autism © 2007

Sensory correlations in autism SAGE Publications

and The National
Autistic Society
Vol 11(2) 123–134; 075702
1362-3613(200703)11:2

JANET K. KERN University of Texas, Southwestern Medical Center,

Dallas, USA

MADHUKAR H. TRIVEDI University of Texas,

Southwestern Medical Center, Dallas, USA

B RU C E D. G R A N N E M A N N University of Texas,
Southwestern Medical Center, Dallas, USA

C A R O LY N R . G A RV E R Autism Treatment Center, Dallas, USA

DA N N Y G. J O H N S O N University of Texas, Southwestern

Medical Center, Dallas, USA

ALONZO A. ANDREWS Autism Treatment Center,

San Antonio, USA

J AY S H R E E S . S AV L A University of Texas, Southwestern

Medical Center, Dallas, USA

J Y U T I K A A . M E H TA University of Texas at Dallas, Dallas, USA

JENNIFER L. SCHROEDER University of Texas,

Southwestern Medical Center, Dallas, USA

A B S T R AC T This study examined the relationship between auditory, K E Y WO R D S

visual, touch, and oral sensory dysfunction in autism and their relation- autism;
ship to multisensory dysfunction and severity of autism. The Sensory sensory
Profile was completed on 104 persons with a diagnosis of autism, 3 to processing;
56 years of age. Analysis showed a significant correlation between the Sensory
different processing modalities using total scores. Analysis also showed Profile
a significant correlation between processing modalities for both high
and low thresholds, with the exception that auditory high threshold
processing did not correlate with oral low threshold or touch low thresh-
old processing. Examination of the different age groups suggests that
sensory disturbance correlates with severity of autism in children, but
not in adolescents and adults. Evidence from this study suggests that: all
the main modalities and multisensory processing appear to be affected;
sensory processing dysfunction in autism is global in nature; and sensory
processing problems need to be considered part of the disorder.
ADDRESS Correspondence should be addressed to: J A N E T K . K E R N , University of
Texas Southwestern Medical Center at Dallas, 6363 Forest Park Road, Suite 13.354,
Dallas, Texas 75390–9119, USA. e-mail: janet.kern@ UTSouthwestern.edu

www.sagepublications.com 123
DOI: 10.1177/1362361307075702
AU T I S M 11(2)
Introduction
Autism is a neurological disorder that limits a person’s ability to function
normally. Behavioral abnormalities, social limitations, and impaired ability
to communicate are the main issues in this multifaceted disorder (American
Psychiatric Association, 1994; Cohen and Volkmar, 1997; Frith, 1997).
Another common characteristic of persons with autism is their differ-
ence in perceptual sensory processing, a disability commonly known as
‘sensory dysfunction’ or ‘sensory difference’ (Bauman and Kemper, 1994;
Kern, 2002; Kern et al., 2001; Moller and Kern, 2005). These problems
were noted early in the study of autism. Kanner (1943), for example, in
his description of 11 children with autistic disturbances, stated that a child
might be overly sensitive to sounds and small changes in the daily routine
and yet unresponsive to parents. Sensory dysfunction results from the brain’s
inability to correctly process stimuli from the sensory inputs including
vision, hearing, touch, taste, smell, vestibular, proprioceptive, and kines-
thetic. Even though sensory dysfunction is mentioned in the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition (DSM-IV: American Psychi-
atric Association, 1994), sensory abnormalities remain excluded from the
indicative profile. As with any medical condition, symptomatology is critical
in directing areas of research. Since the nature or the frequency of abnormal
sensory responses is not included in the diagnostic criteria for autism or
pervasive developmental disorder (PDD), it has been disregarded in some
research (Tadevosyan-Leyfer et al., 2003).
The ability of a person to respond to unexpected stimuli in their environ-
ment is a fundamental characteristic of mammalian behavior and is necess-
ary for functional performance. Dysfunction of this ‘orienting response’
comes in many forms under many more names as symptoms for even more
disorders. However, the numerous forms are hard to label and discuss due
to the highly subjective nature of the language developed by, and most often
discussed with, typically developing people (Cesaroni and Garber, 1991).
Perhaps, then, the best accounts of the various manifestations of sensory
dysfunction are captured in self-reports from high-functioning people with
autism (Grandin, 1992; Grandin and Scarino, 1986; White and White,
1987). However, because descriptions are given from a subgroup, they only
begin to explain the perceptual aversions experienced by the wider autistic
population, from whom such explanations would be nearly impossible to
obtain (O’Neil and Jones, 1997).
Some researchers have suggested that there is a link between the sensory
processing problems that a person with autism experiences and the diffi-
culties in managing daily life (Cook and Dunn, 1998; Dunn, 1997; 1999;
2001; Dunn et al., 1994; Kern et al., 2006). The secondary psychological

