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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 50  |  Issue : 3  |  Page : 86-91

A study to identify prevalence and effectiveness of sensory integration on toilet skill problems among sensory processing disorder


1 Occupational Therapist, Department of Occupational Therapy, KMCH, Coimbatore, Tamil Nadu, India
2 Professor, Department of Occupational Therapy, KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu, India
3 Associate Professor, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India

Date of Web Publication9-Nov-2018

Correspondence Address:
Dr. Nikhila Mary Koshy
Kovai Medical Center and Hospitals, Coimbatore - 641 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0445-7706.244548

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  Abstract 


Background: Toilet skill problems have been reported among children with sensory processing disorders (SPD) in recent literatures. Pollock concluded that children with dysfunctional elimination syndrome (53%) had SPD than was reported for the general population. Occupational therapists from India experience similar observations in their clinical practice. However, there is limited evidence within the Indian context. Objectives: The objectives of the study are to find the prevalence of problems in toilet skills in children with SPD and the effectiveness of sensory integration therapy (SIT) for the improvement of toilet skills in children with SPD. And also to compare the effectiveness of SIT with behavior modification for developing age-appropriate toileting habits in children with SPD. Study Design: A cross-sectional survey and quasi-experimental pre-posttest design were adopted for the study. Methods: The study consisted of 2 phases. In Phase 1, 96 children with SPD were screened to find out the prevalence of toilet skill problems among them. In Phase 2, the study effectiveness of SIT on toilet skill development was investigated on 22 children. The baseline and posttest measurement were done using sensory profile (SP), Canadian Occupational Performance Measure and modified diet schedule. The control group underwent behavior modification therapy, and experimental group, in addition, underwent SIT for 4 months. Both groups also underwent conventional occupational therapy. Results: This study found out among 96 SPD children, 68.75% had toilet skill problems. There was the difference in sections, factors, and quadrants in SP for children with and without toilet skill problems. In Phase 2, the result shows a significant difference (P < 0.05) for experimental group and had improvement in both sensory problems and toilet skill problems in followed by the SIT when compared to control group. Conclusion: The study concluded that there is association between toilet skill problems and SPD. SI has benefits in toilet skills problems in addition to other known benefits cited in the literature.

Keywords: Behavior Modification Therapy, Sensory Integration Therapy, Sensory Processing Disorder, Toilet Skill Problems


How to cite this article:
Koshy NM, Sugi S, Rajendran K. A study to identify prevalence and effectiveness of sensory integration on toilet skill problems among sensory processing disorder. Indian J Occup Ther 2018;50:86-91

How to cite this URL:
Koshy NM, Sugi S, Rajendran K. A study to identify prevalence and effectiveness of sensory integration on toilet skill problems among sensory processing disorder. Indian J Occup Ther [serial online] 2018 [cited 2020 Aug 11];50:86-91. Available from: http://www.ijotonweb.org/text.asp?2018/50/3/86/244548




  Introduction Top


Awareness of the need to void the bowel and bladder depends on the processing of associated sensory stimuli. Engaging in toileting tasks requires a person to tolerate and respond appropriately to a variety of sensory stimuli.[1]

Sensory profile (SP) is a neurological process that organizes sensation from one's body and the environment and makes it possible to use the body effectively within the environment.[2] A. Jean Ayres, PhD, likened sensory processing disorder (SPD) to a neurological “traffic jam” that prevents certain parts of the brain from receiving the information needed to interpret sensory information correctly.[2]

In a recent study, it was found that more children with dysfunction elimination syndrome (53%) had SPD than was reported for the general population.[1] Although few studies had reported the relationship between SPD, sensory over-responsivity, and toilet skill problems; these studies are not adequate report to generalize the relationship between SPD and toilet skill problems.


  Methods Top


A cross-sectional survey and quasi-experimental pre-posttest design were adopted for the study. The study was conducted in and around the Coimbatore and also outside the Coimbatore.

Phase I: Survey

Ninety-six children with the potential of SPD were invited for the study using convenience sampling sample based on criteria. The sample size was determined by the formula:

Confidence level = 95%.

Expected proportion (P) = 0.53 (calculated according to the results of the mother study).[3]

Total width of confidence interval (W) = 0.2.

Normal approximation to the binomial calculation:

α = (1-CL)/2 = 0.025.

Standard normal deviate for α = Za = 1aand.

Sample size = n = 4Za2P (1-P)/(W2) = 96.

