional outcomes before weighted vests can be endorsed as an effective treatment strategy. Stereotyped behaviors are commonly targeted with weighted vests, based on the assumption that both these behaviors and weighted vests serve a homeostatic function. This studys results do not support the use of weighted vests to decrease motoric stereotyped behaviors, nor does it support the theoretical basis for this modality. Therefore, if weighted vests are recommended, a functional analysis of the targeted behavior should occur, desired outcomes should be dened a priori, and outcomes should be systematically monitored.
Acknowledgments The authors express appreciation to the children, parents, educational aides and teachers who participated in this project. This project was supported by grants from the Alberta Centre for Child, Family and Community Research and the Canadian Occupational Therapy Foundation, and research awards received by the rst author through the Alberta Centre for Child, Family and Community Research, Autism Research Training Program (CIHR Strategic Initiative in Health Research), and Sick Kids Foundation: Children and Youth Home Care Network.

References
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