Sensory integration: More evidence that OTs have lost control of the narrative

There are quite a few opinion pieces in this blog about the state of sensory integration as a model for occupational therapy - the reader is particularly referred here and here for quick background if needed.

Continued evidence that occupational therapists have lost control of the 'sensory integration' narrative can be found in the October 2010 Scientific American Article by Nancy Shute entitled "Desperation drives parents to dubious autism treatments."

Sensory integration therapy is described in the article as ranging from "wrapping children in blankets or placing them in a hug machine to having them play with scented clay..." They also note in the article that this intervention costs families up to $200 per hour or $6000 per year. Sensory integration is listed in a chart as Temptations: Dubious Therapies.

These kinds of articles always seem to generate responses from people who disagree from them, but before anyone responds I think this is a good opportunity to pause and reflect on why we are finding ourselves in this position. The 'Fidelity' problem has been discussed forever and our field has not come together to find a solution. We still have different 'camps' of people supporting different iterations of what should be included in sensory integration models and the result is ongoing confusion in the public square. We have too much mythology and too little evidence when it comes to our interventions. The public is confused because we have confused them.

What do parents want? Perhaps OTs should listen closely to Jim Laidler who was interviewed in the article: "Obviously, the goal of my family, and most families, is to lead as normal a life as possible. Normal is going out to dinner as a family."

We can use our knowledge of sensory processing to help us understand why children who have autism have difficulties in these environments, and make suggestions to families on how to help mediate those difficulties. We can also use training methods, direct practice, and skill development to help children learn to function in those environments.

Or we can let people continue to think that we are putting blankets on children and letting them play with scented clay, charging them exorbitant prices for this 'expertise.'

What kind of occupational therapy are you promoting?

Comments

TherExtras said…
Hi, Chris,
Nice to meet you! Came here via a tweet from LizDitz. Nice to meet another (great) same mind.

Here is an early post I did on this topic:
http://www.therextras.com/therextras/2008/07/shotgun-therapy.html

I have several posts on 'all things sensory' linked in a box in the middle column of my blog.

Recently I guest-posted here:
http://thinkingautismguide.blogspot.com/2010/07/what-to-ask-of-occupational-therapist.html

Hope that answers your question.
Barbara
TherExtras said…
Hi, Chris, nice to meet you! Nice to meet a (great) same mind.

An early post I did on this topic:
http://www.therextras.com/therextras/2008/07/shotgun-therapy.html

More recently:
http://thinkingautismguide.blogspot.com/2010/07/what-to-ask-of-occupational-therapist.html

Hope that answers your question.

Barbara
Sarah said…
You know, as someone who was tested for SPD and sent home with a surgery brush for Wilbarger and nothing else (because I told the therapist up front that I couldn't come for more than 2 meetings for financial reasons, and this was the sum total of the "sensory diet" she sent me home with), I can't help but be relieved and (perhaps) somewhat envious of your clients. I have had the pleasure of reading several of your articles, and while it's nice mojo to think that the scented clay and heavy blankets may be all someone needs, reality has to flash in at some point. Is it working? I don't know. I know lots of people who think it works really well for them or their children. But for people like me for whom Wilbarger does nothing but make my skin crawl even worse, one has to wonder why some people want to spend their money on OT visits at all, especially with such confusion out there.
Hello Dr. Alterio! I am a pediatric occupational therapist from the Philippines and I gained so many insights from reading your blog entries.

I'm very relieved that I'm not the only one who questions the effectiveness of classical SI interventions. While I do provide and suggest certain calming activities that can help a child function better in his context, I spend the bulk of my time teaching functional skills to my kids and helping their families discipline them.

To be honest, I sometimes feel "weird" that I don't make my patients finish "obstacle courses" that are suppose to provide them with the enhanced sensory input that they need because that's what a lot of Filipino OT's do. I frequently feel like I'm the odd one out. Reading your blog entries on SI and evidence-based practice gave me the assurance that I am on the right track. Keep up the good work! :)


Maria Anya Paola P. Sanchez, OTRP
Kat said…
Part of the problem, from my perspective anyway, is that few persons but the OT's know the OT's version of the narrative, or even that there is a "narrative." I have kids (adopted with trauma backgrounds, and bio) that have always had some sensory issues and my primary care dr, our school teachers, psychologists, etc., NO ONE ever suggested going to an OT. I've sought answers for years, but my kids' symptoms were not comprehensive or severe enough to get an official label of SPD or ASD. And so we've muddled on, with little to no help. I've learned more in the last two years than in the previous ten, and all through my own unending research. Most of my adopted kids are now adults and still struggling, and I am still struggling to make a difference for them.
Karen said…
Hi Chris
I have been following your posts on this topic for a while now and as an OT, I completely agree with all you've had to say about it.

