Sensory Integration Therapy in Malaysia and Singapore: Sources of Information and Reasons for Use in Early Intervention

Transcription

1 Education and Training in Autism and Developmental Disabilities, 2013, 48(3), Division on Autism and Developmental Disabilities Sensory Integration Therapy in Malaysia and Singapore: Sources of Information and Reasons for Use in Early Intervention H. M. Leong, Mark Carter and Jennifer Stephenson Macquarie University Abstract: Sensory integration (SI) therapy is a popular form of intervention for children with disabilities, particularly those with autism spectrum disorders, even though research evidence demonstrating beneficial outcomes from the use of SI therapy is limited. A questionnaire was distributed to early intervention education service providers in Malaysia and Singapore to explore the reasons why they choose to use SI therapy, their sources of information and training in its use, and the ways in which it was employed. Occupational therapists were consistently reported as a major source of information and training in SI therapy, and their advice was a primary reason for using SI therapy. SI therapy was provided to students based on a wide range of criteria, of which challenging behaviors related to sensory stimuli were the most consistently reported. About half of the participants appeared to believe that there was sufficient evidence on the efficacy of SI therapy from research, even though they seemed to lack direct access to sources such as university courses and academic journals. Based on these findings, it was recommended that efforts be taken to disseminate research information to service providers in order to promote evidence-based practice. Sensory integration (SI) therapy, originally developed by Ayres (1972b), is a form of intervention initially popularized for children with learning disabilities and involves the provision of controlled sensory stimulation. Proponents claim SI therapy can correct underlying neurological problems in processing sensory information, particularly in younger children whose brains have higher plasticity (Ayres, 1972b). Improvements in the neurological systems that integrate sensory information, in particular the tactile, vestibular and proprioceptive systems, are theorized to have effects on higher order learning skills such as reading (Ayres, 1972a) and language (Ayres & Mailloux, 1981) due to the proposed connection between these neurological systems and the parts of the brain which govern these skills (Ayres, 1972b). SI therapy is commonly used in the field of Correspondence concerning this article should be addressed to Leong Han Ming, Macquarie University Special Education Centre, Institute of Early Childhood, Macquarie University, NSW danleohanming@gmail.com occupational therapy (Case-Smith & Miller, 1999). SI therapy gained prominence for individuals with learning disabilities in the 1970s (Ayres, 1972b), and more recently has been used extensively with individuals with autism spectrum disorders (ASD) and is currently a popular intervention for students with autism in North America (Goin-Kochel, Myers, & Mackintosh, 2007; Green et al., 2006; Hess, Morrier, Heflin, & Ivey, 2008; Thomas, Morrissey, & McLaurin, 2007). Apart from learning disabilities and ASD, SI therapy has been used with a wide variety of people with disabilities and difficulties, including intellectual disability (S. A. Smith, Press, Koenig, & Kinnealey, 2005), infants born at risk and/or with regulatory disorders, children from environmentally deprived backgrounds (Schaaf & Miller, 2005), children with developmental coordination disorder (Davidson & Williams, 2000), severely traumatized children and adolescents (Alers, 2005), adopted children who had been institutionalized for long periods (Lin, Cermak, Coster, & Miller, 2005), patients with dementia (Robichaud, Hebert, & Desrosiers, 1994), patients with post-traumatic stress disorder (Kaiser, 2007), and the elderly Sensory Integration Therapy in Malaysia and Singapore / 421

2 (Gielow & Hobler, 1986; Hames-Hahn & Llorens, 1988). It is often suggested that the presence of a sensory integrative dysfunction (Ayres, 1963), or sensory processing disorder (Miller, Anzalone, Lane, Cermak, & Osten, 2007) may indicate that SI therapy is an appropriate intervention. In order to determine if individuals have a sensory processing disorder, a number of assessment tools have been used, such as the Southern California Sensory Integration Tests (SCSIT) (Ayres, 1980), Southern California Post Rotary Nystagmus Test (SCPRNT)(Ayres, 1975), Sensory Integration and Praxis tests (Ayres, 1989), Miller Assessment for Preschoolers (Miller, 1988), FirstSTEP (Miller, 1993) and DeGangi-Berk Test of Sensory Integration (Berk & Degangi, 1983). Wilbarger and Wilbarger (1991) identified children with avoidance behaviors in response to sensory stimuli (sensory defensiveness) as appropriate recipients of the sensory diet and Wilbarger Protocol based on Ayres sensory integration framework. While it has often been suggested that SI therapy be used when a specific sensory processing disorder has been diagnosed, criteria for intervention vary widely and there are examples of studies where the intervention has been applied to a diagnostic group, in the absence of specific assessment of SI dysfunction (see, Bumin & Kayihan, 2001; Grimwood & Rutherford, 1981; Huff & Harris, 1987; Montogomery & Richter, 1977). The efficacy of SI therapy is subject to ongoing