Category: Sensory Processing

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Sensory Regulation through a DIR/Floortime Approach

Sensory processing is so central to what peds OT’s do these days, but there remains a lot of difference in opinions. From “whether it exists,” to what’s the most effective way to treat it. One often leaves OT school feeling like there’s still a lot of new learning to be done.

Learning curves for new grads can be steep. I will say that I personally have shifted my thinking dramatically as an OT since the time I graduated. I have gone from being very detail oriented, goal focused, everything must look like typical to much more practical, holistic and functional.

This journey has led me to be interested in developmental approaches like the DIR/Floortime model. From what I’ve read, it is a collaborative approach between parents and professionals, in which parents are key players. It also emphasizes emotional development and engagement. These are also two elements that have become largely more important to me as I’ve learned to see the forest instead of focusing only on the trees.

I plan to research more into DIR and similar approaches, but this was a basic starting point on an article that reviewed DIR’s impact on communication and self-regulation.

Journal Journal of Occupational Therapy, Schools, & Early Intervention (SNIP 0.535)

Article Title Intervention effects on communication skills and sensory regulation on children with ASD

  • 1A Systematic review of homogeneous 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
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 4 Case series (and low-quality cohort and case control study)
  • 5 Expert opinion without explicit critical appraisal

Methods Professionals recruited 25 children aged 3-6 years old with ASD and their families to participate in this study.

Intervention

A multi-disciplinary team developed focused individualized intervention plans for each child that were completed for a 10 month period. The programs included 1-2 elements that were included in the approach: Floortime, sensory integration and speech therapy (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 349, 2018). Important aspects of the intervention process included:

  • A team of multi-disciplinary professionals who worked as a team with families
  • Identifying children’s strengths, preferences and interests
  • Focusing on developmental areas that emphasis connection, engagement and social skills to promote learning in a child’s natural environments

Every member of the team of professionals was trained in DIR/Floortime and OT’s additionally were trained in Ayres Sensory Integration (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 350, 2018). All team members had also worked for more than 5 years in the Early Intervention System with children with ASD.

Sessions were as follows…

Floortime A psychologist led parents in 30 minute Floortime sessions, in which psychologists coached parents in promoting joint attention from their child. The psychologist also observed and provided feedback to the parent utilizing these skills following the time spent working together.

Sensory Integration OT’s led sessions for 30 minutes if the child participated in multiple therapies from the three options (SI, Floortime and Speech therapy). The children who only participated in SI therapy participated in 45 minute sessions. OT sessions aimed to promote joint attention, social skills, perceptual skills and motor planning through eliciting increased integration of sensory input.

OT’s also provided education to parents as to the connection between sensory integration abilities and difficult behaviors children sometimes display. In this education, OT’s included information on how to adapt the child’s every day routine with modifications to promote regulation.

Speech Therapy Speech therapists used augmentative and alternative communication systems in sessions to promote natural gestures and symbolic communicative forms during their 30 minute sessions (Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida p. 352, 2018).

Measures Parents completed the Assessment Scale of Children with ASD, which gathers information on Social Communication, Repetitive Behaviors and Restricted Interests, and Sensory Processing.

Findings

Children demonstrated statistically significant improved scores for the areas of Social Communication and Sensory Processing. The area of Repetitive Behaviors and Restricted Interests did not yield a statistically significant in the change in parents’ ratings.

Things to Consider

The authors note that the study had no control group, so the results cannot be compared to a lack of treatment, alternative treatment, nor control for development by maturation alone. They also noted that they did not compare or categorize children based upon the severity of their symptoms of each area included.

A limiting element in applying this study to a wide array of OT’s is that the OT’s in this study were trained in both Ayres Sensory Integration and Floortime. I definitely believe I do Sensory Integration Therapy based on the principles in the infographic above, but I’m not officially trained. What I do take away from this article is evidence that developmental models such as DIR/Floortime are a valuable tool to enhance the occupational therapy one is already providing.

