Hello! I have been MIA on the blog, so I felt I need to give you all an update of what I’ve been up to!
Most responsible for my absence is that I got married three weeks ago today! It was a beautiful and sacred day. Everything went as well as I could have hoped it would go, and I felt so much love and care from the people who were there to support us. I have loved pouring over our photos and can’t wait to see the documentary from the videographer. It was truly a special day.
In the meantime, my husband (still feels weird to say that!) has returned to Chile and I’m waiting on my paperwork to join him there. We’ll be living there for at least the next two years. As one can imagine, COVID complicates things, including an immigration process.
For now, I’m reveling in the extra time I have at home. I’ve got plans to go to the pumpkin patch and then trick or treating with my nieces. While I’m sad to be away from my husband, I am realizing it’s best to be present in the moment and accept the gifts that are being given to me.
I write also to update you all on products I have available on my site. I’m fluent in Spanish (although I’m about to get even more so after some immersion growing pains) so providing Spanish resources is something I love to do. You can check out those resources here.
I also love the cute and colorful worksheets I made to teach line adherence and letter sizing. They were very fun to make! I’m sad I’m not working right now, because I would love to use them with kiddos! There are currently drag and drop and cut and paste versions of a letter size worksheet with a safari theme and a fall theme. More to come!
Finally, if you’re interested in having evidence based facts to provide to parents, my first evidence based handout is available on the connection between Sensory Processing and Anxiety, as well as OT’s role in treating anxiety.
I hope you all are well! Either doing virtual therapy, traversing the waters of modified in person therapy, or somewhere in between waiting for the next step in your therapy journeys.
I’ll be back to posting evidence reviews along with my Motor Tips Mondays and Sensory Tip Saturday posts on my Instagram and Facebook pages soon!
Telehealth has drastically changed the way many therapists are practicing in these past six months. (Six months! Can you believe that?) I haven’t personally tried my hand at it because I was let go from my job when COVID closed schools and clinics in March. I am always eager to hear my former coworkers talk about their experiences navigating the unchartered waters of telehealth. I’ve also admired the creativity, ambition and flexibility as I see resources, tips and tricks that therapists new to telehealth have discovered and shared.
Adapting to Telehealth Like Champs
I may be biased, but therapists are incredible people. While the adaptability, creativity, goal setting and executing that many bring to the field has made providing telehealth services possible, I have to believe many are grieving the loss of in person therapy. I’m getting married and moving abroad in a month or so, so it didn’t feel like the right timing for me to get a new job. However, I have thought about how I hope to get an OT job when I move. I’ve had to tell myself that I might have to be open to telehealth if that is what my option ends up being, and that makes me so sad.
But, alas, accept the current state of society we must. My goal in covering this topic is to encourage people doing telehealth that what you’re doing can make a difference! I know I’ve heard many people say, “It’s not really effective.” I can certainly imagine that, if the parents aren’t involved. There are often factors we can’t control. However, there are always things that are within our power to change.
How to Provide Effective Telehealth OT Services
I’m hoping this article review serves as encouragement that doing the hard work to shift our thinking even more from “I’m the therapist and I’ll make the change,” to “We’re working as a team and my collaborating with the caregivers will help this child to continue to succeed,” is worth it. You will also find some specifics and direction of elements that the investigators in this study used in order to promote successful parent coaching.
JournalThe American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Occupation-Based Coaching by Means of Telehealth for Families of Young Children with Autism Spectrum Disorder
Authors Lauren M. Little, Ellen Pope, Anna Wallisch, Winnie Dunn
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods
The study investigators recruited children in underserved and rural areas through early intervention and early childhood programs. Investigators included children with an Autism Spectrum Disorder who were 0-6 years old. Seventeen families completed the intervention.
Intervention
Occupational therapists completed 12 weeks of coaching sessions through Zoom. Therapists used the coaching model to empower families to understand and grow confident in the knowledge they have in regards to their child. The therapists ask questions to promote reflection, guide families to realize what knowledge they already have and use, as well as to guide families in developing and implementing strategies to assist their children in meeting goals the family set.
OT’s used the first session to complete a routine-based questionnaire as a means to gather information on the family’s daily routines and context of their daily activities. The family then came up with goals for the OT sessions. Investigators used the following measures to gather relevant data for the intervention.
Demographic Form-Family
Sensory Profile-Second Edition
Social Responsiveness Scale-Second Edition
Parenting Sense of Competence Scale
Assessment of Preschool Children’s Participation
Canadian Occupational Performance Measure-Second Edition
Study authors also used Goal Attainment Scaling to work with parents in establishing goals. This is a documentation method that uses established, sensitive levels of change for a targeted goal to demonstrate progress in that area.
Findings
Authors compared the mean scores of each measure from pre and post intervention to determine the effects of intervention.
Parent Efficacy as a Result of Telehealth Coaching
Post-intervention scores for the Parenting Sense of Competence Scale (PSOC) demonstrated a significant increase in parents’ feelings of efficacy. This indicates that parents felt more equipped and able to manage the situations they encounter as a parent. Parents did not report increased levels of satisfaction. Satisfaction included the degree to which a parent reports their role as a parent is comfortable and rewarding (Little, Pope, Wallisch, & Dunn, 2018, p. 4)
(Little, Pope, Wallisch, & Dunn, 2018, p. 4)
Child Participation as a Result of Telehealth Coaching
The authors measured child participation with the Assessment of Preschool Children’s Participation (APCP), GAS goals and COPM-2. The frequency with which children participated in activities and the diversity of the activities in which children engaged significantly increased per the APCP. There was also a significant increase in parents engaging in more play activities with their children as well as trying a wider variety of activities to develop their child’s skills (Little, Pope, Wallisch, & Dunn, 2018, p. 5).
Children’s increased participation in activities was significant per data from the COPM-2. Parents’ satisfaction with intervention goals increased significantly, and children made significant gains in their GAS goals.
Things to Consider
The study authors mention that only parent report measures were used to gauge effectiveness of the intervention. They suggested that the addition of objective measures of behavior or performance may enhance understanding of coaching on child performance outcomes. They also mentioned that the use of a control group may be helpful to further understand the effectiveness of telehealth vs. other modes of service or no intervention. Finally, the need for a larger sample size was mentioned.
Experiences of Parents of Children with ASD to Guide Telehealth Intervention for Others
While the current study included only parents of children with ASD, I think this information serves as a good guide for coaching a wide variety of parents. A factor that is relevant to me is that these families lived in rural or underserved areas. There may be cultural differences for families with whom we are working who are receiving telehealth services due primarily to COVID. Most notably, I think of families in suburban or urban areas that may fill their schedules more than what I often see as a slower pace of life in rural areas. However, the fact that families were able to effectively use technology to participate at a distance and make significant measurable change is encouraging.
