Sensory Integration Therapy Research Articles

Sensory Processing Differences in Individuals With Autism Spectrum Disorder: A Narrative Review of Underlying Mechanisms and Sensory-Based Interventions.

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by difficulties with social interaction and restricted, repetitive patterns of behavior. Altered sensory processing and perception are consideredcharacteristics of ASD. Sensory processing differences (SPDs) are commonly observed in individuals with ASD, leading to atypical responses to sensory stimuli.SPDs refer to the way in which individuals receive, process, and respond to sensory information from the environment. People with SPDs may be hypersensitive (over-reactive) or hyposensitive (under-reactive) to sensory input, or they may experience fragmented or distorted perceptions. These differences can make it difficult for individuals with SPDs to filter out irrelevant sensory information, and to integrate sensory information from different sources. This study intends to investigate the underlying mechanisms contributing to SPDs in individuals with autism and determine the effectiveness of sensory-based therapies in addressing these challenges. The literature suggests that altered neural pathways, sensory gating dysfunction, and atypical sensory modulation contribute to SPDs in individuals with ASD. Assistive technology, environmental changes, and sensory-based interventions like sensory integration therapy (SIT) have all shown promise in improving sensory functioning and reducing associated behavioral issues. However, further research is needed to improve our understanding of sensory processing in autism and to optimize interventions for individuals with ASD.

Effects of sensory integration training on balance function and executive function in children with autism spectrum disorder: evidence from Footscan and fNIRS

IntroductionThis study investigates the efficacy of sensory integration training (SIT) in enhancing balance and executive functions in children with autism spectrum disorder (ASD), with the aim of highlighting its potential for organizing and processing sensory information in the brain.MethodsUtilizing Footscan for biomechanical evidence and functional near-infrared spectroscopy (fNIRS) for neural activation, we engaged two participant groups: a control group (n = 9) and an experimental group (n = 9). Assessments involved the Sharpened Romberg Test (SRT) for balance under varied visual conditions and the Go/No-Go task for executive function.ResultsThe SIT intervention significantly improved balance function, particularly in Visual Deprivation (VD) scenarios. Neurophysiological data revealed heightened activation in the right Inferior Frontal Gyrus (R-IFG) and right Middle Frontal Gyrus (R-MFG), suggesting enhanced executive function. The potential of R-IFG/MFG activation as a reliable biomarker for assessing executive function in ASD was identified.DiscussionThe study provides empirical evidence supporting SIT’s effectiveness in enhancing balance and executive functions in children with ASD. The therapy not only improves sensory processing and motor skills but also appears to compensate for sensory deficits, particularly in vision, vestibular perception, and proprioception. Enhanced neural activation in specific PFC regions underscores SIT’s role in improving cognitive aspects, including inhibitory control and cognitive flexibility. The multidisciplinary approach adopted for this research highlights the intricate interplay between sensory-motor functions and cognitive control in ASD, paving the way for integrated therapeutic strategies. Despite these advancements, the mechanisms through which SIT exerts these multifaceted effects require further exploration.

Effectiveness of Sensory Integration Therapy on Functional Mobility in Children With Spastic Diplegic Cerebral Palsy.

Background A set of non-progressive brain abnormalities and nervous system dysfunctions are referred to as cerebral palsy (CP). Due to this,the child's mobility, eyesight, learning, and thought processes are affected. It can evolve before, through birth, or the firstyear of a child's life.The activity through which the brain organizes and analyses external sensations like touch, motion, body awareness, vision, hearing, and gravity is indicated as sensory integration. The use of sensory integration therapy (SIT)necessitates that the sensorimotor exercises target the specific parts of difficulties that the child experiences daily. This study aims tostudy the effectiveness of SIT on functional mobility in children with spastic diplegic CP. Methods In this study, 40 children of CP with spastic diplegic who met the inclusion and exclusion criterion were enlisted and were separated into two groups, with Group A (n=20) receiving SITfor 25 minutes along with conventional physiotherapy for 20 minutes, and Group B (n=20) were given conventional physiotherapy for 45 minutes. A four-week therapy plan was followed. Short sensory profile (SSP) and Gross Motor Function Classification System (GMFCS), Pediatric mini-mental state examination (MMSE), and Modified Ashworth Scale were taken as outcome measures. Results SIT along with traditional treatment is described in the study protocol which aids CP children to improve themselves. Following a four-week protocol, combined therapy of SIT and conventional physiotherapy show an effect on the motor function of the children. After therapy, scores in GMFCS and SSP improved. By using Student's paired t-test, a statistically significant difference was found in GMFCS score at pre and post-test treatment in group A (7.28, p=0.0001) and group B (4.48, p=0.0001),in SSP score at pre and post-test treatment in group A (27.91, p=0.0001) and group B (11.31, p=0.0001), in MMSE score at pre- and post-test treatment in group A (6.89, p=0.0001) and group B (6.32, p=0.0001). The significance threshold was p<0.0001. Conclusion Under the study's experimental conditions, both groups showed substantial improvements in the functional mobility of children. When the efficacy of SIT along with conventional physiotherapy was examined, the impact resulted in a significantly greater improvement in the functional mobility of spastic diplegic CP children.

