The effectiveness of sensory integration to enhance occupational engagement in children with sensory processing difficulties.

Transcription

1 The effectiveness of sensory integration to enhance occupational engagement in children with sensory processing difficulties. Prepared By: Gracie Prisk Date: 5 th June 2012 CLINICAL SCENARIO Sensory Integration (SI) originated from the work of Dr. A. Jean Ayres and was introduced to the Occupational Therapy (OT) profession in the late 1960 s (Diane Parham & Mailoux, 2005). The treatment methods that Ayres established continue to be investigated and questioned today, but there is little doubt that her perspective has had a significant influence on OT practice (Diane Parham & Mailoux, 2005). Ayres clinical insights and original research have transformed OT practice with children and the SI approach is now well established across paediatric settings. In a study looking at the effectiveness of OT for children with sensory modulation disorder, Miller, Coll & Schoen (2007) identified that there is a lack of quality experimental data evaluating the SI approach. They highlight that because of the widespread use of interventions under the approach, studies looking at the effectiveness of SI are essential. FOCUSSED CLINICAL QUESTION In children with sensory processing difficulties, is sensory integration an effective intervention in helping to increase their engagement in occupations? SUMMARY OF SEARCH, BEST EVIDENCE APPRAISED, AND KEY FINDINGS The clinical question was structured to be quite broad, but initially it was still difficult to find a range of sufficient articles that directly addressed the question. A large number of articles were excluded because they were too narrowly focused or didn t evaluate the occupational outcomes of using the SI approach in therapy with children. May-Benson and Koomar (2010) and Cohn (2001) were considered 'best evidence' as they both addressed the focus question and fitted with the inclusion criteria. Overall, after critically appraising these two articles, it was concluded that participation in OT intervention using sensory approaches can result in positive effects on a child s ability to engage in their occupations. CLINICAL BOTTOM LINE There is evidence to support SI being an effective intervention in helping to increase and improve occupational engagement for children who have sensory processing difficulties. LIMITATION OF THIS CAT This critical appraisal has been peer reviewed by one lecturer as part of an assignment. For assignment purposes only two articles have been critiqued.

2 SEARCH STRATEGY The following databases were searched to locate literature relevant to the clinical question: CINAHL OTseeker Google Scholar ProQuest Medical Library The keywords used in the searches included: Paediatric OR Child* Sensory inte* OR Sensory modulation Sensory processing Occupation* Intervention A manual search was also undertaken for articles referenced in relevant textbook chapters that directly related to the clinical question. INCLUSION AND EXCLUSION CRITERIA Inclusion: Participants involved were children < 21 years old (or parents of children 4-10 years) with sensory processing difficulties. Aim of the study was to evaluate or compare effectiveness of interventions using the SI approach. Articles available as full text within the databases. Exclusion: Studies where the full text was not available through the databases or online. Studies where SI was not the main approach used to guide intervention. RESULTS OF THE SEARCH: Study Design/ Methodology of Level Author (Year) Articles Retrieved Systematic Review 1 May-Benson & Koomar (2010) Qualitative Study Grounded 5 Cohn (2001) Theory Quantitative RCT 2 Miller, Coll & Schoen (2007)

3 Quantitative RCT 2 Pfeiffer, Koenig, Kinnealey, Sheppard & Henderson (2011) BEST EVIDENCE The article by May-Benson and Koomar (2010) was identified first as best evidence for critique as it directly related to the clinical question. As it was a systematic review, this article used rigorous methods to find and review the research evidence in relation to the clinical question. The second article selected was Cohn (2001), a qualitative study. Although this article was published in 2001, it was appropriate as it addressed the clinical question from an important perspective, the parents perspective. This was significant as a child s parents are the ones who know them the best and are be able to identify changes in their day-to-day lives. SUMMARY OF BEST EVIDENCE Title of article: Systematic Review of the Research Evidence Examining the Effectiveness of Interventions Using a Sensory Integrative Approach for Children (May-Benson & Koomar, 2010). Please note that the methodology for this article is located in a separate article; Methodology for the Systematic Reviews of Occupational Therapy for Children and Adolescents With Difficulty Processing and Integrating Sensory Information (Arbesman & Lieberman, 2010). 1. Aim of the Systematic Review: The aim of the review was to examine the research question; What is the effectiveness of interventions using the SI approach (including the effect of context [cultural, physical, social, personal, spiritual, temporal, and visual]) to create, promote, establish, restore, maintain, modify, and prevent future limitations in ADLs, IADLs, education/transition, play/leisure, and social participation in children and adolescents whose SI and processing patterns are interfering with everyday life participation? (p. 404). Study Design: Systematic Review. Search strategy: A large number of search terms were identified within the Arbesman and Lieberman (2010) article. These were listed under the categories diagnoses and clinical conditions included and interventions. Examples of each are included below: Diagnoses: Developmental dyspraxia Fine motor deficits OR Gross motor deficits Sensory integrative dysfunction Sensory modulation disorder Sensory processing disorder Interventions: Activities of daily living

