Occupational therapy practitioners focus on performance issues that affect their clients’ ability to engage in meaningful occupations (American Occupational Therapy Association [AOTA], 2008). (The term occupational therapy practitioner in this article refers to both occupational therapists and occupational therapy assistants; AOTA, 2006 .) Practitioners are increasingly being asked to provide evidence of the effectiveness of their interventions. To do so, it is critical to clearly identify the performance difficulties presented by interventions. For people with difficulty processing and integrating sensory information, identification of performance difficulties will help target occupational therapy interventions. These data will be useful to (1) guide assessment and intervention, (2) assist occupational therapists in choosing relevant outcome measures, and (3) guide research design and efficacy trials in areas of occupation that have relevance for children and adolescents with difficulty processing and integrating sensory information. Thus, the goal of this review was to identify the performance difficulties that children and adolescents with difficulty processing and integrating sensory information demonstrate in activities of daily living (ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.

One important step in the process of identifying the performance difficulties observed in a clinical population is to clearly define the target population. Given the heterogeneity of the children and adolescents with difficulties processing and integrating sensory information, this task is challenging; therefore, for this review, performance difficulties that children and adolescents with sensory issues may demonstrate were grouped according to difficulties in the following areas of occupation: play and leisure, social participation, ADLs, IADLs, rest and sleep, education, and work. Although current research has attempted to identify the comorbidity of difficulties processing and integrating sensory information in different diagnostic groups using a variety of measures, the literature often then does not link their sensory issues to actual performance difficulties. Studies may discuss sensory processing issues associated with diagnostic conditions, including fragile X (Baranek et al., 2002), Asperger syndrome (Blakemore et al., 2006; Dunn, Smith-Myles, & Orr, 2002; Pfeiffer, Kinnealey, Reed, & Herzberg, 2005), autism (Baranek, David, Poe, Stone, & Watson, 2006; Ben-Sasson et al., 2009; Kern et al., 2006; Liss, Saulnier, Fein, & Kinsbourne, 2006), and attention deficit hyperactivity disorder (ADHD; Dunn & Bennett, 2002; Mangeot et al., 2001; Parush, Sohmer, Steinberg, & Kaitz, 2007), but fail to link sensory issues to actual performance deficits in the areas of occupation. Additional studies investigating difficulties processing and integrating sensory information with no other diagnostic classifications also do not focus on evaluation of participation difficulties (Davies & Gavin, 2007; Goldsmith, Van Hulle, Arneson, Schreiber, & Gernsbacher, 2006; Reynolds & Lane, 2008).

To further complicate this issue, the population of children with difficulties processing and integrating sensory information often includes children with motor issues as well. For example, Ayres (1985)  showed that children with dyspraxia and developmental coordination disorder (DCD) who have motor execution difficulties also have an underlying sensory deficit. Ayres  hypothesized that motor planning deficits, which she termed developmental dyspraxia, were another significant manifestation of sensory integration dysfunction. Similarly, in a nosology proposed by Miller, Anzalone, Lane, Cermak, and Osten (2007), sensory-based motor disorders are used to describe children who have difficulty with the praxis and postural requirements of a motor task but who may have underlying sensory deficits that contribute to motor coordination problems. Thus, studies addressing these groups were included in the review.

Studies that do include descriptors of functional performance deficits include anecdotal reports and case reviews that describe difficulty with performance of daily routines (e.g., dressing, brushing hair and teeth) and the behavioral outbursts accompanying those routines (Kinnealey, 1998; Reeves, 1998). Studies that use sensory histories and interviews include responses to sensory input and its impact on performance but in a nonstandardized format. With the development of more psychometrically sound sensory measures such as the Sensory Profile (Dunn, 1999) and the Sensory Processing Measure (Parham, Ecker, Kuhaneck, Henry, & Glennon, 2006), more systematic, standardized information can be obtained on the impact that difficulties processing and integrating sensory information have on functional performance.