controversy. While there has been continued advocacy for SI therapy (Schaaf & Miller, 2005) and a few favorable reviews (May-Benson & Koomar, 2010; Ottenbacher, 1982), the consensus of the majority of reviews (American Association of Pediatrics, 2001; Arendt, MacLean, & Baumeister, 1988; Baranek, 2002; Dawson & Watling, 2000; Hoehn & Baumeister, 1994; Hyatt, Stephenson, & Carter, 2009; Leong & Carter, 2008; Maine Administrators of Services for Children with Disabilities, 2000; Myers & Johnson, 2007; National Autism Center, 2009; National Research Council, 2001; New York State Department of Health, 1999; Ospina et al., 2008; Perry & Condillac, 2003; Roberts, 2004; Roberts & Prior, 2006; Shaw, 2002; Simpson, 2005; T. Smith, Mruzek, & Mozingo, 2005; Vargas & Camilli, 1999; Williames & Erdie-Lalana, 2009) indicates that there is little empirical evidence that SI therapy is effective. Parham et al. (2007) developed an instrument to measure the fidelity of interventions using SI therapy by identifying what were deemed to be essential intervention components of SI therapy. They reported that most studies examined with the instrument did not adhere to (or report adherence to) most of the essential components that were identified by their research group. This may be an indication that there are issues in a consistent interpretation and application of SI therapy in research and thus the nature of SI therapy provided may vary across studies, or that the standards for essential intervention components of SI therapy are still being established. While SI therapy is a popular intervention in the US, its popularity in developing nations or even other developed nations is less certain. SI therapy may incur significant costs (Miller, Coll, & Schoen, 2007), so it is of interest to examine in more detail the use of SI therapy in developing countries, such as Malaysia (International Monetary Fund, 2011), where resources may be limited (Leong, Stephenson, & Carter, 2011). Investigation of why SI therapy is chosen by early intervention service providers in developing nations, in spite of the controversy surrounding its efficacy, may help develop an understanding of the factors contributing to the popularity of the intervention and assist efforts to promote evidence-based practice. As a point of comparison, it is also useful to examine why SI therapy is chosen by early intervention service providers in a neighboring advanced economy such as Singapore (International Monetary Fund, 2011). In previous qualitative research (Leong et al., 2011), a small number of administrators and special education teachers from intervention service providers in Malaysia who used SI therapy were interviewed in order to understand why and how SI therapy was chosen. The findings from this study indicated that occupational therapists may be a major source of information and training, that challenging behaviors related to sensory stimuli were a consistent reason for the use of SI therapy, that no or few policies or formal procedures were used to determine which students should receive SI therapy, and that it was used with 422 / Education and Training in Autism and Developmental Disabilities-September 2013

3 students with a wide variety of disabilities. This exploratory study, however, was limited by the small number of participants, and it was uncertain whether the results would be generalizable to a larger sample. The purpose of the study reported here was to explore how and why SI therapy is chosen and how it is used by a larger sample of early intervention service providers in Malaysia and Singapore. Early intervention service providers were targeted as SI therapy is theorized by proponents to be appropriate for younger children whose brains have higher plasticity and thus the intervention is more likely to be able to correct neurological issues in processing sensory information. The research questions were: (a) What were the sources of information about SI therapy used by intervention service providers; (b) why was SI therapy chosen by intervention service providers; and (c) how did intervention service providers determine who should receive SI therapy. Method Procedure A list of early intervention service providers for people with disabilities was sourced from the Service Directory for People with Disabilities by Malaysian CARE (Malaysian Care, 2005) for Malaysia, and the Disability Service Locator (Centre for Enabled Living, 2009) and List of Special Education Schools (Ministry of Education Singapore, 2009) for Singapore. Providers were included in the study if they served children aged six years and below. In some cases the contact information provided in these lists was not current, and for some service providers attempts were made to locate current contact information located through internet searches. Searches of these directories yielded 31 potentially eligible service providers from Singapore and 102 potentially eligible service providers from Malaysia. The large difference in eligible service providers between countries may reflect the difference in population. However, Singapore had more providers per head of population (approximately 6.0 per million) than Malaysia (approximately 3.6 per million) based on current population estimates (Jabatan Perangkaan Malaysia, 2010; Singapore Statistics, 2011) so the differences may also reflect economic development. Service providers who appeared to be eligible were initially contacted informally between February 2011 and July 