Effectiveness of Sensory Integration and Conventional Therapy on Impaired Kinesthesia in Peripheral Neuropathy

Background: Peripheral neuropathy is a result of damage to the nerves located outside of the brain and spinal cord. Over all prevalence in India varies from 5 - 2400 per 10,000 populations. Diabetic neuropathy is the most common type. Kinesthesia is the ability to sense the motion of a joint or limb. It is primarily influenced by muscle spindles and secondarily influenced by skin receptors and joint receptors. Objectives: To determine the effectiveness of sensory integration on kinesthesia in peripheral neuropathy and to compare the effect of sensory integration with conventional therapy on kinesthesia in peripheral neuropathy. Materials And Methods: This was an experimental study conducted on 68 subjects in which Group A received conventional therapy (control) and another group received sensory integration along with conventional therapy (experimental). Simple Random Sampling technique was used. Pre intervention assessment was done and treatment was given for 6 weeks. Post intervention assessment was done with help of outcome measures. Statistical analysis was done using students t test. Results: Among the 68 subjects, Group B which received sensory integration along with conventional therapy showed extremely significant improvement in impaired kinesthesia. In the Weber two point discrimination test, the post intervention comparison (8.6 with group A and 5.98 with group B) showed that group was extremely significant in improving joint position sense. In joint position sense for plantar flexion and dorsiflexion, Group B showed extremely proximate results to range which was asked and the range which was performed by the subjects. Conclusion: Sensory integration therapy was found to be significantly effective on impaired kinesthesia in peripheral neuropathy.

Using Gaze Tracking on Sensory Integration Therapy for Eye-movement Detection

Autism spectrum disorder is a condition that often occurs in infancy (from birth to three years old). A common problem includes eyesight disorders, where children cannot focus on a specific item. We use the method of Convolutional Neural Networks (CNN) to detect eyes and collect eye positions. Then, we use a linear regression model to best fit the movement of the eyeballs through the track of positions. After that, we use an Analytic Hierarchy Process (AHP) model for a multi-perspective judgment on children's performance in eye movement.

Sensory Integration Therapy as a Management of Sensory Deficits in Autistic Spectrum Disorders

Abstract Background Sensory integration therapy (SIT) has been used for the management of sensory processing deficits associated with autism spectrum disorders (ASD). This work presents an overview of these sensory processing deficits and the SIT. This study aims to provide an evidencebased practice regarding the effectiveness of the SIT in the management of such sensory processing disorders in children with ASD. Objective To evaluate the effectiveness of the SIT as a therapy for the sensory processing symptoms associated with autism spectrum disorders in children. This will be made by conducting a systematic review of the literature in this topic area. Material and Method Search for any RCTs or retrospective studies that were in English language only. Study participants were not less than 5 children 3-12 yrs aged diagnosed with ASD. The intervention was validated by Ayres Sensory Integration® Fidelity Measure© (ASIFM) to ensure treatment integrity and effectiveness was measured by outcome measures such as SPM or SP. Data Sources PubMed, Cochrane Central Register of Controlled Trials, ScienceDirect, and all materials available on the Internet till 2020. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information, and defined assessment measures. Conclusion The current systematic review has not concluded that SIT may have a positive effect on improving sensory processing defects that are found in children with ASD. We suggest that more literature review would be effective in giving attention to the limitations of this study.

