Occupational Therapy International, 10(3), 175-184, 2003 © Whurr Publishers Ltd 175

Treatment of sensory
defensiveness in adults

BETH PFEIFFER Pediatric Therapy Associates of the LeHigh Valley,

Allentown, PA; College Misericordia, Dallas, PA
MOYA KINNEALEY Department of Occupational Therapy, Temple
University

ABSTRACT: This pilot study explored the relationship between sensory defen-
siveness and anxiety, as well as the impact of a sensory integration treatment protocol
on normal adults. Fifteen adult subjects identified as having sensory defensiveness
completed the Adult Sensory Questionnaire (ASQ), Adult Sensory Interview
(ADULT-SI), and Beck Anxiety Inventory (BAI) at pre-test and post-test intervals
to measure sensory defensiveness and anxiety. A treatment protocol was imple-
mented which included providing insight into sensory defensiveness, regular and daily
sensory input, and engagement in activities of choice providing primarily proprio-
ceptive, vestibular and tactile sensory input. Subjects engaged in an individualized
self-treatment protocol for one month.
Results indicated a significant correlation between anxiety and sensory defensiveness
(r = 0.62, p = 0.027). The differences in pre-test and post-test mean scores of the
Adult Sensory Interview (p = 0.048) and the Beck Anxiety Inventory (p = 0.0453)
supported the use of a sensory treatment protocol to decrease sensory defensiveness
and secondary anxiety. There is a need for further research using experimental
methodology with a control group to explore the effectiveness of a sensory treatment
protocol on sensory defensiveness and anxiety.

Key words: sensory defensiveness, anxiety, Adult Sensory Interview

Introduction

Sensory defensiveness is a negative reaction to certain sensory inputs (i.e. tactile,

vestibular, auditory, visual, gustatory, olfactory or proprioceptive), which would not
normally be interpreted as aversive (Wilbarger and Wilbarger, 1991). Jean Ayres
(1964) initially described this phenomenon in the literature in the 1960s. Sensory
defensiveness is considered the behavioural manifestation of over-responsivity, a
176 Pfeiffer and Kinnealey

dysfunction in sensory modulation. Sensory modulation dysfunction is ‘a problem in

the capacity to regulate and organize the degree, intensity, and nature of response to
sensory input in a graded manner’ (Lane et al., 2000).
Dunn (1997) provided a framework in which to understand the neuro-
logical and behavioural manifestations of sensory modulation dysfunction. In
order to modulate sensation for adaptive behaviour, there must be an appro-
priate balance between habituation and sensitization. Habituation occurs
when the central nervous system recognizes stimuli as familiar and therefore no
longer responds to them. Sensitization is the process in which the central
nervous system recognizes stimuli as harmful or important and therefore
heightens the response. Individuals with sensory defensiveness have low
thresholds for sensory stimuli, typically leading to heightened responses with
less habituation. This, in turn, may lead to behaviours associated with sensory
sensitivity such as fearfulness, cautiousness, or sensory avoiding.
Sensory defensiveness often has a social–emotional impact as well. For
example, Knickerbocker (1980) discussed clustered clinical patterns among
sensory systems. Her descriptions identified avoidance patterns and emotional
issues in sensory hypersensitive and hyposensitive children as outlined below:

Primary avoidance patterns are patterns of behavior directly related to a hyper- or

hyposensitive response. A secondary avoidance pattern refers to behavior in motor
output, social interaction, or academic performance which is disorganized or interfered
with because of the child’s sensory defensiveness or dormant response. A tertiary
avoidance refers to a more serious emotional disturbance that may be related in part or
originate in large measure from the primary sensory defensiveness and/or dormancy.
(Knickerbocker, 1980: 34)
Kinnealey and colleagues (1995) also identified avoidance as a coping
mechanism for adults with sensory defensiveness.
Oliver (1990) provided further descriptions of the social–emotional impact
of sensory defensiveness in adults. Adults with sensory defensiveness described
feeling anxious and uncomfortable in social situations and having to adapt or
eliminate activities because of their responses to sensory stimuli in those
environments or situations. For example, they would avoid wearing certain
clothing and make-up or participating in social activities that most people
would enjoy. The relationship ‘between sensory defensiveness and more
profound social–emotional problems has long been suspected by clinicians’
(Kinnealey et al., 1995: 450). Preliminary research has also linked sensory
defensiveness to more pervasive social–emotional problems such as anxiety.
Ayres was the first to link anxiety to sensory defensiveness when describing
children with tactile defensiveness, ‘Anxiety surrounds all tactile experiences that
the child himself does not initiate’ (Ayres, 1964: 89). A significant relationship
has been found between the level of anxiety and sensory defensiveness in adults
(Kinnealey and Fuiek, 1999). Anxiety is a state of uneasiness (Sykes, 1982) which
can either promote or interfere with efficient functioning (Thomas, 1985). Beck
and Emery (1985) described symptoms of anxiety as interfering with effective
 Treatment of sensory defensiveness in adults 177

