Sensory interventions for children: Where does our profession stand?

A recent position statement on ‘Sensory Integration Therapy for Children with Behavioural and Developmental Disorders’ by the American Academy of Pediatrics (2012), has led to intense discussions on paediatric occupational therapy list serves around the world, and for some, perceptions that our profession is being ‘attacked’ from outside. It is therefore timely for the profession to carefully consider the issues at hand. Among the matters raised, the American Academy recommends that whereas “occupational therapy using sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan” (p.1186), parents need to be informed that there is limited and inconclusive research evidence to support sensory integration therapy. They also highlight the role of paediatricians and other clinicians in helping parents make informed decisions about interventions for which there is limited and inconclusive research. Rather than be affronted by critique from beyond our profession, occupational therapy researchers and practitioners need to harness the opportunity for professional debate and development in a controversial practice domain. So from our profession's perspective what are the issues we need to consider? Firstly, the lack of clarity in terminology has created confusion for ourselves, other professionals, parents and readers of our research. Confusion and misrepresentation abounds with terms such as sensory integration, sensory-based problems and sensory processing being used indiscriminately without accurate definition, or interchangeably, as evidenced in the literature. Technically, the intervention known as ‘Sensory Integration Therapy’ or ‘Ayres Sensory Integration’, as trademarked by the Baker/Ayres Trust (Roley, Mailloux, Miller-Kuhaneck & Glennon, 2007) refers to a specific therapy that evolved from the work of Ayres (1972). Nevertheless, the catch-all phrase ‘sensory integration therapy’ is often used to describe a wide range of sensory approaches. For example, a review by Lang et al. (2012) uses this term to describe interventions, including, weighted vests, dynamic seating, multi-sensory environments and the Therapressure Program (Wilbarger & Wilbarger, 1991). It is incumbent upon clinicians and researchers to be explicit not only in their choice of terminology, but also the focus of their interventions. Interventions may target the body structure/functions level, activities and or participation (World Health Organization, 2001). At this point in time, sensory-based interventions that claim to remediate the efficiency with which the nervous system processes sensory input, lack supportive evidence. However, it is becoming increasingly common for occupational therapists to work towards the somewhat less ambitious goal of adapting the sensory properties of tasks and environments to accommodate sensory processing challenges. Occupational therapists must clearly articulate this difference, which may not be apparent to others. Secondly, occupational therapy researchers have an ethical responsibility to investigate the efficacy of interventions using rigorous research designs, such as controlled case study designs and randomised controlled trials, and judiciously chosen outcome measures. Thirdly, clinicians must clearly articulate their clinical reasoning in recommending particular sensory interventions, drawing on their clinical experience, clients’ values and preferences, the research evidence and the practice context, among other factors. We must become better at describing to our consumers/clients the evidence (or lack of evidence) underpinning our practice, so that parents fully understand the intervention to which they are committing. Outcomes must be systematically monitored and evaluated using sound documentation and appropriate measures. A ‘decision tree’ approach to systematically detailing the underpinning theoretical perspective and research plan for single case studies for implementation of a school-based sensory diet is described by Reinson (2012). Parents and therapists need to negotiate upfront regarding intervention selection and the points in time when progress will be evaluated and decisions made about continuation/discontinuation of the intervention. As highlighted by the American Academy of Pediatrics (2012), supporting parents to make informed decisions about interventions is an important consideration. This aligns with the principles of evidence-informed practice and should be embedded in the occupational therapist's collaboration with families and other key stakeholders, such as teachers. Finally and most importantly, it is important that occupational therapy is not viewed synonymously with sensory integration. Occupational therapy for children with developmental and behavioural disorders can offer much more than a sensory lens (Rodger, Ashburner, Cartmill & Bourke-Taylor, 2010). Although it is one perspective we bring to the complex picture of occupational challenges faced by children with these disorders, it is only one. Our unique contribution lies in our understanding of the person, their occupations and the environment and how we can enhance occupational performance and participation in life roles by attending to each of these features. A narrow focus on sensory integration, which attempts to change the person at the level of body functions, fails to represent the full potential of occupational therapy. By maximising the person-environment-occupation fit, occupational therapists can enable children to reach their full potential in valued life roles as siblings, friends, students, self-carers and players, to name a few. By continuing to practise and promote interventions that are poorly supported by evidence, we are doing our clients, ourselves and our profession a disservice. We will be judged accordingly by those outside our profession, many of whom have the power to decide what occupational therapy services should/should not be funded by healthcare funds and governments (such as Better Start, Helping Children with Autism Package etc.). Our future is in our hands, we need to use them wisely.