Effectiveness of Neurodevelopmental Treatment and Sensory Integration Therapy on Gross Motor Function, Balance and Gait Parameters in Children With Spastic Diplegia.

Background Spastic diplegic cerebral palsy is the type that is most frequently seen in clinical settings. Spastic diplegic children have trouble maintaining their balance, gait, and gross motor function.This study investigated the effects of the Neurodevelopmental Technique (NDT) and Sensory Integration Technique (SIT) on balance, gross motor function, and gait characteristics in children with spastic diplegia. Method The study's participants were 8 to 12 years old, with spastic diplegia, categorized into stages I to III of the Gross Motor Function Classification System. While individuals in group B underwent sensory integration therapy, group A's subjects received NDT for 45 minutes. Both groups received traditional physiotherapy for 15 minutes. The protocol was given for five days a week, continuously for four weeks. All 40 subjects underwent pre- and post-treatment assessments using the Gross Motor Function Measure-88 (GMFM-88), Paediatric Balance Scale, Gait Parameters, and Gross Motor Function Classification System. Results The trial involved 40 children, divided into two groups of 20 each. Statistical analysis demonstrated a substantial improvement in group B post-intervention (P>0.0001).The study's findings were drawn using the Chi-Square test, paired and unpaired t-tests, and SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, USA).A p<0.05 and theGraphPad Prism version 7.0 (GraphPad Software, Boston, USA)were used. A total of 40 children completed the entire duration of treatment for a month. 20 subjects participated in group A (age range 8-12 years; mean age 10.3 years) and 20 subjects in group B (age range 8-12 years; mean age 10.25 years). The GMFM-88, which assesses motor function, reveals that the between-group comparison indicates a substantial difference of 7.95 (6.04-9.86) in favor of Group B, with a p-value of 0.0001, signifying statistical significance.Similarly, the Pediatric Balance Scale (PBS) outcomes significantly enhanced in both groups post-intervention.The comparison between groups yields a difference of 1.85 (1.11-2.59) in favor of Group B,with a p-value of 0.0001. Conclusion The study concluded that SIT has a positive impact on gait metrics, balance, and gross motor function in children with spastic diplegia.

Retracted: Sensory Integration Training and Social Sports Games Integrated Intervention for the Occupational Therapy of Children with Autism.

[This retracts the article DOI: 10.1155/2022/9693648.].

Contextual sensory integration training vs. traditional vestibular rehabilitation: a pilot randomized controlled trial

BackgroundWe created a clinical virtual reality application for vestibular rehabilitation. Our app targets contextual sensory integration (C.S.I.) where patients are immersed in safe, increasingly challenging environments while practicing various tasks (e.g., turning, walking). The purpose of this pilot study was to establish the feasibility of a randomized controlled trial comparing C.S.I. training to traditional vestibular rehabilitation.MethodsThirty patients with vestibular dysfunction completed the Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence Scale (ABC), Visual Vertigo Analog Scale (VVAS), Functional Gait Assessment (FGA), Timed-Up-and-Go (TUG), and Four-Square Step Test (FSST). Following initial assessment, the patients were randomized into 8 weeks (once per week in clinic + home exercise program) of traditional vestibular rehabilitation or C.S.I. training. Six patients had to stop participation due to the covid-19 pandemic, 6 dropped out for other reasons (3 from each group). Ten patients in the traditional group and 8 in the C.S.I group completed the study. We applied an intention to treat analysis.ResultsFollowing intervention, we observed a significant main effect of time with no main effect of group or group by time interaction for the DHI (mean difference − 18.703, 95% CI [-28.235, -9.172], p = 0.0002), ABC (8.556, [0.938, 16.174], p = 0.028), VVAS, (-13.603, [-25.634, -1.573], p = 0.027) and the FGA (6.405, [4.474, 8.335], p < 0.0001). No changes were observed for TUG and FSST.ConclusionPatients’ symptoms and function improved following either vestibular rehabilitation method. C.S.I training appeared comparable but not superior to traditional rehabilitation.Trial registrationThis study (NCT04268745) was registered on clincaltrials.gov and can be found at https://clinicaltrials.gov/ct2/show/NCT04268745.

