|Year : 2019 | Volume
| Issue : 1 | Page : 8-13
Occupational therapists' perception of efficacy of sensory integration in Tamil Nadu, India: A Statewide Survey
Department of External and Regulatory Affairs, NBCOT Inc., Gaithersburg, MD, USA
|Date of Submission||28-Sep-2018|
|Date of Acceptance||22-Feb-2019|
|Date of Web Publication||19-Apr-2019|
Dr. Karthik Mani
335, W Side Dr, Gaithersburg, MD 20878
Source of Support: None, Conflict of Interest: None
Background: Perception regarding efficacy of any intervention may influence clinical reasoning and treatment choice. Despite the fact that the current evidence on the effectiveness of sensory integration (SI) interventions is equivocal, practitioners use them widely in practice. This could be due to the perceived effectiveness. Objectives: This study aimed to gain an understanding of Tamil Nadu (TN) occupational therapy (TNOT) practitioners' perception of the efficacy of SI interventions in pediatric practice. Study Design: The survey research design was used to conduct this study. A ten-item electronic survey was developed based on the research question. Methods: The survey was e-mailed to 295 occupational therapists in TN identified through convenience sampling. The survey link was also shared on three WhatsApp Messenger groups (TNAIOTA Official Group, OTist Group, and OT Friends Group) with a large number of TN occupational therapists (snowball sampling). Data were collected between March 30, 2018, and April 30, 2018. Results: Forty-nine occupational therapists responded to the survey. Many respondents believed that SI interventions are effective, citing positive therapeutic outcomes and the child-centric nature of the interventions as the reasons behind their beliefs. Respondents also believed that for SI interventions to be effective, therapists' knowledge and skill on SI are critical. Gender, years of experience, additional training on SI, and level of education did not have any influence on practitioners' perceptions regarding the efficacy of SI. Conclusion: Pediatric OT practitioners in TN have a favorable attitude toward SI interventions and use them in practice. Although practitioners report perceived positive therapeutic outcomes, they need validation through clinical research. TNOT practitioners must collaborate with researchers to add to the scientific evidence base of SI.
Keywords: India, Occupational Therapy, Social Media, Surveys and Questionnaires
|How to cite this article:|
Mani K. Occupational therapists' perception of efficacy of sensory integration in Tamil Nadu, India: A Statewide Survey. Indian J Occup Ther 2019;51:8-13
|How to cite this URL:|
Mani K. Occupational therapists' perception of efficacy of sensory integration in Tamil Nadu, India: A Statewide Survey. Indian J Occup Ther [serial online] 2019 [cited 2019 May 21];51:8-13. Available from: http://www.ijotonweb.org/text.asp?2019/51/1/8/256599
| Introduction|| |
The sensory integration (SI) treatment model was introduced to the field of occupational therapy (OT) in the 1970s by Dr. Jean Ayres. The theory originated when Dr. Ayres studied the relationship between the sensory processing ability of the brain and the adaptive behavior of children with learning disabilities. The SI model postulates that interferences in neurological processing and integration of sensory information negatively influence the construction of purposeful behaviors.
Over the decades, SI has become a popular treatment model among pediatric occupational therapists (OTs)., Many OTs in India work in the field of pediatrics. Many therapists prefer to use SI in practice even though the scientific findings on SI's efficacy remain equivocal.,,, One of the reasons for this could be perceived effectiveness. This study aims to understand the perception of OTs in Tamil Nadu (TN) regarding the efficacy of SI interventions.
| Methods|| |
This study was conducted adhering to the principles of the Declaration of Helsinki guidelines. The guidelines were reviewed prior to the survey being sent to the participants. In addition, the invitation e-mail that was sent to participants clearly identified that participation in the survey was “strictly voluntary and the responses will be kept anonymous.”
The population of this study was pediatric OTs currently practicing in TN who use the SI treatment model in their clinical practice. A list of 340 e-mail addresses belonging to OT practitioners in TN was identified from the author's e-mail lists and records. The possibility of two or more e-mail addresses belonging to the same practitioner cannot be ruled out. Similarly, there is a possibility that practitioners may have moved to other states or countries and no longer practice OT in TN. To reach out to all OT practitioners in TN, the author decided to share the survey invitation e-mail on three WhatsApp Messenger groups that have many TNOT practitioners (TNAIOTA Official Group, OTist Group, and OT Friends Group). The author avoided alumni WhatsApp groups because they contain members who belong to a given institution. The first page of the survey clarified that the survey was intended for TNOT practitioners who use SI in pediatric clinical practice.
