Update of therapeutic listening
As promised, I wanted to review some of the articles in the current (March/April 2007) issue of the American Journal of Occupational Therapy. Since I have gotten some emails and blog comments asking me about the Hall & Case-Smith study (see reference below) I thought that this would be a good article to begin discussing.
I was excited to see a study on this intervention technique because I have been hesitant in the past to fully embrace 'therapeutic listening.' In my opinion there is not adequate evidence to support promoting this technique so I was interested to see if this new study would change my mind.
I believe that the authors should be commended for initiating this inquiry, but I also believe that their conclusions are far overstated. There are several fundamental flaws in their design that are concerning.
To begin with, they used a convenience sample. This might have been appropriate if the study was truly exploratory, but there have been several other studies already completed on this topic. Convenience sampling limits our ability to state that the subject pool is truly representative of the entire population.
Sampling size is also an issue - it was based on expected effects for the Sensory Profile but the authors don't discuss the sample size that would be needed for the other tests used. This information is needed in order to determine if the sample size is adequate to draw conclusions about visual motor or handwriting skills.
Finally, their study population was very heterogenous - so even if there were effects within this group it is difficult to know what was causing any of the effects based on the sampling methods used. In sum there are many problems with the sampling procedures reported that severely limit the study.
Another problem is that the measurement methodology relies strongly on parental report. This is also a confounding factor because you are asking the parents if there are changes in behavior, but the parents have invested heavily in the intervention program - and in fact they may be expecting changes based on whatever communication occured in the process of educating them about the 'sensory diet.' It would have been much more useful to have the teachers fill out the Sensory Profile (school version) because they are completely separate from the intervention and could give an opinion that has much less opportunity for bias.
Another problem with measurement is that some of the evaluation tools were administered three times within the three month study period - opening the question of practice effect of these particular tests.
It is also unclear how many of these children were participating in other therapy programs and what the nature of those programs was. The presence or absence of other parallel intervention programs is a significant confounding factor.
All of these factors could be partially acceptable if the study was truly exploratory and if the conclusions were stated more modestly. Instead, this is just another in a long line of studies with significant limitations. What makes it particularly difficult to accept is that the authors conclude that "The present study produced encouraging findings to support the use of therapeutic listening as part of an overall sensory-integrative approach to occupational therapy in elementary school-age children" (p. 215). I don't think that the study accomplished this at all. Rather, I believe that the study is very limited, they relied primarily on the potentially biased self-report of parents that participated in the program, the conclusions overstate the results, and there is very little real conversation about the severity of the problems in sampling and measurement methods.
So for me the jury remains 'out' on therapeutic listening. I don't see any reason to encourage parents to invest heavily in these programs at this time. If anyone wants to rebut my conclusions I will happily post their comments, in full, on this blog.
References:
Hall, J. & Case-Smith, J. (2007) The effect of sound-based intervention on children with sensory processing disorders and visual motor delays. American Journal of Occupational Therapy, 61, 209-215.
I was excited to see a study on this intervention technique because I have been hesitant in the past to fully embrace 'therapeutic listening.' In my opinion there is not adequate evidence to support promoting this technique so I was interested to see if this new study would change my mind.
I believe that the authors should be commended for initiating this inquiry, but I also believe that their conclusions are far overstated. There are several fundamental flaws in their design that are concerning.
To begin with, they used a convenience sample. This might have been appropriate if the study was truly exploratory, but there have been several other studies already completed on this topic. Convenience sampling limits our ability to state that the subject pool is truly representative of the entire population.
Sampling size is also an issue - it was based on expected effects for the Sensory Profile but the authors don't discuss the sample size that would be needed for the other tests used. This information is needed in order to determine if the sample size is adequate to draw conclusions about visual motor or handwriting skills.
Finally, their study population was very heterogenous - so even if there were effects within this group it is difficult to know what was causing any of the effects based on the sampling methods used. In sum there are many problems with the sampling procedures reported that severely limit the study.