2011 (by phone in the first instance or by if current phone numbers were not available) to confirm that they provided SI therapy in early intervention services, that they were willing to consider participating, and to ascertain the number of early intervention teachers employed. Upon confirmation of willingness to consider participation and use of SI therapy in early intervention services, formal consent forms and questionnaires were mailed to these service providers. Reminders were sent to service providers if the surveys were not returned within a month. The current research was part of a larger study and the questionnaire results reported in this research are from respondents who were representative staff member(s) who could answer administrative questions about the center s setting, policies, common practices, number of staff members, history with SI therapy, and other similar questions. The choice of representative(s) was up to the discretion of participating centers, based on who could best answer the questions presented and could be a director, administrator or senior teacher. In the instructions to participating centers, it was made clear that the person completing this questionnaire might check information with colleagues if necessary. Questionnaires and formal consent forms sent to Malaysian service providers were written in both English and Malay, the national language of Malaysia, in order to ensure the representatives understood the contents. The first section of the questionnaire addressed features of the setting including: the disability classifications; age and number of students in the center; number and qualifications of teaching staff; and length of time that SI had been used. The second section addressed sources of information used when considering using SI and how staff were trained to use the intervention. Section 3 addressed the reasons for use of SI in the center. Finally, section 4 addressed: policies and procedures for the use of SI Therapy; specific student behaviors and features used in deter- Sensory Integration Therapy in Malaysia and Singapore / 423

4 mining who should receive SI therapy; and processes (assessments, policy) used in determining who should receive SI therapy. Response options for these questions are provided in the results tables and a full copy of the questionnaire is available from the authors on request. Results Of the 31 service providers contacted in Singapore, 14 were found to not be early intervention service providers, one did not use SI therapy and four could not be contacted. Of the remaining 12 potentially appropriate providers who could be contacted, nine agreed to consider participation and three declined to consider participation. Responses were received from six of nine providers who received the surveys, so the response return rate for Singaporean participants who were mailed the surveys and met the inclusion criteria was 66.7%. Of the 102 contacts from Malaysia, 17 indicated they did not provide early intervention services, 21 indicated they did not use SI therapy and 26 could not be contacted. In the majority of the cases where service providers could not be contacted, the listed contact details were not current and could not be located through internet searches, but there were some instances were centers did not respond to s. Of the 38 potentially appropriate service providers who could be contacted, 32 agreed to consider participation and six declined. Twenty one responses were received from the 32 Malaysian providers who were sent surveys, so the response return rate for Malaysian participants who were mailed the surveys and met the inclusion criteria was 65.6%. Demographic information. The Malaysian and Singaporean service providers served a total of 1,845 and 590 students respectively. The average number of students served by Malaysian service providers (102.5 students, with a range of 14 to 530 students served) was relatively similar to Singaporean service providers who participated in this study (average of 98.3 students, 30 to 317 students served). ASD was the most common disability group served by both Malaysian (85.6%) and Singapore service providers (100%), followed by learning disabilities for Malaysian service providers (81.0%) and mild intellectual disability for Singaporean ones (66.7%). A higher proportion of Malaysian service providers also served age groups other than the 3 6 year old bracket (19 service providers out of 21) compared to Singapore service providers (two service providers out of six Singapore service providers) (see Table 1). Staffing and teaching qualifications. Malaysian and Singapore service providers employed 180 and 80 special education teachers respectively, a mean of 8.6 and 13.3 full-time teachers per center (see Table 2). Excluding centers which did not report number of students served, Malaysian service providers had an average of 11.3 students per teacher and Singapore centers had an average of 7.4 students per teacher in their centers. It is worth noting that 10 out of 21 service providers from Malaysia had no teachers with formal qualifications in special education. A large number (69) of Malaysian staff members had completed high school (roughly equivalent of General Certificate of Education O Levels and A Levels examination) and appeared to have no further qualifications apart from certificate courses. The certificate courses included certificates by Montessori (two), University of Birmingham (one) and University of