functioning. They further categorized these into cognitive (i.e. difficulty with
reasoning or concentration), affective (i.e. edgy, fearful, or uneasy), behavioural
(i.e. avoidance, restlessness, or inhibition), or physiological (i.e. heightened
reflexes, increased heart rate, or insomnia) symptoms (Beck and Emery, 1985).
Preliminary research on the effectiveness of sensory integration treatment
with sensory defensive adults was described in a case study of an individual who
experienced panic attacks. David (1990) identified factors related to sensory
defensiveness in a case report. A 24-year-old female was admitted to an
inpatient psychiatric unit for treatment of depression and panic attacks. An
occupational therapy evaluation identified her as having decreased kinaesthesia
(conscious and internal awareness of one’s body), gravitational insecurity
(abnormal distress reactions to vestibular sensory stimuli), and defensiveness to
tactile, visual and auditory information. This resulted in learned patterns of
avoidance behaviours to certain environments or situations, including
emotional interactions, involving sensory stimuli which elicited defensiveness.
This further influenced her relationships and interactions with others. The
patient was provided with treatment through education regarding sensory
normalization and instruction of a sensory diet. This included the use of tactile
and proprioceptive activities to help regulate her state of arousal. As identified
in clinical observations, self-report, and an increase in her Allen’s cognitive
levels, the treatment reportedly supported her ability to function independently
while controlling her panic attacks without subsequent hospitalization.
Both sensory defensiveness and anxiety have the power to be very debili-
tating across all aspects of an individual’s life including emotional and social
experiences, motor performance, and activities of daily living (Wilbarger and
Wilbarger, 1991; Beck and Emery, 1985; Pfeiffer, 2002). If sensory integration
treatment could ameliorate the effects of sensory defensiveness and anxiety, it
would assist individuals to function more effectively and could greatly improve
productivity and quality of life. Although there is support for a relationship
between sensory defensiveness and anxiety (Kinnealey and Fuiek, 1999), the
authors could find no research that examines the effectiveness of treatment
interventions for sensory defensiveness in adults nor the impact treatment has
on anxiety associated with sensory defensiveness. The purpose of this study
was to explore the relationship between sensory defensiveness and anxiety and
to determine if treatment of sensory defensiveness reduces both sensory defen-
siveness and anxiety.

Methodology

Subjects
A convenience sample of 15 adult volunteers between the ages of 26 and 46
years participated in this study. Fourteen of the subjects were female and one
was male. They were professionals who lived in the northeastern region of
178 Pfeiffer and Kinnealey

the United States. Subject recruitment occurred through an article printed in

Penn Point, a professional newsletter, targeted at occupational therapists
treating individuals with sensory defensiveness. Fliers were also posted in
private clinics and circulated to paediatric occupational therapists. Subjects
were primarily self-referred for the study. Inclusion criteria was as follows: (1)
volunteers between the ages of 20 and 60; (2) no history of sexual or physical
abuse; (3) no clinically diagnosed psychopathology or medical condition; (4)
normal intelligence; and (5) self-identified as having sensory defensiveness in
one or more sensory systems. Subjects were screened with the Adult Sensory
Questionnaire (ASQ; Kinnealey et al., 1995) to determine the presence of
sensory defensiveness. Subjects who scored nine or more on the ASQ were
interviewed using the Adult Sensory Interview (ADULT-SI). Those individuals
deemed sensory defensive by interviewers were included in the study.

Design
This study is a quasi-experimental pilot study. Subjects were pre-tested and re-
tested one month later after intervention. The subjects implemented a
self-treatment programme for one month after which they were re-tested.