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consequences associated with these perceptual differences may include
anxiety related behaviors or disorders, and a detrimental impact on self-
concept or social empathy (O’Neil and Jones, 1997; Watling et al., 2001).
While in the past these problems may have been overlooked in many autistic
programs, attention to sensory dysfunction and the various treatments for
it is increasing (Dunn et al., 1994; Grandin, 1992).
The purpose of this analysis was to examine the relationship between
auditory, visual, touch, and oral sensory dysfunction in autism (including
both high and low thresholds) and also to examine their relationship to
multisensory dysfunction and the severity of autism. The data for the analysis
in this study were collected as part of a larger study (Kern et al., 2006).

Methods

Participant selection and participation

The participants included 104 persons with a diagnosis of autism, 3 to 56
years of age (see Table 1 for demographic information). The participants
were recruited across seven age categories (3–7; 8–12; 13–17; 18–22;
23–27; 28–32; and 33+) in order to ensure a full range of ages and a
balance of participants in the seven categories. Each category had no fewer
than 12 participants.
These persons had been given a diagnosis of autism during childhood.
The diagnosis was confirmed at the time of the study by one of the investi-
gators (JKK, CRG, AAA, or JAM) based on the DSM-IV criteria for autism
and clinical judgment. Each of these investigators (JKK, CRG, AAA, or JAM)
has had at least eight years of experience as a professional in the field. To
determine the severity of the autistic symptoms, the Childhood Autism
Rating Scale (CARS: Schopler et al., 1994) was completed on all participants
in the autism group (see Table 1 for CARS information). The only exclusion

Table 1 Demographics

Autism group Age Age range CARS CARS range

Mean (SD) Mean (SD)

All 19.92 (11.42) 3–56 41.73 (8.80) 20.5–58.5

n = 104
Females 21.54 (10.62) 4–37 41.84 (8.91) 26.5–58.5
n = 25
Males 19.44 (11.66) 3–56 41.70 (8.82) 20.5–58
n = 79

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criteria were the presence of blindness or deafness. The authors acknowl-
edge that eight of the 104 persons in the study had a CARS score between
20 and 30. These persons were included in the study because, although they
were very high functioning, they had previously been given a diagnosis and
still displayed the features of autism.
Forty (40) of the 104 participants with autism were residents of the
Autism Treatment Center (ATC) in Dallas; 28 of the participants were from
the ATC in San Antonio; and 36 were from the local autism societies (see
Table 1 for demographic information). For the autism group, informed
consent and HIPAA forms were signed by the parent, legal guardian, or
caseworker.

Measures
The Sensory Profile (Dunn, 1999) and the Childhood Autism Rating Scale
(CARS: Schopler et al., 1994) were completed for each of the 104 partici-
pants with autism. At the ATC, the Sensory Profile was completed by a
teacher, a job coach, a facilitator, a group home manager, or a therapist who
was very familiar with the participant, seeing him or her 5 days or more
per week. For the participants with autism from the local autism societies,
the Sensory Profile was completed by a family member (typically a parent).
The CARS was completed by the same person that completed the Sensory
Profile with the assistance of one of the investigators: JKK (40 participants
from the ATC in Dallas and 31 participants from the general population in
the Dallas Metroplex, Fort Worth, and Collin County area of community);
AAA (28 participants from the ATC in San Antonio where he is the director);
or JAM (five participants from her practice).