Pediatric and psychiatric models of autism care in Mexico: Differences in diagnostic tools and prescribed interventions.

Low- and middle-income countries face heterogeneity in the way clinicians' approach Autism Spectrum Disorder (ASD) diagnosis and treatment. The current study analyzes the diagnostic tools, laboratory tests, pharmacological and psychosocial interventions received by patients during the steps to diagnosis and treatment of two specialized care centers. Researchers interviewed families with a child with ASD receiving services at either a child psychiatric or a pediatric hospital. Of the total sample, 47% reported clinicians not using a diagnostic tool, 20% reported not receiving any psychosocial intervention, and 88% reported receiving a pharmacological prescription. Patients at the pediatric hospital were more likely to receive interventions with some components of Applied Behavioral Analysis, Early Start Denver Model, Treatment and Education of Autistic and Related Communication Handicapped Children, and Sensory integration therapy; while patients at the psychiatric hospital were more likely to undergo learning, daily living skills, and socialization therapies. Patients at the psychiatric hospital received significantly more requests to obtain auditory and vision tests whilst genetic testing and imaging were more common in the pediatric hospital. The range and variability in terms of diagnostic tools, laboratory tests, and treatment options observed for both sites reflect a lack of consensus. Recommendations to improve ASD diagnostic and treatment in Mexico are given.

Rehabilitation using neurodevelopmental and sensory integration therapy approaches in an 8-month-old infant with self-gratification behavior: A case report

Self-gratification behavior is a normal behavior in infants or children and is usually misdiagnosed with dystonic development delays, repeated movement disorders, or even epilepsy. This case report aims to share our clinical experience in managing a child with self-gratification disorder through physical therapy techniques. An 8-month-old female infant presents with concerns related to poor social interaction, reduced play, irritable behavior, frequent crossing, and stiffness in the legs which she started showing at 3 months of age. She was earlier diagnosed with dystonic developmental delay and referred for a thorough development and sensory assessment. Rehabilitation with sensory integration and neurodevelopmental techniques was delivered to the child. Ages and Stages Questionnaire, Denver’s score, and Sensory profile were assessed at 8–9 months, 9–10 months, and 10–11 months to monitor prognosis. There was a significant improvement in self-gratification habits and improved attention in the child. Self-gratification behavior is a normal behavior in infants or children and is usually misdiagnosed. Treatment mainly constitutes neurodevelopment, sensory integration techniques, and parent education.

Development of sensory integration therapy in Mainland China: A comprehensive study with bibliometrics and visualization techniques

Sensory integration therapy (SIT) is an intervention to improve the developmental and learning problems in children. It was introduced in China from late 1980 s to early 1990 s and has received considerable attention from scholars. However, due to its late development in China and its specialised nature, it is worth exploring in depth whether it is recognized by the general public and how it is researched by academics. Therefore, we used Internet survey approach to explore the actual feedback of users towards SIT through the Internet. At the same time, bibliometric method and visualization techniques were used to study 892 journal articles on SIT in CNKI, Wanfang Database and VIP Database to analyze the spatial and temporal distribution, subject distribution, keyword co-occurrence, and keyword clustering of SIT research in mainland China since it came to China mainland. We found that the research on SIT in mainland China has been fruitful. However, the public is less aware of its basic function, therapeutic effects, and necessity. Our findings point to the need to raise awareness of sensory integration disorder and sensory integration therapy among the general public, and to strengthen academic research on sensory integration therapy.

Rehabilitation of a 15-month-old Child with Orofaciodigital Syndrome Type VI, Joubert Syndrome

Orofaciodigital syndrome (OFDS) type-VI, a rare subtype of Joubert syndrome, is characterized by delays in gross motor development, hypotonia, and the presence of a distinctive molar tooth sign on magnetic resonance imaging. The objective of this case report is to underscore the benefits of physiotherapy rehabilitation and delineate the clinical features associated with OFDS type VI. In this case study, we explore the details of a 15-month-old boy grappling with motor and sensory challenges related to this rare condition. The child has experienced notable improvements through play-based physiotherapy treatments, encompassing neurodevelopmental therapy, sensory integration, and adjunctive methods such as prowraps, kinesiotaping, and treadmill walking. These sessions occurred three times a week over a 10-month period. Gross motor and functional assessments, along with the Sensory Profile 2, were conducted at both the 15-month mark and when the child reached 2.1 years. The pre-GMFM score at the baseline (15th month) was 15.33, demonstrating a remarkable 57.37% improvement post-treatment at 2.1 years. Noteworthy enhancements were observed across all the dimensions of the Sensory Profile 2. This report signifies the significance of physiotherapy rehabilitation, highlighting the efficacy of a comprehensive approach involving neurodevelopmental therapy, sensory integration, and adjunct therapies.

