Running head:​ EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

Educational Transition: Effects of Sensory Integration on Social Anxiety in Children with

Autism Spectrum Disorder

Mackenzie Carter

Zach Ellis

Meg Nielson

Allison Smith

University of Utah
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

Educational Transition: Effects of Sensory Integration on Social Anxiety

In the United States 1 in 68 children are diagnosed with autism spectrum disorder (ASD)
(Christensen et al., 2016). More than 80% of children who are diagnosed with ASD have associated
sensory processing difficulties (Case-Smith, Weaver, & Fristad, 2015). Along with the prevalence of
sensory difficulties, studies have found that anxiety disorders occur in 40% of school age children and
adolescents diagnosed with ASD (Ambler, Eidels, & Gregory, 2015). Sensory integration (SI) is a
intervention approach that is being used with ASD and sensory difficulties in hopes to increase
participation in the child’s age appropriate occupations (Schaaf, Hunt, & Benevides, 2012). Throughout
the literature it is found that there is a link between ASD and anxiety, but a lack of interventions on how
to diminish the child’s anxiety. White et al. (2014) found that social anxiety contributes to loneliness,
which can also impact the transition process and future experiences with social anxiety. Due to recent
statistics, the objective of the proposal is to implement an SI program for kids transitioning to middle
school to reduce social anxiety in children with ASD.

Aims/Hypothesis:

Aim 1: Evaluate whether participating in a sensory integration program for reduces social anxiety in
children with ASD.
○ Hypothesis A: This program will significantly reduce social anxiety experienced by
children with ASD during the transition from elementary to middle school as measured
by reduced number of outbursts.
○ Hypothesis B: This program will significantly improve social anxiety as measured by
higher rating on emotional rating scale post sensory integration program.

Aim 2: Evaluate the use of sensory integration program for improving social participation​. (​Effective
sensory integration techniques introduced to improve social participation during transition from
elementary to middle school.)
○ Hypothesis A: This program will significantly improve social participation as assessed by
increased initiated social interactions through results given on the COPM, per parent and
teacher report.
○ Hypothesis B: This program will significantly improve social participation as assessed by
decreased number of cues post sensory integration program.
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

Background Literature

Anxiety in Children with Autism

Studies consistently show high prevalence of anxiety in school age children with ASD. According

to Keith, Jamieson, and Bennetto (2018), atypical sensory processing and anxiety are highly prevalent in

everyday lives of children with ASD, and can range up to 85%. They found that children and adolescents

with ASD were capable of self-reporting when they were experiencing anxiety symptoms, and is higher

when self-reported as opposed to parent reported. According to Ozsivadjian, Knott, and Magiati (2012),

behaviors can often occur because of anxiety, examples being aggression, avoidance, sensory behavior,

which can be misinterpreted as a behavior associated with ASD rather than anxiety. Anxiety in children

attending mainstream schools can stem from the lack of order and predictability in their environment,

frequent interruptions and changes, new schedules and curriculum, and overall adolescent pressures.

Students with ASD often have difficulty in these areas and may lack the flexibility to overcome them

(Ambler, Eidels, & Gregory, 2015).

Green and Ben-Sasson (2010) explored the connection between anxiety disorders and sensory

over-responsivity (SOR) in children with ASD and came up with three theories to explain the connection.

The first theory is that SOR is caused by anxiety. Second theory is anxiety is caused by SOR. Lastly, the

third theory is that anxiety and SOR are unrelated but associated due to a common risk factor or

diagnosis. The choice of intervention is determined by which theory is chosen. Using SI is a common

treatment for SOR which suggests if anxiety is caused by SOR, then SI would help treat both.

Effectiveness of Sensory Integration on Occupation

Schaaf et al. (2014) performed a study utilizing Ayres SI intervention using activities that were

tailored to the child based on goals. All the activities have a focus on sensory-motor experiences during

child directed play. This study found that the children scored higher on their goal attainment scale and

needed less help from their caregivers during social activities and self-care tasks compared to the group
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

who did not receive intervention. Communication skills have also been shown to improve with Ayres SI

intervention. Working on sensory integration can have a positive impact on children with ASD

communication skills which in turn may improve their overall social performance and participation

(Kashelfimehr, Kayihan, & Meral, 2017).

Emotional regulation strategies, through SI, help children who are experiencing

over-responsiveness, under-responsiveness or need to decrease an emotional response during arousing

situations. Research has found there is a correlation of deficits in emotional regulation and anxiety for

children with ASD (White et al., 2014). It imperative to address how emotional regulation impacts social

participation and social skill development, which affects occupational performance in the school

environment.