References

Helena I. S. Reis, Ana P. S. Pereira & Leandro S. Almeida (2018). Intervention effects on communication skills and sensory regulation on children with ASD, Journal of Occupational Therapy, Schools, & Early Intervention, 11:3, 346-359, DOI: 10.1080/19411243.2018.1455552

Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180030.

http://dx.doi.org/10.5014/ajot.2015.018051

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Feeding: The Impact Parenting Style May Have

feeding
Image by yalehealth from Pixabay

Feeding therapy. I always say it’s a love-hate relationship for me. It’s love because I myself love food and eating. My Italian side of the family is big into cooking, so food definitely is a large part of our culture, and many cultures.

I love seeing kids become more confident and enjoy the process of exploring new foods and flavors. I think it’s fun to be silly with them and talk about taking shark bites vs. mouse bites, seeing who can crunch a carrot the loudest, etc.

The hate side of things isn’t so much a hate as it is a frustration that stems from my impatience. I am through and through a bottom up thinker. I have a hard time not getting to the root of an issue because I feel any progress we’ll see otherwise is likely a temporary bandaid. The struggle I have with feeding therapy is that a child can make lots of progress in the clinic, but seems to have a stand still at home.

As time has gone on, I firmly see that feeding therapy is whole family therapy. That’s not a bad thing, and really every therapy should be that way! However, there are so many emotional dynamics that go into mealtime that unlike learning to cut with scissors, if you don’t somewhat address the bigger emotional dynamic, you’ll likely see very limited progress.

This week’s article is to highlight the connection between family dynamics and feeding outcomes. So while the article doesn’t tell you what to directly do, (although I did write a review that covers that subject) I wanted to review it as a means to support the idea that addressing family dynamics is crucial in feeding therapy.

Journal Eating Behaviors (SNIP score 1.106)

Article Title Mindful Feeding: A Pathway Between Parenting Style and Child Eating Behaviors

  • 1A Systematic review of homogeneous 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
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 4 Case series (and low-quality cohort and case control study) [This study was a cross-sectional study]
  • 5 Expert opinion without explicit critical appraisal

Methods Researchers recruited 496 parents from a sample of a larger study on the topic of feeding. Parents completed an online survey.

Measures

Mindful Feeding Study authors used the Present Centered Awareness subscale of the Mindful Feeding Questionnaire to determine parents’ mindful attention during the process of feeding their children.

feeding

Child Eating Behavior Study authors used subscales from the Child Eating Behavior Questionnaire as a means to measure children’s emotional over-eating and food fussiness per parent report.

Problematic Mealtime Behaviors The Problematic Child Mealtime Behaviors subscale of the Meals in Our Household questionnaire served as a tool to gather parent report on mealtime behaviors.

Parenting Style Investigators used the Parenting Practice Questionnaire to serve as a tool to classify parents’ parenting style as authoritative, authoritarian or permissive.

Findings

In general, the parents who self-reported more authoritative parenting reported higher levels of mindful feeding, while those reporting more authoritarian and permissive parenting reported less mindful feeding (Goodman, L.C., Roberts, L.T. & Musher-Eizenman, D.R., 2020, p. 3). Those parents who used mindful feeding strategies more often had children who they reported were less likely to be fussy, less likely to eat in response to emotions and less likely to have problematic mealtime behaviors ((Goodman, L.C., Roberts, L.T. & Musher-Eizenman, D.R., 2020, p. 4).

Authoritative Parenting Per parents’ self-reports, authoritative parenting had a direct and indirect negative impact on children’s emotional over-eating and food fussiness. Meaning, those with an authoritative parenting style had children who were less likely to be fussy and to eat as a reaction to their emotions. This style of parenting did not demonstrate a negative direct impact on problematic mealtime behaviors.

However, when authors assessed how authoritative parenting impacted mindful feeding and how that in turn impacted problematic mealtime behaviors, they did find a significant effect. So, having an authoritative parenting style doesn’t directly impact mealtime behaviors. However, an authoritative style impacts a parents’ mindful feeding habits, which in turn impacts the problematic mealtime behaviors.