You might be interested in this article from the August 2010 edition of the Australian Occupational Therapy Journal which covers many of the points you've previously made. Sorry I can't make it a live link but copy and paste should do the trick.
http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1630.2010.00877.x/pdf

Keep up the good work!
Karen
Chris said…
Thank you very much for the link, Karen. The article was very interesting to read and I hope that others have the opportunity to look at it.

It is gratifying to see that colleagues in Australia are leading the way with publishing these opinions in journals. I hope that this spurs more conversation and open discussion here in the States!

Thanks again,
Chris
TherExtras said…
I want to thank you, Karen, too. That is an excellent article.
Barbara
Anonymous said…
THANK YOU! THANK YOU! THANK YOU!
I'm an OT in the states and have thought this same thing since day one. When I was in school, they taught us to critically look at articles before we bought into them; the first thing I noticed was that 99.9% of SI articles are done by OTs! (Similar to the cigarette companies telling you that tobacco doesn’t cause cancer).
The sensory system affects EVERYTHING. You cannot be alive without at least one of your sensory systems being affected by the environment, so isn’t that convenient explanation for any behavior? It’s a catch all diagnosis and it’s sad that my profession promotes this snake oil to desperate families.
Sorry for the rant and thank you for telling the truth.
Anonymous said…
Hi Chris! I am an OT graduate student in New York State. I understand your concern for SI intervention, and I also understand the public’s confusion for it. In general, I feel like most parents who sign their kids up for SI treatment think that means their kids are just going to get to play in rooms with cool light fixtures and ball pits. I do think though, that the American Occupational Therapy Association has been making an attempt to clarify and to use evidence to prove the effectiveness of this treatment on specific outcomes. The 2010 May/June volume of The American Journal of Occupational Therapy was titled: Special Issue On- Sensory Integration. This journal is full of the most recent article reviews of SI treatment. In particular, there is an article called the “Systematic Review of the Research Evidence Examining the Effectiveness of Interventions Using a Sensory Integrative Approach for Children,” which includes a review of 27 studies which identify, evaluate, and synthesize the research literature on the effectiveness of SI intervention on the ability of children with difficulty processing and integrating sensory information to engage in desired occupations. Overall, the results indicate the SI may improve sensorimotor skills and motor planning, socialization, attention, behavior regulation, reading-related skills, participation in active play, and achievement of individualized goals. This study also indicated limitations within the studies, including Type II errors due to small sample size, variable intervention dosage, and lack of fidelity to intervention. This study does suggest, that replication of studies using sound methodology is needed to support the current findings, nonetheless, I feel that this study does prove, at least to some extent, that SI is worth your time and effort if you choose to become certified. I have highlighted just a few of the studies:
In the realm of sensory processing, seven studies showed positive outcomes including changes in tactile function/discrimination, decreases in sensory defensiveness, and overall changes in sensory processing. The study also reviewed behavioral outcomes. A study by Miller, Coll, and Schoen (2007) found significant gains in attention, cognitive skills, and social skills among children with sensory processing difficulties compared with a no treatment group and an alternative activity-based treatment group (May-Benson, T. A. & Koomar, 2010). The article also highlights three more recent studies which examines changes in functional occupational performance. Individualized goals and significant gains were demonstrated, including changes in sleep patterns, improved ability to manipulate fasteners, improved ability to pump a swing, improved ability to participate in meal preparation activities, and improved ability to participate in homework activities. A study by Roberts, King-Thomas, and Boccia (2007) showed gains in functional, behavioral, and attention related goals in children with sensory modulation problems.