How is your experience with telehealth going?
Have you had to switch to providing telehealth this past year? What tools and resources are you finding helpful?
References
Little, L. M., Pope, E., Wallisch, A., & Dunn, W. (2018). Occupation-Based Coaching by Means of Telehealth for Families of Young Children With Autism Spectrum Disorder. American Journal of Occupational Therapy,72(2). doi:10.5014/ajot.2018.024786
Parents and therapists alike may tell you picky eating seems to have grown tremendously in recent years. While there is some amount of typical toddler fussiness, sometimes picky eating is indicative of something more.
As with anything, likely there are a wide variety of factors to include in the possible explanations. Challenges with sensory processing often contribute to difficulty with feeding. Processed food has become almost a staple in families’ homes. With this we have seen a decrease in families and children planting, growing, interacting with and preparing food in its fresh and natural form. Eating dinner together as a family is a hugely important activity. Here children observe and learn what to think about food and how to eat it from those with whom they share the dinner table. While some families returned to the dinner table due to lockdowns during COVID-19, it’s a habit that is not as often prioritized into overly packed after school and work schedules.
Picking Eating, Parents and Family Dynamics
Whatever the cause of picky eating, it can greatly impact family stress levels and dynamics. I always say I have a love/hate relationship with feeding therapy. I really think it’s fun, and I love when kids make progress and grow confident to try new foods! However, moving that progress to the family dinner table can be another story. Picky eating requires treatment of the whole family. Parents in particular need to play an active role in learning how to teach their picky eaters about new foods.
That’s why I loved the article I reviewed this week. It specifically focused on educating parents and empowering them so they can be the crucial agents of change their children need them to be! This article actually covers treatment of children who had a diagnosis of Avoidant-Restrictive Food Intake Disorder (ARFID). That is not your garden variety picky eater. The Washington Post published a story last week on the topic. In the article, the author of the study I’m reviewing today shared about her experience working with children with ARFID.
JournalCognitive and Behavioral Practice (SNIP score 0.994)
Article Title The (Extremely) Picky Eaters Clinic: A Pilot Trial of a Seven-Session Group Behavioral Intervention for Parents of Children with Avoidant/Restrictive Food Intake Disorder
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods
The authors trained cohorts of parents whose children presented with criteria for avoidant/restrictive food intake disorder (ARFID). Parents of 21 children, ages 4-11 years old, participated. Cohorts had two to four families each. Seven total cohorts participated, with each cohort participating in seven sessions of the manualized group treatment for parents only.
Interventionists trained the parents in acting as coaches in presenting non-preferred foods on a daily basis in their homes. They also empowered parents on how to reduce problematic mealtime behaviors with parent management training. The participants in this study were referred to a specific provider, the clinical director of an outpatient anxiety speciality clinic which serves to evaluate and treat extremely picky eating (Dahlsgaard & Bodie 2019, p. 9).
Children met inclusion criteria if they were 4-12 years old, had a diagnosis of ARFID and their parents’ main concern was their picky eating in the event of coexisting psychiatric or medical problems. All parents completed the following standardized feeding measures at pretreatment, posttreatment and a 3-month follow-up to assess their child’s picky eating and problematic mealtime behaviors (Dahlsgaard & Bodie 2019, p. 3).
Behavioral Pediatric Feeding Assessment Scale
Child Eating Behaviors Questionnaire
Parents completed the Child Behavior Checklist during intake only as a means of collecting information on behavioral, emotional and social problems (Dahlsgaard & Bodie 2019, p. 12).
Intervention
Parents participated in seven 90 minute sessions which occurred weekly for sessions 1-4. The last two sessions occurred with a 3-4 week gap to promote families practicing the skills they had learned (Dahlsgaard & Bodie 2019, p. 14). The seventh session was an optional follow up. Interventionists educated parents on ARFID, mealtime hygiene, appetite optimization and the key behavioral principles for the program in the first session (Dahlsgaard & Bodie 2019, p. 14).
Interventionists taught parents how to implement daily exposure procedures in the second session. Following sessions focused on improving parents’ ability to follow through with promoting appropriate responses to children’s behaviors as well as implementing contingency management for food exposures and meals. Parents also learned about increasing the size of challenge food portions and incorporating them into meals.
Findings
Behavioral Pediatric Feeding Assessment Scale
Significant reductions were reported for all four subscales of this assessment along with a large within-group effect size at posttreatment (Dahlsgaard & Bodie 2019, p. 16). At the 3-month follow-up, gains were maintained and the large within-group effect size remained.
Child Eating Behaviors Questionnaire
Parents ratings on the CEBQ demonstrated a significant increase for Enjoyment of Food as well as significant decreases for Slowness in Eating, Satiety Responsiveness and Food Fussiness from pre to post treatement (Dahlsgaard & Bodie 2019, p. 16). The author noted large within-group effect sizes in these areas at posttreatment.
No significant improvements were observed for Emotional Undereating on this assessment. Enjoyment of Food resulted with a significant increase from pre-treatment to the 3-month follow up, and significant decreases for Satiety Responsiveness, Slowness in Eating, Emotional Undereating and Food Fussiness. The author reported moderate-large within-group effect sizes. All of these gains remained at the 3-month follow up.
Parent Satisfaction
Of the parents who completed treatment satisfaction questionnaires post-treatment (71% of the total study participants) 96% of those parents rated specific elements of the Picky Eaters Clinic as Very Helpful or Extremely Helpful (Dahlsgaard & Bodie 2019, p. 17). Parents reported the support they received from the group and trainings in food exposures as well as contingency management as the most helpful elements (Dahlsgaard & Bodie 2019, p. 17).
Things to Consider
The parents in this study were highly motivated as demonstrated by 95% attendance rate and 71% of children having two parents attending treatment sessions (Dahlsgaard & Bodie 2019, p. 15). This study’s author noted that this group was fairly heterogeneous, but that previous research indicates that this is consistent for children with a picky eating subtype diagnosis of ARFID (Dahlsgaard & Bodie 2019, p. 27).
Interestingly, there are three subtypes of ARFID. These include those children with extreme picky eating, but also children whose avoidance of eating stems from a specific fear/potential negative consequences they they associate with eating. This can include things like a phobia of choking, having allergic reactions or vomiting. A third group of children who fall into the ARFID category are those who demonstrate decreased interest in eating.
This information is relevant as the treatment one selects varies depending on the subtype the child presents with. It is important to be specific and intentional with our selections of evidence based treatments to promote progress for children and their families!