Sensory integration therapy as enabler for developing emotional intelligence in children with autism spectrum disorder and the ICT’s role

Sensory Integration Therapy (SIT) is a widely known and used intervention by a lot of professionals and practitioners in the field of special education as being an enabler of functionality of the child. Through intervention, the sensory processing components that have been affected are targeted. Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that is highly affected by sensory modulation disorder (SMD), a special subcategory of sensory processing disorder (SPD) that is expressed in various ways causing activation of Autonomic Nervous System (ANS) leading to biological and physiological stress. Emotional Intelligence (EI) is a complex set of skills that drive us to higher mental states. According to theorists the basis of these skills is the ability to manage and regulate stimulus. The purpose of this literature review is to investigate the connections between SIT and EI in children with ASD. In the introduction basic definitions and concepts of ASD and SIT are analyzed and in the main part correlations between EI and SMD are made, discussing the effectiveness of SIT in ASD children.

Research on the Value of Sensory Integration Training in Families with Children Aged 3-6 Years

This article analyzes the value of sensory integration training for children aged 3-6 years from four aspects: the concept of sensory integration, the current status of research, the significance of sensory integration training, and a comprehensive analysis of the implementation of sensory integration training in the family. It is found that the family is the main activity place for children aged 3-6 years old, and parents, as the "first teacher of children", have irreplaceable importance in the development of children's physical and mental health by leading sensory integration training in the family.

Effect of non-pharmacological treatment on the full recovery of social functioning in patients with attention deficit hyperactivity disorder

Long-term treatment of attention deficit/hyperactivity disorder (ADHD) is associated with adverse events, such as nausea and vomiting, dizziness, and sleep disturbances, and poor maintenance of late ADHD medication compromises treatment outcomes and prolongs the recovery of patients' social functioning. To evaluate the effect of non-pharmacological treatment on the full recovery of social functioning in patients with ADHD. A total of 90 patients diagnosed with ADHD between May 2019 and August 2020 were included in the study and randomly assigned to either the pharmacological group (methylphenidate hydrochloride and tomoxetine hydrochloride) or the non-pharmacological group (parental training, behavior modification, sensory integration therapy, and sand tray therapy), with 45 cases in each group. Outcome measures included treatment compliance, Swanson, Nolan, and Pelham, Version IV (SNAP-IV) scores, Conners Parent Symptom Questionnaire (PSQ) scores, and Weiss Functional Impairment Rating Scale (WFIRS) scores. The non-pharmacological interventions resulted in significantly higher compliance in patients (95.56%) compared with medication (71.11%) (P < 0.05). However, no significant differences in SNAP-IV and PSQ scores, in addition to the learning/school, social activities, and adventure activities of the WFIRS scores were observed between the two groups (P > 0.05). Patients with non-pharmacological interventions showed higher WFIRS scores for family, daily life skills, and self-concept than those in the pharmacological group (P < 0.05). Non-pharmacological interventions, in contrast to the potential risks of adverse events after long-term medication, improve patient treatment compliance, alleviate patients' behavioral symptoms of attention, impulsivity, and hyperactivity, and improve their cognitive ability, thereby improving family relationships and patient self-evaluation.