Science, Malaysia (one). Staff of Singaporean service providers also had six teachers with certificates in Autism Studies. Therapists hired by Malaysian and Singapore service providers included speech therapists (four and seven respectively, or average of 0.19 and 1.17 therapists per center respectively), occupational therapists (five and 13 respectively, or average of 0.24 and 2.17 therapists per center respectively), and other therapists (13 and five respectively, or average of 0.62 and 0.83 therapists per center respectively). Malaysian and Singaporean service providers also employed 62 and 42 teacher aides respectively. Sources of information and training and duration of using SI therapy. Occupational therapists appear to be the most consistent source of information (76.2% for Malaysian service providers, 100% for Singaporean service providers, see Table 3) and training in SI therapy (90.5% by courses for Malaysian service providers, 66.7% by courses and internal training by an occupational therapist for Singapore 424 / Education and Training in Autism and Developmental Disabilities-September 2013

5 TABLE 1 Demographic Information of Participating Malaysian (n 21) and Singaporean Service Providers (n 6) Malaysian Service Providers (M, Range) Singapore Service Providers (M, Range) Number of students a,14to , 30 to 317 Type of disability served Malaysian Service Singapore Service Autism Spectrum Disorder (including Asperger s Syndrome) Learning disability/ difficulties Mild intellectual disability Moderate Intellectual disability Emotional/ behavioral problems Physical disability (includes spasticity, cerebral palsy) Severe/ multiple disability Other a Age of students 0 2 years years years years years a Some null responses were excluded. Service providers). All Singapore service providers employed an occupational therapist, either full-time or part-time, and noted that occupational therapists were both a source of information and training (either through an internal occupational therapist, external occupational therapist, or through a course conducted by an occupational therapist) on SI therapy. Only four out of 21 Malaysian service providers reported employing occupational therapists (two service providers employed full time, two part-time). Twenty out of 21 Malaysian service providers received training from an occupational therapist in some manner, mostly through attending a course (90.5%). Books (81.0% for Malaysian service providers, 66.7% for Singaporean service providers) and advice from other therapists (76.2% for Malaysian service providers, 66.7% for Singaporean service providers) were the next most used sources of information on SI therapy. In-staff training by other teachers was also a common means of training in SI therapy (81.0% for Malaysian service providers, 66.7% for Singaporean service providers). Representatives were also asked about the period of time that their center had been using SI therapy. Malaysian service providers on average appear to have had more experience using SI therapy in their practice (mean of 9.7 years of using SI therapy compared to mean of 3 years for Singapore centers). Reasons for using SI therapy. Most respondents gave advice from occupational therapists (81.0% for Malaysian service providers, 83.3% for Singaporean service providers, see Table 4) as the reason for choosing SI therapy. For Malaysian representatives (but not Singaporean), advice from other teachers (71.4%), benefits described in books (71.4%) and at a conference (76.2%) were also consistently chosen as reasons for using SI therapy. Research evidence on the efficacy of SI therapy was chosen by around half of the Singaporean (50.0%) and Malaysian (55.6%) representatives. Twelve of the Malaysian service providers and three of Singapore service providers reported that they had considered the research evidence when they chose to use SI therapy. Most of these particular participants had at least diploma holders among their teaching staff members (10 out of 12 Malaysian service providers, three out of three Singaporean ser- Sensory Integration Therapy in Malaysia and Singapore / 425

6 TABLE 2 Staffing and Teacher Qualifications of Participating Malaysian (n 21) and Singaporean Service Providers (n 6) Staff Members Malaysian Service Providers (M) Singapore Service Providers (M) Special education teachers, full-time Special education teachers, part-time Speech therapist, full-time Speech therapist, part-time Occupational therapist, full-time Occupational therapist, part-time Physiotherapist, full-time Physiotherapist, part-time Psychologist, full-time Psychologist, part-time Psychiatrist, full-time Psychiatrist, part-time Teacher aide, full-time Teacher aide, part-time Other, full-time c Other, part time c Malaysian Service Providers (% of Total Teachers Employed) Singapore Service Providers (% of Total Teachers Employed) Teacher qualifications, special education Diploma 11.8 b 35.0 Bachelor degree Coursework Masters degree Research degree No formal qualifications 51.8 b 22.5 Other c 51.6 b 7.5 b Teacher qualifications, non-special education Diploma Bachelor degree Coursework Masters degree Research degree No formal qualifications 22.3 b 10.0 Other c a Some null responses were excluded. b Some uncodable responses were excluded. c Responses in this category are written in. vice providers), and some had staff with a bachelor degree or higher qualification (five out of 12 Malaysian service providers, three out of three Singapore service providers). Despite stating that they had considered the research evidence, only four out of the 12 Malaysian representatives listed academic journals and two out of 12 listed a university course as a source of information on SI therapy, while none of the three Singapore participants reported use of either of these important sources on research evidence. The most common sources of information referenced by these particular participants when choosing to use SI therapy included occupational therapists (nine out of 12 Malaysian service providers, three out of three Singapore service providers), books (nine out of 12 Malaysian service providers, three out of three Singapore service providers), and the internet (10 out of 12 Malaysian service providers, zero out of three Singapore service providers) (see Table 5). 