4 Activity Intervention Sensory Diet SI These search terms were used within a number of databases, including: CINAHL ERIC BIOSIS Previews Science Citation Index Social Science Citation Index RehabData OTseeker The Cochrane Database of Systematic Reviews and the Campbell Collaboration were also included in the search, as well as a hand search of reference lists from articles in selected journals. Article Selection: Inclusion: Articles published between 1996 and In addition, selected articles published outside this time frame recommended by experts in the field. Peer reviewed scientific literature published in English. Participants in the intervention were < age 21 and were specifically screened and identified as having difficulty processing and integrating sensory information. All control groups were children with clinical problems unless stated otherwise. Authors reported the intervention to be based on the SI approach. Exclusion: Presentations, conference proceedings, non-peer-reviewed research literature, research reports, dissertations and theses. Method: Out of the 1,079 citations that were reviewed, 27 articles were identified for inclusion in the systematic review. The team working on this review evaluated the articles according to their quality and levels of evidence (using the American Occupational Therapy Association [AOTA] grading system). Data from each article included was abstracted using an evidence table that provided an overview of the methods and findings as well as an appraisal of the strengths and weaknesses of each study based on the design and methodology. As well as this, a table that was comprised of information in regards to the quality score, population, type of intervention, number, frequency and duration of intervention sessions of each study was used to compare data. The authors of this systematic review ensured quality control by analyzing and comparing the key data from each of the studies by completing and comparing a Critically Appraised Topic (CAT) for each study.

5 Results: Results from the review of the 27 individual studies were divided and presented by outcome areas, with the studies that were applicable then organised by level of evidence. The outcome areas examined included motor performance, sensory processing, behavioural outcomes, academic and psycho-educational outcomes, and occupational performance. Overall, results suggested that the SI approach may result in positive outcomes in sensorimotor skills and motor planning; socialisation, attention, and behavioural regulation; reading-related skills; participation in active play; and achievement of individualised goals (p. 403). As well as this, gross motor skills, self-esteem, and reading gains may be sustained from 3 months to 2 years (pp. 403). Original Authors Conclusions: The authors stated that the synthesis of evidence suggests that the SI approach may result in positive outcomes in the areas of sensorimotor skills and motor planning; socialisation, attention, and behavioural regulation; reading and reading related skills; and individualised goals for the study populations (p. 412). Despite low power in most studies, this review therefore suggests there is a trend towards positive evidence in support of the SI approach but further research is still needed to support the conclusiveness of these results. 2. Critical Appraisal: This section is guided by questions in Taylor (2007) Appraising systematic reviews (p ). Are the results valid? The review has a clear focus: to identify, evaluate, and synthesize the research literature on studies examining the effectiveness of SI intervention in helping children with sensory processing difficulties to engage in desired occupations. May-Benson and Koomer (2010) identify in their introduction that the SI approach has been reviewed in the past but there has never been a clear agreement in the literature on the effectiveness of the approach itself. The review s goal is to provide evidence to support the role of SI within paediatric OT intervention. Studies were gathered from a range of databases as well as using hand-searching methods. Although in a separate article, the reviewers have given full details of the search strategy used to obtain these articles. Multiple people involved with the review, including the authors and staff from AOTA, developed the search terms. As well as this, a medical research librarian with experience in completing systematic review searches was enlisted to conduct all of the searches and confirmed and improved the search strategies. Inclusion and exclusion criteria were clearly stated, however, there was no information in regards to how this criterion was established and by whom. It was also unclear whether the authors were involved in the inclusion/exclusion screening process. What are the results and how will they help me work with my clients? Results for each of the 27 articles ranged from SI being effective in helping to improve children s occupational engagement to determining that SI was less effective than other or no treatment methods on some variables across all outcome categories. The several studies that

