Sensory Integration Education

Stacey Reynolds and Hope Caracci on using an intensive design model of SI intervention in outpatient paediatric settings: How and why to change practice based on evidence.

Hope and Stacey met some of the Sensory Integration Education team at this year’s American Occupational Therapy Association Annual conference where they spoke about the topic of ASI® and dosage. Their highlights from this congress included Ellen Cohn’s Eleanor Clark Slagle lecture. Another highlight was seeing more and more practitioners speaking at AOTA 2019 about shared decision making tools that may assist therapists be more client-centered and better able to make individualized decisions regarding frequency, duration and intensity of care. Stacey Reynolds is an associate professor at Virginia Commonwealth University (VCU) and has a 10+ year history of conducting funded research with over 30 peer review publications in the area of sensory processing and pediatric neurodevelopmental disorders. Her research, conducted in the VCU Sensory Processing and Space Evaluation (SPASE) lab, has focused on how children with neurodevelopmental disorders respond to sensory stimuli in their environment and how these responses impact functional performance and behavior.

Hope Caracci is the Quality and Staff Development Manager in a large pediatric therapy at The Children’s Hospital of The King’s Daughters in Norfolk, Virginia. Hope has 20 years of experience as an occupational therapist with 15 of those years devoted to children. She specializes in treating children diagnosed with ASD and SPD as well as determining appropriate frequency, intensity and duration for children with chronic conditions. Hope has published and presented on topics such as evidence based practice, episodic care, mentorship, and leadership at the local and national level and is certified to administer the Hope Caracci Sensory Integration and Praxis Test (SIPT).

Ayres Sensory Integration®

According to Ayres’ theory of sensory integration, sensation (in various forms) provides the basis for learning and behavior. Further, successful integration of sensory information is necessary for appropriate adaptive responses and therefore supports participation in occupation. Foundational to sensory integration theory is the idea that both sensation and our responses to sensation shape our interactions with the world, and have the capacity to alter brain pathways through neural plasticity (Schaaf et al., 2010).

The term Ayres Sensory Integration® (ASI®) refers to an individualized therapeutic approach that is based on Ayres theory and practice, which was designed to remediate sensory integrative problems in children. ASI® is also sometimes called OT-SI to emphasize the focus on occupation and participation as outcomes of improved sensory integration. In this intervention, an occupational therapy practitioner presents activity challenges individually tailored to improve the sensory integration capacity of a child by helping the brain be better able to organize sensory information. Within this approach the occupational therapist creates an environment that evokes increasingly complex adaptive responses from the child using the child’s own drive and interest to facilitate engagement. This approach is much different from a sensory – based approach in which a more passive application of sensory strategies is applied to a child (Reynolds et al., 2017).

Best Evidence

The strength of intervention research in the fields of medicine and health care are frequently rated according to hierarchies of evidence. These hierarchies enable different research methods to be ranked according to their rigor and validity of their findings. Three articles have been published studying the effects of OT-SI, which are ranked at the highest level of evidence for their research design and also include other elements of rigor including the use of intervention fidelity manuals and measurable functional goals (Miller, Coll, & Schoen, 2007; Pfeiffer et al., 2011; Schaaf et al., 2014). These three articles are discussed briefly below. Importantly, all three apply OT-SI using a high-frequency dosing model of 2-3 times per week for 6-10 weeks.

Table 1. OT-SI High level of evidence dosage table

Miller, Coll, and Schoen (2007) randomly assigned 24 children with sensory modulation dysfunction (SMD) into an OT-SI group, no treatment group, or an activity group. Children were evaluated for sensory modulation disorder (SMD) using rigorous criteria; comorbidities included attention deficit hyperactivity disorder (ADHD) or learning disability. The children were provided therapeutic intervention 2x per week for 45-60 minutes for 10 weeks. Results found that the group receiving OT-SI made functional gains that were significantly greater than the children in the other two groups. Children in the OT-SI group also increased significantly more than the other groups on the Attention subtest and Cognitive/ Social composites of the Leiter International Performance Scale-Revised. Outcomes on the Short Sensory Profile, Child Behavior Checklist and physiology were in the expected direction, with the OT-SI group having greater gains, but statistically significant differences were not found with the small sample.

Pfeiffer et al. (2011) studied two groups of children who received OT services 3x per week for 45 minutes for six weeks. Group 1 received an OT-SI intervention based on Ayres theory and adhering to fidelity criteria, and group 2 received fine motor (FM) interventions; assignment to either Group 1 or Group 2 was random. Both groups demonstrated significant improvements towards individualized functional goals, but the OT-SI group demonstrated statistically greater improvement than the FM group. The OT-SI group also showed fewer mannerisms associated with autism than the FM group as measured by the Social Responsiveness Scale, indicating OT-SI interventions may have an impact on core features of Autism Spectrum Disorder (ASD).

