Occupational performance and sensory integration therapy: preliminary findings ofa rating scale
Veronica Steer
This article is derived from a paper presented at the 5th State Conference of OT Australia AAOT-SA, Adelaide, SA (October, 1996)
VeronicaSteer, BAppSc(OT), has a private practice in Adelaide, SouthAustralia and is a member of the Sensory Integration Faculty(OTAustralia).
INTRODUCTION
Children with learning disabilities form a large portion of most general paediatric occupational therapy practices. The children are referred for assessment and intervention for difficulties with writing, coordination, perception, perceptual motor and self help skill development. For most of these children, the level of ability, independence and organisation in many areas of their life is effected by the pervasive nature of the disability.
Over the last twenty years, sensory integration theory and practice (Ayres, 1972a, 1972b; Fisher, Murray & Bundy, 1991) has been a major and evolving form of intervention used by occupational therapists for children with learning disabilities who also have sensory integrative dysfunction. Research investigating the effectiveness of therapy using sensory integrative procedures has concentrated on the gains made in coordination, learning and behaviour (see for example, Ayres, 1972a, l977, l985; Ayres & Mailloux, 1981; Ayres & Tickle, 1980; Grimwood & Rutherford, 1980; Humphries et al, 1990; Parham, 1990). There has been little documentation of research that measures the change to the overall adjustment in the day to day life of the child who is receiving sensory integrative intervention. It is well recognised clinically, however, that “sensory integration and the corresponding adaptive behaviours lead to organised and appropriate occupational behaviour, including self-care and self-management, play and academic skills” (Fisher, Murray & Bundy, 1991.p.22).
Rating scales were developed by the author in response to the motivation to start recording the changes that were being noted in the children during their therapy sessions and in their lives, by parents and teachers. The Occupational Performance Model (Australia) (Chapparo & Ranka, 1994; 1996) was used to analyse aspects of the scales. Selected constructs from the model were employed to categorise the occupational performance areas and derive a clearer picture of the trends of change that occurred in children’s lives, in response to therapy as well as in the components that are hypothesised to contribute to a child’s occupational roles.
The paper is a report of a pilot study and the findings are therefore considered preliminary to further development of useful rating scales to measure change.
SENSORYINTEGRATION
Sensory integration is based on the work of A. Jean Ayres (1972a) who recognised a common picture in some children with learning difficulties that related to difficulties in processing sensory information. Based on many years of research with these children, she formulated hypotheses about deficits in neuro behavioural processes that are thought to be associated with learning disabilities. These hypotheses led to the development of treatment procedures designed to enhance sensory integrative processing in children who demonstrate difficulties in that area (Ayres, 1964, 1968, 1974b, 1972a, 1972b; Fisher, Murray & Bundy, 1991). A theory of sensory integration was formed that resulted in an associated standardised assessment (Fisher, Murray, & Bundy) that identified sensory processing difficulties that were interfering with early academic learning.
These sensory integrative difficulties were hypothesised to reflect disorganisation of the central nervous system’s ability to process sensory information about the child’s body and environment. This, in turn, interferes with complex processing required for the child to perform during daily activities. This could be viewed as a basic adaptive response in play, physical interaction with other children through tasks, learning daily living skills involving coordination of body movements, or classroom learning.
Sensory integrative procedures are characterised by child directed, motivating, goal oriented and sensory enriched activities, which are used to stimulate more appropriate or mature adaptive responses in the child’s performance. The goal is not only better physical skills required for the performance of daily activities, but enhanced sensory and motor processing that occurs at a more fundamental level of performance. The benefit of therapy is viewed as a more efficient processing of body and environment factors upon which the higher, more complex processing required for formal learning can develop.
DEVELOPMENT OF RATING SCALES TO MEASURE CHANGE
Purpose
The Sensory Integration Rating Scales were developed by the author out of motivation to start recording the changes that were being noticed in therapy, at school and at home, in the everyday abilities of children undergoing therapy. These changes were not always assessed on other standard measures of change, and were not being recognised in recent literature. The aim of the rating scales was to qualify and quantify the benefits of therapy and to begin to build a bank of data that would contribute to research supporting occupational therapy and sensory integration specifically.
The group of children for whom the rating scales were developed were children seen in the author’s paediatric practice. They have learning, coordination and behavioural difficulties, are assessed as having sensory integrative dysfunction and receive weekly direct intervention based on principles of sensory integration.
Rating scales were chosen over other styles of measurement for two reasons. First, they were viewed as being easy to use in a busy practice.
Second, similar rating scales are currently being used in Adelaide by psychologists, paediatricians and others to measure children’s behavioural changes in response to medication trials, behaviour management and social skills training.
