Sensory Processing Disorder in Children Ages Birth-3 Years Born Prematurely a Systematic Review

Sensory Processing Disorder in Children Ages Birth3Years Born Prematurely: A Systematic Review

Anita Witt Mitchell, Elizabeth M. Moore, Emily J. Roberts,

Kristen W. Hachtel, Melissa S. Brown

MeSH TERMS

premature birth prevalence risk assessment sensation sensation disorders

Anita Witt Mitchell, PhD, OTR, is Associate Professor,

Occupational Therapy Department, University of

Tennessee Health Science Center, Memphis;

[email protected]

Elizabeth M. Moore, MOT, OTR/L, is Occupational

Therapist, Signature Healthcare at St. Francis, Memphis,

TN.

Emily J. Roberts, MOT, OTR/L, is Occupational

Therapist, Regional One Health, Memphis, TN.

Kristen W. Hachtel, MOT, OTR/L, is Occupational

Therapist, First Choice Speech and Occupational Therapy,

Hernando, MS.

Melissa S. Brown, MOT, OTR/L, is Occupational

Therapist, Methodist Healthcare South Hospital, Memphis,

TN.

At the time of the study, Elizabeth Moore, Emily Roberts,

Kristen Hachtel, and Melissa Brown were Students,

Department of Occupational Therapy, University of

Tennessee Health Science Center, Memphis, TN.

This systematic review of multidisciplinary literature synthesizes evidence of the prevalence and patterns of

sensory processing disorder (SPD) in children ages birth3 yr born preterm. Forty-five articles including

physiological, behavioral, temperament, and SPD research met the inclusion criteria and provided 295

findings related to SPD130 (44%) positive (evidence of SPD) and 165 (56%) negative (no evidence of

SPD). The majority of findings related to sensory modulation disorder (SMD; 43% positive). The most

prevalent subcategory of SMD was sensory overresponsivity (82% of findings positive). Evidence of sensory

underresponsivity and sensory-seeking SMD, sensory discrimination disorder, and sensory-based motor

disorder was limited. This study supports the education of neonatologists, pediatricians, and caregivers about

the symptoms and potential consequences of SPD and helps justify the need for follow-up screening for SPD

in children ages birth3 yr born preterm. Research using measures based on sensory processing theory is

needed.

Mitchell, A. W., Moore, E. M., Roberts, E. J., Hachtel, K. W., & Brown, M. S. (2015). Sensory processing disorder in

children ages birth3 years born prematurely: A systematic review. American Journal of Occupational Therapy, 69,

6901220030. http://dx.doi.org/10.5014/ajot.2015.013755

Infants born preterm may be at risk for difficulty processing sensory in-formation. Not only is their in utero neurosensory development cut short(Graven & Browne, 2008), but they may also experience intense stimuli in the

neonatal intensive care unit (NICU) that could alter sensory system development

and function (Nair, Gupta, & Jatana, 2003). Sensory processing dysfunction, in

turn, could influence the development of play, social participation, education,

and self-care occupations (Miller, Anzalone, Lane, Cermak, & Osten, 2007;

Schaaf et al., 2010). Despite these problems, research is limited on the prevalence

and patterns of dysfunction in infants and children born prematurely from the

perspective of sensory integration theory. The aims of this review were to examine

a variety of literature for evidence of sensory processing dysfunction in children

ages birth3 yr born prematurely and to identify the types of sensory processing

deficits that are apparent.

In 2007, Miller and colleagues proposed adoption of the new term sensoryprocessing disorder (SPD) in place of the term sensory integration dysfunction,presenting a new taxonomy in diagnosing subtypes of SPD. This classification

system was developed using focus groups and empirical evidence, with the ex-

pectation of continued scholarly dialogue and research based on the taxonomy.

This systematic review contributes to the discussion of the nosology and explores

its validity for use with children ages birth3 yr born preterm by examining the

literature to determine whether the proposed patterns of SPD can be identified in

this population. Such identification could help justify occupational therapy as-

sessment, follow-up, and intervention for this population and specifically support

an approach based on sensory integration theory. Our two research questions were

The American Journal of Occupational Therapy 6901220030p1

(1) What does evidence in the literature suggest about the

prevalence of SPD in children ages birth3 yr born pre-

term? and (2) What types of SPD are evident in the liter-

ature describing these children?