Schaaf et al. (2014) randomized children into OT-SI group and usual care (UC) intervention group, and they received intervention 3x per week for 60 minutes for 10 weeks. Inclusion criteria included diagnoses of autism and sensory processing disorder (SPD). Results showed a significant difference between the OT-SI group and the UC group on individualized functional goals with the OT-SI group achieving significantly higher scores.

Results also revealed significantly greater improvement for the OT-SI group compared to the UC group in the areas of Self-Care Functional Skills and Social Functions subtests of the Pediatric Evaluation of Disability Inventory (PEDI). No significant changes were shown on the Pervasive Developmental Disorders Behavior Inventory. 

Based on these three high level studies, there is reason to support the use of an OTSI approach for children with deficits in sensory processing which impact function. However, it is important to not only consider the type of intervention, but the dosage used during service delivery. And if we are using these studies to support our clinical practice, there is a need to contemplate how dosage is being determined in clinical practice as well.

Clinical Reasoning

Despite the evidence described above, most practitioners in outpatient pediatric practice settings continue to see clients once a week indefinitely. And little research exists to explain the process practitioners might use to select the dosage for a client’s plan of care or what factors influence their decision making. Some factors might include the culture of the facility (e.g., the expectations that clients will be seen a certain number of times per week) and scheduling logistics (Caracci, Reynolds & Ivey, 2018). However, it’s unlikely that these factors alone will result in the optimal therapeutic dose for each client. There is also pressure that some clinicians feel obliged to continue services as long as a family desires, which may lead to children remaining on a therapists caseload for prolonged periods of time. Fortunately, scientific, pragmatic, narrative, interactive, conditional and ethical reasoning may help therapists make educated decisions about dosage in occupational therapy using OT-SI approach and effectively communicate decisions to families and administrators.

Scientific reasoning guides a therapist to apply research evidence to clinical practice, and in the case of OT-SI, informs practitioners to consider applying an intensive dosage of therapy. However, other forms of reasoning also inform the decision making process. Pragmatic reasoning addresses “…both the practice context in which therapy is occurring as well as personal factors within each individual practitioner” (Schell & Schell, 2008). When applied to OT-SI, pragmatic reasoning leads practitioners to consider if they have the proper training, environment, and equipment to implement the intervention. It also leads the therapist to collaborate with families to ensure that they are able to participate in an intensive frequency of therapy. That is, is the family able to commit to being at therapy 2-3x per week? Do they have the transportation and resources to attend consistently? Do they understand the financial implications of intensive therapy? Are they able to afford multiple co-payments each week? The answers to these questions may support or deter a therapist from recommending a high frequency OT-SI approach.

As a therapist considers whether an intensive OT-SI approach is warranted they may use interactive and narrative reasoning to see the big picture. Practitioners may maximize the therapeutic relationship and build rapport through active listening, sharing personal stories, joint problem solving, and using positive verbal and nonverbal communication. This type of reasoning is closely aligned with Ayres’ approach to using an individualized, client centred approach to intervention. With a “no therapist left behind” mentality clinicians, caregivers and children become partners during intervention.

During this process the therapist will ensure caregivers are directly involved in all sessions, and consider a family’s past experiences and expectations to make sense of their circumstances and recommend dosage based on what is best for the individual client.

Ethical and conditional reasoning should also guide a therapist’s decision for dosage, and national therapy associations have started providing guidance for practitioners related to this decision making process (Caracci, Reynolds, & Ivey, 2018). In 2014 the American Occupational Therapy Association, American Physical Therapy Association, and American Speech-Language-Hearing Association released a joint consensus statement indicating it is not acceptable for administrative guidelines to influence a clinician’s clinical judgment related to dosage. That is, a therapist must ethically make decisions related to how much and how often a client is seen in therapy based on their clinical and professional reasoning secondary to the client’s need for skilled services.

Conditional reasoning guides therapists to monitor therapy progress and be flexible and respond to changing conditions. Therefore, when recommending a high frequency of intervention it becomes increasingly important for practitioners to create goals with caregivers that are realistic and easily monitored, with a specific start and end date. Discharge should be the goal, and therefore discussions regarding discharge should occur upon initial evaluation and at subsequent therapy sessions. Practitioners must monitor and report progress to caregivers regularly, and changes to frequency should be made if a lack of progress is noted. This is especially important because families are investing a high level of time and resources to the care plan, and should not continue to do so if the plan is not working. Goal Attainment Scaling (GAS) may be one way to create goals that provide objective information that may inform a therapist and caregiver of progress or lack thereof (for more information on GAS see Mailloux et al., 2007).

Conclusion

Sensory integration interventions continue to be heavily scrutinized, yet they are one of the professions most evidence based approaches for children with neurodevelopmental disorders. It is important that clinicians and administrators understand how to make the best decisions related to the frequency and duration of OTSI and how to support their decisions using evidence based practice, clinical reasoning and caregiver collaboration.