They are recognised and accepted as measuring trends of change only and their limitations include their subjectivity. Despite this, many investigations have employed rating scales to demonstrate meaningful empirical relationships between data and theoretical constructs (Kidder & Judd, 1986).
Content
The development of the items in the Sensory Integration Rating Scales were based on commonly recognised areas of concern noted by parents, teachers and the author. They were areas of difficulty that were common to children being seen by the author and reflected the areas of performance that usually responded to therapy. They were areas of performance that were thought to reflect improved organisation of behaviour.
These functional indicators of sensory integrative dysfunction were collated into two scales, one to be used by parents and one to be used by teachers. The items reflected measures of the child’s effectiveness in dealing with aspects of everyday life at school and at home. The scales aimed to measure children’s functional performance before and after treatment and consisted of items relative to broad areas of play, self maintenance, gross and fine motor coordination, basic academic and writing abilities and psychosocial, attention and sensory based behaviours.
A five point Likert rating scale was used to rate 52 measures on the Parent Rating Scale form and 32 on the Teachers Rating Scale form. The scale for each item ranged from :
15
significantno
concern/concern/
difficultydifficulty
ParentForm
Examples of items on the Parent Form are as follows:
Doesyour child:
playby self indoors
playon the computer
playby self outdoors
playon bike or other moving equipment
use a knife and fork
eat in a neat manner
remainseated at the table
organiseand complete dressing
getto sleep and stay asleep
have tantrums
have confidence in his abilities
follow instructions
Isyour child:
fussy with different textures of food
freefrom motion sickness
emotionallycontrolled during periods of high activity
sensitiveto noise
ableto cope with change
TeacherForm
The following are examples from items on the Teacher Form:
Isthe child:
coordinated in physical activities
positive in attitude to physical activities
ableto glue
using scissors
formingletters appropriately
using correct pencil grip
writingwithout frustration
independent in organising work
physically restless
talkative
usually playing alone
able to maintain friendships
The scales were trialed and modified over school terms 1, II and III. The following results are from results obtained from school terms II and III.
Administrationof the Rating Scales
The rating forms were given to parents and
teachers of 32 children who had been referred for occupational therapy for perceived difficulties with learning, coordination and behaviour. The rating scales were given to the parents and teachers, via the parent, at the time of the first treatment session. At the end of the term, or block of therapy (6 to 18 treatments), a second rating scale, identical to the initial scale was completed without the parent or teacher referring to the initial record. After the results were documented, they were invited to compare the two and comment.
The return rate from both ratings was 16 (50%) for parents and 7 (25%) for teachers. The 16 children (4 girls, 12 boys) were aged between 4.10 years to 12.5 years (mn age. 7.9). Fourteen children were in state schools and 2 attended private schools. The return rate possibly reflected the voluntary nature of the task and lack of adequate time to make personal and follow up contact with the teachers to ensure appropriate education about the child’s occupational therapy programme.
Parentand teacher knowledge of occupational therapy and sensory integration
The parents’ level of knowledge of sensory integration was variable. It was based primarily on what they gained from the initial occupational therapy assessment and report and initial reading of the Sensory Information Sheet (1991) as well as A Parent’s Guide to Understanding Sensory Integration (1986). Some parents also attended an information evening on sensory integration, signs of difficulties and treatment benefits and had readSensory Integration and the Child (1979).
The teacher’s knowledge was more limited, based on the assessment report, the Sensory Integration Information Sheet, (1991) and AParent’s Guide to Understanding Sensory Integration (1986).
RESULTS
Preliminaryanalysis
a. Parent Rating Scales
Total scores for each child were computed for the entire rating scale for both the pre and post parent ratings. The differences or improvements in performance of each of the children as perceived by their parents is graphed in Table 1.
Table1: Parent Rating Scale: Improvements
Analysis of the increments graphed indicated that the parent’s ratings of their children varied between 5.24% to 27.3%. The average percentage increase in perceived performance for the 16 children was 15%.
b. Teacher Rating Scales
The teachers’ ratings of perceived performance of 7 of the 16 children at school were similarly computed and graphed (Table 2). Of the 7 children reviewed by teachers, the rate of change varied from -6% (after 6 treatments) to 72% (after 18 treatments).