The author also mentions that the data that was used was obtained in clinical procedure as opposed to following a research protocol. She noted that this type of data is often less reliable and complete (Dahlsgaard & Bodie 2019, p. 27). Finally, as there was no control group for this study, we can not compare it to the effectiveness of other common treatments for selective eating.
The More You Know…
So now that you know that involving parents only resulted in significant changes in the relationship with food for children with Avoidant-Restrictive Food Intake Disorder (ARFID), how do you plan to educate and empower parents of the children you’re treating? I highly recommend this article on How to Get Picky Eaters to Try New Foods as a starting point!
References
Dahlsgaard, K. K. & Bodie, J. (2019). The (extremely) picky eaters clinic: A pilot trial of a seven-session group behavioral intervention for parents of children with avoidant/restrictive food intake disorder. Cognitive and Behavioral Practice, 26 (3), 492-505. https://doi.org/10.1016/j.cbpra.2018.11.001
Self-regulation is a crucial element of providing holistic sensory integration and sensory based therapy. But what exactly does it entail? I like the four components of self-regulation that Leah Kyupers, author of the Zones of Regulation, highlights:
(Pfeiffer, Clark, & Arbesman, 2017)
Part of the thought process behind implementing sensory integration and sensory-based therapy is that as a child’s sensory processing abilities improve, so too will their self-regulation. I think this definitely is a possibility, but we must be mindful that oftentimes the children we work with need to be directly taught regulation skills. As their sensory-processing improves, children may be more calm more of the time. This in turn may facilitate them learning self-regulation strategies for the next time they are becoming dysregulated. However, the need for direct modeling and practice of tools to regulate remains.
Journal American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Effectiveness of Cognitive and Occupation-Based Interventions for Children with Challenges in Sensory Processing and Integration: A Systematic Review
4 Case series (and low quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
* This was a systematic review which included a wide array of evidence from RCT to Level IV single-case experimental design. As this type of systematic review doesn’t fall into either 2A nor 3A, I chose to categorize it into a level 2B study. The evidence reviewed was higher than case studies but lower than cohort studies.
Methods
The authors of this systematic review included peer reviewed studies that concentrated on interventions in the scope of OT for children and adolescents who had sensory processing and integration challenges. Authors of this review ensured this in that studies they included demonstrated the use of an assessment that specifically confirmed the participants had sensory processing or sensory integration challenges. The authors selected studies that also included outcome measures that specifically evaluated sensory processing and integration (Pfeiffer, Clark, & Arbesman, 2017, p. 3).
The authors of this review specifically reviewed interventions defined as either cognitive or occupation-based. I appreciate that the authors were specific by excluding studies that did not explicitly indicate subjects as having sensory processing or integration disorders (Pfeiffer, Clark, & Arbesman, 2017, p. 4) While it is sometimes frustrating to have less articles, it is better to have consistent and accurate definitions so that we can feel confident of what is being reported!
Findings
Two studies included evaluated cognitive interventions that targeted outcome measures of self-regulation and executive functions of inhibitory control, social cognition, behavioral and emotional regulation and externalizing behavior problems (Pfeiffer, Clark, & Arbesman, 2017, p. 5).
Alert Program for Self-Regulation
A level I study assessed the effectiveness of 12 individual 1 hour sessions of the Alert Program for Self-Regulation for children with Fetal Alcohol Syndrome. Authors grouped children into an immediate and delayed treatment group. The delayed treatment group served as the control. Both groups received treatment, with the group receiving treatment first demonstrating significant increases in their inhibitory control and social cognition. These gains were maintained at a 6 month follow-up. Also noteworthy is that parents of children in this group indicated their children’s behavior and emotional regulation improved. These parents also noted a reduction in externalizing behavior problems in their children (Pfeiffer, Clark, & Arbesman, 2017, p. 5).
Components of the Alert Program
(Pfeiffer, Clark, & Arbesman, 2017, p. 5)
Social Stories
A level IV study included an intervention of Social Stories for 9 weeks in a self-contained pre-school classroom. This intervention with 3 male pre-schoolers entailed reading and then talking about a Social Story concentrated on the children’s goals (Pfeiffer, Clark, & Arbesman, 2017, p. 5). Children also practiced their strategies as part of the intervention. The interventionists used Social Stories that met Carol Gray’s criteria for social stories.
All three children in this study showed increased frequency of their desired behaviors. The baseline, intervention and maintenance phase percentages of frequency of desired behaviors are shown.
Occupation-Based Interventions
Horseback Riding to Promote Self-Regulation Skills
A level I RCT investigated the effectiveness of horseback riding on children’s social functioning. Subjects were children 4-10 years old with ASD. These children participated in 1 hour per week of horseback riding lessons for 12 weeks. This was done at an equestrian center with trained instructors. Children who participated in the horseback riding intervention demonstrated statistically significant changes in their overall Sensory Profile Score, as completed by their parents (Pfeiffer, Clark, & Arbesman, 2017, p. 6). Specifically, the following subscales were impacted: Sensory Seeking, Sensory Sensitivity, Inattention/Distractibility and Sedentary Behaviors. These children also demonstrated significant changes in social motivation.
A level III study used lessons that a school group coordinator designed about: sensory orientation to the environment, mounting a horse and riding (Pfeiffer, Clark, & Arbesman, 2017, p. 6). Subjects were children in kindergarten through fifth grade with ASD. Children who participated in horseback riding demonstrating significant improvements in their social interaction, sensory processing as well as reduced severity of symptoms associated with ASD. It is noteworthy that in this study, subjects had built in breaks and during breaks, the gains were not consistently maintained (Pfeiffer, Clark, & Arbesman, 2017, p. 6).
Yoga as a Means to Promote Self-Regulation
A level III study assessed the use of yoga for subjects 12-18 years old who were in partial hospitalization or an inpatient mental health unit (Pfeiffer, Clark, & Arbesman, 2017, p. 6). These subjects took part in at least two 50 minute yoga sessions over 5 months. A Yoga Alliance-registered teacher taught the classes. Participants in the yoga intervention demonstrated significant improvements in their pulse rate and self-reported distress ratings.
What’s the Best Way to Promote Self-Regulation?
As OT’s we know that there are many factors that contribute to our clients meeting goals and living fulfilling and enjoyable lives. I liked that this study highlighted both the need for cognitive strategies and occupations. Teaching children to become more aware of their body’s state of regulation helps empower them to self-regulate . I am excited to see that children can participate in occupations that are enjoyable that can also help develop self-regulation skills! What are your favorite programs and tools to teach children self-regulation?