Instrumentation
Adult Sensory Questionnaire (ASQ): The ASQ is a 26-item true/false question-
naire developed to screen for sensory defensiveness in adults. It is a
self-administered questionnaire which can be given to a group or an
individual. When the ASQ was administered to 300 adults, the mean score
was 6 and the standard deviation 4. Therefore, a person with a score of 10 or
above is identified as sensory defensive (Kinnealey and Oliver, 2002). Out of
the 300 subjects, 6% were male and 94% were female although there were no
reported differences between these groups in scores. All of the subjects were
between the ages of 18 and 48 (Kinnealey and Oliver, 2002).
Test–retest reliability for the ASQ was 0.917 when calculated on scores of
16 adult subjects who were tested and re-tested one week later. Another
test–retest study was completed by the authors who looked at the changes in
scores of 97 people before and after a three-day workshop on sensory defen-
siveness. It was suspected that education on sensory defensiveness would result
in changes in the scores on the post-test ASQ. There was a significant
difference at the p = <0.05 level between pre-test and post-test ASQ scores.
The ASQ is intended for use as a screening tool to measure sensory defen-
siveness. The authors suggest that this tool be used in conjunction with
information obtained from the ADULT-SI.
Adult Sensory Interview (ADULT-SI): The ADULT-SI was used to measure
sensory defensiveness in adults (Kinnealey et al., 1995). It is an 82 item semi-
structured, open-ended question format to elicit information regarding a person’s
 Treatment of sensory defensiveness in adults 179

perception and responses to various sensory stimuli. It has a scoring range from 0
to 82 with each question receiving a score of 1 (defensive) or 0 (non-defensive).
The ADULT-SI demonstrated strong inter-rater reliability in four different
preliminary studies. There was a 100% concurrence among raters in identifying
sensory defensive and non-sensory defensive individuals in all of the studies.
Beck Anxiety Inventory: The BAI (Beck et al., 1988) was used to measure
the level of anxiety in subjects and is grounded in Beck and Emery’s (1985)
cognitive theory of anxiety. This theory identifies that an individual’s vulnera-
bility to anxiety begins with a cognitive response, which includes an
assessment of a threat based on the environment, past experiences, and the
individual’s own belief about the ability to cope with the threat. Based on this
cognitive information, a person will either mobilize to cope with the threat or
feel helpless, leading to a higher level of anxiety. The BAI is a self-adminis-
tered paper-and-pencil questionnaire and was designed to be completed in
approximately 15 minutes by individuals between the ages of 17 and 80 years
of age. The BAI consists of 21 items rated on a scale of 0 to 3. Each item is
used to assess subjective, somatic or pain-related symptoms of anxiety. Inter-
pretation of total scores is categorized as minimal, mild, moderate, or severe
levels of anxiety. Caution was used in interpretation, as this tool was initially
administered to adult psychiatric outpatients. Clinical reliability and validity
was reported on 160 individuals diagnosed with panic disorder with and
without agoraphobia, social phobia, obsessive–compulsive disorder, and gener-
alized anxiety disorder (Beck et al., 1988). Beck and colleagues reported an
internal consistency of r = 0.92. Test–retest reliability was r = 0.75 after one
week. Concurrent validity with the Hamilton Rating Scale for Anxiety –
Revised was r = 0.51.

Evaluators
The researchers and evaluators who administered the ADULT-SI and provided
treatment intervention and education were occupational therapists with two
or more years experience. They were all graduate occupational therapy
students assisting with the study to complete their Master’s thesis. All had
training in sensory integration theory and treatment. They also participated in
a one-day training session on the protocol of the study.

Procedure
When potential subjects responded to the announcement of the study and
expressed interest in participating, they were contacted by telephone and
the study time lines and procedures were described to them. The
researchers explained verbally that the study was designed to measure
sensory defensiveness as a distinct condition and that certain additional
conditions would complicate the results. The researcher explained to the
180 Pfeiffer and Kinnealey