Authoritarian Parenting Per parents’ self-reports, authoritarian parenting had a direct and positive impact on children’s emotional over-eating. That is, parents with an authoritarian parenting style reported their children as more likely to eat in reaction to emotions. This result was not seen for food fussiness and problematic mealtime behaviors. As authors assessed how authoritarian parenting impacted mindful feeding and how that in turn impacted problematic mealtime behaviors, food fussiness, and emotional over-eating, they did find a significant effect.

Permissive Parenting Parents who self-reported permissive parenting style had both a direct and indirect positive impact on problematic mealtime behaviors, food fussiness, and emotional over-eating. This means, parents reporting this style also reported their children as presenting with more mealtime behaviors, food fussiness and emotional over-eating.

Things to Consider

The authors mention that it would be beneficial to the research to complete a longitudinal study in which they could assess these outcomes for the same group of parents and children at multiple points in time. This would allow drawing stronger conclusions about the connection between parenting style, parents’ mindful feeding habits and children’s eating behaviors.

Of note is that the sample in this study had a majority demographic of white families (79%), which may impact the ability to generalize findings to the picky eating population. I was not able to find the race demographics for picky eaters, so I can’t conclusively say one way or another.

The study authors also mention that it would be valuable to explore the bidirectional relationship between parents’ mindful eating habits and children’s challenging behaviors, as the children’s challenging behaviors may also impact the parents’ strategies. Finally, they include that exploring other factors, such as other life stressors, that may impact this relationship between parent and child dynamics during feeding would be useful.

What does this all mean for a feeding therapist?

While this data is preliminary and low level evidence, I think it is very important to acknowledge and include families in feeding therapy intervention. I think we are doing a disservice to children and their families if we expect the child’s progress in the comfort of a therapeutic feeding session to transfer over to home without directly also educating parents and caregivers on how to interact with food, respond to their children and shift a mindset of learning to learn about food.

References

Goodman, L.C., Roberts, L.T., & Musher-Eizenman, D.R. (2020). Mindful feeding: A pathway between parenting style and child eating behaviors. Eating Behaviors 36. http://doi.org/10.1016/j.eatbeh.2019.101335

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Sensory Techniques for Children with Difficulties in Sensory Integration

Image by Cheryl Holt from Pixabay
  • 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
  • 3A Systematic Review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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 mostly RCT’s and Level II studies. As this type of systematic review doesn’t fall into either 1A nor 2B, I chose to categorize it into a level 2A study. The evidence reviewed was higher than case studies but lower than cohort studies.

Methods

The authors of this systematic review included studies that investigated the effect of interventions that are not Ayres Sensory Integration specifically. They included studies published between 2007 and May 2015. Authors included studies on sensory-based techniques as well as sensory environmental modifications. Interventions targeted clients between 2-21 years old with sensory integration difficulties. Authors ensured that articles investigated specific sensory techniques or sensory environmental modifications.

Findings

Qi-jong massage The authors concluded there is strong evidence for young children with ASD with Qi-jong massage (Bodison, S.C. & Parham, L.D. 2017, p. 5).

Three Level I and and 1 Level II studies demonstrated improvements in self-regulation, parenting stress, tactile differences and ASD symptoms. Children were 2-7 years old and had ASD. Their parents, after being trained by occupational therapists, provided 15 minute daily massage. The studies lasted 4 and 5 months.

Important to note is that the OT’s had at least 50 hours of training in Qi-jong before training parents on its implementation. This may make it a challenge intervention for most OT’s to implement.

Weighted Vests The authors concluded there is limited evidence for the use of weighted vests for children with ADHD (Bodison, S.C. & Parham, L.D. 2017, p. 5).

A level I study did show improved attention and in-seat behavior when a group of 6-9 year olds wore vests with 10% of their body weight. The authors mention that limitations in the design of the study impacted its internal validity. This in turn caused them to interpret these findings with caution.