Educational Transition

The transition from elementary to middle school requires a great degree of changes and

expectations for children such as moving classes, different teachers and students in each class, using a

locker, and lunchroom and hallway chaos. For children with ASD, these social demands can heighten

social anxiety. A previous peer network intervention program found that increased social engagement and

social supports for students with ASD improved their ability to use adaptive strategies during social

interactions, thus improving their social skills throughout their lifespan (Bourque-Thiemann, 2010).

This school-based program allowed students to use skills in their natural environment. The

proposed summer program would be beneficial as a precursor to the new school year with increased

demands of a new school environment. It would also be beneficial to identify and utilize appropriate

sensory strategies during exacerbated social anxiety. Johnstone, Kemps and Chen (2018) performed a

meta-analysis to examine the effectiveness of universal school-based prevention programs and found that

these school-based programs did not prevent anxiety, but rather they decreased anxiety and depressive

symptoms. In addition, they found that the FRIENDS program had positive effects because it teaches
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

children strategies to be able to recognize their own anxiety and dysfunctional thoughts. Along with

teaching the child to recognize their own emotions, there needs to be individualized transition support as

well as group work and support to incorporate and practice skills learned. Parents should also be included

in this transition to lessen anxiety (Nuske et al., 2018).

Purpose (how the study will advance the field)

This is an important area for study in order for practitioners to effectively assist children with

ASD transitioning from elementary school to middle school with less anxiety. It has also been found that

children with ASD and anxiety commonly have more reactive aggression and are at risk for suspension

due to the increased social demands of a new school environment (White et al., 2014). This study will

allow practitioners to see the potential effect that SI can have on reducing the child’s social anxiety during

school transition. In turn, this would lead to better occupational performance at school.

Current research has indicated there are limited resources for school transition for students with

ASD. Many limitations stated the school staff was unable to individualize the transition for these students.

This proposal would support the student’s individual sensory needs aimed at reducing social anxiety,

which will reduce the risks of disruption in learning (Nuske et al., 2018). The proposed summer program

addresses sensory needs in the natural context of the new environment and allows student to gradually

adjust. When reviewing similar programs, Nuske et al. (2018) found that supporting the transition prior to

the school year often requires fewer, but more effective resources and strategies for students with ASD. In

addition, one study done by Chalfant, Rapee and Carroll (2006) found that cognitive behavioral based

treatment (CBT) decreased anxiety in children with ASD to the point that they no longer fulfilled criteria

for an anxiety disorder. Occupational therapists are currently using CBT; however, incorporating a SI

based intervention would be a valuable method for children with sensory deficits. This proposal provides

more evidence based research in SI, strengthening the repertoire for occupational therapists.

Methods
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

Participants

Participants will be 15 children ages 10-13, who have a diagnosis of ASD and are transitioning

from elementary to middle school. This study will accept participants of both genders. Although the study

is not aiming for a particular gender ratio, we expect to have more boys because that is representative of

the population of ASD.

The inclusion criteria for approval of participants are as follows: 5th or 6th grade students

transitioning into middle school (in a new environment). An official diagnosis of ASD, having sensory

processing difficulties, and social interaction difficulties. Participants need to be able to communicate by

some means (verbal, written, augmentative) due to the type of assessments that will be performed.

Exclusion criteria are as follows: students remaining in the same cohort, school building (K-12) or those

who are being homeschooled. Children with no means of communication and children with a severe

intellectual disability will also be excluded.

Research Design

This study will be a mixed methods design, with quantitative and qualitative data collection. The

quantitative aspect will come from using the Effectiveness of Severity Measure for Social Anxiety

Disorder - Child Age 11-17 to assess the children’s anxiety level. The Canadian Occupational

Performance Measure (COPM) will be used to determine what areas of occupations may be impacted due

to their social anxiety, providing qualitative data. In addition, there will be observable data, through

observation in social participation with peers during the program.

This study will be a quasi-experimental design using a single group design with pre and post tests

to evaluate the use of the sensory intervention on a child’s social anxiety and participation as they

transition schools. A single-group design was selected because research on using SI as an intervention to

work on social anxiety in children with ASD is limited, and empirical research is needed at this level prior
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

to moving to a more rigorous, multi-group design. After the initial study is done further studies will be

conducted using a control group comparison.

The independent variable for this study is the sensory integration program using Ayres SI to track

the progress that participants make using SI. The dependent variables for this study are social anxiety and

social participation. Social anxiety will be measured through effective emotional regulation (decreased

outbursts) and the use of pre and post tests measured by the emotional rating scale. Social participation

will be measured through the number of initiated social interactions (eye contact, conversations, greeting

peers) and decreased number of cues to engage in social interactions.

