Cross-cultural adaptation,reliability,and validity of the Turkish Adult Sensory Processing Scale

Abstract

Introduction

Sensory processing is crucial to adaptive behavioural responses in occupational therapy. Nevertheless, information on sensory processing in adults is limited. The Adult Sensory Processing Scale (ASPS) measures behavioural responses indicative of sensory processing in different sensory systems. The study aimed to examine the cultural adaptation, reliability and validity of the ASPS-Turkish (ASPS-T).

Methods

The ASPS-T was administered to 405 individuals, who were aged 18 to 64 (38.5 ± 11.4) years. The cross-cultural adaptation and translation procedures were conducted following Beaton’s guidelines. Internal consistency was examined by Cronbach’s alpha. Criterion-related validity of the ASPS was determined by the Adolescent/Adult Sensory Profile using Construct validity and was examined by confirmatory factor analysis using AMOS.

Results

The study included 405 participants (271 female and 134 male). Exploratory factor analysis with varimax rotation determined 11 factors with 55.15% total variance. In confirmatory factor analysis (CFA), model fit indices showed an acceptable fit. The reliability of the scale was 0.834, and test–retest reliability changed from 0.94 to 0.99, illustrating high internal consistency and excellent reliability of the scale.

Conclusions

The ASPS-T is reliable and valid for analysing sensory processing patterns of adults in the Turkish population.

Keywords

adult sensory processing scale reliability and validity psychometrics self-report adult

Introduction

People are exposed to sensory stimuli every minute of the day. The sensory integration process is an organization of the sensory stimuli received from the inside of the body or the environment, so as to organise sensory information and give the appropriate behavioural responses (Dunn, 2001; Pollock, 2009; Miller et al., 2007). Peoples’ nervous systems have personal differences in sensory processing processes (Dunn, 2001). While most people seem to have typical sensory processing abilities, more intense sensory processing patterns are seen in 15% of the population. For example, some may show increased sensitivity or decreased sensitivity to sensory stimuli (Ben-Avi et al., 2012; Miller et al., 2007; Smith Roley et al., 2007). The differences in the sensory integration process can result in difficulties in creating adaptive responses in adults (Engel-Yeger and Shochat, 2012). Different patterns of sensory processing have been associated with different problems in adults, including sleep quality, anxiety state, somatisation, distress, morale, difficulties in social interactions, family, work and therapeutic relationships, which can directly affect daily life (Ben-Avi et al., 2012; Engel-Yeger and Shochat, 2012; Redfern et al., 2009; Syu and Lin, 2018).

The responses to sensory stimuli are expressed as over-responsiveness, under-responsiveness and sensory seeking by Ayres’ original sensory integration theory (Ayres, 1972; Ayres and Robbins, 2005; Miller et al., 2007). Current studies demonstrate the effects of over-responsiveness on functional abilities, behaviours, emotions, sleep quality and mental health. This shows that adults who react excessively to environmental stimuli experience daily life differently from other adults. Individuals can feel overwhelmed by sensory bombardment; therefore, they may need to escape from their environment to ‘be recharged’. This condition could result in an increased tendency to develop stress, anxiety and depression symptoms (Abernethy, 2010; Bar-Shalita et al., 2020; Benham, 2006; Engel-Yeger and Shochat, 2012; Kinnealey and Fuiek, 1999; Kinnealey et al., 1995, 2011), whereas people with sensory sensitivity can be as healthy as those who are not sensitive when in low-stress conditions. It is therefore important to determine the sensory sensitivity of adults (Ayres, 1972; Benham, 2006).

Sensory integration therapy is used commonly with children in Turkey and across the world. Furthermore, sensory integration process practices and research are ongoing for adults. Various instruments have different perspectives to evaluate sensory processing, such as the Adolescent/Adult Sensory Profile (AASP), the Sensory Over-Responsivity, Sensory Perception Quotient (SPQ), and the Highly Sensitive Person (Brown et al., 2001; Dunn and Brown, 2002; Schoen et al., 2008; Tavassoli et al., 2014). The use of diverse clinical evaluation tools such as ASPS-T may help to understand adults’ sensory processes and improve new intervention strategies that address the needs of the relevant occupations. In contrast, culturally adapted, reliable and valid assessment tools are needed and can be used in many languages and cultures, and are critical to gaining knowledge and understanding (Kimberlin and Winterstein, 2008). Few standards have been defined for the translation and cultural adaptation of instruments, and the multi-step approach is considered the best practice in achieving cultural and semantic equivalence of the adapted version. The cross-cultural adaptation process includes both translation and cultural adaptation so that it is necessary to use existing tools effectively in other cultural and linguistic settings (Tuthill et al., 2014). Therefore, it is important to reduce the risk of bias when an instrument is used in a different language, setting and time (Herdman et al., 1998). The aim of this study was a cross-cultural adaptation of the ASPS into Turkish (ASPS-T) and to determine its psychometric features including validity, reliability, factor structure and internal consistency in adults.

Instrument

The Adult Sensory Processing Scale (ASPS) as a self-report instrument was developed to assess identifying patterns of sensory responsiveness linked to distinct sensory systems in adults.