potential participants that only those individuals without any history of

mental illness, physical or sexual abuse, or those with medical conditions
would be included in the study. If they did not meet the criteria or for any
reason chose not to be in the study, they were asked to state this and that no
explanations were necessary. This allowed individuals to decline without
disclosing specific confidential information. At the initial testing session
or upon receiving the initial testing package, the subjects signed consent
forms for participation in the study and to allow audio taping of the
ADULT-SI. The ASQ and the BAI were also completed. The results of the
ASQ determined whether or not a person would be included in the study.
The ADULT-SI was used to gather more information on the specific nature
of their sensory defensiveness which was needed to guide treatment. The
interview explored life patterns regarding sensory defensiveness and infor-
mation on the coping mechanisms incorporated into the participants’ lives.
The interview was not only important in determining the presence of
sensory defensiveness, but also it served as a mechanism to educate and
provide insight to the subjects on what sensory defensiveness is and how it
may influence their lives.
A treatment protocol was developed based on the model recommended by
Kinnealey and colleagues (1995). It included the following three components:
(1) patient insight into sensory defensiveness, (2) regular and daily sensory
input, and (3) engaging in physical activities of the patient’s choice which
provided tactile, vestibular and proprioceptive input. The ADULT-SI provided
insight to guide further assessment and to organize the intervention session.
Following the interview, intervention and self-treatment techniques were
explored. Participants tried pieces of clinical equipment to determine their
positive or negative impact in order to design individual ‘sensory diets’. A
sensory diet consists of activities providing regulated sensory input to the
nervous system that can be incorporated into a person’s daily routine. The
equipment included a Morfam vibrator (a large muscle vibrator), an air pillow,
a surgical scrub brush, a floor mat, a platform swing, a rocking chair, a therapy
ball, and, finally, a small trampoline. All activities had elements of deep
pressure tactile, proprioceptive, and vestibular input. The equipment and the
type of sensory input provided is listed in Table 1.
The participants then described how each piece of equipment made them
feel and ranked it from 1 to 10 with 1 being negative and 10 being very
positive. The subjects were also interviewed about activities they liked to
participate in that provided tactile, vestibular and proprioceptive input. From
all of this information, a sensory diet was then designed individually for each
subject to be carried out for the next four weeks. Participants kept a log of their
daily activities and reactions and were provided with possible formats on how
to organize this log.
The participants were contacted on a weekly basis by phone, and inter-
viewed using the following questions:
 Treatment of sensory defensiveness in adults 181

TABLE 1: Equipment and its sensory properties

Equipment Sensory properties

Therapy ball Proprioception and vestibular

Rocking chair Vestibular
Brush Deep pressure touch
Air pillow Ventral deep pressure touch and vestibular
Trampoline Proprioception and vestibular
Platform swing Vestibular
Morfam vibrator Deep pressure touch and vibration
Floor mat Deep pressure touch

1. Are you doing the treatment?

2. Are there any problems or changes needed in the treatment?
3. How are you responding or feeling?
4. Do you have any questions?

During these times, adjustments to the protocol were made if needed.

At the end of the four weeks of self-treatment, subjects completed the BAI
and also another ADULT-SI. The participants were asked their impressions of
the treatment, whether or not it had helped them and if it had in what way.
The study occurred in a variety of settings including the homes of certain
subjects or in a small private occupational therapy clinic.

Data analysis
The data was analysed using t-tests to determine if there were differences
between pre- and post-test group scores on the BAI and ADULT-SI from pre-
test to post-test. Correlations were calculated to determine if there was a
relationship between defensiveness and anxiety.

Results

Question one explored the relationship between sensory defensiveness and

anxiety. To determine if there was a relationship, a Spearman Rho corre-
lation coefficient was calculated between the ADULT-SI scores pre-test and
the BAI scores pre-test. The results confirmed a positive relationship
between sensory defensiveness and anxiety (r = 0.61, p = 0.027). This
further supports the previous findings of Kinnealey and Fuiek (1999) which
identified that individuals who experience sensory defensiveness have higher
levels of anxiety.
Question two asked if there was a difference in ADULT-SI scores following
self-treatment by adults with sensory defensiveness. A Wilcoxon matched-pairs
signed-ranks test was used to compare the pre- and post-test mean scores for the
182 Pfeiffer and Kinnealey

Table 2. T-test for comparison of pre-test and post-test means of the ADULT-SI amd BAI

Test Mean SD t p

ADULT-SI
Pre-test 37.53 12.22 2.17 0.048
Post-test 33.00 9.47
BAI
Pre-test 10.93 10.75 2.20 0.0453
Post-test 6.93 6.51

ADULT-SI. There was a significant difference in pre-test and post-test mean

scores (p = 0.048) (see Table 2).
Question three asked whether there was a reduction of anxiety as a result of
self-treatment of sensory defensiveness. T-tests were completed to determine if
levels of anxiety changed following self-treatment as measured through the
BAI. There was a significant difference (p =0.0453) between the pre-test and
post-test on the BAI (see Table 2).
Results indicated that the mean anxiety level was reduced from
moderate/mild to minimal on the BAI classification following treatment of
sensory defensiveness.