Background Literature

All motor, behavior, emotional, and attention responses

are a result of how the brain processes sensory information.

Sensory information serves as an important foundation for

adaptive behaviors such as self-control, learning, and the

ability to organize (Schaaf et al., 2010). Sensory integration

theory explains how sensations are processed and organized

to facilitate adaptive behaviors.

A. Jean Ayres developed the concepts of sensory in-

tegration theory in 1963 to help explain learning problems

and behaviors in children (Miller et al., 2007). Ayres (1989)

defined sensory integration as the neurological process thatorganizes sensations from ones body and from the envi-

ronment and makes it possible to use the body effectively in

the environment (p. 22). She described sensory integration

dysfunction as impaired sensory processing resulting in

functional problems.

On the basis of patterns observed in children di-

agnosed with sensory integration dysfunction, the term

sensory processing disorder was proposed to increase di-agnostic precision. This nomenclature change was recom-

mended because of the paradigm shift that has occurred as

sensory integration theory has evolved. SPD is defined as thebrains inability to organize sensory input for appropriate

use, and it may be associated with learning, developmental,

and emotional disabilities (Miller et al., 2007).

According to the new nomenclature, SPD consists

of three categories: sensory modulation disorder (SMD),

sensory discrimination disorder (SDD), and sensory-based

motor disorder (SBMD). Sensory modulation is the abilityof the central nervous system to effectively alter neural

messages from sensory input; it allows a person to focus

on some stimuli and ignore others, therefore responding

appropriately to the demands of a particular situation.

In SMD, a mismatch occurs between the demands of the

environment and a persons emotional and attentional

responses.

SMD has three subtypes: sensory overresponsivity

(SOR), sensory underresponsivity (SUR), and sensory

seeking (SS). SOR is characterized by faster and more in-tense responses to sensory input from one or more sensory

systems. These responses may appear uninhibited, aversive,

or defensive and occur for a longer duration than expected.

People with SUR often demonstrate a lack of response tosensory input. This inability to detect and respond to sen-

sory input results in low arousal levels, causing a person to

seem sluggish, passive, and apathetic. SUR is often associ-

ated with other SPDs, particularly SDD and dyspraxia

(discussed later in this article). People who demonstrate SS

behaviors seek out an abnormal type or amount of sensory

input. Their insatiable desire for sensory input can lead to

extreme behaviors that are disruptive, socially unacceptable,

or unsafe. SMD can involve any sensory system and more

than one sensory system (Miller et al., 2007).

SDD is characterized by the inability to interpret

qualities of sensory stimuli, such as the location of

stimuli or similarities and differences between stimuli.

Some people have difficulty identifying stimuli. People

with SDD can present with motor, learning, or language

disorders depending on the sensory systems affected

(Miller et al., 2007).

SBMD results in postural instability or deficits in vol-

untary movement caused by problems processing sensory

input in one or more sensory systems (Miller et al., 2007).

The two subtypes of SBMD are postural disorder (PD) and

dyspraxia. PD occurs when sensory processing deficits result

in poor postural stability. Dyspraxia is defined as an im-

paired ability to conceive of, plan, sequence, or execute novel

actions (Miller et al., 2007, p. 138). People with dyspraxia

may have difficulty generating ideas for action, move

awkwardly and in a disorganized manner, demonstrate

inaccurate timing and sequencing of movement, and fail

to anticipate the movement needed in a particular sit-

uation. These three categories of SPD are not mutually

exclusive; a person may demonstrate one or more SPD.

Prematurity

Premature birth is birth before the 37th week of gestation.Premature delivery occurs in 13% of all pregnancies

(Rais-Bahrami & Short, 2013). A child can also be classified

as premature on the basis of low, very low, or extremely

low birthweight. Low birthweight is defined as

interfere with the sensory development when exposed to

stimuli (p. 170).