The ASPS is consistent with the original sensory integration theory of Ayres, which emphasises different processing models according to different sensory systems (Brown et al., 2001). The ASPS is designed to measure different behavioural response patterns (over-responding, under- responding and sensory seeking) of specific sensory systems (tactile, proprioceptive, vestibular, auditory and visual) that indicate sensory processing challenges. According to ASPS, over-responsiveness is a tendency towards increased sensitivity, or an aversion in response to ordinary sensory input that would not bother most people. For example, if a visually over-responsive individual goes out without sunglasses, they will feel uncomfortable. Under-responsiveness is a tendency towards a decreased sensitivity, or a lack of awareness of sensory input that most people would notice. For instance, the individual with an ‘under-responding to auditory’ may tend to listen to music louder than other people. Sensory seeking is a tendency to initiate behaviours that produce sensations with greater intensity or frequency than is typical for most people. A person with a sensory seeking to proprioception may prefer activities such as rock climbing or boxing or to be overly active in comparison to others. Sensory responsiveness models related to different sensory systems in adults have been defined by over-responsiveness, under-responsiveness and sensory seeking patterns similar to those in children. A total of 11 factors and 48 items are defined, and the number of questions for each factor is different. All items are rated on a 5-point Likert scale with Never = 1, Rarely = 2, Sometimes = 3, Often = 4 and Always = 5. In the ASPS, the behavioural pattern range is defined as a typical range with possible difficulties and definite difficulties for each factor and low scores reflects the typical range. The Typical Range and Definite Difficulties for each factor are defined as follows: <15.77 and >21.01 for factor 1, <20.05 and >25.61 for factor 2, <15.53 and >20.73 for factor 3, <10.04 and >13.63 for factor 4, <11.80 and >15.33 for factor 5, < 9.03 and > 12.02 for factor 6, < 17.28 and > 20.38 for factor 7, < 5.58 and > 7.62 for factor 8, < 7.33 and > 9.66 for factor 9, < 7.56 and > 10.27 for factor 10, and < 7.48 and > 10.08 for factor 11 (Blanche et al., 2014).

Methods

Participants

This study was conducted in the Faculty of Health Sciences at Uskudar University between April 2019 and March 2020. A total of 405 adults took part in this study on a voluntary basis. Participants comprise the student community, faculty members, other employees and their families and other voluntary individuals who are included in the study with brochures placed in the collective use area. The adequacy of the sample size was measured with the Kaiser–Meyer–Olkin (KMO) test. Fifty-five of the 405 participants were randomly selected to be re-interviewed, and they completed the questionnaire once more. The study included criteria such as being aged 18–64 years, able to read and write, and healthy. Participants were excluded who had a diagnosis of any disorders that prevented them from completing the survey, such as cancer or cognitive problems. Participants comprised university students, faculty employees, other employees and their families. Each participant was invited to take part in the study using a face-to-face interview. After receiving both written and oral information about the project, all the participants who voluntarily took part provided a signed consent form. A total of 460 individuals were called to participate in the study and 55 individuals were rejected. Among the individuals invited to the study, 21 were excluded because they refused to participate in the study, 29 did not meet the age criteria, 2 because of having a diagnosis of dementia and 3 were cancer survivors.

Data collection

Participants completed the socio-demographic form, the ASPS-T, and the AASP in the study. The socio-demographic form contained items regarding age, gender, general health status and other health interventions.

The concurrent validity of the ASPS was demonstrated using the AASP as an external criterion (Chang et al., 2016). Therefore ASPS-T’s external validity was examined with the AASP. The AASP was developed and built on Dunn’s sensory processing model and is suitable for those aged 11 years and over (Dunn and Brown, 2002). It comprises 60 items and is used to evaluate individuals’ sensory processing skills in daily life. Each item is related to responses to sensory input through six sensory factors that refer to everyday activities, including taste and smell, movement, vision, touch, processing, auditory processing, as well as activity levels. Responses of the participants’ sensory stimuli are evaluated in four quadrants: low registration, sensory sensitivity, sensory avoiding and sensory seeking. Low registration refers to behaviours such as missing stimuli or taking longer to respond to them than other people. Sensory sensitivity is defined as being easily distracted from stimuli, feeling discomfort with sensation, and responding more than normal to stimuli, but not actively limiting exposure to uncomfortable sensations. Sensation avoiding is defined as actively limiting exposure to sensations and avoiding distracting situations, whilst sensory seeking refers to the tendency to create additional stimuli or look for an environment that provides sensory stimuli (Dunn, 1997). The responses record on a Likert scale as almost always, often, sometimes, rarely and almost never, and the scores of the related items are added to supply the score for each quadrant. The tests to settle the validity and reliability of the AASP were completed by Ucgul et al. (Üçgül et al., 2017).

Procedure

The current study comprises three parts: cross-cultural adaptation, piloting and examination of psychometric properties of the ASPS-T. The researcher contacted the developers of the original ASPS and received written permission from the authors to translate it into Turkish. Our study was conducted by the Helsinki Declaration and Uskudar University. The Clinical Research Ethical Board approved the study (Approval Number: 61351342-193). The questionnaires were filled out once and included a 5-minute break.

Phase 1: The cross-cultural adaptation process

Translating the Turkish version of ASPS and the cross-cultural adaptation procedure was carried out under the guidance of Beaton et al. (Beaton et al., 2000). The translation from English to Turkish was performed by two therapists whose mother tongue is Turkish, but who are also fluent in English. Each of the translations was reviewed by three therapists to synthesise them. After consensus of the final version, it was back-translated by two native English-speaking translators. An expert committee meeting was held with the team of authors, an occupational therapist and linguists to consider the final version of the ASPS-T. The final version was compared with the original version to reveal any inconsistencies; no discrepancies were observed. During the translation phase, minimal adjustments were made to address linguistics.