The author developed a survey [Appendix 1] by reviewing the literature and following survey-writing guidelines. The survey consisted of ten questions that were designed to gather information about participants' demographics, practice setting, years of experience in the field of pediatrics, additional training on SI, use of SI in practice, perception of effectiveness of SI interventions, and views on factors that influence SI. The survey tool was reviewed by four experienced OTs for clarity and face validity. The author made minor revisions to the survey based on the review feedback.
The survey was conducted using SurveyMonkey® (SurveyMonkey, San Mateo, California). On March 30, 2018, an invitation to participate in the survey was sent to all 340 e-mail addresses. Forty-five e-mails bounced back due to invalid e-mail addresses. On the same day, the survey invitation was shared on the three identified WhatsApp Messenger groups. The invitation identified the response deadline as April 30, 2018.
Following the Tailored Design Method, the author designed a simple survey and contacted participants three times during the open survey period to maximize the response rate. The first reminder e-mail was sent 10 days after the original invitation e-mail, and the final reminder was sent 5 days prior to the response deadline. The reminder messages were also shared on the WhatsApp Messenger groups on the same days.
Descriptive statistics were used to summarize and report the responses received. Data were reported as percentages and aggregate numbers to protect the identity of respondents. Fisher's exact test was performed to determine the association between “perceived effectiveness of SI” and each of the following variables: gender, educational level, years of work experience, and additional training on SI.
| Results|| |
Forty-nine responses were received by the survey response deadline. There were no incomplete responses. [Table 1] presents the sample characteristics.
More than 90% of the respondents have used SI intervention techniques to treat children with autism, attention deficit hyperactivity disorder (ADHD), and sensory processing disorder (SPD). Based on average ranking, obstacle course activities, deep pressure, and suspended equipment activities were the most-used SI intervention strategies, while weighted garments, sensory discrimination activities, and traction techniques were the least-used interventions [Table 2]. Eighty-four percent (n = 41) of the respondents perceived that SI interventions were effective. Respondents believed that for SI interventions to be effective, child/parent cooperation, the therapist's knowledge and skill on SI, and well-equipped SI rooms are critical.
|Table 2: Respondents Ranking of Frequently Used Sensory Integration Interventions in Practice|
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Univariate analysis using Fisher's exact test was performed to determine the association between the variables. The analysis yielded nonsignificant probability value (P > 0.05), explaining the lack of association. The relationship of gender, years of experience, additional training on SI, and educational level to the perception regarding SI effectiveness gave an exact P = 0.23 (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.03, 2.14), 0.70 (OR: 0.58; 95% CI: 0.08, 3.43), 1.00 (OR: 0.79; 95% CI: 0.13, 4.85), and 0.27 (OR: 2.80; 95% CI: 0.43, 31.54), respectively.
Two themes were revealed from respondents' responses to the survey question, “Why do you think SI interventions are effective?” They were “therapeutic effectiveness” (“I had seen good prognosis with children after SI therapy;” “As we provide good sensory diet to clients, they show better performance in ADL work, play and leisure activities …;” “I can clearly see it definitely helps in organizing the senses of a child and it increases the attention and learning focus … effective;” “I see a drastic improvement in my clients within a few sittings of therapy;” and “Effective positive feedback from children and parents”) and “nature of the intervention” (“According to me, it is play oriented;” “Because SI intervention can implement through play so it easy to bring rapport with children;” and “It's play based, unstructured …”).
A subtheme related to therapeutic effectiveness, observed in respondents' comments, was “effective if delivered properly” (“It gives the necessary responses that we plan for when done in the right way;” “Yes, when it is combined with proper handling of children and designed home/school intervention, SI is very effective;” and “… very effective if the therapist has the sound knowledge of the frame of reference”).
| Discussion|| |
This study explored TN occupational therapy (TNOT) practitioners' perception regarding the efficacy of SI interventions. Pediatric TNOT practitioners, in general, believed that SI interventions are an effective form of treatment for children with developmental disorders. This aligns with the findings of a recent study that found the inclination of therapists outside the US toward sensory-based approaches.