Many babies who are born prematurely are admitted

to the NICU. Stimuli in the NICU are both unusual and

much more intense than stimuli experienced by infants in

utero (Als & McAnulty, 2011). Bright lights may deter

them from opening their eyes and taking in the environ-

ment around them. Babies in the NICU are also subjected

to necessary aversive procedures such as needle sticks and

nasogastric intubation. Handling of the infant can lead to

behavioral stress, and touch may be stressful rather than

soothing (Nair et al., 2003). Exposure to high-pitched

sounds can cause physiological changes such as tachycardia,

tachypnea, apnea, oxygen desaturation, sudden increases in

blood pressure, the release of stress hormones, and disturbed

sleep (Graven & Browne, 2008; Nair et al., 2003). Rapid-

eye-movement sleep deprivation in itself could alter the

development of sensory systems (Graven & Browne, 2008).

Research Based on a Sensory Processing Perspective

Only four published studies have examined sensory pro-

cessing in infants and young children born preterm from

a sensory integration theoretical basis (i.e., Bart, Shayevits,

Gabis, & Morag, 2011; Case-Smith, Butcher, & Reed,

1998; Wickremasinghe et al., 2013; Wiener, Long, De-

Gangi, & Battaile, 1996), with three of the four including

a comparison group of children born at term (i.e., Bart

et al., 2011; Case-Smith et al., 1998; Wiener et al., 1996).

Two of the studies were published before the SPD nosology

was proposed (i.e., Case-Smith et al., 1998; Wiener et al.,

1996), and their findings were somewhat contradictory.

Case-Smith and colleagues found little evidence of SPD

except for tactile overresponsivity. Wiener and colleagues,

however, found evidence of vestibularproprioceptive

overresponsivity and some evidence of PD (i.e., 1 of 3

findings was positive). Somewhat consistent with Case-

Smith and colleagues, Wiener and colleagues also reported

some evidence of tactile overresponsivity (i.e., 3 of 6 find-

ings were positive). Although both studies tested children in

the age range of 718 mo, they used different instruments

to measure sensory processing (i.e., the Test of Sensory

Functions in Infants [TSFI; DeGangi & Greenspan, 1989]

in Wiener et al. and the Sensory Rating Scale [SRS; Provost

& Oetter, 1993] in Case-Smith et al.). In both studies,

limitations of the instruments were identified as factors that

may have influenced the results.

In a more recent study, Bart and colleagues (2011)

used both the Infant/Toddler Sensory Profile (Dunn,

2002) and the TSFI to assess sensory modulation of in-

fants born from 3435 6/7 wk gestational age. Similar to

Wiener and colleagues (1996), they found some evidence

of SMD in the tactile (i.e., 2 of 3 findings were positive)

and vestibularproprioceptive systems (i.e., 1 of 2 findings

was positive). These positive findings tended to be in the

direction of SOR. In addition, Bart and colleagues found

evidence of SMD in the auditory system (i.e., 1 of 1 finding

was positive) and of dyspraxia (i.e., 1 of 1 finding was

positive).

Wickremasinghe et al. (2013) found atypical overall

scores on the Sensory Profile (either the Infant/Toddler

Sensory Profile or the Sensory Profile [Dunn, 1999],

depending on childs age) in 39% of a group of children

ages 18 yr born preterm. Consistent with Bart and

colleagues (2011), auditory, tactile, and vestibular deficits

were most common, with relatively few atypical Sensory

Profile scores on the oral sensory processing and visual

processing sections. Wickremasinghe and colleagues also

found that a larger-than-expected proportion of children

born preterm had atypical scores in each of the four

quadrants of the Sensory Profile (i.e., low registration,

sensory seeking, sensory sensitivity, and sensory avoiding);

however, unlike the other three studies, the largest per-

centage of participants (24%) in Wickremasinghe and

colleagues study demonstrated low registration, which is

consistent with SUR rather than SOR. In the other three

quadrants, 10%11% of participants had atypical scores.

This systematic review could add to the literature in

several ways. Compilation of evidence from multiple

studies may provide a more reliable representation of the

sensory processing characteristics of infants and young

children born preterm than evidence from a single study

with a relatively small number of participants. Findings

from the studies discussed previously show some similar

trends but also inconsistencies.

Further, Bart and colleagues (2011) reported a dif-

ference in their findings based on the instrument used to

gather the data (the TSFI vs. the Infant/Toddler Sensory

Profile). Scores on the TSFI reflect ratings of observed

behaviors, whereas scores on the Infant/Toddler Sensory

Profile are derived from parent responses to a question-

naire. Consideration of a variety of types of evidence

from multiple disciplines, including behavioral obser-

vations, parent reports, and physiological data, may allow

for a broader picture of the prevalence and patterns of

SPD in infants and young children born preterm.

