Thoughts about use of seat cushions to promote attending behaviors in children

I encourage everyone to open up the current American Journal of Occupational Therapy and read 'Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder.' This is a fantastic article that looks at the issue of whether or not seat cushions were effective at promoting 'in seat' and 'on task' behavior.

I think this is a fantastic study because it take a very common OT intervention and puts it to the test. For many years OTs have been dispensing seat cushions to children in classrooms based on the thought that the seats provided sensory stimulation that busy children were 'seeking' or that the seats would demand a postural reaction that would promote attention and erect sitting. This has been done for so many years in so many settings that it becomes a common request from teachers who don't know what to do with fidgety children. How many OTs hear the request "Can we try to see if sitting on a seat cushion will help?"

We have precious little evidence that seat cushions do anything at all for children - and the lack of evidence is reflected in the fact that this intervention is barely mentioned in some common pediatric occupational therapy texts. However, given the formulaic and mythical popularity of the intervention you might think there would be more research!! This is good reason to celebrate this article - because it provides a great first step in researching issues like this.

This issue was a large enough concern in our practice that we recruited some local OT students to help us do an in-house study on effectiveness of HowdaHug chairs in promoting attention for preschoolers. Our study found that the chairs were most effective for promoting visual attending and facing the teacher. This was most likely attributed to the physical design of the seats that provided a measure of physical confinement as opposed to any sensory benefits that were offered by the chairs.

The study in the current AJOT used a different measuring approach with interval recording. They had similar difficulties with the fact that issues in the natural context could not be easily controlled, but they did an excellent job of operationally defining their parameters. Overall their design was very clear and well-explained.

The study did not indicate that there were any substantial changes in sitting or task-related behavior when seated on cushions. The authors contrast this to a previous study where children demonstrated improved attention while seated on a therapy ball and suggest that the ball is more effective because it demands a more complex postural reaction from the child.

My takeaway from all this is that the objective of 'meeting sensory seeking need' may not be supported by research. In our own study we found that actual physical constraint was the primary reason for improving attending. This study does not support the hypothesis that attending will improve by allowing for sensory seeking behaviors/needs to be met in the chair. What seems to be evident is that seating that either controls extraneous movement or that demands controlled postural reactions may be most effective in promoting on task and in seat behavior.

The best part of this is that these conclusions have the best face validity. It is logical that attending would improve under control and demand contexts. It is not logical that attending would improve by allowing children to move more on an unstable seating surface. In anticipation of the comment "aren't therapy balls also an unstable surface" I offer this for thought: despite the ball being an extremely unstable surface, it makes the greatest postural demand on control. If you fail to activate a postural response on a ball you will likely fall right off. The seat cushion provides for movement that is supported by a stable surface - and thus there is less postural demand, decreased likelihood of falling off, and only the opportunity to increase fidgeting!

Congratulations and thanks to Caroline Umeda and Jean Deitz for excellent work that has real clinical application!


Umeda, C., & Deitz, J. (2011). Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder. American Journal of Occupational Therapy, 65, 152–159.


Cheryl said…
I believe Delanah Honaker also had a collection of student projects on various types of cushions (mostly the disco-sit) but this seems to be more in-depth. This is the kind of walking talking research that we need clinicians and academians to team up on.

PS- I just noticed your little checkboxes at the bottom of the entries, very nice! how'd you do that?
Chris said…
Does she have these posted online somewhere? I would be interested in reading them.

The little checkboxes were a blogger template option or perhaps a gadget. I found them a couple months ago but was just looking through the settings and couldn't find them! It may have been an option that used to be on the template and is no longer an option - but is still embedded in my template html. Odd.
I agree 100% with your comments. Many interventions that OTs and PTs recommend do not have research to back them up. Some therapists respond to that with "well if it works I don't need research". The problem is it may work for one student and then the school staff (including therapists at times) assume it will work for all. Year after year of this almost makes it folklore (strong word but true in certain circumstances).

Are you familiar with the Scale of Sensory Strategies Tool Kit? It was created by Ileana McCaigue OTR/L. It allows for data collection for what sensory strategies are effective. You can view more info about it on our website if interested.
Cheryl said…
Chris, I looked but cannot find that course book that had the studies listed. I will let you know if it turns up.
Nicole said…
Wow! How interesting... shows just how important research really is before using these interventions!
Pip said…
I think it's really interesting to see when things are examined clinically whether or not they actually have any effect. On placement I sometimes felt that my OT was prescribing things purely due to tradition rather than actually attending to the needs of the client. this kind of post is really helpful for me as a student. thanks :)
Pip said…
this is really interesting. on placement I sometimes felt like my OT was prescibing interventions according to tradition rather than actually responding to the clients needs. these kinds of pages really help me as a student evaluate different types of interventions and their actual usefulness and effect on clients. thanks (PS sorry if I have posted almost the exact same comment twice I couldn't figure out if I'd posted it or not so I posted it again

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