At this stage, to fully understand the performance challenges experienced by children and adolescents who have difficulty processing and integrating sensory information, we must be inclusive of all clinical groups who may have these problems but pose questions specific to their sensory issues. For example, we might pose questions such as, How do underresponsive or overresponsive sensory patterns affect daily routines and ADLs? What impact do difficulties processing and integrating sensory information have on school performance? Do atypical sensory processing patterns have a direct impact on play and social participation? Do children with dyspraxia and DCD have more difficulty with the task demands of the environment and with everyday participation, and are these related to their sensory or motor problems or some combination of both? This systematic review contributes to the identification of performance deficits in children and adolescents with difficulties processing and integrating sensory information and provide recommendations for future research to include demonstrated performance measures that are relevant to performance in areas of occupation that are critical to successful participation.

The portion of the Evidence-Based Literature Review of Occupational Therapy for Children and Adolescents With Sensory Processing Disorder/Sensory Integrative Dysfunction reported in this article addresses the challenges for children and adolescents with difficulty processing and integrating sensory information in areas of occupation. Detailed information about the methodology for the entire literature review can be found in the article “Methodology for the Systematic Reviews of Occupational Therapy for Children and Adolescents With Difficulty Processing and Integrating Sensory Information” in this issue (Arbesman & Lieberman, 2010). An exception to the methodology listed in Arbesman and Lieberman is that several studies were added that were published after 2007 because of their particular relevance to the question of performance difficulties.

Also of note is the inclusion of articles on participants with DCD. As stated previously, DCD is frequently used as a synonym for dyspraxia. It is a relevant diagnostic group to include in this systematic review because some evidence indicates a sensory component to the motor difficulties of people with DCD. Finally, although an extensive body of literature exists as to how autism spectrum disorders affect social, educational, and functional outcomes, inclusion was limited to research that included a measure of sensory behaviors in addition to demonstrated performance deficits to identify potential relationships.

Thirty-five studies met the inclusion criteria for the following question: What are the demonstrated performance difficulties for children and adolescents with difficulties processing and integrating sensory information in the areas of play, leisure, and social participation; ADLs and IADLs; rest and sleep; and education and work? There were 19 Level II studies, 11 Level III studies, 2 Level IV studies, 2 Level V studies, and 1 qualitative study. No Level I studies were found that were relevant to the topic. The articles in the review were divided into four areas of occupational performance: (1) play, leisure, and social participation; (2) ADLs and IADLs; (3) rest and sleep; and (4) education, transition, and work. An evidence table including all articles reviewed in this systematic review is available at www.ajot.ajotpress.net (navigate to this article, and click on “supplemental materials”).

Seventeen articles related to the areas of play, leisure, and social participation were reviewed. Thirteen were Level II studies, and 4 were Level III studies relevant to social skill development, play, and physical activity. All but one of the studies were nonintervention observational studies using various tools and measures to describe performance and areas of difficulty for children and adolescents with difficulty processing and integrating sensory information or related conditions, such as DCD. One intervention study (Lloyd, Reid, & Bouffard, 2006) was included because of the descriptive nature of the measures taken at baseline that give information relevant to functional performance deficits. Table 1 presents sample articles that are most representative of the 17 articles reviewed for this area of occupation and includes information about the objectives, design, procedures, findings, and limitations of the reviewed studies.

The studies provide evidence to suggest that children with difficulty processing and integrating sensory information show decreased quality and quantity of play skills and social participation. In terms of social participation, a Level III study that directly linked sensory processing symptoms and social competence (Hilton, Graver, & LaVesser, 2007) found statistically significant correlations between sensory processing and social competence. In this study of 36 children with high-functioning autism ages 6–10, patterns of sensory avoiding and sensory sensitivity, as measured by the Sensory Profile, displayed the strongest correlations between social performance and sensory processing. Children who had high sensory overresponsivity demonstrated the poorest social performance. A direct link between sensory overresponsiveness and social performance may exist, but cross-sectional studies are unable to infer that one variable is causally related to the other, and it has not been established, beyond anectodal information, how sensory issues affect social participation.