6 determined SI was less effective may have been as a result of low statistical power from the small sample sizes. Overall, as outlined above, the results suggested that the SI approach may result in positive effects across all outcome categories. The results can be applied to most paediatric settings where children with sensory processing difficulties receive therapy from OT s as the review population was clearly identified in terms of the criteria for participants involved. This means that the results can be applied to children that fall under or come close to, that same criteria (< 21 with sensory processing difficulties). Summary The review was conducted by AOTA as part of a project to highlight the benefits of using a SI approach for OT practitioners in paediatric settings. Authors, AOTA staff and experts in the field of systematic reviews carried out extensive searches in order to locate articles for inclusion and the data collection process itself was thorough and clear helping to ensure trustworthiness and validity. In relation to practice, this review presents evidence that supports the effectiveness of SI within paediatric OT. It is justified that the results from this review can begin to be applied to and used within paediatric settings around New Zealand. Title of article: Parent Perspectives of Occupational Therapy Using a Sensory Integration Approach (Cohn, 2001). 1. Aim of the Study: This study aims to explore parents points of view in regards to their children s participation in OT using a SI approach. The study also aims to build on an earlier study by Cohn, Miller and Tickle-Degnen (2000, as cited in Cohn, 2001) by thoroughly describing these parents opinions of the sensory approaches being used in therapy with their children. Study Design: Qualitative study - Grounded theory. Setting: All participants were parents of children who received OT at a private clinic in a northeastern U.S. suburban community. Participants: The participants for this study were parents of children aged 4-10 years who had documented diagnoses of some type of sensory integration dysfunction, who had taken part in at least 32 1-hour therapy sessions and who had stopped therapy sessions at least 1 month to 2 years before the interview. Parents of 22 children were selected randomly from a list of 42 children who met the inclusion criteria for taking part in the study. Of these 22 parents, 16 (14 families consisting of 12 mothers and 2 husband-and-wife couples) were interviewed for the study. Method: Data was obtained using a collective case study approach. Interviews ranging from 1-2 hours were conducted with each of the participants in their homes. Each interview was audio

7 taped, transcribed and checked by thorough review, as well as comparing the two medias. The researcher also wrote reflective and analytical memos throughout the research process to record their thoughts. Recruitment was stopped after the 16 th participant because the researcher had reached a point where no new information was being collected. Findings: The study first examined why parents decided to seek OT services for their children and all participants reported that it was because they were worried about their children not fitting in or keeping up with their peers. Findings from the study were then categorised into child focused outcomes and parent focused outcomes. Within the child-focused outcomes, findings suggested that the parents who recognized positive outcomes from OT perceived changes in three areas of their children s functioning: abilities, activities and sense of self-worth. They described how changes in one area had an affect on the other areas. All participants, even those who questioned the value of OT, described concrete, directly observable changes in their children s abilities. The participants who clearly described the benefits of OT using SI approaches reported that their children improved their participation in activities by using their newfound abilities. Parents viewed these improvements in abilities and engagement in activities as factors that contributed to rebuilding their children s self-worth. The participants who questioned the benefits of OT, however, did not describe links between their children s abilities and broader social world. It was unclear whether this was to do with a lack of understanding about the therapists assumptions (that improved abilities may influence activity engagement and improve self-worth) or because they simply did not observe any relationships between these three domains in their children. In regards to parent focused outcomes, the most robust finding was that participants reported numerous benefits from understanding their children s behaviours from a sensory processing perspective (p. 290). The participants suggested that reframing their views about therapy using the SI approach led to a shift in expectations for themselves and their children, validated their parenting experience, and enabled them to support and advocate for their children. As parents looked at their children s behaviour from a sensory processing point of view, they reported that it led them to become more accepting of their children and in turn they believed that this led to their children s improved sense of self-worth. Original Authors Conclusions: Cohn (2001) summarised that The insights gained from the study highlight the importance of understanding parents expectations for therapy and how they are making sense of what is occurring in and as a result of therapy. Parents perceptions may serve as a powerful indicator of whether therapy has had an impact on aspects of the child s life considered important by parents (p. 291). Although in this study some parents expressed that they were initially searching for a cure for their children, they all reframed their expectations and after their children participated in OT using the SI approach, many of them envisioned a future for their children that included ongoing acceptance, accommodation and advocacy (pp. 291). 2. Critical Appraisal: This section is guided by questions in Taylor (2007) Appraising qualitative reviews (p ).