Table2: Teacher Rating Scale: Improvement
Analysisof results using occupational performance constructs
To gain further information about the specific areas of performance that improved, or did not improve after therapy, the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) was employed. Items on the teacher and parent rating scales were grouped relative to their perceived placement within various constructs within the model. Three constructs were utilised: occupationalroles,occupational performance areas of self-
Table 2
maintenance, productivity, play and rest; and five component abilities, biomechanical, sensorimotor, cognitive, intrapersonal,
Table3: Rating Scale Items Categorised by Occupational PerformanceConstructs
interpersonal. Table 3 outlines how items from both the scales were able to fit the constructs in this particular model. Some items tapped more that one area.
table 3
Total scores for the following occupational performance areas were derived from pre and post treatment scores of items assumed to depict performance in the targeted area.
Total incremental scores were converted to percentage scores which depict the total percentage of perceived improvement in each area. This process was completed for both the teacher and parent rating scales (Table 4).
OCCUPATIONALPERFORMANCE AREAS
Selfmaintenance
Parents identified an improvement in children’s performance of 18.5%. These items included those relating to mealtime, bedtime
Table4: Percentage of improvement in
occupationalperformance as rated by Parents and Teachers
routines, dressing routines.
Productivenessas a student
Data primarily from teacher’s information identified an average improvement of 17% in this area. Questions included those related to fine motor skills, scissor and pencil use, construction and letter formation, completing set work, following instructions, reading, spelling, maths, attention and maintaining emotional control and activity in the classroom.
Play
Parents (13.4%) and teachers (17%) noted improvements in this area through items that related to performance with different types of
Table 4
indoor and outdoor play in terms of fine motor, sensory motor, visual motor, independent and interactive play; as well as coordination and stamina.
Restand sleep
Parents registered the highest increment of improvement in this area (25%). Items related to the ability with which children were able to get to sleep and stay asleep and obtain the quantity of sleep needed for balanced daily activity.
COMPONENTPERFORMANCE
Biomechanical
Parents (15.5%) and teachers (13%) rated improvements in this area through items relating to how well the child managed fine motor skill, utensils, play on equipment, PE, classroom activity, pencil grip, drawing, writing and physical effort required for outdoor tasks.
SensoryMotor
Perceived improvements by parents (14.1%) and teachers (16%) was identified by items that related to vestibular/proprioceptive play on swings, trampolines, climbing equipment, motion sickness, PE and coordination in physical activities; tactile daily function including tolerance of hugs, textures in clothing, play and food, excessive touching behaviours as well as auditory and olfactory indicators.
Cognitive
Perceived improvements (parents, 11.9% and teachers, 18%) were derived from scores on items such as cognitive play such as puzzles, construction, computer, boardgames as well as dressing and following instructions; letter formation, completing set work, reading, spelling, maths, maintaining appropriate levels of attention.
Intrapersonal
Perceived improvements of parents (15.6%) and teachers (17%) were indicated through items such as being able to play alone without the need for adult direction, emotional control, frustration with self, self image, confidence in
abilities as well as basic tolerances to everyday touch and interaction. Teachers particularly noted improvements in positive attitude to physical activity and PE, decreased frustration with writing, being able to maintain appropriate emotional control and confidence in school work.
Interpersonal
Parents (17.6%) and teachers (16%) these rated percentages of improvements through items such as ability to play with others, being able to keep up with family activities, tolerance to being touched by others, emotional control in times of high environmental activity, maintaining friendships and following instructions.
Along with the interpersonal and intrapersonal perspective outlined above, several behaviours associated with the ‘core element’ (Chapparo & Ranka, 1996) diagnosis of attention deficit disorder were targeted for noted improvement. Parents (24.1%) and teachers (17.3%) rated improvements in being able to remain seated at the table, being able to get to sleep, emotionally in control, coping with changes and conflict, reduction in physical restlessness, being able to follow instructions and rules; being independent in organisation of work, completing set work, maintaining appropriate levels of attention, reduced fidgetiness and talkativeness.
DISCUSSION
Three implications arise from this pilot study. First, there is some empirical support for using sensory integrative procedures to improve occupational performance in children who have difficulties in everyday home and school tasks. Improvements, as perceived and rated by parents and teachers were variable across a number of children. Parents perceived the most dramatic improvements to be in the occupational performance areas of self maintenance and rest, and viewed the children as establishing functional roles in these dimensions. This is consistent with early claims made by Ayres (1972) who suggested that appropriate balance of excitation and inhibition of sensory processing is required for organisation of arousal and attention. As yet, however, few studies have looked at the relationships between rest and sleep occupations and sensory integrations that are seen clinically. Teachers noticed
improvements in most areas required by the children to establish functional occupational roles as students. Most noticeable improvements were in the cognitive skills required for the classroom. These findings are consistent with clinical reports of improvements that therapists notice as a result of sensory integrative procedures (Fisher, Murray, & Bundy, 1991).