References
Pfeiffer, B., Frolek Clark, G., & Arbesman, M. (2017). Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: A systematic review. American Journal of Occupational Therapy, 72, 7201190020. https://doi.org/10.5014/ajot.2018.028233.
Last week I reviewed an article that investigated the relationship between preschoolers with sensory over-responsivity and school-age anxiety disorders. The authors found a significant correlation between the two factors. Now we know that sensory over-responsivity may contribute to clients who present with anxiety. The next question is, “What is my role in treating childhood anxiety as an occupational therapist?”
It intrigues me that despite OT’s mental health origins, I don’t want to overstep and treat a child with anxiety. Using the Zones of Regulation curriculum has equipped me to help a child who presents with generalized anxiety and self-regulation troubles.
When It’s More Than Anxiety
I personally feel that when I sense a bigger family dynamic, it’s time to refer to a family counselor. Also, I see that many professions are supporting trauma informed care. I believe [read: my opinion] to work with children with more complex psychological involvement, we have an obligation to pursue continuing education in that realm and/or know when it’s time to refer out.
OT’s Role in Treating Childhood Anxiety from AOTA’s Perspective
Let’s see what AOTA has to say. In its Anxiety Disorders fact sheet, AOTA mentions that anxiety impacts children’s participation because the fears they may have of failing, interacting with others, or more intense factors like panic attacks may cause children to limit the activities they are willing to participate in.
They next point to the cycle of how not being able to participate in these activities can lead to low self-esteem and impact their habits and routines. This is totally the stuff of OT! Also very interesting to me is children not knowing what activities to do to relax. This seems especially important in the age of technology when it’s way too easy to do everything online. We as OT’s know that occupations we do with our hands promote mental health!
Alright, now that we know where OT can help children in managing their anxiety, what action steps we can take?
Action Steps for OT’s to Address Anxiety
At home OT’s help the child and family in establishing routines, educating family members on how anxiety presents and how it impacts a child’s engagement in activities. An OT can also help a family to find activities they can enjoy together to promote balance and relaxation.
An OT at school may similarly provide information to staff on how anxiety may impact a child’s participation. OT’s also can present ideas for how to structure a child’s day and strategies to assist with regulation. An OT may also promote presenting activities in a modified way to reduce anxiety.
The AOTA fact sheet recommends that an OT can help on the community level by offering education and ideas of how to cope with anxiety symptoms to organizations that involve parents and work with youth.
What’s Your Next Move?
Knowing that AOTA recommends the above in treating children with anxiety, what will you do differently the next time you join a child and family on their journey with anxiety?
References
Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Anxiety Disorders. Retrieved July 20, 2020, from https://www.aota.org/~/media/Corporate/Files/Practice/Children/SchoolMHToolkit/Anxiety
We’re all overly familiar with the phrase, “sensory or behavior,” but I think we may leave important factors out when we pit the two as an “or” situation as well as the connotation of what “behavior” means to us. Behavior, while simplified by an Antecedent, Behavior, Consequence model can seem straightforward, is often just the opposite.
What impacts a child’s behavior? So. many. things. We know that physiological factors like blood sugar and being tired impact it. We also know that emotional processing and patterns shaped by dynamics at home and with caregivers impacts it. Communication skills, especially an impairment of, guide behavior.
Today’s review explores a study that investigated the relationship between sensory processing and anxiety. A CuriosOT follower on Facebook requested that I explore this topic, and I was happy to do so as this is a topic I’ve wondered about myself in recent years.
In our busy society, I think we can see that more adults and children alike are presenting with mental health concerns. As an OT I know that I have seen kids who may have sensory issues, but definitely have anxiety. Other times I’ve seen children who seem to me that they obviously have anxiety, and I’m not sure if sensory processing is contributing to their challenges in occupational performance.
So, are sensory processing and anxiety related? Either way, what is OT’s role in treatment when we receive a child who has one or both of these diagnoses? Today’s post will cover the relationship between sensory processing and anxiety, and my next post will cover what is OT’s role.
Journal Journal of Abnormal Child Psychology (SNIP score 1.759)
Article Title Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods
The study authors obtained their baseline sample from the larger sample of the Duke Preschool Anxiety Study. That study had three parts: screening, in-home assessment and a laboratory phase (Carpenter et al., 2018, p. 4). The sample from the Duke Anxiety studied was obtained by screening children between 2-5 years old during visits to their primary care clinics. The sample was found to be representative of the general population.
Authors of the Duke Anxiety study invited the children who met criteria for generalized anxiety disorder (GAD), separation anxiety disorder (SAD) and/or social phobia to participate in the Phase 3 laboratory assessment (Carpenter et al., 2018, p. 4). Authors of the current study recruited children from this phase 3 to participate in the Learning About the Developing Brain (LABD) study. This was a five year study in which researchers followed a group of 191 children to assess relationships between sensory processing during preschool years and anxiety during school-age years.
Assessments
Study authors used the Preschool Age Psychiatric Assessment to assess anxiety and sensory over responsivity characteristics. Parents completed interviews to assess for symptoms of a variety of psychiatric disorders for children of preschool age. Parents of 191 children completed this assessment when their child was in preschool and age at school-age.
Anxiety
Researchers classified children as either meeting impairment and symptom criteria for the included anxiety disorders (GAD, SAD and/or social phobia) or not meeting those criteria. Children were identified as positive on the anxiety screening if their parent included at least 4 of 10 items on the screening tool.
Sensory Over-Responsivity
Researchers used the PAPA at baseline and follow-up to assess sensory over-responsivity. Responses to the following sensory experiences were accounted for: 1. physical contact with other people 2. Contact with fabrics, clothes tags, etc. 3. Contact with food textures 3. Visual experiences 5. Auditory experiences, including loud or high-pitched noises 7. Olfactory experiences 7. Tastes 8. Sensations of motion 9. Any other sensory experiences.
Behavioral Challenges
This study highlighted sleep problems, GI problems, food selectivity and irritability as related behavioral challenges.
Findings
Sensory Over-responsivity is not Uncommon for Preschool Children
Twenty percent of parents reported at least one sensory domain as over-responsive from the pre-school sample (Carpenter et al., 2018, p. 8). The most commonly rated areas were tactile (18%) and auditory (4%). Children with sensory over-responsivity at preschool who remained rated as such by school-age was 56%.Sixteen percent of children whose parents did not rate them as sensory over-responsive in preschool were rated as having sensory over-responsivity by school-age.
The proportion of females who parents described as sensory over-responsive was higher than the proportion of males who parents ranked as so (Carpenter et al., 2018, p. 8). Parents of children whose children were categorized as below the federal poverty line also were significantly ranked more often as sensory over-responsive.
