Physiotherapy - The Journal of Indian Association of Physiotherapists

: 2022  |  Volume : 16  |  Issue : 2  |  Page : 43--47

Effect of multimodal sensorimotor training on the stereotypical behavior in children with autism spectrum disorder

Himani Bhagwasia, Baljeet Kaur 
 Department of Physiotherapy, I. T. S Institute of Health and Allied Sciences, Ghaziabad, Uttar Pradesh, India

Correspondence Address:
Dr. Baljeet Kaur
Department of Physiotherapy, I. T. S Institute of Health and Allied Sciences, Ghaziabad, Uttar Pradesh


OBJECTIVE: To analyze the effect of multimodal sensorimotor training on the stereotypical behavior in children with autism spectrum disorder (ASD). MATERIALS AND METHODS: A group of 60 children with autism were taken in the study who met the inclusion and exclusion criteria and were grouped into two groups using simple random sampling. Group 1 was the interventional group with 30 participants and Group 2 was control group with 30 participants. A 12-week multi-modal sensorimotor training program was given to Group 1. The control group (Group 2) was also given a 12-week conventional physiotherapy intervention. The outcome measure used was the Indian Scale for Autism Assessment (ISAA). Pretest and posttest findings on ISAA were noted for both groups. RESULTS: Multimodal sensorimotor training program has good results compared to the control group in improving the stereotypical behavior in children with ASD. Children who were given conventional physiotherapy programs also showed improvement in their posttest results. On comparing the two groups, multimodal sensorimotor training was found to be more effective in children with ASD. CONCLUSION: There is a significant improvement in stereotype behavior, such as head banging, hand flapping, and repetitive behavior. Multimodal sensorimotor training helps to improve the stereotypic behavior in children with ASD. The present study gives a promising intervention program for children with ASD.

How to cite this article:
Bhagwasia H, Kaur B. Effect of multimodal sensorimotor training on the stereotypical behavior in children with autism spectrum disorder.Physiother - J Indian Assoc Physiother 2022;16:43-47

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Bhagwasia H, Kaur B. Effect of multimodal sensorimotor training on the stereotypical behavior in children with autism spectrum disorder. Physiother - J Indian Assoc Physiother [serial online] 2022 [cited 2023 Mar 23 ];16:43-47
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Autism spectrum disorder (ASD) is a range of neurodevelopmental disorders which is typically diagnosed during childhood. The main symptoms are difficulty with social interaction and communication.[1]

Motor skills deterioration is common among children with ASD. Autism is typically regarded as a neuro-developmental disorder that include paucity in social communication and social interaction, associated with narrow patterns of behavior and interests.[2],[3] Sensory symptoms can cause many behavior and symptoms associated with autism like restrictive and repetitive behavior, self–injurious behavior, anxiety, inattention, and gastrointestinal complaints.[2],[4]

On the other hand, Autism is regarded as a set of typical behaviors seen in these children. Hand flapping, arms flapping, toe walking, spinning and rocking the body, and flicking of fingers are stereotypic behaviors.[5],[6],[7]

Developmental delay among children with ASD can result in lack of physical activities. ASD makes it difficult to participate with peers due to behavior and social issues, so intervention programs must focus on this.[5],[8],[9]

In India, there is a need that intervention programs must address not only muscle strength and functional activities but also must focus to minimize the child's stereotypical behaviors.

The effects of different exercise and training programs have been studied to decrease stereotypic behavior among children with ASD. Ferreira et al. evaluated that there is a decrease in symptoms of ASD after a physical exercise program[10] and in stereotypic behavior following physical activities such as vigorous jogging.[5]

The use of deep pressure is helpful in reducing symptoms of stress, and anxiety and improving the performance of school-going children.[11],[12] Other types of deep pressure comprise therapeutic brushing, weighted vest,[13] hugging, squeezing, stroking, holding, and swaddling.[11] Case-Smith et al., 2015, explored through a systematic review that these sensory problems can be treated by working on sensory processing such as goal attainment, a variety of sensory modalities, and behaviors linked to sensory problems.[14] Bressel et al. used whole-body vibration in children with ASD and revealed that whole-body vibration does not reduce stereotypy uniformly in the body, but it was very enjoyable for students.[15]

The present study wants to investigate the effects of multimodal sensory motor training to improve the stereotypical behaviors in children with ASD. This therapy is required because the conventional physiotherapy given to children with autism mainly involves stretching exercises, strengthening exercises, play therapy, and relaxation exercises.