426 / Education and Training in Autism and Developmental Disabilities-September 2013

7 TABLE 3 Duration Using Sensory Integration (SI) Therapy, Sources of Support and Professional Development by Participating Malaysian (n 21) and Singaporean Service Providers (n 6) Malaysian Service Providers (M) Singapore Service Providers (M) Duration using SI therapy (years) 10.8 a 3.6 b Sources of information used when considering using SI therapy Malaysian Service Singapore Service Books about SI therapy Advice from occupational therapists Advice from other therapists Advice from teachers or educational professionals Information from conference Suppliers of equipment for SI therapy Sources on the internet Parents Information from academic journals Information in newspapers or magazines Information from university course Other sources c How staff are trained to use SI therapy Courses/workshops by occupational therapists In staff training by other teachers/ advice from teachers Courses/workshops by other professionals (not occupational therapists) Internet sources Printed/online materials produced by center Printed sources not produced by center Training/advice from external occupational therapists Video or audio sources Advice from parents Training/advice from internal occupational therapist Academic journals Others c a Some null responses were excluded. b Some uncodable responses were excluded. c Responses in this category are written in. Criteria for using SI therapy. A summary of factors identified as considerations in selecting children to receive SI therapy is presented in Table 4. For Malaysian service providers, 76.2% (15 out of 21) decided through informal teacher assessment or observation, and 61.9% (13 out of 21) provided SI therapy to all students (blanket policy) and about half reported using assessments by occupational therapists. Most Singapore service providers depended on occupational therapist assessment, discussion or recommendation (50% or three out of six), formal assessments by a multi-disciplinary team (50% or three out of six) or both (17% or one out of six). When asked directly to briefly describe policies and procedures for the use of SI therapy in their own words, two Singapore service providers reported use of individual assessment by teachers or an occupational therapist, one carried out SI therapy under supervision and following a time schedule, and one center avoided using the intervention for students with severe health problems such as epilepsy or asthma. Most Malaysian service providers did not provide a response (9 out of 21) or Sensory Integration Therapy in Malaysia and Singapore / 427

8 TABLE 4 Why Sensory Integration (SI) Therapy Was Chosen, and Procedures of its Use by Participating Malaysian (n 21) and Singaporean Service Providers (n 6) Why SI Therapy Chosen Malaysian Service Singapore Service Advice from occupational therapists Benefits described at a conference Advice from teachers or educational professionals Benefits described in a book Research evidence about efficacy Benefits described in professional journals or magazines Benefits described on internet sites Philosophical appeal of a sensory approach Advice from other therapists or non-educational professionals (not occupational therapists) Benefits described in catalogues from equipment suppliers Benefits described in a university course Advertising in the print media Advertising on the internet Other reasons c How the decision who gets SI therapy is made Informal teacher assessment or observation Blanket policy; all students in center receive SI therapy Occupational therapist assessment, discussion or recommendation Formal teacher assessment Parent request or recommendation Other professional assessment, discussion or recommendation Formal team assessment from multiple disciplines Other c Criteria students should meet to receive SI therapy Sensory seeking behaviors Too active/hyperactive Low concentration or attention Sensory avoidance behaviors Self-injurious behavior Poor gross motor skills Poor fine motor skills Too passive Low level of participation or not responsive to surroundings Poor preacademic skills Issues related to eating/drinking Low cooperation with teachers/parents and similar behavior issues Avoidance of activities in center Issues related to wearing clothes Issues related to self hygiene and grooming Poor academic skills Diagnosis group autism spectrum disorders 65.0 b 83.3 Diagnosis group Downs Syndrome Diagnosis group cerebral palsy, spasticity or severe physical disability Diagnosis group severe intellectual disability Blanket policy all students in center receive SI therapy Blanket policy students aged 3 years and below receive SI therapy / Education and Training in Autism and Developmental Disabilities-September 2013