Study authors also noted that the evidence they found for the use of weighted vests with children with ASD had low levels of evidence, so these studies were not formally included in the review. The authors conclude the evidence for the effectiveness of weighted vests for children with ASD is insufficient at this time.

Slow Linear Swinging The authors concluded there is insufficient evidence to support the use of slow linear swinging to improve attention for children with ASD.

A level I study investigated the impact of being on-task following slow, linear swinging in a group of children with ASD. The study demonstrated no significant difference between children who swung and those in the control group (Bodison, S.C. & Parham, L.D. 2017, p. 6).

Study authors did note a limitation of this study is that the arousal level of children was not assessed prior to their participation in swinging. They posited, therefore, that if a child was in a low arousal state prior to a calming activity, this may have demonstrated no positive impact on the child’s on-task behaviors.

Sensory Enrichment in Preschool The authors concluded there is insufficient evidence supporting sensory enrichment in a preschool classroom.

This level I study investigated the impact of embedding tactile, proprioceptive and vestibular activities for 12 weeks in a preschool classroom’s daily routine. All children in the classroom participated in these activities, but one group of children also received ASI through OT sessions.

Both groups improved in their play skills, but no difference was noted between them. Study authors of this review mention that design limitations, including a very small sample size of 8, limit the implications of the study findings.

Sensory Environmental Modifications The authors concluded there is moderate evidence supporting sensory adaptations of a dental environment to assist participation for children with ASD in their routine dental cleanings (Bodison, S.C. & Parham, L.D. 2017, p. 6).

Children reported improved measures of pain intensity and sensory discomfort as well as improved participation in dental cleaning for typically developing children and those with ASD. Children received deep pressure from a decorative wrap and the auditory and visual aspects of the the dental environment (Bodison, S.C. & Parham, L.D. 2017, p. 7).

Most interesting to me is that investigators measured children’s electrodermal responses as a means to quantify impact on stress and anxiety. They found a moderate to large effect size for children with ASD after they received the intervention!

So What Do You Think?

I appreciate when studies have high standards for the research they include in their reviews. However, due to the nature of the current evidence in OT, that sometimes means there is limited information on the interventions we use most.

I’m interested in the idea of Qi-jong massage, but I will say that the skeptic in me thinks, “Well, if anyone received a 15 minute massage to start their day, I would definitely expect them to show improvements in their behaviors.” I also am curious to see if the massage was compared to other interventions such as a tailored sensory diet. If families really followed up with those every day with good fidelity, I hypothesize that we would similarly see as good if not better results in the developmental gains for children.


Reference

Bodison, S.C., and Parham, L.D. (2017). Specific Sensory Techniques and Sensory Environmental Modifications for Children and Youth with Sensory Integration Difficulties: A Systematic Review. American Journal of Occupational Therapy 72 (1). https://doi.org/10.5014/ajot.2018.029413

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Parents as Agents of Change: A Group Behavioral Intervention for Parents of Children with Avoidant-Restrictive Food Intake Disorder

parent

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.

Journal Cognitive 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

  • 1A Systematic review of homogeneous 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
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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.

parent training

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.

parent training for daily exposure procedure

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

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Self-Regulation: Cognitive and Occupation-Based Interventions

Self-regulation

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:

Self-regulation
(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

  • 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
  • 3A Systematic Review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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

Self-regulation
(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. 

Self-regulation

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.

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Childhood Anxiety-What’s an OT to do?

Childhood anxiety

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

Childhood anxiety
Childhood 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

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Is it Sensory Over-Responsivity or Anxiety?

Sensory over-responsivity
Image by Med Ahabchane from Pixabay

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

Level of Evidence

  • 1A Systematic review of homogenous RCTs
  • 1 B 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
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 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.

Sensory over-responsivity

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

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Sensory Processing Disorder: Investigating White Matter Differences

Sensory Processing Disorder
Image by ElisaRiva from Pixabay

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
  • 3A Systematic review of case-control studies
  • 3B Individual retrospective case-control study; one-group, non-randomized pre-post test study; cohort 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.