Second, the rating scales, although in the early stages of development provide important information which can be used by therapists for planning further intervention, or documenting changes in performance. It is clear that the scales will require further development before they can be used as a sound research and clinical tool.
Third, the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) is an effective framework within which to demonstrate changes made in occupational therapy. The constructs within the model gave adequate scope to demonstrate the variability and complexity of individual gains made by these children.
CASESTUDY: K
To further illustrate how the rating scales can be used in practice guide intervention and to demonstrate performance outcomes for children who receive occupational therapy intervention, a case study of one child K will be discussed.
Backgroundinformation
K attended occupational therapy for an assessment of ability related to fine and gross motor coordination, attention and behaviour in the classroom. He presented as an active, inquisitive, and articulate boy, who needed firm expectations and a quiet environment to assist application to most tasks.
Assessment
A full sensory integration assessment was undertaken using the Sensory Integration and Praxis Test (Ayres, 1989). This assessment identified relative strengths in visual perception and visual-motor integration, but significant postural control, balance and bilateral coordination difficulties. He demonstrated good motor planning abilities, and only one low score on measures of tactile perception.
In view of his broad areas of difficulty, and a
family history of dyslexia, K was referred for psychometric assessment. This indicated that K, at 6 years 1 month, was underachieving by around a year below his intellectual potential in written language skills due to significant attention deficit disorder. This affected concentration, recall and work output, and some minor phonic confusions based on sequential memory weaknesses.
His parents were not interested in trialing psycho-stimulant medication to assist his attention, as suggested by the psychologist, but elected to proceed with her additional recommendation of occupational therapy utilising sensory integration therapy. The speech pathologist established that K was progressing well with his literacy skills, and that no intervention was required at this stage.
RatingScales
On the initial rating scales completed by the parents, two fifths of the measures were rated as a ’1′, primarily reflecting difficulties with dressing, sleep, soiling, and wetting, tolerance of touch from others, noise, self image, frustration with himself, coping with conflict and others and physical restlessness.
His teacher rated two thirds of K’s measures as a ’4′ or ’5′, with gross motor coordination, maths, construction and stamina being of no concern. Scores of between ’1′ and ’3′ reflected more concerns with fine motor skills using scissors and pencil grip, following instruction, attending, talkativeness and maintaining concentration for extended periods. Problems with K’s tendencies to harass and bully other children were of concern.
Therapy
In therapy, tasks were initially chosen to develop processing of movement as it related to postural motor control, balance and coordination. However, due to his overreaction to such tasks, therapy was modified to provide moderate amounts of proprioceptive and touch input with muscle resistance to develop postural tone, equilibrium and lower his levels of arousal.
K sought out large amounts of tactile based tasks in the first half of the total programme. Skills training with letter and number formation and tying shoelaces was undertaken with K firmly
wrapped or seated in rugs, cushions and other tactile environments that provided firm body pressure. Introduction of more dynamic forms of movement equipment was gradual.
Therapy concluded when he was accepted into an occupational therapy programme at a local public hospital.
The Rating Scales indicated that the biggest changes (of 3 or 4 points on the scale) occurred at home in his fine motor play, balance, stamina, sleep, being free from soiling and wetting, tolerance of touch from others, and reduction in motion sickness. Improvements of one grade included construction, playing by himself both indoors and outdoors, use of utensils and remaining seated at mealtime.
The teacher’s Rating Scale at the conclusion of treatment indicated a marked change in K’s abilities and adjustment at school with 29 of the 30 measures being a ’4′ or ’5′. Improvements of two points on the scale included letter and number formation, following group instructions, reading and spelling. Changes of one point included reduction in fidgetiness, maintaining appropriate levels of attention, writing without frustration and scissor and drawing skills. K was only occasionally harassing other children.
In K’s case, the Rating Scales clearly defined the changes that had occurred over many occupational performance areas of the child’s everyday life. It would be been impossible to define these changes based on any other formal clinical assessment.
SUMMARY
Preliminary use and interpretation of the Parent and Teacher Sensory Integration Rating Scales to measure trends of change in the lives of children undergoing sensory integration therapy has been encouraging. The results, when considered clinically, support the use of sensory integrative procedures to improve occupational performance. Interpretation of the results of the rating scales are made more meaningful by using the Occupational Performance Model (Australia). The use of the model enabled identification of both broad and specific areas of benefit which are regularly appreciated by parents and teachers, but are often not illustrated by formal reassessment procedures used. Further development of the scales will hopefully result
in a useful tool which can be used by therapists to illustrated the effectiveness of their programmes.
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