Relationship Between Sensory Over-responsivity and Anxiety Disorders in the Preschool Sample
Researchers found a significant relationship between sensory over-responsivity and anxiety diagnoses in preschool, as 43% of children who were categorized as sensory over-responsive also demonstrated criteria of anxiety disorder. Researchers found that there was also a significant relationship between sensory over-responsivity and other disorders (i.e. ADHD) from the preschool sample (Carpenter et al., 2018, p. 9).
Did Sensory Over-responsivity in Preschool Predict Anxiety Symptoms by School-age?
The authors found that sensory over-responsivity in preschool significantly predicted anxiety symptoms by six years old. This stayed true when other potentially confounding variables (including sex, age, race, poverty status) were accounted for. This also remained true when the factors of a child having sensory over-responsivity by school age, anxiety symptoms when in preschool and a diagnosis of other disorders in preschool were accounted for. All this to say that potentially confounding factors assessed for in preschool did not otherwise explain the development of anxiety by school-age.
What Type of Anxiety Disorder Does Sensory Over-responsivity Predict?
The authors found sensory over-responsivity as a significant predictor only for generalized anxiety disorder, not separation anxiety disorder or social phobias.
Could Preschool Anxiety Cause School-age Sensory Over-responsivity?
A child having anxiety symptoms in preschool did not significantly predict a presence of sensory over-responsivity in school age children. When researchers assessed if preschool sensory over-responsivity predicted non-anxiety disorders for school age children, they found it did not. This indicates that preschool sensory over-responsivity is a significant predictor specifically of anxiety for school age children as opposed to a wide variety of non-anxiety disorders.
So What’s the Link Between Preschool Sensory Over-responsivity, School-age Anxiety and the Behavioral Challenges We See by School-age?
Researchers found a significant relationship between preschool children with higher levels of sensory over-responsivity showing higher levels of anxiety by school-age. They also noted that school-age children with higher levels of anxiety have higher incidences of irritability and sleep problems. Researchers did not find a significant relationship between the sensory and anxiety measures as they impacted GI symptoms or food selectivity by school age.
Things to Consider
The authors mention that they only collected data for two periods of time which is insufficient to completely achieve the ideal statistical criteria to state the impact sensory over-responsivity has on how anxiety and behavioral challenges manifest.
The authors also mentioned that to measure sensory over-responsivity they used an interview that was comprehensive and not specific to sensory over-responsivity. They feel it may be best to use a tool that specifically measures that.
Also of note is that the measures for anxiety and over-responsivity came exclusively from parent-report. It would be beneficial to have a second rater to corroborate these levels. They also mentioned that research has shown that sometimes a mother’s emotional symptoms impacts her rating of her child’s symptoms of mental health conditions.
The researchers would also like to assess how sensory under-responsivity and sensory seeking relate to anxiety.
What Do You Think?
How do you decide if a child presents with anxiety or sensory processing disorder? How would you use this information to guide your treatment?
References
Carpenter, K. L., Baranek, G. T., Copeland, W. E., Compton, S., Zucker, N., Dawson, G., & Egger, H. L. (2018). Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children. Journal of Abnormal Child Psychology,47(6), 1075-1088. doi:10.1007/s10802-018-0502-y
Ah, handwriting. The source and summit of our profession, right? (Just kidding.) However, while a lot of school OT’s like to remind people, “we are not handwriting teachers,” (I agree) it also makes sense as to why OT’s are called into action when a child’s handwriting is preventing them from participating in their school day.
Where do we start? What program or method do we use? Personally, I started with what information was handed down to me on Handwriting Without Tears. I particularly like the idea of developmental teaching order that they use. I think sometimes people think, “Oh, A is the first letter of the alphabet, let’s start with A.” There are diagonal lines in A, though, and children start forming those around 4 ½ years old. So, makes sense to me to start with the straight line letters first.
In recent years, I’ve been intrigued by the Size Matters program. It was new to me and I like some of the concepts I picked up from learning about it. All this to say, which program should we use?
Journal American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Curriculum-Based Handwriting Programs: A Systematic Review with Effect Sizes
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
* This was a systematic review which included many two-group non-randomized studies. As this type of systematic review doesn’t fall into either 2A nor 3A, I chose to categorize it into a level 2B study. The evidence reviewed was higher than case studies but lower than cohort studies.
Methods
A systematic review gathered articles from January 2006-December 2015 that included curriculum-based programs and handwriting intervention for students in preschool through 5th grade.
The researchers included 13 studies total, with 10 Level II, 2 Level III and 1 Level II-III studies.
Findings
Handwriting Legibility
For legibility, the programs with the largest effect size was the Explicit Handwriting Program. Medium to large effects on legibility came with the Size Matters Handwriting Program and Write Start.
Programs with small or very small effect sizes on legibility included the Fine Motor and Early Writing Pre-K Curriculum, Handwriting Without Tears, Write Direction and Intensive Handwriting Practice.
Handwriting Speed
The Explicit Handwriting Program also the largest effect sizeon speed. The Write Start and Intensive Handwriting Practice programs had small to medium effect sizes.
Size Matters Handwriting Program had small to medium effect size in the opposite direction, meaning kids wrote slower.
Fluency
Four studies assessed fluency, all investigating the Write Start program. There were significant differencesfor fluency in three of four studies. The authors noted that the studies being too similar and variations in post-test findings led them to determine there is insufficient evidence to speak to the effects of the program on fluency.
Handwriting Program Characteristics
All interventions lasted a minimum of 6 weeks, with the majority lasting more than 12 weeks. However, the total number of hours of intervention did not show a relationship with the impact on legibility and speed of writing.
The only two programs to have a larger than small effect size on both legibility and speed were the Write Start program and Explicit Handwriting Program.
Choosing a Handwriting Curriculum Based on Your Needs
An interesting highlight of this review is that different curriculums had significant effects on different outcomes. The authors suggest that OT’s consider this when choosing a curriculum to use. It may be most effective to choose a curriculum that improves legibility if that’s what you’re most concerned with.
So, the findings from this review may suggest that at this point in time, an OT may consider the following:
Legibility
The largest effect size on legibility came from students using the Explicit Handwriting Program. My initial thought was, “Okay! Let’s explore this. Seems like the best option!” Upon reading the program characteristics, it was very detailed. Intervention included dexterity exercises, discussions about context of writing with children, learning 2-3 letters in cursive per session given modeling, etc. (Kaiser, Albaret, & Doudin, 2011, p. 613, 614). That is to say, it was thorough, but is not a standardized program. The may be why the authors suggested the use of Size Matters Handwriting Program over Explicit Handwriting Program. On average, children using the Size Matters Handwriting Program and Write Start Program showed medium to large effects for improved legibility. For my part, I’m going to investigate Write Start in more detail.