Phase 2: Piloting process

A pre-assessment was made with a pilot study to explore ASPS-Turkish’s cultural harmony. The translated questionnaire was completed by 20 participants to identify any items that were not coherent. Four participants stated they could not understand the meaning of avoid-kaçınmak, so therapists suggested yaşamamak, and this was accepted by participants. Three participants could not respond to the first item on factor 10 because they had not travelled by boat or transportation before, so we added the phrase ‘all types of vehicles’ to the sentence. All the authors met to compare the ASPS-T with the original version and assess its suitability after minimal changes and concluded the current correction did not cause any loss in the meaning of the word. After the changes, pilot study participants evaluated the intelligibility of the scale with a 1 to 5 Likert scale and confirmed the clearness unanimously. Therefore, the final version of the ASPS-T, which has minor changes, was the best representation of the original, and each item was found to be suitable for Turkish patients. The pilot study participants were not included in the sample. After cultural equivalence had been achieved, 405 healthy individuals aged 18 and over were asked to complete the ASPS questionnaire.

Phase 3: Data analysis and psychometric properties

IBM SPSS Statistics 26.0 was used for the statistical analysis. CFA was examined with IBM AMOS software. The dataset was divided into two randomized parts (60%, n = 244–40%, n = 161) with SPSS – select cases function. The first dataset (n = 244) was used to analyse factor loads by Exploratory Factor Analysis (EFA). The second part of the dataset was used for Confirmatory Factor Analysis (CFA). Gorsuch suggested that sample size for explanatory factor analysis would be 5 participants for each item and at least 100 participants in total; and Kline suggested sample size should be between 100 and 200 for confirmatory factor analysis (Gorsuch, 1988; Kline, 2013). Both datasets covered the minimum requirements for both EFA and CFA in this study.

The Shapiro–Wilk test was used to evaluate the distribution of the collected data (normal = p>0.05) (Razali and Wah, 2011). The ceiling effect was causing measurement inaccuracy and was checked for all factors and the total score (Taylor, 2010). Descriptive analysis was used to describe participants’ demographic data and questionnaire results. Numerical values were represented as mean and standard deviation, and categorical data were represented as frequencies. Exploratory factor analysis and confirmatory factor analysis (EFA and CFA) were used to measure the construct validity of the instrument. In the EFA, principal component analysis with Varimax rotation, the KMO test, Barlett’s test of sphericity, anti-image correlation and total variance explained were used. Model fit indices were used to determine the best suitable analysis to model the dataset and theoretical model in CFA. Reliability was determined using internal consistency and test–retest reliability. Internal consistency was evaluated by Cronbach’s alpha internal consistency coefficient for each factor. Cronbach’s alpha coefficient reliability increases as it approaches 1 and decreases as it approaches 0. The scales’ Cronbach’s alpha values were interpreted as (<0.40) not reliable, (0.40–0.60) low reliability, (0.60–0.80) moderate reliability and (>0.80) high reliability (Alpar, 2013). Test–retest reliability was assessed by comparing responses for the first and second administrations of the ASPS-T using the intra-class correlation coefficient (ICC) (Koo and Li, 2016). ICC rates were accepted as poor (<0.40), moderate (0.40–0.60), good (0.60–0.75) and excellent (0.75–1.00) (Alpar, 2013). Test–retest reliability, a week after the first application of the ASPS, was evaluated by re-interviewing 55 people who were randomly selected and who completed the questionnaire.

Results

A total of 405 participants (271 women and 134 men) were included in this study. The mean age of the participants was 38.5 ± 11.4 years (min = 18 years, max = 64 years). The ASPS-T completed in 12.8 ± 2.29 minutes by participants. The baseline characteristics of participants are presented in Table 1.

Table 1.

Demographic characteristics of respondents.

Characteristic	Mean (SD) or frequency (%)
Age, mean (SD)	38.5 ± (11.4)
Education status	n (%)
Less than high school	13 (3.2)
High school	171 (42.2)
University	196 (48.3)
Postgraduate degree	25 (6.17)
Marital status	n (%)
Single	167 (41.23)
Married	238 (58.76)
Working status	n (%)
Working	271 (66.9)
Not employed	134 (33.1)

According to the results of the ceiling effect analysis, there were no statistically significant ceiling effects for all factors and total scale value (p < 0.05). This finding was per the fact that all factor means were not close to their maximum or minimum values. Thus, the nature of factor means distributions also supported the results of the ceiling calculation.

The ASPS-T results showed that the participants had experience with specific sensory systems with possible or definite difficulties in everyday life. Almost all participants were in the typical range in factor 7 (%99.01), which is related to the vestibular-proprioceptive motor/postural system. On the contrary, more than half of the participants demonstrated sensory system difficulties at factors 2, 4, 5 and 8. The sensory system response of participants is presented in Table 2.

Table 2.

The sensory system response of participants.

Adult Sensory Processing Scale factors (n = 405)	Typical range (%)	Possible difficulties (%)	Definite difficulties (%)
Factor 1: Over-responsive to vestibular	71.6	20.98	7.4
Factor 2: Over-responsive to auditory	45.18	30.12	24.69
Factor 3: Over-responsive to visual	61.97	26.17	11.85
Factor 4: Over-responsive to tactile	41.97	28.14	29.87
Factor 5: Proprioceptive seeker (under)	40.74	19.5	39.75
Factor 6: General under-responsive	54.32	30.12	15.55
Factor 7: Vestibular–Proprioceptive motor/postural	99.01	0.98	0
Factor 8: Under-responsive to auditory (seeking)	29.13	30.12	40.74
Factor 9: Over-responsive to tactile	76.04	17.7	6.17
Factor 10: Over-responsive to vestibular	58.27	31.6	10.12
Factor 11: Over-responsive to tactile (clothing)	27.65	40.24	32.09

Explanatory factor analysis

According to the results of the descriptive statistics of the EFA (n = 244), the KMO level showed sampling adequacy with a 0.755 level. Bartlett’s test of sphericity (X2 = 4116.814) was applicable due to the df 1128, and 56.55% variance explaining the level and was compatible with the EFA. The EFA resulted in 11 factors in which items were distributed similarly to the original scale. The factor structure and weight of each item in the scale are provided in Table 3.

