Abstract
Evidence Connection articles provide case examples of how practice decisions may be informed by findings of systematic reviews sponsored by the American Occupational Therapy Association (AOTA) Evidence-Based Practice (EBP) Project. This Evidence Connection article describes a case report of a child with a diagnosis of autism spectrum disorder who has difficulties in function and participation related to challenges in sensory integration. This article is the first in a two-part series, and it focuses on occupational therapy provided to the child by a clinic-based therapist in collaboration with the child’s school-based occupational therapist. Part 2 in this series will describe the same child’s intervention by the school-based therapist. Intervention decisions are informed by findings of systematic reviews of intervention effectiveness that were part of an AOTA EBP Project addressing occupational therapy interventions for children and youth with challenges in sensory integration and sensory processing.
The purpose of this Evidence Connection article is to demonstrate how the findings of systematic reviews are useful in clinical decision making when providing occupational therapy to children with participation challenges related to sensory integration and processing. Recently, the Evidence-Based Practice Project of the American Occupational Therapy Association sponsored a series of systematic reviews that critically examined the findings and quality of research evidence addressing effectiveness of diverse occupational therapy interventions for children and youth with sensory integration and processing difficulties. The review examined several types of interventions within the scope of occupational therapy practice, including Ayres Sensory Integration® (ASI) intervention (Schaaf et al., 2018), specific sensory techniques and sensory environmental modifications (Bodison & Parham, 2018), parent and teacher education and coaching (Miller-Kuhaneck & Watling, 2018), and cognitive and occupation-based interventions (Pfeiffer et al., 2018). The results of these systematic reviews were collectively summarized in Watling et al.’s (2018) Occupational Therapy Practice Guidelines for Children and Youth With Challenges in Sensory Integration and Sensory Processing. In this article, we present a case study to demonstrate how these systematic reviews are useful in practice.
Case Background
Alejandro is a 6½-yr-old boy with a diagnosis of autism spectrum disorder (ASD). He was born at full term with no complications and was developmentally typical in early infancy. Since his birth, Alejandro has lived with both of his parents and his typically developing sister, who is 1 yr older. At about age 18 mo, his parents began to notice unusual behavior patterns, such as repetitive, stereotyped movement patterns, limited eye contact, and failure to respond when his name was called. He received the diagnosis of ASD at age 2 yr, 4 mo, and began home-based early intervention shortly thereafter.
When Alejandro was 3½ yr old, his parents enrolled him in the preschool that his sister had attended, but he was expelled after 6 mo because of disruptive behaviors such as difficulty following daily routines and inappropriate interactions with other children. By this time, Alejandro was 4, and his parents placed him in a home day care setting with one other child. He continued to struggle with social interactions in this setting. Soon after his 5th birthday, Alejandro was enrolled in his local public school kindergarten, where he was successful academically but continued to have difficulty with peer interactions and compliance with classroom routines.
Alejandro is now in the first grade at his local elementary school, where he continues to experience challenges with self-regulation of behavior; social engagement with peers; and difficulty following classroom routines, particularly when he is required to remain seated for desk work. As part of the school district’s Multi-Tiered Systems of Support, the school occupational therapist, Malcolm, was asked to provide assistance to the general education teacher to help Alejandro succeed in school.
Occupational Therapy Evaluation
Alejandro’s parents heard about occupational therapy from friends who were also parents of a child with ASD. They spent a few weeks searching for and visiting local occupational therapy settings to gather information about the availability of occupational therapy services in their town. In one of the clinic-based settings they visited, they met Adri, an occupational therapist whose practice setting focused on ASI intervention. Adri had extensive knowledge and skills in sensory integration (SI) assessment as well as mentored experience providing ASI and other occupational therapy interventions to children with sensorimotor difficulties.