This review could lend further support for NICU

adaptations such as reducing sound and light and mod-

ifying touch stimuli. Implementation of these adaptations

may help prevent SPD. Moreover, if preterm infants are

at risk for developing SPD, pediatricians need to be ed-

ucated to recognize the disorders symptoms and provide


appropriate referrals for occupational therapy intervention.

If children born prematurely were regularly screened for

SPD, early intervention could be implemented to address

dysfunction and potentially prevent future disability, which

has both quality-of-life and financial implications.

Method

Sources

We independently searched multidisciplinary literature

using electronic databases, including CINAHL, PsycINFO,

Medline, Scopus, and PubMed, from 1990 to present. A

medical research librarian also assisted in developing the search

strategy and conducting the search. In addition, we examined

references cited by articles included in the review for potential

articles. Key search terms, used in a variety of combinations,

included sensory processing disorder, sensory processing dys-function, sensory integration, sensory underresponsiveness, sen-sory overresponsiveness, sensory seeking, visual processing, tactileprocessing, auditory processing, proprioception, vestibularprocessing, premature, preterm, low birth weight, regulatorydisorders, developmental coordination disorder, temperament,evoked potentials, and 03 yr.

Inclusion Criteria

The review included peer-reviewed research articles published

in English since 1990 that provided evidence of SPD in

children ages birth3 yr born preterm or with low birth-

weight, or both. Studies compared children born preterm

either with a control group of children born full term or

with normative data. Articles that focused on sensory im-

pairments (e.g., deafness or blindness) or major motor im-

pairment such as cerebral palsy were excluded. Data from

presentations, conference proceedings, non-peer-reviewed

research literature, dissertations, and theses were also ex-

cluded. To reach consensus, the five authors discussed

whether articles met the inclusion criteria.

Data Extraction and Analysis

We composed an evidence table of all articles, summarizing

participant characteristics (chronological age, gestational age,

and birthweight), outcomemeasures used, findings related to

SPD, level of evidence, and study limitations. We used SPD

categories and their descriptions from Miller and colleagues

(2007) and descriptions and explanations of outcome

measures provided in each study to categorize data on the

basis of SPD type and sensory system involved. We con-

sulted additional literature describing the study instruments

when necessary. For 23 articles, we used group discussion

and consensus to classify the findings according to SPD

type. The first author (Mitchell) classified the remaining 22

articles. The number of positive (evidence of SPD) and

negative (evidence of typical sensory processing) findings

in each category were tallied, and total percentages were

calculated.

Results

Initially, the searches found 81 articles, 45 of which met

inclusion criteria. Most (91%) of these 45 articles pro-

vided Level II evidence (nonrandomized two-group

design), whereas 9% provided Level III evidence (non-

randomized one-group design). Randomized controlled

trials were not expected because of the nature of the research

questions.

The total number of preterm study participants was

2,584, with an age range of 1 day to 3 yr, 1 mo; gestational

age from 22 to 37wk; and birthweight from 450 to 2,865 g.

Mean values cannot be reported because some articles

lacked necessary information. Study instruments included

physiological measures, temperament questionnaires (In-

tensity, Approach/Withdrawal, and Threshold subtests),

and behavioral measures (Table 1). Only 3 studies included

measures based on theories of sensory processing.

Within the 45 studies, 295 findings related to SPD.

Of these, 130 (44%) were positive and 165 (56%) were

negative. These findings were categorized according to

sensory system affected, SPD, and SPD subtype (Table 2).

The majority of findings related to SMD. Because of the

nature of the assessment tools used in the studies, many of

these findings could not be classified according to SMD

subtype. For example, neurobehavioral and temperament

Table 1. Sensory Processing Measures Used by SystematicReview Studies

Type of Sensory Processing MeasureNo. of SystematicReview Studies

Physiological measures (e.g., cardiac or respiratoryresponses, event-related potentials, reaction time,salivary cortisol)

17

Temperament questionnaires and ratings 12

Neurobehavioral assessments (e.g., Assessment ofPreterm Infants Behavior, Einstein NeonatalNeurobehavioral Assessment Scale)

9

Observations of behavioral reactivity (e.g., facialexpressions, gross body movements)