Table 3.

Factor structure and weight of each item in the scale.

Items	Component
Items	1	2	3	4	5	6	7	8	9	10	11
1		.754	−.174	.158
2		.792	−.145	.139			−.128
3	.163	.751								.107
4	.318	.514	−.195		.145	.170			.189
5	.231	.392	−.142		.174	.143		.296
6		.404	−.356	−.157	.128	−.231				−.244
7	.404			.126		.373	−.159			.196	−.150
8	.724			.128		.194		.146	−.107		−.259
9	.672				.181	.188		.131	.128
10	.358		.246	.220				.283			.186
11	.591					−.157			.348		.200
12	.441	.262			.207	.153	−.509				.179
13	.671	.119			.306		−.165
14	.559	.260			.111		−.307	.134			.247
15				.724				−.159	.173	−.146	−.156
16		.111		.721			−.113	−.152	.102		−.111
17	.110			.726	.157			.164
18	.257		−.132	.621	.248		.172	.164	−.125
19	.132	.110		.474		−.138		.293		.218	.376
20	.254		−.112	.435				.306	−.192	.269
21				.163	.828
22	.147			.117	.824			.106
23	.193	.251			.682
24	.146	.265			.466		.143			.314	−.202
25	−.214	−.255	.681								.174
26			.739
27		−.134	.697				.125
28		−.113	.771				.112
29	−.170				.163	.637	−.243		−.105	.221
30	.127					.653		.100		.240
31		.108				.727
32						.755				.126
33	.113				.100	.562	−.244	−.127	.228
34	.273		−.247			.336	.404	.364			.199
35	.343		−.283			.247	.298	.357	.110		.215
36	.182	.225	−.315	.113	.145	.290	.249	.420
37	.160	.161	−.322		.217		.265	.101		.134	.230
38		−.107	.209							.815
39			.175					−.110		.814
40		.145			−.282	−.195			.448	.204	.472
41	−.120		.123								.675
42	.126	.130			−.154	.115		−.235			.480
43	.178		−.225	.113		.140		.264	.583	−.233	.112
44		.130	.150			.177	.125	.213	.565		−.128
45	.164	.244	−.171		.210				.544	.175
46			.140					.678	.177
47	.135	.167	.114				−.155	.692	.123		−.235
48	.157	.223			.357		−.165	.331	.143

Extraction method: Principal component analysis. Rotation method: Varimax with Kaiser normalization rotation converged in 11 iterations.

Confirmatory factor analysis

The goodness of fit indices was used to analyse the construct validity of the 11 factored structured scale. The scale’s (χ2)/df ratio shows good agreement with 1.365. The goodness of fit indices of TLI (0.836), CFI (0.854) and RMSEA (0.458) showed acceptable fit. The test–retest correlation coefficients of each item’s score between the test and the ASPS-T retest phases were found to be excellent with an ICC value above 0.9 (p < 0.01) (Table 4).

Table 4.

Items of factors, min–max, mean scores, reliability, and the test–retest reliability of the ASPS.

Adult sensory processing scale factors	Min-max	Mean ± SD	Cronbach’s alpha	Factor Cronbach’s alpha if item deleted	ASPS Cronbach’s alpha if item deleted	ICC
Factor 1: Over-responsiveness to vestibular input (6 items)	6–25	13.716 ± 4.2	0.763			0.98
Item 1		2.518 ± 1.22	-	0.698	0.829
Item 2		2.385 ± 1.39	-	0.695	0.829
Item 3		2.118 ± 1.17	-	0.716	0.829
Item 4		2.530 ± 1.2	-	0.721	0.826
Item 5		1.797 ± 1.08	-	0.746	0.827
Item 6		−2.37 ± 1.16		0.760	0.836
Factor 2: Over-responsiveness to auditory input (8 items)	8–40	21.624 ± 5.8	0.795			0.94
Item 7		2.343 ± 1.15	-	0.780	0.827
Item 8		2.567 ± 1.1	-	0.768	0.827
Item 9		2.874 ± 1.18	-	0.758	0.826
Item 10		2.609 ± 1.34	-	0.804	0.831
Item 11		2.977 ± 1.11	-	0.784	0.829
Item 12		2.340 ± 1.1	-	0.762	0.827
Item 13		2.916 ± 1.19	-	0.757	0.824
Item 14		2.995 ±	-	0.758	0.826
Factor 3: Over-responsiveness to visual input (6 items)	6–30	14.832 ± 4.5	0.749			0.99
Item 15		2.32 ± 1.22	-	0.734	0.834
Item 16		1.41 ± 0.78	-	0.725	0.831
Item 17		2.59 ± 1.23	-	0.667	0.828
Item 18		2.5 ± 1.2	-	0.678	0.827
Item 19		2.79 ± 1.17	-	0.732	0.829
Item 20		3.19 ± 1.17	-	0.731	0.828
Factor 4: Over-responsiveness to social touch (4 items)	4–20	11.5457 ± 3.5	0.703			0.97
Item 21		3.365 ± 1.17	-	0.581	0.828
Item 22		3.113 ± 1.12	-	0.562	0.826
Item 23		2.629 ± 1.15	-	0.596	0.825
Item 24		2.437 ± 1.4	-	0.739	0.830
Factor 5: Proprioceptive seeking (4 items)	4–20	11.565 ± 4.08	0.776			0.94
Item 25		2.938 ± 1.32	-	0.708	0.840
Item 26		3.09 ± 1.31	-	0.718	0.837
Item 27		2.822 ± 1.2	-	0.744	0.837
Item 28		2.711 ± 1.46	-	0.664	0.837
Factor 6: Overall under-responsiveness (5 items)	5–22	9.563 ± 2.9	0.628			0.95
Item 29		2.128 ± 0.92	-	0.623	0.834
Item 30		2.377 ± 0.93	-	0.604	0.831
Item 31		1.730 ± 0.95	-	0.506	0.830
Item 32		1.533 ± 0.81	-	0.516	0.830
Item 33		1.792 ± 0.97	-	0.609	0.830
Factor 7: Under-responsiveness to proprioceptive–vestibular input affecting postural-motor abilities (4 items)	4–20	8.9333 ± 3.36	0.695			0.95
Item 34		1.921 ± 1.04	-	0.594	0.828
Item 35		2.755 ± 1.2	-	0.644	0.830
Item 36		2.167 ± 1.11	-	0.584	0.827
Item 37		2.088 ± 1.28	-	0.700	0.829
Factor 8: Auditory seeking (2 items)	2–10	6.785 ± 2.31	0.831			0.94
Item 38		3.590 ± 1.21	-	-	0.841
Item 39		3.195 ± 1.29	-	-	0.840
Factor 9: Under-responsiveness to tactile input (3 items)	3–14	6.135 ± 2.11	0.258*			0.99
Item 40		2.185 ± 1.07	-	0.273	0.835
Item 41		2.580 ± 1.37	-	0.228	0.837
Item 42		1.370 ± 0.81	-	0.082	0.834
Factor 10: Intolerance to movement (3 items)	3–15	7.256 ± 2.57	0.506			0.96
Item 43		2.259 ± 1.09		0.314	0.830
Item 44		2.819 ± 1.34		0.412	0.834
Item 45		2.177 ± 1.65		0.486	0.826
Factor 11: Over-responsiveness to touch involving textures (3 items)	3–15	9.229 ± 2.8	0.618			0.96
Item 46		3.404 ± 1.22		0.523	0.831
Item 47		3.069 ± 1.18		0.363	0.830
Item 48		2.755 ± 1.31		0.658	0.828
Adult sensory processing scale total	78–186		0.834