Adri was familiar with the systematic reviews on effectiveness of interventions for children with SI and sensory processing (SP) challenges after having read the January–February 2018 issue of the American Journal of Occupational Therapy. She explained to Alejandro’s parents that strong evidence (demonstrated by at least two randomized clinical trials [RCTs] of high quality) currently indicates effectiveness of two interventions for improving the participation of young children with ASD: ASI intervention (individual occupational therapy that targets the sensorimotor difficulties affecting the child’s participation) and Qigong massage (traditional Chinese medicine–based massage provided by occupational therapists to improve the child’s daily functioning; Bodison & Parham, 2018; Schaaf et al., 2018). Each intervention requires that the occupational therapist receive postprofessional training to deliver the intervention appropriately. Adri further explained that she had received formal training in ASI intervention as well as mentored experience providing ASI and other occupational therapy interventions for children with sensorimotor difficulties.
Alejandro’s parents expressed their wish that Alejandro begin receiving occupational therapy with ASI intervention, and Adri initiated clinic-based occupational therapy services for Alejandro, with written authorization from his parents to communicate with the school occupational therapist (Malcolm) regarding Alejandro’s current performance in school as well as any additional information that might be relevant to provision of occupational therapy. This authorization was essential for coordination of clinic- and school-based services to produce optimal outcomes.
Initial intake information included reasons for referral and a developmental history. Clinical evaluation began with a parent interview to construct an occupational profile and identify the domains of occupation that were challenging for Alejandro; a home visit took place to gain insight into the contexts of the behavioral difficulties that Alejandro’s parents described.
Because the presenting problems suggested that SI difficulties might be affecting Alejandro’s motor performance and participation at home, in school, and in the community, Adri chose to follow the evidence-based, data-driven, decision-making occupational therapy approach to implementing ASI (Schaaf & Mailloux, 2015) and began by creating Alejandro’s occupational profile. Next, Adri administered several norm-referenced, standardized instruments to gain a deeper understanding of Alejandro’s sensory and motor functions and how they might be affecting his participation.
The results of the evaluation would guide creation of hypotheses, goals, and an appropriate intervention plan that targets Alejandro’s needs. Throughout the evaluation and intervention processes, Adri and Malcolm regularly communicated and collaborated to optimize Alejandro’s participation at home, in school, and in the community.
Occupational Profile
Parent Interview
First, Adri interviewed Alejandro’s parents to create his occupational profile. The interview was followed by direct observation of Alejandro during daily routines at home. During the interview, the parents reported that, at home, Alejandro enjoys playing computer games, watching his favorite shows on television, and listening to his favorite music. He likes to play simple games with his sister for short periods of time. When his parents try to engage him in tabletop activities to do homework, he routinely reacts by screaming and crying for 5 to 15 min, but then he can be calmed with hugs and redirection to one of his preferred activities (playing with his tablet device, watching cartoons, or swinging outside in a swing with side and back supports).
Mealtimes are especially challenging, because Alejandro eats only three foods: cereal, crackers, or pizza. He refuses or gags on other foods, and he often gags at the smell of nonpreferred foods when they are cooking.
Community outings present safety challenges because Alejandro often runs toward the street without heeding traffic. At playgrounds, he often unsafely climbs and leaps off playground equipment. Alejandro’s parents feel that other children avoid him because of his intrusive behaviors, which include hugging too tightly or entering another child’s personal space without realizing that the other child is uncomfortable.
Home Observations
Observations were consistent with parent report. During a 1-hr home visit, Alejandro rejected tabletop activities by running away, screaming, and crying for about 10 min. He eventually was calmed by hugs from his mother followed by playing music and games on his tablet. During lunch, he ate a slice of pizza, strongly rejecting any other food offered. Preferred activities included watching TV, playing music and games on his tablet, and lining up toy cars and trucks from the toy bin. He resisted any transitions or bids to engage in social play with his parents or sibling.
Evaluation of Occupational Performance Skills and Patterns
Sensory Processing Measure Home Form
Alejandro’s parents completed the Sensory Processing Measure (SPM) Home Form (Parham & Ecker, 2007). The SPM is a norm-referenced questionnaire completed by parents (Home Form) or teachers (Main Classroom Form) to provide key information about sensorimotor behaviors of school-age children. It provides T scores for sensory systems, praxis (ideation and motor planning), and social participation. T scores of 50–59 indicate typical behavioral responses at home or in school, and higher scores indicate increasingly more challenging behaviors.