8

Standardized sensory processing instruments (e.g.,Infant/Toddler Sensory Profile, Test of SensoryFunctions in Infants)

3

Standardized motor scales (e.g., Neurosensory MotorDevelopment Assessment)

2

Study-designed parent reports of sensoryresponsiveness

2

Motor planning tasks 2

6901220030p4 January/February 2015, Volume 69, Number 1

Table 2. Sensory Processing Disorder and Typical Sensory Processing Findings According to Sensory System Affected and SensoryProcessing Disorder Subtype

Sensory SystemAffected

Sensory ProcessingDisorder Subtype

Level ofEvidence Authors

No. of SensoryProcessing

Disorder Findings

No. of TypicalSensory Processing

Findings

Sensory Modulation Disorder

Auditory Unclassified SMD II Bart, Shayevits, Gabis, & Morag (2011) 1 0

II Case-Smith, Butcher, & Reed (1998) 0 1

II Coles, Bard, Platzman, & Lynch (1999) 0 3

II Majnemer, Rosenblatt, & Riley (1993) 3 15

SOR II Fellman et al. (2004) 2 0

Nonspecific Unclassified SMD II Brown, Doyle, Bear, & Inder (2006) 1 0

II Coles et al. (1999) 0 2

II DiPietro, Porges, & Uhly (1992) 0 5

II Gennaro, Tulman, & Fawcett (1990) 0 2

II Lester, Boukydis, & LaGasse (1996) 2 2

II Haley, Grunau, Oberlander, & Weinberg (2008) 6 0

II Hara Mitsuishi, & Yamaguchi (1990) 0 3

III Hughes, Shults, McGrath, & Medoff-Cooper (2002) 0 9

II Ishaik et al. (2000) 0 2

II Jeng, Yau, & Teng (1998) 1 0

II Langkamp, Kim, & Pascoe (1998) 0 6

II Langkamp & Pascoe (2001) 0 4

II Majnemer, Brownstein, Kadanoff, & Shevell (1992) 1 0

II Newman et al. (1997) 0 1

II Oberklaid, Sewell, Sanson, & Prior (1991) 0 8

II Oberlander et al. (2000) 2 2

II Parslow et al. (2002) 0 4

II Sajaniemi, Salokorpi, & von Wendt (1998) 0 1

II Scher, Steppe, & Banks (1996) 0 6

III Weiss, St. John-Seed, & Wilson (2004) 0 2

II Wolf et al. (2002) 26 14

SOR II Brown et al. (2006) 1 1


II Duffy, Als, & McAnulty (1990) 6 0

II Gennaro et al. (1990) 4 0

II Huppi et al. (1996) 4 2

II Ishaik et al. (2000) 1 0

II Jeng et al. (1998) 1 2

II Langkamp & Pascoe (2001) 3 0

II Sajaniemi et al. (1997) 1 0

II Wolf et al. (2002) 10 3

SUR II Brown et al. (2006) 1 1

II Jeng et al. (1998) 2 4

II Oberklaid et al. (1991) 1 0

II Sajanienemi et al. (1998) 1 0

III Weiss et al. (2004) 1 0

Tactile Unclassified SMD II Bart et al. (2011) 1 1

II Grunau et al. (2010) 0 3

II Hellerud & Storm (2002) 0 2

II Riese (1998) 0 2

II Slater et al. (2010) 0 1

II Wiener, Long, DeGangi, & Battaile (1996) 0 1

SOR II Abdulkader (2008) 3 0

II Bart et al. (2011) 1 0

II Case-Smith et al. (1998) 1 0

II Hellerud & Storm (2002) 3 0

(Continued )


assessments often did not describe the direction of differences

in sensory responses (greater vs. lesser responsivity); therefore,

these findings were considered unclassified SMD. Negative

findings in this category were not considered negative find-

ings for each SMD subtype because this conclusion would

result in overrepresentation of negative findings. For all three

categories (unclassified SMD, SOR, and SUR) in total, 43%

of findings were positive and 57% were negative. Numbers

and total percentages of positive and negative findings in

different sensory systems for each SMD category were

tallied and calculated (Table 3). Of the SMD findings that

could be classified, the majority were positive for SOR.

Very few findings of SUR were identified, and no findings

were classified as SS.