AASP low registration was significant and positively correlated with all ASPS responses except for proprioceptive seeking and auditory seeking. While the AASP low registration has a medium positive correlation with over-responsiveness to auditory and vestibular input, overall the under-responsiveness, and under-responsiveness to proprioceptive-vestibular input affecting postural-motor abilities, others have a weak positive correlation. AASP sensory seeking showed a significant weak negative correlation with over-responsiveness to vestibular input. In addition, it showed a moderate positive correlation with ASPS proprioceptive seeking and auditory seeking. AASP sensory sensitivity was shown to be correlated with all the ASPS input except for proprioceptive seeking and under-responsiveness to tactile input. While the AASP Sensory Sensitivity responded a significantly weak positive correlation with over-responsiveness to visual input and overall under-responsiveness, and weak negative correlation with auditory seeking, and other responses have a medium positive correlation. AASP sensory avoiding demonstrated a significant correlation with AASP factors except for proprioceptive seeking and under-responsiveness to tactile input (p<0.05). AASP sensory avoiding has a positive weak correlation with overall under-responsiveness and intolerance to movement and has a negative weak correlation with auditory seeking. Correlation results between the ASPS total and AASP factors are presented in Table 5.

Table 5.

Correlation results between ASPS total and AASP factors.

Adult Sensory Processing Scale	AASP Low registration		AASP sensory seeking		AASP sensory sensitivity		AASP sensory avoiding
Factors	p	r	p	r	p	r	p	r
Factor 1: Over-responsiveness to vestibular input	<0.001	.344	<0.001	−.172	<0.001	.458	<0.001	.406
Factor 2: Over-responsiveness to auditory input	<0.001	.407	.105	−.081	<0.001	.578	<0.001	.567
Factor 3: Over-responsiveness to visual input	<0.001	.205	.138	−.074	<0.001	.267	<0.001	.301
Factor 4: Over-responsiveness to social touch	<0.001	.298	.274	−.054	<0.001	.450	<0.001	.506
Factor 5: Proprioceptive seeking	,513	−.033	<0.001	.488	.093	−.084	.118	−.078
Factor 6: Overall under-responsiveness	<0.001	.489	.692	.020	<0.001	.268	<0.001	.283
Factor 7: Under-responsiveness to proprioceptive- vestibular input affecting postural-motor abilities	<0.001	.491	.422	−.040	<0.001	.461	<0.001	.388
Factor 8: Auditory seeking	,508	−.033	<0.001	.411	<0.05	−.111	<0.001	−.185
Factor 9: Under-responsiveness to tactile input	<0.001	.217	.524	.203	.694	−.020	.287	−.053
Factor 10: Intolerance to movement	<0.001	.175	.234	.059	<0.001	.332	<0.001	.209
Factor 11: Over-responsiveness to touch involving	<0.001	.243	.420	.040	<0.001	.446	<0.001	.392
ASPS total score	<0.001	.514	.228	0.60	<0.001	.655	<0.001	.614

AASP: adolescent/adult sensory profile.

Discussion

Although sensory integration was based on Ayres, there is still a need for further knowledge concerning this core concept in occupational therapy (Ayres, 1964). The literature has shown that healthy individuals experienced different sensory responsiveness under daily living conditions. In this study, most of the participants have had specific sensory system responses different from the ‘normal range’. This study aimed to translate the ASPS into Turkish and to determine the validity and reliability of the ASPS in a Turkish population using psychometric methods. The mean duration of patients completing the ASPS-T was 13 minutes. Psychometric analysis indicated that the ASPS-T is a valid and reliable scale for evaluating the responsiveness within specific sensory systems in the Turkish population aged 18–64 years.