Given that the majority of respondents, regardless of gender, educational level, practice experience, and additional training on SI, believed that SI is an effective approach and indicated positive therapeutic outcomes as a major reason that they believed SI is effective, one may assume that SI interventions indeed yield effective results. However, as perception is a subjective variable and respondents belonged to a specific geographical region, caution must be exerted before generalizing this assumption.
Perceptions may influence clinical decision-making and treatment choice. In this study, it is evident that many respondents did not base their perception on empirical evidence, based on their response to the survey question, “Why do you think SI interventions are effective?” This relates to a finding in the literature. Ashburner et al. found that OTs working with children with autism spectrum disorder generally rely on evidence from conference or workshops rather than research literature. At the same time, it is also essential to note that the research evidence on SI is inadequate and equivocal. Studies on the efficacy of SI lack scientific rigor due to small sample sizes, varied treatment dosage and frequency, questionable statistical procedures, and methodological limitations.
Respondents identified “therapists' knowledge and skill on SI” to be a critical factor for SI intervention effectiveness. However, there is a possibility that respondents' interpretation of knowledge and skill is limited to identifying and treating sensory dysfunctions and does not include seeking and appreciating evidence related to SI interventions.
Respondents stated that they believed SI interventions are effective because of positive therapeutic outcomes. However, the observed positive outcomes could have been due to other factors, such as natural development, other interventions, schooling, behavioral training, etc. It is also important to note that therapeutic outcomes may be influenced by the type of outcome measures used and their psychometric properties. Literature revealed that many OT practitioners used anecdotal opinions and notes to measure SI's efficacy rather than psychometrically sound outcome measures.
This study found no association between additional SI training, years of work experience, and perceived effectiveness of SI interventions. This is contrary to Thompson-Hodgetts and Magill-Evans' study, which found an association, at the univariate level, between years of work experience, a fee-for-service funding model, additional training on SI, and increased perceived effectiveness of sensory-based approaches.
If today's practitioners use SI interventions widely and act as mentors to the next generation of therapists, they may pass on the favorable attitude toward SI interventions to their protégés, thereby fueling SI's widespread use. Thompson-Hodgetts and Magill-Evans found that having a mentor who promoted sensory-based approaches was associated with increased recommendation of sensory-based approaches by therapists.
This survey was administered electronically and yielded 49 responses. A mail or telephone survey may have increased the number of responses.
A survey question on how therapists measured the therapeutic effectiveness of SI interventions may have provided additional data to validate therapists' beliefs. This survey did not include such a question.
This survey also did not include a national sample, which limits the generalization of the findings. Further, some respondents may have experienced difficulty in comprehending the questions since the survey was administered in English. Although English is considered one of the official languages in India, Tamil is the commonly used language for communication in TN.
The possibility of voluntary response bias cannot be ruled out as the survey invitation may have appeared interesting only to those who had a favorable attitude toward SI interventions. If only therapists who view SI favorably responded to this survey, then the obtained data were likely skewed.
Future research may identify nonsensory-based interventions used by TNOT practitioners to treat children with autism, ADHD, learning disabilities, and SPD to learn about other approaches used in pediatric OT practice. In addition, an exploratory study to learn about the influence of the identified favorable attitude on therapists' clinical reasoning may provide valuable insights.
Implications for Practice
- During the clinical reasoning process, therapists must demonstrate awareness of their perceptions and exert caution to avoid any negative influence they may cause
- Occupational therapy practitioners in TN must seek and appraise the available evidence on SI approach when planning SI interventions for their clients
- When seeking mentors, practitioners must seek therapists and scholars who demonstrate sound understanding of the concepts of SI and evidence-based practice
Implications for Research
- To add to the evidence base of SI interventions, OT practitioners must accurately and objectively record, analyze, and present the findings related to therapeutic outcomes
- TNOT practitioners must collaborate with OT researchers to guide future research and validate their beliefs regarding SI effectiveness
- Since practitioners in TN frequently use obstacle course activities, deep pressure, and suspended equipment activities in practice, OT researchers may focus on studying the clinical effectiveness of these interventions.
| Conclusion|| |
Occupational therapists in TN appear to have a favorable attitude toward SI interventions, which may influence their treatment planning. Although practitioners reported perceived positive therapeutic outcomes as the reason behind their beliefs, they need validation through clinical research. As best practice guidelines recommend choosing interventions that are supported by scientific evidence to yield optimal therapeutic outcomes, OTs must consider interventions with empirical evidence in practice. Future research may simultaneously evaluate and compare therapists' perception and therapeutic outcomes related to SI.