In the present study, the Indian Scale for Autism Assessment (ISAA) is used. It is a 40-point scale that is used to assess the severity of autism. Test-retest and inter-rater reliability was 0.93–0.99 and 0.99, respectively. Pearson correlation coefficient (r) was 0.8–0.89.[16]


Children with ASD were invited to participate in the study. A written informed consent was taken from children's parents. The subjects were included through simple random sampling using the lottery method for the experimental group and control group. Only those who met the inclusion criteria were included. Inclusion criteria constituted pre-diagnosed cases of ASD. The child should not participate in any other sensory– motor therapy. Recent medical reports to determine the fitness to participate in the study. There should be no other syndrome and motor impairment, condition associated with ASD. Those who met these criteria were included in the study. Children with any other neurological disorder/diseases for example- hydrocephalus. All severe cases of Autism, and children who had difficulty in communication were excluded from the study.[1]

Two groups, each of 30 members, i.e., experimental group (Group 1) and control group (Group 2), were recruited from an autism school in Delhi.

The participants who met the inclusion criteria were randomly selected for the intervention group. They were assessed on the ISAA, to determine the pretest scores on ISAA. The intervention group was given a 12-week multimodal sensorimotor training intervention. Multimodal sensory motor training includes motor exercises and sensory experiences to stimulate various type of sensory modalities in children with ASD, i.e., running on treadmill, jumping on trampoline,[17]therapeutic brushing, weighted vests,[13] deep pressure (gym ball), and vibrations using hand held vibrator. The multimodal sensorimotor training was given three sessions/week with a duration of 45 min for 12 weeks. The progression of the intervention was done by increasing speed and duration. For example, children were guided to increase the speed of running on treadmill. Moreover, time duration was increased for sensory modalities like brushing and deep pressure.

To monitor the intensity of the training program, heart rate was monitored using wrist-worn heart rate sensing device. Various studies[18],[19],[20] have reported the intensity of motor training to a range of 50%–60% of the predicted maximum heart rate (PMHR) with a progressive increase to 70%–80% of the PMHR by using the Karvonen's formula[21] to predict target HR but with HR max being calculated using the equation formula:

HR max (age-predicted max heart rate) =220– age

Heart rate reserve (HRR) = HR max-HR Rest

TRAINING RANGE%=HRR × (60% to 80%) + resting heart rate, i.e.,

(HR max-HR rest) × X + HR rest where X is the exercise factor (60% to 80%) dependent on training status.

With this, we can predict each child's target heart rate during training. This also helps in achieving progression if we can increase their target HR gradually.

The control group also had 30 participants. These participants were assessed on ISAA for pretest scores. Then they were provided with conventional physiotherapy program for 12 weeks. The dosage for conventional physiotherapy is 3 sessions/week with a duration of 45 min. The control group was also assessed after 12 weeks for the posttest scores of ISAA.

Maximum heart rate was measured by using Karvonen's formula.


The data were analyzed using SPSS software. Both the groups (intervention and control) were compared based on age, weight, height, and gender. The mean age of the population (n = 60) was 6.87 years (standard deviation [SD] = 1.96), mean weight −21.58 kgs (SD = 6.49), and mean height was 3.18 feet (SD = 0.60).

Result within Group 1 (Intervention group), pretest scores of ISAA were compared to posttest scores using paired t-test at 95% confidence interval. The results showed significant improvement with t = 19.67 at df 29 and P = 0.0001.

Result within Group 2 (Control Group), pretest scores of ISAA were compared to Post-test scores using paired t-test at a 95% confidence interval. The results showed significant improvement with t = 7.477 at df 29 and P = 0.000.

Result among groups 1 and 2 on comparing posttest scores of ISAA between intervention group and control using independent t-test at a 95% confidence interval [Table 1]. The results showed significant improvement with t = −4.04 at df 58 and P = 0.000 [Graph 1].{Table 1}[INLINE:1]

Thus, the results show that sensory-motor training has significantly improved the stereotypical behaviors in the intervention group as scored on ISAA.


In the present study, the multimodal sensorimotor training program (intervention program) was compared with conventional physiotherapy treatment to determine if there are any changes and if this intervention program is more effective than conventional physiotherapy. The results were promising. In both the groups, multimodal sensorimotor training group and control group, mean values of postintervention were significantly higher than the mean values of preintervention for the ISAA scale, indicating improvement in both groups. The interventional group shows a significant improvement between the pre- and post-ISAA scores. The postintervention scores of ISAA are compared for both the experimental and control group, and there were significant differences indicating that multimodal sensorimotor training is more effective in reducing stereotypical behaviors in children with ASD than the conventional physiotherapy treatment given to the control.

The present study has used ISAA as the outcome measure. This scale is a reliable scale and has been compared with Childhood Autism Rating Scale. Mukherjee et al. have also described that ISAA can be used to identify and certify autism in children between the age of 2-9 years.[16]

Marc J. Lanovaz, Kirsty M. Robertson (2013) explained the importance of reducing stereotypical behaviors in children with ASDs. In their systematic review, they observed that the greater the level of stereotypy greater is the child's impairment in social and adaptive functioning. They also emphasized that reducing the stereotypy is very crucial for children with ASD as this potentially increases their social and adaptive behaviors.[22] The present study evaluated these stereotypical behaviors and how sensory motor training program affects stereotypy in children with ASD.