Speed
From their review, the authors suggest that Explicit Handwriting Program, Write Start or Intensive Handwriting Program may be the best choices for curriculum if your primary concern is speed.
Things to Consider
The authors mention that they did not include level I studies in the review, as there were not any studies of that level of evidence that met inclusion criteria. Level I studies would give us more robust evidence to make our decisions on which program to use. The authors also mentioned that the way they measured their data on effect sizes did not take into consideration for repeated measures. They note that they intentionally did this to be conservative, but that this method may have produced effect sizes that were smaller than they really were.
What Do You Think?
What programs do you typically use with your students? Which programs mentioned here are new to you?
References
Engel, C., Lillie, K., Zurawski, S., & Travers, B. G. (2018). Curriculum-Based Handwriting Programs: A Systematic Review With Effect Sizes. American Journal of Occupational Therapy,72(3). doi:10.5014/ajot.2018.027110
Kaiser, M., Albaret, J., & Doudin, P. (2011). Efficacy of an Explicit Handwriting Program. Perceptual and Motor Skills,112(2), 610-618. doi:10.2466/11.25.pms.112.2.610-618
Case series (and low-quality cohort and case control study)
Expert opinion without explicit critical appraisal
Play as Occupation
Play is the quintessential occupation of all children. It impacts self-regulation, problem solving, confidence, emotional well being, creativity and more. In our ridiculously overscheduled culture, play is losing its footing and child development specialists are strongly advocating for people to comprehend and believe its worth. Play is fundamentally crucial right now as children live in a season of history with significant change to routines and dynamics. We are addressing important social issues, and throughout this children need time to play to help their emotional and mental health.
Uncovering the Skills That are Already There
Children with an Autism Spectrum Disorder have a different approach to many domains of life, including play. I personally believe that there is great value in children playing in a way that is naturally motivating, interesting and rewarding to them. However, I also believe that scaffolding and expanding the play skills of children with ASD is extremely beneficial. Improving play skills can lead to improved problem solving, perspective taking, relationships, communication skills and more. Meeting the child at their interests and style of play while emphasizing connection and relationship building both respects who they are while also seeking to provide them with an increased range of life skills.
More Play is Better for Everyone!
Also, let’s not forget how important it is for parents, siblings and friends to be able to meaningfully connect with their loved ones who have ASD. The child who expands his or her play skills is not the only person who benefits from their increased engagement in the world around them.
So how do we go about promoting an increase in play skills for kids with an ASD?
Many children on the Autism Spectrum often seek out play that is driven by the enjoyment derived by sensory stimulation. In the clinic I have loved seeing my kids with ASD grow their play skills. What most especially brings me joy is seeing them look at me in anticipation of me doing something silly or animated and then their laughter and joy that explodes when I deliver. I also love seeing what ideas they come up with and how they try to engage me in their play scheme. I have had a lot of success in using cause and effect play with balls, blocks, cars, and figurines. We often hit a stumbling block when it comes to symbolic play.
It’s Not “Just Play.”
I took the course, Play with a Purpose: Effective Play-Based Therapy & Early Child Development by Cari Ebert, and it was a game changer for me. It totally changed how I thought about therapy. I am purposeful, intentional and focused when it comes to getting things done in therapy. Sometimes I miss the forest for the trees. Learning about the development of play and how it impacts everything in a child’s development helped me to take a step back and fall in love with play. Parents often come to us wanting to address handwriting, shoe tying and meltdowns. All of those are occupations that I love. However, I came to see that if we neglect play, we are seriously limiting the progress we can help our kids to make in all other areas.
Methods
Participants
Researchers recruited caregivers and 86 children with an Autism Spectrum Disorder aged 22-36 months who attended an early intervention program. The children attended the program for 30 hours per week, during which they received behavioral, speech and occupational therapy. The researchers randomly assigned children and their caregiver to receive 10 weeks of either hands-on parent training in the JASPER program or a psychoeducational intervention (PEI).
JASPER promotes joint attention, symbolic play, engagement and regulation through a naturalistic approach. The PEI provides parents individual education and support on having children with an Autism Spectrum Disorder.
Intervention
Parents in the PEI group spent 1 hour with an interventionist per week. They learned about Autism, details of specific behavioral impairments, principles of managing behavior, strategies for teaching new skills, improving social interaction and communication, service availability, managing parent stress, and sibling/family and community responses to Autism.
A trained interventionist instructed parents in the JASPER group in 2 thirty minute sessions per week. Parents learned through a hands on approach the strategies of the JASPER method. Parents learned to identify their child’s developmental level of play as well as the child’s demonstration of social communication gestures. Interventionists taught parents to use strategies in a structured sequence in order to promote opportunities for their child to initiate interest in an activity or a toy. Parents also used these skills to promote joint attention in their play interactions with their children.
Measures
Play & Joint Attention with Parents
Examiners who were blind to the interventions coded interactions between children and parents by watching 10 minute video recordings of play sessions. This occurred pretreatment, posttreatment and 6 months after the study ended. During the sessions, researchers gave parents a standard set of toys (dolls, dishes, puzzles, trucks, shape sorter and blocks) (Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015, p. 556). Parents engaged in free play with their child using these toys. Raters qualified engagement as joint engagement if the child was aware of the parent’s participation, acknowledged their parent with non-verbal language and/or used language or demonstrated following their parent’s language in play (Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015, p. 556).
Evaluators also coded observed instances of children’s play levels, diversity of their play and instances of initiating joint attention.
Parent Stress, Language Assessment & Joint Attention with Teacher
In addition, researchers coded play interactions between children and their teacher playing together in the classroom, assessing for time spent in joint engagement. This occurred pretreatment and at the end of treatment.
Examiners used the Mullen Scales of Early Learning and Reynell Developmental Language Scales to assess receptive and expressive language skills. These items were completed pretreatment and at the follow up 6 months after intervention ended.
Parents completed the Parenting Stress Index pre-treatment, post-treatment and at the 6 month follow up, providing information about parent stress levels.
Meat and Potatoes
Duration of Joint Attention
The data analysis demonstrated a significant increase in time spent in joint engagement for the children in the JASPER group compared to the PEI group. The children in the JASPER group’s length of time jointly engaging increased by more than double. At the six month follow up, children in the JASPER group continued to have significantly higher amounts of time spent in joint engagement than peers in the PEI group (Kasari, Gulsrud, Paparella, Hellemann, & Berry 2015, p. 558).