Another problem is that the measurement methodology relies strongly on parental report. This is also a confounding factor because you are asking the parents if there are changes in behavior, but the parents have invested heavily in the intervention program - and in fact they may be expecting changes based on whatever communication occured in the process of educating them about the 'sensory diet.' It would have been much more useful to have the teachers fill out the Sensory Profile (school version) because they are completely separate from the intervention and could give an opinion that has much less opportunity for bias.
Another problem with measurement is that some of the evaluation tools were administered three times within the three month study period - opening the question of practice effect of these particular tests.
It is also unclear how many of these children were participating in other therapy programs and what the nature of those programs was. The presence or absence of other parallel intervention programs is a significant confounding factor.
All of these factors could be partially acceptable if the study was truly exploratory and if the conclusions were stated more modestly. Instead, this is just another in a long line of studies with significant limitations. What makes it particularly difficult to accept is that the authors conclude that "The present study produced encouraging findings to support the use of therapeutic listening as part of an overall sensory-integrative approach to occupational therapy in elementary school-age children" (p. 215). I don't think that the study accomplished this at all. Rather, I believe that the study is very limited, they relied primarily on the potentially biased self-report of parents that participated in the program, the conclusions overstate the results, and there is very little real conversation about the severity of the problems in sampling and measurement methods.
So for me the jury remains 'out' on therapeutic listening. I don't see any reason to encourage parents to invest heavily in these programs at this time. If anyone wants to rebut my conclusions I will happily post their comments, in full, on this blog.
References:
Hall, J. & Case-Smith, J. (2007) The effect of sound-based intervention on children with sensory processing disorders and visual motor delays. American Journal of Occupational Therapy, 61, 209-215.
Comments
Several occupational therapists who are active users of web 2.0 tools such as blogs are trying to connect up more cohesively. I've popped by to drop you this invitation...You can check out my profile on http://oteducation.wordpress.com
I'm also just going about trying to get all occupational therapy blog feed into my bloglines page (http://www.bloglines.com/public/merrolee).
While I'm at it... I'm also sharing around Will's last posting from his blog...
Please read on:
The OT blogosphere has really taken off over the past few months. Without a doubt this is pretty much down to Merrolee's group in New Zealand but also to student's and of course a few bods like James Lampert Housing-OT Blog and Chris' ABC Therapeutics Blog in the States.
Merrolee and I were talking on GTalk just the other night and discussing ways on broadening the blogosphere / getting methods on us all talking to each other. Then something struck me. In a lot of other communities on the net these various bloggers and community members get together once in a while - yes, actually get away from a computer! Call it a meetup, blogmeet - whatever. I can't accommodate the world (although hey, your’re all invited!) so I have setup a upcoming group for anyone to join titled "OT's On The Net - UK" and in the upcoming future (like it?) I will organise a suitable venue/date to have a beverage and a chat. So, if your in the UK and reading this.. thinking of starting a Blog, contributing to the net in someway and your an OT (or student OT) then add yourself to the group to be informed of when/where!
Update I stupidly forgot to post the URL in the first revision of this post. To add yourself go to : http://upcoming.yahoo.com/group/3203/ (It's a yahoo application so you will need to join yahoo)
So… join up on the yahoo group set up by Will, make sure you blog is connected in my bloglines page (http://www.bloglines.com/public/merrolee) and lets spread the message!
But then I became very concerned about several issues that you identified in your review, particularly that of the sample size. I also wondered about the 2 who dropped out of the study and the lack of explanation for why they dropped out.
The impact on our child has been terrible. We put our child through several weeks of TL and were encouraged to stick with it. However, our child became impossible to control, creating dangers for herself and others. So we had to stop. We are concerned that she may be having mild seizures.
We were told by the company that there is no way that TL can have the terrible side affect that our child is experiencing.
However, I have spoken to another OT who said that one of the contraindications of TL is seizures.
Needless to say we are very upset with this company and are concerned about the lack of credible information supporting the use of this intervention.
There are probably some very solid reasons to sing praises of TL. However, I think it needs to be used with much more caution that indicated by those promoting it.