Several recent studies have used components of motor and sensory training in pediatric conditions and have seen good recovery.[23],[24],[25],[26],[27],[28] Hakim et al. also supported the use of balance training to improve postural control and balance in children with autism.[29],[30] Moreover, the results of the present study are congruent with these studies. Lana Bestbier, Tim I. Williams 2017 suggested that deep pressure has immediate effects on children with autism as it helps in improving their mood and behavior.[11] The efficacy of physical exercise programs in children with ASDs was studied by many researchers and they found that the exercise program reduces the symptom profile of these children and also improves their physical activity.,[10] Lin et al. 2014 evaluated the effect of a weighted vest in children with autism, and their study results suggested improvement in attention, speed of processing, and response.[23] The present study has included multiple components of sensory and motor training as these components have been shown to improve behaviors and symptoms in children with ASDs. Therefore, multimodal sensorimotor training may be a promising tool with which to promote functional ability and reduce stereotypical behavior among autistic children.

The incidence of autism is as high as 11,914 people per year in India. However, there is still a need for the development of instrumentation and procedures to identify these children and their needs, especially in developing countries.[31] The rate of incidence of autism is increasing 10%–17% per year in the US (as per the Autism Society of America). Therefore, there is an urgent need to have defined protocols for therapy programs.[32] Therefore, the present study explored this multimodal sensory motor intervention protocol which is very well defined and relevant as per Indian conditions and resources. At the ground level, Indian pediatric therapy centers have only some common equipment which are readily available; and this intervention uses just those equipment. Therefore, in the absence of advanced equipment also children with autism must get effective therapy.

Limitations of the study

The sample size was small to generalize the result of this study to a large populationNo follow-ups were taken to see the long-term effects of this trainingA specific age group was considered the among the subject; it might be a limitation of the study as the technique used can have different effects on different age groups.

Clinical relevance

Multimodal sensorimotor training can be used to enhance the efficacy and efficiency of physiotherapy in the treatment of children with ASD. The present study has shown good improvement in children with autism using this intervention protocol. A basic stretching and strengthening program may not be as effective as a complete multimodal sensorimotor training program. Hence, in all kinds of physiotherapy setups where children with ASD are treated, their treatment program should include multimodal sensorimotor training as described in the present study. The multimodal Sensorimotor training described in the present study does not require expensive instruments or high-technology gadgets. In developing countries and in geographical locations where there is a lack of sophisticated equipment, these kinds of defined training protocols are required for the therapist.

Future studies

The study can be done using a larger sample size so that the results can be generalised to the patient population.

Follow-ups can be done to see the long-term effect of this training.

Other outcome variables can also be measured.