Initiating Joint Attention
No difference by treatment group existed in impacting the rate at which children initiated joint attention. So many children demonstrated such low incidences of initiation of joint attention that they did not fall within the measurable range at baseline. Taking data from the entire sample of study participants, the mean number of children initiating joint attention increased and the total number of children demonstrating initiation of joint attention increased significantly over the six months. It did not differ by group.
Functional Play Types
Children in the JASPER group demonstrated statistically significant higher types of functional play than the children in the PEI group. At the time of the 6 month follow up, the difference between the incidences of functional play between groups was not significant.
Symbolic Play Types
The group to which children belonged had no statistically significant impact on the occurrences of symbolic play or the rate at which children increased their symbolic play skills. This remained consistent at the 6 month follow up.
Highest Play Level Achieved
Children in the JASPER group increased more in achieving higher levels of play than their peers in the PEI group. However, at 6 months, the difference between the achievement of highest play level between groups was not significant.
Reynell Receptive Language
The group to which the children belonged had no impact on the rate of their receptive language improvement scores. Children in both groups improved their receptive language skills by approximately 17 months over the 9 months of the study and follow up (Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015, p. 560).
Reynell Expressive Language
The group to which the children belonged had no impact on the rate of their expressive language improvement scores. Children in both groups improved their receptive language skills by an average of 10 months over the 9 month time frame (Kasari, Gulsrud, Paparella, Hellemann, & Berry., 2015, p. 560).
Parent Stress Index
Parents in the PSI group reported statistically significant lower stress in the child-related domain. At follow up, more parents reported lower levels of stress in this domain, but there was no difference based on the group to which they belonged. Parents in the PSI and JASPER group reported insignificantly different levels of stress for the parent-related domain.
Classroom observations
Children in the JASPER group spent statistically significant more time jointly engaging with their teacher than their peers in the PEI group by the end of treatment. The children in the JASPER group increased from 5.7 minutes to 8.9 minutes jointly engaging with their teacher. Children in the PEI group increased from 6.9 minutes to 7.4 minutes.
Things to Consider
The external validity of the study is limited as the children were recruited from an early intervention program that they all attended. We all work with children who tend to come from a variety of settings and attend a variety of programs.
It’s exciting that children in the JASPER group made gains in functional play skills and achieved higher levels of play by the end of intervention. However, the gains did not remain significantly different than those who did not receive the treatment. The authors mention exploring providing parents with sessions after intervention to ensure that the carryover at home continues.
Carryover from Parents to Classroom
I did find it impressive that the children’s joint attention carried over to engaging with their teachers even though the children were learning the skills at home. Also noteworthy is that the children from the JASPER group continued to have higher joint attention at the time of follow up.
I love structure and routine, and I need to learn more about the JASPER program to develop my opinion of it. You can also find more information about it here. It even seems that there is a training you can complete for free. I think it’s important to give kids the lead with play, but I do think we as adults can effectively scaffold their play by using specific techniques that may reach them most. For a lot of kids, you might not have to think too hard to figure them out. However, as kids on the Spectrum process in a unique way, we always have to be open to learning how to most effectively communicate with and reach them also.
What Do You Think?
Have you heard of the JASPER model before? What other strategies or programs have you used to promote play skills for children on the Autism Spectrum?
References
Kasari, C., Gulsrud, A., Paparella, T., Hellemann, G., & Berry, K. (2015). Randomized comparative efficacy study of parent-mediated interventions for toddlers with autism. Journal of Consulting and Clinical Psychology,83(3), 554-563. doi:10.1037/a0039080
As the United States has had a great awakening to racial inequality within many of the systems in our society that impact the quality of daily life for its citizens, we as occupational therapists are likely thinking, what do I need to address in my OT practice?
I am not yet a mother. I don’t have a child with special needs, and I am not latina nor black. My empathy in providing OT services can only go so far when attempting to offer practical and comparable insight to a parent who comes from a minority background and has a child with special needs. According to the 2019 Bureau of Labor Statistics data, the demographics of race are as follows for occupational therapists. Data for occupational therapy assistants was not available.
That being said, while we need to work to increase the diversity of OT practitioners, we must also recognize the limitations of the insight we are able to provide. The numbers make it plainly obvious that most OT’s are white, which impacts our ability to provide first hand experience. The use of Family Peer Advocates (FPA) is an example of closing that gap.
Article Details
Journal
Journal of Autism and Developmental Disorders (SNIP score 0.984)
Article Title
Examining the Efficacy of a Family Peer Advocate Model for Black and Hispanic Caregivers of Children with Autism Spectrum Disorder
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods
Thirty nine children (31 males, 8 females) were recruited through the Young Adult Institute/National Institute for People with Disabilities network. Referral criteria was having a previous diagnosis of an Autism Spectrum Disorder (ASD) or a suspected diagnosis as indicated by a school professional, clinician or other knowledgeable individual (Jamison et. al 2017, p. 1316). Inclusion criteria was an ASD diagnosis based on the DSM-5 per psychiatric evaluation, the Autism Diagnostic Observation Schedule-2 (ADOS-2) and the Autism Diagnostic Interview-Revised.
The researchers found no significant differences between the FPA and the control group for age, IQ or adaptive functioning of the children. The analysis indicated no significant difference between the FPA and control group for use of the number of services prior to the study (Jamison et al. 2017).
Selection of Family Parent Advocates
The Young Adult Institute (YAI) reached out to parents from the group who were active in the YAI community, had given presentations on supporting other parents or who staff identified as being “particularly skillful” in advocating for their family members. Four FPAs participated in the study. Each FPA worked with 3-7 families and received reimbursement for their time.
Training of Family Peer Advocates
FPAs completed 10 hours of training using an adapted Parent Empowerment Program curriculum. They spoke with a licensed social worker from YAI weekly to keep treatment fidelity. The FPAs consulted with their families at least 12 times over a 6 month period.
Members of the control group met with an intake specialist who determined their eligibility for services, provided program and clinic referrals to families as needed and assessed families’ level of motivation to follow through with services and recommendations (Jamison et al, 2017, p. 1317). All participants completed parent report measures at 3 and 6 months with a retention rate of 85%. Participants completed the following measures:
Maternal Autism Knowledge Questionnaire
Caregiver Strain Questionnaire
Parent Stress Index-Short Form
Social Support Survey
Family Empowerment Scale
Autism Service Utilization Questionnaire
Meat and Potatoes
Investigators completed repeated measure and multivariate ANOVAs, which assess the relationship between and within multiple variables.
Maternal Autism Knowledge Questionnaire
All participants made significant improvement in their knowledge of Autism over the 6 months regardless of the group to which they belonged.