Again, because of the assessment tools used in the

studies (e.g., temperament questionnaires, neurobehavioral

assessments), a majority (64%) of the SMD findings could

not be classified according to sensory system. These findings

Table 2. Sensory Processing Disorder and Typical Sensory Processing Findings According to Sensory System Affected and SensoryProcessing Disorder Subtype (cont. )

Sensory SystemAffected

Sensory ProcessingDisorder Subtype

Level ofEvidence Authors

No. of SensoryProcessing

Disorder Findings

No. of TypicalSensory Processing

Findings

II Slater et al. (2010) 1 0

III Weiss & Wilson (2006) 0 1

II Wiener et al. (1996) 2 3

SUR II Grunau, Whitfield, & Petrie (1994) 1 0

VestibularProprioceptive Unclassified SMD II Bart et al. (2011) 0 1


SOR II Bart et al. (2011) 1 0


SUR II Bougle et al. (1990) 1 0

Visual Unclassified SMD II Bart et al. (2011) 0 1




II Majnemer et al. (1993) 2 15

II Mirabella, Kjaer, Norcia, Good, & Madan (2006) 0 1

SOR II Coles et al. (1999) 1 0


II Mirabella et al. (2006) 2 0

Sensory Discrimination Disorder

Auditory II Fellman et al. (2004) 5 1

II Hemgren & Persson (2007) 0 1

Proprioceptive II Hemgren & Persson (2007) 0 1

Tactile II Hemgren & Persson (2007) 0 1

II Nevalainen et al. (2008) 1 2

II Tombini et al. (2009) 1 0

Visual II Hemgren & Persson (2007) 0 1

II Oliveira, Costa, de Souza, & Ventura (2004) 0 4

II Rose, Feldman, Jankowski, & Caro (2002) 1 2

Sensory-Based Motor Disorder

Unclassified SBMD II Hemgren & Persson (2007) 0 1

PD II Newman et al. (1997) 1


II Wolf et al. (2002) 2 0

III Yeo & Chan (2005) 4 0

Dyspraxia II Bart et al. (2011) 1 0

II DiPietro et al. (1992) 1 0

II Sun, Mohay, & OCallaghan (2009) 3 1


Note. PD 5 postural disorder; SBMD 5 sensory-based motor disorder; SMD 5 sensory modulation disorder; SOR 5 sensory overresponsivity; SUR 5 sensoryunderresponsivity.


were therefore labeled unspecific. Of those that could be

categorized by sensory system, the largest number of

findings related to the tactile (30) and visual (29) systems.

Whereas 79% of the visual system findings were negative

for SPD, more than half of the tactile system findings

were positive. All but 2 of the positive tactile system

findings reflected SOR.

There were far fewer findings of SDD and SBMD than

of SMD. Evidence of SDDwas found in 6 studies (see Table

2). Most of the findings related to the auditory, visual, and

tactile systems. Whereas the majority of findings for visual

discrimination were negative, there were more positive than

negative findings for auditory discrimination. For tactile

discrimination, there were close to equal numbers of positive

and negative findings (see Table 3).

Evidence of SBMD was found in 8 articles (see Table

2). One finding could not be classified by subtype and

therefore was considered unclassified SBMD. This finding

was negative. For PD, there were 7 positive and 3 negative

findings, and for dyspraxia, there were 5 positive and 4

negative findings.

Findings from research articles that used the three most

common types of instrumentsphysiological measures,

temperament questionnaires, and neurobehavioral assess-

ments (see Table 1)were examined separately. Findings

from the physiological measures and neurobehavioral as-

sessments mirrored the overall findings; however, the large

majority (46 of 57, or 81%) of findings from temperament

questionnaires were negative. Of the 11 positive findings,

9 suggested SOR and 2 suggested SUR.

In summary, of the 295 findings from the 45 articles

included in the review, 44% were positive and 56% were

negative for SPD. The majority of findings related to SMD,

with 43% of those being positive. The most prevalent

subcategory of SMD was SOR, and the majority of these

findings were positive. Evidence of SUR and SS, SDD, and

SBMD was limited.