9 TABLE 4 (Continued) Why SI Therapy Chosen Malaysian Service Singapore Service Blanket policy students aged 6 years and below receive SI therapy Blanket policy students aged 7 years and older receive SI therapy Other c a Some null responses were excluded. b Some uncodable responses were excluded. c Responses in this category are written in. wrote that no policies and procedures were in place (5 out of 21). Both Malaysian and Singaporean service providers consistently cited a large number of behaviors or characteristics that would indicate that children should receive SI therapy in their centers. The most common criteria selected by Malaysian service providers were the presence of sensory seeking behaviors (90.5%), children being too active/hyperactive (85.7%), having low concentration or attention (85.7%), and the presence of sensory avoidance behaviors (81%). It is especially notable that about half of the Malaysian service providers (52.4%) had a blanket policy of providing SI therapy to all their students. All of the Singapore service providers listed the presence of sensory seeking behaviors, too active or hyperactive, and low level of participation or not responsive to surroundings as a criteria, and also consistently cited other criteria. Students with ASD were most frequently targeted for the intervention (65.0% for Malaysian service providers, 83.3% for Singapore service providers). Discussion The present study examined the use of SI therapy by early intervention centers in Malaysia and Singapore through questionnaire responses provided by representatives at each center. Of specific interest were the sources of information about SI therapy, reasons for selecting the intervention and factors in determining who should receive SI therapy. Sources of information. Consistent with findings in previous research (see Leong et al., TABLE 5 Sources of Information Used by Participating Malaysian (n 12) and Singaporean Service Providers (n 3) which considered the research evidence when considering to use SI therapy Sources of Information Used When Considering Using SI Therapy Malaysian Service Providers (%) Singapore Service Providers (%) Books about SI therapy 10 3 Advice from occupational therapists 9 3 Advice from other therapists 9 2 Advice from teachers or educational professionals 7 2 Information from conference 8 0 Suppliers of equipment for SI therapy 7 2 Sources on the internet 10 0 Parents 6 2 Information from academic journals 4 0 Information in newspapers or magazines 4 0 Information from university course 2 0 Sensory Integration Therapy in Malaysia and Singapore / 429

10 2011), it appears that occupational therapists played a major role in advocating the use of SI therapy to both Malaysian and Singaporean service providers. Occupational therapists were a primary source of information when choosing to use SI therapy as well as the main providers of further training in its use. Advice from occupational therapists was also the most consistent reason why Malaysian and Singaporean service providers chose to use SI therapy. The role of occupational therapists in the advocacy of SI therapy is even more apparent for Singaporean service providers, which is not surprising considering they had employed more occupational therapists. Since certification in SI therapy is usually exclusive to professionals with occupational therapy training, it may be considered appropriate that occupational therapists are the main source of information and training on SI therapy. Reasons for using SI therapy. As noted in the introduction, the consensus of reviews on SI therapy is that there is limited evidence for its efficacy. About half of the service providers interviewed reported consideration of the research evidence about the efficacy of SI therapy when selecting reasons for the use of the intervention in their centers. These particular service providers, however, appeared to have little access to university courses and academic journals, and appeared to have depended largely on occupational therapists and books as sources of information on SI therapy. These findings suggest that these service providers may not be fully aware of the controversies surrounding SI therapy and may have the misconception that adequate evidence of its efficacy is available in the research literature. It is worth noting that, at least for Malaysian service providers, it is understandable that access to academic sources is limited, and their initiative to seek out information and training in the use of intervention strategies is commendable. Unfortunately, it may be that they were still not adequately aware of the lack of research evidence to support the intervention or, at the very least, the ongoing controversy. Factors in determining who should receive SI therapy. While children with ASD were most commonly served by the participating service providers, it appears that both Malaysian and Singapore providers served students with a wide range of disabilities and viewed SI therapy as appropriate intervention for their children. Both Malaysian and Singapore service providers consistently reported a wide range of behaviors and characteristics that they believed indicated that SI therapy would be an appropriate intervention. Students with a diagnosis of ASD in particular were targeted more often compared to other diagnostic groups by both Malaysian and