For children with DCD, a Level II study of 39 children with and without DCD by Cummins, Piek, and Dyck (2005)  showed that scores on tests of neuromotor coordination were significant predictors of social problems in children. In addition, Cummins et al. (2005)  found a significant relationship between motor coordination and social problems.

In terms of play skill development, Smyth and Anderson (2000)  found that children with DCD spent more time alone and were more often onlookers in social play, indicating that play involvement is affected by poor coordination. In addition, physical social play was decreased in children with DCD but varied among people with DCD; some boys with DCD took part in team games, but others did not. No differences were found between children with and without DCD in social fantasy play, suggesting that coordination disorders have more impact on motor-based play.

In a cross-sectional, Level III study by Cairney et al. (2005), the authors attempted to determine whether a link exists between DCD and reduced physical activity. Results showed that DCD is associated with decreased variation in physical activity level. Poulsen, Ziviani, Cuskelly, and Smith (2007)  found that boys with DCD recorded significantly lower participation rates in both structured and unstructured physical activities than boys without DCD. In addition, physical coordination difficulties were significantly related to loneliness. The authors did, however, find an inverse relationship between physical coordination ability and loneliness when mediated by participation in team sports. The social participation appeared to act as a protective factor for boys with DCD when compared with boys with DCD who did not participate in team sports.

Table 2 presents sample articles from the studies related to the theme of ADLs and IADLs. Two Level II studies, four Level III studies, two Level IV studies, and one qualitative study addressed ADLs and IADLs related to performance areas such as eating and self-care as well as overall functional behaviors and participation. Evidence was found to suggest that children with difficulty processing and integrating sensory information demonstrate more difficulty with functional performance, particularly the motor aspects of the functional tasks. Functional performance is defined as demonstrated performance in the areas of ADLs including but not limited to eating, dressing, grooming, and hygiene.

In a Level III study by White, Mulligan, Merrill, and Wright (2007), significant differences in Assessment of Motor and Process Skills (AMPS; Fisher, 2003) and ADL measures were found between typically developing children and children with atypical scores on the Sensory Profile. Children with low scores on the Sensory Profile demonstrated more difficulties than typically developing children, especially with the motor aspects of ADLs. In another Level III study, however, with children with difficulties processing and integrating sensory information, Case-Smith (1995)  found few correlations between foundational components of fine motor skill and functional performance in self-care, mobility, and social function in the investigation of relationships of sensorimotor components and functional skills. The study did find significant correlations among sensorimotor components and discrete fine motor skills. Case-Smith’s findings on the correlations between sensorimotor components and fine motor skills were supported in another Level III study of children with DCD by Rodger et al. (2003) . The children with DCD were found to perform on the lower end of the normal range of the developmental fine and gross motor scales, with the children using unusual pencil grasp patterns and immature prehension of scissors, but they scored in the average range on tests of visual–motor integration. In addition, the children with DCD generally had performance in the average range in social and functional mobility function, but self-care function was below average for their age.

Two Level IV case study design articles by Linderman and Stewart (1999)  and Reeves (1998)  assessed functional behaviors in single-case participants who were referred for occupational therapy to address difficulties processing and integrating sensory information; participants displayed performance deficits in the areas of functional ADLs, poor feeding behaviors, and functional behaviors. These were descriptive studies that then examined response to intervention. In both studies, only baseline assessments were used to view performance difficulties for the purpose of this review.