The cross-cultural adaptation of the ASPS was uncomplicated, and the instrument translators, back translators and pilot study participants’ feedback shaped the final version of the ASPS-T. According to the feedback received in phase 1 and 2, minor adjustments to the translated questionnaire were sufficient. After the adjustments, the participants could understand the questionnaire items, which were perceived to reflect the concept of sensory processing. The cultural adaptation process in phase 2 was explained in the introduction. The instrument translation included a change of language and context; therefore, translation can generate confusion in how the instrument is able to measure what it is supposed to measure (Mokkink et al., 2010). After the translation and adaptation process, this study has shown that the measurement properties of the ASPS-T reflect those of the original. The questions in the ASPS included daily personal experiences to facilitate the participants’ comprehension of the questionnaire. The ASPS’s sensory patterns are defined according to Ayres’ original sensory integration theory. It measures the reported different response patterns to inputs from auditory, visual, tactile, vestibular and proprioceptive systems that are sensitive to individual differences in the adult population, for instance, investigations of reactions of visual over-responsive behaviours through questions, such as ‘I carry sunglass with me wherever go’ or ‘I tend to look for the shade or stay in the shade if I am outside’. Therefore, it is crucial as it reveals relationships, between recognisable sensory processing patterns of adults and indicators of well-being, such as daily activity preferences and quality of life (Blanche et al., 2014). This study has indicated that the Turkish of ASPS is crucial that includes specific sensory responses that could support a more inclusive perspective when planning intervention.

The factor loading of the ASPS was analysed across the ASPS-T. According to the results, the factor loading of items factor load similarly to the original ASPS (Blanche et al., 2014). According to Tabachnick and Fidell (2013), the factor load of items should be a minimum of 0.32 (Tabachnick and Fidell, 2013). The ASPS-T minimum factor load was .351(item 45) and the original ASPS was .325 (item 37). Both are acceptable loads.

The scales’ Cronbach’s alpha values should be >0.40 to be accepted as reliable (Alpar, 2013). The lowest Cronbach’s alpha level of ASPS-T was found in factor 9 (0.258) and factor 10 (0.506), respectively. Factor 9’s Cronbach’s alpha value was not reliable but when looked at the ‘Cronbach’s alpha if item deleted’, it was seen that factor 9 did not decrease the total α value of the ASPS-T. So, factor 9 was considered appropriate within the scale. In addition, it was 0.56 on the original scale and had low reliability. Factor 9 has been criticised for containing few items or showing poor internal consistency in the original ASPS (Blanche et al., 2014). Thus, we considered the Cronbach’s alpha value for factor 9 in both surveys and we recommend improving this factor on the original scale. While factor 10’s Cronbach’s alpha value was above the 0.60 level, factor 11’s value was below 0.60 in the original ASPS. However, a contrary situation was observed in the ASPS-T (Blanche et al., 2014). Although these factors indicated poor internal consistency, they are crucial to the specificity of sensory responses within particular sensory systems, so that they could be used in large sample sizes. Split half-analysis using the Spearman–Brown coefficient was used to determine the test–retest reliability. Excellent test–retest reliability was found for each factor of the scale. After all the adjustments were made, the ASPS-T had high reliability, and the internal consistency and test–retest reliability are comparable to those of the English version.

We predicted a 4-factor structure analysis for our database and showed a good model fit so that the CFA results of the present study provided additional evidence for the construct adequate validity of the ASPS-Turkish. These findings are consistent with those of the study carried out by Blanche (Blanche et al., 2014). Thus, the ASPS-T is an applicable tool to figure out the relationship between occupational choices and diverse modes of processing within specific sensory systems. We conducted a correlation analysis between ASPS-T and AASP sub-parameters to analyse the convergent validity of the scale. Dunn’s model established a relationship between sensory sensitivity and sensory avoidance because of low thresholds for sensory information. The same explanation was appropriate to low registration and sensory seeking as both include high thresholds for sensory information (Dunn, 2001). The AASP Turkish and Israeli version correlation results have similarly shown a positive correlation between low registration and sensory sensitivity and sensory avoidance. In addition, the results demonstrated the correlation between sensory avoidance and sensory sensitivity (Engel-Yeger, 2012; Üçgül et al., 2017). Our study indicated similar results, ASPS-over-responsiveness detected a low to moderate positive significant correlation between AASP sensory sensitivity, sensory avoiding and low registration. Our analyses confirmed Dunn’s model with indicated low to moderate correlations between ASPS and AASP sub-parameter scores. This result showed us that closely the ASPS is related to other variables and other measures of the same construct.

ASPS is a questionnaire that assesses different behavioural response patterns of specific sensory systems and sensory processing challenges. Our study showed that the ASPS-T is valid and reliable in the Turkish sample.

