JOURNAL CLUB 5-2-2007

1. JOURNAL CLUB 5-2-2007 Sensory Integration

2. Learning Objectives • Apply our knowledge of evaluating research in an EBP era • Define SI • Discuss issues that plague many disciplines in outcomes research • Discuss what SI has to do with speech and language • Reach consensus on how SLPs should approach SI

3. Why should we as SLP’s be concerned with SPD’s or OT-SI? • 1. Ayres states that normal SI functioning allows us to lay the framework to build higher level cortical functioning. • 2. Ayres also claims that “speech and language are one of the end products of SI.” • 3. SLPs and OTs often have overlapping caseloads. Which means many children we see will also be seeing an OT, and possibly for OT-SI. In many settings OTs and SLPs work together with the child. It is important for us to know what benefits, if any, this treatment might have on the patients that we see.

4. Traditional A theory A diagnosis - SPD or DSI A functional pattern A treatment approach Modern SI theory (J. Ayres) SPD Sensory processing OT - SI What is Sensory Integration? This is a very ambiguous term that has been classically used to describe:

5. The Theory • Developed by Dr. Jean Ayres in 1979(O.T. and clinical psychologist) • The ability to organize and process the sensory stimuli required for an appropriate response to the environment. (Polotajko et. al., 1991) • The foundations of sensory processing • Body centered senses (proprioceptive, vestibular & tactile) • Higher levels of functioning built on top of the body centered senses • Cognition, language & academic performance (Ayres, 1989)

6. The Assessment • Primarily assessed by an OT. (On the internet, there are websites claiming that SLPs can assess) • Several assessment batteries are available. • Sensory Integration and Praxis Tests (SIPT) = Most common • Developed by Ayres in 1989 • Measures aspects of: • Visual sensory processing • Tactile sensory processing • Kinesthetic sensory processing • Vestibular sensory processing • Motor planning abilities

7. The Diagnosis of an SPD • Someone who cannot properly register and/or effectively modulate sensory input. • This results in an inability to produce effective responses to stimuli and appropriate functional behaviors.

8. The Diagnosis of SPD/DSI • Manifestations/signs • A poor foundation for more complex skills that are built through basic sensation • Results in impaired cognition, language, and lower academic performance • Basic sensations are impaired(i.e. balance) and this results in decreased attention • Frustration/aggression • May lack emotional stability • Poor social skills • Newer thinkers changed the name from Sensory Integrative Dysfunction to SPD and others to DSI in an attempt to more accurately reflect the disorder.

9. SPD Taxonomy

10. Does this disorder actually exist? • Rarely still in debate by OTs, considering that more recent evidence indicates that this disorder really does exist. • Populations: autism spectrum disorders, dyslexia, dyspraxia, pervasive developmental disorder, Tourette’s Syndrome, multiple sclerosis, and children with speech delays?. (Wikipedia)

11. The Intervention OT-SI • “Sensory Integration” • Originally designed for children with LD • Administered by a skilled OT who alters the levels and modalities of treatment to increase the child's motor skill level and ability to tolerate sensory stimulation. This facilitates an adapted response and this response helps organize the nervous system.

12. The Intervention OT-SI • Lets watch a quick video! • The end results of OT-SI: • Ability to concentrate and self-organize • Increased self-esteem and self confidence • Increased self-control • Improved learning ability • The capacity for abstract thought and reasoning • These results enable the child to have more success for higher cortical functions(i.e. Reading and writing) (Kramer & Hinojosa, 1999)

13. Big Question • Is this treatment effective or is it just another hype in the therapy world? • Lets review the evidence!

14. Miller,L.J., Coll,J.R., Schoen, S.A.(2007) A Randomized Controlled Pilot Study of the Effectiveness of Occupational Therapy for Children With Sensory Modulation Disorder. The American Journal of Occupational Therapy. 61(2), 228-238. Background: -A lack of EBP can lead to wasted money, time, and energy. -For 16% of OTs in the US, SI is a primary or secondary focus. -Evaluation=$500-$1000 -Tx=$80-$180 for 45-60min session -For children with DD, 40-80% comorbidity rate of SMD. -It is estimated that 5% of children have a SMD. -SI is spoken of very highly in the parental realm, SI oriented products are widely distributed, and it is common for OT and SLP clinicians to advocate for SI. -SI has been around since the 1970’s -So, where is the empirical evidence? Why is it so scant? -This study was designed as a pilot study for an RCT.

