This review aims to systematically examine whether motor interventions could improve not just motor skills, but also social, communication, and cognitive outcomes in autistic children and young people aged 0-21 years. 

Methods

The team followed rigorous systematic review guidelines, using the PRISMA framework and searching seven databases including EMBASE, PubMed, PEDro, Cochrane Library, Web of Science, CINAHL, and Clinical Trials registries. PRISMA is the gold standard approach to conducting systematic reviews. The search covered January 2000 May – 2024.

To be included the research had to: 

1. be a randomised controlled trial published after 2000, 
2. include autistic participants aged 0 to 21 years with autism,
3. use a motor intervention which explicitly targeted motor skill acquisition, 
4. measured social, communication, or cognitive outcomes.

They excluded studies where more than 30% of participants were born preterm or had intellectual disability with an IQ below 70.

The review process identified 23 eligible randomised controlled trials. The 23 studies included 636 participants in total, with only 93 being female, which represents about 15% of the sample. The mean age across studies ranged from 4.3 to 12.3 years, no studies included children under age four.

Intervention

The interventions varied considerably but fell into several clear categories:

• General aerobic exercise (43.5% of studies): motor skills training, physical activity programmes, and cooperative movement games
• Therapeutic horseback riding (21.7% of studies)
• Martial arts (17% of studies), specifically nei yang gong
• Other interventions: virtual fitness, yoga, and music therapy

Session duration typically ranged from 30 to 70 minutes, with sessions varying from as few as one up to 108 sessions over periods ranging from one week to 36 weeks. Interventions were delivered by physical educators, expert sports coaches, riding instructors, physical therapists, occupational therapists, and clinical psychologists. Control groups typically received standard care, wait-list control, or alternative activities.

The Results

Combined Effect Sizes

• Meta-analysis of 15 studies revealed small to medium positive effect size (g = 0.41, p = 0.011) across all domains
• Social and social communication domains showed the most significant improvements (statistically significant small to medium positive effects)
• Cognitive domain did not reach statistical significance
• Communication domain had insufficient data for analysis
• Motor domain alone was not statistically significant – likely because:
  • Many studies used motor measures only at baseline
  • Studies without social/communication/cognitive outcomes were excluded
  • Outcome measures (standardized tests) may not have captured functional improvements in participatory skills like dancing, horseback riding, or martial arts

Age Effects

• Initial analysis suggested interventions may be less effective for children over age nine
• However, regression analysis didn’t reach statistical significance
• Authors concluded age was not a significant factor

Practical Takeaways

For therapists working with school-aged children with autism, these findings have several important implications. The meta-analysis indicates that the motor interventions did have a positive effect on the children’s overall results, and that the impact on the social and social communication domains were more statistically significant. Therefore, motor interventions such as martial arts, dance and horse riding can be considered a viable approach for addressing social and communication difficulties, not just motor impairments. As OTs we are always looking for participation and engagement so it’s great to see the wider impacts that physical activity can have on autistic children’s overall outcomes.

This study was a systematic review of randomised controlled trials investigating the impact of Ayres Sensory Integration. The aim of the review was to explore if when ASI intervention follows fidelity, does it lead to positive outcomes for children.

The authors searched all the main medical databases up until June 2024. They only included peer reviewed studies where intervention sessions followed the ASI Fidelity Measure™. If you’re not familiar with this measure, it was published in 2007, you can see the article here. The measure includes the structural and process elements that evaluate whether the intervention is ASI or not. Structural elements include things like the therapist’s qualifications and the type of equipment available, process elements include things like whether the session is child-led and if there is evidence of the just right challenge. This measure was developed to help separate interventions that may use sensory integration theory, but are not actually ASI – for example it would separate out a brushing protocol or sensory diet or weighted vests or sensory exercise intervention. 

Following the article screening, nine RCTs met the inclusion criteria. These nine studies included 344 children total from the following countries: Australia, Brazil, Iran, Turkey, South Africa, and the United States. 

ASI intervention sessions in all of the studies were performed by OTs. Dosage, or the amount of intervention, ranged from 1-3 sessions over 10-12 week periods. The studies often measured a variety of outcomes, including individualised goals, behaviour outcomes, functional skills, carer stress and quality of life. Control groups received differing interventions including usual care, routine school based OT, sensory motor activities and fine motor interventions.

Results

The majority of the studies (6) explored intervention sessions with autistic children. For this reason, the review has broken the results into using ASI with autistic children and using it with other populations. 

Autistic Children (6 studies)

• “Strong evidence” that ASI helps autistic children achieve individualized goals including:
  • Self-care skills
  • Communication
  • School participation
  • Play skills
  • Motor coordination 
• “Moderate evidence” that ASI does not change behaviours of concern (non-compliance, irritability, resistance to change, hyperactivity) – suggesting ASI isn’t the right intervention for behavioral issues.
• “Low evidence” for changes in functional and developmental skills measured on standardized assessments (mixed results across studies).
• Note: Just over half of the children in this section of the review are from the SENITA trial (n=138 vs n=124). The SENITA trial only assigned goals to the treatment group, so statistical analysis between the groups could not be completed for the individual goal data. 

Other Populations

• Three studies looked at sensory modulation disorders, premature infants, and cerebral palsy
• Some positive outcomes reported but insufficient research to draw strong conclusions

Practical applications

When ASI was effective, it involved sessions of 45-60 minutes, happening 2-3 times per week, typically over 10-12 weeks. As OTs using ASI, we need to keep this high dosage in mind when recommending ASI to parents and organising intervention timetables.

The evidence is telling us that we shouldn’t reach for ASI when the main concern is behaviours of concern such as non-compliance, irritability, resistance to change, or hyperactivity. 

Individualised functional goals can be achieved with ASI. However, none of the studies compared ASI against top down functional approaches to see whether the same results could be achieved, with potentially less resource intensive approaches with lower dosage. So, we do have evidence that ASI can help children with functional goals if delivered at high intensity, but not whether this is the most time and cost effective approach to supporting our children to achieve their goals.

Extra links

Fidelity measure: Parham, L. D., Roley, S. S., May-Benson, T. A., Koomar, J., Brett-Green, B., Burke, J. P., Cohn, E. S., Mailloux, Z., Miller, L. J., & Schaaf, R. C. (2011). Development of a Fidelity Measure for Research on the Effectiveness of the Ayres Sensory Integration® Intervention. The American Journal of Occupational Therapy, 65(2), 133–142. https://doi.org/10.5014/ajot.2011.000745 

SENITA trial full report: Randell, E., Wright, M., Milosevic, S., Gillespie, D., Brookes-Howell, L., Busse-Morris, M., Hastings, R., Maboshe, W., Williams-Thomas, R., Mills, L., Romeo, R., Yaziji, N., McKigney, A. M., Ahuja, A., Warren, G., Glarou, E., Delport, S., & McNamara, R. (2022). Sensory integration therapy for children with autism and sensory processing difficulties: The SenITA RCT. Health Technology Assessment (Winchester, England), 26(29), 1–140. https://doi.org/10.3310/TQGE0020