Measures

Canadian Occupational Performance Measure. ​The Canadian Occupational Performance

measure (COPM) (Law et al, 1990) is an individualized outcome measure that will be used with

participants and their parents. The COPM has occupational performance categories of self-care,

productivity, and leisure. Using this measure allows the parent and child to discuss strengths, weaknesses,

and what occupations are most impacted. The parent and child rate the occupations on a scale 1 (not

important) to 10 (extremely important) on how important they are in their life. A scale of 1 to 10 will then

be used on their performance (1-not able to do at all, 10-able to do extremely well) and their satisfaction

(1-not satisfied, 10-extremely satisfied) with the way they do the occupation. This information will be

useful to identify occupations being impacted and this gives insight to social aspects of occupations that

may be affected. Debbing, Cardol, Eyssen, and Beelen (2004) examined the validity of the COPM and

found that there is supportive evidence for the convergence and divergence validity.

Measure of Social Anxiety Disorder. ​The Severity Measure for Social Anxiety Disorder-Child

Age 11-17 (SAD-D) is a self-report developed by the American Psychological Association. This

questionnaire has 10 questions for the child to answer about how they felt, acted, and thought about

certain situations during the last 7 days. On a 5-point scale (0 being never to 4 being all of the time). High
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

scores indicate higher social anxiety. A study found that self-reports used with children with ASD have

the most accurate perspective on their own internal feelings and experiences. These self-reports along

with parent reports will provide the most comprehensive information which will be useful for intervention

(Jamieson & Bennetto, 2018). Lebeau et al. (2012) examined the psychometric properties of the DSM-V

self-rated scales of social anxiety which determined internal consistency (𝝰 = 0.85-0.92), convergent

validity (r = 0.39-0.69) and test-retest reliability (ICC=0.51-0.81) for the SAD-D.​ ​This study will be using

this measure biweekly to gauge the level of anxiety the participants have felt the last week.

Anxiety Scale for Children. ​The Anxiety Scale for Children – Autism Spectrum Disorder –

Child version (ASC-ASD)© is a 24 statement questionnaire that the child will rate how often the

statements occur using never, sometimes, often, and always. These statements reflect how the child feels

and what they worry about. Research found that the reliability of this survey was good and validity shows

that it does measure anxious affect experienced by children (Rodgers et al, 2016).

Procedures

Participants will be recruited from elementary schools, outpatient clinics, parent support group,

doctor referrals, and specialized ASD programs. The primary means of recruitment will be pamphlets at

doctors offices, outpatient clinics and elementary schools. In addition, alternative means for recruitment

will be meetings/presentations for parent support groups and specialized ASD programs. Participants will

give assent and their guardians will give informed consent to participating in the study and summer

program.

This program will be a 12 week summer program beginning with creating a sensory profile of the

child to formulate an intervention plan for SI. Occupational therapists will administer the ASC-ASD to

the student, and the COPM to the parent, which will give insight to how anxiety is impacting their

occupations. The first 4 weeks of an individualized SI program will includes educating and teaching the

child how to utilize emotional regulation strategies. The following 6 weeks will include other children to
EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

participate in social groups so that the study participants can utilize their new skills. In the final 2 weeks

participants will go to their new schools and do a walk through to show them where classes are, meeting

teachers, practice using locker, and other needed skills. The time in the school will establish places the

students can use individualized SI tools, strategies, and resources, if experiencing anxiety in the new

school in the future. Classmates and volunteers will be asked to join the last 2 weeks in hope of creating

an environment resembling what the school will be like with having noise and people in the hallways.​ ​The

post assessments will be given one month post completion of the program.

Human Participants Protection. ​The proposed program requires assent from participant who

are minors, with parental consent to protect this vulnerable population. Coping and emotional regulation

strategies will also be provided. Consultative services from the school psychologist provides support to

students who may need it. University of Utah Institutional Review Board (IRB) approval will be obtained

prior to beginning this project.

Data Analysis:

The data analysis will be a mixed design with both qualitative measures (COPM) and quantitative

measure (Measure for Social Anxiety Disorder, ASC-ASD child comparison, and COPM). This is going

to be a multivariate analysis with two variables (social participation and social anxiety), analyzed with a

paired sample t-test to determine whether there are significant differences from pre- to post-intervention.

Significance of the T-test is by measured by p < 0.05. The performance and satisfaction scores of the

COPM will be measured pre/post study as well as using grounded theory to identify themes of

occupational performance concerns reported by parents.

EFFECTS OF SENSORY INTEGRATION ON SOCIAL ANXIETY

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