T scores indicated that in the home environment, Alejandro demonstrates relative strengths in visual and auditory processing (T = 60 on both scales). Greater difficulties were apparent in all other sensory systems (T ≥ 63). Social participation and praxis scores indicated that these areas were most severely compromised (T ≥ 70). Item analysis of ratings on the SPM Home Form indicated that Alejandro demonstrates hyporeactivity to tactile sensations (which may contribute to safety concerns on the playground, incoordination, and social difficulties), hyperreactivity to smell and taste (which may contribute to limited food acceptance), and poor vestibular and proprioceptive processing (which may contribute to difficulties with sustained sitting, incoordination, and safety concerns).
Sensory Integration and Praxis Tests
To conduct a more in-depth evaluation of Alejandro’s visual perception, tactile perception, proprioception, vestibular processing, and praxis, Adri administered the Sensory Integration and Praxis Tests (SIPT; Ayres, 1989) to Alejandro in two 1-hr sessions on consecutive days. The results of the SIPT showed that Alejandro has above-average abilities (z score > +1.0) in motor-free visual perception and three-dimensional visual construction. Alejandro is similar to most peers in his ability to trace over a line with minor errors; however, his ability to follow verbal instructions to assume novel body positions is borderline low. He has significant difficulty with tasks that require balance, bilateral coordination, tactile perception, complex visual–motor ability, and motor planning to imitate novel body positions and movement sequences (z score range = −1.36 to −3.00).
Bruininks–Oseretsky Test of Motor Proficiency, Second Edition
To obtain additional data about Alejandro’s motor skills, Adri administered the Bruininks–Oseretsky Test of Motor Proficiency, Second Edition (BOT–2; Bruininks & Bruininks, 2005) during two 45-min sessions on 2 consecutive days. The BOT–2 yields T scores whereby a score of 50 indicates average for age performance. Alejandro’s overall motor proficiency was well below average (T = 33). Areas of difficulty included bilateral coordination, motor planning, postural control, fine motor control, and balance.
Relationship of Assessment Findings to Occupational Performance
Integration of findings from the parent interview, home observations, and clinic-based occupational therapy assessments provided key information on the factors that likely affect Alejandro’s occupational performance. We summarize the assessment findings below to describe the hypothesized impacts of Alejandro’s sensorimotor strengths and challenges on his participation. For each finding, an aspect of his occupational participation is linked with specific sensorimotor strengths or challenges that were detected in the evaluation process.
Alejandro’s academic strengths in reading are supported by his strong visual processing abilities and a relative strength in auditory processing.
Alejandro has difficulty sustaining his engagement in tabletop activities in part because he has difficulty maintaining a stable sitting position. This difficulty is due to inefficient processing of vestibular and proprioceptive sensations that are necessary for postural control.
Alejandro has challenges participating in gross motor activities on the playground because his vestibular and proprioceptive difficulties affect balance and other aspects of motor coordination.
Alejandro does not participate appropriately and safely in gross motor play, fine motor activities, or social interactions with peers because his praxis (ability to plan and organize body movements) is not well developed. This is likely related to poor tactile perception and proprioception affecting his body awareness.
Alejandro’s management of writing tools and other materials needed for participation in tabletop activities at home and in school is also a major challenge. This problem occurs because his difficulties with praxis, bilateral motor coordination, and postural control converge to affect fine motor control.
Playground safety concerns and poor peer interactions are affected by his hyporeactivity to tactile sensations (including pain); for example, Alejandro does not seem to notice sensations that most peers would consider painful or distressing.
Alejandro’s limited mealtime participation is influenced by his hyperreactivity to smell and taste, which cause him to react strongly and negatively to smells and tastes of novel foods.