Singaporean service providers. This is not surprising given the widespread reported use of SI therapy with this population in other countries (Green et al., 2006). A large number of Malaysian service providers, however, provided SI therapy for all their students as a blanket policy (which may possibly be related to restricted access to occupational therapists and training). This would suggest that the wide range of criteria are inclusive rather than exclusive in that SI therapy is provided to students who meet any one or at least a few of the criteria listed, and that Malaysian service providers used SI therapy for a wide variety of disabilities as well as ASD. This is consistent with the findings of previous research by Leong et al. (2011) that Malaysian service providers appeared to provide SI therapy for students with a wide range of disabilities. The increased use of SI therapy for younger students compared to older ones, however, does not appear to have been emphasized consistently by either Malaysian or Singapore service providers. As noted above, service providers consistently listed a large number of features that might indicate that students would be helped by SI therapy. The most consistent feature was that the student exhibited sensory seeking behaviors. Sensory avoidance behaviors were also very consistently reported as an indication by both Malaysian and Singaporean service providers. This finding lends limited support to results of the previous study by Leong et. al. (2011) that challenging behaviors related to sensory stimuli were an important consideration when teachers considered the use SI therapy for their students. Data from the current research support the findings of Leong et al. (2011) that Malaysian service providers had limited formal procedures for determining who should receive SI therapy. Singaporean service providers did not appear to suffer this limitation, as many reported that they relied on assessments (or 430 / Education and Training in Autism and Developmental Disabilities-September 2013

11 discussion with or recommendation) by an occupational therapist or a formal assessment by a multi-disciplinary team. This may be because Singaporean service providers had better access to resources in general as well as employing a much larger number of occupational therapists. Putting aside efficacy issues, this appears to be a more appropriate strategy for identifying children for whom SI therapy may be suitable although it should be noted that the research literature reveals a wide variety of practices in the prescription of SI therapy (see, Bumin & Kayihan, 2001; DeGangi, Wietlisbach, Goodin, & Scheiner, 1993; Humphries, Wright, Snider, & McDougall, 1992; Miller, Coll, et al., 2007). Access to resources and qualifications. Singaporean service providers employed about 1.5 times more full-time teachers per center, had proportionately more teachers with higher qualifications in special education overall, on average hired more speech therapists (average 1.17 per center compared to 0.19), occupational therapists (average 2.17 per center compared to 0.24) and more teacher aides (average 6.5 per center compared to 2.57). The difference may be related to the relative difference in economic wealth between the two countries: Singapore had a GDP per capita USD 43, in 2010 compared to Malaysia s GDP per capita of USD (World Bank, 2012). Ideally, only interventions that have been demonstrated to be effective should be used in clinical practice (Hyatt et al., 2009; Leong & Carter, 2008). This issue is especially relevant in the face of limited resources as is the case in developing countries like Malaysia. As noted earlier, few of the respondents had reported to have made the decision to use SI therapy based on benefits described in professional journals or magazines and university courses. The service providers who participated in this study appear to have sought out information from numerous other sources such as books, therapists, other educational professionals, conferences, and the internet when they had considered using SI therapy. Thus, it may be reasonable to believe that the limited use of the research literature in their decision making was due to a genuine lack of access to such materials rather than lack of motivation. The reasons are not clear, but based on the reported qualifications of teaching staff there is some indication (particularly for Malaysian teachers) that teachers may have limited access to the appropriate skills needed to locate, read and apply research literature adequately. Financial costs may be a barrier to accessing research knowledge as well as qualifications and skills teachers may need. As previously noted, SI therapy is extremely popular and widely acknowledged in the field of occupational therapy in spite of the controversies. In view of possible limited access to resources, especially for Malaysian service providers, it is difficult to find fault with special education service providers who fail to recognize the controversies surrounding the lack of research evidence supporting the use of SI therapy. Regardless, the lack of access to research information of service providers in Malaysia and possibly Singapore presents a challenging barrier to promoting evidence-based practice in the field of special education. The promotion of evidence-based practice in special education in these countries may require universities or other organizations with access to research information to take