In the literature, it is asserted that sensory responses in healthy individuals are related to various factors such as age, gender, geographic area, culture, belief, education level and employment status. In the evaluations made according to age ranges in different cultures, and including the original AASP study, it was highlighted that reference values specific to each age group should be established (Brown and Dunn, 2002; Gándara-Gafo et al., 2019; Al-Momani et al., 2020; Almomani et al., 2014). Engel-Yeger found that a relatively high percentage of Israeli participants in the three age groups were in the performance ranges ‘more or less than most people’ in the different AASP quadrants; however, in general, quadrant mean scores and standard deviations of the evaluated population have been reported to have achieved results consistent with the AASP guideline (Engel-Yeger, 2012). The Chinese conducted an AASP study with 96 healthy people and 33 people living with dementia, all aged 65 years and above. When the averages of the four sensory processing quadrants of the healthy participants were compared with the AASP guideline, the registration, sensitivity, and avoidance quadrants were found to be ‘similar to most people’, whereas the sensation-seeking score was ‘less than most people’ (Chung, 2006). On the other hand, Gándara-Gafo et al. indicated that the quadrant reference values for the Hispanic population were different from the values in the original study and from other populations, such as Israel and China, and emphasised the importance of determining reference values according to cultures (Gándara-Gafo et al., 2019). Similarly, Almomani et al. detected that the sensory processing skills of the Arabic participants were different from those of the people from the European population in the Arabic version of the AASP study. They advised to compare sensory processing skills between different cultures and to examine the effect of different factors such as socioeconomic status and demographics in future studies (Almomani et al., 2014). Al-Momani et al. have compared the cut-off scores between the Arabic and the English versions of AASP. The results showed the cut-off scores were larger in the ‘less’ categories and higher in the ‘more than’ categories in the Arabic version. Arabic people’s different sensory stimuli responses have been associated with religion, cultural habits and the plain physical features in cities (Al-Momani et al., 2020). When the AASP Turkish sensory quadrant scores were compared to the original study reference values, Üçgül et al. found that almost half of the healthy participants differed from ‘like most people’ as demonstrated in the sensory seeking (45%), sensory sensitivity (50%) and sensory avoidance (49%) quadrant scores (Üçgül et al., 2017). There was no detailed analysis for AASP sensory quadrants in our study, but when the outcomes were compared with the reference values determined in the original ASPS study, the Turkish sample indicated difficulties in auditory, tactile, proprioceptive (seeker), auditory (seeking) and tactile (clothing) senses, which were out of the typical range. It was determined that the sensory responses were outside the normal range of more than 50% of the participants in 5 out of 11 factors. These responses included over-responsive to auditory (54.82%), tactile (58.03%), tactile-clothing (72.35%), proprioceptive seeker-under (59.26%), and under-responsive to auditory seeking (70.87%). We consider the difference in results may have been affected by factors such as culture, habits, working status, gender, or age, but the analysis made in the study is not sufficient to make inferences on this issue. In future studies, we suggest that the factors affecting the sensory responses of Turkish people should be investigated in detail and that reference values in Turkey should be defined. In addition, both results indicate the presence of sensory processing problems that may affect the daily lives of adults. Considering that our sample group consists of healthy adults, we think that occupational therapists working with adults should consider using sensory processing processes in their evaluations. In addition, we recommend a detailed study of the sensory processing processes of adults, the factors affecting this, and their effects on daily living.

Methodological strengths and limitations

The current study had several limitations. First, the AASP and the ASPS contain approximately 100 items in total, and we observed that the participants found it difficult to remain focused. Moreover, it might be appropriate to define a standard time frame between the two surveys in questionnaires with so many items for future studies. Second, sensory processing abilities can vary among genders, different ages, healthy individuals or certain diseases such as schizophrenia, depression and anxiety. This study was not conducted with people who had been diagnosed with sensory processing disorders. However, this study did not any consider specific health conditions, so our sampling was not appropriate for the generalisation of our findings. Future studies could focus on specific groups such as schizophrenia, different ages and gender. Thus, we recommend conducting studies to define specific health conditions at the item distribution of the scale, factor loading and validity of the subscales. In this study, most of the participants’ specific sensory system responses were different from the ‘normal range’, and so we considered that tools that evaluate the sensory system in adults should be spread, researched and encouraged in this area. The current form of ASPS-Turkish can contribute to the understanding of sensory processing in adults.

Conclusion

In this study, ASPS was translated and adapted to Turkish. In summary, the results demonstrated that the ASPS-T is a valid and reliable instrument for assessing the different behavioural response patterns in specific sensory systems among adults. The current form of ASPS-Turkish can contribute to the understanding of sensory processing in adults with healthy or specific health conditions.

Footnotes

Acknowledgments

Thanks to all participants.

Patient and Public Statement

Not included at any stage of the research.

Research ethics

This study was conducted in ethical approval, which was obtained by the Uskudar University Ethical Commission of Clinical Research with the confirmation number 61351342-2019-193.

P & P Statement

Not included at any stage of the research.

Informed Consent

This study’s process was carried out by ethical standards of the Responsible Committee on Human Experimentation (institutional and national) and per the Declaration of Helsinki, as revised in 2000. All patients were informed about the study, and informed consent was obtained.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Contributorship

ZBA and SŞ researched literature, developed and designed concept, obtained ethical approval, and collected and processed data. ZBA and OA were involved in data analysis and interpretation. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

ClinicalTrials.gov Identifier

NCT04713839.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

ORCID iD

Zeynep Bahadir

References

Abernethy

(2010) The assessment and treatment of sensory defensiveness in adult mental health: a literature review. British Journal of Occupational Therapy 73: 210–218.

Al-Momani

Alghadir

Al-Momani

, et al. (2020) Performance of the Arabic population on the adolescent-adult sensory profile: an observational study. Neuropsychiatric Disease and Treatment 16: 35.

Almomani

Brown

Dahab

, et al. (2014) Cross cultural adaptation of the adolescent/adult sensory profile: establishing linguistic equivalency and psychometric properties of the Arabic version. Disability and Rehabilitation 36: 765–770.

Alpar

(2013) Application of multivariate statistical methods. Ankara, Turkey: Detay Yayıncılık.

Ayres

(1964) Tactile functions. Their relation to hyperactive and perceptual motor behavior. The American journal of occupational therapy: Official publication of the American Occupational Therapy Association 18: 6.

Ayres

(1972) Sensory Integration and Learning Disorders. Torrance, CA: Western Psychological Services.

Ayres

Robbins

(2005) Sensory Integration and the Child: Understanding Hidden Sensory Challenges. Torrance, CA: Western Psychological Services.

Bar-Shalita

Ben-Ziv

Granovsky

, et al. (2020) An exploratory study testing autonomic reactivity to pain in women with sensory over-responsiveness. Brain Sciences 10: 819.