Discussion

The results supported the hypothesis that there is a significant relationship

between sensory defensiveness and anxiety. This further supports clinical
observations by Ayres (1964) and results of other studies (Kinnealey and
Fuiek, 1999; Oliver 1990). Kinnealey and Fuiek (1999) included 32 normal
functioning adults in their study who were identified as either sensory
defensive or non-sensory defensive based on the ADULT-SI. Those
identified with sensory defensiveness demonstrated significantly higher
levels of anxiety. Others have identified the social–emotional costs of
sensory defensiveness (Kinnealey et al., 1995; Pfeiffer, 2002). Kinnealey and
colleagues described the experiences of living with sensory defensiveness in
five adults and the impact on their lives. They found that in addition to the
perceived unpleasantness of the sensory experiences, the coping mechanism
used took a toll on their lives in terms of time, effort and thought as well as
affecting their choice of social activities. Pfeiffer (2002) conducted a case
study identifying the impact of sensory integration dysfunction including
sensory defensiveness on occupational participation and choice and
social–emotional well-being of an adult. Pfeiffer (2002) found that the
presence of sensory integration dysfunction limited the choices of occupa-
tions for the individual and lead to an avoidance of those occupations that
were not individual in nature.
The relationship between anxiety disorders and sensory defensiveness may
 Treatment of sensory defensiveness in adults 183

extend beyond observable social–emotional behaviours. Anxiety is a complex

process but most specifically relates to the threat-response apparatus of the
brain, primarily the reticular formation. Sallee and March (2001), in a liter-
ature review, identified research evidence supporting the reticular formation’s
involvement in controlling arousal and attention levels related to the
emotional distress associated with anxiety disorders. They further found that
the functions of the limbic system, amygdala and hippocampus affect the
emotional-processing circuits. It was also hypothesized that sensory defen-
siveness is associated with reticular activation and limbic system dysfunction
(Lane, 2002). Further research into the similarities between the neurological
processes of anxiety and sensory defensiveness may provide insight into
their relationship.
Results also identified significant changes in both sensory defensiveness, as
measured by the ADULT-SI, and anxiety, as measured by the BAI, from pre-
test to post-test. Sensory defensiveness and anxiety decreased after
self-treatment for sensory defensiveness. This provides support for inter-
vention to decrease both sensory defensiveness and secondary
social–emotional impacts such as anxiety.
This study was limited by the small sample size and lack of a control
group. It is essential to continue research with larger sample sizes, random
assignment and with a control group in order to make generalizations to a
larger population. In particular, a study focusing on anxiety and depression
in individuals with sensory defensiveness who have a self-treating lifestyle
versus those who do not would further identify effective interventions
integrated into daily routines and functional occupations. Those people
with a self-treating lifestyle engage in activities either daily or several
times a week that provide them with proprioceptive, vestibular and/or
tactile stimulation.
This research focused on adults with no psychiatric diagnoses. It is highly
recommended that future research includes adults who have clinical anxiety,
depression, and defensiveness, since a number of subjects were not included
in this study because they had a psychiatric diagnosis. A study exploring the
effectiveness of treatment for sensory defensiveness in those individuals
diagnosed with anxiety disorders is most relevant. Studies could also expand
assessment measurements to include physiological measurements such as
electrodermal responses (McIntosh et al., 1999) to determine whether or not
physiological responses are affected by sensory integrative interventions.
In summary, this study provided additional support for the relationship
between anxiety and sensory defensiveness as well as support for the effec-
tiveness of self-treatment interventions to decrease sensory defensiveness and
secondary anxiety. As it is a pilot study, further studies are necessary to
determine the effectiveness of treatment for sensory defensiveness on behav-
iours associated with both anxiety and sensory defensiveness.
184 Pfeiffer and Kinnealey

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Address correspondence to Beth Pfeiffer, Pediatric Therapy Associates of the LeHigh Valley,
Allentown, PA College Misericordia, Dallas, PA, 801 Evergreen Circle, Telford, Pennsylvania
18969, USA. Tel and fax: 1-r215-721-6420.