Three to ten years of children with conditions such as autism, attention deficit hyperactive disorder, learning disability, Fragile X Syndrome, and children with emotional problems with the potential of SPD were included in Phase I. Children with physical dysfunctions, visual, and hearing impairments were excluded from the study.

Tools used were SP and Canadian occupational performance measure (COPM). SP is a 125-question caregiver-completed profile that reports the frequency of the person's response to various sensory experiences (Dunn, 1999).

COPM: For the present study, under self-care component, caregivers were asked to identify issues in toilet skills and rate importance, performance and satisfaction scores ranging from 1 to 10, hence identified problems in toileting skills of their children.

Procedure

After the attainment of approval from the Ethical Committee, the parents of children with the potential of SPD and having complaints of toileting problems were invited for the study. Permission from the institutions and written consent from parents were then received. Parents were asked to fill the SP and COPM was used to analyze problems in toileting skills. The collected data were then subjected to statistical analysis.

Phase II: Effectiveness of Sensory Integration Therapy on Toilet Skill Development in Children With Sensory Processing Disorders

Twenty-two children with SPD and problems in toilet skills (problem in defecation regularity in toilet) using convenience sampling were included for the study purpose.

Children of 3–10 years with poor toileting skills (bowel) and who had been screened out using SP (with a score of probable difference or definite difference, i.e., deviating more than or less than from typical performance) were included in Phase II.

Children who are under other laxative therapy, enemas, and suppositories, biofeedback and medication for constipation were excluded.

Independent variables were sensory integration therapy (SIT), and behavior therapy and dependent variables were sensory processing over responsiveness to tactile, olfactory, and auditory stimulus; under-responsive to tactile stimuli, toileting skills. Moreover, the extraneous variables were children regularly attending occupational therapy (OT), children receiving conventional medical management, positive reinforcements used naturally by adults.

Outcome measures used for Phase II were SP, COPM, and toileting scheduling chart-modified baseline chart. The baseline chart was developed for this study to identify the diet followed by the child (the amount of water intake and fiber intake), the regularity of defecation, spontaneity of defecation, the place and amount of defecation and also the information regarding readiness cue.

Procedure

Baseline measures were collected using SP, COPM, and toilet scheduling chart. The modified baseline schedule marked by the parents for 1 week was collected before the intervention. Both experimental group and control group were undergoing regular OT session and diet modification classes for the parents.

For experimental group, SI treatment was based on the particular SPD met by each child according to SP, and the goal was to make children skilled in toileting by integrating their sensory processing difficulties.

The intervention was continued for 4 months, twice in a week for 45 min by the researcher and the same therapy is continued by the parents in the rest of the days.

For control group, behavior modification therapy (BMT) was administrated and also taught to parents to be followed at home to develop appropriate toilet skills and to reduce bowel accidents for their children for 4 months.

After 4 months, postschedules were distributed to the parents of both control and experimental group and data were analyzed.


  Results Top


This study consisted of 96 children with SPD of whom 76 were boys and 20 were girls. The children age ranged from 3 to 10 year with a mean age of 5.10 ± standard deviation value 3.48.

[Graph 1] shows the percentage of children with and without toilet skill problems.



Among them, 68.75% had toilet skill problems and 31.25 did not have toilet skill problem. The percentages of section, factor, and quadrant domains were analyzed and are discussed after the results.

To measure the effectiveness of SIT for toilet skill problems, 22 children were taken from the survey. The participants were divided into two groups equally. SIT was used for children in the experimental group and BMT were used for the control group. Among the 11 children in the experimental group, one discontinued the therapy and ceased coming for the therapy. Hence for the posttest experimental n1= 10, and control n2= 11.

When analyzing the effectiveness of SIT on toilet skill problems, results show there is a significant difference in both experimental group and control group for performance and satisfaction components, (with confidence interval: 95%) P = 0.005 (<0.05) for experimental group and P = 0.004 (<0.05) for control group in for performance and satisfaction components, respectively. Hence, effect size was calculated. [Graph 2] shows that there is a medium effect size for COPM components of experimental group and small effect size for control group.