15. Questions • What 3 factors comprise an RCT? • What is the difference between efficacy research and effectiveness research? • What one thing do you absolutely need in order to have a true experiment? • What are the three elements needed to get control?

16. Research Question • Does OT-SI better ameliorate attention, cognitive/social, sensory, or behavioral problems than an active alternate placebo treatment or a passive placebo?

17. Method • Level of Evidence? • What are the Independent Variables? • How many levels? • Bivalent, Multivalent, or parametric? • Dependant Variables? • What did they measure?

18. Methods • IV= Type of treatment • DVs= • Leiter International Performance Scale-Revised • Short Sensory Profile • Vineland Adaptive Behavior Scales • Child Behavior Checklist • Goal Attainment Scale • Electrodermal reactivity • How many of these are purely parent reports? • Who is really evaluating the child?

19. Method • Inclusion Criteria • Dx of SMD • Hyperreactive electrodermal activity to stimuli in more than 2 sensory domains on Sensory Challenge Protocol • -3SD from mean on SSP • Clinical confirmation of SMD after parent interview

20. Methods • Exclusion Criteria • DSM-IV Dx other than ADHD, LD, or anxiety symptoms. • Younger than 3, older than 11.6 • IQ less than 85 • Previous OT treatment • Serious life events • IEP resulting in pull-out services

21. Methods • Subjects • Children referred for outpatient occupational therapy at a Denver hospital between 4-99 and 12-01. • N=24 • 5 had Dx of ADHD • 3 had Dx of LD • 1 had anxiety symptoms • 15 of them had no previous Dx • All children were screened for ADHD, and 15 of the subjects met criteria for ADHD.

22. Methods • Treatment Conditions • Group A- (OT-SI) Seen 2x week for 10 weeks. Tx was based on principles of Ayres (1972). Therapist and child had sessions in an OT gym filled with sensory toys and activities. The child was told to use his/her imagination and then to play in the gym. The objective of this Tx was to improve the child’s sensory responsivity, social behavior, motor competence, and participation in meaningful occupations. The OTs did a lot of parent education. • Group B- (Alternative Placebo Treatment) Sessions were conducted by non-certified OT personnel and the parents were not educated about the child’s disorder • Group C-(No Treatment) They were simply waitlisted.

23. Results • Differences among Txs were evaluated with one-way ANOVA. • What P value makes a finding significant? • Significant Findings • OT-SI made gains significantly greater than the other groups on the GAS • Trends toward significant findings • Leiter-R =Attention • Leiter-R =Cognitive/social • Non-significant Findings • OT-SI showed greater reductions in amplitudes of EDR than the other 2 groups. • Children in the placebo group made greater gains than the other two on socialization-Vineland • Children in the No Treatment group made greater gains on the CBCL

24. Results • Effect Sizes • .29= Leiter-R (Cog/Emo. and Att.) • .08= SSP • .14= Vineland socialization • .10= CBCL Externalizing • .07= CBCL Internalizing • 1.62= GAS

25. Implications • What do the results from our RCT pilot study indicate? • Findings suggest that OT-SI may be effective in ameliorating difficulties of children with SMD

26. Critique • Internal threats to validity? • External threats to validity? • Any methodological flaws?

27. SI and Language • As mentioned earlier, Ayres stated that “speech and language are one of the end products of SI.” • If this is true, then OT-SI might actually improve language in any child with a SPD and a comorbid language disorder. • Griffer conducted a study to find out what the story was. • She did so by reviewing previously published studies.

28. Griffer, R.M. (1999). Is Sensory Integration Effective for Children With Language-Learning Disorders?: A Critical Review of the Evidence. Language, Speech, and Hearing Services in Schools, 30, 393-400. • How were studies chosen? • Independent variables? • Dependant variables? • What were common problems with the studies chosen for the meta-analysis? • Language outcome measures? • What was the researchers definition of a language disorder?

29. Results • There was not sufficient evidence to support or to disprove SI as having any impact on language. • The measures used were not adequate • Each researcher had their own idea of what constituted a language disorder

30. Does sensory integration have any impact on children with language disorders? • I could not find any articles published after this review that actually used appropriate measures to see how SPDs or SI therapy impacted children with language disorders.

31. How should we as SLPs view OT-SI? • After reading these articles, what is your consensus? • My opinion-