Joy

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. The American Journal of Occupational Therapy, 64(3), 403-414
Anonymous said…
Hi Chris! I am an OT graduate student in New York State. I understand your concern for SI intervention, and I also understand the public’s confusion for it. In general, I feel like most parents who sign their kids up for SI treatment think that means their kids are just going to get to play in rooms with cool light fixtures and ball pits. I do think though, that the American Occupational Therapy Association has been making an attempt to clarify and to use evidence to prove the effectiveness of this treatment on specific outcomes. The 2010 May/June volume of The American Journal of Occupational Therapy was titled: Special Issue On- Sensory Integration. This journal is full of the most recent article reviews of SI treatment. In particular, there is an article called the “Systematic Review of the Research Evidence Examining the Effectiveness of Interventions Using a Sensory Integrative Approach for Children,” which includes a review of 27 studies which identify, evaluate, and synthesize the research literature on the effectiveness of SI intervention on the ability of children with difficulty processing and integrating sensory information to engage in desired occupations. Overall, the results indicate the SI may improve sensorimotor skills and motor planning, socialization, attention, behavior regulation, reading-related skills, participation in active play, and achievement of individualized goals. This study also indicated limitations within the studies, including Type II errors due to small sample size, variable intervention dosage, and lack of fidelity to intervention. This study does suggest, that replication of studies using sound methodology is needed to support the current findings, nonetheless, I feel that this study does prove, at least to some extent, that SI is worth your time and effort if you choose to become certified. I have highlighted just a few of the studies:
In the realm of sensory processing, seven studies showed positive outcomes including changes in tactile function/discrimination, decreases in sensory defensiveness, and overall changes in sensory processing. The study also reviewed behavioral outcomes. A study by Miller, Coll, and Schoen (2007) found significant gains in attention, cognitive skills, and social skills among children with sensory processing difficulties compared with a no treatment group and an alternative activity-based treatment group (May-Benson, T. A. & Koomar, 2010). The article also highlights three more recent studies which examines changes in functional occupational performance. Individualized goals and significant gains were demonstrated, including changes in sleep patterns, improved ability to manipulate fasteners, improved ability to pump a swing, improved ability to participate in meal preparation activities, and improved ability to participate in homework activities. A study by Roberts, King-Thomas, and Boccia (2007) showed gains in functional, behavioral, and attention related goals in children with sensory modulation problems.

Joy

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. The American Journal of Occupational Therapy, 64(3), 403-414
Mallory said…
Hello Chirs,
I am an occupational therapy student, about to recieve my masters, and your blog really caught my interest. At this stage in my education we are learning all about sesnory integration techniques and the use of evidence based practice. What you are saying I saw on my fieldwork; we are confusing the public and not using enough evidence.
We are learning how to use our skills and knowledge of sensory processing to help children function the best they can in their environment.
I think my generation of future OT's will help clear up the confusion,"gain control" back and focus more on client centered care using SI. We are being taught to use evidence, focus on occupation based interventions, and advocate for what my profession does. this is the kind of therapy I hope to promote.
Chris said…
Thanks for your comments Joy. I encourage you to closely study the fidelity issue because this is the largest problem with trying to use systematic review or even meta-analysis. The articles that are included are so varied in what they are doing and how they are doing it that it can hardly be claimed to represent a single intervention strategy. I am comfortable with the statement that the studies indicate some support for occupational therapy, but I am less convinced that they represent any cohesive adherence to a single intervention method.

I applaud your interest and hope that you continue to study this important issue!

Chris
TherExtras said…
Hi, Chris,
Your last comment brought me back:
"varied in what they are doing and how they are doing it that it can hardly be claimed to represent a single intervention strategy. I am comfortable with the statement that the studies indicate some support for occupational therapy, but I am less convinced that they represent any cohesive adherence to a single intervention method."

My responses at the Your Therapy Source blog on this post are related to what you just said. (But Margaret hasn't published my last comment yet, so you might wait a bit before going over there.)

http://yourtherapysource.blogspot.com/2010/11/motor-learning-versus.html

Barbara
kelly said…
Throughout class as an OT student we have discussed this topic many times! Sensory integration is techniue which OT needs to fully regain control of. So many times others views of OT impact the profession as a whole. I feel as a practitioner in the future I want to be proud of the profession I am in, and change the views others hold, in that the profession as a whole is much more than the views some hold of it. There is great opportunity to expand approaches such as sensory integration, and bring respect for all the hard work given by OTR and COTA's everyday.
Anonymous said…
Regarding your question "What type of OT are you promoting?" I would say this - first, never SI.

As I said in my other comment to you, I have been working for more years than I care to say. I have found my own way, if you will, but I have always stayed true to function and occupation, and working in schools I have always stuck to "academic relevance" in what I am doing with children, my goals and treatment. I also always concern myself with student and parent desires, as they match up with the above. What teachers see as student needs is also always a concern of mine in determining treatment goals.

I continue to look at children's function in gross motor and postural control, ability to functionally sit erect with hands free for use for example, fine motor ability, UE and hand development, ability to functionally use tools of the academic environment (scissors, pencil, tape, etc.), pencil control and how it impacts speed and quality of handwriting, visual motor and visual perception as it impacts academic skill specifically handwriting and reading, visual testing specifically ocular motor control, screening for strabismus and other problems, sensory testing such as tactile testing and kinesthetic testing as it directly impacts hand function, vestibular function as it impacts the postural reflex mechanism and functional balance. Behavioral observations and play behavior is another area I always consider, as well as oral motor, eating, ADL, AT, Musculoskeletal exams as they are pertinent to the child.