Discussion

Although the results of this systematic review appear

mixed, a substantive proportion of the findings suggests

children ages birth3 yr born preterm may be at risk for

sensory processing dysfunctions such as those defined by

Miller et al. (2007). Evidence of SMD, specifically SOR,

was most prominent, which seems logical considering the

immaturity of newborns sensory systems and the po-

tentially overwhelming and aversive stimuli to which they

may be exposed in the NICU. These results are also

consistent with studies by Case-Smith and colleagues

(1998), Wiener and colleagues (1996), and Bart and

colleagues (2011), who based their research on a sensory

integration theoretical perspective and reported SOR in

infants and young children born preterm.

The preponderance of SOR findings in this review is

in contrast to Wickremasinghe and colleagues (2013)

study, which found a greater incidence of SUR in chil-

dren ages 18 yr born preterm. Several explanations are

possible for this difference. For example, this review included

studies published as early as 1990; therefore, some of the

participants in the early studies may have been exposed to

NICUs that had not yet implemented developmental care

and environmental modification. Changes in NICU envi-

ronments over the years may have resulted in differences in

sensory processing outcomes for infants and young children

born prematurely. However, a more recent study by Bart

and colleagues (2011) found evidence of SOR in children

born preterm, which is consistent with this review.

Another potential explanation for the difference in

Wickremasinghe and colleagues (2013) findings could in-

volve the outcome measures used. This review included

a variety of measuresincluding evoked potentials, behav-

ioral observations, and temperament questionnaires com-

pleted by parentswhereas Wickremasinghe and colleagues

used the Sensory Profile, which involves only parent

Table 3. Number of Positive (1) and Negative () Findings of Sensory Modulation Disorder and Sensory Discrimination Disorder inDifferent Sensory Systems

Sensory System

Sensory Modulation Disorder

Unclassified SMD SOR SUR

SensoryDiscrimination

Disorder

1 1 1 1

Auditory 4 19 2 0 0 0 5 2

Tactile 1 10 14 4 1 0 2 3

Vestibularproprioceptive 0 2 4 0 1 0 0 1

Visual 2 23 4 0 0 0 1 7

Unspecific 39 73 32 8 6 5 0 0

Total, n 46 127 56 12 8 5 8 13

Total, % 27 73 82 18 62 38 38 62

Note. SDD 5 sensory discrimination disorder; SMD 5 sensory modulation disorder; SOR 5 sensory overresponsivity; SUR 5 sensory underresponsivity.


responses to a questionnaire. Some parents inWickremasinghe

and colleagues study may not have recognized behaviors in-

dicating SOR. For example, some children who are over-

responsive may shut down as a way of coping with their

overresponsivity (Schaaf et al., 2010). Therefore, what may

have appeared to a parent to be underresponsivity may

actually have been overresponsivity. This reviews inclusion

of studies that used physiological measures and behavioral

observations may have provided a clearer picture of sensory

processing than a single study using one type of outcome

measure. Finally, this review focused on children ages birth

3 yr, whereas Wickremasinghe and colleagues participants

ranged in age from 1 to 8 yr. Wickremasinghe and col-

leagues reported a trend toward a greater incidence of

atypical Sensory Profile scores in older children and sug-

gested SPD may become more evident with age.

The SS pattern was not found in the literature in-

cluded in this review, except for a mention in 1 study. On

the basis of analysis of two SRS items, Case-Smith and

colleagues (1998) reported that SS behaviors were com-

mon in children born preterm; however, they considered

these to be age-appropriate behaviors. This lack of SS

findings may also be related to the tools used in the

studies. For example, Wickremasinghe and colleagues

(2013) study used the Sensory Profile, which does iden-

tify the SS pattern, and found that a statistically larger

proportion of participants than expected (11%) demon-

strated SS behaviors. Further research using standardized

measures that identify the SS pattern is needed before

drawing conclusions about its prevalence in children ages

birth3 yr born preterm.

Evidence related to SDD and SBMD was also scarce.

These patterns were difficult to identify in the current

review because of limits in the number and variety of per-

ceptual andmotor skills demonstrated by children ages birth

3 yr and tested by the tools for children in this age range.

Thus, the outcome measures used often provided limited

findings that could be classified as SDD or SBMD. Even if

evidence of mild motor disorders was present, it was often

difficult to determine whether they were sensory-based dis-

orders because the instruments used in the studies usually

did not measure tactile, vestibular, or proprioceptive pro-

cessing. Again, research using measures consistent with the

SPD nosology is needed to clarify the incidence of these

patterns in children ages birth3 yr born preterm.