Sensory Profile
The Sensory Profile is a 125-question caregiver-completed profile that reports
the frequency of the person’s response to various sensory experiences
(Dunn, 1999). Caregivers are asked to check the box that best describes the
frequency with which the participant engages in the listed behaviors.
Choices are: never (5 points); seldom (4 points); occasionally (3 points);
frequently (2 points); and always (1 point). On the Sensory Profile, lower
scores indicate greater symptoms. The level of measurement is interval. Most
of the sections on the Sensory Profile (and all of the sections used in this
study) include high threshold and low threshold items. High threshold
items measure an individual’s lack of response or need for more intense
stimuli. Low threshold items measure a person’s notice of or annoyance with
sensory stimuli. The items on the Sensory Profile are grouped into three
categories: (1) sensory processing, (2) modulation, and (3) behavioral and
emotional responses. The Sensory Profile has 14 sections: (A) auditory
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processing; (B) visual processing; (C) vestibular processing; (D) touch
processing; (E) multisensory processing; (F) oral sensory processing; (G)
sensory processing related to endurance/tone; (H) modulation related to
body position and movement; (I) modulation of movement affecting
activity level; (J) modulation of sensory input affecting emotional response;
(K) modulation of visual input affecting emotional responses and activity
level; (L) emotional/social response; (M) behavioral outcomes of sensory
processing; (N) items indicating thresholds for response. The Sensory Profile
characterizes the person’s responsiveness to sensory input, sensory seeking,
emotional reactive, endurance/tone, oral sensory sensitivity, inattention/
distractibility, poor registration, sensory sensitivity, sedentary, and fine
motor perceptual. Cronbach’s alpha for the internal consistency for the
various sections ranged from 0.47 to 0.91 (Dunn, 1999). Construct validity
was rated as high when compared to the functional tasks measured by the
School Function Assessment (Coster et al., 1998). Internal validity correla-
tions ranged from 0.25 to 0.76, suggesting that the sections of the Sensory
Profile use relatively unique constructs and support the factor structure
developed. Construct validity was obtained by comparing the results of the
Sensory Profile to electrodermal response rating (EDR) which captures the
physiological response to sensation. The EDR and the Sensory Profile showed
a correlation (p < 0.05) (Dunn, 1999).
The scoring of the Sensory Profile was conducted in two ways. First, the
standard scoring was conducted. Second, the high and low threshold scores
were scored separately, providing a separate high and low threshold score for
that subscale. For the multisensory subscale, please note that there is only
one item defined as a low threshold item.

Autism rating
The CARS (Schopler et al., 1994) is a 15-item behavioral rating scale
developed to identify autism as well as quantitatively describe the severity
of the disorder. The CARS is a well established measure and psychometrics
are available. The CARS has been used in previous studies to rate autism in
children, adolescents, and adults (Elia et al., 2000; Njardvik et al., 1999;
Schopler et al., 1994). The CARS ratings were compared to the sensory
processing data only; no normative values were obtained.

Analyses
In order to determine the relationships between the different sensory sub-
scales, two sets of correlations were conducted. The first set of correlations
(see Table 2) included the standard scoring of the sensory items. The second
set of correlations (see Table 3) included the high threshold and low
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Table 2 Correlations between Sensory Profile subscales and CARS total:
correlations significant beyond the 0.05 cutoff are in bold

Visual Oral Touch Multisensory CARS total

Auditory 0.46 0.40 0.49 0.63 0.01

Visual 0.47 0.53 0.50 0.15
Oral 0.46 0.47 0.07
Touch 0.58 –0.10
Multisensory –0.01

Table 3 Correlations between the Sensory Profile high and low subscales and
the CARS total: correlations significant beyond the 0.05 cutoff are in bold

Auditory Visual Oral Touch Multisensory CARS

High Low High Low High Low High Low High Total

Auditory Low 0.26 0.41 0.34 0.35 0.29 0.28 0.43 0.35 0.42 0.14
High 0.23 0.25 0.18 0.23 0.16 0.56 0.42 0.50 –0.23
Visual Low 0.51 0.39 0.33 0.41 0.45 0.29 0.44 0.11
High 0.35 0.38 0.26 0.51 0.32 0.50 0.22
Oral Low 0.43 0.32 0.29 0.22 0.44 0.14
High 0.33 0.42 0.29 0.42 0.001
Touch Low 0.47 0.16 0.40 –0.08
High 0.45 0.59 –0.10
Multi- Low 0.42 0.05
sensory High –0.004

threshold scores analyzed separately. On the multisensory subscale, note

that there is only one item defined as a low threshold item. In order to
determine the relationship between the sensory sensitivities and severity of
autism symptoms, the CARS total score was also included in both sets of
correlations. The goal of the study was to explore the relationships between
the auditory, visual, touch, and oral sensory dysfunction in autism (includ-
ing both high and low thresholds) and also examine their relationship to
multisensory dysfunction and severity of autism; therefore, no Bonferroni
correction was made to correct for the number of tests being conducted,
and these results need to be interpreted cautiously.
In previous research we have found that, as ages increased in autism,
there was an apparent lessening of abnormal sensory processing (Kern et
al., 2006). Because there were differences in sensory sensitivities that were
related to age, analyses were conducted in the three age groups to determine
if the overall test masked differences for these age groups. Therefore, a third
correlation analysis examined the change over age in the relationship
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between the individual sensory modalities (including high and low thresh-
olds) and severity of autism (CARS score). In order to do this analysis, we
divided the overall sample into three approximately even groups: 3 to 12
years of age (N = 37); 13 to 25 years of age (N = 33); and 26 and over
(N = 34). This was divided such that we could ensure an adequate sample
in each group. Though these are not developmentally defined samples, these
samples do describe children and adults, with adolescents and young adults
in between.