Odds ratio method was used to compare pretest and posttest scores of the control and experimental group. [Table 1] shows the value 0.20 is <1 it indicate the event is occur less likely in the control group, that mean the control group children defecate inside the toilet less than experimental in the posttest.
Table 1: Percentage of quadrant domain among sensory processing disorders children having toilet skill problem

Click here to view



  Discussion Top


Prevalence of Toilet Skill Problem in Sensory Processing Disorders

The findings of this study revealed the presence of 68.75% of SPD children with toilet skill problem [Graph 1]. The study by Pollock et al. supports this finding, where they found out children with dysfunction elimination syndrome (53%) has SPD than was reported for the general population.[1]

In the section variable, of 96 children with SPD having toilet skill problem, 60.6% have a deviation in auditory processing, whereas 39.9 showed typical performance in it. This result is in relation to the finding of Guthrie and Bryant that the auditory startle reflex is considered a measure of hyperarousal and also Bakker et al. found that children with irritable bowel syndrome and functional abdominal pain syndrome demonstrated significantly greater auditory startle reflexes than a sample of typical children.[3],[4]

It also shows a variation of 80.3% of total deviation in children for vestibular processing and only 20% of children had typical performance. The study by Bellefeuille and Polo supports this finding that in most homes height of the toilet is not appropriate for young children and not having the feet in contact with the ground can cause insecurity and fear in children with vestibular hypersensitivity.[5]

In touch processing, there is not much difference in between the percentage of total deviation (48.5%) and typical performance (51.5%). This is in contrast to the study of Bellefeuille and Polo's that Sensations such as those relating to anal distension, to be without clothes or sit on a toilet or a hard potty and cold can make defensive tactical child within uncomfortable. The common position adopted defecation stretches the skin of the anal area, which also it can cause discomfort.[5]

In multisensory processing, there were total deviations of 68.2% and typical performance of 31.8%.

Sensory over-responsivity is well documented in children with feeding problems.[6] The classic study by Bellman documented a high prevalence of food refusal among children with fecal incontinence.[7] About 58.5% shows a deviant behavior in oral sensory processing, whereas 37.9% shows typical performance.

There were 60.6% of deviant performance and 39.4% of typical performance in behavioral outcomes of sensory processing. The prevalence of behavioral problems in children with constipation and fecal incontinence has been reported in several studies. There are many reports that children with constipation and fecal incontinence have more behavioral problems than typically developing children.[7],[8]

Engaging in toileting tasks requires a person to tolerate and respond appropriately to a variety of sensory stimuli.[6] In contrast, this study shows 54.5% of the children had typical performance while 45.5% were deviant performance for poor registration in factor variable.

44.94% of children showed deviation in sensory sensitivity factor, whereas 54.5% shows typical performance. Bellefeuille found out that a group of children (n = 16) with retentive fecal incontinence presented with significantly more behaviors related to sensory over-responsivity than a group of typically developing children (n = 27).[6] An overall deviant behavior for sedentary was 59.1%, and typical performance was 33.3 for children with SPD and toilet skill problems.

Awareness of the need to void the bowel and bladder depends on the processing of associated sensory stimuli.[1] This supports the finding that registration in quadrant variable had a percentage of 56.1% total deviation and 43.9% of typical performance among children with SPD and toilet skill problems among [Table 1].

About 77.2% of children had a deviant performance in Sensitivity and 62.1% had deviant performance in avoiding. This result relates to the study by Mazurek et al., showed Children with any type of gastrointestinal problem, including chronic constipation, had higher levels of sensory over-responsivity than children without such problems. The researchers found that sensory over-responsivity significantly contributed to the prediction of constipation, abdominal pain, nausea, and bloating.[9]

Most of the parents failed to return diet charts in the survey as it is a 1-week schedule. When excluding the children who included in the Phase 2 only 16 of the parents were able to return. Among them, most of them did not have a toilet skill problem. Constipation for more than 2 days was seen in children without fiber intake and decreased water intake. A review of the efficacy of nonpharmacological therapies for constipation concludes that current evidence related to increased fiber intake is weak.[10]

Effectiveness of Sensory Integration Therapy on Toilet Skill Development

Among the 11 children in the experimental group, one discontinued the therapy and ceased coming for the therapy. Hence for the posttest experimental n1= 10, and control n2= 11.

The effect of SIT on toilet skills was measured using COPM as toileting is one of the occupational performances.