Synthesis of Assessment Findings to Inform Evidence-Based Intervention Planning
Sensorimotor assessment data indicated that Alejandro’s occupational performance is affected by two classic patterns of SI difficulty: somatosensory-based praxis difficulties (also called somatodyspraxia) and vestibular–bilateral integration challenges. These patterns of SI difficulty have been identified and replicated across several decades of research (e.g., Ayres, 1971; Mailloux et al., 2011; Mulligan, 1998). The presence of these known SI patterns and their relevance to the concerns of Alejandro’s teacher and parents, together with Alejandro’s ASD diagnosis and the absence of an intellectual disability, make him a strong candidate for ASI intervention because independent, well-designed studies have shown that children with these characteristics usually benefit from this intervention (Pfeiffer et al., 2011; Schaaf et al., 2014, 2018).
Assessment findings from parent interviews also indicated that Alejandro’s participation is affected by difficulties with self-regulation, such as throwing tantrums when prompted to do tabletop activities at home. ASI intervention is designed to support self-regulation to improve participation, for example, by expanding the recipient’s ability to sustain attention on a tabletop activity while seated.
Clinic-Based Occupational Therapy Intervention Plan and Goals
Adri met with Alejandro’s parents to share her evaluation report. Insights from evaluation findings, together with awareness of relevant intervention effectiveness research and the wishes of Alejandro’s parents, guided Adri in selecting interventions for Alejandro. In discussing the evaluation findings, Adri and Alejandro’s parents agreed that Alejandro’s sensory strengths in auditory and visual processing, as well as his verbal strengths, should be used more intentionally and more often to incorporate compensatory and motivational strategies into daily life challenges. For example, written instructions with pictures could be used to break down the steps to complex tasks or chores that Alejandro needed to do at home to. Alejandro’s strengths and talents will also be important for his parents to nurture over the coming years to help him develop life skills for healthy and satisfying work and leisure as he grows older.
Adri’s evaluation report concluded with a recommendation for occupational therapy using individual ASI intervention. Adri specified a series of 30 individual ASI sessions over the course of 10 wk, the dosage shown to be effective in previous research (Schaaf et al., 2014). Adri additionally shared with Alejandro’s parents the research evidence on effectiveness of ASI intervention for children with ASD (e.g., Pfeiffer et al., 2011; Schaaf et al., 2014, 2018), and the parents agreed to her recommendations. Adri sent a copy of her evaluation report to Malcolm, along with a summary of research evidence supporting ASI intervention for high-functioning children with ASD, such as Alejandro. Malcolm then shared Adri’s occupational therapy evaluation report with Alejandro’s teacher and educational team.
Malcolm and Adri’s collaboration with each other, and their respective collaboration with Alejandro’s parents, led to establishment of the following five goals for the clinic-based occupational therapy services in which Alejandro can improve:
Participation in fine motor play activities and in homework activities at home. Alejandro will remain seated for 10 min during tabletop activities, with verbal prompts and postural supports as needed.
Participation in play. Alejandro will be able to swing himself without bumping into other children or falling off the swing, in a regular playground swing without side or back supports, for at least 5 min.
Participation in homework activities. Alejandro will write his first and last name without tearing the paper and with improved legibility as measured by ability to appropriately rest letters on the bottom line, accurately form letters, and appropriately space letters.
Participation at mealtimes. Alejandro will add 3 new foods each week to his diet.
Safety awareness during community outings. Alejandro will appropriately stop before running into the street in response to a parent’s verbal prompt (“Is it safe to cross the street now?”) in 3 of 5 opportunities.
To document whether Alejandro would achieve his goals, his parents were asked to keep an informal diary of Alejandro’s daily behavior in relation to each of the goals. For example, in the diary they recorded notes about his behavior while swinging, the amount of time that he remained seated during fine motor and homework activities (and the number of prompts needed), and the number of new foods tried per week. Adri briefly discussed these diary notes with Alejandro’s parents on a weekly basis.