Results
The first correlation analysis showed that there was a significant correla-
tion between the different auditory, visual, touch, oral, and multisensory
processing modalities (using the total scores) (see Table 2). These correla-
tions ranged from 0.40 to 0.63. This result indicates that abnormal sensory
processing in each of the main sensory modalities correlates with each
other; if a lower score was found in one modality, a lower score was more
likely to be found in another modality. There was no significant correla-
tion between the CARS and any of these subscale total scores. This finding
suggests that, overall, abnormal sensory processing is not related to severity
of autism.
The second correlation analysis showed that there was a significant
correlation between the different auditory, visual, touch, oral, and multi-
sensory processing modalities (both high and low thresholds) ranging
from 0.22 to 0.59. This result indicates that, in general, abnormal sensory
processing in each of the main sensory modalities (both high and low
thresholds) correlates with each other. There were some exceptions:
auditory high threshold processing did not correlate with oral low thresh-
old or touch low threshold processing, and touch low threshold did not
correlate with multisensory low threshold processing (see Table 3). The
sensory high and low subscales did not correlate with the CARS total score,
except there was a significant correlation between the CARS total score with
only auditory high threshold (–0.23) and visual high threshold (0.22)
processing. This finding also suggests that overall, abnormal sensory process-
ing is not related to severity of autism, except possibly with auditory high
threshold and visual high threshold.
The third correlation analysis showed that in the children (3 to 12 years
of age) there is a significant correlation between abnormal sensory process-
ing and the autism severity score (CARS). In the children (3 to 12 years of
age), auditory, visual, touch, oral, and multisensory processing modalities
(both high and low thresholds) showed a correlation with the CARS score;
scores in this group ranged from –0.31 to –0.70, with the exception of
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visual low threshold processing and oral low threshold processing (see
Table 4). The adolescent and young adult group (13 to 25 years of age) did
not show a significant correlation between abnormal sensory processing and
the autism severity score, except there was a significant correlation between
the CARS and visual high threshold processing (0.35) (see Table 4). Likewise,
the adult group (26 years of age and older) did not show a significant
correlation between abnormal sensory processing and the autism severity
score, except, similar to the 13- to 25-year-old group, there was a signifi-
cant correlation between the CARS and visual high threshold processing
(0.42). This correlation analysis suggests that sensory dysfunction in autism
may relate to the severity of autistic symptoms in the children, but not in
adolescents and adults. Table 5 shows the mean and standard deviation (SD)
of the variables in the three age categories.

Table 4 Correlations of the CARS score with sensory modalities (high and low
thresholds) across three age groups: correlations significant beyond the 0.05
cutoff are in bold

CARS Auditory Visual Oral Touch Multisensory

Low High Low High Low High Low High Low High

Age 3–12 –0.31 –0.49 –0.18 –0.46 –0.02 –0.42 –0.45 –0.70 –0.46 –0.58
Age 13–25 0.11 –0.32 0.16 0.35 –0.01 0.02 0.05 0.05 0.11 0.02
Age 26+ 0.22 –0.25 0.12 0.42 0.15 0.08 –0.06 –0.09 0.21 0.02

Table 5 Mean and SD of the variables in the three age categories

Variable Age 3–12 Age 13–25 Age 26 and over

Mean (SD) Mean (SD) Mean (SD)

Auditory low 17.09 (4.74) 19.21 (4.28) 21.59 (4.17)

Auditory high 9.03 (2.36) 9.70 (3.01) 10.41 (2.86)
Visual low 27.48 (4.50) 27.12 (5.78) 30.04 (4.69)
Visual high 6.51 (1.57) 6.91 (1.89) 7.56 (1.99)
Oral low 17.70 (5.43) 19.96 (5.82) 21.44 (4.73)
Oral high 25.66 (5.67) 27.72 (6.60) 28.99 (6.55)
Touch low 42.91 (7.38) 41.20 (9.21) 45.63 (5.87)
Touch high 24.00 (5.70) 24.06 (5.41) 28.79 (4.80)
Multisensory low 2.51 (1.02) 2.64 (1.11) 3.03 (1.27)
Multisensory high 14.30 (2.82) 16.66 (2.93) 16.91 (2.96)
CARS total 37.23 (7.81) 42.43 (8.92) 45.39 (8.47)