There is so much for us to do in schools, that is functionally and occupationally based, that I don't know how OT's have the time to waste on "sensory diets." I worked for an SI therapy group, and they NEVER solved a functional problem. They had some fancy charts in their reports, but never helped a child functionally. Very sad - and because the schools and Committees on Special Education never made them accountable for a lack of progress, they continued.

Great developmental progress is possible! I make impressive progress with students every school year. It is sad that the OT profession, and AOTA in particular, has gotten "lost" in all of this. Our reputation as a profession is sadly suffering badly. Often I can say I am embarrassed to be a part of the profession.

I think that the advice given by the American Academy of Pediatrics to physicians to ask for goals and monitor progress is a good step in making people accountable. Years ago, when I had to obtain my own MD Rx’s and justify my treatment to physicians on the phone by answering specific questions about what and why I was doing something, things were better. If physicians were more involved, and asked for pre and post-testing results, the profession would be accountable and we would not be in this mess now.

I think that AOTA should be making themselves accountable. They made a bad turn when they bought into SI hook, line, and sinker for all types of problems and populations. When they eliminated the actual "specialty certification" and changed it into an academic task instead of a clinical competence measure they lost my confidence greatly. It seems if you are not in academia, but you are "only" a clinician, you are not respected by AOTA any longer. I don't know the politics of what happened, but it hasn't been good for the profession. The magazine gets smaller and smaller, doesn't it, and the advertising in it is mostly by AOTA itself for its products.


Good for you for doing such detailed work to tell the truth about SI. If we are to remain as a profession at all, especially in pediatrics and in the schools, we had better start doing something practical for those entrusted to our care.
Anonymous said…
Clearly there needs to be someone on this blog that has updated knowledge on the research out there. There is enough evidence to consider Ayres SI an EBP now when working with clients with autism. In addition, fidelity criteria and a fidelity tool do actually exist. Further, modalities such as use of weighted blankets, sound therapies, therapeutic brushing and so forth are not considered part of the AIS frame of reference, they are tools - that is it. Anyone with a clue about ASI would never call the use of weighted blankets Ayres SI and I would only refer to any of the weighted modalities as one of a large variety of possible sensory-based tools that can be offered to people to try for a variety of different therapeutic reasons and when using any number of theories or frames of reference (PEO for example).

Anyone charging for their services, which all OTs do either through insurance companies or other means, is making a living off of what they do for work. To talk about people who are doing a lot of work and research in this area in the way being done here is highly concerning.

Please do your research before talking poorly about fellow colleagues. Also, unless you are doing research that is peer reviewed and published to show any given approach is not beneficial you cannot state that it is not as you would have no evidence to support your claim and by the way be sure to use the fidelity tool to be sure how you define ASI is in fact accurate - that would be a good start!
Hi Anonymous,

Did you read this entry or are you just making angry comments?

The purpose of this entry was to discuss how (in 2010) an article was written in Scientific American that demonstrated how the public (and the article author in particular) still did not know what ASI was, despite all of the work of those who were attempting to clarify this topic. The purpose was to show how OTs still did not control the narrative, or the definition, on what ASI was.

I am not sure what all of your comments are referring to as it relates to the article, but I will try to address them:

1. I invite you to provide evidence that Ayres SI is evidence-based practice - because if you can do so perhaps some insurance companies could be informed. As it stands, virtually no insurance company that I deal with in the state of NY will cover these services. I suspect that is also true elsewhere, based on information and belief.

2. As for fidelity criteria, they are so stringent as to make the model inapplicable to the vast majority of practitioners and their work environments.

3. I understand that sensory-based modalities are not formally a part of the ASI model, but try telling that to many clinicians around the country. There is a problematic lack of adherence to the tenets of ASI - that is precisely why the fidelity tool was and still is needed. That is the whole point of this entry - to show how variably these definitions still were.

Can you please explain what is concerning about discussing the ethics of charging money for experimental and unproved interventions?

I encourage you to read the entirety of the over 50 blog entries here that discuss the SI model. If you object to something then you should be able to debate it intelligently - not just hurl random insults and hide behind an anonymous moniker when you make comments.

I invite you (or anyone) to critique my opinions, back up your statements, and print your real name. With so much information in this blog on the topic of SI you have a lot of material to comment on.

Start your critique this way: if ASI is so clear in everyone's mind, why do we continually see articles like this even though the fidelity tools were supposed to address the problem?

As a final point, it is the responsibility of the people promoting the intervention to provide the validation for the intervention. Clinicians and scientists are certainly free to evaluate the evidence that has been presented, to critique it fairly, and to render an opinion. A critic does not have to 'prove' that something is wrong. The proof needs to be provided by the people making the claims.

In that regard, many OT researchers have failed.

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