In a Level V case study description by Reynolds and Lane (2008), children with sensory overresponsive patterns, as measured by the Sensory Profile, demonstrated disruption of family routines and more difficulty with self-care performance. Tactile sensitivity was associated with performance deficits (refusal, avoidance) in dressing, and taste sensitivity was associated with restricted food preferences. These three children with sensory overresponsivity and no other diagnostic classification demonstrated performance difficulty primarily associated with self-care skills in the home. Specifically, parent descriptions included avoidance of tooth brushing, hair and face washing, and hair combing; restricted food preferences; and difficulty with dressing. In fact, parents reported that the “biggest sensory related challenges at home were due to tactile sensitivities, especially dressing” (p. 525). In children with sensory overresponsivity without any co-occurring diagnoses, similar restricted diets were seen in children with taste sensitivity (Reynolds & Lane, 2008). In this case report, overresponsivity to tactile stimulation was a consistent area of deficit that affected family routines and ADLs.

Table 3 presents a Level III study that makes a direct link between sensory hypersensitivity and sleep disturbances: Shochat, Tzischinsky, and Engel-Yeger (2009)  found significant relationships between sensory processing, sleep, and behavior in a sample (n = 51) of typically developing schoolchildren. Specifically, children who had tactile sensitivity had significantly higher disturbances in sleep behavior, and differences in tactile sensitivity accounted for 25% of the variance in sleep behaviors. Underresponsive/seeks sensation was a predictor of behavior as well, indicating links to arousal that may affect day and night sleep and behavior.

Table 4 includes sample articles related to education, transition, and work. Seven articles were reviewed within this topic, including five Level II studies, one Level III study, and one Level V study. Evidence from several studies found that children and adolescents with difficulties processing and integrating sensory information showed lower participation in school activities; children from diagnostic groups associated with difficulties processing and integrating sensory information demonstrated decreased academic achievement and attention and were at a higher risk for learning difficulties. Specifically, this phenomenon is demonstrated in a Level III study by Baranek et al. (2002)  in which the relationship between sensory processing and occupational performance was examined in children with fragile X syndrome. Several significant correlations were found that were independent of effects of age and IQ. Children who demonstrated aversive–avoidant sensory behaviors had lower scores in school function. The results were mixed in that children with greater internally controlled aversion (avoidance) had lower levels of participation in school activities, were less independent in self-care, and engaged for shorter play durations; however, children with high externally controlled aversion tended to be more independent in self-care performance. A Level II study by Parham (1998)  also found that academic skills were affected by sensory integrative development. Sensory integrative factors, such as dyspraxia and motor coordination, were strongly related to arithmetic achievement for children at younger ages; this finding declined with age. The reverse was true of reading skills in which reading achievement was significantly related to sensory integrative factors at older ages. In addition, the relationship between praxis and academic achievement was found to be surprisingly strong.

In a similar Level II study, Rogers, Hepburn, and Wehner (2003)  found that sensory reactivity had a significant relationship with the acquisition of adaptive behavior skills in children. Neither developmental level nor IQ was found to be related to abnormal sensory reactivity in children with autism or developmental disorders.

In two Level II studies related directly to academic skills, Dewey, Kaplan, Crawford, and Wilson (2002)  compared 51 children with DCD to 78 children without motor coordination deficits. They found that children with DCD had significantly poorer performance on attention tasks and learning tasks such as spelling, reading, and writing than the comparison group. No studies were reviewed that specifically examined transition issues and how a sensory integrative/sensory processing disorder may affect transitioning from school to work settings.

The results of the evidence-based literature review indicate that children and adolescents with difficulties processing and integrating sensory information do display performance deficits in areas of occupation such as social participation, play, IADLs, ADLs, and school function. A significant limitation in the interpretation of this work is that studies often do not have a specific measure of occupational performance or participation, thus making it challenging to link difficulties processing and integrating sensory information with performance difficulties, which affect participation. However, the results of this review may help occupational therapy practitioners in three ways: guiding assessment, guiding intervention, and improving research design.