This review revealed a difference between findings of

studies that used temperament measures and findings of

studies that used other types of instruments. Although

DeSantis, Harkins, Tronick, Kaplan, and Beeghly (2011)

found evidence to support the idea that sensory processing

assessments and temperament questionnaires may describe

the same behaviors using different theoretical perspectives,

in this review few positive findings were based on the

temperament measures. Although this difference may sim-

ply reflect a lack of SPD in infants and young children born

preterm, it contrasts with the evidence from studies using

other sensory processing measures. However, the difference

may relate to the type of SPD most associated with scores

on temperament questionnaires.

In a study of children with autism spectrum disorder,

Brock et al. (2012) found evidence of commonalities

between five of the nine dimensions of a temperament

questionnaire and measures of sensory processing. Three

of the temperament dimensions related to SUR, and two

related to SMD in general. The researchers found no

statistically significant effects between SOR or SS and the

temperament measure. This may explain the difference be-

tween the findings of studies using temperament measures

and findings of studies using other types of measures. That is,

temperament assessments tend to reflect SUR rather than

SOR or SS and infants born preterm are more prone to

SOR. Interestingly, in this review, of the few positive findings

based on temperament questionnaires, most suggested SOR,

which is consistent with the overall findings of the review.

Limitations

The exclusion of unpublished literature and non-English

studies may have been a limitation of this review because their

inclusion could have changed the proportions of positive and

negative findings. In addition, few of the instruments used in

the included studies were designed to directly assess any of the

SPD categories defined by Miller et al. (2007). Thus, these

results were based on inferences drawn from a variety of

types of data, described previously. To address this challenge,

at least two of the authors examined and appraised findings

from a subset of 23 of the 45 studies. All five authors then

agreed on the classification of the findings from these 23

studies to ensure the credibility of the classification of the

remaining articles. Finally, many of the studies tested rela-

tively small convenience samples, with limited power to

detect differences between groups. Despite these limi-

tations, the substantive number of positive SPD findings

(particularly in the SMD category) has implications for

occupational therapy practice with children ages birth

3 yr born preterm.

Recommendations for Future Research

Further research examining the prevalence of SPD in

infants born prematurely would be beneficial. This re-

search should be based on a sensory processing theoretical


perspective and use instruments that allow detection of

SPD patterns. Multisite studies with large samples of

participants and examiners blinded to term or preterm

status would also increase the reliability of the findings.

Expansion of the review to include preschool- and

school-age children may provide an opportunity to detect

SPD patterns difficult to identify in children ages birth

3 yr. Wickremasinghe and colleagues (2013) noted a trend

toward increasing frequency of atypical Sensory Profile

scores with increasing age; therefore, they argued, SPD may

increase in severity or become more evident as children age.

Implications for OccupationalTherapy Practice

The results of this review have the following implications

for occupational therapy practice:

Children ages birth3 yr born preterm should bescreened for SPD, particularly SOR.

Parents whose infants are born preterm and spendtime in the NICU may benefit from education about

SPD, including signs and symptoms to be alert for and

techniques and approaches to incorporate at home.

Findings of this study could be used to support theneed for environmental modification in the NICU.

Education of pediatricians about the risk of SPD inchildren ages birth3 yr born preterm is needed to

promote follow-up and early intervention services for

young children whose subtle dysfunctions may other-

wise be overlooked.

Conclusion

The results of this study could help justify the need for

children born preterm to be referred for post-NICU

follow-up to assess sensory processing. Infants who are

born before their sensory systems can fully develop in

utero and are exposed to atypical, overwhelming, and

aversive stimuli in the NICU appear to be more at risk for

SPD, particularly SOR. Occupational therapy can play an

important role in intervention with this population. Oc-

cupational therapy practitioners can help identify the risks in

the NICU and make recommendations for modifications,

recognize the signs and symptoms of SPD, and provide

treatment of SPD for children born preterm. s

Acknowledgments

The authors thank Brenda Green, medical research li-

brarian at the University of Tennessee Health Science

Center, for her assistance.

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Sensory Processing Disorder in Children Ages Birth-3 Years Born Prematurely a Systematic Review