After a 12-week intervention with multimodal sensorimotor training, there is a significant improvement in stereotypical behavior such as head banging, hand flapping, and repetitive behavior in children with ASDs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Lang R, Koegel LK, Ashbaugh K, Regester A, Ence W, Smith W.Broad Physical exercise and individuals with autism spectrum disorders: A systematic review. Res Autism Spectr Disord 2010;4:565-76.
2National Consultation Meeting for Developing IAP Guidelines on Neuro Developmental Disorders under the aegis of IAP Childhood Disability Group and the Committee on Child Development and Neurodevelopmental Disorders, Dalwai S, Ahmed S, Udani V, Mundkur N, Kamath SS, et al. Consensus statement of the Indian academy of pediatrics on evaluation and management of autism spectrum disorder. Indian Pediatr 2017;54:385-93.
3National Institute of Mental Health. A Parent's Guide to Autism Spectrum Disorder; 2011. Available from: [Last retrieved on 2022 Oct 10].
4Hazen EP, Stornelli JL, O'Rourke JA, Koesterer K, McDougle CJ. Sensory symptoms in autism spectrum disorders. Harv Rev Psychiatry 2014;22:112-24.
5Oriel KN, George CL, Peckus R, Semon A. The effects of aerobic exercise on academic engagement in young children with autism spectrum disorder. Pediatr Phys Ther 2011;23:187-93.
6Macdonald M, Esposito P, Ulrich D. The physical activity patterns of children with autism. BMC Res Notes 2011;4:422.
7Atun-Einy O, Lotan M, Harel Y, Shavit E, Burstein S, Kempner G. Physical therapy for young children diagnosed with autism spectrum disorders–clinical frameworks model in an israeli setting. Front Pediatr 2013;1:19
8Koegel RL, Center KA. Social development in individuals with high functioning autism and Asperger disorder. Res Pract Pers Severe Disabil 2007;32:140-1.
9Yeo KJ, Teng KY. Social skills deficits in autism: A study among students with austim spectrum disorder in inclusive classrooms. Univ J Educ Res 2015;3:1001-7.
10Ferreira JP, Andrade Toscano CV, Rodrigues AM, Furtado GE, Barros MG, Wanderley RS, et al. Effects of a physical exercise program (PEP-Aut) on autistic children's stereotyped behavior, metabolic and physical activity profiles, physical fitness, and health-related quality of life: A study protocol. Front Public Health 2018;6:47.
11Bestbier L, Williams TI. The immediate effects of deep pressure on young people with autism and severe intellectual difficulties: Demonstrating individual differences. Occup Ther Int 2017;2017:1-7.
12Koegel LK, Krasno AM, Taras H, Koegel RL, Frea W. Is medication information for children with autism spectrum disorder monitored and coordinated across professionals? Findings from a teacher survey. School Ment Health 2013;5:48-57.
13Stephenson J, Carter M. The use of weighted vests with children with autism spectrum disorders and other disabilities. J Autism Dev Disord 2009;39:105-14.
14Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism 2015;19:133-48.
15Bressel E, Gibbons MW, Samaha A. Effect of whole body vibration on stereotypy of young children with autism. BMJ Case Rep 2011;2011:1-8. 10.1136/bcr. 02.2011.3834.
16Mukherjee SB, Malhotra MK, Aneja S, Chakraborty S, Deshpande S. Diagnostic accuracy of Indian scale for assessment of autism (ISAA) in chidren aged 2-9 years. Indian Pediatr 2015;52:212-6.
17Lourenço C, Esteves D, Corredeira R, Seabra A. Children with autism spectrum disorder and trampoline training. Wulfenia J 2015;22:342-51.
18Petrus C, Adamson SR, Block L, Einarson SJ, Sharifnejad M, Harris SR. Effects of exercise interventions on stereotypic behaviours in children with autism spectrum disorder. Physiother Can 2008;60:134-45.
19Todd T, Reid G. Increasing physical activity in individuals with autism. Focus Autism other Dev Disabil 2006;21:167-76.
20Kern L, Koegel RL, Dunlap G. The influence of vigorous versus mild exercise on autistic stereotyped behaviors. J Autism Dev Disord 1984;14:57-67.
21Gardener H, Spiegelman D, Buka SL. Prenatal risk factors for autism: Comprehensive meta-analysis. Br J Psychiatry 2009;195:7-14.
22Marc JL, Robertson KM, Soerono K, Watkins N. Effects of reducing stereotypy on other behaviors: A systematic review. Research in Autism Spectrum Disorders 2013;7:1234-43.
23Lin HY, Lee P, Chang WD, Hong FY. Effects of weighted vests on attention, impulse control, and on-task behavior in children with attention deficit hyperactivity disorder. Am J Occup Ther 2014;68:149-58.
24Iwanaga R, Honda S, Nakane H, Tanaka K, Toeda H, Tanaka G. Pilot study: Efficacy of sensory integration therapy for Japanese children with high-functioning autism spectrum disorder. Occup Ther Int 2014;21:4-11.
25Sam KL, Chow BC, Tong KK. Effectiveness of exercise-based interventions for children with autism: A systematic review and meta-analysis. Int J Learn Teach 2015;1:98-103.
26Kufleitner AR. Perseveration or perseverance: Investigating interpretations of echolalia, self-stimulatory behaviors, and intervention approaches for children who have autism. Senior Independent Study Theses. 2019. Available from: [Last accessed on 2022 Nov 12].
27Thompson-Hodgetts S, Magill-Evans J. Sensory-based approaches in intervention for children with autism spectrum disorder: Influences on occupational therapists' recommendations and perceived benefits. Am J Occup Ther 2018;72:7203205020p1-8.
28Pan CY, Frey GC. Physical activity patterns in youth with autism spectrum disorders. J Autism Dev Disord 2006;36:597-606.
29Cheldavi H, Shakerian S, Boshehri SN, Zarghami M. The effects of balance training intervention on postural control of children with autism spectrum disorder: Role of sensory information. Res Autism Spectr Disord 2014;8:8-14.
30Stins JF, Emck C. Balance performance in autism: A Brief Overview. Front Psychol 2018;9:901.
31Srinath S, Kandasamy P, Golhar TS. Epidemiology of child and adolescent mental health disorders in Asia. Curr Opin Psychiatry 2010;23:330-6.
32Cynthia C, Duck M, McQuillan R, Brazill L, Malik S, Hartman L, et al. Exploring the role of physiotherapists in the care of children with autism spectrum disorder. Phys Occup Ther Pediatr 2019;39:614-28.