Soon after ASI intervention was initiated, Alejandro’s parents expressed to Adri their interest in having Alejandro wear a weighted vest at home because they had heard from friends that some children with ASD benefit from this intervention. Adri informed the parents that research support for weighted vests is insufficient for children with ASD because of limited research designs and existing results that do not indicate positive outcomes, as noted in the American Occupational Therapy Association Practice Guidelines (Watling et al., 2018). However, because the existing research did not report any adverse effects for use of the weighted vest, and because it is an inexpensive technique, Adri agreed to work with Alejandro’s parents to implement a trial period of weighted vest usage for him at home, which would allow Alejandro’s parents to document his response and evaluate whether the weighted vest was helpful for him.
Occupational Therapy Intervention Implementation and Outcomes
Ayres Sensory Integration Intervention
Clinic-based occupational therapy focused on provision of ASI intervention to address the sensorimotor challenges that affected Alejandro’s occupational participation at home, in school, and in the community. Alejandro completed all 30 scheduled individual ASI sessions. At the end of each session, Alejandro’s parents were educated about ASI intervention and provided with suggestions for activities and strategies to implement at home. ASI intervention adhered to the structural elements of the ASI Fidelity Measure (Parham et al., 2011) to ensure safety and adequacy of the therapeutic environment, equipment, and therapist qualifications (May-Benson et al., 2014) as well as the process elements of the ASI Fidelity Measure. Adherence to the structural and process elements of the ASI Fidelity Measure is consistent with RCTs that found this intervention effective for high-functioning children with ASD (Pfeiffer et al., 2011; Schaaf et al., 2014).
During ASI sessions, Alejandro engaged in active, individually tailored sensorimotor activities that presented just-right challenges contextualized in play (Schaaf & Mailloux, 2015). See Table 1 for a list of some sample treatment activities that were incorporated into the individual ASI sessions. Note that although outcome measures for ASI intervention focus on participation in specific daily life occupations, the process of this intervention aims to improve the identified sensory and motor difficulties hypothesized to be affecting the child’s participation. The intervention process presents sensorimotor challenges that are tailored to the child’s specific needs but experienced by the child as play. Activities such as those in Table 1 might be suggested or structured by the therapist but, in general, the therapist encourages the child to actively choose, modify, or create activities, with the therapist’s ongoing support for maximal success. The therapist inserts challenges into the activity that target the child’s SI and praxis difficulties. Each activity should involve challenges that require effort from the child to be attainable (“just-right challenges”), moving the child toward success.
Sample Activities in Ayres Sensory Integration Intervention Sessions
After each ASI session, Alejandro’s parents were debriefed by Adri in an informal conversation, with Alejandro present, to share what he had accomplished. Parents were included in the ASI sessions as frequently as possible so that they might gain insights into strategies for facilitating Alejandro’s participation at home and in the community. In addition, weekly phone appointments with Alejandro’s parents allowed Adri to monitor how Alejandro was functioning at home, which helped her to further educate the parents on how Alejandro’s SI challenges affected his functioning at home and in school, to discuss progress, and to collaboratively problem solve emerging issues. Adri also suggested ways to informally support Alejandro’s developmental progress. For example, to support his emerging praxis abilities, she suggested giving him simple chores or duties at home and school that would provide strong somatosensory input (e.g., carrying out the trash) while expanding on his new abilities and providing him with an important role in the household or classroom.
After the final intervention session, Adri collaborated with Alejandro’s parents and teacher to determine whether his goals had been achieved using the parents’ daily diary. The data collected by the parents and teaching staff indicated that Alejandro met 4 of his 5 goals. Although he did not achieve Goal 4 (adding 3 new foods each week to his diet), he made measureable progress by adding 1 new food each week. Adri discussed Alejandro’s progress with his parents and suggested that they embed and adapt sensory experiences and activities into his everyday life to maintain and expand Alejandro’s occupational engagement. Adri provided Alejandro’s parents with community support resources and educational aids to reinforce Alejandro’s gains and to support the entire family going forward.