Parent Stress Index
Parents in the FPA group showed significantly greater improvements on the Parent Stress Index. Parents in this group also had statistically significant greater improvements on the Parental Distress, Parental Child Dysfunction Interaction and Difficult Child subtests of the PSI.
Caregiver Strain Questionnaire
Parents in the FPA group showed statistically significant greater improvement on Objective and Subjective Internalizing subscales of the Caregiver Strain Questionnaire. Researchers found no significant improvement on the Subjective Externalizing subscale for the FPA group vs. control.
Social Support Survey & Family Empowerment Scale
Researchers found no significant improvement on the Social Support Survey or Family Empowerment Scale for either group. Researchers found no change in utilization of ASD services for either group nor no statistically significant difference between outcomes when they analyzed groups by ethnicity. The study authors found no difference in outcomes when assessing family ethnicity, which indicates there was not a benefit to Latino-Latino vs. African-American-Latino pairings.
Things to Consider
The study authors mention that although both groups increased their knowledge of ASD, they found no improvement in service utilization. Research has shown that current systems sometimes correlate with decreased ease of access for minority families. The 6 month duration of the study and the fact the main services referred to in the study were from services through public schools could also have impacted this finding.
This study included FPAs who had high levels of education and experience in mentoring other families with children with disabilities. To increase the confidence of the use of FPAs in the community at large, a study should investigate the use of FPAs with a more diverse range of education and experience mentoring families. It would also be interesting to see the effects of male FPAs influence on family outcomes.
References
CPS Databases. (2020, January 22). Retrieved June 9, 2020, from
We all know we’ve seen kids who “definitely have sensory issues.” We all also know many people (doctors and other medical professionals included) who think that Sensory Processing Disorder isn’t valid and there’s not enough evidence to prove otherwise.
Well, there are studies that have investigated biological and physiological functions comparing those with sensory processing disorder and those without that have in fact showed–it’s a thing. Examples of measures studies included are responses to electrodermal activity as well as imaging of white matter in the brain. Below is a review of a study that analyzed differences in white matter microstructures and how they relate to auditory and tactile processing in typically developing children vs. those with a sensory processing disorder.
Article Details
Journal
Frontiers of Neuroanatomy (SNIP score 0.961) See this post for explanations of SNIP scores and levels of evidence used.
Article Title
White Matter Microstructure is Associated with Auditory and Tactile Processing in Children with and without Sensory Processing Disorder.
Level of Evidence
1A Systematic review of homogenous RCTS
1B Well-designed individual RCT
2A Systematic review of cohort studies
2B Individual prospective cohort study, low quality RCT, ecological studies; and two group, non-randomized studies
4 Case series (and low-quality cohort and case control study)
5 Expert opinion without explicit critical appraisal
Methods
MRI Measurements of Sensory Processing
Chang et al. 2016 used diffusion tensor imaging with an MRI to compare white matter microstructure between a group of 41 typically developing children (28 male 13 female) and 40 children with a diagnosis of sensory processing disorder (32 male 8 female).
They used measures of fractional anisotropy to quantify movement in white matter microstructure while mean diffusivity indicated white matter lesions on MRIs and radial diffusivity measured axonal/myelin damage on the MRIs.
Parent and Performance Measures of Sensory Processing
Parents of children in both groups completed the Tactile and Auditory Processing subtests of The Sensory Profile. Researchers used these in addition to the Acoustic Index of Differential Screening Test for Processing and the Graphesthesia subtest of Sensory Integration Praxis Test. These provided both parent reported and objective measures of childrens’ sensory processing performance.
Investigators ran statistical analyses of the above measures (both MRI imaging and performance on parent report and objective assessments), accounting for differences in age and gender.
What They Found
Researchers found statistically significant evidence that typically developing children have more white matter than those with sensory processing disorders per the fractional anisotropy measurements and analyses. Also statistically significant was that the white matter in children with SPD was more damaged than typically developing children, per the analysis of mean diffusivity and radial diffusivity.
How White Matter Impacts Graphesthesia
The movement in white matter activity (measured with FA) as related to performance on the graphesthesia subtest of the Sensory Integration Praxis Test was statistically significantly related for 16 of 25 assessed areas of the brain. FA relation to parent rating on the Sensory Profile was statistically significant for 12 of 25 areas of the brain that were assessed.
How White Matter Impacts Auditory Processing
The movement in white matter activity (measured with FA) as related to performance on the Acoustic Index of Differential Screening Test for Processing was statistically significantly related for 23 of 25 assessed areas of the brain! FA relation to parent rating on the Sensory Profile was statistically significant for 6 of 25 areas of the brain that were assessed.
Where the White Matter Impacts Auditory Processing
Both the sensory profile auditory score and Acoustic Index of Differential Screening Test for Processing are associated with white matter activity in the posterior thalamic region (PTR), which contains the primary auditory projection pathway.
Things to Consider
So, good news that researchers are developing methods to physiologically quantify and demonstrate differences between typically developing children and those with Sensory Processing Disorder!
Keep in mind while applying this study to those with whom you work that it looked at children with SPD without other comorbidities (such as an Autism Spectrum Disorder). An SPD diagnosis from a community based OT and Definite Difference Scores in at least one of these subtests on the Sensory Profile (tactile, auditory, multisensory or visual) placed children in the SPD group.
Many Diagnoses or Factors Can Mimic Sensory Processing
I don’t know about you…but I have definitely encountered children who I think do not have SPD although they have an SPD diagnosis or rate as definite difference across many subtests of the Sensory Profile. I’m talking about kids with anxiety or ADHD for whom parents attribute any atypical behaviors to the sensory processing factor. I know it’s relevant, but it’s not always the main contributor to a child’s behavior in my opinion.
Related to that thought is to keep in mind that the analyses in this study showed that parent ratings were less accurate of a predictor of performance on the graphesthesia and Acoustic Index of Differential Screening Test than the MRI measures. I bring this up to remind you that your clinical reasoning is a valid component in making decisions about treatment. Parents are sometimes biased in their ratings of how sensory processing impacts behaviors.
MRIs for everyone?
So far as the use of these imaging techniques for diagnosis of SPD? I don’t think we need to be sure a child has structural evidence to justify outpatient occupational therapy services. I do think this tool could prove valuable when assessing targeted interventions. It could provide information of how they can impact white matter changes as well as functional gains for the child.
Reference
Chang Y-S, Gratiot M, Owen JP, Brandes-Aitken A, Desai SS, Hill SS, Arnett AB, Harris J,
Marco EJ and Mukherjee P (2016) White Matter Microstructure is Associated with
Auditory and Tactile Processing in Children with and without Sensory Processing Disorder. Front. Neuroanat. 9:169. doi: 10.3389/fnana.2015.00169.
