Questions about AOTA's response to the National Autism Center
The National Autism Center published a comprehensive National Standards report regarding evidence-based practice guidelines for children and young adults who have autism. The report is an excellent summary of research about intervention methods and effectiveness. It was particularly interesting to me that this report referenced and hoped to expand on the New York State Early Intervention Clinical Practice Guidelines for autism spectrum disorders which of course is a document that is familiar to many of the families in my geographic area. The NYS guidelines were published ten years ago so an update to include new research was needed.
The new report focuses on quantitative studies and in this sense some important occupational therapy literature may not have met the inclusion criteria. There have been some excellent qualitative studies completed that make important occupational therapy contributions to best-practice considerations so I am really looking forward to the next report that promises to include qualitative methodologies.
In reviewing the report I was intrigued by the treatment classification process. It is undoubtedly a daunting task to conglomerate such a large number of articles into discrete categories. It was particularly interesting to me that many articles that have 'sensory' issues in them were listed in 'behavioral' treatment packets - for example there was an excellent article on the use of a fading technique to improve tolerance for milk drinking. Now I suppose that you could describe this intervention as a behavioral fading but you could just as easily describe it in sensory terms because in this study they manipulated amount of chocolate syrup until the child was drinking plain milk. Either way, many OTs use similar techniques when addressing the feeding problems of people who have sensory intolerances associated with their autism.
There are many other important established and emerging interventions that are used by occupational therapists and supported in the NAC document including social stories, relation/interaction approaches, behavioral approaches, and functional skills training.
This brings us to the AOTA response to the report. The AOTA response stated "We believe it unfortunate that the National Standards Report of the National Autism Center did not include valuable research findings available regarding occupational therapy and sensory integration." I don't agree - I think that there was a lot of supportive evidence for occupational therapy interventions in general and also for sensory-based interventions in particular (depending, of course, on how you are choosing to 'label' and 'categorize' the studies)! Deep reading of the report validates this observation. The NAC report validated MANY important occupational therapy intervention approaches, including some sensory-based approaches that were just labeled in different categories.
Again, the underlying problem contributing to misconceptions about the report and about so-called "sensory integration" research is an absolute mish-mash of definitions and total lack of research and intervention fidelity. It is always disappointing to see summation reports or meta-analysis mislabel sensory interventions - but this time AOTA also contributes to the fuzzy definitions. The AOTA response letter references the Case-Smith & Arbeson (2008) study that lumps 'auditory integration' and 'massage' into the sensory-based category. I know a few respected OTs who might object to passive auditory and tactile sensory approaches being termed sensory integration.
So the bottom line here is this: what are sensory integration studies and can they be lumped together with sensory-based intervention studies? Are they classic sensory integration models in specially designed play environments? Are they deep pressure massage or weighted vests? Are they listening to music with headphones? Are they gustatory fading techniques to improve tolerance to milk????
My recommendation for practitioners is to read the report and be very happy that there is so much evidence for so many occupational therapy interventions. I encourage people to use those techniques that are established or those which are emerging. For those where there are less evidence - encourage families to use discretion and try those techniques AFTER other methods have not been effective. Resources are not unending and we need to first promote interventions that have the best likelihood of success.
My recommendation to AOTA is to re-think these response letters. I believe that there can be more harm than good accomplished with responses that don't celebrate the many OT interventions supported in the report - including those sensory-based and sensory-related studies that are listed in other categories! Finally, our profession really needs to get its definitions straight and we need to tackle this fidelity issue once and for all. Harm is being done by continually failing to appropriately define these interventions and have a robust professional debate on this topic.
References:
(please read the links as well!)
Case-Smith, J., & Arbesman, M. (2008). Evidence-Based Review of Interventions for Autism Used in or of Relevance to Occupational Therapy. American Journal of Occupational Therapy, 62, 416-427.
Luiselli, J. K., Ricciardi, J. N., & Gilligan, K. (2005). Liquid fading to establish milk consumption by a child with autism. Behavioral Interventions, 20(2), 155-163.
The new report focuses on quantitative studies and in this sense some important occupational therapy literature may not have met the inclusion criteria. There have been some excellent qualitative studies completed that make important occupational therapy contributions to best-practice considerations so I am really looking forward to the next report that promises to include qualitative methodologies.
In reviewing the report I was intrigued by the treatment classification process. It is undoubtedly a daunting task to conglomerate such a large number of articles into discrete categories. It was particularly interesting to me that many articles that have 'sensory' issues in them were listed in 'behavioral' treatment packets - for example there was an excellent article on the use of a fading technique to improve tolerance for milk drinking. Now I suppose that you could describe this intervention as a behavioral fading but you could just as easily describe it in sensory terms because in this study they manipulated amount of chocolate syrup until the child was drinking plain milk. Either way, many OTs use similar techniques when addressing the feeding problems of people who have sensory intolerances associated with their autism.
There are many other important established and emerging interventions that are used by occupational therapists and supported in the NAC document including social stories, relation/interaction approaches, behavioral approaches, and functional skills training.
This brings us to the AOTA response to the report. The AOTA response stated "We believe it unfortunate that the National Standards Report of the National Autism Center did not include valuable research findings available regarding occupational therapy and sensory integration." I don't agree - I think that there was a lot of supportive evidence for occupational therapy interventions in general and also for sensory-based interventions in particular (depending, of course, on how you are choosing to 'label' and 'categorize' the studies)! Deep reading of the report validates this observation. The NAC report validated MANY important occupational therapy intervention approaches, including some sensory-based approaches that were just labeled in different categories.
Again, the underlying problem contributing to misconceptions about the report and about so-called "sensory integration" research is an absolute mish-mash of definitions and total lack of research and intervention fidelity. It is always disappointing to see summation reports or meta-analysis mislabel sensory interventions - but this time AOTA also contributes to the fuzzy definitions. The AOTA response letter references the Case-Smith & Arbeson (2008) study that lumps 'auditory integration' and 'massage' into the sensory-based category. I know a few respected OTs who might object to passive auditory and tactile sensory approaches being termed sensory integration.
So the bottom line here is this: what are sensory integration studies and can they be lumped together with sensory-based intervention studies? Are they classic sensory integration models in specially designed play environments? Are they deep pressure massage or weighted vests? Are they listening to music with headphones? Are they gustatory fading techniques to improve tolerance to milk????
My recommendation for practitioners is to read the report and be very happy that there is so much evidence for so many occupational therapy interventions. I encourage people to use those techniques that are established or those which are emerging. For those where there are less evidence - encourage families to use discretion and try those techniques AFTER other methods have not been effective. Resources are not unending and we need to first promote interventions that have the best likelihood of success.
My recommendation to AOTA is to re-think these response letters. I believe that there can be more harm than good accomplished with responses that don't celebrate the many OT interventions supported in the report - including those sensory-based and sensory-related studies that are listed in other categories! Finally, our profession really needs to get its definitions straight and we need to tackle this fidelity issue once and for all. Harm is being done by continually failing to appropriately define these interventions and have a robust professional debate on this topic.
References:
(please read the links as well!)
Case-Smith, J., & Arbesman, M. (2008). Evidence-Based Review of Interventions for Autism Used in or of Relevance to Occupational Therapy. American Journal of Occupational Therapy, 62, 416-427.
Luiselli, J. K., Ricciardi, J. N., & Gilligan, K. (2005). Liquid fading to establish milk consumption by a child with autism. Behavioral Interventions, 20(2), 155-163.
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