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Discussion
The first and second correlation analyses suggest that all of the main modal-
ities (auditory, visual, touch, and oral) and multisensory processing appear
to be affected in autism, and that abnormal processing in the individual
modalities correlates with each other. This suggests that sensory process-
ing dysfunction in autism is global or comprehensive in nature.
In interpreting the correlation analyses between the Sensory Profile and
the CARS, it is important to note that the lower the score on the Sensory
Profile, the greater the abnormal sensory processing. In contrast, the lower
the score on the CARS, the less the severity of autism. Thus, a positive corre-
lation means that as sensory processing is improving, autism is more severe,
or as sensory processing is worsening, autism is less severe. A negative corre-
lation means that as sensory processing is worsening, autism is more severe,
or as sensory processing is improving, autism is less severe.
In the first analysis (using the total scores for the modalities), there was
no correlation between the modalities and the severity of autism. However,
in the second analysis (where high and low thresholds were looked at
separately), a few correlations were noted. The CARS total score did corre-
late negatively with auditory high threshold. Thus, the negative correlation
means that the more severe the autism, the more abnormal the auditory high
threshold processing. This makes sense because the items in this section of
the Sensory Profile reflect aspects commonly seen in autism, e.g. the person
does not ‘tune in’ to what you say, appears to ignore you. In addition, the
CARS total score did correlate positively with visual high threshold process-
ing. This means that the more severe the autism, the less abnormal the visual
high threshold processing. The items in this section ask questions that may
or may not be seen often in autism, depending on how the question is inter-
preted, e.g. whether the person looks carefully or intensely at objects/people.
The third correlation analysis (that looked at the three age groups) found
that there was a significant correlation between abnormal sensory process-
ing and the autism severity score in the youngest group (3 to 12 years of
age). The older groups (13 to 25 years of age; and 26 years of age and older),
in general, did not show a significant correlation between abnormal sensory
processing and the autism severity score.
In a previous article, based on these data, comparing the autism group
to a gender- and age-matched typically developing community control
group, we found that, in general, as ages increased for the group with
autism there was an apparent lessening of abnormal sensory processing.
Thus, the finding from the previous article, plus the finding from this corre-
lation analysis, may suggest that there is an adaptive or maturation process
that occurs in sensory processing over time. There were some exceptions

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in the correlations in the third analysis. In children, visual low threshold
processing and oral low threshold processing did not correlate with the
CARS score. This is difficult to explain and may seem counterintuitive
because, anecdotally, so many of these children are reported to be orally
and visually sensitive. The authors have no explanation for this finding.
Also, the adolescents and adults showed a significant positive correlation
between the CARS score and visual high threshold processing. This means
that the more severe the autism, the less abnormal the visual high threshold
processing. There are two items in visual high threshold processing, and one
item asks whether the person looks carefully or intensely at objects/people
as discussed above. This item would have different responses according to
whether the emphasis was on persons or objects, so this may be a mislead-
ing question in autism.
Synchronization of brain areas is crucial for normal multisensory
processing because multiple areas of the brain are involved once the sensory
information reaches the cortices (Gomot et al., 2002); sensory processing
involves a cascade of events that involve not only cortical regions, but also
subcortical regions and the cerebellum (Claeys et al., 2003). If any step in
the processing of sensory information is abnormal or poorly synchronized,
subsequent processing would be abnormal, and possibly more so.

Conclusion
In summary, evidence from our study on sensory processing suggests that
all the main modalities (auditory, visual, touch, and oral) appear to be
affected, and that, at least behaviorally, the abnormal sensory processing in
each of the modalities is not independent of the other modalities. It suggests
that abnormal sensory processing dysfunction in autism is global in nature.
The results also suggest that sensory dysfunction in autism may relate to the
severity of autistic symptoms in the children, although this relationship does
not hold beyond childhood.

Acknowledgements
This research was funded in part by a grant from the Hogg Foundation
no. 4456. The authors wish to acknowledge the help of Anna Hundley, the
Executive Director of the Autism Treatment Center, Dallas and San Antonio,
Texas and Anne Russell-Bramlett of East Side Speech and Language Clinic
in Plano, Texas.

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