Weighted Vest Intervention
During the trial of parent-implemented weighted vest at home, Alejandro wore a vest weighted at 10% of his body weight for 45 min, 5 days/wk, while seated at a table doing homework, usually in the late afternoon or evening. On the other 2 days of the week, Alejandro did not wear the vest while doing homework to provide a comparison condition. At first, his mother monitored Alejandro’s performance with and without the vest by using a stopwatch to record the number of minutes and seconds he continuously engaged in homework and by counting the number of times he left the table during each 45-min homework session.
After the first 3 days of the trial, it was evident that this method was too cumbersome to implement during a busy family time, so with Adri’s guidance, Alejandro’s mother decided to simply record how many times Alejandro left the table each day, along with a brief note on her impressions of the duration and quality of his engagement. At the end of the 2-wk trial, Alejandro’s parents reviewed and discussed with Adri his responses to the weighted vest. Although Alejandro readily accepted wearing the vest, his mother’s recordings and notes indicated fluctuating engagement across the trial period, regardless of whether he wore the vest. Alejandro’s parents felt that his engagement in homework was not affected by use of the weighted vest, and they decided to discontinue its use.
Conclusion
Occupational therapy using ASI in a clinic-based setting was chosen for Alejandro because his assessment data showed that he had significant challenges in SI and SP. Following the evidence-based approach described in the literature, Adri implemented ASI and worked with Alejandro’s parents to educate them about how his sensorimotor challenges affected his successful participation in daily activities and learning tasks. Adri also suggested activities for the home that supported Alejandro’s gains through the clinic-based intervention. After 30 sessions of occupational therapy using ASI, 4 of the 5 clinic-based occupational therapy intervention goals were achieved or exceeded:
Alejandro routinely remained seated for at least 15 min during tabletop activities with minimal or no verbal prompts (exceeded goal).
Alejandro was able to swing himself in a regular playground swing without side or back supports for 5 min or longer, without bumping other children or falling off the swing (goal met).
Alejandro consistently wrote his first and last name with improved legibility, as measured by comparison of pre- and postintervention writing samples, administered and scored using standardized test procedures by an occupational therapist not involved in the case. In addition, he consistently used appropriate pressure on the pencil, with no tearing of paper. Alejandro’s pride in his written work increased, and he participated in homework activities more cooperatively (goal met).
Alejandro added 1 new food per week to his diet but did not achieve the goal of adding 3 new foods each week. Adri felt that it might be useful to add a supplemental intervention to address Alejandro’s eating challenges, and she informed his parents about the different types of eating interventions available. His parents were interested in trying an intervention that they could implement during regular mealtimes at home, so Adri searched for a therapist in a nearby city who had expertise in this area. Although few eating interventions are designed to be implemented by parents in the family mealtime environment, Adri located a colleague experienced in such an intervention and referred the parents to this practitioner. After being informed about the intervention requirements for parent involvement and the research evidence available for this intervention, they opted to try this intervention with careful monitoring to ensure its effectiveness for Alejandro and appropriateness for the family.
Alejandro stopped himself before running into the street in response to a verbal prompt (“Is it safe to cross the street now?”) 100% of the time (exceeded goal), and he stopped himself without any adult prompts on at least five occasions.
Implications for Occupational Therapy Practice
This case demonstrates the use of evidence-based strategies within occupational therapy for a child with ASD whose occupational therapy evaluation identified specific challenges in SI and SP that were hypothesized to affect his occupational performance and participation. When following the example of this case, occupational therapists must be mindful of the key evidence-based evaluation and intervention procedures that were implemented:
Conduct a comprehensive evaluation of SI and SP.
Use evaluation findings to hypothesize why participation challenges occur.
Create goals that relate to the presenting problems and are meaningful to the family.
Provide ASI occupational therapy with strong fidelity to structure and process.
Measure outcomes carefully to determine the extent to which goals were attained.
Footnotes
Acknowledgment
We thank Deborah Lieberman and Elizabeth Hunter for their valuable guidance and suggestions.