Occupational therapy using a sensory integration

The article analyzes the use of occupational therapy with elements of sensory integration to improve functional capacity and quality of life for children who have problems with coordination of movements, hypersensitivity or hyposensitivity to certain stimuli.&#x0D; Principles of sensory integration and various techniques that can be used during occupational therapy are described. It was noted that occupational therapy using sensory integration can be an effective method of rehabilitation and improvement of the quality of life of children with autism, Down syndrome, mental retardation, cerebral palsy and other disorders.&#x0D; The goal of sensory integration therapy is to strengthen, balance and develop the processing of sensory stimuli by the central nervous system. A complex of sensory integration exercises is created based on sensory diagnostics individually for each patient. The choice of exercises and tasks for sensory integration should depend on the individual characteristics of the patient and the specific goal of therapy.&#x0D; The results of our study indicate that the use of sensory integration in patients with various diagnoses allows to achieve positive results in improving their physical, mental and social condition. Moreover, children love to perform these tasks, since the classes are played in a playful way.&#x0D; In particular, in patients with motility disorders, improvement in coordination of movements, increase in muscle tone, improvement in motor skills and balance was recorded. In children with impaired speech development, the use of sensory integration made it possible to improve the articulation of sounds, expand the vocabulary and improve coherent speech.&#x0D; The use of sensory integration in children with mental retardation and autism has helped to improve communication, reduce behavioral problems and increase her level of independence, learning to regulate her sensations and adapt to different types of stimuli, allowing her to function better in everyday life and be more independent.

Assessment of Balance Parameters in Children with Weakened Axial Muscle Tone Undergoing Sensory Integration Therapy.

The ZEBRIS platform was used to measure the balance parameters (MCoCx, MCoCy, SPL, WoE, HoE, and AoE). The study was conducted twice: before and after two months of sensory integration therapy. The results were compiled using the TIBICO® Statistica software version 13.3.0. After the SI program, statistically significant changes were observed in the values of MCoCy_oe, WoE_oe, AoE_oe in the group of four-year-olds, MCoCX_ce in the group of five-year-olds, and in SPL_ce and AoE_ce in six-year-olds. A statistically significant, highly positive correlation was observed between body height and changes in SPL_oe, HoE_oe, and AoE_oe in the group of six-year-olds, as well as in the case of changes in SPL_oe in the group of five-year-olds. In the group of four-year-olds, a statistically significant correlation occurred only between body height and the change in the MCoCx_oe value. the sensory integration therapy used in the study group of 4-6-year-old children with reduced muscle tone gave positive results in the form of improved static balance and balance.

Behavior Analysts' Use of Treatments for Individuals with Autism: Trends within the Field.

Previous surveys revealed the majority of certified behavior analysts reported using applied behavior analysis (ABA) as a treatment for individuals on the autism spectrum. However, some certificants have also reported using treatments without evidence (Schreck et al. Behavioral Interventions, 31(4), 355-376, 2016; Schreck & Mazur Behavioral Interventions: Theory & Practice in Residential & Community- Based Clinical Programs, 23(3), 201-212, 2008). The field of ABA has undergone many changes in the last five years. This survey evaluated trends in the use and variables influencing the use of autism treatments over that time. Results indicated that study participants (N = 921 BCBA-Ds, BCBAs, BCaBAs, and RBTs) were significantly less likely to report current use of ABA and some unestablished treatments (e.g., DIR Floortime, sensory integration therapy) than participants in 2016 (Schreck et al. Behavioral Interventions, 31(4), 355-376, 2016). Participants frequently cited persuasion by others as an influence for their treatment selections. Because behavior analysts' use of unestablished treatments may be detrimental to client outcomes and the reputation and success of the field of ABA, future research is needed to identify methods for increasing behavior analysts' use of empirically supported treatments.

Düşük Kas Tonusu ve Konuşma Bozukluğu Olan 3 Yaşındaki Bir Çocukta Ayres Duyu Bütünleme İçeren Fizyoterapi Programının Etkileri: Tek Vaka Çalışması

This case report describes how a physiotherapy program with Ayres Sensory Integration was associated with changes in a 3 years old child with low muscle tone and speech disorders. To see how the Ayres Sensory Integration Physiotherapy Program affects muscle tone, speech, and the relation between muscle tone and speech, a 24-week physiotherapy program with Ayres Sensory Integration was initiated. Before and after the therapy, Development Screening Test, speech, muscle tone, and Antigravity Test were assessed and recorded. Muscle tone, speech, Development Screening Test and Antigravity Test results have all improved. Children with low muscle tone and speech difficulties can benefit from physiotherapy programs involving Ayres Sensory Integration. In addition to speech therapy, children with speech issues should get sensory integration therapy