There are randomized control trials (2006) and other studies[11],[12] which shows behavior modification techniques improves toileting behavior of children with autism and other special needs. This is consistent with the results of this study, 88.54% of children included in this study with SPD had a diagnosis of autism. There shows a significant difference in pre- and post-tests of both control and experimental group. Although it shows significant difference in the pre- and post-tests in both experimental and control group, which indicates changes in toilet skills, experimental group have improved more as the effect size of experimental group is more when compared with the control group. This correlates with the case study conducted by Bellefeuille et al. (2013) which shows SIT has an effect in toilet skill development in a child with fecal incontinence.[13]

The odds ratio between pretest of control and experimental group based on defecation inside the toilet and outside the toilet were analyzed The odds ratio between pretest of control and experimental group based on defecation inside the toilet and outside the toilet were analyzed. It shows the odds ratio value 1.05, which is >1 which indicates, that the control group children defecate inside the toilet more than the experimental group.

[Table 2] shows odds ratio between posttest of the control and experimental group based on defecating inside and outside the toilet. This table shows the odds ratio value 0.20 is <1, indicating the event occurs less likely in control group. This means that the control group children defecate inside the toilet less than the experimental group in the posttest. The ratio between the control and experimental group for defecation inside toilet is 1:0.83 and 1:1.72. Comparing the experimental group with control group (control group: experimental group) is clear that of defection inside toilet was 0.83 times before therapy, has increased to1.72 times after the therapy. This improvement in achievement of toilet skill in experimental group can be directly attributed to SIT.
Table 2: Odds ratio between posttest of the control and the experimental group based on the defecation inside the toilet and outside the toilet

Click here to view


This finding is strongly supported by the result of case study done by Bellefeuille reports notable improvements in acquiring age-appropriate toileting habits were documented and measured using daily defecation logs.[13]

Toilet and Diet Chart to Measure the Intake and Output Before and After the Intervention

When scrutinizing the diet they followed, most of the children had a regular diet, which repeats very often and amount of nonfibrous food was observed more often. Amount of water intake was minimal for the children; say for an average of 3–4 glasses of water/day. These children had an irregular time, and frequency of defecation which was mostly spontaneous and elimination is with urine. If the amount of defecation was very small a day, there was a high change of elimination at the second time. Milk was found one of the reasons for multiple defecation a day for 50% of children. Mostly elimination is followed by a warm drink or food. There was the absence of elimination when there was decreased amount of fluid intake or less fiber intake for most children and consumption of baked food (cake, biscuits, and bread), whereas some of them had none of these history for no elimination. Most of the children soiled in their pants and few soiled outside when they were undressed. They showed minimal readiness cue of facial expression, and few did not have readiness cue.

Diet/toilet charts for posttest were able to collect from parents of both groups except the child in experimental group who discontinued the therapy. Most of the parents found fiber-rich food was useful for their child's easy defecation. Almost all the parents followed a fiber-rich food at least 4 times in a week after the diet awareness class.

For the experimental group children, the changes were noted on showing readiness cue from no readiness cue to pulling the parent to toilet/potty or removing dress most of the times. Those who had speech started verbalizing. Children were able to defecate most of the days but not in a regular time always.

For the control group, most of them achieved potty/toilet sitting tolerance even though they all were not toilet trained fully except a child.

Effectiveness of Sensory Integration Therapy

On comparison between the posttest scores in section domains in which children showed a significant difference in touch processing, oral sensory processing, modulation of sensory input affecting emotional responses, emotional/social responses, and items indicating thresholds. There were changes in most of the section domains. This finding is supported by Lane et al. 2010. A combination of increased sensory processing difficulties, especially in the areas of taste and smell sensitivity and movement-related sensory behavior, was associated with greater challenge in self-care skills, adaptive behaviors, and emotional regulations.[14]

Sensory modulation is the intake of sensation via typical sensory processing mechanisms such that the degree, intensity, and quality of response are graded to match environmental demand and so that a range of optimal performance/adaptation is maintained.[15] SIT postulates that on controlled sensory input the children show adaptive responses. In the current study, toilet skill is one of the adaptive responses which improved as the children had to accept different textures, food, and need to follow directions when SIT was undergoing.

There is a significant difference in the experimental group for sensitivity and avoiding. This implies effectiveness in SIT for avoiding and sensitivity components. This is correlating to the case report by Dunn, 2007 which shows intervention in the child's daily routines illustrate the impact on sensory processing for children with registration, seeking, sensitivity, and avoiding problems.[16] All the components in posttest have improved in experimental group when compared with pretest of the same group; whereas there is no change or decrease in improvement for the control group.