an active role in disseminating this knowledge, such as through easily digestible summaries of research information that is made accessible to service providers and their teachers (Leong & Carter, 2008). Organized efforts in establishing professional relationships between academics, researchers and service providers may also help bridge the gap between research and what is practiced in the field. Conferences appeared to be a relatively important source of information to respondents, and may be a useful means of connecting academics with special education teachers. Limitations Some limitations of this study should be acknowledged. As with most questionnaires of this nature, voluntary participation in the survey may introduce bias due to self-selection. It is uncertain how service providers who use SI therapy but declined to participate would have responded. It is also uncertain if the results would be significantly different had the return rates been higher, especially from Singaporean service providers. Additionally, Sensory Integration Therapy in Malaysia and Singapore / 431

12 some of the participating service providers also provided services to older students as well as providing early intervention. Although a request from the authors was made to participants to answer questions based on their work in early intervention, it is not certain whether respondents complied with this request. Conclusion The current research appears to lend further support for some of the previous findings of Leong et al. (2011), that occupational therapists were instrumental in the popularity of SI therapy in spite of its controversial status. It was also found that about half of the early intervention service providers who use SI therapy appeared to mistakenly believe that the efficacy of SI therapy is clearly supported by research. Early intervention service providers in Malaysia seemed to attempt to provide SI therapy services to students with a wide variety of disabilities as well as ASD, sometimes all of their students, but this finding was not clear for Singaporean service providers. It appears that Singapore service providers had better access to occupational therapy services and thus the assessment tools that are used to specifically identify a sensory integration dysfunction or sensory processing disorder. Malaysian service providers however lacked formal policies, procedures or assessments concerning the use of SI therapy that may be related to more limited access to such resources. From the results of this survey, it appears that Malaysian service providers have limited access to training and academic qualifications. While Singaporean service providers did seem to have relatively better access to training and academic qualifications, about half of the participating service providers from both countries may have been unaware of the controversies surrounding the evidence supporting the efficacy of SI therapy. Reviews of the research evidence supporting the use of interventions from academic journals which are available to universities may have been difficult to access, even for Singaporean service providers. In order to promote evidence-based practice in the field of special education in these countries, initiatives by organizations with ready access to research information such as universities may be needed to disseminate information to service providers in a easily readable and accessible fashion. References Alers, V. (2005). Treating severely traumatised children and adolescents using sensory integration, attachment theory and clinical reasoning. Journal of Child and Adolescent Mental Health, 17, vi vii. doi: / American Association of Pediatrics. (2001). Technical report: The pediatrician s role in the diagnosis and management of autistic spectrum disorder in children. 107, e85. Retrieved from policy.aappublications.org/cgi/content/full/ pediatrics;107/5/e85 doi: /peds e85 Arendt, R. E., MacLean, W. E., Jr., & Baumeister, A. A. (1988). Critique of sensory integration therapy and its application in mental retardation. American Journal on Mental Retardation, 92, Ayres, A. J. (1963). Eleanor Clarke Slagle Lecture - The development of perceptual-motor abilities: A theoretical basis for treatment of dysfunction. American Journal of Occupational Therapy, 27, Ayres, A. J. (1972a). Improving academic scores through sensory integration. Journal of Learning Disabilities, 5, doi: / Ayres, A. J. (1972b). Sensory integration and learning disorders. Los Angeles, CA: Western Psychological Services. Ayres, A. J. (1975). Southern California Postrotary Nystagmus Test Manual. Los Angeles, CA: Western Psychological Services. Ayres, A. J. (1980). Southern California Sensory Integration Test Manual - Revised (SCSIT). Los Angeles, CA: Western Psychological Services. Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles, CA: Western Psychological Services. Ayres, A. J., & Mailloux, Z. K. (1981). Influence of sensory integration procedures on language development. American Journal of Occupational Therapy, 35, Baranek, G. T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders, 32, doi: /A: Berk, R. A., & Degangi, G. A. (1983). The Degangi- Berk Test of Sensory Integration. Los Angeles, CA: Western Psychological Services. Bumin, G., & Kayihan, H. (2001). Effectiveness of two different sensory-integration programmes for 432 / Education and Training in Autism and Developmental Disabilities-September 2013

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