The author extends his sincere thanks to all occupational therapists who responded to this survey and reviewed the survey tool for validation. He also extends his gratitude to his friends, Ms. Savitha Sundar, MS, OTR/L, and Ms. Pui-man Mak, for proofreading the manuscript.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| Appendix|| |
Appendix 1: TNOTs' Perception of the Efficacy of Sensory Integration Interventions
This survey intends to gather data from pediatric occupational therapists regarding their perception of the efficacy of sensory integration interventions. Please complete this survey only “if you are a pediatric occupational therapist practicing in TN, India” and “you use sensory integration interventions in your clinical practice.” Your responses will help generate valuable data for the profession.
Thanks in advance for your time.
- What is your highest level of education?
- How long have you been practicing OT in the area of pediatrics (number of years)?
- Please indicate the type of practice setting(s) in which you currently practice OT (Select all that apply).
Other (please specify)
- Did you obtain additional training/education in sensory integration (SI) after you graduate with your entry-level occupational therapy degree to effectively use SI in practice?
- Please identify the diagnoses that you treat using SI intervention techniques (Select all that apply).
Sensory Processing Disorder
Other (please specify)
- Please rank the following interventions based on the frequency of use in your clinical practice.
Joint compression techniques
Obstacle course activities
Sensory discrimination activities
Suspended equipment activities
Therapy ball activities
- In your view, how effective sensory integration interventions are?
Always effective – I see positive outcomes in all children I treat with SI.
Usually effective – I see positive outcomes in most of the children I treat with SI.
Sometimes effective – I see positive outcomes in some children I treat with SI.
Rarely effective – I see positive outcomes in a very few children I treat with SI.
Never effective – I have never seen positive outcomes in children I treat with SI.
Other (please specify)
- In your view, in order for the SI intervention to be effective, which of the following factors are critical? (Select all that apply)
Duration of intervention
Frequency of intervention
Symptom severity (SI works better if symptoms are (or are not) severe
Therapist knowledge and skills on SI
Well-equipped SI room
Other (please specify)
- Why do you think SI interventions are effective?
| References|| |
Ayres AJ. Sensory Integration and Learning Disorders. Los Angeles: Western Psychological Services; 1972.
Kadar M, McDonald R, Lentin P. Evidence-based practice in occupational therapy services for children with autism spectrum disorders in Victoria, Australia. Aust Occup Ther J 2012;59:284-293.
Watling R, Deitz J, Kanny EM, McLaughlin JF. Current practice of occupational therapy for children with autism. Am J Occup Ther 1999;53:498-505.
Mani K, Provident I. Compensation received by occupational therapists in India: A national survey. Indian J Occup Ther 2017;49:22-28.
Case-Smith J, Bryan T. The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. Am J Occup Ther 1999;53:489-497.
Dawson G, Watling R. Interventions to facilitate auditory, visual, and motor integration in autism: A review of the evidence. J Autism Dev Disord 2000;30:415-421.
Parham LD, Cohn ES, Spitzer S, Koomar JA, Miller LJ, Burke JP, et al.
Fidelity in sensory integration intervention research. Am J Occup Ther 2007;61:216-227.
Schaaf RC, Dumont RL, Arbesman M, May-Benson TA. Efficacy of occupational therapy using Ayres sensory integration®: A systematic review. Am J Occup Ther 2018;72:7201190010p1-7201190010p10.
Dillman DA, Smyth DJ, Christian LM. Internet, Mail, and Mixed Mode Surveys: The Tailored Design Method. 3rd
ed. New Jersey: John Wiley & Sons; 2009.
Thompson-Hodgetts S, Magill-Evans J. Sensory-based approaches in intervention for children with autism spectrum disorder: Influences on occupational therapists' recommendations and perceived benefits. Am J Occup Ther 2018;72:7203205020p1-7203205020p8.
Ashburner J, Rodger S, Ziviani J, Jones J. Occupational therapy services for people with autism spectrum disorders: Current state of play, use of evidence and future learning priorities. Aust Occup Ther J 2014;61:110-120.
May-Benson TA, Koomar JA. Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. Am J Occup Ther 2010;64:403-414.
Tiringer S. Occupational Therapists' Perception of the Efficacy of Sensory Integration Interventions. Dissertation. Ann Arbor: Touro College; 2006.
[Table 1], [Table 2]