In children who are demonstrating difficulties processing and integrating sensory information as demonstrated by assessment of specific sensory functions, occupational therapists need to assess their ability to perform their everyday occupations using performance-based assessments at home and school. Evidence suggests that individual differences in occupational performance may be seen in children with difficulties processing and integrating sensory information that may be related to use of coping strategies during functional tasks (Baranek et al., 2002). For example, some children with sensory overresponsivity showed greater independence in self-care skills, which may be an effort to control incoming stimuli. In addition, for children with dyspraxia, DCD, or other sensory-based motor disorders, it is important that assessment of sensory functions as well as motor functions be assessed so that the relationship between these variables and participation measures can be elucidated.

The results of this review suggest that occupational therapy practitioners who work with children and adolescents with difficulty processing and integrating sensory information should strengthen their role in programs that encourage social skills and community participation in natural settings. Difficulties with processing and integrating sensory information, including dyspraxia, have been shown in this review to be moderately related to social competence and socialization. In addition, motor coordination deficits or dyspraxia affect a child’s actual and perceived level of participation. For children with deficits in motor planning and coordination, their participation in school and play activities is compromised, which has implications for social and emotional well-being. Occupational therapy practitioners should not only focus intervention on the motor planning issues but also explore how these affect social competence in community settings.

Occupational therapy researchers need to perform more studies that directly examine and describe the relationships between sensory processing/sensory integration and everyday performance of areas of occupation. Examining actual demonstrated performance in areas of education, play, ADLs, and social participation and correlating that performance to specific problems in sensory integration and sensory processing will add to our understanding. This understanding will likely differ among clinical groups (e.g., autism vs. DCD); thus, it will be important to systematically conduct studies within and among various clinical groups. Moreover, researchers should more clearly elucidate the relationship between subtypes of sensory processing (hyporesponsive, hyperresponsive, sensory-based motor disorders) and the differential effect on occupational performance. For example, if research demonstrates that children with sensory overresponsive patterns and sensory-related motor disorders have more difficulty with social participation and ADL performance than children with underresponsive patterns, therapists can target these areas of occupation during assessment and intervention. With this information, occupational therapy practitioners could use the evidence to directly translate to practical application that discriminates which interventions work best for specific populations and what outcomes need to be targeted.

Limitations of the studies incorporated into the review include lack of randomization, lack of control group, small sample sizes, use of parent-report measures, and minimal use of functional performance measures to examine differences between typically developing children and children with difficulties processing and integrating sensory information. In addition, for children with dyspraxia, DCD, or other sensory-based motor disorders, it was not possible to tease out the sensory and motor contributions to the participation difficulties found. Thus, the interpretations of this aspect of the literature may be limited.

Few articles examined demonstrated functional performance versus test scores as outcome measures. Researchers should conduct studies with children and adolescents who have difficulties processing and integrating sensory information to describe functional performance deficits on measures related to (1) actual demonstrated performance; (2) measures of participation in home, school, and community activities; and (3) assessments that have a functional component that directly applies to key areas of occupation, such as the School Function Assessment (Coster, Deeney, Haltiwanger, & Haley, 1998) or the AMPS. Inherent limitations of the Level IV and V studies include lack of any comparison group or participants who limit generalizability; use of subjective assessment measures that provide description but do not have good psychometrics; and, similar to Level II and III articles, a lack of relating functional performance to sensory processing issues. As researchers more clearly differentiate sensory processing patterns, it will be imperative to include functional behavior and demonstrated performance measures to understand the effect of difficulty processing and integrating sensory information in the daily lives of these children and adolescents. This systematic review demonstrated the effects that difficulties processing and integrating sensory information have on all areas of occupation. By addressing problems in sensory integration and processing, occupational therapy practitioners can have a direct impact on children’s or adolescents’ ability to engage in play, school, and functional ADLs.

We acknowledge the contributions of Amy Krivda, Karissa McHugh, and Crystal Prince, who were involved in a collaborative project with Kristie Patten Koenig while at Temple University as entry-level master's students that yielded the initial critically appraised papers for this review. We also acknowledge the invaluable contributions and support of Marian Arbesman and Deborah Lieberman.

*indicates studies that were systematically reviewed for this article and are listed in the evidence table available at www.ajot.ajotpress.net.