8 Are the results trustworthy? A qualitative methodology was appropriate for this study as the paper identifies the need to understand the outcomes of OT from the child and family perspective. The chosen qualitative grounded theory approach appears to be the most appropriate to use in obtaining the data needed to form a conclusion about these outcomes. In addition, although a research question wasn t specifically stated, the aims were included and although broad, they did give some idea about the parameters of the study. Grounded theory procedures as recommended by Strauss and Corbin (1998, as cited in Cohn, 2001) were used to review transcripts from the interviews and to name and categorise the changes described by the parents into themes that emerged. This process is clearly described and is appropriate for use within the qualitative study. The QSR NUD*IST 4.0 (Non-numerical Unstructured Data-Indexing Searching & Theorizing) qualitative data analysis software was also used to manage and explore the data. This was beneficial but Taylor (2007) explains that using computer programs can mean that subtleties within the data are lost. To ensure that this wasn t the case the researcher used peer examination to check the emergent categories developed from the data analysis. The researcher clearly acknowledges influences of their own background as both a parent of school-aged children and as an occupational therapist who has provided OT using a SI approach. Rather than eliminating their own subjective reactions, the researcher took on recommendations by Frank (1997, as cited in Cohn, 2001) to use reflections productively for insight and analysis. By clearly acknowledging their influence on the research process, the researcher ensured the reader was clear about where they stood in relation to the study. There is evidence of strategies for both ensuring credibility and addressing the issues of confirmability and dependability. The researcher prepared written summaries of each interview and sent them to participants for review, contacted them to discuss feedback and made modifications as needed. The researcher described that the data was rigorously analysed and examined to ensure that the information obtained from participants was correct and consistent with the emerging concepts. As stated before, peer examination was also used to check categories developed from the data analysis. This involved the transcripts being analysed and discussed by eight OT s with experience providing OT using SI approaches. Lastly, there was also evidence of continuing the process of data collection until data saturation had been achieved. How will the results from this study help me to work with my clients? While the majority of results from this study support the notion that OT using a SI approach with children is effective, just as importantly, if not more, were the findings that highlighted the influence parents views of the value of OT can have on their children s therapy outcomes. This study highlights the need for OT s to ensure that parents understand SI itself, the need for intervention and the possible benefits in order for them to be more open, supportive and aware of therapy outcomes. The results confirmed this and showed that an understanding of OT with SI

9 helped parents to accept their children and this in turn led to improvements in their children s occupational functioning and self-worth. Summary This article provides a detailed and reliable overview of parents perspectives of OT using a SI approach. SI was shown to have been effective in helping to increase children s occupational engagement but this was heavily influenced by parents views of therapy. The findings are transferrable to most paediatric settings and are of value to OT s seeking to understand how parents view the effectiveness of OT using a SI approach. While in consideration of applying the findings to New Zealand paediatric settings some may question the small sample size used for the study, the overall findings appear to be quite generic and rigid meaning that the article will still be of value and of use. IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH OT s use SI approaches and techniques to guide intervention with children in the hopes of making positive gains in occupational performance as well as behavioural aspects of the child s life. As SI is a commonly used intervention within paediatrics in New Zealand and around the world, it is important that clinicians have evidence to support the use of this approach. From these two articles, it was found that SI approaches can be effective in helping to improve occupational engagement in children. Not only this but that parents perceptions of OT using this approach have a large influence on whether or not they see their children benefit from the therapy. In regards to implications for practice, these two articles remind us to consider the broader context in which children live and to design interventions that move beyond fixing their sensory processing difficulties to supporting them to manage these difficulties in their environments. As well as this, although the parents perspectives of therapy have proven to be highly important, we need to remember that the children s experiences of therapy (using a SI approach) and everyday life are also critical to our evaluation of the therapy. Lastly, although the consistency of findings from the reviews is limited by a variety of methodological concerns, given the large effects of positive results, OT s can use the information to start to support the use of the SI approach in clinical practice. Further research is still needed, in particular more qualitative studies looking at the occupational performance and participation outcomes valued by families, as well as studies looking at perspectives of teachers, as the school setting is central to children s lives. Further exploration is also needed about why some parents didn t perceive changes in their children s activities, abilities and self-worth as well as exploring the voices and opinions of the children themselves. Most importantly there is a need to look into not whether the SI approach within OT is effective but how it is effective. Although there are slight limitations and a need for further research, both of these articles in themselves have proven to be valid and trustworthy. The findings provide evidence to support

10 the SI approach being effective in paediatric OT; however, these two articles alone don t provide enough high quality evidence to heavily influence or change practice. Practitioners will be able to use the information from these articles to begin to support the use of the SI approach within their clinical practice and promote the movement of the SI approach forward. Overall, these two articles both have their own strengths given their different designs and together they summarise a lot of research about the effectiveness of SI interventions in helping to increase occupational engagement in children that will help to support therapists in ensuring evidence-based practice.

11 REFERENCES Arbesman, M., & Lieberman, D. (2010). Methodology for the systematic reviews of occupational therapy for children and adolescents with difficulty processing and integrating sensory information. American Journal of Occupational Therapy, 64(3), doi: /ajot Cohn, E. S. (2001). Parent perspectives of occupational therapy using a sensory integration approach. American Journal of Occupational Therapy, 55(3), Diane Parham, L., & Mailoux, Z. (2005). Sensory integration. In J. Case-Smith (Ed.), Occupational therapy for children (pp ). St. Louis, Missouri: Elsevier Mosby. May-Benson, T. A. & Koomar, J. A. (2010). Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. American Journal of Occupational Therapy, 64(3), doi: /ajot Miller, L. J., Coll, J. R., & Schoen, S. A. (2007). A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. American Journal of Occupational Therapy, 61(2), Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65(1), doi: /ajot Taylor, M. C. (2007). Evidence-based practice for occupational therapists (2nd ed.). Oxford: Blackwell Publishing Ltd.