In summary, for the experimental group, sensory problems have decreased, and toilet skills were improved due to regular and consistent SIT for 4 months. For the control group, although toilet skill problems had improved after the intervention by BMT, their sensory issues have not come done. This can be due to irregular and inconsistent SIT without prior proper sensory processing evaluation.

Limitations

  • As the diet chart was for 7 days all the parents were unable to return the diet chat; only few were returned. Hence, the information regarding diet was not generalized
  • The subjects for the intervention phase were assigned using purposive sampling, and the size was too small to generalize the results
  • Involvement of mother is an important factor in maintaining diet and toilet chart. It was difficult to sort complete co-operation from mothers.


Recommendation

  • Further investigation should include large sample size
  • Correlation studies between toilet skill problems and SPD
  • Comparison between three interventions (SIT, BMT, SIT + BMT) can be added to an extensive knowledge into this area of research.



  Conclusion Top


The study concluded that there is association between toilet skill problems and SPD. SI has benefits in toilet skills problems in addition to other known benefits cited in the literature.

Acknowledgments

I would like to express sincere gratitude to my parents, teachers, and friends for all their support and guidance throughout.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pollock MR, Metz AE, Barabash T. Association between dysfunctional elimination syndrome and sensory processing disorder. Am J Occup Ther 2014;68:472-477.  Back to cited text no. 1
    
2.
Bundy AC, Lane SJ, Murray EA. Sensory Integration: Theory and Practice. 2nd ed. Philadelphia: F.A. Davis Company; 2002.  Back to cited text no. 2
    
3.
Guthrie RM, Bryant RA. Auditory startle response in firefighters before and after trauma exposure. Am J Psychiatry 2005;162:283-290.  Back to cited text no. 3
    
4.
Bakker MJ, Boer F, Benninga MA, Koelman JH, Tijssen MA. Increased auditory startle reflex in children with functional abdominal pain. J Pediatr 2010;156:285-910.  Back to cited text no. 4
    
5.
Bellefeuille IB, Polo RE. Combined treatment of volontary stool retention with medication and occupational therapy. Bol Soc Pediatr Astur (Cantabria, Castilla y León) 2011;51:169-176.  Back to cited text no. 5
    
6.
Bellefeuille IB. Examining the sensory characteristics of preschoolchildren with retentive fecal incontinence. Am J Occup Ther 2015;69:6911505022p1.  Back to cited text no. 6
    
7.
Bellman M. Studies on encopresis. Acta Paediatr Scand 1966;170:120.  Back to cited text no. 7
    
8.
van Dijk M, Benninga MA, Grootenhuis MA, Last BF. Prevalence and associated clinical characteristics of behavior problems in constipated children. Pediatrics 2010;125:e309-317.  Back to cited text no. 8
    
9.
Mazurek MO, Vasa RA, Kalb LG, Kanne SM, Rosenberg D, Keefer A, et al. Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. J Abnorm Child Psychol 2013;41:165-176.  Back to cited text no. 9
    
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Tabbers MM, Boluyt N, Berger MY, Benninga MA. Nonpharmacologic treatments for childhood constipation: Systematic review. Pediatrics 2011;128:753-761.  Back to cited text no. 10
    
11.
Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C, et al. The effectiveness of different methods of toilet training for bowel and bladder control. Evid Rep Technol Assess (Full Rep) 2006;147:1-57.  Back to cited text no. 11
    
12.
Kroeger K, Sorensen R. A parent training model for toilet training children with autism. J Intellect Disabil Res 2010;54:556-567.  Back to cited text no. 12
    
13.
Bellefeuille IB, Schaaf RC, Polo ER. Occupational therapy based on ayres sensory integration in the treatment of retentive fecal incontinence in a 3-year-old boy. Am J Occup Ther 2013;67:601-606.  Back to cited text no. 13
    
14.
Lane AE, Young RL, Baker AE, Angley MT. Sensory processing subtypes in autism: Association with adaptive behavior. J Autism Dev Disord 2010;40:112-122.  Back to cited text no. 14
    
15.
Wilbarger J, Gunnar M, Schneider M, Pollak S. Sensory processing in internationally adopted, post-institutionalized children. J Child Psychol Psychiatry 2010;51:1105-1114.  Back to cited text no. 15
    
16.
Dunn W. Supporting children to participate successfully in everyday life by using sensory processing knowledge. Infants Young Child 2007;20:84-101.  Back to cited text no. 16
    



 
 
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