Beaton

Bombardier

Guillemin

, et al. (2000) Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 25: 3186–3191.

10.

Ben-Avi

Almagor

Engel-Yeger

(2012) Sensory processing difficulties and interpersonal relationships in adults: an exploratory study. Psychology 3: 70.

11.

Benham

(2006) The highly sensitive person: stress and physical symptom reports. Personality and individual differences 40: 1433–1440.

12.

Blanche

Parham

Chang

, et al. (2014) Development of an adult sensory processing scale (ASPS). American Journal of Occupational Therapy 68: 531–538.

13.

Brown

Dunn

(2002) Adolescent/adult Sensory Profile. San Antonio, TX: Pearson.

14.

Brown

Tollefson

Dunn

, et al. (2001) The adult sensory profile: measuring patterns of sensory processing. American Journal of Occupational Therapy 55: 75–82.

15.

Chang

McNeil

Lord

, et al. (2016) Concurrent validity of the adult sensory processing scale and the adolescent/adult sensory profile. American Journal of Occupational Therapy 70: 7011500059p1.

16.

Chung

(2006) Measuring sensory processing patterns of older Chinese people: psychometric validation of the adult sensory profile. Aging & Mental Health 10: 648–655.

17.

Dunn

(1997) The impact of sensory processing abilities on the daily lives of young children and their families: a conceptual model. Infants and young children 9: 23–35.

18.

Dunn

(2001) The sensations of everyday life: empirical, theoretical, and pragmatic considerations. American Journal of Occupational Therapy 55: 608–620.

19.

Dunn

Brown

(2002) Adolescent-Adult Sensory Profile: User’s Manual. San Antonio, TX: Psychological corporation.

20.

Engel-Yeger

(2012) Validating the adolescent/adult sensory profile and examining its ability to screen sensory processing difficulties among Israeli people. British Journal of Occupational Therapy 75: 321–329.

21.

Engel-Yeger

Shochat

(2012) The relationship between sensory processing patterns and sleep quality in healthy adults. Canadian Journal of Occupational Therapy 79: 134–141.

22.

Gándara-Gafo

Santos-del Riego

Muñiz

(2019) Reference values for the adolescent/adult sensory profile in Spain. American Journal of Occupational Therapy 73: 7305205040p1–7305205040p48.

23.

Gorsuch

(1988) Exploratory factor analysis. Handbook of Multivariate Experimental Psychology. US: Springer, 231–258.

24.

Herdman

Fox-Rushby

Badia

(1998) A model of equivalence in the cultural adaptation of HRQoL instruments: the universalist approach. Quality of life Research 7: 323–335.

25.

Kimberlin

Winterstein

(2008) Validity and reliability of measurement instruments used in research. American journal of health-system pharmacy 65: 2276–2284.

26.

Kinnealey

Fuiek

(1999) The relationship between sensory defensiveness, anxiety, depression and perception of pain in adults. Occupational Therapy International 6: 195–206.

27.

Kinnealey

Koenig

Smith

(2011) Relationships between sensory modulation and social supports and health-related quality of life. American Journal of Occupational Therapy 65: 320–327.

28.

Kinnealey

Oliver

Wilbarger

(1995) A phenomenological study of sensory defensiveness in adults. American Journal of Occupational Therapy 49: 444–451.

29.

Kline

(2013) Exploratory and confirmatory factor analysis. Applied Quantitative Analysis in the social sciences: 171–207.

30.

Koo

(2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. Journal of Chiropractic Medicine 15: 155–163.

31.

Miller

Anzalone

Lane

, et al. (2007) Concept evolution in sensory integration: a proposed nosology for diagnosis. American Journal of Occupational Therapy 61: 135–140.

32.

Mokkink

Terwee

Patrick

, et al. (2010) The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. Journal of Clinical Epidemiology 63: 737–745.

33.

Pollock

(2009) Sensory integration: a review of the current state of the evidence. Occupational Therapy Now 11: 6–10.

34.

Razali

Wah

(2011) Power comparisons of shapiro-wilk, kolmogorov-smirnov, lilliefors and anderson-darling tests. Journal of Statistical Modeling and Analytics 2: 21–33.

35.

Redfern

Jennings

Mendelson

, et al. (2009) Perceptual inhibition is associated with sensory integration in standing postural control among older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences 64: 569–576.

36.

Schoen

Miller

Green

(2008) Pilot study of the sensory over-responsivity scales: assessment and inventory. American Journal of Occupational Therapy 62: 393–406.

37.

Smith Roley

Mailloux

Miller-Kuhaneck

, et al. (2007) Understanding Ayres’ sensory integration. OT Practice 12(7): CE1–CE8.

38.

Syu

Lin

(2018) Sensory overresponsivity, loneliness, and anxiety in Taiwanese adults with autism spectrum disorder. Occupational therapy international 2018: 9165978.

39.

Tabachnick

Fidell

(2013) Using Multivariate Statistics. New York, NY: Pearson International edition.

40.

Tavassoli

Hoekstra

Baron-Cohen

(2014) The sensory perception quotient (SPQ): development and validation of a new sensory questionnaire for adults with and without autism. Molecular Autism 5: 29.

41.

Taylor

(2010) Ceiling effect. Encyclopedia of Research Design. Thousand Oaks, CA: SAGE Publishing, 133–134.

42.

Tuthill

Butler

McGrath

, et al. (2014) Cross-cultural adaptation of instruments assessing breastfeeding determinants: a multi-step approach. International breastfeeding journal 9: 16.

43.

Üçgül

MŞ

Karahan

Öksüz

(2017) Reliability and validity study of Turkish version of adolescent/adult sensory profile. British Journal of Occupational Therapy 80: 510–516.